Cutaneous infection by Phaeoacremonium parasiticum.

BACKGROUND: Phaeoacremonium parasiticum is considered a rare infectious agent that is part of a heterogeneous group of fungi causing phaeohyphomycosis. This organism is capable of producing subcutaneous infections, eumycetomas, osteomyelitis, arthritis, myositis and also disseminated diseases, such as fungemia and endocarditis. CASE REPORT: We describe a case of cutaneous infection by P. parasiticum in a kidney transplant patient. The identification of this microorganism was performed by microbiological and histopathological studies and confirmed with the sequence of the gene encoding ß-tubulin and a real time panfungal PCR targeting 18S ribosomal RNA gene. The microorganism was correctly identified by phenotypic and molecular methods. The patient was treated with oral antifungal therapy and a debulking surgery and evolved without any complication. CONCLUSIONS: The diagnosis of this infection is difficult and usually affects kidney transplant patients, but the reasons of this association are still unknown.

[Clinical features and outcome in patients with mucormycosis in a tertiary hospital (2012-2016)]. / Características clínicas y evolución de los pacientes diagnosticados de mucormicosis en un hospital de tercer nivel (2012-2016).

BACKGROUND: The most common presentation of mucormycosis in the past was the nasosinusal involvement in patients with diabetic ketoacidosis. However, in the last few years, new groups of patients with risk of mucormycosis have emerged. AIMS AND METHODS: Retrospective analysis of the characteristics, treatment and evolution of patients with mucormycosis in a tertiary hospital in the years 2012-2016. RESULTS: Of the 12 patients included in the study, 7 had a haematological disease as a predisposing factor, most of them (6 patients) related to transplantation of haematopoietic progenitors. Only one patient had diabetic ketoacidosis. Seven out of the twelve patients were receiving an antifungal treatment at the onset of symptoms, and 9 patients had received them three months before. The clinical presentation was rhinosinusal (16.6%), localised lung disease (33.3%), and musculoskeletal (25%) and disseminated disease (25%). Surgical debridement was performed on 8 patients. Combination therapy with amphotericin B and posaconazole was received by 6 patients (16% mortality), and 4 patients were treated with amphotericin B alone (50% mortality), with an overall mortality of 41%. The mortality of patients with pulmonary involvement was 71%, increasing to 100% in the case of disseminated disease. None of the patients with only musculoskeletal involvement died. CONCLUSIONS: Mucormycosis has a high mortality rate, especially the pulmonary forms. Musculoskeletal involvement had a better prognosis. The main group at risk was that of patients with haematopoietic stem cell transplantation. Combination therapy had better results than monotherapy, although more experience is needed to define the most appropriate treatment.

Risk factors associated with potentially antibiotic-resistant pathogens in community-acquired pneumonia.

RATIONALE: To identify pathogens that require different treatments in community-acquired pneumonia (CAP), we propose an acronym, "PES" (Pseudomonas aeruginosa, Enterobacteriaceae extended-spectrum ß-lactamase-positive, and methicillin-resistant Staphylococcus aureus). OBJECTIVES: To compare the clinical characteristics and outcomes between patients with CAP caused by PES versus other pathogens, and to identify the risk factors associated with infection caused by PES. METHODS: We conducted an observational prospective study evaluating only immunocompetent patients with CAP and an established etiological diagnosis. We included patients from nursing homes. We computed a score to identify patients at risk of PES pathogens. MEASUREMENT AND MAIN RESULTS: Of the 4,549 patients evaluated, we analyzed 1,597 who presented an etiological diagnosis. Pneumonia caused by PES was identified in 94 (6%) patients, with 108 PES pathogens isolated (n = 72 P. aeruginosa, n = 15 Enterobacteriaceae extended-spectrum ß-lactamase positive, and n = 21 methicillin-resistant Staphylococcus aureus). These patients were older (P = 0.001), had received prior antibiotic treatment more frequently (P < 0.001), and frequently presented with acute renal failure (P = 0.004). PES pathogens were independently associated with increased risk of 30-day mortality (adjusted odds ratio = 2.51; 95% confidence interval = 1.20-5.25; P = 0.015). The area under the curve for the score we computed was 0.759 (95% confidence interval, 0.713-0.806; P < 0.001). CONCLUSIONS: PES pathogens are responsible for a small proportion of CAP, resulting in high mortality. These pathogens require a different antibiotic treatment, and identification of specific risk factors could help to identify these microbial etiologies.

