Very low level viraemia and risk of virological failure in treated HIV-1-infected patients.

OBJECTIVES: The aim of the study was to investigate whether very low level viraemia (VLLV) (20-50 HIV-1 RNA copies/mL) was associated with increased risk of virological failure (VF) as compared with persistent full suppression (< 20 copies/mL). METHODS: From the VACH Cohort database, we selected those patients who started antiretroviral therapy (ART) after January 1997 and who achieved effective viral suppression [two consecutive viral loads (VLs) < 50 copies/mL] followed by full suppression (at least one VL <20 copies/mL). We carried out survival analyses to investigate whether the occurrence of VLLV rather than maintaining full suppression at < 20 copies/mL was associated with virological failure (two consecutive VLs > 200 copies/mL or one VL > 200 copies/mL followed by a change of ART regimen, administrative censoring or loss to follow-up), adjusted for nadir CD4 cell count, sex, age, ethnicity, transmission group, type of ART and time on effective suppression at < 50 copies/mL. RESULTS: Of 21 480 patients who started ART, 13 674 (63.7%) achieved effective suppression at < 50 copies/mL, of whom 4289 (31.4%) further achieved full suppression at < 20 copies/mL after May 2009. A total of 2623 patients (61.1%) remained fully suppressed thereafter, while 1666 had one or more episodes of VL detection > 20 copies/mL (excluding virological failure). A total of 824 patients had VLLV after suppression at < 20 copies/mL. VLLV was not associated with virological failure as compared with persistent full suppression [hazard ratio (HR) 0.67; 95% confidence interval (CI) 0.44-1.00], independently of the number of blips recorded (from one to 18). CONCLUSIONS: In our population of HIV-infected patients on ART who achieved viral suppression at < 20 copies/mL, the risk of virological failure was no different for patients who remained fully suppressed compared with those who experienced subsequent episodes of VLLV.

[Clinical-microbiological management of blood cultures positive for coagulase-negative staphylococci]. / Manejo clínico-microbiológico de los hemocultivos positivos por Staphylococcus coagulasa negativos.

A 53-year old male admitted for episodes of sustained ventricular tachycardia subjected to electrical cardioversion, carrier of a right femoral central venous catheter, began with febrile peaks, and Staphylococcus epidermidis was isolated in the blood cultures. What is the value of isolation in the blood cultures of S. epidermidis, a microorganism that forms a part of the usual flora of the skin and mucous of the patient? How should this situation be managed? Should an antimicrobial agent be administered? Which one? For how long?

Haemophagocytic syndrome associated with infections: Not so uncommon. / Síndrome hemofagocítico asociado a infecciones: no tan infrecuente.

BACKGROUND: Haemophagocytic syndrome (HPS) is a severe immunological disorder characterised by uncontrolled inflammation and multiple organ failure. HPS can be triggered by viral, bacterial, fungal and parasitical infections. We report our experience with infection-related HPS and estimate its local incidence. MATERIAL AND METHOD: We conducted an observational retrospective study of infection-associated HPS in patients treated in the Department of Infectious Diseases of a university hospital within a 5-year period, as well as a review of the published series in Europe. RESULTS: HPS was associated with infection by cytomegalovirus in 2 women with Crohn's disease and was associated with visceral leishmaniosis in 4 patients (3 men, 1 woman; 1 case of multiple myeloma; 2 cases of solid tumours; 1 case of no apparent disease). Two patients died, and the estimated incidence rate was 0.58/100,000 inhabitants/year. The published series are mixed. CONCLUSIONS: Infection-related HPS must be more common than reported. The geographical environment can influence the triggering infections (in our environment, Leishmania should be considered).

The relationship between antiretroviral prescription patterns and treatment guidelines in treatment-naïve HIV-1-infected patients.

