Economic burden of skin and skin structure infections due to Gram-positive bacteria in patients on hospital at home-based outpatient parenteral antibiotic therapy (OPAT).

OBJECTIVE: To describe and quantify resource use and direct health costs associated with skin and skin structure infections (SSSIs) caused by Gram-positive bacteria in adults receiving outpatient parenteral antimicrobial therapy (OPAT), administered by Hospital at Home units (HaH) in Spain. METHODS: Observational, multicenter, retrospective study. We included patients of both sexes included in the HaH-based OPAT Registry during 2011 to 2017 who were hospitalized due to SSSIs caused by Gram-positive bacteria. Resource use included home visits (nurses and physician), emergency room visits, conventional hospitalization stay, HaH stay and antibiotic treatment. Costs were quantified by multiplying the natural units of the resources by the corresponding unit cost. All costs were updated to 2019 euros. RESULTS: We included 194 episodes in 189 patients from 24 Spanish hospitals. The most frequent main diagnoses were cellulitis (26.8%) and surgical wound infection (24.2%), and 94% of episodes resulted in clinical improvement or cure after treatment. The median HaH stay was 13 days (interquartile range [IR]:8-22.7), and the conventional hospitalization stay was 5 days (IR: 1-10.7). The mean total cost attributable to the complete infectious process was €7,326 (95% confidence interval: €6,316-€8,416). CONCLUSIONS: Our results suggest that OPAT administered by HaH is a safe and efficient alternative for the management of these infections and could lead to lower costs compared with hospital admission.

Usefulness of Hospital at Home in nosocomial infections: advantages and limitations.

Hospital at Home units allows ambulatory treatment and monitoring of complex and serious infections. Nosocomial infections produce an extension of the stay in hospital often specifying long intravenous treatments without any effective oral alternatives. Daily dosing of antimicrobial are easier to administer at home. The use of portable programmable pump infusion and elastomeric devices allow efficient and safe infu-sions for most antimicrobials at home. Some antibiotics against multidrug-resistant organisms of recent introduction have a suitable profile for outpatient intravenous treatment.

Costs of outpatient parenteral antimicrobial therapy (OPAT) administered by Hospital at Home units in Spain.

The aim of this study was to assess the direct healthcare costs of outpatient parenteral antimicrobial therapy (OPAT) administered by Hospital at Home (HaH) units in Spain. An observational, multicentre, economic evaluation of retrospective cohorts was conducted. Patients were treated at home by the HaH units of three Spanish hospitals between January 2012 and December 2013. From the cost accounting of HaH OPAT (staff, pharmacy, transportation, diagnostic tests and structural), the cost of each outpatient course was obtained following a top-down strategy based on the use of resources. Costs associated with inpatient stay, if any, were estimated based on length of stay and ICD-9-CM diagnosis. There were 1324 HaH episodes in 1190 patients (median age 70 years). The median (interquartile range) stay at home was 10 days (7-15 days). Of the OPAT episodes, 91.5% resulted in cure or improvement on completion of intravenous therapy. The mean total cost of each infectious episode was €6707 [95% confidence interval (CI) €6189-7406]. The mean cost per OPAT episode was €1356 (95% CI €1247-1560), mainly distributed between healthcare staff costs (46%) and pharmacy costs (39%). The mean cost of inpatient hospitalisation of an infectious episode was €4357 (95% CI €3947-4977). The cost per day of inpatient hospitalisation was €519, whilst the cost per day of OPAT was €98, meaning a saving of 81%. This study shows that OPAT administered by HaH units resulted in lower costs compared with inpatient care in Spain.

[Community-acquired pneumonia in the aged: prognostic factors]. / Neumonía comunitaria en el anciano: factores pronósticos.

We studied the clinical characteristics and the initial supplementary test available in the emergency service, in aged patients with community-acquired pneumonia, as well as their mortality prognosis value. We assessed 190 patients attended consecutively during one year. Clinical, analytical and radiological data were registered. The parameters associated to a higher mortality were: age, absence of thoracic pain, reduction in the level of consciousness, leukocytosis, increased urea levels, aminotransferases, lactate dehydrogenase and reduction in prothrombin activity and pH. The data associated to a greater relative risk were: age above 80 years, absence of thoracic pain, prothrombin activity lower than 70% and ALT < 40 U/l. The presence of three to four of these variables had a sensitivity of 62% and a specificity of 94% in the prediction of mortality. In the multivariable analysis, the following variables remained significative: age, obnubilation and decrease of prothrombin. We stress the relevance of a high clinical suspicion, given the frequency of these cases with little symptomatology, in order to allow for an early treatment and the identification of right risk patients at the initial assessment.

[Rhabdomyolysis in acute intoxications]. / Rabdomiolisis en intoxicaciones agudas.

The development of rhabdomyolysis is a complications of acute intoxications, although its actual incidences is unknown. We had studied the frequency and differential characteristics of the patients with such complications. A prospective study was conducted with 200 patients admitted to a General Hospital from an urban area due to acute intoxication, recording the etiology of the intoxication, motivation and analytical characteristics of the patients with rhabdomyolysis compared to their patients without rhabdomyolysis. The incidence of rhabdomyolysis was 7.7%. Among the patients with rhabdomyolysis, ludic motivation (59%) and etiology associated to drug abuse (heroin 30%, cocaine 24%) were more frequent compared to the patients without rhabdomyolysis. Twenty per cent of the patients consuming cocaine and 17% of the patients consuming heroin developed rhabdomyolysis. Acute rhabdomyolysis was, thus, a significant complication of acute intoxications, associated to the consumption of illegal drugs and, at least in our cases, with a good evolution regarding the renal function.

