Valganciclovir modulates the tumor necrosis factor axis molecules expression and CD4+ T-cell subsets in disseminated Kaposi Sarcoma patients.

Valganciclovir (VGC) was used in a randomized clinical trial in patients with disseminated Kaposi Sarcoma/human immunodeficiency virus (DKS/HIV) as add-on therapy to evaluate the proinflammatory axis tumor necrosis factor (TNF) and its receptors (TNFRs) in T cells. Two treatment schedules were used: an experimental regime (ER) and a conventional treatment (CT). Mononuclear cells from patients with DKS/HIV were obtained at baseline (W0), 4 (W4), and 12 weeks (W12). Ten DKS/HIV patients received CT (antiretroviral therapy [cART]) and 10 ER (valganciclovir [VGC] initially, plus cART at the fourth week). HIV+ without KS and HIV- patient groups were included as controls. Correlation between T-cell subsets and HHV-8 viral load (VL) and a multivariate linear regression was performed. Data showed that DKS/HIV patients have an increased frequency of CD8+ T cells, which display a high density of CD8 expression. The ER scheme increases naïve and central memory CD4+ T cells at W4 and W12 of follow-up and induces a balanced distribution of activated CD4+ T-cell subsets. Moreover, ER decreases solTNFR2 since W4 and CT decreased the transmembrane forms of TNF axis molecules. Although CT induces a positive correlation between HHV-8 VL and TNFRs, the use of ER positively correlates with TNF and TNFRs levels through follow-up and a moderate correlation with HHV-8 VL and TNF soluble levels. In conclusion, VGC, as an add-on therapy in DKS/HIV patients, gradually modulates the activation of CD4+ T-cell subsets and the TNF/TNFRs axis, suggesting a better regulation of the inflammatory status.

Multimorbidity in people living with HIV and cancer in Mexico.

BACKGROUND: The proportion of older people living with HIV (PLWH) has increased. Non-communicable diseases occur earlier in PLWH than in the general population. OBJECTIVE: The goal of this study was to estimate the prevalence of comorbidities in PLWH and cancer in a tertiary referral center in Mexico City. MATERIAL AND METHODS: In this retrospective study, we included PLWH > 40 years with a history of cancer, coming to Instituto Nacional de Cancerologia from 2010 through 2019. All patients needed to be on antiretrovirals for at least six months. Data collected included cancer type, comorbidities, frequency of polypharmacy, FRAX score and 10-year cardiovascular risk. Patients were evaluated for depression with the Beck Inventory Depression-II Scale. Variables associated to multimorbidity (2 or more comorbidities) were evaluated. RESULTS: Of 125 patients, 69% had at least one comorbidity; 32% had ≥ 2. Common comorbidities were dyslipidemia (54%), hypertension (19%), obesity (14%) and Diabetes (12%). In patients ≥ 50 years, 29 (62%) already undergone a densitometry and 9 (31%) had osteoporosis; 56 depression questionnaires were used: 30% had mild-to-severe depression. Being ≥ 50 years was associated with multimorbidity (aOR 2.57 (1.18-5.58), p = 0.017). CONCLUSIONS: A high prevalence of multimorbidity and poor screening of bone disease and mental health is reported in patients with PLWH and cancer. A holistic approach to the PLWH in the Infectious Diseases consultation is needed to improve the detection and management of non-communicable diseases, to go beyond viral suppression and towards an improved quality of life.

INTRODUCCIÓN: La proporción de personas mayores que viven con VIH (PVVIH) va en aumento, y las enfermedades no transmisibles ocurren antes en PVVIH comparado con la población general. OBJETIVO: El objetivo de este estudio fue estimar la prevalencia de las comorbilidades en PVVIH con cáncer de un centro de tercer nivel de la Ciudad de México. MÉTODOS: Este estudio retrospectivo incluyó todas las PVVIH > 40 años con cáncer, que acudieron al Instituto Nacional de Cancerología entre 2010 y 2019). Se incluyeron datos sobre el tipo de cáncer, comorbilidades y polifarmacia. Se calcularon la puntuación FRAX, el riesgo cardiovascular a 10 años, y se aplicó un cuestionario para evaluar depresión (Beck Inventory Depression-II Scale). RESULTADOS: De 125 pacientes, 69% tenía al menos una comorbilidad; 32% tenía ≥ 2. Las comorbilidades más comunes fueron dislipidemia (54%), hipertensión (19%), obesidad (14%) y diabetes (12%). En pacientes ≥ 50 años, 29% tenía una densitometría osea; 31% tenía osteoporosis. Se aplicaron 56 cuestionarios: 30% tenía algún grado de depresión. Tener ≥ 50 años se asoció con multimorbilidad (aOR 2.57, 1.18-5.58), p = 0.017. CONCLUSIONES: Se reporta una alta prevalencia de multimorbilidad en PVVIH y cancer, con pobre escrutinio de enfermedad ósea y salud mental. Se requiere un enfoque holístico para las PVVIH en la consulta de infectología, para mejorar el manejo de las enfermedades no transmisibles, yendo más alla de la supresión virológica.

Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico.

BACKGROUND: Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy. METHODS: We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival. RESULTS: A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients. CONCLUSIONS: SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.

INFECTIOUS COMPLICATIONS AS A PREDICTOR OF MORTALITY IN PATIENTS WITH NON-HODGKIN LYMPHOMA RECEIVING RITUXIMAB-CONTAINING CHEMOTHERAPY.

BACKGROUND: Rituximab is a monoclonal antibody that increases the disease-free and overall survival of patients with non-Hodgkin lymphoma (NHL) CD20+. The objective of this study is to describe the prevalence and spectrum of infections in patients with NHL receiving rituximab-containing chemotherapy and the impact on survival. MATERIALS AND METHODS: From January 2011 to December 2012, all patients diagnosed with NHL who received at least one dose of rituximab were included. RESULTS: During the study period, 265 patients received rituximab; 108 (40.8%) males; the mean age was 60 ± 15 years. There were 177 infections in 85 patients, being the most common febrile neutropenia (n = 38; 21.5%) and mucosal barrier injury-related infections (n = 28; 15.8%). In 88 events (49%), there was a microbiologic diagnosis, being bacterial infection the most frequent (39.6%), but tuberculosis (TB) was developed in 4 cases (1.5%; incidence rate 721/100,000 person-year). During follow-up, 71 patients died (27%); in 35 cases, it was related to infection. There were no differences in follow-up between those who died due to infection versus those who died from another cause (p = 0.188). Multivariate analysis for mortality showed that age >60 years, failure to achieve a complete response, and development of an infectious complication increased the risk of death. CONCLUSIONS: It is important to perform a screening test for TB in all patients who will receive rituximab and maintain a constant monitoring to detect an infectious process and begin treatment as soon as possible.

Stenotrophomonas maltophilia bacteremia and pneumonia at a tertiary-care oncology center: a review of 16 years.

PURPOSE: The aim of this study was to describe the clinical characteristics and antimicrobial patterns of Stenotrophomonas maltophilia bloodstream infections (BSI) and pneumonia episodes in patients with cancer. METHODS: Patients with S. maltophilia BSI or pneumonia admitted from 1 Jan. 2000 to 31 Dec. 2016 were identified at the Instituto Nacional de Cancerología (INCan), a tertiary-care oncology hospital in Mexico City. RESULTS: During the study period, there were 171 isolates identified. The mean age of the whole group was 46.9 ± 17.4 years; 99 (57.9%) were women. There were 95 BSI: 64 ambulatory catheter-related BSI (CRBSI), 20 nosocomial CRBSI, and 11 secondary BSI. Mortality was higher in nosocomial CRBSI (40%) vs. that in ambulatory CRBSI (7.8%) (p = 0.001). There were 76 pneumonia episodes; all were nosocomial acquired; 46 (60.5%) ventilator-associated. From all the group, nine strains (5.2%) were resistant to sulfamethoxazole/trimethoprim/(SMX/TMP). At the first month, 54 patients (31.6%) have died, 38 due to pneumonia (70%) and 16 due to BSI (30%, p < 0.001). Multivariate analysis showed that removal of central venous catheter was associated with a favorable outcome in patients with bacteremia. For patients with pneumonia, age ≥ 65 years and inappropriate antimicrobial treatment were risk factors associated with 30-day mortality. CONCLUSIONS: S. maltophilia related with ambulatory CRBSI have a better prognosis than other sources of BSI. Older patients with pneumonia who do not receive appropriate antibiotics have higher mortality. SMX/TMP is still the antibiotic of choice.

