Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies.

BACKGROUND: There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection. METHODS: This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007-2016). The impact of ED and factors associated with mortality were assessed. RESULTS: Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48-10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94-9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14-5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48-10.61), and prior surgery (OR, 0.29; 95% CI, 0.08-0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16-1.53). CONCLUSIONS: Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.

How to: EUCAST recommendations on the screening procedure E.Def 10.1 for the detection of azole resistance in Aspergillus fumigatus isolates using four-well azole-containing agar plates.

BACKGROUND: The emergence of azole-resistant Aspergillus fumigatus isolates is a matter of significant concern in Europe, with countries reporting resistance rates (which can be as high as 30%) in hospitalized patients. Consequently, the treatment guidelines in The Netherlands, the country with the highest documented prevalence of azole-resistant A. fumigatus, has just been revised to now recommend initial therapy with combination therapy until the susceptibility pattern is known. Therefore, susceptibility testing of clinically relevant isolates has been strongly recommended in the ESCMID-EFISG aspergillosis guidelines. Furthermore, mixed azole-susceptible and azole-resistant (isogenic as well as non-isogenic) infections have been reported to occur, which implies that colonies of clinical cultures may harbour various phenotypes of azole susceptibility. OBJECTIVES: The EUCAST-AFST (European Committee on Antimicrobial Susceptibility Testing Subcommittee on Antifungal Susceptibility Testing) has released a new screening method document (E.Def 10.1) for the detection of azole-resistant A. fumigatus isolates and updated the QC tables for antifungal susceptibility testing with associated QC endpoints. This review described in detail how to perform the screening test. SOURCES: This "How to document" is based on the EUCAST azole agar screening method document E.Def 10.1 and the QC tables for antifungal susceptibility testing document, v 2.0 (available at http://www.eucast.org/ast_of_fungi/qcafsttables/) CONTENTS: The method is based on the inoculation of azole-containing and azole-free agars and visual determination of fungal growth after one and two days of incubation. It can easily be implemented in routine laboratories of clinical microbiology and has been validated for simultaneous testing of up to five A. fumigatus colonies using itraconazole and voriconazole (mandatory), and posaconazole (optional). IMPLICATIONS: This easy-to-use screening procedure for the detection of azole resistance in clinical A. fumigatus isolates will allow rapid testing in the daily routine of the microbiology laboratory and thus facilitate earlier appropriate therapy.

Is biofilm production a prognostic marker in adults with candidaemia?

OBJECTIVES: The role of biofilm production in the outcome of candidaemia remains under discussion. Current evidence relies on variable biofilm detection methods while evaluating distinct clinical end points. We aimed to determine the impact of biofilm production measured by metabolic activity (MA) and biomass (BM) on the prognosis of adults with candidaemia. METHODS: Retrospective cohort including 280 adults with candidaemia admitted from 2010 to 2016. BM was assessed using crystal violet binding stain and the XTT reduction assay was used to detect MA. Strains were classified as high and moderate-low biofilm producers according to published cut-offs. The primary outcome was overall mortality within 7 and 30 days. The secondary outcome was unfavourable prognosis defined as metastatic infection, admission to an intensive care unit due to the severity of candidaemia, or death within 30 days. RESULTS: High BM and high MA were detected in 90 (32.1%) and 114 (40.7%) of the 280 isolates, respectively. Comparison of high and moderate-low biofilm forming isolates revealed no correlation between biofilm production and 7-day mortality (BM high 15/90 (16.7%) versus moderate-low 24/190 (12.6%); MA high 12/114 (10.5%) versus moderate-low 27/166 (16.3%)), 30-day mortality (BM high 34/90 (37.8%) versus moderate-low 61/190 (32.1%); MA high 33/114 (28.9%) versus moderate-low 62/166 (37.3%)), or unfavourable prognosis (BM high 45/90 (50.0%) versus moderate-low 73/190 (38.4%); MA high 41/114 (36.0%) versus moderate-low 77/166 (46.4%)). CONCLUSIONS: Biofilm production was not a predictor of mortality or of unfavourable prognosis in adults with candidaemia.

