Safety and Efficacy of Prolonged Use of Dalbavancin in Bone and Joint Infections.

Dalbavancin is a lipoglycopeptide with potent activity against Gram-positive microorganisms, a long half-life, a favorable safety profile, and a high concentration in bone, which makes it an interesting alternative for treatment of osteoarticular infections. We performed a multicentric retrospective study of all patients with an osteoarticular infection (septic arthritis, spondylodiscitis, osteomyelitis, or orthopedic implant-related infection) treated with at least one dose of dalbavancin between 2016 and 2017 in 30 institutions in Spain. In order to evaluate the response, patients with or without an orthopedic implant were separated. A total of 64 patients were included. Staphylococcus epidermidis and Staphylococcus aureus were the most frequent microorganisms. The reasons for switching to dalbavancin were simplification (53.1%), adverse events (25%), or failure (21.9%). There were 7 adverse events, and no patient had to discontinue dalbavancin. In 45 cases, infection was related to an orthopedic implant. The implant material was retained in 23 cases, including that in 15 (65.2%) patients that were classified as cured and 8 (34.8%) that presented improvement. In 21 cases, the implants were removed, including those in 16 (76.2%) cases that were considered successes, 4 (19%) cases were considered improved, and 1 (4.8%) case that was considered a failure. Among the 19 cases without implants, 14 (73.7%) were considered cured, 3 (15.8%) were considered improved, and 2 (10.5%) were considered failures. The results show that dalbavancin is a well-tolerated antibiotic, even when >2 doses are administered, and is associated with a high cure rate. These are preliminary data with a short follow-up; therefore, it is necessary to gain more experience and, in the future, to establish the most appropriate dose and frequency.

Successful treatment of postsurgical meningitis caused by Bacillus cereus: a case report and literature review.

Bacillus cereus is a spore-forming, gram-positive bacterium that is ubiquitous in the environment. Central nervous system involvement with B. cereus is rare. Despite aggressive treatment with broad-spectrum antibiotics and using them appropriately, the mortality is high. A 72-year-old patient suffered a central nervous system infection associated with postsurgical meningitis and was successfully treated with a novel antibiotic therapy. This study includes the first case report of postsurgical B. cereus meningitis in the last ten years. It provides a different line of treatment to the previous ones.

Antimicrobial resistance in Gram-negative bacilli in Spain: an experts' view.

BACKGROUND: Antibiotic resistance in Gram-negative bacilli poses a serious problem for public health. In hospitals, in addition to high mortality rates, the emergence and spread of resistance to practically all antibiotics restricts therapeutic options against serious and frequent infections. OBJECTIVE: The aim of this work is to present the views of a group of experts on the following aspects regarding resistance to antimicrobial agents in Gram-negative bacilli: 1) the current epidemiology in Spain, 2) how it is related to local clinical practice and 3) new therapies in this area, based on currently available evidence. METHODS: After reviewing the most noteworthy evidence, the most relevant data on these three aspects were presented at a national meeting to 99 experts in infectious diseases, clinical microbiology, internal medicine, intensive care medicine, anaesthesiology and hospital pharmacy. RESULTS AND CONCLUSIONS: Subsequent local debates among these experts led to conclusions in this matter, including the opinion that the approval of new antibiotics makes it necessary to train the specialists involved in order to optimise how they use them and improve health outcomes; microbiology laboratories in hospitals must be available throughout a continuous timetable; all antibiotics must be available when needed and it is necessary to learn to use them correctly; and the Antimicrobial Stewardship Programs (ASP) play a key role in quickly allocating the new antibiotics within the guidelines and ensure appropriate use of them.

Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm.