[Multidrug resistance E-ESKAPE strains isolated from blood cultures in patients with cancer]. / Cepas E-ESKAPE multidrogorresistentes aisladas en hemocultivos de pacientes con cáncer.

OBJECTIVE: To describe the trend of multidrug resistant (MDR) strains isolated from blood in patients with cancer from 2005 to 2015. MATERIAL AND METHODS: 33 127 blood cultures were processed by retrospective analysis. Identification and antimicrobial sensitivity were performed through automated methods: WaLK away (Siemens Labora- tory Diagnostics) and BD Phoenix (Becton, Dickinson and Company). Resistant strains were determined according to the minimum inhibitory concentration, following the parameters of the Clinical and Laboratory Standards Institute (CLSI). RESULTS: Of 6 397 isolates, 5 604 (16.9%) were positive; 3 732 (58.4%) Gram- bacilli; 2 355 (36.9%) Gram+ cocci; 179 (2.7%) yeasts, and 126 (1.9%) Gram+ bacilli. Escherichia coli (n=1 591, 24.5%) was the most frequent bacteria, with 652 (41%) strains being extended-spectrum beta-lactamases producers (ESBL); of Enterococcus faecium (n=143, 2.1%), 45 (31.5%) were vancomycin resistant; of Staphylococcus aureus (n=571, 8.7%), 121 (21.2%) methicillin resistant (MRSA); of Klebsiella pneumoniae (n=367, 5.6%), 41 (11.2%) ESBL; of Acinetobacter baumanii (n=96, 1.4%), 23 (24%) MDR, and of Pseudomonas aeruginosa (n=384, 5.6%), 43 (11.2%) MDR. MDR strains were significantly more frequent in patients with hematological malignancies, compared to those with solid tumors: MRSA (OR=4.48, 95%CI 2.9-6.8), ESBL E. coli(OR=1.3, 95%CI 1.10-1.65) and MDR Acinetobacter baumanii (OR=3.2, 95%CI 1.2-8.3). CONCLUSIONS: We observed significantly higher isolations of E-ESPAKE MDR strains in patients with hematological malignancies.

OBJETIVO: Describir la tendencia de cepas multidrogorre- sistentes (MDR) aisladas en hemocultivos de pacientes con cáncer durante el periodo de 2005 a 2015. MATERIAL Y MÉTODOS: Análisis retrospectivo en el que se procesaron 33 127 hemocultivos. La identificación y la sensibilidad antimicrobianas se realizaron a través de métodos automatizados WaLK away (Siemens Laboratory Diagnostics) y BD Phoenix (Becton,Dickinson and Company). Se determinaron cepas resistentes de acuerdo con la concentración mínima inhibitoria, según los parámetros del Clinical and Laboratory Standards Institute (CLSI). RESULTADOS: 5 604 (16.9%) aislamientos fueron positivos, con 6 397 aislamientos, 3 732 (58.4%) bacilos gramnegativos,2 355 (36.9%) cocos grampositivos, 179 (2.7%) levaduras y 126 (1.9%) bacilos grampositivos. Escherichia coli (n=1 591,24.5%) fue la bacteria más frecuente, 652 (41%) productoras de beta-lactamasas de espectro-extendido (BLEE); Enterococcus faecium 143 (2.1%), 45 (31.5%) resistente a vancomicina; Staphylococcus aureus 571 (8.7%), 121 (21.2%) resistentes a meticilina (SARM); Klebsiella pneumoniae 367 (5.6%), 41 (11.2%) BLEE, Acinetobacter baumannii 96 (1.4%), 23 (24%) MDR; Pseudomonas aeruginosa 384 (5.6%), 43 (11.2%) MDR. Las cepas MDR se aislaron más frecuentemente en pacientes con neoplasias hematológicas en comparación con tumores sólidos; SARM (RM=4.48, IC95% 2.9-6.8); E. coli BLEE (RM=1.3, IC95% 1.10-1.65) y A. baumannii-MDR (RM=3.2, IC95% 1.2-8.3). CONCLUSIONES: Se observó un aislamiento significativamente mayor de cepas E-ESKAPE MDR en pacientes con neoplasias hematológicas.

Streptococcus pneumoniae: distribution of serotypes and antimicrobial susceptibility in patients with cancer.

