[Clinical patterns of community acquired pneumonia microbiologically documented compared to the not documented.]Prospective and comparative study between 1991 and 1997]. / Patrones clínicos en neumonías comunitarias con documentación y sin documentación microbiológica. Estudio prospectivo y comparativo 1991-1997.

INTRODUCTION: The diagnostic of the pneumonia is the problems more important for its adequate treatment and best evolution. OBJECTIVES: To study in a prospective way the patron clinic de la NAC compared the documented with the not documented in a microbiological way. PATIENTS Y METHODS: We have studied patients with NAC hospitalized in the HUVA between January of 1991 and May of 1997. The diagnostical criterion of pneumonia and of the hospitable ingress were the classics accepted for this infections, was doing in all cases diagnostical studies not invasive. It was analyzed the clinical patron of the NAC microbiologically documented compare to with the not documented. In the same way, the documented was divided in typical and not typical according to the microorganisms aisled. Besides was realized an statistic study using tables of contingency and test Fisher. RESULTS: It was studied 409 patients with NAC, from which 161 (39.6%) had microbiological documentation, it was found 119 micro organism typical and 42 atypical. On the one hand, the female sex, EPOC, fever, tos and purulence esputum and hyperglucaemia, were associated significantly with the documented NAC. The presence of cardiopaty, seriously initial clinical situation, gastrointestinal disorders and previous infections and use of antibiotics, were associated with not documented. The age more than 65 years, presence of comorbility, purulence sputum, pleural pain, toghether with VSG>50 and lobar infiltrate, were associated significantly to typical pneumonia, while tabaquical habit and extrapulmonary sintoms (artromialgias) were with the atypical. CONCLUSIONS: The knowledge of the clinical patrons of the NAC are great impact in the diagnostic and treatment antibiotic adecuate.

[Influence of consensual protocols on the use of antibiotics and bacterial resistance in a general hospital. A prospective study 1995-2000]. / Influencia de la protocolizacion consensuada en el consumo de antibioticos y resistencias bacterianas en un hospital general. Estudio prospectivo 1995-2000.

Reasoned and consensual protocols, by means of diversification of the use of antibiotics, significantly influence their consumption, preventing and reducing the development of bacterial resistance against the Gram-negative microorganisms most frequently isolated in general hospitals. The increase in the consumption of piperacillin-tazobactam was found to be significantly associated with an increased resistance of E. cloacae, but less so in K. pneumoniae and E. coli. Its activity against P. aeruginosa and against P. mirabilis was not affected throughout the study and it maintained a high sensivity to the end against P. aeruginosa and against P. mirabilis and partial recovery of activity against A. baumannii. No statistically significant differences were found between the stable consumption of cefotaxime, ciprofloxacin, ceftazidime and imipenem and bacterial resistance against E. coli, P. aeruginosa, P. mirabilis, K. pneumoniae, E. cloacae and A. baumannii. Imipenem presented greater activity against E. coli, K. pneumoniae, E. cloacae and A. baumannii. Piperacillin-tazobactam showed greater activity against P. aeruginosa, while ciprofloxacin showed the least activity against E. coli and P. mirabilis. Cefotaxime had the least activity against E. cloacae, P. aeruginosa and A. baumannii. Ceftazidime showed stable activity and was similar to piperacillin-tazobactam against E. coli, P. mirabilis, K. pneumoniae, E. cloacae and A. baumannii.

[Pseudomonas aeruginosa bacteremia: clinical and epidemiological patterns and treatment]. / Bacteriemias por Pseudomonas aeruginosa: epidemiología, clínica y tratamiento. Estudio prospectivo de siete años.

Pseudomonas aeruginosa bacteremia has the highest mortality among Gram-negative infections. We studied its clinical and epidemiological patterns in order to achieve an early and accurate diagnosis and treatment. We prospectively studied 211 cases of P. aeruginosa bacteremia admitted to our hospital from 1991 to 1998. All patients had at least one positive blood culture for P. aeruginosa and clinical symptoms of bacteremia. The prognosis of the underlying disease, past illnesses, foci location, initial clinical status, type of bacteremia, complications, and the type of antibiotic treatment were analyzed. Clinical and microbiological controls were carried out at baseline, at the end of the treatment period, and 1 month later. Of the 211 cases, 73% were men with a mean age of 56.5 years. Overall, 45.5% were hospitalized in the ICU, 28% in the surgical ward, and 26% in the medical service, with a mean length of stay of 40.4 days. As risk factors we identified a length of stay more than 14 days (76.7%), previous manipulations (87.6%), and surgery (44.5%). A total of 43.1% had had an infection in the last 6 weeks, and 46.4% were treated with antibiotics, usually broad-spectrum antibiotics without activity against P. aeruginosa. The most frequent underlying diseases were neoplasia (25.5%), postsurgical cardiopathy (24.1%), nephrosis (22.7%), chronic obstructive pulmonary disease (17.5%) and diabetes (13.2%). The most frequent foci were pulmonary (29.3%), urinary (21.8%), and undetermined (38.3%). The mortality rate was 27.9% and was considered related to P. aeruginosa bacteremia in 76.2% of the cases. The antibiotic treatment was considered adequate in 89% of the cases. It was concluded that knowledge of the clinical and epidemiological factors of patients with P. aeruginosa bacteremia may help to optimize its management and to reduce its morbidity and mortality.