The misleading effect of serum galactomannan testing in high-risk haematology patients receiving prophylaxis with micafungin.

OBJECTIVES: To investigate the performance of the routine serum galactomannan (sGM) assay in the diagnosis of invasive aspergillosis (IA) in high-risk haematology patients receiving prophylaxis with micafungin. METHODS: Retrospective study including all haematological patients who received prophylaxis with micafungin during high-risk IA episodes (neutropenic patients after chemotherapy for acute myeloid leukaemia/myelodysplastic syndrome; allogeneic haematopoietic stem-cell transplantation during early neutropenic phase or graft-versus-host disease requiring high prednisone doses) and for whom at least one sGM result was available. Episodes were classified as follows: true-positive (positive GM in the context of IA), false-positive (positive GM result in patients who had no evidence of IA), true-negative (negative GM test results and no IA), or false-negative (negative GM test in the context of IA). Non-evaluable patients were excluded. RESULTS: Among 146 evaluable episodes, four were true-positive in the context of probable breakthrough IA (incidence of breakthrough IA, 2.7%); 111/146 high-risk episodes (76%) were considered true-negative and 31/146 (21.2%) were considered false-positive. No false-negative episodes were detected. All but one of the false-positive episodes were detected in surveillance GM tests, leading to high-resolution CT scans in eight cases (8/31; 25.8%), all of which were negative. The positive predictive and negative predictive values of sGM for surveillance and diagnostic approaches were 3.2% (1/31) and 100% (110/110) and 75% (3/4) and 100% (1/1), respectively. CONCLUSIONS: Surveillance of asymptomatic patients receiving prophylaxis with micafungin using sGM is unnecessary, because the results are either negative or false-positive. However, sGM remains useful in the diagnosis of breakthrough IA in symptomatic patients during prophylaxis.

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others.

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.

ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: diseases caused by black fungi.

The aetiological agents of many invasive fungal infections are saprobes and opportunistic pathogens. Some of these fungi are darkly pigmented due to melanin production and traditionally have been named 'dematiaceous'. The melanized fungi cause a wide array of clinical syndromes ranging from superficial to deep-seated infections. Diagnosis relies on histopathological examination of clinical specimens and on examination of cultures. Sequencing is recommended for accurate species identification, especially for unusual or newly described pathogens. In cases of mycetoma and chromoblastomycosis, pathognomonic histological findings are useful and the Fontana-Masson stain, specific for melanin, usually confirms the diagnosis. There are no standardized therapies but voriconazole, posaconazole and itraconazole demonstrate the most consistent in vitro activity against this group of fungi. Oral itraconazole has been considered the drug of choice, given the extensive clinical experience with this drug. However, voriconazole may presumably be superior for central nervous system infections because of its ability to achieve good levels in the cerebrospinal fluid. Posaconazole is a well-tolerated alternative drug, backed by less clinical experience but with excellent salvage treatment results after failure of other antifungals. Amphotericin B has been useful as alternative therapy in some cases. Combination antifungal therapy is recommended for cerebral abscesses when surgery is not possible and for disseminated infections in immunocompromised patients.

ESCMID and ECMM joint clinical guidelines for the diagnosis and management of mucormycosis 2013.

These European Society for Clinical Microbiology and Infectious Diseases and European Confederation of Medical Mycology Joint Clinical Guidelines focus on the diagnosis and management of mucormycosis. Only a few of the numerous recommendations can be summarized here. To diagnose mucormycosis, direct microscopy preferably using optical brighteners, histopathology and culture are strongly recommended. Pathogen identification to species level by molecular methods and susceptibility testing are strongly recommended to establish epidemiological knowledge. The recommendation for guiding treatment based on MICs is supported only marginally. Imaging is strongly recommended to determine the extent of disease. To differentiate mucormycosis from aspergillosis in haematological malignancy and stem cell transplantation recipients, identification of the reverse halo sign on computed tomography is advised with moderate strength. For adults and children we strongly recommend surgical debridement in addition to immediate first-line antifungal treatment with liposomal or lipid-complex amphotericin B with a minimum dose of 5 mg/kg/day. Amphotericin B deoxycholate is better avoided because of severe adverse effects. For salvage treatment we strongly recommend posaconazole 4×200 mg/day. Reversal of predisposing conditions is strongly recommended, i.e. using granulocyte colony-stimulating factor in haematological patients with ongoing neutropenia, controlling hyperglycaemia and ketoacidosis in diabetic patients, and limiting glucocorticosteroids to the minimum dose required. We recommend against using deferasirox in haematological patients outside clinical trials, and marginally support a recommendation for deferasirox in diabetic patients. Hyperbaric oxygen is supported with marginal strength only. Finally, we strongly recommend continuing treatment until complete response demonstrated on imaging and permanent reversal of predisposing factors.

