Epidemiology, risk factors and comorbidity for urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing enterobacteria.

AIM: Urinary tract infection (UTI) caused by resistant bacteria is becoming more prevalent. We investigate characteristics and associated risk factors for UTIs resulting from extended-spectrum beta-lactamase (ESBL)-producing enterobacteria. METHODS: Retrospective study of urinary tract isolates of ESBL-producing enterobacteria in adults (2009 and 2010). We included 400 patients and 103 controls (UTI caused by non-ESBL Escherichia coli). Clinical and demographic information was obtained from medical records. Comorbidity was evaluated using Charlson Index (CI). Strains were identified using VITEK 2 system. RESULTS: A total of 400 isolates were obtained (93%E. coli and 7%Klebsiella spp). In 2009, 6% of cultures were ESBL-producing E. coli and 7% in 2010. 37% of patients were men and 81% were aged ≥60years. CI was 2.3±1.8 (high comorbidity: 42.8%). 41.5% of strains were susceptible to amoxicillin-clavulanate, 85.8% to fosfomycin and 15.5% to ciprofloxacin. The total number of ESBL E. coli positive urine cultures during hospital admission was 97 and, compared with 103 controls, risk factors for UTI caused by ESBL- E. coli strains in hospitalised patients were nursing home residence (p<0.001), diabetes (p=0.032), recurrent UTI (p=0.032) and high comorbidity (p=0.002). In addition, these infections were associated with more symptoms (p<0.001) and longer admission (p=0.004). CONCLUSIONS: Urinary tract infection caused by ESBL are a serious problem and identifying risk factors facilitates early detection and improved prognosis. Male sex, hospitalisation, institutionalisation, diabetes, recurrent UTI and comorbidity were risk factors and were associated with more symptoms and longer hospital stay.

Assessment of factors influencing health-related quality of life in HIV-infected patients.

OBJECTIVES: Health-related quality of life (HRQL) is used in the assessment of chronic illness. Regarding HIV infection, HRQL assessment is an objective for physicians and institutions since antiretroviral treatment delays HIV clinical progression. The aim of this study was to determine the factors with the most influence on HRQL in HIV-infected people and to create a predictive model. METHODS: We conducted a cross-sectional study in 150 patients in a tertiary hospital. HRQL data were collected using the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire. The research team created a specific template with which to gather clinical and sociodemographic data. Adherence was assessed using the Simplified Medication Adherence Questionnaire (SMAQ) and depression data were obtained using the Beck Depression Inventory, Second Edition (BDI-II) inventory. Logistic regression models were used to identify determinants of HRQL. RESULTS: HIV-related symptoms and presence of depression were found to be negatively associated with all the MOS-HIV domains, the Physical Health summary score and the Mental Health summary score. Patients receiving protease inhibitor (PI)-based treatment had lower scores in four of the 11 domains of the MOS-HIV questionnaire. Gender, hospitalization in the year before enrolment, depression and parenthood were independently related to the Physical Health Score; depression and hepatitis C virus coinfection were related to the Mental Health Score. CONCLUSIONS: Optimization of HRQL is particularly important now that HIV infection can be considered a chronic disease with the prospect of long-term survival. Quality of life should be monitored in follow-up of HIV-infected patients. The assessment of HRQL in this population can help us to detect problems that may influence the progression of the disease. This investigation highlights the importance of a multidisciplinary approach to HIV infection.

Depression and health related quality of life among HIV-infected people.

BACKGROUND AND OBJECTIVES: Little is known about the impact of comorbid psychiatric symptoms in health related quality of life (HRQL) in patients with HIV infection. The aim of this investigation was to describe depressive symptoms and the impact in HRQL in HIV infected people. MATERIALS AND METHODS: A cross-sectional study over 150 HIV-outpatients in a tertiary hospital was designed. Depression data were obtained using the Beck Depression Inventory, Second Edition (BDI-II) inventory. HRQL data were collected by disease-specific questionnaire MOS-HIV. Researchers' team designed a specific template to get rest of the data. RESULTS: Almost three-quarters of the population were men. After adjusting for gender and age, HIV-related symptoms and presence of depression were found to be negatively associated with all the Medical Outcomes Study HIV Health Survey (MOS-HIV) general domains and in the Physical Health Summary score and Mental Health Summary score. CONCLUSIONS: Optimization of HRQL is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Quality of life and depression should be monitored in follow-up of HIV infected patients. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV.