[Microbiological diagnosis of bacterial lower respiratory tract infections]. / Diagnóstico microbiológico de las infecciones bacterianas del tracto respiratorio inferior.

Microbiological diagnosis of bacterial lower respiratory tract infections has relevant limitations and related controversy, depending on the clinical setting and diagnostic methods used, and its value is contingent on an accurate clinical diagnosis and previous antimicrobial therapy. The limitations reside in a low diagnostic yield of the causative agent and the difficulty of determining the clinical significance of the agents recovered. This report examines the current microbiological diagnostic yield of the main clinical entities and etiological agents, indications for invasive or non-invasive specimen collection procedures, and proper specimen processing and culture in the appropriate media. Criteria regarding specimen suitability and indications for quantitative cultures are established. Criteria for evaluating the results are provided, and the current fast diagnostic techniques are described.

Bronchoscopic validation of the significance of sputum purulence in severe exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Antibiotics are commonly prescribed in exacerbations of chronic obstructive pulmonary disease (COPD). However, the role of bacteria in these exacerbations is controversial. OBJECTIVE: To identify clinical predictors of bacterial infection as a cause of exacerbation, considering the protected specimen brush (PSB) as the gold standard. METHODS: Clinical data, sputum and PSB samples were collected from 40 patients with COPD requiring hospitalisation due to severe exacerbations who had not received previous antibiotic treatment. RESULTS: Quantitative cultures of PSB samples (n = 40) yielded 23 potential pathogenic microorganisms (PPMs) at concentrations of > or =10(2) colony-forming units/ml in 18 (45%) patients. Sputum samples were obtained from all 40 patients. Culture of good-quality sputum samples (n = 18) yielded 16 PPMs corresponding to 14 (35%) patients. The concordance between the PSB and sputum rate was high (kappa = 0.85, p < 0.002). The self-reporting patient observation of sputum purulence (odds ratio (OR) 27.20 (95% confidence interval (CI) 4.60 to 60.69), p = 0.001), the percentage predicted forced expiratory volume in 1 s (FEV(1)%) <50 (OR 2.27 (95% CI 1.55 to 3.21), p = 0.014), >4 exacerbations in the past year (OR 6.9 (95% CI 0.08 to 1.08), p = 0.028) and previous hospitalisations due to COPD (OR 4.13 (95% CI 1.02 to 16.07), p = 0.041) were associated with the presence of PPMs in the distal airways. The operative characteristics for predicting distal airway infection when patients presented with purulent exacerbation were as follows: sensitivity 89.5%, specificity 76.2%, positive predicted value 77.3% and negative predicted value 88.9%. CONCLUSIONS: The self-reporting presence of purulence in the sputum, as well as common previous exacerbations and hospitalisations due to COPD in patients with severe airflow obstruction (FEV1% <50) predict the presence of bacterial infection in the distal airways. The use of these clinical variables may help in selecting candidates to receive antibiotic treatment.

Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery.