[Influence of the application of a rational, consensual protocol on the use of antibiotics in a general hospital]. / Influencia de la protocolización razonada y consensuada en el uso de antibióticos en un hospital general.

A large increase in the use of wide-spectrum antibiotics has occurred in Spain. The objective of our study was to evaluate the influence of applying protocols for the use of such antibiotics. A prospective, observational study was carried out based on the information provided by the pharmacy service about prescriptions of ceftriaxone, cefotaxime, ceftazidime, imipenem and ciprofloxacin at the single-dosing department of the hospital. Two groups were included in the study: 1) control group (October-December 1995), which did not take into account the protocols for antibiotic treatment; and 2) the study group, during the same months in 1996, which took into account the consensual protocols. The criteria for the type of patient, infection and outcome, and type of antibiotic treatment were evaluated according to the rules of the international literature for this type of study. The baseline characteristics of both groups of patients were similar. Following the application of the protocol, a decrease in the use of antibiotics was observed (108 cases in group 2 vs. 207 cases in group 1); an increase in the appropriateness of treatment (50.72% in group vs. 77.57% in group 2); an increase in the cure rate (78.26% in group 1 vs. 91.67% in group 2); and a decrease of 5.01 days in the length of hospital stay (22.99 days in group 1 vs. 17.98 days in group 2), which was statistically significant, and thus led to a savings of 2073.74 Euros per cured patient. The application and adherence to a consensual protocol is a beneficial method of using antibiotics since it improves the quality of their use and makes it more cost-effective.

Fungemia due to Scedosporium prolificans: a description of two cases with fatal outcome.

Two cases, probably related, of fungemia due to Scedosporium prolificans are described in two patients with acute leukemia. Both were admitted to the hematological ward in nearby rooms, during building work in the hospital. After a previous bacterial sepsis in the neutropenic phase, which improved with antibiotic treatment, the respiratory status in both patients deteriorated presenting acute dypsnea, with a lung infiltrate in one of them. A few hours later both patients died. Blood cultures were positive for S. prolificans. These two new cases of S. prolificans infection stress the importance of awareness of this emerging pathogen in patients who suffer a hematologic malignancy during the neutropenic phase, especially if building work is taking place in the hospital.

[Nosocomial fungemias in a general hospital. Epidemiology and prognostic factors. Prospective study 1993-1998]. / Fungemias nosocomiales en un hospital general: epidemiología y factores pronóstico. Estudio prospectivo 1993-1998.

BACKGROUND: Nosocomial fungemias are infections with a high mortality rate. In last years the incidence of these infections has increased probably because of the growing population of immunocompromised patients who undergo aggressive diagnostic and therapeutic techniques. OBJECTIVE: To know the epidemiologic characteristics, risk factors, clinical features and prognosis of fungemia. PATIENTS AND METHODS: We prospectively evaluated all the patients with proven fungemia in our center during a 5 year-period. After finishing antifungal treatment a minimum follow-up of 1 month was carried out. Fungal isolation and identification were performed by standard tests. RESULTS: During the period of study we evaluated 81 patients with an episode of nosocomial fungemia. Global incidence was 0,9 episodes per thousand admitted patients. Candida albicans was the more frequently isolated species (n=53), followed by C. parapsilosis (n=11), C. tropicalis (n=6) and C. glabrata (n=5). Most of the patients had a central intravenous line and were on parenteral nutrition therapy. All of them previously received at least one course of broad-spectrum antibiotics. Overall mortality was 49,6%. A worst prognosis was significantly associated with: age over 65 years, surgical procedures during present admission, leucocytosis, shock, and delay in antifungal treatment. CONCLUSIONS: Fungal bloodstream infection incidence is high in our environment. It is associated with a high mortality rate, specially in patients in whom the beginning of antifungal treatment was delayed. A higher clinical suspicion index may improve the poor outcome in these patients.