OBJECTIVE: To describe the distribution of pneumococcal serotypes causing infectious diseases in patients with hematological malignancies and solid tumors and their antimicrobial susceptibility before and after introduction of pneumococcal conjugate vaccine (PCV7) in Mexico. MATERIALS AND METHODS: Consecutive pneumococcal isolates from hospitalized patients from the SIREVA-network were serotyped using the Quellung reaction and antimicrobial susceptibility was performed using the broth microdilution method. RESULTS: A total of 175 pneumococcal isolates were recovered, 105 from patients with hematological malignancies and 70 with solid tumors. Serotypes 19A (22.7%), 19F (20.4%), and 35B (17.7%) were the most frequent isolates in the first group and serotypes 3 (27.2%) and 19A (28.6%) in the second group. No decreased susceptibility to beta-lactams or TMP/SMX was observed after introduction of PCV7. CONCLUSIONS: An increase in non-vaccine types is observed without significate changes in antimicrobial susceptibility after introduction of PCV7.

Late Diagnosis Due to Missed Opportunities and Inadequate Screening Strategies in HIV Infected Mexican Women.

Late diagnosis of HIV remains a public health issue in Mexico. Most national programs target high-risk groups, not including women. More data on factors associated with late diagnosis and access to care in women are needed. In 2012-2013, Mexican women recently diagnosed with HIV were interviewed. Socio-cultural background, household-dynamics and clinical data were collected. Of 301 women, 49 % had <200 CD4 cells/mm3, 8 % were illiterate, 31 % had only primary school. Physical/sexual violence was reported by 47/30 %; 75 % acquired HIV from their stable partners. Prenatal HIV screening was not offered in 61 %; 40 % attended consultation for HIV-related symptoms without being tested for HIV. Seeking medical care ≥3 times before diagnosis was associated with baseline CD4 <200 cells/mm3 (adjusted OR 3.74, 95 % CI 1.88-7.45, p < 0.001). There were missed opportunities during prenatal screening and when symptomatic women seeked medical care. Primary care needs to be improved and new strategies implemented for early diagnosis in women.

Hospital-acquired infections at an oncological intensive care cancer unit: differences between solid and hematological cancer patients.

BACKGROUND: Cancer patients have a higher risk of severe sepsis in comparison with non-cancer patients, with an increased risk for hospital-acquired infections (HAI), particularly with multidrug resistant bacteria (MDRB). The aim of the study is to describe the frequency and characteristics of HAI and MDRB in critically ill cancer patients. METHODS: We conducted an 18-month prospective study in patients admitted ≥48 h to an ICU at a cancer referral center in Mexico. Patients with hematological malignancies (HM) were compared with solid tumors. Demographic and clinical data were recorded. Mortality was evaluated at 30-days. RESULTS: There were 351 admissions during the study period, among whom 157 (66 %) met the inclusion criteria of the study as follows: 104 patients with solid tumors and 53 with HM. Sixty-four patients (40.7 %) developed 95 episodes of HAI. HAI rate was 4.6/100 patients-days. MDRB were isolated in 38 patients (24 %), with no differences between both groups. Escherichia coli was the main bacteria isolated (n = 24), 78 % were extended spectrum beta-lactamases producers. The only risk factor associated with HAI was the presence of mechanical ventilation for more than 5 days (OR 3.12, 95 % CI 1.6 - 6.2, p = 0.001). At 30-day follow-up, 61 patients (39 %) have died (38 % with solid tumors and 60 % with HM, p < 0.001). No differences were found in mortality at 30-day between patients with HAI (n = 25, 39 %) vs. non-HAI (n = 36, 38.7 %, p = 0.964); neither in those who developed a HAI with MDRB (n = 12, 35.3 %) vs. HAI with non-MDRB (n = 13, 43.3 %, p = 0.51). CONCLUSIONS: Patients with cancer who are admitted to an ICU, have a high risk of HAI, but there were no differences patients with solid or hematologic malignancies.

Fecal ESBL Escherichia coli carriage as a risk factor for bacteremia in patients with hematological malignancies.

