RESUMEN
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.
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Antibacterianos , Antiinfecciosos , Humanos , Antibacterianos/uso terapéutico , Antibacterianos/farmacología , Farmacorresistencia Bacteriana , España/epidemiología , Bacterias Gramnegativas , Antiinfecciosos/uso terapéuticoRESUMEN
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.
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Bacillus cereus , Meningitis , Humanos , Anciano , Antibacterianos/uso terapéuticoAsunto(s)
Antibacterianos/uso terapéutico , Linezolid/uso terapéutico , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Estafilocócicas/tratamiento farmacológico , Teicoplanina/análogos & derivados , Adulto , Desbridamiento , Quimioterapia Combinada , Femenino , Prótesis de Cadera/microbiología , Humanos , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/cirugía , Staphylococcus epidermidis/aislamiento & purificación , Teicoplanina/uso terapéuticoRESUMEN
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.
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Huesos/microbiología , Articulaciones/microbiología , Osteomielitis/microbiología , Teicoplanina/análogos & derivados , Anciano , Femenino , Bacterias Grampositivas/efectos de los fármacos , Bacterias Grampositivas/patogenicidad , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Osteomielitis/tratamiento farmacológico , Staphylococcus aureus , Staphylococcus epidermidis/efectos de los fármacos , Staphylococcus epidermidis/patogenicidad , Teicoplanina/uso terapéuticoRESUMEN
PURPOSE: To evaluate the accuracy of preoperative 3T multiparametric magnetic resonance imaging (3TmMRI) for local staging of prostate cancer and its influence on the decision to change the clinical target volume (CTV), total dose and hormonal therapy when treating prostate cancer patients with radiotherapy. METHODS: From 2009 to 2013, 150 patients, who had confirmed prostate cancer and underwent a 3TmMRI before treatment with radical prostatectomy or radical radiation therapy, were included. Radiation therapy treatment (CTV, total dose and hormonal therapy) was initially determined on the basis of the clinical information, and radiation therapy plan was reevaluated after 3TmMRI review. The value of preoperative 3TmMRI in local staging and in the decision of radiotherapy treatment according to NCCN risk classification was analyzed. RESULTS: 3TmMRI performed correct, over- and under staging in 78.7 % (37/47), 6.3 % (3/47), 14.8 % patients (7/47), respectively. 3TmMRI identified 6 cT2a, 7 cT2b, 28 cT2c, 3 cT3a, 3 cT3b tumors. At final pathology, 5 tumors were classified as pT2a, 5 as pT2b, 30 as pT2c, 4 as pT3a, 3 as pT3b. After reviewing the MRI reports, the initial radiotherapy and hormonal therapy plan was changed in 33.9 % patients (35/103). CONCLUSIONS: In our group of patients, 3TmMRI has been a reliable technique providing an optimal staging for prostate cancer. Its routine use could induce important changes in radiation therapy treatments in a significant number of such patients. However, more additional studies are needed to clarify this issue.
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Adenocarcinoma/patología , Imagen por Resonancia Magnética/métodos , Estadificación de Neoplasias/métodos , Neoplasias de la Próstata/patología , Oncología por Radiación/métodos , Anciano , Humanos , Masculino , Persona de Mediana Edad , Planificación de la Radioterapia Asistida por Computador , Estudios RetrospectivosRESUMEN
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.
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Endocarditis/patología , Endocarditis/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Endocarditis/tratamiento farmacológico , Endocarditis/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
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.
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Endocarditis/epidemiología , Infecciones Estreptocócicas/epidemiología , Streptococcus agalactiae/aislamiento & purificación , Anciano , Estudios de Cohortes , Endocarditis/microbiología , Endocarditis/mortalidad , Endocarditis/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , España , Infecciones Estreptocócicas/microbiología , Infecciones Estreptocócicas/patología , Streptococcus agalactiae/patogenicidadRESUMEN
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.
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Infección Hospitalaria/epidemiología , Endocarditis Bacteriana/epidemiología , Infecciones Estafilocócicas/epidemiología , Adulto , Anciano , Bacteriemia/epidemiología , Cateterismo Periférico/efectos adversos , Infecciones Comunitarias Adquiridas/complicaciones , Infección Hospitalaria/complicaciones , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , España/epidemiología , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/mortalidad , Staphylococcus/clasificación , Staphylococcus/aislamiento & purificación , Staphylococcus/patogenicidad , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
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.
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Amiodarona/administración & dosificación , Antiarrítmicos/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Flecainida/administración & dosificación , Propafenona/administración & dosificación , Anciano , Análisis de Varianza , Fibrilación Atrial/diagnóstico por imagen , Intervalos de Confianza , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Ecocardiografía Doppler , Femenino , Sistema de Conducción Cardíaco/efectos de los fármacos , Sistema de Conducción Cardíaco/fisiología , Humanos , Inyecciones Intravenosas , Masculino , Probabilidad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
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.
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Infecciones por VIH/inmunología , Hipersensibilidad Tardía/inmunología , Pruebas Cutáneas , Adolescente , Adulto , Anciano , Recuento de Linfocito CD4 , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prueba de TuberculinaRESUMEN
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.
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Infecciones por VIH/complicaciones , Nódulo Pulmonar Solitario/diagnóstico , Nódulo Pulmonar Solitario/etiología , Síndrome de Inmunodeficiencia Adquirida/complicaciones , Adulto , Biopsia con Aguja , Lavado Broncoalveolar , Broncoscopía , Diagnóstico Diferencial , Femenino , Humanos , Infecciones/complicaciones , Infecciones/microbiología , Linfoma no Hodgkin/complicaciones , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Sensibilidad y Especificidad , Nódulo Pulmonar Solitario/diagnóstico por imagen , Esputo/citología , Tasa de Supervivencia , ToracotomíaRESUMEN
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.
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Antifúngicos/uso terapéutico , Candidiasis/tratamiento farmacológico , Fluconazol/uso terapéutico , Adolescente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
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.