STUDY OBJECTIVES: To evaluate the risk factors associated with postoperative respiratory infection in patients undergoing lung cancer surgery, with special emphasis on the perioperative pattern of airway colonization. DESIGN: Prospective cohort study. SETTING: Department of Pneumology and Thoracic Surgery of a tertiary hospital. PATIENTS: Seventy-eight consecutive patients undergoing lung cancer surgery were evaluated. Patients were followed up until hospital discharge or death. INTERVENTIONS: Fiberoptic bronchoscopies with bilateral protected specimen brush or bronchial aspirates were performed during anesthesia prior to the initiation of the surgical procedure. RESULTS: Sixty-five patients (83%) had perioperative bronchial colonization by either potentially pathogenic microorganisms (PPMs) [28 patients, 36%] or non-potentially pathogenic microorganisms (56 patients, 72%). The 24 patients (31%) with a postoperative respiratory infection (pneumonia, purulent tracheobronchitis, or pleural empyema) had significantly higher perioperative bronchial colonization by PPMs (15 patients [63%] vs 13 patients [24%], p = 0.003) and a higher bacterial index (mean +/- SD, 3.6 +/- 3.3 vs 0.9 +/- 1.4; p = 0.003), compared to patients without infection. The agreement between pathogens found in perioperative evaluation and during postoperative infection was total in 5 patients (21%), partial in 5 patients (21%), and no concordance in 14 patients (58%). In the multivariate analysis, the presence of perioperative airway colonization by a PPM (odds ratio [OR], 6.9; p = 0.001) and a higher postoperative pain score (OR, 4.1; p = 0.014) were independent predictors of postoperative respiratory infection. CONCLUSION: Adequate control of postoperative pain, as well as the conditions that potentially cause airway colonization by PPMs, could be beneficial in preventing postoperative respiratory infections after lung cancer surgery.

Prospective evaluation of procalcitonin in adults with febrile neutropenia after haematopoietic stem cell transplantation.

Serum procalcitonin (PCT) levels have been proposed as a new discriminative marker for bacterial and fungal infections. We analysed the diagnostic relevance of PCT in febrile episodes of neutropenic adult patients after haematopoietic stem cell transplantation (HSCT). PCT was determined prospectively in 92 febrile episodes, classified according to the final diagnosis as: neutropenic fever of unknown origin (n = 51), microbiological (n = 26) or clinical (n = 5) documented infection and non-infectious febrile episodes (n = 10). On first day of fever, mean (+/- SD) PCT level was 0.3 ng/ml (0.2) in neutropenic fever of unknown origin, 0.5 ng/ml (0.7) in microbiologically confirmed infections, 0.2 ng/ml (0.2) in clinically documented infections and 1.7 (4.2) in non-infectious fever (P = not significant). Five days after the antibiotic therapy was started, fever persisted in 29 neutropenic episodes (32%). Cases that were eventually diagnosed with invasive aspergillosis had PCT values significantly higher [10.1 ng/ml (6.7)] than all remaining groups (P = 0.027; Kruskal-Wallis). Our analysis indicates that the PCT level on first day of fever did not facilitate the differential diagnosis of neutropenic febrile episode. However, when fever persisted for more than 5 d, PCT values > or = 3 ng/ml had a high sensitivity and specificity for the diagnosis of invasive aspergillosis.

[Aspergillus galactomannan detection in allogenic hematopoietic cell transplantation]. / Detección de antígeno galactomanano de Aspergillus en el trasplante alogénico de progenitores hematopoyéticos.

Invasive aspergillosis has become the leading cause of death after allogeneic hematopoietic stem cell transplantation. This is partially due to the lack of a prompt diagnosis. Recently the detection of Aspergillus galactomannan antigen by means an ELISA technique in serum has been described. The objective of this study was to validate its usefulness in the allogeneic hematopoietic stem cell transplantation setting.

Pulmonary infiltrates in immunosuppressed patients: analysis of a diagnostic protocol.

A diagnostic protocol was started to study the etiology of pulmonary infiltrates in immunosuppressed patients. The diagnostic yields of the different techniques were analyzed, with special emphasis on the importance of the sample quality and the role of rapid techniques in the diagnostic strategy. In total, 241 patients with newly developed pulmonary infiltrates within a period of 19 months were included. Noninvasive or invasive evaluation was performed according to the characteristics of the infiltrates. Diagnosis was achieved in 202 patients (84%); 173 patients (72%) had pneumonia, and specific etiologic agents were found in 114 (66%). Bronchoaspirate and bronchoalveolar lavage showed the highest yields, either on global analysis (23 of 35 specimens [66%] and 70 of 134 specimens [52%], respectively) or on analysis of each type of pneumonia. A tendency toward better results with optimal-quality samples was observed, and a statistically significant difference was found in sputum bacterial culture. Rapid diagnostic tests yielded results in 71 of 114 (62.2%) diagnoses of etiological pneumonia.