Analysis of predisposing factors for the development of Clostridioides difficile infection recurrence.

AbstractThe purpose of this study is to evaluate the influence of several risk factors and, among them, the role of different types of antibiotics, in the development of the first recurrent episode of Clostridioides difficile (CD) infection. We performed a case control study from 2006 to 2016. We included patients admitted to the hospital with CD infection that received any antibiotic treatment during the year before the onset of the infection. First, we described the characteristics of CD infection in a Spanish third level hospital and then we compared first cases of CD infection that presented recurrence with those that did not. We included 110 cases, corresponding to 94 individuals. There were 14 first CD infection episodes that later presented recurrence (12.7%). Receiving more than 3 types of antibiotics during the year before the onset of symptoms was associated with higher risk of presenting a recurrent episode (OR = 4.69, 95% CI 1.01-21.78), as well as the past history of neoplasia (OR = 4.58, 95% CI 1.00-20.98). The number of previous hospital admissions was associated with the development of recurrences in the univariate study (p < 0.05). No differences were observed related to the type of antibiotic used immediately before the CD episode neither with the treatment received. The number of types of antibiotics used during the year before the first episode of CD infection or having a personal history of neoplasia was associated with 4 times higher risk of recurrent episodes. Type of antibiotic used did not show to influence recurrences.

Skin and soft-tissue infections: Factors associated with mortality and re-admissions.

INTRODUCTION: Skin and soft-tissue infections (SSTIs) are common and are linked to a wide variety of clinical conditions. Few studies have analysed the factors associated with mortality and re-admissions in medical patients with SSTIs. Accordingly, this study sought to describe the clinical and microbiological characteristics of patients diagnosed with SSTIs, and identify mortality and re-admission related factors. PATIENTS AND METHODS: A total of 308 patients were included in the study. Clinical, socio-demographic and microbiological characteristics were collected. Univariate and logistic regression multivariate analyses were performed in order to identify factors associated with mortality and re-admission. RESULTS: The bacteria responsible were identified in 95 (30.8%) patients, with gram-positive bacteria being isolated in 67.4% and gram-negative in 55.8% of cases. Multi-resistant bacteria were frequent (39%), and the initial empirical treatment proved inadequate in 25.3% of all cases. In-hospital mortality was 14.9%; the related variables were heart failure (OR=5.96; 95%CI: 1.93-18.47), chronic renal disease (OR=6.04; 95%CI: 1.80-20.22), necrotic infection (OR=4.33; 95%CI: 1.26-14.95), and inadequate empirical treatment (OR=44.74; 95%CI: 5.40-370.73). Six-month mortality was 8%, with the main related factors being chronic renal disease (OR: 3.03; 95%CI: 1.06-8.66), and a Barthel Index score of under 20 (OR: 3.62; 95%CI: 1.17-11.21). Re-admission was necessary in 26.3% of cases, with the readmission-related variables being male gender (OR: 2.12; 95%CI: 1.14-3.94), peripheral vascular disease (OR: 3.05; 95%CI: 1.25-7.41), and an age-adjusted Charlson Comorbidity Index score of over 3 (OR: 3.27; 95%CI: 1.40-7.63). CONCLUSIONS: Clinical variables such as heart failure, chronic renal disease, peripheral vascular disease, and necrotic infection could help identify high-risk patients. The main factor associated with higher mortality was inadequate initial empirical treatment. Physicians should consider gram-negative, and even extended-spectrum beta-lactamase-producing bacteria when assigning initial empirical treatment for SSTIs, especially in healthcare-associated cases.

Burn-out syndrome in Spanish internists during the COVID-19 outbreak and associated factors: a cross-sectional survey.

