Antimicrobial resistance claimed an estimated 4.95 million lives in 2019. When clinicians prescribe empiric therapy that follows guidelines, mortality drops by roughly a third; when they de-escalate on the basis of culture results, it drops by more than half. Yet the document that should drive both decisions, the antibiogram, is often read superficially or misinterpreted, particularly by physicians without infectious-disease training. Existing stewardship frameworks address prescribing principles, timing, or ecological impact, but none walks the clinician step by step through an individual susceptibility report and out the other side with a treatment plan. PRECISE is a seven-step mnemonic designed for that purpose. Each letter corresponds to a clinical action: Pathogen assessment, Resistance phenotype interpretation, Evaluate MIC, Curtail spectrum, Individualize PK/PD, Switch route, and Endpoint optimization. Three clinical vignettes (including one in which the steps deliberately collide) illustrate how the framework operates in practice.
INTRODUCTION:Antimicrobial resistance is a major global public health challenge with particular implications in pediatrics. Antimicrobial stewardship programs (ASPs) require structured tools to assess prescribing quality, especially in complex clinical scenarios such as bloodstream infections and multidrug-resistant organism infections. The aim of this study was to design and implement a structured support program for managing these infections in a pediatric hospital, including an evaluation tool, a standard operating procedure, and its integration into the electronic health record. MATERIAL AND METHODS:The program was developed in 2025 within the ASP team of a tertiary pediatric hospital. Two evaluation tools were designed based on the AFinf methodology of the Spanish Society of Hospital Pharmacy and quality indicators reported in the literature. A standard operating procedure was developed in accordance with the PROA certification standards, and the tools were integrated into the hospital's electronic prescribing system. RESULTS:Two structured evaluation tools were obtained (23 items for bloodstream infections and 21 for multidrug-resistant organisms), organized across four dimensions: patient identification, diagnostic adequacy, antimicrobial treatment adequacy, and ASP intervention. A multidisciplinary care pathway was formalized, and electronic integration was completed, enabling systematic data analysis. CONCLUSIONS:The program represents a feasible strategy aligned with current ASP certification standards, with the added value of being specifically designed for the pediatric population, a setting where dedicated and validated tools remain a pressing need.
INTRODUCTION:Given the current increase in the incidence of Neisseria gonorrhoeae infection, a rise in disseminated forms of the disease may also be expected. Within disseminated gonococcal disease, gonococcal arthritis has specific clinical, diagnostic and therapeutic characteristics. METHODS:A retrospective search was conducted for synovial fluid samples that tested positive for N. gonorrhoeae by culture or molecular biology techniques between 2013 and 2023 at several hospitals in northern Spain. A descriptive analysis was subsequently performed. RESULTS:Fifteen patients were analysed. Monoarthritis was the most frequent presentation (60%), followed by polyarthritis, predominantly affecting the wrist or knee. Arthralgia or tenosynovitis at other sites, particularly the wrist, was common. Microbiological identification was performed by conventional culture (12/14) or PCR (7/7). Repeated ultrasound-guided drainage or surgical washout was required in 30% of cases. The mean duration of intravenous antibiotic therapy was 12 days, while the mean total duration of antibiotic therapy was 22 days. The clinical response was favourable in all cases. CONCLUSION:In the current context of increasing gonococcal infection incidence, gonococcal arthritis should be considered in patients with septic monoarthritis or polyarthritis and concomitant tenosynovitis, particularly when the radiocarpal joint is involved. Molecular biology techniques may be useful for identifying N. gonorrhoeae in suspected cases. The clinical course may vary and may require surgical washout and prolonged treatment.
Introducción: La resistencia a los antimicrobianos es un problema de salud pública global con especial impacto en pediatría. Los programas de optimización del uso de antimicrobianos (PROA) precisan herramientas estructuradas para evaluar la calidad de la prescripción, especialmente en infecciones complejas como las bacteriemias y las causadas por microorganismos multirresistentes. El objetivo fue diseñar e implementar un programa estructurado de apoyo al manejo de estas infecciones en un hospital pediátrico, incluyendo una herramienta de evaluación, un procedimiento normalizado de trabajo y su integración en la historia clínica electrónica. Material y métodos: El programa se desarrolló en 2025 en el equipo PROA de un hospital pediátrico de tercer nivel. Se diseñaron dos herramientas de evaluación basadas en la metodología AFinf de la SEFH y en indicadores de calidad descritos en la literatura. Asimismo, se elaboró un procedimiento normalizado de trabajo conforme a la norma de certificación PROA y se integraron las herramientas en el sistema de prescripción electrónica. Resultados: Se obtuvieron dos herramientas estructuradas, de 23 ítems para bacteriemias y 21 para microorganismos multirresistentes, organizadas en cuatro dimensiones: identificación del paciente, adecuación diagnóstica, adecuación del tratamiento e intervención PROA. Además, se formalizó un circuito asistencial multidisciplinar y se completó la integración electrónica, permitiendo la explotación sistemática de los datos. Conclusiones: El programa es una estrategia factible, alineada con los estándares de certificación PROA y específicamente orientada a población pediátrica, donde siguen siendo necesarias herramientas propias y validadas.