In a prospective, single-blind trial, we randomized 150 consecutive symptomatic patients with acute (< or = 48 hours' duration) atrial fibrillation to receive intravenous flecainide, propafenone, or amiodarone. Flecainide and propafenone were administered as a bolus dose of 2 mg/kg in 20 minutes. A second bolus dose of 1 mg/kg in 20 minutes was administered if conversion to sinus rhythm was not achieved after 8 hours. Amiodarone was administered as a bolus of 5 mg/kg in 20 minutes followed by a continuous infusion of 50 mg/hour. By the end of a 12-hour observation period, conversion to sinus rhythm was achieved in 45 patients (90%) in the flecainide group, 36 (72%) in the propafenone group, and 32 (64%) in the amiodarone group (p = 0.008 for the overall comparison, p = 0.002 for flecainide vs amiodarone, p = 0.022 for flecainide vs propafenone, and p = 0.39 for propafenone vs amiodarone). When compared with amiodarone, this higher reversion rate with flecainide was present from the first hour of the study period. However, only after administering the second bolus was there a significant difference between flecainide and propafenone. Median time to conversion to sinus rhythm was different among groups (p < 0.001), and it was lower in the flecainide (25 minutes; range 4 to 660) and propafenone (30 minutes; range 10 to 660) groups than in the amiodarone group (333 minutes; range 15 to 710; p < 0.001 for both comparisons). Flecainide, at the doses administered in this study, is more effective than propafenone and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Propafenone and amiodarone have similar conversion rates, although propafenone was faster in achieving the conversion to sinus rhythm.

Surgical treatment for infective endocarditis in elderly patients.

OBJECTIVES: We evaluate the clinical, echographic and prognostic characteristics of infective endocarditis (IE) in a large population of elderly patients, and the results of surgical approach. METHODS: Multicentric, prospective, observational cohort study with 961 consecutive left-sided IE: 356 patients aged ≥65 years were compared with 605 younger. Indications for cardiac surgery, potential surgical risk, time and outcome, were compared. RESULTS: Hospital-acquired endocarditis, comorbidity, renal failure and septic shock were more frequent in elderly, but embolisms were less. Intracardiac destruction and ventricular failure were similar in both groups, but significantly fewer elderly patients underwent cardiac surgery (36% vs 51%; p < 0.01), and this group showed a worse outcome (43.2% of mortality vs 27% in younger; p < 0.01), resulting age as an independent predictor of mortality (OR: 1.02 CI95%: 1.01-1.03). Compared with medical treatment, surgery showed lower percentages of mortality compared with medical treatment (23.3% vs 31.3%; p = 0.03) in younger group, but a high mortality was observed with both procedures (47.6% vs 40.3%; p = 0.1) in the elderly. CONCLUSIONS: Although similar percentages of heart failure and intracardiac complications, increasing age is associated with higher mortality in IE. Lower rates of surgical treatment and a worse outcome after operation are common features in elderly patients.

Healthcare-associated infective endocarditis: an undesirable effect of healthcare universalization.

Invasive medical technology has led to an increase in the incidence of healthcare-associated infective endocarditis (HAIE). A prospective multicentre cohort study was conducted at seven hospitals in Andalusia, Spain, to establish the characteristics of HAIE and to compare them with those of community-acquired infective endocarditis (CAIE). HAIE was defined as either infective endocarditis (IE) manifesting >48 h after admission to hospital, or IE associated with a significant invasive procedure performed in the 6 months before diagnosis. Seven hundred and ninety-three cases of IE were investigated, and HAIE accounted for 127 (16%). As compared with patients with CAIE, patients with HAIE were older (60.1 ± 14.4 years vs. 53.6 ± 17.5 years) and had more comorbidities (Charlson index 3.3 ± 2.3 vs. 1.8 ± 2.3) and staphylococcal infections (58.3% vs. 24.8%). Vascular manipulation was the main cause of bacteraemia responsible for HAIE (63%). Peripheral vein catheter-associated bacteraemia accounted for 32.8% of the catheter-related bacteraemias. In-hospital mortality (44.9% vs. 24.2%) was higher in the HAIE group. Septic shock (OR 2.2, 95% CI 2.9-30.2) and surgery not performed because of high surgical risk (OR 1.6, 95% CI 1.2-20) were independent predictors of mortality in HAIE. The present study demonstrates that HAIE is a growing health problem associated with high mortality. Careful management of vascular devices is essential to minimize the risk of bacteraemias leading to HAIE.