[Family physician's role in the HIV infection management]. / Papel del médico de familia en el manejo de la infección por VIH.

The human immunodeficiency virus (HIV) infection is a disease with great sociosanitary impact. Since 1981, when the first cases of AIDS were described, more than 60 million people have become infected. During these 25 years there have been a lot of advances in the infection management and we know that prevention and early diagnosis are crucial. Family Physician s role is essential since this is a privileged point of global attention, counseling and support for these patients. The main objective is to reduce the new HIV infections incidence. In addition, other objectives are: primary prevention and health promotion, early diagnosis, recruitment infected patients, monitoring and end-of-life caring. It is important to know that all of us are susceptible to contract the virus and, although the HIV testing is voluntary, there are screening recommendations from the CDC: persons with signs or symptoms that suggest infection, pregnant women, persons at high risk for infection and all patients aged 13-64 years, as a part of routine clinical care. The communication of the result is a key point in the therapeutic relation. If it is negative we must make intervention on risk attitudes. If it is positive we must inform and support the patient, to convince him about the need to be followed up by an specialized level. The AIDS terminal patient is a very immunodeficient one and needs palliative cares like other terminal disease. Another challenge is prevention and control of HIV infection among the immigrant community. In conclusion, Family Physicians must investigate risk practices, inform, prevent new cases and, in the infected people, monitor the evolution, supporting and comforting.

[Clinical manifestations, diagnosis and treatment of Haemophilus influenzae infection]. / Manifestaciones clínicas, diagnóstico y tratamiento de la infección por Haemophilus influenzae.

Haemophilus influenzae is a small, nonmotile, non-spore-forming bacterium, and a strict parasite of humans found principally in the upper respiratory tract. The production of capsule is of major significance to clinicians since it is an important virulence factor. We described six antigenically distinct capsular types, designated a-f. Spread from one individual to another occurs by airborne droplets or by direct contagion with secretions. Haemophilus influenzae produces at least two factors that inhibit the ciliary activity of human epithelial cells in vitro. One of this has been shown to be lipopolysaccharide and the other factor is of low molecular weight, most likely a heat-stable glycopeptide. Type b strains are distinguished by the production of capsular polysaccharide composed of repeating units of ribosyl-ribitol phosphate, account for greater than 95 percent of systemic infections in children. Two contrasting patterns of Haemophilus influenzae disease can be identified. The first and the most serious in its consequences is invasive infection such as meningitis, septic arthritis, epiglottitis, and cellulitis in which bacteremia is a prominent feature; these infections are usually caused by type b strains and occur in young children. The second category includes less serious but numerically more common infections, that occur as a result of contiguous spread of Haemophilus influenzae within the respiratory tract; e.g. otitis media, sinusitis. These latter infections are usually, but not invariably, caused by unencapsulated strains. A provisional diagnosis of meningitis, epiglottitis, facial cellulitis, or septic arthritis will usually be prompted by the history and clinical findings. Confirmation requires microbiologic studies. Cultures of blood, CSF and other normally sterile fluids are diagnostic and therefore under the appropriate circumstances mandatory. Whenever feasible, specimens obtained for culture should also the gram-strained. Detection of capsular antigen in serum, CSF or concentrated urine using immunoelectrophoresis, latex agglutination or enzyme linked immunosorbent assay may be diagnosed and can be found in up to 90 percent of culture proved cases of meningitis. Without treatment, infection due to Haemophilus influenzae can be rapidly fatal, particularly by meningitis and epiglottitis. There is currently a trend to use certain parenteral third generation cephalosporins as initial therapy when lifethreatening Haemophilus influenzae infection is known or suspected in children beyond the neonatal period, commonly used agents included cefotaxime or ceftriaxone. Antibiotic therapy is only one facet of the management of the child with Haemophilus influenzae infection, and critical attention must also be given to supportive therapy. In the ambulatory setting, ampicillin or amoxicillin for 10 days is often satisfactory for the less severe Haemophilus influenzae infections. Cephalosporins are often chosen for treatment of adults, with pneumonia when Haemophilus influenzae is documented.