BACKGROUND: Reports have shown that the publication of practice guidelines does not guarantee their use in clinical practice. The objective of this study was to evaluate the agreement between antiretroviral treatments (ARTs) prescribed in clinical practice and the recommendations in published guidelines. METHODS: A retrospective cohort study was carried out in ART-naïve adults of the Spanish Asociacion Medica Vach de Estudios Multicentricos (VACH) Cohort for the period from 2003 to 2006. RESULTS: A total of 945 patients initiated ART. Of these patients, 12.3% had a CD4 cell count above 350 cells/microL. A 'nonrecommended' antiretroviral regimen was prescribed to 5.3, 5.1 and 7.8% of patients with CD4 counts <200, 200-350 and >350 cells/microL, respectively. Multivariate analyses demonstrated that only a higher viral load was associated with the selection of a combination treatment that was recommended by the guidelines. CONCLUSIONS: Most patients were prescribed initial treatments in agreement with the recommendations. Appropriate routine data collection in databases can be used to evaluate the level of antiretroviral guideline compliance. We propose that routine evaluations of the guidelines must be part of quality assessment to improve medical care.

The Impact of Culturing the Organ Preservation Fluid on Solid Organ Transplantation: A Prospective Multicenter Cohort Study.

BACKGROUND: We analyzed the prevalence, etiology, and risk factors of culture-positive preservation fluid and their impact on the management of solid organ transplant recipients. METHODS: From July 2015 to March 2017, 622 episodes of adult solid organ transplants at 7 university hospitals in Spain were prospectively included in the study. RESULTS: The prevalence of culture-positive preservation fluid was 62.5% (389/622). Nevertheless, in only 25.2% (98/389) of the cases were the isolates considered "high risk" for pathogenicity. After applying a multivariate regression analysis, advanced donor age was the main associated factor for having culture-positive preservation fluid for high-risk microorganisms. Preemptive antibiotic therapy was given to 19.8% (77/389) of the cases. The incidence rate of preservation fluid-related infection was 1.3% (5 recipients); none of these patients had received preemptive therapy. Solid organ transplant (SOT) recipients with high-risk culture-positive preservation fluid receiving preemptive antibiotic therapy presented both a lower cumulative incidence of infection and a lower rate of acute rejection and graft loss compared with those who did not have high-risk culture-positive preservation fluid. After adjusting for age, sex, type of transplant, and prior graft rejection, preemptive antibiotic therapy remained a significant protective factor for 90-day infection. CONCLUSIONS: The routine culture of preservation fluid may be considered a tool that provides information about the contamination of the transplanted organ. Preemptive therapy for SOT recipients with high-risk culture-positive preservation fluid may be useful to avoid preservation fluid-related infections and improve the outcomes of infection, graft loss, and graft rejection in transplant patients.

67-Gallium SPECT/CT in febrile syndromes of unknown origin. / SPECT/TC con galio-67 en los síndromes febriles sin foco conocido.

INTRODUCTION AND OBJECTIVE: Febrile syndromes of unknown origin (FSUO) are complex processes in hospital practice. Their management includes an exhaustive medical history and examination, as well as an extensive number of biochemical tests. If these are inconclusive, diagnostic imaging techniques such as SPECT/CT with 67-Gallium Citrate (67Ga-SPECT/CT) could play an important role. We evaluated its role in the management of FSUO in our healthcare area. MATERIAL AND METHODS: We reviewed 57 patients who underwent a 67Ga-SPECT/CT due to a FSUO (32 women and 25 men, age range: 32-83 years old) obtaining scintigraphic findings, previous treatments and final diagnosis. Values of sensitivity, specificity, positive predictive values (VPP) and negative values (NPV) were obtained and compared with the results for PET/CT with 18Fluor-deoxy-glucose (18F-FDG PET/CT) found in the literature. RESULTS: The diagnoses found were: infection in 27/57 (47%), inflammatory disease in 15/57 (26%), neoplasm in 1/57 (1.75%) and patients without final diagnosis in 14/57 (24%). The statistical values of 67Ga-SPECT/CT were: sensitivity, specificity, PPV and NPV of 67%, 93%, 97% y 48%, respectively which were slightly lower than those found for the 18F-FDG PET/CT (86%, 52%, 70% and 92%, respectively). The diagnostic yield was 73% which increased to 80% in the patients who lacked empirical treatment. CONCLUSION: Despite the better results of 18F-FDG PET/CT, 67Ga-SPECT/CT behaved as a useful technique in the management of FSUO. It is advisable to use it if 18F-FDG PET/CT is not available.