PURPOSE: The purpose of this study is to evaluate the impact of fecal extended-spectrum ß-lactamase-producing Escherichia coli (ESBL-EC) colonization for bloodstream infection (BSI), clinical outcome, and costs in patients with hematologic malignancies (HM) and severe neutropenia. METHODS: This is a cohort study, carried out at a cancer-referral hospital. The study population comprises patients with HM, hospitalized prior to administration of the first chemotherapy cycle. A stool culture was taken during the first 48 h; they were grouped as colonized by ESBL-EC or non-ESBL-EC. Patients were followed upon completion of chemotherapy or death. The sum of the days of antibiotics and the length of stay of all hospitalizations in the different cycles of chemotherapy were recorded. RESULTS: We included 126 patients with a recent diagnosis of HM, grouped as 63 patients colonized by ESBL-EC and 63 colonized by non-ESBL-EC, aged 42 ± 16 years old, 78 males (62%). BSI by ESBL-EC developed in 14 patients (22.2%) colonized by the same strain and in 5 (7.9%) in the group colonized with non-ESBL-EC. BSI by non-ESBL-EC was observed in 3 patients (4.7%) colonized by ESBL-EC and in 17 (26.9%) patients colonized by non-ESBL-EC. Colonization with ESBL-EC increased the risk of BSI by the same strain (relative risk (RR) = 3.4, 95% confidence interval (95% CI) 1.5-7.8, p = 0.001), shorter time to death (74 ± 62 vs. 95 ± 83 days, p < 0.001), longer hospital stay (64 ± 39 vs. 48 ± 32 days, p = 0.01), and higher infection-related costs ($6528 ± $4348 vs. $4722 ± $3173, p = 0.01). There was no difference in overall mortality between both groups. CONCLUSIONS: Fecal colonization by ESBL-EC is associated with increased risk of BSI by this strain, longer hospital stay, and higher related costs.

[Bacterial resistance from urine cultures at an oncological center: follow-up to 10 years]. / Resistencia bacteriana de cultivos de orina en un hospital oncológico: seguimiento a diez años.

OBJECTIVE: To describe the incidence and patterns of bacterial resistance in urine samples from a tertiary care oncology hospital in Mexico, from 2004 to 2013. MATERIALS AND METHODS: We included the strains obtained from urine cultures, describing separately multidrug-resistant (MDR) bacteria. We analyzed the susceptibility to different antibiotics. RESULTS: 51 202 urine cultures were processed during the study; 14 480 (28.3%) cultures were positive. In 11 427 samples Gram negative (79%) were isolated, 2 080 Gram positive (14.4%), and 973 yeasts (6.6%). Escherichia coli was the most frequent bacteria identified (56.1%); 24% of the community strains and 65.7% of the nosocomial were extended-spectrum beta-lactamase producers (ESBL). Klebsiella pneumoniae was isolated in 705 samples (4.8%); 115 were ESBL (16%), 13.1% from community and 29.8% from nosocomial source. Pseudomonas aeruginosa was identified in 593 cultures (4.1%): 9% from community and 51% nosocomial. CONCLUSIONS: MDR bacteria were more frequent in nosocomial isolates. It should be a priority to intensify the rational use of antimicrobials in the community and antibiotic stewardship in the hospital.

Invasive and Complicated Pneumococcal Infection in Patients with Cancer.

BACKGROUND: In susceptible patients, Streptococcus pneumoniae can cause complicated pneumonia and invasive pneumococcal disease. The aim of this study was to assess the clinical and antimicrobial features of complicated and invasive pneumococcal disease in patients with cancer. METHODS: We conducted a retrospective study including all S. pneumoniae isolates between January 1, 2007 and December 31, 2015 in an oncology center. Capsular serotyping was done in isolates from sterile sites. RESULTS: There were 103 episodes: 69 with invasive pneumococcal disease and 34 with complicated pneumonia. Sixty-two patients were male (60%); mean age was 50 years. Eighty-four isolates were susceptible to penicillin (81.6%), 11 (10%) were intermediate, and eight (8.3%) were resistant. Serotyping was performed in 64 isolates; the main serotypes identified were 3 (n = 13) and 19A (n = 11). No patient had a record of vaccination. Mortality at seven days attributed to pneumococcal infection was different in invasive pneumococcal disease (n = 18, 28.6%) vs. pneumonia (n = 3, 8.9%; p = 0.04). Thirty-day mortality related with the infectious process was statistically different between both groups: 21 patients with invasive pneumococcal disease (30.4%) and six with pneumonia (17.6%; p = 0.04). By logistic analysis, the risk factor associated with mortality was not having received appropriate antimicrobial treatment in the first 48 hours. CONCLUSIONS: S. pneumoniae is a pathogen related with high mortality in patients with cancer. Pneumococcal immunization needs to be reinforced in this population.