[Impact of arterial hypertension on the central nervous system]. / Repercusión de la hipertensión arterial sobre el sistema nervioso central.

Cerebrovascular diseases (CVD) entail high costs associated to therapies, hospitalizations and disabilities. Arterial hypertension (AHT) is the major modifiable risk factor for the development of all types of CVDs (cerebrovascular accidents, vascular dementias, etc.). The increase of arterial pressure causes functional and anatomical changes in the cerebral circulation which facilitate the development of CVDs. The time of evolution and the severity of the AHT, as well as the associated vascular risk factors, will determine its impact on the central nervous system.

[Atrial fibrillation and cerebral infarct]. / Fibrilación auricular e infarto cerebral.

The importance of atrial fibrillation (AF) as a risk factor (RF) for cerebral infarction (CI) is well-known. It is probably caused by cardiac embolism but other explanations can also justify this association. Our aim was to analyse the features of the patients with CI and AF and sinus rhythm (SR), as well as to form hypotheses as regards the pathogenesis. 250 patients with CI, 204 in RS and 46 in AF (31 non-valvular and 15 associated to a valvular disease) were studied, analysing the prevalence of RF and initial blood tests. The group of patients with valvular AF of probably embolic mechanism had a minor prevalence of RF (hypertension, diabetes, smoking, alcoholism) but higher mortality. The group with non-valvular AF, had a lower RF prevalence compared to the SR group (non-embolic mechanism), without statistical significance and with a similar mortality rate. We concluded that the atherothrombotic mechanism can be the cause of a considerable proportion of CI in patients with non-valvular AF.

[Hypertensive crises and emergencies: the concept and initial management]. / Urgencias y emergencias hipertensivas: concepto y manejo inicial.

The high prevalence of blood hypertension together with a deficient control, make this one of the frequent causes requiring urgent medical attention. The concepts are reviewed and the treatment of the hypertensive urgency and emergency are described. The term hypertensive emergency means a serious affliction of vital organs caused by the increased of blood pressure, this needing a very close control and parenteral treatment. Hypertensive urgency is a less severe situation, which requires a less aggressive via-oral or sublingual treatment.

[Pulmonary fibrosis and autoimmune manifestations. A diagnostic problem]. / Fibrosis pulmonar y manifestaciones autoinmunes. Un problema diagnóstico.

A case of 54-year-old male who, during the development of a pulmonary fibrosis, showed extrapulmonary autoimmune symptoms (polyarthritis and hemolytic anemia), is presented. The antinuclear antibodies and rheumatoid factor positives have been described in up to 30% of the idiopathic pulmonary fibrosis, complicating the differential diagnosis with lung fibrosis caused by alterations of connective tissue. We discuss the prognosis and treatment of this difficult diagnosis.

[Risk factors in cerebrovascular disease and their prognostic importance]. / Factores de riesgo en la enfermedad cerebrovascular y su importancia pronóstica.

The prevalence of cerebrovascular disease risk factors and their immediate mortality prognostic value together with the initial analytical parameters are evaluated. 250 cases of cerebral infarction (CI), 150 cases of intracerebral hemorrhage (ICH) and 60 cases of transitory ischemic events (TIE) were studied and compared to a control group. A higher prevalence of arterial hypertension, cardiopathy, previous cerebrovascular disease and elevated hematocrit was found in the CI group. In the TIE group there was an increased prevalence of cardiopathy, previous cerebrovascular disease and high hematocrit. In the ICH group an increased prevalence of hypertension and left ventricular hypertrophy was found. We have to point out the importance of a global approach of the risk factors. The intrahospital mortality due to CI was associated with old age, low hematocrit, leukocytosis and high blood sugar at admission. ICH was associated with a higher systolic arterial pressure leukocytosis and elevated blood glucose at admission.

[Abdominal pain at the emergency service. Follow-up of patients with pain of unknown origin]. / Dolor abdominal en el servicio de urgencias. Seguimiento de pacientes con dolor no filiado.

450 patients who arrived at the emergency department with abdominal pain were studied. 71% arrived without having previously consulted another doctor. The most frequent diagnosis was reno ureteral pain, non-specific pain, gastroenteritis and in geriatric patients (hernia, biliar pathology) other pathology. 69 patients with non-specific pain were followed-up during a period of one year. The symptoms returned in 40% of patients. Only 3% required urgent medical treatment.

[Diabetic nephropathy: a review for clinicians]. / Nefropatía diabética: una revisión para clínicos.

Diabetic nephropathy is one of the most serious complications of diabetes mellitus because of the associated mortality and morbility. The proteinuria, together with hypertension and renal function, are the clinical features. It is linked with a major prevalence of the other late complications of the disease. In recent years progress has been made in the knowledge of the natural history of the disease, as well as, its predictive factors. We review the etiopathogenia, the actual therapeutic management with special emphasis on hypertension treatment and the controversial metabolic control.