Etiology of bloodstream infections at a population level during 2013-2017 in the Autonomous Community of Valencia, Spain.

OBJECTIVE: Bloodstream Infections has become in one of the priorities for the antimicrobial stewardship teams due to their high mortality and morbidity rates. Usually, the first antibiotic treatment for this pathology must be empirical, without microbiology data about the microorganism involved. For this reason, the population studies about the etiology of bacteremia are a key factor to improve the selection of the empirical treatment, because they describe the main microorganisms associated to this pathology in each area, and this data could facilitate the selection of correct antibiotic therapy. METHODS: This study describes the etiology of bloodstream infections in the Southeast of Spain. The etiology of bacteremia was analysed by a retrospective review of all age-ranged patients from every public hospital in the Autonomous Community of Valencia (approximately 5,000,000 inhabitants) for five years. RESULTS: A total of 92,097 isolates were obtained, 44.5% of them were coagulase-negative staphylococci. Enterobacteriales was the most prevalent group and an increase in frequency was observed along the time. Streptococcus spp. were the second microorganisms more frequently isolated. Next, the most prevalent were Staphylococcus aureus and Enterococcus spp., both with a stable incidence along the study. Finally, Pseudomonas aeruginosa was the fifth microorganism more frequently solated. CONCLUSIONS: These data constitute a useful tool that can help in the choice of empirical treatment for bloodstream infections, since the knowledge of local epidemiology is key to prescribe a fast and appropriate antibiotic therapy, aspect capital to improve survival.

Prevalence and associated risk factors of latent tuberculosis infection in a Spanish prison.

AIM: To determine the prevalence of latent tuberculosis infection (LTI) in a Spanish prison, analyze the main sociodemographic and clinical variables associated with this condition and estimate the percentage of individuals with LTI who have received chemoprophylactic treatment. MATERIALS AND METHODS: Cross-sectional study including inmates hosted in the Madrid VI Prison on 16/07/2016. Exclusion criteria: history of tuberculosis; non-updated tuberculin test according to the Tuberculosis Prevention and Control Program in Prisons protocol. Information of the variables was collected from SANIT and SIP programs, and by checking the clinical records of inmates. Description of the participant population and comparison between the frequency of distribution of the independent variables in LTI present and absent groups were performed, the last calculating the p value with Ji2 and Mann-Whitney U tests. Bivariate and multivariate analysis have been carried out with a logistic regression model. RESULTS: 936 individuals have been included. The prevalence of LTI in prison is 54.6%. This condition has been linked to the sociodemographic variables age, sex and nationality of origin, being age the one that has shown the strongest association. Among the other factors analyzed, only HCV infection behaves as a predictor of LTI. 30.3% of the individuals with LTI have completed or are receiving chemoprophylactic treatment in the moment of the study. DISCUSSION: LTI prevalence is high in the Spanish current prison population. The results of the study emphasize the relevance of the LTI screening in the prison setting, specially among high risk groups, and point out the need of a greater effort in the indication and completion of the chemoprophylactic treatment.

[Evolution of treatment of syphilis through history]. / Evolución del tratamiento de la sífilis a lo largo de la historia.

In this article, we present a historical revision of syphilis treatment since the end of the XV century up until the current days. For centuries, it was understood that syphilis had been brought to Spain by Columbus after coming back from America. It became an epidemic soon after. Later on, it was spread all over Europe. The chronologic and geographic origin of this illness have been debated in recent years, however, there has been no agreement about it as yet. Mercury was the main used therapy for four and a half centuries, until the discovery of penicillin in 1943. This discovery changed the therapeutic approach to syphilis since then. Other remedies were used during this period. Guaiacum was one of them, but it was dismissed in the mid-sixteenth century. Iodides were also used, especially in the tertiary symptoms of the disease. The discovery of arsphenamine (Salvarsan) at the beginning of the XX century, used by itself at its onset and associated to mercury or bismuth later on, was a significant therapeutic contribution. Bismuth was in itself a great therapeutic asset. It displaced the use of mercury in an important way until 1943, when the appearance of penicillin became the treatment of choice.