[Nosocomial pneumonia in patients with haematological malignancies]. / Neumonía nosocomial (NN) en pacientes con neoplasias hematológicas (NH).

INTRODUCTION: Nosocomial pneumonia (NP) in patients with hematological malignancies (HM) has an attributable mortality over 90%. There are few studies that report the incidence of nosocomial infections in patients with HM. OBJECTIVE: To describe the epidemiology and clinical course of NP in a cohort of patients with hematologic malignancies. MATERIAL AND METHODS: Single-center study of patients with leukemia, lymphoma or multiple myeloma diagnosed with NP, hospitalized between January 2011 and December 2012. RESULTS: One-hundred and five NP were recorded: 51 leukemias (48%) and 45 lymphomas (43%); 50 (48%) were in relapse or progression. Median days for NP development were 13 days (IQ 6-20). Sixty percent of the patients had severe neutropenia. The most frequent symptom was fever 73 (70%). CT scan showed infiltrates in 100% of cases; 45 (43%) with findings suggestive of invasive fungal infection. Seven (7%) had confirmed invasive fungal infection, possible 9 (9%) and 45 (43%) probable. There were 99 cultures taken, 30 blood cultures (67% were positive) and 31 sputum (71% positive). Sixty percent of Gramnegative bacteria were multi-drug resistant and 50% of the Grampositive, E. coli, 19 (30%) was the most frequent isolated, Aspergillus spp. was the third, but the one with the highest associated mortality. Attributable mortality for pneumonia was 50% and 73% in patients that required mechanical ventilation (p = 0.001). CONCLUSIONS: We observed a high mortality rate in patients with HM and NP. Standardized diagnostic routes are needed for patients with HM with suspicion of pneumonia. Novel diagnostic techniques to enhance Aspergillus and respiratory viruses diagnosis should be introduced in this setting.

[In-hospital mortality in HIV-infected patients: 10 years after the implementation of universal access to HAART in Mexico]. / Mortalidad hospitalaria en pacientes con infección por VIH: a diez años del acceso universal a TARAA en México.

OBJECTIVE: To establish the characteristics and causes of death of HIV patients who die while hospitalized. MATERIALS AND METHODS: We included HIV+ patients who died during hospitalization, in three hospitals in Mexico City between 2010 and 2013. Sociodemographic and clinical data were collected as well as causes of death. We identified preventable deaths (defined as deaths that occurred in patients with less than six months of HAART, or without HAART, with less than 350 CD4 at diagnosis and/or opportunistic events as the cause of hospitalization). RESULTS: 128 deaths were analyzed. The median of CD4 count was 47 cells/mm³; 18% of the patients ignored their HIV status at the time of hospitalization, 51% had less than six months of HAART, 40.5% had never received HAART before. The main causes of death were AIDS defining events, with 65.6%. We identified 70 preventable deaths (57%). CONCLUSIONS: Despite universal access to HAART, HIV patients in Mexico are still dying of AIDS defining illnesses, an indicator of late diagnosis. It is urgent to implement HIV testing programs to allow earlier diagnosis and make HAART benefit accessible to all.

Idiopathic granulomatous mastitis. Experience at a cancer center.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a benign breast disease that has been described as a rare granulomatous inflammation (GI). It can mimic inflammatory breast cancer. MATERIAL AND METHODS: We included women with a diagnosis of IGM referred to an oncologic hospital between January 01, 2007 and to March 31, 2011, with diagnosis of breast cancer, in whom biopsy reported GI, without other cause related. The aim of this study was to review the clinical, radiologic and pathologic characteristics of a cohort of women with IGM. RESULTS: We analyzed 58 patients; mean age was 38 ± 12 years. Mammography showed diffuse asymmetry (n = 19) and focal asymmetry (n = 13); breast ultrasound showed heterogeneous and hypoechoic areas (n = 28) and lumps (n = 21) as the most frequent lesions. All biopsies showed lobulocentric GI. Treatment included antibiotics (n = 20), steroids (n = 8), both treatments (n = 20), surgical excision (n = 3) and observation (n = 7). Forty-three patients (74%) had complete remission; mean time to remission was 9.5 ± 5.8 months. Fifteen (26%) had partial remission. Any patient had progression or relapse. CONCLUSIONS: IGM is a benign breast condition that may mimic breast inflammatory cancer. Ultrasonography and mammography findings reveal characteristic data that can be useful for establishing the diagnosis; however, biopsy is the gold standard for its diagnosis and should be taken in any patient even with a mild suspicion of cancer.