Streptococcus agalactiae left-sided infective endocarditis. Analysis of 27 cases from a multicentric cohort.

SUMMARY OBJECTIVE: To evaluate the current trends in the clinical characteristics and the prognosis of Streptococcus agalactiae infective endocarditis (IE), uncommon disease associated with high mortality. METHODS: Descriptive analysis of 27 cases of a large cohort (961 episodes) of infective endocarditis collected in seven hospitals of Andalusia (Spain) between 1984 and 2008. RESULTS: Native valves were affected in most cases (85. 2%), multiple valves were frequently involved (22.2%). The median age of the patients was 65 (51-76) years (59.3% men), with a comorbidity, according to the Charlson index, of 2.6+/-2.3. The most frequent underlying diseases were diabetes mellitus (25.9%), chronic obstructive pulmonary disease (14.8%), neoplasms (14.8%), urological disorders (11%) and chronic liver disease (11%). Clinical presentation was characterized by rapid worsening (median of 9 (5.7-15) days from onset of symptoms until diagnosis), a high rate of embolisms (37%) and cardiac complications (abscesses, fistulas or valve rupture) - 37% of cases. Surgery was performed in 12 patients (44.4%) and a high mortality (40.7%) was observed. CONCLUSION: S. agalactiae IE is a serious disease with aggressive course and high mortality rate and affects patients with debilitating diseases. We must be alert of the development of complications and consider early valve surgery when it is necessary.

Etiology of solitary pulmonary nodules in patients with human immunodeficiency virus infection.

We assessed 10 patients with human immunodeficiency virus (HIV) infection (nine of whom had AIDS) and solitary pulmonary nodules (SPNs) that were detected on roentgenograms. Five of the patients presented with respiratory symptoms. The etiology of the SPN was determined for eight of these patients: six had infections (hydatidosis, mucormycosis, or infection with Nocardia asteroides, Cryptococcus neoformans, cytomegalovirus, or Pneumocystis carinii), one had non-Hodgkin's lymphoma, and the remaining patient had round atelectasis. Sputum studies were of no diagnostic value in any of these cases. Fiberoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was diagnostic in two of seven cases, and percutaneous transthoracic needle biopsy (PTNB) was diagnostic in one of four cases. Several microorganisms that were not the cause of the SPNs were observed in samples of sputum, bronchoscopic specimens, and PTNB specimens. Thoracotomy was diagnostic in the three cases in which it was performed. We conclude that the management of SPNs in HIV-infected patients is complicated by the low sensitivity and specificity of the diagnostic tests used.

Comparison of two methods for the assessment of delayed-type hypersensitivity skin responses in patients with human immunodeficiency virus infection.

We compared two techniques for detecting delayed-type hypersensitivity (DTH) skin responses in 359 patients infected with human immunodeficiency virus (HIV) (mean CD4+ lymphocyte count, 387/microL). DTH responses were assessed with use of two antigenic panels administered simultaneously: tuberculin purified protein derivative (PPD) plus three control antigens (Candida albicans, mumps antigen, and tetanus toxoid) administered by the Mantoux method and by a multiple-puncture device delivering seven antigens percutaneously (MULTITEST CMI; Institut Mérieux, Lyon, France). Eighty-three patients (23%) were anergic, 216 (60%) reacted to both panels, 55 (15%) did not react to MULTITEST CMI but did react to the antigens administered by Mantoux method, and only five (1%) reacted to MULTITEST CMI without reacting to antigens administered by the Mantoux method (P < .001, McNemar's test). Each of the three possible combinations of PPD plus two control antigens administered by the Mantoux method were also superior to MULTITEST CMI for classifying patients as nonanergic (P < .001, McNemar's test). We conclude that the application of antigens by the Mantoux method is more efficient than MULTITEST CMI for detecting DTH skin responses in HIV-infected patients.

[Curative treatment with fluconazole in 5 cases of invasive candidiasis]. / Tratamiento curativo con fluconazol en 5 casos de candidiasis invasiva.