[Aseptic meningitis caused by the rupture of an epidermoid cyst]. / Meningitis aséptica causada por la ruptura de quiste epidermoide.

INTRODUCTION: Epidermoid cysts are rare tumours. The aseptic meningitis that comes about as a result of their rupture is frequent after tumour resection, although they may occasionally occur spontaneously. CASE REPORT: A 36-year-old male who had been submitted to surgery twice because of an epidermoid cyst in the cerebellopontine angle presented a month old history of clinical features consisting in high temperature, headache, a stiff neck and ataxia. After computerized tomography (CT) scans and a spinal tap had been performed because of the suspicion of meningitis, empirical antibiotic therapy was administered but no improvement was observed. Thus, the usual studies employed to diagnose aseptic meningitis were carried out. Magnetic resonance imaging (MRI) was performed and showed lesions that suggested tumorous recurrence and perilesional meningeal hyperenhancement. Corticoid therapy quickly lessened the symptoms and the patient was asymptomatic when discharged. A week later he returned with headaches and disorders affecting behaviour and memory. A CT scan was performed and revealed the presence of tetraventricular hydrocephalus, which required the introduction of ventriculoperitoneal drainage. Spinal MRI carried out two weeks later revealed perimedullar foci of hyperenhancement. CONCLUSIONS: We describe the case of a patient with aseptic meningitis brought on by the rupture of an epidermoid cyst, which followed a subacute course and responded to corticoid therapy in a spectacular manner. Nevertheless, the patient still went on to develop tetraventricular hydrocephalus. Spontaneous aseptic meningitis is rare and corticoids lower its development time, but hydrocephalus may occur as a complication due to upsets in the reabsorption of cerebrospinal fluid.

[Leukocytoclastic vasculitis due to hypersensitivity to microfilariae]. / Vasculitis leucocitoclástica por hipersensibilidad a microfilarias.

A case of a Caucasian girl with leukocytoclastic vasculitis, polyarthritis and eosinophilia is presented. A blood test showed microfilariasis, probably of the Loa Loa type. The epidemiology, clinical features, diagnosis and treatment of filariasis is described. In the western literature revised, reactive arthritis has been described but none of the other clinical features of our case. The presence of circulating immune complex might explain the pathogenic mechanism. We believe that filariae should be included amongst the causes of hypersensitivity vasculitis and in the differential diagnosis of eosinophilic vasculitis.

Prevalencia y factores predictores de infección tuberculosa latente en un centro penitenciario tipo español / Prevalence and associated risk factors of latent tuberculosis infection in Spanish prison

Objetivo: Determinar la prevalencia de infección tuberculosa latente (ITL) en un centro penitenciario tipo español, analizar las principales variables sociodemográficas y clínicas asociadas a este padecimiento, y estimar el porcentaje de individuos con ITL que han realizado tratamiento quimioprofiláctico. Materiales y métodos: Estudio descriptivo transversal incluyendo a los internos registrados en el Centro Penitenciario Madrid VI a fecha de 16/07/2016. Criterios de exclusión: antecedente de enfermedad tuberculosa o no disponer de prueba de tuberculina actualizada conforme al Programa de Prevención y Control de Tuberculosis en el Medio Penitenciario. Recogida de las variables desde los programas SANIT, SIP y mediante revisión de los historiales clínicos de los internos. Descripción de la población participante y comparación de la frecuencia de distribución de las variables predictoras en los grupos de ITL presente y ausente, calculando el valor p mediante las pruebas de Chi cuadrado y U de Mann-Whitney. Análisis bivariante y multivariante mediante regresión logística. Resultados: 936 pacientes incluidos. La prevalencia de ITL es del 54,6%, y se ha relacionado con las variables edad, sexo y nacionalidad de procedencia, siendo la edad la que mayor fuerza de asociación ha demostrado. Entre el resto de los factores analizados, solo la infección por el virus de la hepatitis C se comporta como elemento predictor de ITL. El 30,3% de los individuos con ITL ha completado o se encuentra realizando tratamiento quimioprofiláctico en el momento del estudio. Discusión: La prevalencia de ITL en la población penitenciaria española actual es alta. Los resultados refuerzan la importancia de su cribado en el medio penitenciario, especialmente en aquellos grupos de mayor riesgo, así como la necesidad de un mayor esfuerzo en la indicación y la cumplimentación del tratamiento quimioprofiláctico (AU)