Mortality in patients with hematological malignancies, febrile neutropenia, and septic shock.

INTRODUCTION: Patients with severe neutropenia who develop septic shock (SS) have high mortality. This study aimed to evaluate the risk factors and mortality of SS in patients with HM and febrile neutropenia. METHODOLOGY: We included all patients with hematological malignancies (HM) who presented fever and severe neutropenia, admitted to an oncological tertiary care center in Mexico City for one year. RESULTS: Two hundred ninety-two episodes of fever and severe neutropenia were documented; 68 patients (23.2%) developed SS. Documented clinical infection was different between SS and non-SS patients (94.1% vs. 63.4%, p < 0.001); pneumonia was the most frequent infection (36.8% vs. 23.2%, p = 0.02). Also, in SS vs. non-SS, there were more positive cultures (69.1% vs. 38.4%, p < 0.001), higher frequency of Gram-negative bacteria (89.3% vs. 63.9%, p < 0.001), particularly Escherichia coli (68% vs. 44.2%) and Klebsiella spp. (23.4% vs. 15.1%). There were no differences when multidrug-resistant (MDR) microorganisms were compared. In the multivariate analysis, associated risk factors for SS were: prolonged neutropenia, a documented site of infection, and having received highly myelosuppressive chemotherapy. Risk factors for mortality at 30 days were: older patients, prolonged neutropenia, and SS. CONCLUSIONS: Severe and prolonged neutropenia was associated with SS development and mortality at 30 days. ICU management should be offered to all critically ill patients with HM if long-term survival of the underlying malignancy is expected.

Fungal-associated pneumonia in patients with hematological malignancies.

PURPOSE: Patients with hematologic malignancies (HM) are at high risk of invasive lung fungal infections (ILFI). To describe the main characteristics, treatment, and outcomes for five years in adult patients with HM and fungal pneumonia. METHODS: We conducted a retrospective study at Instituto Nacional de Cancerología (INCan), a referral tertiary care oncology hospital with 135 beds in Mexico City, Mexico. We included all cases of fungal pneumonia in patients with HM from January 1, 2017, to December 31, 2022. Cases were classified as proven, probable, and possible according to EORTC/MSG criteria 2021. RESULTS: Two hundred ten patients were included; the mean age was 40 years. The most frequent HM was acute lymphoblastic leukemia (n = 74) and acute myeloid leukemia (n = 68). One hundred forty patients (66.7%) had severe neutropenia for a median of 16 days. All patients had a CT thorax scan; in 132 (62.9%), multiple nodules were documented. Serum galactomannan (GM) was positive in 21/192 (10.9%) and bronchoalveolar lavage in 9/36 (25%). Fifty-three patients (25.2%) died in the first month. In the multivariate analysis for mortality in the first 30 days, hypoalbuminemia, shock, possible ILFI, and inappropriate antifungal treatment were statistically associated. CONCLUSIONS: In high-risk HM patients, CT thorax scan and GM help diagnose ILFI. An appropriate antifungal improves mortality.

Bacteremia caused by Aeromonas species in patients with cancer: Clinical manifestations and outcomes.

INTRODUCTION: Oncologic patients can have severe infections due to Aeromonas. This study aims to investigate the clinical characteristics and outcomes of cancer patients with bloodstream infections (BSI) caused by Aeromonas. METHODOLOGY: We included patients with bacteremia caused by Aeromonas species from 2011 to 2018. RESULTS: Seventy-five BSI events in the same number of patients were identified. Forty patients were men (53.3%); the mean age was 49 years (IQR 28-61). A. caviae was the most frequent isolate (n = 29, 38.6%), followed by A. hydrophila (n = 23, 30.6%), A. sobria (n = 15, 20%), and A. veronii (n = 8, 10.6%). The most frequent underlying diagnosis was hematologic malignancy (n = 33, 44%), followed by breast cancer (n = 12, 16%) and gastrointestinal tract cancer (n = 8, 10.6%). The most frequent type of bacteremia was CRBSI in 32 cases (42.6%), followed by mucosal barrier injury-laboratory confirmed BSI (n = 20, 26.7%). Sixteen (26.2%) were hospital-acquired BSI. Attributable mortality occurred in 11 patients (14.6%). In univariate analysis A. hydrophila bacteremia, liver failure, skin/soft tissue infection, septic shock, inappropriate antimicrobial treatment, and relapse or cancer progression were associated with 30-day mortality. In multivariate analysis, only septic shock, inappropriate antimicrobial treatment, and relapse or cancer progression were associated with 30-day mortality. CONCLUSIONS: Aeromonas species should be considered one of the causative pathogens of healthcare-associated bacteremia, especially in immunocompromised patients. In addition, it can be associated with high fatality, particularly in patients with severe clinical infections.

