Amphetamine-related intoxications in people living with HIV: An observational study in an emergency department in Barcelona (Spain) from 2018 to 2020.

BACKGROUND: Stimulant drugs, particularly amphetamines, are more commonly implicated in drug-related deaths in people living with HIV; however, the clinical characteristics of amphetamine-related intoxication in people living with HIV are poorly described. MATERIAL AND METHODS: We conducted a retrospective study in people living with HIV who were admitted for amphetamine-related intoxication to an emergency department of a teaching hospital between 2018 and 2021. Severe intoxication (SI) was arbitrarily defined as requiring admission to the emergency medical support unit and receiving medical treatment for ≥6 h. RESULTS: In total, 170 male patients with a median age of 36.2 + 7.5 years were included in the study. A total of 77 (45.3%) individuals had mental disorders, and 120 (85.7%) had HIV-1 RNA suppression, with a median CD4 cell count of 696 (interquartile range 490-905). In total, 61 (37.9%) individuals were on ritonavir/cobicistat-based regimens. Presenting clinical syndromes included agitation in 60 (35.3%) subjects, anxiety in 37 (21.7%), psychosis in 27 (15.8%), chest pain in 26 (15.3%) and altered level of consciousness in 20 (11.7%). SI was observed in 48 (28.2%) individuals, 12 (7.1%) required admission to the intensive care unit, and two (1.2%) died. Altered level of consciousness (odds ratio [OR] 6.5; 95% confidence interval [CI] 2.2-18.9; p < 0.01), psychosis (OR 5.8; 95% CI 2.2-15.1; p < 0.01) and suicide attempt (OR 4.6; 95% CI 1.8-11.6; p 0.01) were associated with SI in the adjusted analysis. CONCLUSIONS: Amphetamine-related intoxication causes high morbidity in people living with HIV. Healthcare providers serving these patients should consider incorporating harm-reduction measures in the prevention of amphetamine-related intoxication.

Characteristics of febrile urinary tract infections in older male adults.

BACKGROUND: Urinary tract infections (UTI) are among the most frequent bacterial infections in older adults. The aim of the study was to analyse the existence of differences in clinical features, microbiological data and risk of infection by multidrug-resistant organisms (MDRO) between older and non-older men with febrile UTI (FUTI). METHODS: This was an ambispective observational study involving older males with a FUTI attended in the Emergency Department. Variables collected included age, comorbidity, diagnostic of healthcare-associated (HCA)-FUTI, clinical manifestations, hospitalization, mortality, and microbiological data. RESULTS: Five hundred fifty-two males with a FUTI, 329 (59.6%) of whom were older adults, were included. Older males had a higher frequency of HCA-FUTI (p <  0.001), increased Charlson scores (p <  0.001), had received previous antimicrobial treatment more frequently (p <  0.001) and had less lower urinary tract symptoms (p <  0.001). Older patients showed a lower frequency of FUTI caused by E. coli (p <  0.001) and a higher rate of those due to Enterobacter spp. (p = 0.003) and P. aeruginosa (p = 0.033). Resistance rates to cefuroxime (p = 0.038), gentamicin (p = 0.043), and fluoroquinolones (p <  0.001) in E. coli isolates and the prevalence of extended-spectrum beta-lactamase and AmpC producing E. coli and Klebsiella spp. strains (p = 0.041) and MDRO (p <  0.001) were increased in older males. Inadequate empirical antimicrobial treatment (p = 0.004), frequency of hospitalization (p <  0.001), and all cause in-hospital mortality (p = 0.007) were higher among older patients. In the multivariate analysis, being admitted from an long term care facility (OR 2.4; 95% CI: 1.06-5.9), having a urinary tract abnormality (OR 2.2; 95% CI: 1.2-3.8) and previous antimicrobial treatment (OR 3.2; 95% CI: 1.9-5.4) were associated to FUTI caused by MDRO. CONCLUSIONS: Older male adults with a FUTI have different clinical characteristics, present specific microbiological features, and antimicrobial resistance rates. In the multivariate analysis being an older male was not associated with an increased risk of FUTI caused by MDRO.

Clinical predictors of ceftriaxone resistance in microorganisms causing febrile urinary tract infections in men. / Factores clínicos predictivos de resistencia a ceftriaxona en microorganismos causantes de infección del tracto urinario febril en hombres.

