[Indirect effects of cytomegalovirus infection]. / Efectos indirectos de la infección por citomegalovirus.

Despite improvements in prevention strategies, cytomegalovirus (CMV) continues to be the main cause of infection in solid organ transplant recipients. In these patients, in addition to direct effects, such as viral syndrome or invasive organ disease, CMV can cause indirect effects resulting from the interaction of the virus with the host's immune system. This interaction may increase immunosuppression, with a consequent rise in opportunistic infections and the risk of malignancies (Epstein-Barr virus-associated posttransplantation lymphoproliferative disease) and graft dysfunction. Currently, a direct causal relation between CMV and most of the indirect effects described cannot be established. However, numerous experimental and clinical studies have found an association between the development of these effects and CMV. Moreover, some of these effects, such as the development of opportunistic infections, have been reduced by CMV prophylaxis.

[Candidemias: multicentre analysis in 16 hospitals in Andalusia (Spain)]. / Candidemias: análisis multicéntrico en 16 hospitales andaluces.

INTRODUCTION: Candidemia is a nosocomial infection with high associated mortality. There have been changes in microbiology, epidemiology and treatment over the last few years, which has led us to analyse our own situation. MATERIAL AND METHODS: Prospective, multicentre and observational study. All episodes of candidemia in adult patients seen in 17 Andalusian hospitals from 1 October 2005 to 30 September 2006 were included. RESULTS: Were detected 220 cases, the incidence was 0.58 cases/1,000 hospital discharges. Candida albicans was the most frecuent species (53% of cases). The majority of isolates (89%) was susceptibility to fluconazole. Sepsis was the most frequent clinical manifestation (65.7%). The treatment was inadequate in 38.7% of cases. Overall mortality was 40%. On univarite analysis death was found to be significantly associated with: aged > 60 years, unknown candidemia focus, Pitt score ≥ 2, APACHE II, shock at onset, persistents positive second blood cultures, non-removal of the central venous catheter and Candida species different of C. parasilopsis, among others. In the multivariate analysis death was found to be significantly associated with: aged > 60 years, Pitt score ≥ 2, Candida species different of C.parasilopsis and inadequate treatment. CONCLUSIONS: The candidemia clinical epidemiology in our region is similar to other areas and receiving inadequate treatment is the only modifiable risk factor associated with higher odds of mortality. Therefore, this modifiable factor needs to be improved to reduce the mortality.

[Impact of initial cytomegalovirus viral load on efficacy of preemptive therapy with ganciclovir in allogeneic stem cell transplant recipients]. / Impacto de la carga vírica inicial de citomegalovirus sobre la eficacia del tratamiento anticipado con ganciclovir en receptores de trasplante de progenitores hematopoyéticos.

OBJECTIVE: To study the impact of initial cytomegalovirus (CMV) viral load on virological response to ganciclovir preemptive therapy in allogeneic stem cell transplant (SCT) recipients after 4 weeks of treatment. METHODS: Eighty-one consecutive allogeneic SCT recipients were included. Preemptive therapy was initiated when CMV load was positive for 2 consecutive weeks or when a viral load >5000copies/mL was detected in 1 sample. If viral load was >400copies/mL after 2 weeks of treatment, maintenance treatment with ganciclovir was continued for 2 additional weeks. Virological failure was defined as a CMV load >400copies/mL after 4 weeks of treatment. RESULTS: Ganciclovir preemptive therapy was initiated in 32 patients (39.5%) who had 39 episodes of CMV replication. Virological failure occurred in 16 patients (50%) after 18 episodes of replication (46%). Clinical failure additionally occurred in 2 episodes (5%). The only risk factor for virological failure was a peak viral load >20,000copies/mL at the beginning of treatment (OR 5.88; 95% CI: 1.49-25, P=.03). The main risk factor for CMV replication >20,000copies/mL at the start of treatment was the presence of grade II-IV acute graft-versus-host-disease (OR 16; 95% CI: 8.5-45). CONCLUSION: CMV viral load >20,000copies/mL is the main risk factor for virological failure after 4 weeks of ganciclovir preemptive therapy following SCT.

[Variability in coronary risk assessment in HIV-infected patients]. / Variabilidad en la valoración del riesgo coronario en pacientes infectados por el virus de la inmunodeficiencia humana.

BACKGROUND AND OBJECTIVE: Antiretroviral treatment of human immunodeficiency virus (HIV)-infected patients seems to increase the coronary risk (CR) in these patients. Adequate assessment of CR has significant implications for the management of these patients. Our objective was to compare 2 systems for assessing 10-year CR in HIV-infected patients. PATIENTS AND METHOD: CR was calculated in a prospective cohort of 205 HIV-infected patients using Framingham tables and REGICOR adapted tables. Prevalence of cardiovascular risk factors in these patients was evaluated. RESULTS: Mean age (standard deviation) was 41.4 (8.2) years. Most patients were taking antiretrovirals and had a good immunological status. Current smoking was reported by 77.1% of patients, while a history of dyslipidemia, hypertension, or diabetes was found in 29.3%, 7.3%, and 4.9% of patients, respectively. Lipodystrophy was seen in 41% of patients, abdominal obesity in 21.5%, and a sedentary lifestyle in 50.7% Mean values obtained were 6.55 (6.36) in the Framingham scale and 2.85 (2.31) in the REGICOR scale. A 10-year CR greater than 10% was found in 26 patients (12.9%) with the Framingham tables and in 4 patients (2.0%) with the REGICOR tables. The difference between both methods was significant (p < 0.001). CONCLUSIONS: Application of the Framingham tables to our cohort may overestimate the CR. Studies aimed at identifying the most adequate method for measuring CR in HIV-infected patients are required. Until such data are available, estimation of CR in these patients should be taken with caution.

[Risk factors of nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus]. / Factores de riesgo de neumonía nosocomial por Staphylococcus aureus resistente a meticilina.

BACKGROUND AND OBJECTIVE: To include a specific antibiotic in the empiric therapy, it is necessary to predict when a nosocomial pneumonia (NP) is caused by methicillin-resistant Staphylococcus aureus (MRSA). We have developed a model for the prediction of the probability of a NP being caused by MRSA, when the carrier status and the microbiological diagnosis are unknown. PATIENTS AND METHODS: A retrospective case-control study (1999-2005) was designed. A univariate and multivariate logistic regression was performed to identify the risk factors for suffering a NP due to MRSA. Demographic factors, related to hospitalization, immunosuppression or neutropenia, to medication and severity were included. RESULTS: Three hundred and sixty three patients (121 cases and 242 controls) were studied. The final model of multivariate logistic regression included an age>14 years (OR 7.4, CI 95% 1.5-37.4, P<.015), NP appearance>6 days after admittance (OR 4.1, CI 95% 2.4-7,1, P<.001), NP development excluding summers (OR 2.5, CI 95% 1.2-5.2, P<.015), respiratory diseases (OR 4.9, CI 95% 1.5-15.8, P<.007) and multilobar involvement (OR 4, CI 95% 2.3-7.2, P<.001).The probability of developing a pneumonia due to MRSA was studied for each of the possible combinations and subsequently classified in minor and major criteria. CONCLUSIONS: MRSA coverage should be included in the empirical treatment of NP when: a) an adult patient (>14 years old) presents, at least, 2 major criteria or 1 major criterion together with 2 minor criteria, and b) a patient <14 years-old has 2 major criteria as well as 2 minor criteria.