[Observational study on the efficacy of the application of two classical regimens of triple antiretroviral therapy]. / Estudio de campo sobre la eficacia de la aplicación de dos modalidades clásicas de triple terapia antirretroviral.

BACKGROUND: To compare the temporal evolution of viral load and CD4 parameters in two cohorts of HIV infected patients enrolled in classical triple antiretroviral regimens. METHODS: Retrospective, observational, descriptive study of the proportions of patients reaching undetectable levels of viral load (VL) as well as the time necessary to get it. The two cohorts were as follows: 91 HIV patients on triple therapy with zidovudine plus lamivudine and indinavir (cohort A) versus 80 HIV patients with Stavudine plus Didanosine and Indinavir (cohort B). RESULTS: The evolution of the patients in terms of percentages who reach undetectable VL was similar in the two therapeutic cohorts (75.8%for cohort A vs 73.8% for cohort B) along the duration of the study (four years). However, the mean time period needed to reach undetectable VL was different, 209 days (IC 95% 175-243 days) for patients in zidovudine plus lamivudine and indinavir and 330 days (IC 95% 263-396 days) for stavudine plus didanosine and indinavir regimen. The immunological status observed in the patients when reaching his first undetectable VL was significantly different. The proportion of patients with CD4 cells counts >200/mm3 in cohort A was 83.1% while for patients from cohort B was 65.4% (p=0.032). CONCLUSIONS: This observational study from clinical settings seems demonstrate similar efficacy to reach undetectable VL with both classical triple antiretroviral therapies evaluated but a shorter delay of time to reach that virological situation for zidovudine plus lamivudine and indinavir regimen is reported.

[Tularemia in the differential diagnosis of cervical lymph node enlargement. An outbreak of tularemia in Castilla-León, Spain]. / La turalemia en el diagnóstico diferencial de las adenopatías cervicales. A propósito de un brote tularémico en Castilla-León.

The presence of enlarged cervical lymph nodes is a diagnostic challenge in disease of the head and neck. Lymph node enlargement may be secondary to local or general infectious disease, to non-infectious systemic disease, or to lymphatic metastasis of tumoral processes. Among the many infectious processes that originate cervical lymph nodes is tularemia. This disease is uncommon in Spain, but was unusually frequent in Castilla-León in the last months of 1997, with 136 cases diagnosed in our hospital, 13 accompanied by lymph node enlargement of the head and neck. This article shows that tularemia should be considered in the differential diagnosis of cervical lymph node enlargement in our region.

[Serum antibodies against Haemophilus influenzae in children from the province of Valladolid (Spain)]. / Anticuerpos séricos contra Haemophilus influenzae en niños de la provincia de Valladolid.

OBJECTIVE: Invasive infections by Haemophilus influenzae type b (Hib) in children are increasing in Spain. Moreover, they are becoming more resistant to antibiotics. Currently, effective vaccines against Hib are available and their inclusion in the routine schedule of immunizations is discussed. Knowledge of the childhood serology appears to be useful in decision making. PATIENTS AND METHODS: Two hundred and thirty-five normal children, between 1 month and 15 years of age, were studied. Thirty-six adults sera were also included as controls. Polysaccharide of Hib was conjugated with tyramine and used to coat polystyrene microtitration plates. The determination of antibodies was performed by ELISA and the results are expressed in optical density units. The mean level of antibodies present in 6 sera from a patient with Bruton syndrome (17 uu), just before degammaglobulinotherapy, was considered as the limit of protection. RESULTS: The antibody titer correlated with age (p < 0.001). The levels in children younger than 3 years (25.7 +/- 32.5) were lower than in older children (p < 0.001). Of the children younger than 3 years of age, 53% did not reach the protective level of antibodies, compared to 15.2% of those between 3-6 years and 22.7% of children between 6 and 14 years. Whereas the mean antibody level increased with age in positive sera, the percentage of seropositive children decreased after 3 years of age. CONCLUSIONS: The number of children spontaneously protected against Hib is low (47%) until 3 years of age. Nevertheless, this number increases rapidly after this age. Immunization must be restricted to this age group.

