Fecal microbiota transplantation in the intestinal decolonization of carbapenamase-producing enterobacteriaceae.

BACKGROUND AND AIMS: fecal microbiota transplantation (FMT) is effective for recurrent Clostridium difficile infection (CDI). Intestinal decolonization of carbapenamase-producing enterobacteriaceae (CPE) can prevent transmission and infection by these agents. The aim of this study was to assess CPE decolonization after FMT. METHODS: this was a case-series study that consecutively included all CPE-carriers that underwent FMT between 2014 and 2019. The indications included refractory/recurrent CDI and CPE-decolonization. RESULTS: out of 21 CPE-carriers, eight were excluded due to incomplete post-FMT testing. CPE decolonization was confirmed in 76.9 % (n = 10). The median decolonization time was 16-weeks (IQR-23) and ranged from two to 53 weeks. CONCLUSION: FMT may be used in the clinical practice for CPE-decolonization as an alternative to combined antibiotic regimens.

Fecal microbiota transplantation in refractory or recurrent Clostridium difficile infection: a real-life experience in a non-academic center.

AIM: this study aimed to describe the efficacy and safety of fecal microbiota transplantation (FMT) for the treatment of refractory and recurrent Clostridium difficile infection (CDI). METHODS: this was an observational study of patients with refractory or recurrent CDI treated with FMT between June 2014 and January 2017. Primary and secondary outcomes were the resolution of diarrhea without CDI recurrence within two months after one or more FMT. A descriptive analysis was performed. RESULTS: thirty-four FMT were performed in 28 patients, 88.2% (n = 30) using an upper route with a gastroscopy and 11.8% (n = 4) with colonoscopy; 50% (n = 17) of FMT were due to recurrent CDI and 50% (n = 17) were due to refractory CDI. The overall cure rate of upper FMT was 87.5% (21/24) and 100% (4/4) when colonoscopy was performed. A cure was achieved after one FMT in 88% (22/25) of cases and after two or more FMT in 8% (2/25) of cases, resulting in an overall cure rate of 96% (24/25). No severe adverse events were reported. CONCLUSION: FMT constitutes an effective and safe approach for the management of refractory and recurrent CDI, with an overall cure rate of 96% and no reported severe adverse events.

Initial experience with fecal microbiota transplantation in Clostridium difficile infection - transplant protocol and preliminary results.

BACKGROUND AND AIMS: Clostridium difficile infection (CDI) constitutes an important cause of antibiotic-associated diarrhea. Recurrence after first-line treatment with antibiotics is high and fecal microbiota transplantation (FMT) may be effective for refractory and recurrent CDI. This series aims to describe the efficacy of FMT in the treatment of refractory and recurrent CDI. METHODS: A prospectively recorded single-centre case series of patients with persistent or recurrent CDI treated with FMT between June 2014 and March 2015 was analyzed. Primary and secondary outcomes were defined as resolution of diarrhea without recurrence of CDI within 2 months after one or more FMT, respectively. A descriptive analysis was performed. RESULTS: 8 FMT were performed in 6 patients, 3 with refractory CDI and 3 with recurrent CDI. The median age of recipients was 71 years and 66.7% were women. One FMT was delivered through colonoscopy and the remaining 87.5% through esophagogastroduodenoscopy. One upper FMT was excluded due to recurrence of CDI after antibiotic exposure for a respiratory infection. The overall cure rate of FMT was total with lower route and 83.3% with upper route. Primary cure rate was achieved in 83.3% of patients and secondary cure rate was achieved in all patients. Median time to resolution of diarrhea after FMT was 1 day and no complications were reported during follow-up. CONCLUSION: FMT appears to constitute a safe and effective approach in the management of refractory and recurrent CDI. Difference between primary and secondary cure rates may result of insufficient restoration of intestinal microbiota with a single FMT.

McArdle's Disease: A Differential Diagnosis of Metabolic Myopathies.