Global trends in the distribution of Candida species causing candidemia.

Only five species account for 92% of cases of candidemia (Candida albicans, C. glabrata, C. tropicalis, C. parapsilosis, and C. krusei); however, their distribution varies in population-based studies conducted in different geographical areas. C. albicans is the most frequent species, but considerable differences are found between the number of cases caused by C. glabrata and C. parapsilosis. Studies from Northern Europe and the USA reported a high number of cases caused by C. glabrata, whereas studies from Spain and Brazil demonstrated a lower number of cases caused by C. glabrata and a higher number of cases attributed to C. parapsilosis. Globally, the frequency of C. albicans is decreasing, while that of C. glabrata and C. krusei is stable, and C. parapsilosis and C. tropicalis are increasing. Patient characteristics and prior antifungal therapy also have a considerable influence on the distribution and frequency of Candida spp., regardless of the geographical area. C. albicans is more frequent in patients aged up to 18 years, the frequency of C. parapsilosis decreases with age, and C. glabrata is more common in the elderly. Finally, the presence of horizontal transmission of Candida spp. isolates (reported mainly in patients from the adult medical and post-surgical ICU, patients from oncology-haematology units, and neonates) can affect species distribution.

Bioconcentration of pesticides in zebrafish eleutheroembryos (Danio rerio).

The feasibility of a bioaccumulation test based on the use of zebrafish eleutheroembryos as an alternative to adult-individual-based approaches for REACH application has been evaluated for three test compounds, chlorpyrifos, dicofol and atrazine. Following the OECD 305 guidelines, zebrafish eleutheroembryos (72 h after hatching, hpf) were separately exposed to the investigated pesticides at two nominal concentrations below 1% of its corresponding LC(50). The uptake experiments lasted for 48 h. Then, the exposure medium was replaced by a non-contaminated medium for depuration experiments (up to 72 h). Zebrafish eleutheroembryos (larvae 144 hpf, i.e. at the end of the depuration step) and their corresponding exposure media was sampled at ten different times during each experiment and the concentration of the investigated pesticide determined in both the organisms and in the exposure medium. The experimentally determined pesticide accumulation profiles in the eleutheroembryos demonstrated that atrazine has a very fast accumulation kinetic, reaching steady sate (SS) within 24h. Chlorpyrifos and dicofol did not reach the SS within the 48-h uptake experiments although they exhibit higher accumulations than the former pesticide. Two toxicokinetic models were used to calculate the bioconcentration factor (BCF) of the studied pesticide in zebrafish eleutheroembryos. In the former, the BCF was calculated under SS conditions (BCF(SS)). The second was used when the compounds did not reach the SS during the uptake experiment (BCF(k)). Log BCF values of 3.55 and 3.84 for chlorpyrifos; 0.6 and 1.17 for atrazine, and 3.90 for dicofol were experimentally calculated at selected exposure concentrations. These values have been compared with those reported in related bioaccumulation studies and official databases.

Outbreak of invasive aspergillosis after major heart surgery caused by spores in the air of the intensive care unit.