OBJECTIVES: The objective of this study is to evaluate the impact of the COVID-19 outbreak on mental health and burn-out syndrome in Spanish internists and the factors that could be related to its appearance. DESIGN: We performed an observational, cross-sectional, descriptive study for which we designed a survey that was distributed in May 2020. SETTING: We included internists who worked in Spain during the COVID-19 outbreak. PARTICIPANTS: A total of 1015 internists responded to the survey. Of those 62.9% were women. RESULTS: Of 1015 people, 58.3% presented with high emotional exhaustion, 61.5% had a high level of depersonalisation and 67.6% reported low personal fulfilment. 40.1% presented with the 3 criteria described, and therefore burn-out syndrome.Burn-out syndrome was independently related to the management of patients with SARS-CoV-2 (HR: 2.26; 95% CI 1.15 to 4.45), the lack of availability of personal protective equipment (HR: 1.41; 95% CI 1.05 to 1.91), increased responsibility (HR: 2.13; 95% CI 1.51 to 3.01), not having received financial compensation for overtime work (HR: 0.43; 95% CI 0.31 to 0.62), not having rested after 24-hour shifts (HR: 1.61; 95% CI 1.09 to 2.38), not having had holidays in the previous 6 months (HR: 1.36; 95% CI 1.01 to 1.84), consumption of sleeping pills (HR: 1.83; 95% CI 1.28 to 2.63) and higher alcohol intake (HR: 1.95; 95% CI 1.39 to 2.73). CONCLUSIONS: During the COVID-19 outbreak, 40.1% of Internal Medicine physicians in Spain presented with burn-out syndrome, which was independently related to the assistance of patients with SARS-CoV-2, overworking without any compensation and the fear of being contagious to their relatives. Therefore, it is imperative to initiate programmes to prevent and treat burn-out in front-line physicians during the COVID-19 outbreak.

Fusobacterium Nucleatum Empyema: An Atypical Presentation.

A 40-year-old man presented to the emergency room and was evaluated in the internal medicine department for unexplained weight loss, asthenia, anorexia and night sweats over the previous 2 months. After a loculated pleural effusion was identified on thoracic computed tomography, purulent fluid was drained from the lung and Fusobacterium nucleatum was isolated. The patient was successfully treated for 27 days with amoxicillin-clavulanic acid. This was an atypical presentation of a common micro-organism implicated in lung infections. LEARNING POINTS: Empyema due to Fusobacterium nucleatum can have an atypical presentation, manifesting only with unexplained weight loss and night sweats.F. nucleatum lung infection usually responds well to treatment with common antibiotics.In patients with unexplained weight loss, the differential diagnosis should include cancer, tuberculosis and atypical presentations of other bacterial infections.

Miliary pattern, a classic pulmonary finding of tuberculosis disease.

INTRODUCTION: The increase in age of the population and in the use of immunosuppressive treatment makes tuberculosis (TB) with hematogenous or lymphatic dissemination a current problem. METHODS: We collected all the patients diagnosed with tuberculosis with miliary pulmonary pattern at the Santiago de Compostela University Teaching Hospital (NW Spain) from 1 January 2006 to 31 December 2015. RESULTS: A total of 27 patients were included, 70.4% women, with a median age of 69.0 years old. A cause of immunosuppression was observed only in 51.9% of patients. The majority of the cases (65.0%) presented pulmonary affectation. The most frequently isolated species was Mycobacterium tuberculosis (88.9%). Multiresistance to first-line antituberculosis drugs was observed only in 3.7%. 92.6% of the patients received treatment with Isoniazid, Rifampicin and Pyrazinamine, associated in 48.1% of them with Ethambutol. Two patients died during admission and there were no recurrences in the 2-years follow-up. CONCLUSIONS: Miliary tuberculosis remains a current pathology. Most patients do not have a known cause of immunosuppression. The response to the typical treatment is usually good.

Menigococcal endophthalmitis: A rare cause of endogenous endophthalmitis.

Neisseria meningitidis is a rare but severe cause of endogenous endophthalmitis. We report a case of a 46-year-old woman who presented an endophthalmitis secondary to an infection by Neisseria meningitidis that caused with meningitis. She was treated with corticosteroids and systemic and topical antimicrobials, but she presented loss of visual acuity as a consequence. We also review the cases reported in medical literature, and find out that 75.7 % of patients presented diverse complications. The prevalence of complications is higher in patients who received local treatment in combination with antibiotics. Patients who received corticosteroids as treatment presented a similar rate of complications than patients who did not.

Q fever in Spain: Description of a new series, and systematic review.