Impact of coronavirus disease 2019 (COVID-19) pandemic in hospital-acquired infections and bacterial resistance at an oncology hospital.

Objective: Hospital-acquired infection (HAI) rates were negatively affected by the the coronavirus disease 2019 (COVID-19) pandemic. We describe the incidence of HAIs, main pathogens, and multidrug-resistant organisms (MDROs) isolated in cancer patients before and during the pandemic. Design: This retrospective, comparative study included patients with HAIs. We compared 2 periods: the prepandemic period (2018, 2019, and the first 3 months of 2020) with the pandemic period (April-December 2020 and all of 2021). Setting: Instituto Nacional de Cancerología, a tertiary-care oncology public hospital in Mexico City, Mexico. Methods: Patients with the following HAIs were included: nosocomial pneumonia, ventilator-associated pneumonia (VAP), secondary bloodstream infection (BSI), central-line-associated bloodstream infection (CLBSI), and Clostridioides difficile infection (CDI). Demographic data, clinical characteristics, pathogens isolated, and MDRO data were included. Results: We identified 639 HAIs: 381 (7.95 per 100 hospital discharges) in the prepandemic period and 258 (7.17 per 100 hospital discharges) in the pandemic period. Hematologic malignancy was documented in 263 (44.3%) patients; 251 (39.2%) were in cancer progression or relapse. Nosocomial pneumonia was more frequent during the pandemic period (40.3% vs 32.3%; P = .04). Total episodes of VAP were not different between the 2 periods (28.1% vs 22.1%; P = .08), but during the pandemic period, the VAP rate was higher among COVID-19 patients than non-COVID-19 patients (72.2% vs 8.8%; P < .001). Escherichia coli, Stenotrophomonas maltophilia, and Staphylococcus aureus bacteremia cases were more frequent in the pandemic period. Extended-spectrum ß-lactamases (ESBL)-E. coli was the only MDRO that occurred more frequently during the pandemic period. Conclusions: In cancer patients, nosocomial pneumonia was more frequent during the pandemic period. We did not observe a significant impact on other HAIs. MDROs did not significantly increase during the pandemic.

Cellulitis in patients with chronic lower-limb lymphedema due to HIV-related Kaposi sarcoma.

OBJECTIVE: Chronic Lower Limb Lymphedema (CL-LL) secondary to Kaposi sarcoma (KS) has not been recognized as a risk factor for cellulitis. The aim was to describe the clinical spectrum and use of antimicrobial prophylaxis in patients with cellulitis and CL-LL due to KS. METHODS: HIV patients with KS, CL-LL, and at least one episode of cellulitis seen at the AIDS Cancer Clinic at INCan in Mexico from 2004 to 2019 were included. Demographic and clinical data were obtained from medical records. RESULTS: Thirty-nine men all with CL-LL were included. Clinical factors associated with cellulitis were groin and/or lymph-node KS infiltration (69.2%), onychomycosis and/or tinea pedis (44.7%), ulcerated lesions (38.4%), and obesity (2.5%). Eighteen (46.1%) were hospitalized in the first episode and eight (20.5%) in recurrence. Six (25.3%) died, two of toxic shock syndrome (TSS), and one of septic shock. Fourteen (35.8%) had at least one recurrent episode of cellulitis. Twenty-five (64.1%) received prophylaxis. Patients without prophylaxis had significantly more unfavorable outcomes (hospitalization and recurrences) than those with prophylaxis. CONCLUSIONS: CL-LL due to KS is a risk factor for cellulitis and severe complications in patients with a long life expectancy. Antimicrobial prophylaxis needs to be explored as it could prevent complications.