BACKGROUND: Outbreaks of invasive aspergillosis (IA) are believed to be caused by airborne Aspergillus conidia. Few studies have established a correlation between high levels of Aspergillus fumigatus conidia and the appearance of new cases of IA or have demonstrated matching genotypes between clinical isolates and those from the environment. METHODS: We detected an outbreak of IA (December 2006 through April 2008) in the major heart surgery intensive care unit (MHS-ICU) of our institution. Our local surveillance program consists of monthly environmental air sampling in operating rooms and ICUs for quantitative and qualitative identification of filamentous fungi. During the study period, we obtained 508 environmental samples from 3 different periods: 6 months before the outbreak, during it, and 6 months after it. Available environmental and clinical strains were genotyped according to the short tandem repeats assay. RESULTS: Seven patients developed proven or probable IA (5 with lung infection, 1 with mediastinitis, and 1 with lung infection and mediastinitis). A. fumigatus was involved in 6 cases. The underlying conditions of the patients were heart transplantation (n = 3), corticosteroid-dependent conditions (n = 2), and diabetes mellitus (n = 2). The mortality rate was 85.7%. Before and after the outbreak (±6 months), the median airborne A. fumigatus conidia levels were 0 colony-forming units (CFUs) per cubic meter, and no cases of IA occurred during these periods. However, during the outbreak period, the occurrence of the 6 cases of IA caused by A. fumigatus was linked to peaks of abnormally high A. fumigatus airborne conidia levels (175, 50, 25, 20, 160, and 400 CFUs/m(3)) in the MHS-ICU, whereas counts in the air of both operating rooms remained negative. Matches between A. fumigatus genotypes collected from the air of the MHS-ICU and from representative clinical samples were found in 3 of the 6 patients. The outbreak abated when high-efficiency particulate air filters were installed in the affected areas. CONCLUSIONS: Our study revealed that abnormally high levels of airborne A. fumigatus conidia correlated with new cases of IA, even in patients who were not severely immunocompromised. The demonstration of matches between air and clinical genotypes reinforces the role of environmental air in the acquisition of IA during the period following MHS. Environmental monitoring of Aspergillus spores in the air of postoperative units is mandatory, even when these units receive nonimmunocompromised patients undergoing major surgery.

Candida tropicalis fungaemia: incidence, risk factors and mortality in a general hospital.

The risk factors and clinical features of patients with Candida tropicalis fungaemia have not been fully defined. We performed a case-control study comparing 59 cases of C. tropicalis fungaemia with 177 episodes of fungaemia caused by other species of Candida in our hospital over a 24-year period (January 1985 to December 2008). Patients with C. tropicalis fungaemia were more likely to be older (median age, 67 vs. 56 years; p 0.01), to have cancer (45.5% vs. 31.6%, p 0.04), and to have the abdomen as the portal of entry (32.2% vs. 11.9%, p 0.001), and had a higher in-hospital mortality rate (61% vs. 44%, p 0.03). Multivariate analysis showed that the independent risk factors for C. tropicalis fungaemia were cancer (OR 4.5; 95% CI 1.05-3.83; p 0.03) and the abdomen as the portal of entry (OR 13.6; 95% CI 1.9-8.2; p <0.001). When survivors were compared with non-survivors, the risk factors associated with a poor outcome were neutropenia (19.4% vs. 0; p 0.03), corticosteroid treatment (36% vs. 13%; p 0.07), and septic shock (50% vs. 17.4%; p 0.01). The independent risk factors for mortality in the multivariate analysis were corticosteroid treatment (OR 8.2; 95% CI 0.9-27.7; p 0.04) and septic shock (OR 14.6; 95% CI 2.4-90.2; p 0.004), whereas urinary tract infection (OR 0.07; 95% CI 0.01-0.8; p 0.03) and catheter removal (OR 0.06; 95% CI 0.01-0.4; p 0.002) were protective factors. C. tropicalis is the fourth most common cause of fungaemia in our hospital. It is associated with underlying malignancy, the abdomen as the portal of entry, and poor outcome.

Workload due to Aspergillus fumigatus and significance of the organism in the microbiology laboratory of a general hospital.