BACKGROUND: Forms of presentation of Q fever vary widely across Spain, with differences between the north and south. In the absence of reported case series from Galicia (north-west Spain), this study sought to describe a Q-fever case series in this region for the first time, and conduct a systematic review to analyse all available data on the disease in Spain. METHODS: Patients with positive serum antibodies to Coxiella burnetii from a single institution over a 5-year period (January 2011-December 2015) were included. Patients with phase II titres above 1/128 (or documented seroconversion) and compatible clinical criterial were considered as having Q fever. Patients with clinical suspicion of chronic Q-fever and IgG antibodies to phase I-antigen of over 1/1024, or persistently high levels six months after treatment were considered to be cases of probable chronic Q-fever. Systematic review: We conducted a search of the Pubmed/Medline database using the terms: Q Fever OR Coxiella burnetii AND Spain. Our search yielded a total of 318 studies: 244 were excluded because they failed to match the main criteria, and 41 were discarded due to methodological problems, incomplete information or duplication. Finally, 33 studies were included. RESULTS: A total of 155 patients, all of them from Galicia, with positive serological determination were located during the study period; 116 (75%) were deemed to be serologically positive patients without Q fever and the remaining 39 (25%) were diagnosed with Q fever. A potential exposure risk was found in 2 patients (5%). The most frequent form of presentation was pneumonia (87%), followed by isolated fever (5%), diarrhoea (5%) and endocarditis (3%). The main symptoms were headache (100%), cough (77%) and fever (69%). A trend to a paucisymptomatic illness was observed in women. Hospital admission was required in 37 cases, and 6 patients died while in hospital. Only 2 patients developed chronic Q-fever. Systematic review: Most cases were sporadic, mainly presented during the winter and spring, as pneumonia in 37%, hepatitis in 31% and isolated fever in 29.6% of patients. In the north of Spain, 71% of patients had pneumonia, 13.2% isolated fever and 13% hepatitis. In the central and southern areas, isolated fever was the most frequent form of presentation (40%), followed by hepatitis (38.4%) and pneumonia (17.6%). Only 31.7% of patients reported risk factors, and an urban-environment was the most frequent place of origin. Overall mortality was 0.9%, and the percentage of patients with chronic forms of Q-fever was 2%. CONCLUSIONS: This is the first study to report on a Q-fever case series in Galicia. It shows that in this region, the disease affects the elderly population -even in the absence of risk factors- and is linked to a higher mortality than reported by previous studies. While pneumonia is the most frequent form of presentation in the north of the country, isolated fever and hepatitis tend to be more frequent in the central and southern areas. In Spain, 32% of Q-fever cases do not report contact with traditional risk factors, and around 58% live in urban areas.

Eosinofilia asociada a miopatía y diplopía / Eosinophilia-associated myopathy and diplopia

Patient presents in ER with symptoms and history indicative of infectious disease, with muscle pain and double vison being the main complaints. After several consultations, it is decided to admit the patientto the internal medicine ward, where following clinical investigationfocused on a differential diagnosis of eosinophilia and myopathy. (AU)

Paciente acude al servicio de urgencias con un cuadro compatible conpatología infecciosa, siendo dolor muscular y visión doble las principales quejas. Tras consultar con diferentes servicios, se decide ingresoen el servicio de medicina interna, donde la investigación clínica sefocaliza en un diagnóstico diferencial de eosinofilia y miopatía. (AU)

Skin and soft-tissue infections: Factors associated with mortality and re-admissions / Infecciones de piel y partes blandas: factores asociados a mortalidad y reingreso

