Background: Extended-spectrum ␤-lactamase (ESBL)producing Escherichia coli is an increasingly important group of community pathogens worldwide. These organisms are frequently resistant to many of the antimicrobial agents usually recommended for the treatment of infections caused by E coli, such as penicillins, cephalosporins, fluoroquinolones, and trimethoprim-sulfamethoxazole. Data concerning risk factors, clinical features, and therapeutic options for such infections are scarce. Methods: A case-control study was performed to investigate the risk factors for all types of community-acquired infections caused by ESBL-producing E coli in 11 Spanish hospitals from February 2002 to May 2003. Controls were randomly chosen from among outpatients with a clinical sample not yielding ESBL-producing E coli. The clinical features of these infections were investigated in the case patients. The efficacy of fosfomycin tromethamine and amoxicillin-clavulanate potassium was observationally studied in patients with cystitis. Results: A total of 122 cases were included. Risk factors selected by multivariate analysis included the fol-Author Affiliations are listed at the end of this article.

ESBLEC is an important cause of COBSI due to E. coli. Clinicians should consider adequate empirical therapy with coverage of these pathogens for patients with risk factors.

Extended-spectrum-␤-lactamase (ESBL)-producing Escherichia coli (ESBLEC) is an increasing cause of community and nosocomial infections worldwide. However, there is scarce clinical information about nosocomial bloodstream infections (BSIs)caused by these pathogens. We performed a study to investigate the risk factors for and prognosis of nosocomial BSIs due to ESBLEC in 13 Spanish hospitals. Risk factors were assessed by using a case-control-control study; 96 cases (2 to 16% of all nosocomial BSIs due to E. coli in the participating centers) were included; the most frequent ESBL was CTX-M-14 (48% of the isolates). We found CTX-M-15 in 10% of the isolates, which means that this enzyme is emerging as a cause of invasive infections in Spain. By repetitive extragenic palindromic sequence-PCR, most isolates were found to be clonally unrelated. By multivariate analysis, the risk factors for nosocomial BSIs due to ESBLEC were found to be organ transplant (odds ratio [OR] ‫؍‬ 4.8; 95% confidence interval [CI] ‫؍‬ 1.4 to 15.7), the previous use of oxyimino-␤-lactams (OR ‫؍‬ 6.0; 95% CI ‫؍‬ 3.0 to 11.8), and unknown BSI source (protective; OR ‫؍‬ 0.4; 95% CI ‫؍‬ 0.2 to 0.9), and duration of hospital stay (OR ‫؍‬ 1.02; 95% CI ‫؍‬ 1.00 to 1.03). The variables independently associated with mortality were a Pitt score of >1 (OR ‫؍‬ 3.9; 95% CI ‫؍‬ 1.2 to 12.9), a high-risk source (OR ‫؍‬ 5.5; 95% CI ‫؍‬ 1.4 to 21.9), and resistance to more than three antibiotics, apart from penicillins and cephalosporins (OR ‫؍‬ 6.5; 95% CI ‫؍‬ 1.4 to 30.0). Inappropriate empirical therapy was not associated with mortality. We conclude that ESBLEC is an important cause of nosocomial BSIs. The previous use of oxyimino-␤-lactams was the only modifiable risk factor found. Resistance to drugs other than penicillins and cephalosporins was associated with increased mortality.Gram-negative organisms are an important cause of nosocomial bloodstream infections (BSIs) (33), particularly when the source of the BSI is the urinary, respiratory, or gastrointestinal tract. Recently, the reemergence of Gram-negative organisms as a cause of primary BSIs has also been reported (1). In the United States, Escherichia coli is the fifth most common cause of nosocomial BSIs and is the first most common cause among Gram-negative organisms, and BSIs caused by E. coli are reported to be associated with a crude mortality rate of 22% (34); in Spain, it is the second most common cause of nosocomial BSIs (23).In recent years, extended-spectrum ß-lactamases (ESBLs), particularly those of the CTX-M family, have spread worldwide among E. coli strains inside and outside hospitals (20,26); consequently, the prevalence of BSIs caused by ESBL-producing E. coli has significantly increased (24, 28). ESBLs confer resistance to penicillins and cephalosporins and are frequently associated with resistance to fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole (18); thus, ESBLproducing microorganisms are frequently truly multidrug resistant. Both antibiotic resistance a...

BackgroundThe adequate information about the functional capacity of elderly populations is a key for the comprehensive assessment of their health status and autonomy. The Lawton IADL (instrumental activities of daily living) Scale is a very often used scale to assess independent living skills, but has never been validated for its use in Spanish-speaking populations. The purpose of this study was to assess the validity, the reliability, and responsiveness of this widely used scale.MethodsThe validation was based on a prospective cohort of 1,965 patients aged 65 or over who suffered an accidental fall with a hip or wrist fracture as a result. These patients were followed up six months after the production of the fracture. Cronbach’s alpha was used to assess reliability, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) for the construct validity. Convergent and discriminant validity were examined by the correlation of the IADL Scale with the Barthel Index, SF-12, WOMAC short form, and QuickDASH questionnaires. Known-groups validity was also studied comparing IADL Scale according to different groups, and responsiveness was assessed by means of effect sizes.ResultsThe mean age was 80.04 years (SD 8.04). The Cronbach alpha coefficient was 0.94. In the EFA, factor loadings ranged from 0.67 to 0.90, and CFA confirmed the homogeneity of the construct. Regarding the convergent validity, all correlation coefficients were higher than 0.40. Significant differences were found according to different groups, supporting known-groups validity. Responsiveness parameters showed moderate to large changes (effect sizes, 0.79 and 0.84 among patients classified as worsened).ConclusionsThese results confirm that the Spanish version of the Lawton IADL Scale has excellent reliability and validity and a moderate to large sensitivity to change. This study provides a proper validation, not only of the Spanish version of the Lawton IADL Scale, but also of the original instrument.

BackgroundThe Minnesota Living with Heart Failure Questionnaire (MLHFQ) is one of the most widely used health-related quality of life questionnaires for patients with heart failure (HF). It provides scores for two dimensions, physical and emotional, and a total score. However, there are some concerns about its factor structure and alternatives have been proposed, some including a third factor representing a social dimension. The objectives of the present study were to analyze the internal structure of the MLHFQ and the unidimensionality of the total score, and to compare the different factor structures proposed.MethodsThe MLHFQ was given to 2565 patients with HF. The structural validity of the questionnaire was assessed by confirmatory factor analysis (CFA), and Rasch analysis. These two approaches were also applied to the alternative structures proposed.ResultsThe CFA results for the hypothesized model of two latent factors and the Rasch analysis confirmed the adequacy of the physical and emotional scales. Rasch analysis for the total score showed only two problematic items. The results of the CFA for other two-factor structures proposed were not better than the results for the original structure. The Rasch analyses applied to the different social factors yielded the best results for Munyombwe’s social dimension, composed of six items.ConclusionsOur results support the validity of using the MLHFQ physical, emotional and total scores in patients with HF, for clinical practice and research. In addition, they confirmed the existence of a third factor, and we recommend the use of Munyombwe’s social factor.