The increase in the immunocompromised population and the incidence of invasive aspergillosis (IA) are leading to an overinterpretation of the potential clinical significance of many isolates of Aspergillus fumigatus. Our work prospectively assesses the workload of the isolation of A. fumigatus and its clinical significance in the microbiology laboratory of a large teaching hospital. During a 3-year period, all patients from whom A. fumigatus was isolated were prospectively monitored and classified as having IA or "nonsignificant" disease. A point score based on the prediction of five easily obtained laboratory and clinical parameters was applied. We found 404 A. fumigatus isolates in 260 patients (1/1,000 microbiology laboratory samples; 2.1 patients/10,000 admissions). A total of 90 isolates (22.3%) were from patients with IA. Of the 260 patients, 31 (12%) had invasive disease (IA), and the remaining 229 had "nonsignificant" disease. A score based on points for five parameters was applied to our population. It was constructed as follows: "sample obtained by invasive procedures" (1 point), "presence of two or more positive samples from the same patient" (1 point), "leukemia" (2 points), "neutropenia" (5 points), and "corticosteroid treatment" (2 points). Patients with a score of 0 had only a 2.5% probability of IA. Those with a score of 1 or 2 had an increased probability of 10.3%. The probabilities rose to 40% and 70%, respectively, for patients with a score of 3 or 4 or a score of > or = 5. A simple score based on five easily available parameters may be of help to microbiologists and clinicians to predict the risk of IA.

Nosocomial invasive aspergillosis in a heart transplant patient acquired during a break in the HEPA air filtration system.

We report a case of nosocomially acquired invasive aspergillosis (IA) in a low-risk heart transplant recipient due to a break in the air conditioning system. A high overload of Aspergillus spores in the intensive care unit room led this patient to acquire IA. Identical environmental and patient isolates allowed our hypothesis to be confirmed and a very precise incubation time to be estimated.

Selective effects of E1B-defective adenoviruses and adenovirus E1A mutants in deficient mouse primary embryonic fibroblasts.

E1B-defective adenoviruses have been described as exerting selective cytopathic effects on transformed cells. Previously, we showed that adenovirus dl118, lacking both E1B proteins, very efficiently kills most human malignant cell lines. In order to study whether these selective effects were due to selective replication of dl118 in cells harboring specific genetic alterations, we compared the viability of various deficient mouse primary fibroblasts. We studied mouse embryonic fibroblasts (MEFs) derived from p16, p21, p27 and p53 knockout mice, as well as wild-type MEFs. We infected them with 100 p.f.u. of adenoviruses adl118, adwt300, and adenoviruses carrying the E1A mutant 922 (the E1a product only binds to the p300 and related proteins) and Ad646 (the E1A product binds to the pRb and related proteins). The percentage of infectivity was evaluated with an adenovirus carrying the green fluorescent protein (AdGFP). With AdGFP, clear green fluorescent signals were detected in more than 70% of the cells after 3 days of infection. After infection with several adenoviruses, we observed that E1A mutant 922 killed all the MEFs. Conversely, the E1a mutant Ad646 exerted its major effects on control wild-type MEFs. Moreover, Adl118 killed the wtMEFs and other MEFs slightly more efficiently than did wtAd, but less than Ad922. No viral replication was detected by adding the obtained supernatants to HEK293 cells. Due to the absence of significant viral replication on these cells, the results could be interpreted as direct effects of E1A and E1A mutant proteins on the different mouse cells carrying diverse genetic alterations.

An association between viral genes and human oncogenic alterations: the adenovirus E1A induces the Ewing tumor fusion transcript EWS-FLI1.

Malignant transformation of human cells requires the accumulation of multiple genetic alterations, such as the activation of oncogenes and loss of function of tumor suppressor genes or those related to genomic instability. Among the genetic alterations most frequently found in human tumors are chromosomal translocations that may result in the expression of chimeric products with transforming capability or are able to change the expression of oncogenes. We show here that the adenovirus early region 1A (E1A) gene can induce a specific human fusion transcript (EWS-FLI1) that is characteristic of Ewing tumors. This fusion transcript was detected by RT-PCR in normal human fibroblasts and keratinocytes after expression of the adenovirus E1A gene, as well as in human cell lines immortalized by adenoviruses. Cloning and sequencing of the RT-PCR product showed fusion points between EWS and FLI1 cDNA identical to those detected in Ewing tumors. In addition, we detected a chimeric protein by western blot analysis and immunoprecipitation and a t(11,22) by fluorescent in situ hybridization. This association between a single viral gene and a specific human fusion transcript indicates a direct link between viral genes and chromosome translocations, one of the hallmarks of many human tumors.

