Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort.

OBJECTIVES: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). METHODS: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. RESULTS: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. CONCLUSION: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective.

Serum Calcitonin Gene-Related Peptide α and ß Levels are Increased in COVID-19 Inpatients.

BACKGROUND: Vasoactive peptides play an important role in a wide range of physiological and pathological conditions. Due to its known functions, the calcitonin gene-related peptide (CGRP) has been suggested as a possible modulator of the hyperimmune response in COVID-19 and thus, blocking its action may lessen the pulmonary effects of COVID-19. AIM OF THE STUDY: To compare the circulating levels of CGRPα and CGRPß in healthy controls compared to hospitalized COVID-19 patients. The study also analyzed how different comorbidities and treatments may affect these concentrations in cases of COVID-19 infection with pulmonary involvement METHODS: Serum samples were collected from the antecubital vein of 51 control subjects (mean age = 55 ± 14 years; range = 26-77; 56.9% female) and 52 patients hospitalized with COVID-19 infection (mean age = 55 ± 13; range = 23-77; 55.8% female) from December 2020 to May 2021. Enzyme-linked immunosorbent assays (ELISAs) were used for CGRPα (Abbexa, UK) and CGRPß (CUSABIO, China) measurements. Comorbidities, symptoms, and treatments of infection were listed. RESULTS: The results showed that the serum levels of both isoforms of CGRP were significantly higher in patients with COVID-19 (α: 57.9 ± 35.8 pg/mL; ß: 6.1 ± 2.6 pg/mL) compared to controls (α: 41.8 ± 25.4 pg/mL; ß: 4.5 ± 2.4 pg/mL) (p <0.01). Also, the presence of arterial hypertension (HT), obesity, or corticosteroid treatment significantly alter the serum concentration of CGRPα in the subgroups compared to controls. CONCLUSION: The elevated serum CGRP levels found in our COVID-19 group compared to controls may suggest that CGRP plays a role in the pathophysiology of the disease, more specifically, in the cytokine storm and in the pulmonary involvement. Future studies should focus on the source of this CGRP elevation.

Isavuconazole for the Treatment of Invasive Mold Disease in Solid Organ Transplant Recipients: A Multicenter Study on Efficacy and Safety in Real-life Clinical Practice.

BACKGROUND: Isavuconazole has theoretical advantages over other mold-active triazoles for the treatment of invasive aspergillosis and mucormycosis after solid organ transplantation (SOT). The available clinical experience, nevertheless, is scarce. METHODS: We performed a retrospective study including all adult SOT recipients with proven or probable invasive mold disease (IMD) that received isavuconazole for ≥24 h as first-line or salvage therapy at 10 Spanish centers between September 2017 and November 2021. The primary efficacy outcome was clinical response (complete or partial resolution of attributable symptoms and findings) by weeks 6 and 12. Safety outcomes included the rates of treatment-emergent adverse events and premature isavuconazole discontinuation. RESULTS: We included 81 SOT recipients that received isavuconazole for a median of 58.0 days because of invasive aspergillosis (n = 71) or mucormycosis (n = 10). Isavuconazole was used as first-line (72.8%) or salvage therapy due because of previous treatment-emergent toxicity (11.1%) or refractory IMD (7.4%). Combination therapy was common (37.0%), mainly with an echinocandin or liposomal amphotericin B. Clinical response by weeks 6 and 12 was achieved in 53.1% and 54.3% of patients, respectively, and was more likely when isavuconazole was administered as first-line single-agent therapy. At least 1 treatment-emergent adverse event occurred in 17.3% of patients, and 6.2% required premature discontinuation. Daily tacrolimus dose was reduced in two-thirds of patients by a median of 50.0%, although tacrolimus levels remained stable throughout the first month of therapy. CONCLUSIONS: Isavuconazole is a safe therapeutic option for IMD in SOT recipients, with efficacy comparable to other patient groups.

Prognostic models for mortality after cardiac surgery in patients with infective endocarditis: a systematic review and aggregation of prediction models.