BACKGROUND: Amphotericin B is the treatment of choice for invasive and disseminated Candida sp. infections. Fluconazole is an antifungal drug with less toxicity. Because of its pharmacokinetic properties, fluconazole can be specially useful in the treatment of invasive candidiasis. Although it is useful in several forms of candidiasis, its efficacy in deep-seated candidal infections is not totally proved due to the lack of comparative studies with amphotericin. In order to contribute new data about the usefulness of fluconazole in the treatment of invasive candidiasis, we report 5 patients which cured with this antifungal drug. METHODS: The clinical records of those patients with invasive candidiasis that cured with fluconazole were retrospectively reviewed. RESULTS: Fluconazole was used in 2 patients after detecting toxicity to amphotericin. Fluconazole was used from the beginning in the other 3 patients. None of the patients were neutropenic. All the patients cured without recurrence. CONCLUSIONS: In this series, the employment of fluconazole was a non-toxic and effective alternative to amphotericin B in nonneutropenic patients with invasive candidiasis.

Interleukin-8 in cerebrospinal fluid from patients with meningitis of different etiologies: its possible role as neutrophil chemotactic factor.

Interleukin (IL)-8 concentrations were analyzed in 70 cerebrospinal fluid (CSF) samples from patients with meningitis of different etiologies and in 34 normal CSF samples. Patient groups included those with pyogenic meningitis, viral meningitis, self-resolving aseptic meningitis without a specific diagnosis, and meningitis of other etiologies and normal CSF from patients with and without neurologic disease. All samples from patients with pyogenic meningitis (18) but only 3 from patients with meningitis of other etiologies and with CSF polymorphonuclear leukocyte (PMNL) counts > or = 80% had IL-8 levels > or = 2.5 ng/mL. IL-8 was above the normal level (< or = 0.5 ng/mL) in samples from 5 of 13 viral and 8 of 23 self-resolving aseptic meningitis patients and in 7 of 13 samples from patients with meningitis caused by other microorganisms. There was a significant relationship between IL-8 levels and CSF PMNL counts in patients with nonpyogenic meningitis. The data suggest a possible role of IL-8 as PMNL chemotactic factor in different infections of the subarachnoid space, not only in pyogenic meningitis.

Diagnóstico de la espondilodiscitis brucelar en urgencias / Brucellar spondylodiscitis in the emergency department

La lumbalgia es uno de los síntomas guía en la presentación de la espondilodiscitis infecciosa, que puede pasar desapercibida si no se tiene en cuenta la importancia de la anamnesis y las pruebas complementarias iniciales. Presentamos dos casos de espondilodiscitis por Brucella que consultaron por lumbalgia al servicio de urgencias. Revisamos la presentación clínica y los métodos diagnósticos de esta complicación, con especial atención al manejo que debe hacerse en urgencias (AU)

Low back pain is a key symptom of infectious spondylodiscitis, a condition that may be overlooked if attention is not focused on the patient’s medical history and the initial set of tests. We report the cases of 2 patients diagnosed with spondylodiscitis due to Brucella species who came to the emergency department because of low back pain. We review the presenting symptoms of this complication and the diagnostic methods used, and pay particular attention to the treatment that should be initiated in the emergency department (AU)

Edema pulmonar en el tromboembolismo pulmonar masivo / Pulmonary oedema in massive pulmonary thromboembolism

La aparición de un infiltrado alveolar bilateral en el contexto de un episodio agudo de tromboembolismo pulmonar (TP) es un hecho infrecuente que puede producirse por diversas causas con diferente mecanismo fisiopatológico. Entre ellas se encuentran la aparición de un síndrome de distrés respiratorio del adulto, el desarrollo de insuficiencia cardiaca, el edema por sobreperfusión y el edema por reperfusión. Presentamos el caso de un paciente con TP masivo que fue tratado con fibrinolisis sistémica y que desarrolló un infiltrado pulmonar bilateral extenso con hipoxemia grave y necesidad de ventilación mecánica. Se discuten las distintas causas que pudieron precipitar esta evolución (AU)