Aim: To determine the prevalence of latent tuberculosis infection (LTI) in a Spanish prison, analyze the main sociodemographic and clinical variables associated with this condition and estimate the percentage of individuals with LTI who have received chemoprophylactic treatment. Materials and methods: Cross-sectional study including inmates hosted in the Madrid VI Prison on 16/07/2016. Exclusion criteria: history of tuberculosis; non-updated tuberculin test according to the Tuberculosis Prevention and Control Program in Prisons protocol. Information of the variables was collected from SANIT and SIP programs, and by checking the clinical records of inmates. Description of the participant population and comparison between the frequency of distribution of the independent variables in LTI present and absent groups were performed, the last calculating the p value with Ji2 and Mann-Whitney U tests. Bivariate and multivariate analysis have been carried out with a logistic regression model. Results: 936 individuals have been included. The prevalence of LTI in prison is 54.6%. This condition has been linked to the sociodemographic variables age, sex and nationality of origin, being age the one that has shown the strongest association. Among the other factors analyzed, only HCV infection behaves as a predictor of LTI. 30.3% of the individuals with LTI have completed or are receiving chemoprophylactic treatment in the moment of the study. Discussion: LTI prevalence is high in the Spanish current prison population. The results of the study emphasize the relevance of the LTI screening in the prison setting, specially among high risk groups, and point out the need of a greater effort in the indication and completion of the chemoprophylactic treatment (AU)

[The progression of liver fibrosis in prison inmates co-infected by HIV and HCV who started on boosted protease inhibitor therapy]. / Evolución de la fibrosis hepática en reclusos coinfectados por VIH y VHC que inician tratamiento con inhibidores de la proteasa potenciados.

OBJECTIVES: To analyse the progression of liver fibrosis as measured by elastography and biochemical testing in prisoninmates co-infected by HIV and HCVwho started on ritonavir-boosted protease inhibitor (PI) therapy. METHODS: A prospective, observational and multi-centre study. The progression of liver fibrosis as measured by transient elastography (FibroScan) and biochemical testing was monitored for 48 weeks in a Spanish prison population co-infected with HIV and HCV. RESULTS: Of the 94 patients included, 54 (57.4%) were followed-up for 48 weeks. At week 48, no significant changes were seen in the grade of fibrosis measured using FibroScan (8.1 kPa vs. 8.3 kPa; p=0.20) or the Forns index (5.6 vs. 5.1; p= 0.50), although significant changes were detected using the APRI (0.7 vs. 0.6; p=0.05) and the FIB-4 indexes (p= 0.02).When measurement was done compared to baseline fibrosis, it was seen that therapy reduced the percentage of patients with fibrosis ≥3 but <4 (50% vs. 15%; p=0.001), but no change was seen in those found to have grade 4 fibrosis at baseline (20.4% vs. 20.4%). CONCLUSION: The inmates co-infected with HIV and HCV who were started on antiretroviral therapy with the boosted protease inhibitor (PI) showed stasterilizationbilisation of the liver fibrosis as measured with FibroScan after one year of follow-up. Overall, the therapy improved fibrosis when measured using the APRI or FIB-4 indexes, but not when using the Forns index or elastography.

Evolución de la fibrosis hepática en reclusos coinfectados por VIH y VHC que inician tratamiento con inhibidores de la proteasa potenciados / The progression of liver fibrosis in prison inmates co-infected by HIV and HCV who started on boosted protease inhibitor therapy

