Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia最新文献

Sepsis is a life-threatening condition resulting from the body's dysregulated response to infection that demands timely diagnosis and effective antimicrobial treatment to reduce mortality and healthcare burden. Microbiology laboratories play a critical role in sepsis management by delivering rapid and accurate diagnostic information. This article explores the framework and implementation of diagnostic stewardship programs, their integration with antimicrobial stewardship programs, and the evolving microbiological techniques enabling earlier, targeted antimicrobial therapy in sepsis. We highlight the critical synergy between microbiology, clinical teams and innovation, in optimizing patient outcomes.

The spread of metallo-β-lactamases (MBL)-producing Gram-negative bacilli represents a global health challenge, associated with increased mortality rates. The prevalence of MBL-producing isolates, particularly of New Delhi metallo-β-lactamase (NDM) subclass, is increasing globally. The optimal antibiotic for infections depends on the species and MBL subclass produced. Currently, the antimicrobial cornerstones against these pathogens are aztreonam/avibactam and cefiderocol. Successful therapy requires the early and adequate initiation of antibiotic treatment, optimisation of its pharmacokinetics/pharmacodynamics, and appropriate control of the infection source.

Nosocomial pneumonia is one of the most common nosocomial infections and is associated with significant clinical and economic burdens, such as long-term hospitalization, high medical costs, and increased morbidity and mortality. The increasing incidence of nosocomial pneumonia caused by multidrug-resistant bacteria is a challenge in certain clinical settings, as it often carries a higher risk of delays in initiating an appropriate treatment and, therefore, a worse prognosis. The aim of this article is to analyze some of the key aspects that should be taken into account when choosing an antibiotic treatment for a patient with a nosocomial pneumonia in a multidrug-resistant environment.

Primary immunodeficiencies, now referred to as inborn errors of immunity (IEI), are increasingly recognized in adults, not only in the pediatric population. In adults, they may present with recurrent, severe, or unusual infections, but also with autoimmunity, malignancy, allergies, or inflammation, posing a diagnostic challenge. This review is based on clinical experience and the 2022 International Union of Immunological Societies classification. It includes four clinical cases and proposes a practical approach for the evaluation of adults. In the presence of suspected IEI, a stepwise laboratory approach is proposed to facilitate early detection and improve prognosis. Initial screening with basic immunological tests-including complete blood count, immunoglobulin and complement levels, and lymphocyte immunophenotyping-is emphasized. Confirmation of each IEI requires more specific testing, often involving molecular techniques.

The timely and appropriate administration of empirical antibiotic therapy is critical for patient survival. However, several studies suggest that approximately 20-30% of patients presenting with sepsis receive inadequate antibiotic treatment, a factor strongly associated with increased mortality. Furthermore, approximately 20% of these patients experience adverse effects. The emergence of multidrug-resistant bacteria has significantly complicated the selection of appropriate antibiotic therapy and contributed to increased mortality. This challenge is particularly pronounced in conditions such as ventilator-associated pneumonia and bacteremia of various origins, which represent some of the most common infectious pathologies in the intensive care unit. This has resulted in the development of a range of rapid diagnostic tools, including syndromic panels. The primary objective of these panels is to identify the causative agent of infection at an early stage and to guide the selection of the optimal treatment as quickly as possible.

The treatment of infections caused by multidrug-resistant microorganisms (MDROs) in critically ill patients remains a major clinical challenge due to the high mortality associated with therapeutic failure. Delays in administering effective antibiotics is a determining factor, especially in patients with sepsis. The presence of MDROs is one of the main causes of failure of empirical treatment. Identifying patients at risk of MDRO infection is essential, although complex. Factors such as prior use of antibiotics disrupt the intestinal microbiome balance and promote colonization by MDROs. Immunosuppression, disruption of physical barrier, systemic or organ-specific frailty, and the length of hospital stay increase the risk of colonization and infection by MDROs. In patients with sepsis and a high risk of MDRO infection, empirical therapy should be broad-spectrum and administered early. Traditionally, combination therapy has been recommended, preferably including a classical β-lactam together with aminoglycosides or colistin-drugs that may be suboptimal in certain infection sites and are associated with significant toxicity risks. The new broad-spectrum β-lactams, already validated as first-line targeted treatment, are emerging as a promising empirical option in selected patients. Their early use, guided by colonization status, can optimize initial coverage in terms of spectrum and pharmacokinetic/pharmacodynamic, and reduces delays in the initiation of effective treatment. This strategy should be integrated into antimicrobial stewardship programs and be followed by deescalation once microbiological results are available.

Sepsis remains a major cause of morbidity and mortality and continues to pose substantial diagnostic challenges in its early stages. Monocyte Distribution Width (MDW), a parameter automatically integrated into complete blood counts by next-generation haematology analysers, has emerged as a promising biomarker. This study evaluates the diagnostic performance of MDW compared with traditional markers (C-reactive protein and leukocyte count) and clinical scoring systems (SOFA and NEWS) in a cohort of critically ill patients presenting to a hospital emergency department, with the aim of distinguishing those with infection from those whose severity was attributable to other causes.

Invasive fungal infections are a major cause of morbidity and mortality in critically ill patients, with an increasing global incidence and species diversity, especially after the SARS-CoV-2 pandemic. Diagnosis relies on a combination of classical methods (microscopy, culture) and non-classical tools including biomarkers (1,3-β-D-glucan, galactomannan, mannan) and molecular assays. Fungal infections (candidiasis, aspergillosis, pneumocystosis, and mucormycosis) requires tailored diagnostic strategies based on host risk factors, epidemiology and specimen type. Combining diagnostic tests improves sensitivity and negative predictive value, guiding timely antifungal treatment. An integrated, pathogen-specific approach is essential to improve outcomes in the critical ill patient.

Cytomegalovirus (CMV) infection is a leading cause of morbidity and mortality among immunocompromised individuals, especially hematopoietic stem cell transplant and solid organ transplant recipients. In recent years, significant advances have transformed the approach to CMV prevention and therapy. This manuscript explores key evidence regarding antiviral prophylaxis, treatment strategies, resistance mechanisms, and the potential of immune-guided monitoring in transplant settings. The role of novel agents such as letermovir and maribavir is highlighted. These findings support personalized strategies that balance efficacy, toxicity, and resistance in managing CMV infection.