Effect of Cytomegalovirus Infection on Survival of Older Kidney Transplant Patients (D+/R+): Impact of Valganciclovir Prophylaxis Versus Preemptive Therapy.

BACKGROUND: Kidney transplant patients with D+/R+ serology can be treated with either prophylaxis or preemptive valganciclovir. The older transplant population suffers severe immunosenescence, especially patients with latent cytomegalovirus (CMV) infection (R+). They are more likely to develop indirect CMV effects. Likewise, many patients have significant cardiovascular comorbidity, which makes them more sensitive to these indirect effects. The aim of this study was to evaluate the incidence of CMV viremia and indirect effects on survival, comparing prophylaxis (V) against preemptive (P) valganciclovir in an older kidney transplant population. METHODS: We analyzed the data of 233 recipients from 2002 (age, >55 years; D+/R+) with ≥6 months of follow-up. The patients were divided into 2 groups: 167 (71.7%) in the V group and 66 (28.3%) in the P group. RESULTS: The incidence of CMV infection in the P group was 32% versus 6% in V group. Patients with CMV viremia showed worse survival values than patients without viremia (log rank P = .031). Five-year survivals were 74% vs 88%, respectively. Cox regression showed that the adjusted effect of CMV infection on overall survival was a significant risk (hazard ratio [HR], 2.07; 95% CI, 1.003-4.29). Patients with CMV viremia showed worse cardiovascular survival than patients without viremia, with 5-year survivals of 79% vs 94%. Cox regression showed that the adjusted effect of CMV infection was a significant risk (HR, 2.62). CONCLUSIONS: CMV infection has a detrimental effect on the survival of older patients. Valganciclovir prophylaxis induces a protective effect against CMV infection and could improve survival of older patients with cardiovascular comorbidities.

Pulmonary haemorrhage and focal necrotizing glomerulonephritis in a case of systemic sclerosis.

We report a case of a 53-year-old woman diagnosed of systemic sclerosis. She underwent an episode of pulmonary haemorrhage, characterized by haemoptysis, sudden anaemization, and bilateral alveolar infiltration during her hospitalization, which was resolved with steroid treatment. Subsequently, she developed a focal necrotizing glomerulonephritis. After searching in the literature, we have found only three cases of systemic sclerosis associated with pulmonary haemorrhage. We discuss the etiopathogenesis of this association and stress the importance of early steroid therapy.

[Paraneoplastic hypouricemia in Hodgkin's lymphoma secondary to a renal tubular reabsorption defect of uric acid (author's transl)]. / Hipouricemia paraneoplástica en el linfoma de Hodgkin por defecto en la reabsorción tubular postsecretora de ácido úrico.

A patient is reported with stage IV-B Hodgkin's lymphoma, lymphocyte depletion type, and associated hypouricemia (1,7 mg/dl). In the few cases described of this association hypouricemia was secondary to a high renal clearance of urate, but in no case was the involved tubular level precisely delimited. In the present case the pyrazinamide and the probenecid tests were performed, disclosing the existence of a possible defect in the postsecretory reabsorptive phase which was improved by therapy. The different pathogenetic mechanisms described to explain this transitory tubular defect are reviewed.

Leptospirosis in South-western Spain.