[Haemophilus influenzae infections in children less than 5 years of age in the community of Murcia during the 1992-1999 period]. / Infecciones por Haemophilus influenzae en niños menores de 5 años en la comunidad murciana durante el período 1992-1999.

BACKGROUND: Invasive disease due to Haemophilus influenzae has changed substantially since the introduction of the conjugated vaccine. This report studies the incidence and the clinical-epidemiological characteristics of invasive H. influenzae disease in children under five years of age during 1992-94 (before vaccination), 1995-97 (voluntary vaccination) and 1998-99 (obligatory vaccination). PATIENTS AND METHODS: The study was performed by reviewing the clinical histories of 39 patients with H. influenzae isolates from sterile samples, according to microbiology data. The reference population's subgroup of the study, 40,322 children under 5, comprises 60% of the total in our community. RESULTS: The overall incidence of invasive H. influenzae disease was 12.1/100,000 children under 5 and 15.7, 12.4 and 6.2 for the following periods respectively: before vaccination, during voluntary vaccination, and obligatory vaccination. All cases except one of them, were produced by H. influenzae type b and they were seen in children under 3. Meningitis accounted for more than half of the cases (51.3%). Fever was the most frequent sign (38 of 39 cases). Epiglottitis was the cause of the highest average hospital stay (20.8 days). All the patients were treated with cefotaxime, but half were also administered other antibiotics. Sequelae were seen in 7 cases, with no deaths. CONCLUSIONS: The incidence of invasive H. influenzae disease was drastically reduced and no cases were seen in the last year. However, one vaccinated patient suffered a bacteremic etmoiditis. This case and the possibility of infection due to non-b serotypes requires ongoing surveillance for these infections.

Salmonella enterica serovar virchow with CTX-M-like beta-lactamase in Spain.

Four Salmonella enterica serovar Virchow strains resistant to broad-spectrum cephalosporins were isolated from patients with gastroenteritis in 1997 and 1998 in Murcia and Barcelona, Spain. The isolates expressed a beta-lactamase with a pI of about 8 and a positive PCR when specific primers for CTX-M-9 were used. These results suggest the presence of a CTX-M-9 beta-lactamase in these strains.

[Pacemaker lead endocarditis: analysis of 11 cases]. / Endocarditis por cable de marcapaso: análisis de 11 casos.

BACKGROUND: The prevalence of infection of permanent pacemaker ranges from 0.13 to 19.9%. Our objective is to review our experience and to analyze the epidemiology and treatment of those diagnosed as having pacemaker lead endocarditis. METHODS: A retrospective study include all cases diagnosis of pacemaker endocarditis in our hospital, since 1991 to 1998. Eleven patients with pacemaker endocarditis were included. RESULTS: Eleven patients were admitted for endocarditis related to pacemaker-lead infection. Fever occurred in nine patients (81.8%). A germ was isolated in nine patients (81.8%) and was a Staphylococcus in eight (88.9%). Transthoracic echocardiography demonstrated vegetations in only two patients (18.2%), whereas transesophageal echocardiography disclosed abnormal appearances on the pacemaker lead in eleven patients (100%). Six patients were treated with antibiotics initially and four patients required the removal of the whole infected material after finishing treatment with antibiotic. Five patients were treated since the beginning with a electrode removal who responded favorably. CONCLUSIONS: The diagnosis of endocarditis related to pacemaker infection should be suspected in the presence of fever and patient with pacemaker. Transesophageal echocardiography should be performed to look for vegetations. S. aureus and S. epidermidis are involved in the majority of these infections. The best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

Meningitis caused by Pseudallescheria boydii treated with voriconazole.

Meningitis caused by Pseudallescheria boydii is an uncommon infection of the CNS that usually has a poor prognosis and a difficult treatment. We describe a case of chronic meningitis caused by P. boydii in an immunocompetent host that was successfully treated with voriconazole, a new antifungal agent.

Left atrial calcification in a hemodialysis patient with cor triatriatum.

Myocardial calcification is a rare manifestation of abnormal calcium metabolism seen in some patients with chronic renal failure. This report describes the transesophageal echocardiographic and spiral computed tomography (CT) findings in a young hemodialysis female with severe secondary hyperparathyroidism. These findings included calcification of the multiperforated membrane of a cor triatriatum and the wall of the left atrium.