BACKGROUND: There are several prognostic models to estimate the risk of mortality after surgery for active infective endocarditis (IE). However, these models incorporate different predictors and their performance is uncertain. OBJECTIVE: We systematically reviewed and critically appraised all available prediction models of postoperative mortality in patients undergoing surgery for IE, and aggregated them into a meta-model. DATA SOURCES: We searched Medline and EMBASE databases from inception to June 2020. STUDY ELIGIBILITY CRITERIA: We included studies that developed or updated a prognostic model of postoperative mortality in patient with IE. METHODS: We assessed the risk of bias of the models using PROBAST (Prediction model Risk Of Bias ASsessment Tool) and we aggregated them into an aggregate meta-model based on stacked regressions and optimized it for a nationwide registry of IE patients. The meta-model performance was assessed using bootstrap validation methods and adjusted for optimism. RESULTS: We identified 11 prognostic models for postoperative mortality. Eight models had a high risk of bias. The meta-model included weighted predictors from the remaining three models (EndoSCORE, specific ES-I and specific ES-II), which were not rated as high risk of bias and provided full model equations. Additionally, two variables (age and infectious agent) that had been modelled differently across studies, were estimated based on the nationwide registry. The performance of the meta-model was better than the original three models, with the corresponding performance measures: C-statistics 0.79 (95% CI 0.76-0.82), calibration slope 0.98 (95% CI 0.86-1.13) and calibration-in-the-large -0.05 (95% CI -0.20 to 0.11). CONCLUSIONS: The meta-model outperformed published models and showed a robust predictive capacity for predicting the individualized risk of postoperative mortality in patients with IE. PROTOCOL REGISTRATION: PROSPERO (registration number CRD42020192602).

La formación de grado en enfermedades infecciosas, resistencia y uso de antibióticos desde la perspectiva de los estudiantes de Medicina / Perspective of Spanish medical students regarding undergraduate education in infectious diseases, bacterial resistance and antibiotic use

Introducción: Una de las principales herramientas para optimizar el uso de los antibióticos es la formación de los prescriptores. El objetivo de este trabajo es conocer la opinión de los estudiantes de Medicina españoles sobre la formación en enfermedades infecciosas. Material y métodos: Se distribuyó un cuestionario on line anonimizado entre estudiantes de sexto curso a través de distintos canales. El cuestionario incluyó 45 preguntas sobre conocimientos, actitudes y percepciones sobre el diagnóstico, resistencia antimicrobiana, uso de antibióticos y la formación de pregrado en enfermedades infecciosas. Resultados: Se recibieron un total de 441 encuestas de 21 facultades. Se obtuvieron 374 respuestas (84,8%) de las 8 facultades más representadas, con una tasa de respuesta del 28,9%. La mayoría de los alumnos se sentían preparados para identificar los signos clínicos de infección (418; 94,8%) y para interpretar correctamente las pruebas de laboratorio (382; 86,6%). Reconocieron saber elegir un antibiótico con seguridad sin consultar libros ni guías (178; 40,4%). Solo 107 alumnos (24,3%) consideraron haber recibido suficiente formación en el uso prudente de los antimicrobianos. Respecto a los métodos de aprendizaje, se percibieron como más útiles la discusión de casos clínicos, los rotatorios en servicios o unidades de enfermedades infecciosas y los talleres de pequeños grupos: se evaluaron favorablemente en un 76,9; en un 76 y en un 68,8% de los casos, respectivamente. Conclusión: Los estudiantes de Medicina se encuentran más seguros en el diagnóstico de enfermedades infecciosas que en el tratamiento antibiótico. Asimismo, sienten la necesidad de recibir mayor formación en antibioterapia y uso prudente en antibióticos

Introduction: One of the main tools to optimize antibiotics use is education of prescribers. The aim of this article is to study undergraduate education in the field of infectious diseases, antimicrobial resistance and antibiotic stewardship from the perspective of Spanish medical students. Material and methods: An anonymous online questionnaire was distributed among sixth grade students using different channels in Europe, within the ESGAP Student-Prepare survey. The questionnaire included 45 questions about knowledge, attitudes and perceptions about diagnosis, bacterial resistance, use of antibiotics and undergraduate training in infectious diseases. We present here the Spanish results. Results: A total of 441 surveys were received from 21 medical schools. A total of 374 responses (84.8%) were obtained from the 8 most represented faculties, with a response rate of 28.9%. Most students felt adequately prepared to identify clinical signs of infection (418; 94.8%) and to accurately interpret laboratory tests (382; 86.6%). A total of 178 (40.4%) acknowledged being able to choose an antibiotic with confidence without consulting books or guidelines. Only 107 (24.3%) students considered that they had received sufficient training in judicious use of antibiotics. Regarding learning methods, the discussion of clinical cases, infectious diseases units rotatories and small group workshops were considered the most useful, being evaluated favorably in 76.9%, 76% and 68.8% of the cases. Conclusion: Medical students feel more confident in the diagnosis of infectious diseases than in antibiotic treatment. They also feel the need to receive more training in antibiotics and judicious antibiotic use

Perspective of Spanish medical students regarding undergraduate education in infectious diseases, bacterial resistance and antibiotic use. / La formación de grado en enfermedades infecciosas, resistencia y uso de antibióticos desde la perspectiva de los estudiantes de Medicina.