The appearance of bilateral pulmonary infiltrates during acute pulmonary embolism is a rare event. It may be produced by several causes with different physiopathologyc mechanism, such as the appearance of adult respiratory distress syndrome, development of cardiac failure, overperfusion edema and reperfusion edema. We report the case of a patient with massive pulmonary embolism that was treated with systemic thrombolysis, who developed bilateral diffuse pulmonary infiltrates with severe hypoxia requiring mechanical ventilation. We discuss the different causes that could precipitate this evolution (AU)

Bloqueo auriculoventricular completo secundario a toxicidad cardíaca por cloroquina / Complete auriculoventricular block secondary to cardiac toxicity due to chloroquine

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Acidosis láctica grave, insuficiencia hepática y fallo multiorgánico secundarios al tratamiento con análogos de los nucleósidos / Severe lactic acidosis, hepatic failure and multi-organ failure secondary to treatment with nucleoside analogues

t course, and then, we review the cases of patients with this rare syndrome reported in the literature. Los análogos de los nucleósidos utilizados en el tratamiento de la infección por el VIH pueden provocar acidosis láctica grave asociada a disfunción hepática de elevada mortalidad. Presentamos el caso de un varón de 38 años con dicha complicación que cursó de forma fulminante y, posteriormente, revisamos lo publicado en la literatura respecto a esta rara entidad (AU)

Insuficiencia cardiaca con patrón de pseudoinfarto en el electrocardiograma como forma de presentación de amiloidosis / Heart failure with electrocardiographic pseudo-infarction pattern as presentation form of amyloidosis

La afectación cardiaca por amiloidosis es una entidad infrecuente que implica un sombrío pronóstico, con una mediana de supervivencia de menos de un año. Aunque su diagnóstico es difícil al poder simular otras formas de cardiopatía, su existencia puede ser sospechada en pacientes que se presenten con la conjunción de: 1) insuficiencia cardiaca con datos ecocardiográficos de disfunción diastólica e hipertrofia ventricular; y 2) patrón de pseudoinfarto en el ECG (alteraciones electrocardiográficas que simulan un infarto de miocardio en ausencia de este antecedente). Presentamos el caso de un paciente con amiloidosis cuya enfermedad comenzó de este modo, y posteriormente revisamos la literatura al respecto (AU)

Neumotórax anterior oculto masivo / Massive occult anterior pneumothorax

El neumotórax oculto definido como aquel que no es posible detectar, debido a su tamaño o localización, con la radiología convencional es una entidad de creciente interés en los pacientes politraumatizados, que determina el abordaje terapéutico inicial de estos pacientes y su evolución clínica posterior. El mayor uso de la tomografía computarizada abdominal y torácica ha permitido conocer su verdadera incidencia y relevancia. Describimos el caso de un paciente de 68 años que sufre un accidente de tráfico con traumatismo torácico y de las extremidades con un neumotórax oculato masivo en la radiografía simple de tórax debido a su localización anterior, y que se manifestó como un enfisema subcutáneo progresivo. Realizamos una revisión bibliográfica sobre el diagnóstico y manejo terapéutico del neumotórax oculto (AU)

Área de Cuidados Mínimos. Un complementode la Observación de urgencias hospitalaria / The Minimal Care Area. A complement to observation in the in-hospital Emergency Ward

Objetivo: Analizar el rendimiento de un área específica de Urgencias, denominada Cuidados Mínimos (CM), y compararla con la Observación tradicional (OBS).Métodos: Se analizan las diferencias epidemiológicas y clínicas de ambas áreas durante los años 1998 y 1999 en un hospital general. Resultados: Con respecto a OBS, en CM se atendieron doble número de enfermos (24.495 vs 10.882) en la mitad de tiempo (6,5 ñ 4,7 horas vs 13,4 ñ 8,5 horas), con predominio del alta domiciliaria (73 por ciento vs 40,3 por ciento) sobre el ingreso (17,2 por ciento vs 47 por ciento) y con menor mortalidad (0,08 por ciento vs, 1,79 por ciento, p<0,001). Conclusiones: En CM se resuelven de manera rápida, eficiente y segura procesos agudos destinados a Observación y por tanto puede contribuir a evitar su saturación (AU)