¿ES NECESARIO REALIZAR UN CRIBADO DE S. AUREUS? ¿Y DE OTROS MICROORGANISMOS MULTIRRESISTENTES?DR. MIQUEL PUJOL. SERVICIO DE ENFERMEDADES INFECCIOSAS, HOSPITALUNIVERSITARIO DE BELLVITGE, L ́HOSPITALET DE LLOBREGAT, BARCELONA

GEIRAS 2018

¿Es necesario realizar un cribado de Staphylococcus aureus? ¿Y de otros microorganismos multirresistentes?

Miquel Pujol

Servicio de Enfermedades Infecciosas

Hospital Universitario de Bellvitge

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Magnitud del problema La infección es la segunda causa de muerte en los

pacientes en hemodiálisis crónica periódica

25% de pacientes con infección fallecen

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National Healthcare Safety Network (NHSN) DialysisEvent Surveillance Report for 2014

• 6.005 centros de diálisis en USA (318 mill/habitantes)

• 380.000 pacientes en Hemodiálisis Periódica

• Eventos 2014: 160.971 • Bacteriemias: 29.515 episodios (76.5% relacionadas con el

acceso vascular)

• Infección del acceso vascular: 38.310 episodios

• Inicio de tratamiento antibiótico: 149.722 inicio ATB’s

Clin J Am Soc Nephrol 12: 1139–1146, 2017. doi: https://doi.org/10.2215/CJN.11411116

Tasa de Incidencia de bacteriemias: 0.64 / 100 pacientes-mes

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Rate of BSI per 100-patient-month by type of vascular access

0,260,39

2,16

0

0,5

1

1,5

2

2,5

Fistula A-V Injerto A-V CVC

All BSI: 0,64/100 patients-month

Densidad de incidencia GEIRAS 2018

Micro-organisms isolated from blood cultureDialysis Event Surveillance, NHSN 2014

31,8

15,6

9,7

4,9

2,9 3,2 2,6 2 1,4

0

5

10

15

20

25

30

35

Categoría 1

S.aureus S.epidemidis SCN E.faecalis E.coli E.cloacae K.pneumoniae P.aeruginosa S.marcescens

Clin J Am Soc Nephrol 12: 1139–1146, 2017. doi: https://doi.org/10.2215/CJN.11411116

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The role of nasal carriage in S.aureus infections

Los pacientes en HD, son con frecuencia portadores nasales de S. aureus (Kluytmans)

S.aureus es la causa más frecuente de bacteriemia en pacientes en HD. Riesgo de infección: ∆2-12

Las bacteriemias por S.aureus son de origen endógeno (80%) y se originan de colonias de la mucosa nasal. (von Eiff)

Estos resultados apoyan las estrategias para prevenir las infecciones por S.aureus eliminando la situación de portador nasal (Simor)

• Kluytmans J; CMR, 2007. Von Eiff C; NEJM, 2001. Simor AE; Lancet ID 2011

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Staphylococcus aureus nasal carriage and infection in patients on hemodialysis. Efficacy of antibiotic prophylaxis.

VL YU et al. N Engl J Med. 1986;315:91-96

Conclusions: The incidence of infection at the dialysis access site, skin, and soft tissue of patients on hemodialysis can be decreased by interventions directed at nasal carriage of S. aureus.

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Oral rifampin for prevention of S. aureus carriage-related infections in patients with renal failure--a meta-analysis of randomized controlled trials.

ME Falagas et al. Nephrol Dial Transplant. 2006;21:2536-42

CONCLUSION:Prophylactic use of oral rifampin reduces access-site infections with S. aureus in patients with renal failure undergoing dialysis. However, development of toxicity and antimicrobial resistance during the treatment with rifampin occur in considerable proportions of patients, limiting its use.

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Mupirocin Prophylaxis to Prevent Staphylococcus aureus Infection in Patients Undergoing Dialysis: A Meta-análisis

E. Tacconelli et al. Clin Infect Dis. 2003;37:1629-38.

Objective: to determine the overall benefit of mupirocin therapy in reducing the rate of S. aureus infection among patients undergoing hemodialysis (HD) or peritoneal dialysis (PD)

Methods: randomized clinical trials or cohort studies; adults requiring HD or PD; Mupirocin was administered to the treatment group, and placebo or no therapy to the

control group. Primary outcome: difference in the number of S. aureus infections among mupirocin-

treated and -untreated patients Patient population: 9 articles were analyzed. A total of 2.445 patients were included in

the analysis

Results: S. aureus bacteremia was reduced by 78% among patients undergoing HD

Conclusions: Mupirocin prophylaxis substantially reduces the rate of S. aureus infection in the dialysis population

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Risk ratios and 95% CIs for mupirocin

versus placebo or no prophylaxis in clinical trials of prevention of Staphylococcus aureus bacteremia

Mupirocin Prophylaxis to Prevent Staphylococcus aureus Infection in Patients Undergoing Dialysis: A Meta-análisis

E Tacconelli et al. Clin Infect Dis. 2003;37:1629-38.

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Staphylococcus aureus nasal carriage in patients on haemodialysis: role of cutaneous colonization

Peña C, et al. Journal of Hospital Infection (2004) 58, 20–27

Objective: to determine the role of cutaneous colonization in the aetiology of recurrent nasal colonization

Patients: 71 patients on chronic haemodialysis in the dialysis unit at a university hospital were screened monthly for S. aureus nasal carriage

Intervention:

Carriers received nasal mupirocin for five days and were tested for nasal and cutaneous carriage two days later and monthly thereafter

Using genotyping results, recurrence was defined as relapse if pretreatment and subsequent nasal isolates were clonally identical

Results: 55% were nasal carriers. Among the mupirocin-treated patients, the eradication of S. aureus nasal carriage rate was 88.5%. Nasal recurrence was documented in 43.5%. By PFGE, 70% recurrence episodes were considered relapses and 30% recolonizations.

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Recomendaciones:

• APIC 2010: Guide to the Elimination of Infections in Hemodialysis. Unresolved issue. Major concerns are relapses and mupirocin resistance. Eradication of S. aureus nasal carriage for the individual HD patient for a single incident of elective surgery only

• CDC’s National Healthcare Safety Network (NHSN). Surveillance of dialysis events. No screening of S.aureus carriers recommended.

• NHS. Guidelines for patients on chronic haemodialysis program. No plans for screening of MSSA carriage.

• Canadian Dialysis Units: no routine use of a S. aureus nasal carriage eradication protocol.

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¿Es necesario realizar un cribado de S. aureus? ¿Y de otros microorganismos multirresistentes?

Impresión personal

El paciente en hemodiálisis periódica es frágil y susceptible a desarrollar infecciones de elevada mortalidad.

Limitar el uso de CVCs es probablemente el factor individual modificable más importante para prevenir la bacteriemia en esta población.

En el caso de que sea necesaria la utilización de un CVC es de extrema importancia la asepsia durante la inserción y cuidados del catéter.

En los pacientes portadores de catéter vascular, puede ser coste-eficaz el screening y la descolonización de S.aureus

La baja incidencia de infecciones por BGN y la ausencia de tratamientos efectivos de descolonización desaconsejan el screening de estos microorganismos

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