[Differential health and toxicological features of drug-dependents in treatment and in active consumption]. / Características diferenciales sanitarias y toxicológicas de drogodependientes en tratamiento y consumo activo.

OBJECTIVES: To describe and compare the demographic and health characteristics and drug use patterns in a group of drug dependent individuals who were actively using drugs versus those in different types of treatment. To analyze the interventions used with the different groups. DESIGN: Descriptive study. SETTING: Users at the Association for Aid to Drug Dependent Persons (Asociación de Ayuda al Drogodependiente, ACLAD) in the city of Valladolid in northwestern Spain. PATIENTS: 1224 drug dependent persons. MEASURES: We reviewed the medical records for a 30-month period for users who were seen at a treatment center and who were participating in a damage reduction program. We recorded demographic, drug use and clinical variables and compared changes. RESULTS: We studied 1224 patients in all. One-third had human immunodeficiency virus infection, 63% had markers for previous hepatitis A infection, 48% had markers for hepatitis B, and 68.5% for hepatitis C. The Mantoux test was positive in 39.1%. We found differences in the prevalence of infections between active drug users and users in treatment, between drug dependent persons receiving different types of treatment, and between different periods of study. CONCLUSIONS: There were clear differences in demographic and health characteristics and drug use patterns between users. Those who were not in rehabilitation were in worse health, and were studied in less detail that other groups of drug users. During follow-up we noted a slight improvement in their health conditions, along with a tendency toward improved primary care interventions.

Tularemia epidemic in northwestern Spain: clinical description and therapeutic response.

This study describes the clinical characteristics of tularemia in Spain's first epidemic outbreak and the therapeutic response and compares the efficacy of 3 antibiotics (streptomycin, ciprofloxacin, and doxycycline). For 142 cases of tularemia, the therapeutic failure rate was 22.5%; ciprofloxacin was the antibiotic with the lowest percentage of therapeutic failures and with the fewest side effects.

Report on five cases of tularaemic pneumonia in a tularaemia outbreak in Spain.

A report is given on five cases of atypical tularaemic pneumonia selected from among 140 cases of tularaemic infection in a previously reported outbreak occurring in 1997. Prior to this outbreak no human cases of tularaemia had been reported in Spain. All cases were diagnosed serologically. All five patients reported on here had a mild form of the disease, which was treated successfully with streptomycin in four cases and ciprofloxacin in one case. Tularaemic pneumonia should be considered in the differential diagnosis of atypical pneumonia in Spain, especially in hunters and other persons who handle animal carcasses.

[Variability of HIV-1 viral load in patients cared along 4 years]. / Variabilidad de la carga vírica de VIH-1 en individuos atendidos a lo largo de 4 años.

BASIS: Analysis of the variations of HIV-1 viral load (VL) in a cohort of patients. MATERIAL AND METHODS: A retrospective study was designed for the calculation and analysis of the differences between two consecutive measurements of VL in a cohort of 1,336 patients along a 48 months follow-up. RESULTS: At the beginning of the follow-up period the highest proportion of patients with decreases of VL (54.2% in their first measurement, at 0-75 days) as well as the least proportion of patients both without changes (30.7%) and with increases of their VL (15.1%), were registered. The proportion of patients with decreases was declining along the study period. More than half of the patients did not experience significant variations in the measurements carried out. CONCLUSIONS: The significant decreases of VL appeared in our series at the beginning of the follow-up period, and a growing proportion of individuals showed elevations of the VL along the period studied.

[Preliminary report of an epidemic tularemia outbreak in Valladolid]. / Descripción preliminar de un brote epidémico de tularemia en Valladolid.