Objetivos: Analizar la evolución de la fibrosis hepática medida por elastografía y pruebas bioquímicas en reclusos coinfectados por VIH y VHC que han iniciado tratamiento antirretroviral con lopinavir/ritonavir u otros inhibidores de la proteasa potenciados con ritonavir. Métodos: Estudio prospectivo, observacional y multicéntrico. Se comprobó durante 48 semanas la evolución de la fibrosis hepática medida mediante elastografía de transición (FibroScan) y pruebas bioquímicas en población penitenciaria española coinfectada por VIH y VHC. Resultados: De los 94 pacientes incluidos, 54 (57,4%) fueron seguidos durante 48 semanas. En la semana 48, no hubo cambios significativos en el grado de fibrosis medida mediante FibroScan (8,1 Kpa vs 8,3; p=0.20) o índice de FORNS (5,6 vs 5,1; p=0,50), aunque sí con el índice APRI (0.7 vs 0.6; p=0.05) y el índice FIB-4 (p=0,02). Cuando la medición se realizó en función del grado de fibrosis basal, se observó que el tratamiento redujo el porcentaje de pacientes con fibrosis basal de grado 3/4 (50% vs 15%; p=0,001), pero no hubo cambios en los que ya tenían basalmente grado 4 (20,4% vs 20,4%). Conclusión: Los reclusos coinfectados por VIH y VHC que inician tratamiento antirretroviral con lopinavir/ritonavir muestran una estabilización de la fibrosis hepática medida con FibroScan® tras un año de seguimiento. En conjunto, el tratamiento mejoró la fibrosis cuando la referencia de medición fue el índice APRI y el FIB-4, pero no con el índice FORNS o la elastografía (AU)

Objectives: To analyse the progression of liver fibrosis as measured by elastography and biochemical testing in prison inmates co-infected by HIV and HCVwho started on ritonavir-boosted protease inhibitor (PI) therapy. Methods: A prospective, observational and multi-centre study. The progression of liver fibrosis as measured by transient elastography (FibroScan) and biochemical testing was monitored for 48 weeks in a Spanish prison population co-infected with HIV and HCV. Results: Of the 94 patients included, 54 (57.4%) were followed-up for 48 weeks. At week 48, no significant changes were seen in the grade of fibrosis measured using FibroScan (8.1 kPa vs. 8.3 kPa; p=0.20) or the Forns index (5.6 vs. 5.1; p=0.50), although significant changes were detected using the APRI (0.7 vs. 0.6; p=0.05) and the FIB-4 indexes (p= 0.02).When measurement was done compared to baseline fibrosis, it was seen that therapy reduced the percentage of patients with fibrosis ≥3 but <4 (50% vs. 15%; p=0.001), but no change was seen in those found to have grade 4 fibrosis at baseline (20.4% vs. 20.4%). Conclusion: The inmates co-infected with HIV and HCV who were started on antiretroviral therapy with the boosted protease inhibitor (PI) showed stasterilizationbilisation of the liver fibrosis as measured with FibroScan after one year of follow-up. Overall, the therapy improved fibrosis when measured using the APRI or FIB-4 indexes, but not when using the Forns index or elastography (AU)

[Expert recommendations for the diagnosis and treatment of chronic hepatitis C infection in the prison setting]. / Recomendaciones de expertos sobre el diagnóstico y tratamiento de la hepatitis C crónica en el medio penitenciario.

The prevalence of HCV infection in Spanish prisons is very high (38.5%). The characteristics of the infected patients, particularly the high rate of HIV coinfection, makes it very likely that the morbidity and mortality produced by serious liver disease secondary to this infection will increase considerably in the coming years. A group of Spanish experts with experience in patients who are inmates has been invited to establish a series of recommendations for the diagnosis and treatment of chronic hepatitis C infection in Spanish prisons.

Brote nosocomial de gripe A en un hospital de tercer nivel / Nosocomial influenza outbreak in a tertiary hospital

Objetivo: Describir un brote nosocomial de gripe A. Material y métodos: Se describe el Servicio de Medicina Digestiva donde aparecieron los casos. A los pacientes ingresados (n=47), entre el 17 de febrero y el 10 de marzo de 2012, se les realizó una encuesta epidemiológica, y a partir de esta, se describen sus características clínico-epidemiológicas (motivo de ingreso, días de hospitalización hasta el inicio de los síntomas, etc.) de los casos de gripe. Se evaluó la cobertura vacunal y la presencia de sintomatología respiratoria entre el personal sanitario (n=44), y se describen las medidas de control de infecciones puestas en marcha. Resultados: Hubo 10 pacientes con sospecha de gripe (seis de ellos confirmados) y 12 profesionales sanitarios con sospecha (dos confirmados). La cobertura vacunal en el personal sanitario de la unidad era del 18,2% (8/44). Conclusión: Se ha producido una asociación temporo-espacial de casos de gripe de adquisición nosocomial, donde la baja cobertura de la vacunación antigripal y la escasa adherencia a las Precauciones Estándar por parte del personal sanitario han podido ser factores determinantes para su aparición