Introducción: Ante el aumento actual de la incidencia de la infección por Neisseria gonorrhoeae, cabe esperar asimismo un incremento de las formas diseminadas de la enfermedad. Dentro de la enfermedad gonocócica diseminada, la artritis gonocócica presenta peculiaridades clínicas, diagnósticas y terapéuticas. Métodos: Se realizó una búsqueda retrospectiva de muestras de líquido articular con resultado positivo para N. gonorrhoeae mediante cultivo o técnicas de biología molecular entre 2013 y 2023 en varios hospitales del norte de España. Posteriormente, se realizó un análisis descriptivo. Resultados: Se analizaron 15 pacientes. La monoartritis fue la presentación más frecuente (60 %), seguida de la poliartritis, con afectación predominante de la muñeca o la rodilla. Las artralgias o la tenosinovitis en otras localizaciones, especialmente en la muñeca, fueron frecuentes. La identificación microbiológica se realizó mediante cultivo convencional (12/14) o PCR (7/7). En el 30 % de los casos fue necesaria la evacuación ecoguiada repetida o la limpieza quirúrgica. La duración media de la antibioterapia intravenosa fue de 12 días y la de la antibioterapia total, de 22 días. La respuesta fue favorable en todos los casos. Conclusión: En el contexto actual de incremento de la incidencia de la infección gonocócica, en los pacientes con monoartritis o poliartritis séptica y tenosinovitis concomitante, especialmente con afectación radiocarpiana, debe considerarse la posibilidad de artritis gonocócica. Las técnicas de biología molecular pueden ser relevantes para la identificación de N. gonorrhoeae en casos sospechosos. La evolución clínica puede ser variable y requerir limpieza quirúrgica y tratamientos más prolongados.
Hantaviruses are rodent-borne zoonotic RNA viruses with a worldwide distribution and the capacity to cause severe human disease. More than 40 hantavirus species have been identified, of which over 20 are known to be pathogenic to humans. Old World hantaviruses are classically associated with Hemorrhagic Fever with Renal Syndrome (HFRS), whereas New World hantaviruses predominantly cause Hantavirus Cardiopulmonary Syndrome (HCPS), a condition characterized by rapid progression to respiratory failure, shock, and substantial mortality. Human infection is usually acquired through the inhalation of aerosols contaminated with excreta from infected reservoir animals, primarily rodents, although person-to-person transmission has been demonstrated for the Andes virus. This review summarizes current knowledge on hantavirus biology, reservoirs, transmission, epidemiology, clinical manifestations, laboratory diagnosis, treatment, prognosis, and prevention, with particular emphasis on the situation in Spain. Worldwide, hantavirus infections remain underdiagnosed because many cases are asymptomatic or present with nonspecific clinical manifestations. Diagnosis relies mainly on serological and molecular methods. No universally effective antiviral therapy is currently available for hantavirus disease, and management remains largely supportive, with intensive care and extracorporeal membrane oxygenation playing a crucial role in severe cases. Evidence accumulated over the last three decades confirms the circulation of hantaviruses in Spain, both in animal reservoirs and in humans. Although clinically recognized disease remains uncommon, serological and ecological studies demonstrate that these infections are present in the country. Continued surveillance, improved diagnostic awareness, and the development of effective preventive and therapeutic strategies remain important public health priorities.