We make here a preliminary report of the first 65 cases of tularemia diagnosed at our hospital pertaining to an epidemic outbreak occurred in the area served by the hospital. Diagnosis was made by the presence of a consistent clinical picture and the following laboratory criteria: antibody titre to. Francisella tularensis (tube agglutination) higher than or equal to 1/160, seroconversion or recovery of the microorganism from biological material. The mean age of our patients was 53.8 +/- 13.5 years and female sex predominated (45 women). Fever, lymph node enlargement, cutaneous ulcers, asthenia, and weight loss were the most common symptoms. The presentation clinical forms included: ulceroganglionar (69%), typhoidal (14%), ganglionar (12.5%), pneumonic (1.5%), oculoganglionar (1.5%) and atypical (1.5%). The analytical data did not show significant changes with the exception of erythrocyte sedimentation rate. Streptomycin was the antibiotic of choice, followed by ciprofloxacin and gentamicin. The failure rate was 22%, and ciprofloxacin was used for retreatment in twelve occasions and ofloxacin in 1 occasion with a good response. Tularemia is an infective disease which can become endemic in Spain and that should be considered by clinicians, particularly when unilateral enlarged lymph nodes, prolonged febrile syndromes, pharyngitis with negative culture, poor response to beta-lactams and atypical pneumonia are present.

Papel del médico de familia en el manejo de la infección por VIH / Family phisician´s role in the HIV infection management

La infección por el virus de la inmunodeficiencia humana (VIH) es una enfermedad con gran impacto sociosanitario. Desde 1981, cuando se describieron los primeros casos de sida, se han infectado más de 60 millones de personas. En estos 25 años se han realizado muchos avances en cuanto a su manejo y sabemos que la prevención y el diagnóstico precoz son fundamentales. El papel del médico de familia es esencial ya que es un punto privilegiado de atención global, counseling y apoyo para estos pacientes. El principal objetivo es disminuir la incidencia de nuevas infecciones por VIH. Además, otros objetivos son: prevención primaria y promoción de la salud, diagnóstico precoz, captación de pacientes infectados, seguimiento y cuidados al paciente terminal. Es importante conocer que todos somos susceptibles de contraer el virus y, aunque la realización de la serología de VIH es voluntaria, existen recomendaciones de los CDC: sujetos con signos o síntomas sugestivos de infección, mujeres embarazadas, sujetos con situaciones de riesgo y entre los 13 y 64 años de manera rutinaria. La comunicación del resultado es un punto clave en la relación terapéutica. Si es negativo se debe hacer intervención sobre las conductas de riesgo. Si es positivo debemos informar y apoyar al paciente, además es importante una buena captación y valoración para su derivación a la consulta especializada. El paciente terminal de sida está muy inmunodeprimido y necesita cuidados paliativos como otra enfermedad terminal. Otro reto es la prevención y control de la infección VIH en la población inmigrante. En conclusión, el médico de familia debe investigar prácticas de riesgo, informar, prevenir nuevos casos y, en la población infectada, seguimiento de la evolución, apoyando y confortando

The human immunodeficiency virus (HIV) infection is a disease with great sociosanitary impact. Since 1981, when the first cases of AIDS were described, more than 60 million people have become infected. During these 25 years there have been a lot of advances in the infection management and we know that prevention and early diagnosis are crucial. Family Physician’s role is essential since this is a privileged point of global attention, counseling and support for these patients. The main objective is to reduce the new HIV infections incidence. In addition, other objectives are: primary prevention and health promotion, early diagnosis, recruitment infected patients, monitoring and end-of-life caring. It is important to know that all of us are susceptible to contract the virus and, although the HIV testing is voluntary, there are screening recommendations from the CDC: persons with signs or symptoms that suggest infection, pregnant women, persons at high risk for infection and all patients aged 13-64 years, as a part of routine clinical care. The communication of the result is a key point in the therapeutic relation. If it is negative we must make intervention on risk attitudes. If it is positive we must inform and support the patient, to convince him about the need to be followed up by an specialized level. The AIDS terminal patient is a very immunodeficient one and needs palliative cares like other terminal disease. Another challenge is prevention and control of HIV infection among the immigrant community. In conclusion, Family Physicians must investigate risk practices, inform, prevent new cases and, in the infected people, monitor the evolution, supporting and comforting