OBJECTIVES: Because of high rates of resistance to fluoroquinolones, ceftriaxone has become one of the main options for treating febrile urinary tract infection (FUTI). This study aimed to identify predictors of ceftriaxone resistance in community-acquired FUTIs in men. MATERIAL AND METHODS: Cross-sectional ambispective study enrolling men with FUTIs treated in the emergency department of a local area hospital in Spain. RESULTS: A total of 552 FUTI episodes were studied; 103 (18.6%) were caused by a ceftriaxone-resistant microorganism. Variables associated with a ceftriaxone-resistant FUTI were older age, health care-associated FUTI, dementia, diabetes mellitus, neoplasms, a history of UTIs, urologic disease, and complicated FUTI. Patients with ceftriaxone-resistant FUTIs also had higher rates of recent antibiotic treatment. Independent variables associated with FUTI due to a ceftriaxoneresistant microorganism were cirrhosis of the liver (odds ratio [OR], 6,00 95% CI, 1.25-28; P = .025), health careassociated FUTI (OR, 2.3 95% CI, 1.23-4.27; P = .009), and prior treatment with antibiotics (OR, 2.15; 95% CI, 1.23-3.76 P = .007). Components of health care-associated FUTI were a history of admission to a long-term residence (OR, 2.90 95% CI, 1.21-7.16; P = .017) and use of penicillins with or without beta-lactamase inhibitors (OR, 2.16; 95% CI, 1.05-4.42; P = .035). CONCLUSION: Cirrhosis of the liver; history of health care-associated FUTI, especially in patients residing in a long-term care facility; and recent use of antibiotics, mainly penicillins with or without beta-lactamase inhibitors, are risk factors for ceftriaxone-resistant FUTI in men.

OBJETIVO: Las elevadas tasas de resistencia a fluoroquinolonas han hecho de la ceftriaxona una de las principales opciones terapéuticas en las infecciones del tracto urinario febriles (ITUF). El objetivo del estudio es identificar factores predictivos de infección por microorganismos resistentes a ceftriaxona (MRC) en ITUF comunitaria en hombres. METODO: Estudio transversal ambispectivo en el que se incluyeron hombres con ITUF atendidos en el servicio de urgencias de un hospital comarcal. RESULTADOS: Se incluyeron 552 episodios de ITUF, 103 (18,6%) causadas por MRC. Los pacientes con ITUF por MRC tenían mayor edad, más frecuencia de ITUF relacionada con la atención sanitaria (ITUF-AS), demencia, diabetes mellitus, neoplasia, ITU previa, patología urológica, ITUF complicada y antecedente de tratamiento antibiótico reciente. Las variables independientemente asociadas a ITUF por MRC fueron la cirrosis hepática (OR 6,00; IC 95%: 1,25-28; p = 0,025), tener una ITUF-AS (OR 2,3; IC 95%: 1,23-4,27; p = 0,009) y el consumo previo de antibióticos (OR 2,15; IC 95%: 1,23-3,76; p = 0,007). Entre los componentes de la ITUF-AS, el antecedentes de estancia en centro larga estancia (OR 2,90; IC 95%: 1,21-7,16; p = 0,017) y entre los antibióticos el consumo de penicilinas con/sin inhibidores de betalactamasa (OR 2,16; IC 95%: 1,05-4,42; p = 0,035) se asociaron a ITUF por MRC. CONCLUSIONES: La cirrosis, presentar una ITUF-AS, especialmente provenir de un centro de larga estancia, y el consumo reciente de antibióticos, principalmente de penicilinas con/sin inhibidores de betalactamasa, son factores de riesgo de ITUF por MRC en hombres.

Efficacy and safety of direct-acting antiviral agents when combined with secukinumab.

BACKGROUND: The interference in the immune response induced by biological disease-modifying antirheumatic drugs (bDMARDs) increases the risk of reactivation of infections. Treatment of patients with chronic hepatitis C virus (HCV) infection and psoriasis is complex. The efficacy and safety of the new direct-acting antiviral agents (DAA) when combined with bDMARDs remain unknown. CASE REPORT: We present a case of a 44-year-old Caucasian man affected with psoriasis and HCV infection. Throughout the course of the psoriatic disease, this patient received several lines of treatment, including secukinumab, a new type of bDMARD. At the time of commencing secukinumab, new DAA agents (ledipasvir/sofosbuvir) were also initiated. At week 12 post-treatment, hepatitis C viral load was undetectable and the patient remained in remission of psoriasis. CONCLUSION: This case report suggests that secukinumab is a therapeutic option in patients with psoriasis, particularly in those cases with HCV infection where treatment with DAA agents is warranted.

Epidemiological and clinical assessment of a shared territorial malaria guideline in the 10 years of its implementation (Barcelona, North Metropolitan Area, Catalonia, Spain, 2007-2016).