Double-chamber right ventricle in a 63-year-old woman.

Double-chamber right ventricle (DCRV) is a rare congenital heart disease consisting in right ventricular obstruction due to one or several anomalous muscle bundles that divide the right ventricle into two chambers. Because of the rarity of this anomaly in adults, we present the case of a 63-year-old woman suffering from this heart disease, being on the other hand, one of the few cases described in the literature in such an old patient.

[Influence of serious infections due to Gram-negative bacteria on the hospital economy]. / Influencia de las infecciones graves por gramnegativos en la economía hospitalaria.

Nosocomial infections due to Gram-negative bacteria are very important since they are associated with high morbidity and high hospital costs. A prospective study of 250 inpatients was carried out, 200 of whom had Gram-negative bacterial infections. Patients were divided into groups of 50 according to the localization of the infection (urinary, surgical wound, respiratory tract and bacteremia), with a control group of 50 patients with similar characteristics but no infection. We calculated the cost for the different groups by multiplying the average length of hospital stay in days by the daily cost of the stay. Significant differences were observed in the average length of stay per patient according to the type of infection and how it was acquired. In terms of cost, nosocomial infection due to Gram-negative bacteria was 1,049,139 pesetas more expensive than community-acquired infection. The cost of the stay for patients with postsurgical infection due to Gram-negative bacteria was 1,108, 252 pesetas more expensive than for the group of control patients. Nosocomial infection due to Gram-negative bacteria is associated with a prolongation in hospital stay of 9 to 28 days, which is the factor that most reflects the cost that can be attributed to nosocomial infection. Consensual and protocolized measures which allow for better clinical management need to be developed.

[Prospective, comparative study (1994-1998) of the influence of short-term prophylactic treatment with azithromycin on patients with advanced COPD]. / Estudio prospectivo y comparativo (1994-1998) sobre la influencia del tratamiento corto profiláctico con azitromicina en pacientes con EPOC evolucionada.

Despite the advances in therapy, chronic obstructive pulmonary disease (COPD) requires frequent hospital admissions due to acute exacerbations. We carried out a prospective randomized study of two groups of patients with COPD, one (n = 54) treated with azithromycin (500 mg/day) for three days every 21 days during the winter months, and a control group (n = 40) without treatment. A statistically significant reduction in the number of acute infectious episodes (187) and hospital admissions (22) was observed in the treated group versus the control group (249 and 45, respectively). A short prophylactic treatment course with azithromycin is a good alternative in the management of patients with severe, advanced COPD, and could lead to an improvement in social and healthcare costs

Six-year prospective study of risk and prognostic factors in patients with nosocomial sepsis caused by Acinetobacter baumannii.

In this prospective study, the risk factors associated with nosocomial sepsis Caused by Acinetobacter baumannii or Pseudomonas aeruginosa were compared. Prior use of broad-spectrum antibiotics, urinary tract catheter, prior surgery, and mechanical ventilation were significantly associated with nosocomial sepsis caused by Acinetobacter baumannii. The mean prognostic factors significantly associated with mortality were known focus of infection, multiresistant Acinetobacter baumannii, and inappropriate antibiotic treatment. Adequate knowledge of these findings is important to ensure appropriate management of patients and rational use of antibiotics.

Evolution of resistance among clinical isolates of Acinetobacter over a 6-year period.

The aim of this report was to study the evolution of susceptibilities of 1532 clinical isolates of Acinetobacter recovered over a period of 6 years. The minimal inhibitory concentrations (MICs) of 15 antimicrobial agents were determined for all the isolates. The respective percentages of resistant strains in the years 1991 and 1996 were as follows: ciprofloxacin, 54.4% and 90.4%; tobramycin, 33% and 71.8%; amikacin, 21% and 83.7%; ampicillin plus sulbactam, 65.7% and 84.1%; ceftazidime, 57.4% and 86.8%; ticarcillin, 70% and 89.4%; trimethoprim plus sulfamethoxazole, 41.1% and 88.9%; and imipenem, 1.3% and 80%. The MIC90s of ciprofloxacin, sparfloxacin, biapenem, meropenem, imipenem, cefepime, cefpirome, and rifampicin against 250 imipenem-resistant Acinetobacter strains were >32, >32, 128, >256, 256, >256, 256, and 16 mg/l, respectively. With serious infections, it was necessary to resort to the use of colistin, the only antibiotic active in vitro.

Long-term results of the Spanish trial on treatment and survival of patients with predominantly mild heart failure.

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.