INTRODUCTION: Leptospirosis is a zoonosis of worldwide distribution and tropical predominance. Its incidence could be underestimated in template regions. We describe the manifestations of leptospirosis in an area of Southwestern Spain. PATIENTS AND METHODS: Eighty-six cases of leptospirosis (April 1997-April 2013) were retrospectively analyzed. The diagnosis was based in clinical and serological (Leptospira IgM ELISA) judgement. Epidemiological, clinical, laboratory, and prognostic dates were recorded. RESULTS: The mean age was 43.1 ± 13.8 years (84.9% males). The mean annual incidence was 1.99/100.000. There were activities of risk in 94%: 82.5% contact with animals (57.4% pigs, 38.1% dogs, 31.7% cows, 22.2% sheeps), and 31.7% contact with pooled water. The most frequent symptoms were fever (94.1%), arthromyalgias (60.7%), and cephalalgia (53.3%). The main laboratory alterations were hypertransaminemia (48%), renal insufficiency (26.3%), and thrombocytopenia (16.9%). A lymphocytic meningitis was associated in 11 cases (12.5%) and a picture of Weil's disease was observed in 13 patients (15.1%). The patients with meningitis were younger (31.2 ± 9.2 versus 44.8 ± 15.2, p=0.004). The patients with Weil's disease were older (53.5 ± 15.8 versus 41.2 ± 14.5, p=0.007). Fifty seven patients were hospitalized (66.3%) and 6 patients died (7.0%). Factors independently associated with mortality were age >60 years (odds ratio [OR] 45.0, confidence interval 95% [CI95%] 4.7-434.6) and diagnosis of Weil's disease (OR 15.8, CI95% 2.5-98.7). CONCLUSIONS: In our experience, leptospirosis have a not despicable incidence and tends to show fever and arthromyalgias in men with risk activities. Leptospirosis should be included in the differential diagnosis of lymphocytic meningitis. Mortality is associated with older age.

Síndrome hemofagocítico asociado a infecciones: no tan infrecuente / Haemophagocytic syndrome associated with infections: not so uncommon

Introducción: El síndrome hemofagocítico (SHF) es un trastorno inmunológico grave caracterizado por una inflamación descontrolada con fracaso multiorgánico. Puede estar desencadenado por infecciones víricas, bacterianas, fúngicas o parasitarias. Se describe nuestra experiencia de SHF asociado a infecciones y se estima su incidencia local. Material y método: Estudio retrospectivo observacional de SHF asociado a infecciones en adultos atendidos en el Servicio de Patología Infecciosa de un hospital universitario durante 5años y revisión de las series publicadas en Europa. Resultados: En 2 mujeres con enfermedad de Crohn, el SHF se asoció a infección por citomegalovirus y a leishmaniosis visceral (mieloma múltiple 1, tumor sólido 2, sin enfermedad evidente 1) en 4 pacientes (3 hombres). Fallecieron 2 enfermos. La incidencia estimada fue 0,58/100.000/año. Las series publicadas son heterogéneas. Conclusiones: El SHF asociado a infecciones debe de ser más frecuente de lo descrito. El entorno geográfico puede influir en las infecciones desencadenantes (en nuestro medio, debe buscarse Leishmania)

Background: Haemophagocytic syndrome (HPS) is a severe immunological disorder characterised by uncontrolled inflammation and multiple organ failure. HPS can be triggered by viral, bacterial, fungal and parasitical infections. We report our experience with infection-related HPS and estimate its local incidence. Material and method: We conducted an observational retrospective study of infection-associated HPS in patients treated in the Department of Infectious Diseases of a university hospital within a 5-year period, as well as a review of the published series in Europe. Results: HPS was associated with infection by cytomegalovirus in 2 women with Crohn's disease and was associated with visceral leishmaniosis in 4 patients (3 men, 1 woman; 1 case of multiple myeloma; 2 cases of solid tumours; 1 case of no apparent disease). Two patients died, and the estimated incidence rate was 0.58/100,000 inhabitants/year. The published series are mixed. Conclusions: Infection-related HPS must be more common than reported. The geographical environment can influence the triggering infections (in our environment, Leishmania should be considered)