McArdle's disease, also known as glycogen storage disease type V or McArdle syndrome, is a pure muscle myopathy with an autosomal recessive inheritance pattern. It is caused by mutations in the gene that encodes muscle phosphorylase. Symptoms typically begin in late adolescence or early adulthood, presenting as exercise intolerance. This review focuses on the diagnosis of McArdle's disease, initially manifesting as a clinical picture of rhabdomyolysis in an 18-year-old male patient with a history of minor thalassemia who had been followed in pediatric consultation since age three for failure to thrive. After excluding common causes such as alcohol consumption, drug use, traumatic muscle compression, and other conditions, the diagnosis of McArdle's disease was considered. The diagnosis was supported by laboratory tests showing myoglobinuria and elevated creatine kinase levels, as well as the absence of increased serum lactate following ischemic exercise. Genetic testing confirmed the presence of mutations in the PYGM gene, corroborating the diagnosis. Treatment includes administering a diet rich in slow-absorbing carbohydrates, regular low-intensity physical exercise, and, in some cases, supplementation with vitamin B6 and creatine. The prognosis is generally favorable with proper disease management, although vigorous exercise should be avoided to prevent complications such as severe muscle injury and rhabdomyolysis. Although McArdle's disease is a rare condition, it is likely underdiagnosed. Ideally, it should be considered in the differential diagnosis of rhabdomyolysis in all patients with symptoms of exercise intolerance and/or recurrent myoglobinuria.

High prevalence of cardiovascular disease and risk factors among type 2 diabetes patients followed in a hospital setting in Portugal: The PICT2RE observational study.

INTRODUCTION AND OBJECTIVES: Portugal is a country with a high prevalence of type 2 diabetes (T2D) and cardiovascular disease (CVD). The prevalence of CVD and cardiovascular (CV) risk factors among T2D patients followed in hospitals in Portugal is not known. The primary objective of this study was to assess the prevalence of CVD and CV risk factors among T2D patients in a hospital setting in Portugal. The clinical management of CVD in the hospital setting was also assessed. METHODS: We performed a non-interventional, multicenter, cross-sectional study with a retrospective phase. T2D patients were consecutively invited to participate. Data were collected retrospectively. RESULTS: A total of 715 patients were included in the study. Mean age and diabetes duration were 66.6 and 17.4 years, respectively. Of these, 286 patients (40.0%) had been diagnosed with CVD, mostly ischemic heart disease (50.4%). All patients had at least one CV risk factor. CVD was significantly associated with hypertension, hypercholesterolemia, low high-density lipoprotein cholesterol, hypertriglyceridemia and smoking. During the three years prior to study inclusion, the incidence of hyperglycemic episodes and T2D complications increased among patients with established CVD, but the numbers of hospitalization episodes and specialist appointments remained stable. An improvement was observed in key cardiometabolic risk factors. CONCLUSIONS: Our study revealed a high prevalence of CVD and CV risk factors among a sample of T2D patients in a hospital setting. Patients with established CVD seem to be adequately managed but further efforts are needed at the prevention stage for better control of risk factors and morbidity.

Aortitis Secondary to Cogan's Syndrome: A Rare Cause of Fever of Unknown Origin.

Fever of unknown origin remains a diagnostic challenge. Aortitis, defined as inflammation of the aorta, has multiple infectious and non-infectious causes. We report the case of an elderly woman with vertigo and bilateral hearing loss, presenting with fever of unknown origin. Blood tests were remarkable for leucocytosis with neutrophilia, elevation of C-reactive protein and the erythrocyte sedimentation rate, and positive antinuclear antibodies and rheumatoid factor, and an unremarkable search for multiple infectious causes of fever. During admission the patient developed a bilateral red eye. Abdominal and chest computed tomography was performed and demonstrated signs of aortitis. Due to the coexistence of aortitis, ocular inflammation, vertigo and bilateral hearing loss in a patient with persistent fever and elevation of inflammatory parameters, a presumptive diagnosis of Cogan's syndrome was made, with improvement after initiation of steroid therapy. LEARNING POINTS: Fever of unknown origin is a diagnostic challenge with an extensive list of possible causes.The coexistence of fever, aortitis, ocular and vestibulo-cochlear symptoms should raise the suspicion of Cogan's syndrome.Steroid therapy is the first-line treatment for Cogan's syndrome.

Bio-medicolegal scientific research in Europe. A country-based analysis.