Objective: Describe a nosocomial flu outbreak. Material and methods: The Service of Digestive Medicine where cases appeared is here described. Patients admitted (n=47) between February 17 and March 10, 2012 an epidemiological survey was does to each of them, obtaining their clinical and epidemiological characteristics (entry reason number of hospitalization days until the beginning of the symptoms, etc.) of the influenza cases. The vacunal coverage and the presence of respiratory symptoms in the health personnel were evaluated (n- 44). Moreover, the descriptions of all the infectious diseases control measures that were initiated are also described. Results: There were 10 patients (six of them confirmed) and 12 health professionals (two of them confirmed) with flu suspicion. The vaccination coverage in the health care workers of the unit was 18, 2% (8/44). Conclusions: An association was established between those cases of nosocomial influenza and the low influenza vaccination coverage of healthcare workers, which also had poor adherence to Standard Precautions. This may have been decisive risk factors for the emergence of this nosocomial outbreak of influenza

[Visceral leishmaniasis in Alicante. Analysis of 21 cases]. / Leishmaniasis visceral en Alicante. Análisis de 21 casos.

We present 21 cases of visceral Leishmaniasis diagnosed in our hospital during the past 8 years. The diagnostic method used was the visualization of the parasite in bone marrow aspiratory puncture. All cases presented fever at admission, hepatosplenomegaly, anemia elevated sedimentation rate and polyclonal gammapathy. Two of our patients were diagnosed of AIDS during the course of the disease. Cure was observed in all cases after one cycle treatment with pentavalent antimonials except for the two AIDS cases one of whom died due to cerebral toxoplasmosis. We point out visceral Leishmaniasis as an opportunistic infection in patients with AIDS and its resistance to the usual treatment.

[Liver tuberculous abscess in patients with human immunodeficiency virus infection: report of 2 cases and review of the literature]. / Abscesos tuberculosos hepáticos en pacientes con infección por el virus de la inmunodeficiencia humana: presentación de dos casos y revisión de la literatura.

Two cases are reported of hepatic tuberculous abscesses (HTBA) in patients infected with the human immunodeficiency virus (HIV), stressing the rarity of this location. Likewise, a review is made of cases reported in the literature. Our two patients presented with a prolonged febrile condition, with constitutional symptoms and nonspecific abdominal discomfort. In one patient the hepatic location was accompanied by a pulmonar location too. The course of the patients was good and symptoms subsided with tuberculostatic therapy. To note the possibility of finding hepatic tuberculous abscesses in HIV patients with prolonged fever and nonspecific abdominal pain more frequently than considered until now.

Recomendaciones de expertos sobre el diagnóstico y tratamiento de la hepatitis C crónica en el medio penitenciario / Expert recommendations for the diagnosis and treatment of chronic hepatitis C infection in the prison setting

La prevalencia de la infección por el virus de la hepatitis C (VHC) en las prisiones españolas es muy elevada (38,5%). Las características de los pacientes infectados, especialmente la elevada coinfección con el virus de la inmunodeficiencia humana (VIH), hacen probable que la morbilidad y mortalidad producida por enfermedad hepática grave secundaria a esta infección aumente de forma considerable en los próximos años. Un grupo de expertos multidisciplinar con experiencia con pacientes internados en prisiones españolas ha sido invitado a establecer una serie de recomendaciones para el diagnóstico y tratamiento de la hepatitis C en las prisiones españolas