BACKGROUND: Malaria remains a major source of morbi-mortality among travellers. In 2007, a consensual multicenter Primary Care-Hospital shared guideline on travel-prior chemoprophylaxis, diagnosis and clinical management of imported malaria was set up in the Barcelona North Metropolitan area. The aim of the study is to assess the evolution of malaria cases in the area as well as its clinical management over the 10 years of its implementation. RESULTS: A total of 190 malaria cases, all them imported, have been recorded. The overall estimated malaria crude incidence was of 0.47 cases per 10,000 population/year (95% CI 0.34-0.59) with a slight significant positive slope especially at the expense of an increase in Indian sub-continent Plasmodium vivax cases. The number of patients who attended the pre-travel consultation was low (13.7%) as well as those with prescribed chemoprophylaxis (10%). Severe malaria was diagnosed in 34 (17.9%) patients and ICU admittance was required in 2.6% of them. Organ sequelae (two renal failures and one post-acute distress respiratory syndrome) were recorded in 3 patients at hospital discharge, although all three were recovered at 30 days. None of the patients died. Patients complying with severity criteria were significantly males (p = 0.04), came from Africa (p = 0.02), were mainly non-immigrant travellers (p = 0.01) and were attended in a hospital setting (p < 0.001). The most frequently identified species was Plasmodium falciparum (64.2%), P. vivax (23.2%), Plasmodium malariae (1.6%) and Plasmodium ovale (1.1%). Those patients diagnosed with P. falciparum malaria came more often from sub-Saharan Africa (p < 0.001) and those with P. vivax came largely from the Indian sub-continent (p = 0.003). Among the 126 patients in whom an immunochromatographic antigenic test was performed, the result was interpreted as falsely negative in 12.1% of them. False negative results can be related to cases with <1% parasitaemia. CONCLUSIONS: After 10 years of surveillance, a moderate increase in malaria incidence was observed, mostly P. vivax cases imported from the Indian sub-continent. Although severe malaria cases have been frequently reported, none of the patients died and organ sequelae were rare. Conceivably, the participation of the Primary Care and the District and Third Level Hospital professionals defining surveillance, diagnostic tests, referral criteria and clinical management can be considered a useful tool to minimize malaria morbi-mortality.

Drug reaction with eosinophilia and systemic symptoms related to antiretroviral treatment in human immunodeficiency virus patients.

BACKGROUND: The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening condition caused by different medications. The objective of this study was to analyze DRESS cases related to antiretroviral therapy in human immunodeficiency virus (HIV) patients. MATERIALS AND METHODS: Systematic review of DRESS suspected cases in HIV patients associated to antiretrovirals published between January 1998 and April 2017. The registry of the severe cutaneous adverse reactions score was used to classify each report as a "definitive," "probable," "possible," or "no" DRESS case. Clinical characteristics, management, and outcomes were evaluated. RESULTS: Thirty-five case reports were analyzed involving 5 antiretrovirals: Abacavir in 10 (28.6%) cases, efavirenz in 6 (17.1%), nevirapine in 12 (34.3%), raltegravir in 6 (17.1%), and tenofovir in 1 (2.9%). Mean age of the patients was 40 ± 13 years, 65% of which were male. A total of 57.1% reports were classified as having a "definitive-probable" DRESS case. Management was based on withdrawal of the causal antiretroviral and corticosteroids in 68.6% of the cases. None of the patients died. Treatment with nevirapine or raltegravir, the longer onset of symptoms and the presence of lymphadenopathy, eosinophilia, liver involvement, and a longer time for clinical resolution were more frequent among "definitive-probable" DRESS cases. CONCLUSIONS: A DRESS syndrome has to be suspected in HIV patients with lymphadenopathy, eosinophilia, and liver involvement developing weeks after the initiation of nevirapine or raltegravir. Suspension of the causal antiretroviral and in most cases treatment with corticosteroids allowed adequate clinical control.

Diagnostic and management of spontaneous rectus sheath hematoma.

BACKGROUND: Spontaneous rectus sheath hematoma is an uncommon and often misdiagnosed cause of abdominal pain. The aim of this study is to describe our experience in their management. METHODS: Retrospective analysis of the characteristics and outcomes of the spontaneous rectus sheath hematomas diagnosed over the last 12years was conducted. RESULTS: 24 patients were included (66% women; mean age: 74years; range: 54-87). All cases presented predisposing factors mainly anticoagulant therapy in 21 (87.5%) patients, hypertension in 19 (79.1%) and abdominal surgery in 12 (50%) cases. Eighteen (75%) referred triggering factors like coughing being the most common one, present in 17 (70.8%) patients. The main clinical findings were abdominal pain in 21 (87.5%) cases and the existence of an abdominal mass in 20 (83.3%). The diagnosis was confirmed by abdominal ultrasonography and/or computerized tomography in 23 (95.8%) patients. Nineteen cases (79.1%) responded to conservative management while 5 (20.8%) required interventional treatment, which consisted in an arteriography with selective embolization of the epigastric arteries in all cases. Four (80%) of the patients needing interventional treatment were receiving low molecular weight heparin. Nine (37.5%) patients developed hypovolemic shock and 1 (4%) died. CONCLUSIONS: Spontaneous rectus sheath hematomas should be considered in the differential diagnosis of abdominal pain, particularly in elderly women under anticoagulant therapy with onset of symptoms after a bout of cough. Most cases respond to conservative management, although those related to low molecular weight heparin might require interventional treatment; arteriography with selective embolization of the epigastric arteries is the first therapeutic option.