The European mosaic of socio-cultural, economic and legal realities is reflected in forensic and legal medicine, in which a great variety of operational modes of forensic medical services, organisational systems, structures, functional competences and scientific research strategies can be observed. The present work analyses the European bio-medicolegal scientific output of the last 5.5 years (exact time window, January 1, 2005-June 1, 2010), categorising papers by nationality of the corresponding author and forensic sub-discipline in question, in order to identify the peculiarities of national sub-specialised competences and to build up international research projects. This country-based bibliometric analysis, based on the number of articles and the impact factor produced by each European country, also considering its economic profile (gross domestic product and per capita gross domestic product), highlights the prevailing productive role of Western and Southern Europe (Germany, Great Britain, Italy, Switzerland, Spain and France). Categorising scientific output by forensic sub-discipline and branch, significant in terms of impact factor are contributions from Germany (coming first in Pathology, Toxicology, Genetics, Anthropology and Biological Criminalistics), Great Britain (first in Clinical Forensic Medicine, Malpractice and Invalidity-Social Insurance), Switzerland (first in Criminology), Italy (second in Toxicology, Anthropology and Invalidity-Social Insurance), The Netherlands (third in Clinical Forensic Medicine and Medical Law and Ethics), Spain (third in Genetics, Criminalistics and Invalidity-Social Insurance) and France (third in Toxicology and Malpractice). Interestingly, several countries with low gross domestic product, such as Poland, Turkey and other Eastern European nations, show notable scientific production in specific sub-disciplines such as Pathology, Toxicology and Forensic Genetics, suggesting that fruitful international cooperation could be planned and be of interest to funding sources within the European Community, also taking into account funds reserved for depressed areas undergoing development.

Antibiotic Clinic: Two Years' Experience in Outpatient Parenteral Antimicrobial Therapy in a Portuguese Hospital.

INTRODUCTION: Outpatient antimicrobial therapy programs have been in place for more than four decades. They provide safe and effective treatment for a selected group of patients while reducing costs. In Europe in general, and in Portugal in particular, these programs are still a relatively new phenomenon. The aim of this study is to describe our center's two years' experience with such a program (Antibiotic Clinic). MATERIAL AND METHODS: The cohort of treatments administered by the Antibiotic Clinic in its first two years of existence (September 12th 2016 to September 11th 2018) was analyzed and data pertaining to patients, infections, infectious agents, antimicrobials and outcomes (infection resolution, adverse events and death) were characterized. RESULTS: The Antibiotic Clinic treated 231 patients in 250 episodes, providing a total of 2357 days of antibiotic treatment. The urinary tract was the most common site (39.2%) and Enterobacteriaceae the most common agents (63.7% of isolates). Infections were resolved in 90.8% of treatments (95.6% of patients), adverse events were few (1.2%) and direct mortality was not found. The dropout rate was 1.6%. DISCUSSION: Infection resolution and adverse event rates were comparable to other centers. High treatment and low dropout rates point to high physician and patient acceptance. CONCLUSION: Our experience with this program suggests it is a safe and effective alternative to inpatient admission. This is in line with current literature which suggests efforts should be made to expand this treatment modality.

Introdução: Os programas de administração de antimicrobianos parentéricos em ambulatório (outpatient parenteral antimicrobial therapy) iniciaram-se há mais de quatro décadas. Para além de proporcionarem tratamento seguro e eficaz num grupo selecionado de doentes, permitem também a redução de custos. Na Europa, e em particular em Portugal, a implementação destes programas é um fenómeno recente. O objetivo deste estudo é descrever dois anos de experiência de Clínica do Antibiótico. Material e Métodos: Foram incluídos todos os doentes tratados na Clínica do Antibiótico nos dois primeiros anos de existência (12 de setembro de 2016 a 11 de setembro de 2018), sendo descritas variáveis relativas à população, infeções, agentes infeciosos, tratamentos e outcomes (resolução de infeção, eventos adversos e morte). Resultados: A Clínica do Antibiótico tratou 231 doentes em 250 episódios, garantindo 2357 dias de antibioterapia. O local de infeção mais comum foi o trato urinário (39,2%) e os agentes mais comuns foram as Enterobacteriaceae (63,7% dos isolamentos). Obteve-se resolução da infeção em 90,8% dos tratamentos (95,6% dos doentes), ocorreram poucos eventos adversos (1,2%) e a mortalidade direta foi nula. Houve uma taxa de abandono de 1,6%. Discussão: As taxas de resolução e de complicações foram comparáveis às de outros centros. Elevado número de tratamentos e baixa taxa de abandono apontam para boa aceitação por médicos e doentes. Conclusão: A nossa experiência sugere ser uma alternativa eficaz e segura ao tratamento em internamento. Estes resultados estão de acordo com a literatura, sugerindo que esforços deverão ser feitos para expandir a utilização destes programas.