INTRODUCTION: Skin and soft-tissue infections (SSTIs) are common and are linked to a wide variety of clinical conditions. Few studies have analysed the factors associated with mortality and re-admissions in medical patients with SSTIs. Accordingly, this study sought to describe the clinical and microbiological characteristics of patients diagnosed with SSTIs, and identify mortality and re-admission related factors. PATIENTS AND METHODS: A total of 308 patients were included in the study. Clinical, socio-demographic and microbiological characteristics were collected. Univariate and logistic regression multivariate analyses were performed in order to identify factors associated with mortality and re-admission. RESULTS: The bacteria responsible were identified in 95 (30.8%) patients, with gram-positive bacteria being isolated in 67.4% and gram-negative in 55.8% of cases. Multi-resistant bacteria were frequent (39%), and the initial empirical treatment proved inadequate in 25.3% of all cases. In-hospital mortality was 14.9%; the related variables were heart failure (OR=5.96; 95%CI: 1.93-18.47), chronic renal disease (OR=6.04; 95%CI: 1.80-20.22), necrotic infection (OR=4.33; 95%CI: 1.26-14.95), and inadequate empirical treatment (OR=44.74; 95%CI: 5.40-370.73). Six-month mortality was 8%, with the main related factors being chronic renal disease (OR: 3.03; 95%CI: 1.06-8.66), and a Barthel Index score of under 20 (OR: 3.62; 95%CI: 1.17-11.21). Re-admission was necessary in 26.3% of cases, with the readmission-related variables being male gender (OR: 2.12; 95%CI: 1.14-3.94), peripheral vascular disease (OR: 3.05; 95%CI: 1.25-7.41), and an age-adjusted Charlson Comorbidity Index score of over 3 (OR: 3.27; 95%CI: 1.40-7.63). CONCLUSIONS: Clinical variables such as heart failure, chronic renal disease, peripheral vascular disease, and necrotic infection could help identify high-risk patients. The main factor associated with higher mortality was inadequate initial empirical treatment. Physicians should consider gram-negative, and even extended-spectrum beta-lactamase-producing bacteria when assigning initial empirical treatment for SSTIs, especially in healthcare-associated cases

INTRODUCCIÓN: Las infecciones de piel y partes blandas (IPPB) son frecuentes y se asocian a una amplia variedad de presentaciones clínicas. Los factores asociados a mortalidad y reingreso en pacientes con IPPB han sido poco estudiados hasta ahora. En este sentido, el objetivo del presente trabajo es describir las características clínicas y microbiológicas de pacientes diagnosticados de IPPB e identificar factores asociados a mortalidad y reingreso en ellos. PACIENTES Y MÉTODOS: Fueron incluidos un total de 308 pacientes. Se realizó una descripción de las características clínicas, sociodemográficas y microbiológicas. Se llevaron a cabo análisis uni y multivariantes de regresión logística para identificar factores asociados a mortalidad y reingreso en pacientes con IPPB. RESULTADOS: Los microorganismos responsables fueron identificados en 95 (30,8%) pacientes, de ellos el 67,4% presentaban bacterias grampositivas y el 55,8%, gramnegativas. La presencia de bacterias multirresistentes fue frecuente (39%) y el tratamiento empírico fue inadecuado en el 25,3% de los casos. La mortalidad intrahospitalaria fue del 14,9% y las variables asociadas a ella fueron la insuficiencia cardiaca (OR=5,96; IC95%: 1,93-18,47), la insuficiencia renal crónica (OR=6,04; IC95%: 1,80-20,22), la infección necrótica (OR=4,33; IC95%: 1,26-14,95) y el tratamiento antibiótico empírico inadecuado (OR=44,74; IC95%: 5,40-370,73). La mortalidad a 6 meses fue del 8%, y los principales factores asociados, la insuficiencia renal crónica (OR=3,03; IC95%: 1,06-8,66) y una puntuación en el índice de Barthel inferior a 20 puntos (OR=3,62; IC95%: 1,17-11,21). Reingresaron durante el seguimiento a 6meses el 26,3% de los pacientes; las variables asociadas a este hecho fueron el sexo masculino (OR=2,12; IC95%: 1,14-3,94), la enfermedad vascular periférica (OR=3,05; IC95%: 1,25-7,41) y una puntuación en el índice de Charlson ajustado por edad superior a 3puntos (OR=3,27; IC95%: 1,40-7,63). CONCLUSIONES: Variables clínicas como la insuficiencia cardiaca, la insuficiencia renal crónica, la enfermedad vascular periférica y la infección necrótica podrían ayudar a identificar pacientes con IPPB de alto riesgo. El principal factor asociado a una mayor mortalidad fue el tratamiento antibiótico empírico inadecuado. Debería considerarse la posibilidad de que bacterias gramnegativas, o incluso enterobacterias productoras de betalactamasas de espectro extendido, sean las responsables de IPPB, sobre todo en casos asociados a los cuidados sanitarios, a la hora de plantear el tratamiento antibiótico empírico en estos pacientes

Piomiositis por Escherichia coli en un paciente en tratamiento crónico con glucocorticoides / Pyomiositis caused by Escherichia coli in a patient on chronic glucocorticoid treatment

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