The prevalence of HCV infection in Spanish prisons is very high (38.5%). The characteristics of the infected patients, particularly the high rate of HIV coinfection, makes it very likely that the morbidity and mortality produced by serious liver disease secondary to this infection will increase considerably in the coming years. A group of Spanish experts with experience in patients who are inmates has been invited to establish a series of recommendations for the diagnosis and treatment of chronic hepatitis C infection in Spanish prisons

Aplicación de una técnica de lavado seminal en pacientes infectados por VHC y coinfectados con VIH / Application of a technique of seminal washing in patients infected by VHC and co-infected with HIV

Objetivo Estudiar el aclaramiento de la carga viral en muestras de semen en pacientes con VHC y coinfectados con VIH tras realizar dos lavados seguidos de swim-up. Diseño experimental Estudio longitudinal prospectivo Pacientes Once pacientes con serología VHC positiva, seis de ellos coinfectados por VIH. Métodos Las muestras de semen se recogieron por masturbación, extrayéndose el mismo día muestras sanguíneas a los pacientes para la determinación de carga viral plasmática (CVP), genotipaje VHC, poblaciones linfocitarias CD4/CD8, anticuerpos anti-VHC y serología VIH: En una alícuota inicial se hizo el seminograma y al resto del semen se le realizaron dos lavados con medio de cultivo, seguidos de un swim-up determinándose CV seminal en todas las fracciones plasmáticas y celulares en el Cobas Amplicor HIV monitor 1.5 y Cobas TaqMan HCV. Resultados Grupo VHC (edad 37,2 años; 60% genotipo 3; anticuerpos anti VHC: 35,3; CVP-VHC: 1xl06 copias ARN/ml. Grupo coinfección (edad 34,5 años; 80% genotipo 3; media anticuerpos anti-VHC: 34,8, CVP-VHC: 4xlOS copias ARN/ml. No se detectó CV seminal- VHC en ninguna de las muestras de semen detectándose CV seminal- VIH en el 85% de las muestras, siendo sus medias en las distintas fracciones seminales: Sedimento celular inicial: 1,8xl03 copias ARN+ADN/ml; Plasma seminal inicial: 8,9xl03 copias ARN/ml; Primer lavado: 4, 7xl 04 copias ARN/ml; Segundo lavado: 876 copias ARN/ml; Swim-up: Indetectable en todos los pacientes. Conclusiones El protocolo de dos lavados seguido de swim-up nos permite eliminar hasta límites indetectables la CV seminal en los pacientes a estudio. Los resultados del estudio deben ser completados con una casuística mayor

Objective To study the clearance of the viralload in samples of semen in patients with VHC and co-infected with HIV alter two washings followed by swim-up. Experimental design Prospective longitudinal study. Patients Eleven patients with positive serology VHC, six of them co-infected by HIV: Methods The samples of semen were laten by masturbation. The same day, blood samples were extracted from patients for the determination of plasmatic viral load (CVP), genotype VHC, linfocyte populations CD4/CD8, antibodies anti-VHC and HIV serology. In an initial sample a seminograme was carried out.To the rest of the semen samples the following was carried out: two washings to culture medium followed by a swim-up finding out the seminal CV in all the plasmatic and cellular fractions in the Cobas Amplicor HIV 1,5 monitor and Cobas TaqMan HCV: Results Group VHC (age 37,2 years; 60% genotype 3; antibodies anti VHC: 35.3,. CVP-VHC: lxl06 copiesRNA/mililiter: Group co-infection (age 34,5 years; 80% genotype 3; average antibodies anti VHC:34.8, CVP-VHC: 4xl05 copies RNA/mililiter: lt was not detected CV seminal- VHC in any of the samples of semen detecting itself CV seminal- VIH in 85% of the samples being its averages in the different seminal fractions: lnitial cellular sediment: 1.8xl03 copies RNA+DNAmililiter; lnitial seminal plasma: 8.9xl03 copies RNA/mililiter; First washing: 4.7xl04 copies RNA/mililiter; Second washing: 876 copies RNA/mililiter; Swim-up: Indetectable in all the patients. Conclusions The protocol of the two washings followed by a swim-up allows us to reduce below detectable levels the seminal CV in the population of the study. The result must be completed with a greater number of patients