Introducción: El manejo de pacientes sépticos continúa siendo un desafío importante en los servicios de urgencias, con una mortalidad hospitalaria superior al 30%. La administración temprana y adecuada de antibioterapia constituye un pilar esencial del tratamiento inicial del código sepsis, ya que su retraso o inadecuación incrementa la morbimortalidad. Sin embargo, los factores que contribuyen a un tratamiento empírico inadecuado aún son poco conocidos. El objetivo de nuestro estudio fue identificar aquellos factores de riesgo asociados a un tratamiento inicial inadecuado en pacientes atendidos como código sepsis, así como evaluar el impacto de la adecuación inicial del tratamiento empírico sobre la mortalidad. Material y métodos: Estudio observacional, retrospectivo de cohortes realizado en urgencias de un hospital de tercer nivel (2021-2024). Inclusión: adultos mayores de 18 años con activación del código sepsis y hemocultivos positivos. Se analizó la adecuación del tratamiento empírico inicial, factores de riesgo asociados y su efecto en la mortalidad a 7 y 30 días. Resultados: Se incluyeron 339 pacientes con sepsis, el 56,9% con más de 80 años. Los factores asociados a tratamiento antibiótico inadecuado fueron S. aureus y bacterias multirresistentes. El 23,6% recibió tratamiento empírico incorrecto. La mortalidad fue del 10,9% a los 7 días y del 17,1% a los 30 días. Conclusión: Una proporción relevante de pacientes con sepsis en urgencias recibe tratamiento antibiótico empírico inadecuado, lo que se asocia a mayor mortalidad temprana, especialmente en infecciones por S. aureus y bacterias multirresistentes.
Background: Empirical linezolid for respiratory infections risks overtreatment and therapeutic inertia. Methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs have high negative predictive value for ruling out MRSA pneumonia, yet their systematic integration into clinical practice remains poorly documented in Spain. The aim of the study was to quantify three sequential quality gaps in the empirical linezolid prescribing process and estimate the potential for improvement through an antimicrobial stewardship programme (ASP). Methods: A retrospective observational study of 83 patients receiving empirical linezolid for respiratory infections at a secondary-level hospital during five non-consecutive months of 2025. Three quality gaps were defined: Gap 0 (initiation without MRSA risk criteria); Gap 1 (failure to request a nasal swab in eligible patients); and Gap 2 (therapeutic inertia following a negative result). Results: Gap 0 affected 30.1% of patients, predominantly CAP (72%), discontinuation was more frequent in Gap 0 patients than in eligible candidates. Gap 1 affected 32.5%, with marked inter-unit variability: swabs were requested in 78% of Internal Medicine patients versus 41.7% in Respiratory Medicine. Among 56 patients with results, 85.7% were negative; Gap 2 affected 20.8%, generating 56 days of linezolid administered after a negative result was available. Patients with positive swabs had significantly higher cumulative risk scores than negative patients. Overall, 62.7% of patients presented ≥1 gap, accounting for 69.5% of 377 total linezolid-days. Conclusions: Quality gaps in empirical linezolid use affect two-thirds of patients and are associated with nearly 70% of treatment days. Targeted two-level ASP interventions, explicit indication criteria, and systematic de-escalation prompts after negative swabs are warranted.
INTRODUCTION:Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) is a preferred antiretroviral regimen in international guidelines, but long-term real-world data in Latin American people living with HIV (PLWH) are scarce. This study describes 48-month persistence, virological effectiveness, safety and metabolic changes in the Argentine BICTARG cohort. MATERIAL AND METHODS:We conducted an observational, retrospective, open cohort study including treatment-naïve (TN) and treatment-experienced (TE) adults with HIV who initiated B/F/TAF between October 2019 and December 2022 at a large HIV centre. Persistence on B/F/TAF, virological suppression (VS, <50 copies/mL), B/F/TAF-related adverse events (AEs), and metabolic parameters (fasting glucose, cholesterol, and triglycerides) were assessed at 24, 36 and 48 months. RESULTS:Overall, 3,057 PLWH were included: 425 TN (14%) and 2,632 TE (86%). In TN, persistence at 24, 36 and 48 months was 99%, 97% and 95%, and VS rates were 95%, 93% and 90%, respectively, with no AEs reported. In TE, persistence was 98%, 96%, and 88%, and VS rates were 96%, 98%, and 98%; AE rates were ≤0.4%, with no virological failure. Fasting glucose remained unchanged; TN participants showed increases in total, LDL, and HDL cholesterol, whereas in TE participants, lipid levels were stable and triglycerides decreased over time (p<0.001). CONCLUSIONS:In this large Argentine cohort, B/F/TAF demonstrated high persistence, sustained VS, low AE rates and an overall favourable metabolic profile over 48 months in both TN and TE PLWH, providing the first long-term real-world evidence from Latin America.