Polyphasic taxonomy of a novel yeast isolated from antarctic environment; description of Cryptococcus victoriae sp. nov.

In 1992 some samples of mosses, lichens and soils were collected from Botany Bay, Southern Victoria Land (77 degrees 01' S 162 degrees 32' E) and, as a result of a routine screening programme some yeasts were isolated. One of them, designated as strain G5, showed marked differences when compared to other antarctic yeasts. According to morphological and physiological characteristics, we were able to identify the strain G5 as a yeast belonging to the genus Cryptococcus. Some characteristics of this genus are the growth response to myo-inositol, celobiose, raffinose and D-glucuronate, no-fermentation, the absence of mycelium and pseudomycelium, asexual reproduction, Diazolium blue B test (DBB) and urea hydrolisis positive and the growth without vitamines. This strain (G5) formed cream colonies of slimy appearance with cells of 3 x 2 microns in size, that grew between 4 degrees C and 20 degrees C. The G + C content of strain G5 was 50.3 mol%. The molecular characterization by whole-cell proteins and RFLP analysis of the 5.8S rRNA gene and the two ribosomal internal transcribed spacers (5.85-ITS region), revealed that this strain was different from other antarctic species of this genus. The phylogenetic tree deduced from the 5.8S rRNA gene sequence showed the strain G5 as a member of the genus Cryptococcus, clearly separated from other basidiomycetous yeasts. On the basis of the physiological, genotypical and phylogenetical data, the new isolate G5 was described as Cryptococcus victoriae, sp. nov., with the type strain G5 (= CECT 11114).

[Results of preoperative autotransfusion with ferrous ascorbate prophylaxis in orthopedic surgery patients]. / Resultados de la autotransfusión preoperatoria con profilaxis con ascorbato ferroso en enfermos de cirugía ortopédica.

PURPOSE: Restrictive erythropoiesis caused by iron deficiency may hinder pre-deposit autotransfusion in surgical procedures. In order to evaluate the response to prophylactic ferrous ascorbate, a prospective study was conducted on patients subjected to orthopaedic surgery and autotransfusion. PATIENTS AND METHODS: Sixty-eight patients were included in the study: hip prostheses 67%, knee prostheses 25%, other procedures 7.4%. Their mean age was 61.3 +/- 10.2 years, and there were 42% male and 57% female. A mean of 2.8 +/- 0.6 units (450 mL) of blood were drawn to each patient in a month. Starting one week before their first blood donation and up to 2 months after surgery, each patient received 99 mg elementary iron per days as oral ferrous ascorbate. Blood cell counts were done at the beginning of the programme and after the first, second, third and fourth blood withdrawal, as well as one month after finishing the treatment. A survey of iron profile including serum iron, total iron binding capacity, transferrin saturation, serum ferritin and free erythrocyte protoporphyrin was carried out at onset and end of the programme in each patient. All data were analysed with the SPSS-PC 4.0 statistical programme. RESULTS: Haemoglobin rates decreased in every control, returning to values close to the initial ones by the end of the programme (mean figures are as follows: 14.63; 13.17; 12.70; 11.88; 14.11 g/dL); and similar changes were seen with respect to the other parameters of blood. The initial and final values for ferritin were 157.32 and 91.06 ng/mL, respectively, and no significant changes were appreciated in the other data from the iron profile, regardless of the number of blood units collected in a given case. Minor intolerance to ferrous ascorbate appeared in 11% of the patients. No significant differences with control patients were seen regarding hospitalization (16.54 vs 19.82 days) or postoperative fever (14.1% vs 17.11%). CONCLUSIONS: As opposed to others, we feel that iron treatment should be maintained up to 2 months after surgery since better results are thus attained. Recombinant erythropoietin is more expensive a method. Ferrous ascorbate is better tolerated than ferrous sulphate plus additives.