Non-adherence to antibiotic therapy in patients visiting community pharmacies.

BACKGROUND: Patient non-adherence to antibiotic therapy may lead to therapeutic failure, re-infection, and bacterial resistance. Assessing the factors associated with this problem is important for promoting rational use of antibiotics. OBJECTIVE: This study aimed to measure prevalence and reasons for non-adherence to antibiotic treatment and to identify associated factors. METHOD: Patients were recruited for the study in community pharmacies in Lisbon, Portugal, from February to April, 2009. Data from prescriptions for oral antibiotics were collected for adult subjects. Adherence to treatment was assessed with a modified Portuguese version of the Morisky scale. Factors associated with non-adherence were identified through bivariate analysis and logistic regression models. RESULTS: A total of 243 patients were included in the study. They had a mean age 46.5 ± 16.6 years and 74.5 % of the sample was female. The prevalence of non-adherence was 57.7 % and was related to delays and failures in taking the prescribed medicine. Increasing age (OR 0.97), difficulty in buying the antibiotic (OR 2.34), duration of treatment (OR 1.28), difficulty with ingestion (OR 3.08), and satisfaction with the information given by physician (OR 0.33) were identified as independent factors associated with non-adherence. CONCLUSION: Non-adherence to antibiotics is common in the community setting. Factors related to the antibiotic, the patient, and the patient-physician relationship should be addressed to promote adherence. Pharmacists should provide information to patients about correct use of antibiotics and address barriers to adherence.

Traveler's myopericarditis.

Colitis caused by Shigella is an uncommon etiology of infectious diarrhea in developed countries, usually presenting as traveler's diarrhea. Aside from clinical intestinal manifestations, shigellosis can present with a wide variety of extra-intestinal symptoms. We present the case of a 38-year-old man with diarrhea, fever, and chest pain that started after a holiday in Cape Verde (Africa). Blood samples revealed an increase in cardiac enzymes. An electrocardiogram revealed a widespread elevation of the ST segment. Echocardiography showed a swift pericardial effusion, confirming the diagnosis of acute myopericarditis. Shigella boydii was identified in stool cultures. The patient was treated with ciprofloxacin and acetylsalicylic acid, resulting in improvement in clinical and laboratory findings.

[Appropriateness of hospitalization in a ward of internal medicine--using the Appropriateness Evaluation Protocol]. / Adequação do internamento num serviço de medicina interna. Utilizando o Appropriateness Evaluation Protocol.

INTRODUCTION: The Appropriateness Evaluation Protocol (AEP) is an instrument to study the appropriate use of hospital beds based in objective criteria that classify a hospital admission as appropriate or inappropriate. OBJECT: Evaluate the appropriateness of hospital admissions and stays of the patients of our Internal Medicine Department using the concurrent version of AEP. METHOD: Transversal study where was evaluated the clinical record of the patients admitted to our Department of Internal Medicine on March 13th of 2003, excluding all these who were admitted the day of the study. We analyzed demographic and clinic parameters and the appropriateness of hospital admission and stay using the AEP. RESULTS: 22 patients fulfilled the inclusion criteria, 54.5% of male gender with a average age of 70.7 years. All the admissions were considered appropriate. The most common criteria was the need of intravenous therapy (100%), followed by the sudden lost of corporal mobility (12.3%). 27.3% of stays were considered inappropriate on the day of the study. The most common criteria of appropriateness was the need of intravenous therapy (93.7%). The most usual reason of inappropriate stay was the existence of planned discharge, but without the order written down in the clinical file (66.7%). CONCLUSIONS: The AEP allows an efficient evaluation of the appropriateness of the hospital admissions and stays in a Health Unit, being used for a better utilization of resources. In our department all admissions were justified and about a quarter of stays were considered inappropriate using the AEP.