BACKGROUND:High-risk human papillomaviruses (HR-HPVs) are the main etiological agents of cervical cancer. Although coinfections with multiple HPV types are common, it remains unclear whether certain genotypes tend to associate preferentially or whether these associations occur randomly. In particular, HPV16 is considered the most oncogenic type, but its behavior in the context of mono- versus coinfection is less well defined. METHODS:We retrospectively analyzed cervical cytology and HPV genotyping results from 1,140 women aged 25-65 years. We calculated absolute and relative frequencies of individual HR-HPV types, examined between associations of two-type coinfections, and compared observed versus expected frequencies to assess whether genotype combinations occurred beyond chance. Special attention was given to HPV16, analyzing cytological outcomes in monoinfections versus coinfections. RESULTS:Most HR-HPV coinfections occurred at frequencies consistent with chance, suggesting no preferential interactions between genotypes. HPV16, however, was disproportionately present as a monoinfection. Importantly, no HPV16 monoinfections were significantly more associated with high-grade squamous intraepithelial lesions (HSIL) than HPV16 coinfections (p=0,365). CONCLUSIONS:HPV16 was the most frequent genotype and was more commonly observed as a monoinfection than several other HR-HPV types. However, HPV16 monoinfections were not significantly associated with a higher frequency of HSIL compared with HPV16 coinfections. The observed genotype distribution patterns should be interpreted cautiously within the epidemiological context of opportunistic prevaccination screening.
Objective: To evaluate the diagnostic accuracy of the biomarkers procalcitonin (PCT), interleukin-6 (IL-6), and mid-regional pro-adrenomedullin (MR-ProADM), individually and in combination, for early detection of sepsis and septic shock during emergency department (ED) triage. Materials and methods: A retrospective observational study was conducted in adults presenting to the ED with triage levels 2 and 3 between December 2021 and July 2023. Blood samples were collected at admission, prior to any therapeutic intervention. Plasma concentrations of PCT, IL-6, and MR-ProADM were measured using CMIA or ELISA. Diagnostic accuracy was assessed using ROC curves and AUC analysis. Results: A total of 248 patients were included (214 with sepsis and 34 non-septic controls). Simultaneous elevation of PCT, IL-6, and MR-ProADM was observed in 70% of septic patients compared with 3% of controls. Each biomarker showed high diagnostic accuracy for sepsis (AUROC >0.90). The combined assessment increased specificity and was strongly associated with sepsis and septic shock, with progressively higher odds as the number of elevated biomarkers increased. Higher biomarker burden was also associated with indicators of greater clinical severity, including higher SOFA scores and ICU admission. Conclusions: Combined measurement of PCT, IL-6, and MR-ProADM at ED triage, before therapeutic intervention, improves early identification of patients with sepsis and provides relevant information on initial disease severity. This multiplex platform approach may support clinical prioritization and protocol activation in the ED.
Background: Antifungal resistance is a growing global concern in the context of antimicrobial resistance. Although primary care is the main setting for managing superficial fungal infections, national evidence on antifungal consumption in Spain remains limited. This study analyzes the characteristics of antifungal use in Spanish primary care. Methods: A retrospective observational study was conducted using data from the Primary Care Clinical Database of the Spanish Ministry of Health. The study included individuals assigned to primary care with at least one antifungal dispensation per year between 2019-2024. Consumption was measured as Defined Daily Doses (DDD) per 1,000 inhabitants per day (DHD), following the WHO ATC/DDD methodology. Trends were analyzed by sex, age, municipality size, income level, country of birth, and employment status, using annual percentage change (APC) estimated through joinpoint regression models. Results: From 2019 to 2024, antifungal DHD in Spanish primary care increased significantly overall (APC: 8.4% [6.2-10.5]; p<0.001 for both sexes); the number of individuals with ≥1 dispensation declined in 2020 and then stabilized (APC: 5.3% [2.0-8.6]; p=0.004). Use was consistently higher in women, especially among pensioners (with a widening gap after 2020), unemployed individuals, those with very low income, and those born in Spain; D01A led consumption. Significant APC values were observed across all age, country of birth, employment, municipality size, and income strata, with the largest increases in active workers, small and medium municipalities, males <15 years, and foreign-born. Conclusions: Systematic monitoring of antifungal consumption in primary care is key to anticipating shifts in epidemiology and guiding antifungal stewardship. This study provides the first nationwide assessment of outpatient antifungal use in Spain from 2019 to 2024, offering critical evidence for public health planning and antimicrobial resistance mitigation.