Genotypes coding for low serum levels of mannose-binding lectin are underrepresented among individuals suffering from noninfectious systemic inflammatory response syndrome.

Gene polymorphisms, giving rise to low serum levels of mannose-binding lectin (MBL) or MBL-associated protease 2 (MASP2), have been associated with an increased risk of infections. The objective of this study was to assess the outcome of intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS) regarding the existence of functionally relevant MBL2 and MASP2 gene polymorphisms. The study included 243 ICU patients with SIRS admitted to our hospital, as well as 104 healthy control subjects. MBL2 and MASP2 single nucleotide polymorphisms were genotyped using a sequence-based typing technique. No differences were observed regarding the frequencies of low-MBL genotypes (O/O and XA/O) and MASP2 polymorphisms between patients with SIRS and healthy controls. Interestingly, ICU patients with a noninfectious SIRS had a lower frequency for low-MBL genotypes and a higher frequency for high-MBL genotypes (A/A and A/XA) than either ICU patients with an infectious SIRS or healthy controls. The existence of low- or /high-MBL genotypes or a MASP2 polymorphism had no impact on the mortality rates of the included patients. The presence of high-MBL-producing genotypes in patients with a noninfectious insult is a risk factor for SIRS and ICU admission.

Polymorphic receptors of the innate immune system (MBL/MASP-2 and TLR2/4) and susceptibility to pneumococcal bacteremia in HIV-infected patients: a case-control study.

UNLABELLED: Some deficient genetic polymorphisms of the innate immune system have been correlated to a higher susceptibility to different infections, especially in immunocompromised patients. The possible association between an increased incidence of pneumococcal bacteremia in HIV-infected patients, and deficient polymorphisms of the mannose-binding lectin (MBL), MBL-associated serine protease 2 (MASP-2), and toll-like receptors (TLR) 2 and 4 is analyzed by means of a case-control study. CASES: HIV-infected patients with pneumococcal bacteremia. CONTROLS: HIV-infected patients without previous pneumococcal bacteremia matched with cases by sex and CD4 count in a 2:1 ratio. Fifty-seven cases and 114 controls were studied. Demographics, HIV infection status, antiretroviral therapy, risk factors for pneumococcal disease, and genotypes of MBL2, MASP2, TLR2 and TLR4 were analyzed. The prevalence of the MBL2, MASP2, TLR2 and TLR4 gene polymorphisms was similar in both groups. No statistical significance was found (OR 0.77, IC 95% 0.27 - 2.13) when analyzing the possible association of MBL2 deficient polymorphisms with pneumococcal bacteremia. In HIV infected patients, no association between the presence of deficient polymorphisms of MBL2, MASP2, TLR2 and TLR4 and the incidence of pneumococcal bacteremia was found.

Association between mannose-binding lectin deficiency and septic shock following acute pyelonephritis due to Escherichia coli.

Structural and promoter MBL2 gene polymorphisms responsible for low MBL levels are associated with increased risk of infection. The objective of this study was to assess the possible association between polymorphisms of the MBL2 gene and the incidence of septic shock and bacteremia in patients with acute pyelonephritis due to Escherichia coli. The study included 62 female patients with acute pyelonephritis due to E. coli who required hospital admission, as well as 133 healthy control subjects. Six single-nucleotide polymorphisms (-550 G/C, -221 C/G, +4 C/T, codon 52 CGT/TGT, codon 54 GGC/GAC, and codon 57 GGA/GAA) in the MBL2 gene were genotyped by using a sequence-based typing technique. No significant differences were observed in the frequencies for low-expression MBL2 genotypes (O/O and LXA/O) between patients with acute pyelonephritis and healthy controls. Patients with acute pyelonephritis and septic shock had a higher incidence of low-expression MBL2 genotypes than patients with acute pyelonephritis without septic shock (odds ratio = 9.019, 95% confidence interval = 1.23 to 65.93; P = 0.03). No association was found between bacteremic acute pyelonephritis and low-expression MBL2 genotypes. We found that low-expression MBL2 genotypes predispose to septic shock but not to bacteremia in patients with E. coli-induced acute pyelonephritis. Determination of MBL2 polymorphisms could be useful for assessing the risk of septic shock in women undergoing acute pyelonephritis.