INTRODUCTION: One of the main tools to optimize antibiotics use is education of prescribers. The aim of this article is to study undergraduate education in the field of infectious diseases, antimicrobial resistance and antibiotic stewardship from the perspective of Spanish medical students. MATERIAL AND METHODS: An anonymous online questionnaire was distributed among sixth grade students using different channels in Europe, within the ESGAP Student-Prepare survey. The questionnaire included 45 questions about knowledge, attitudes and perceptions about diagnosis, bacterial resistance, use of antibiotics and undergraduate training in infectious diseases. We present here the Spanish results. RESULTS: A total of 441 surveys were received from 21 medical schools. A total of 374 responses (84.8%) were obtained from the 8 most represented faculties, with a response rate of 28.9%. Most students felt adequately prepared to identify clinical signs of infection (418; 94.8%) and to accurately interpret laboratory tests (382; 86.6%). A total of 178 (40.4%) acknowledged being able to choose an antibiotic with confidence without consulting books or guidelines. Only 107 (24.3%) students considered that they had received sufficient training in judicious use of antibiotics. Regarding learning methods, the discussion of clinical cases, infectious diseases units rotatories and small group workshops were considered the most useful, being evaluated favorably in 76.9%, 76% and 68.8% of the cases. CONCLUSION: Medical students feel more confident in the diagnosis of infectious diseases than in antibiotic treatment. They also feel the need to receive more training in antibiotics and judicious antibiotic use.

Potential impact of the 4CMenB vaccine on oropharyngeal carriage of Neisseria meningitidis.

The analysis of the potential impact of the meningococcal vaccines in asymptomatic carriers has become one of the key aspects in the evaluation of new vaccines and of their impact on disease control. An important step in this direction is provided by the analysis of the sequence variability and surface-exposure of the 4CMenB (Bexsero®) vaccine antigens, as well as the cross-reactivity of vaccine induced antibodies, in isolates from healthy carriers. The Spanish Reference Laboratory, in collaboration with the University Hospital Marqués de Valdecilla in Santander (Spain), carried out a meningococcal carrier survey between May 2010 and April 2012 (population aged 4 to 19 years). The present study was done on 60 meningococcal carrier strains representative of the overall strain panel obtained and compared to invasive strains isolated in Spain in the same time. We found quantifiable levels of fHbp and NHBA expression and immunologic cross-reactivity in 10% and 75% of analyzed carrier strains, respectively, so the potential impact of the 4CMenB vaccine on Spanish asymptomatic carrier strains is expected to be mediated by the NHBA antigen.

Antibióticos humanos modulados por calcitriol: nuevos aspectos fisiopatológicos de la hipovitaminosis D / Calcitriol-modulated human antibiotics: New pathophysiological aspects of vitamin D

El calcitriol ha sido considerado durante años exclusivamente como una hormona reguladora del metabolismo fosfocálcico, pero últimamente se ha demostrado que numerosas células implicadas en la inmunidad innata (epitelios de barrera, monocitos/macrófagos, etc.) son capaces de reconocer determinadas moléculas repetitivas características de diversos gérmenes patógenos mediante receptores de membrana o intranucleares. La activación de estos receptores induce la síntesis de la 1α-hidroxilasa, con lo que dichas células son capaces de sintetizar calcitriol a partir de la 25 hidroxivitamina D circulante. El calcitriol, a través del receptor la vitamina D, modula la expresión de determinados péptidos antimicrobianos, como la catelicidina, la β2-defensina o la hepcidina. Estos péptidos representan un mecanismo versátil de la lucha antibacteriana innata y su producción se ve alterada en la hipovitaminosis D. Se realiza un análisis de la literatura sobre sus mecanismos de secreción, las concentraciones en diversos líquidos orgánicos, y los mecanismos de acción y su relación con la vitamina D (AU)

Traditionally, calcitriol has been considered a calcium and phosphate regulating hormone, but has recently been shown to play a pivotal role in innate immunity. Many barrier and immune cells have membrane and intracellular receptors that recognize different microbial antigens. Activation of these receptors induces synthesis of 1α-hydroxylase, which acts on 25 hydroxyvitamin D to generate intracellular calcitriol. Calcitriol activates its receptor and enhances the synthesis of important human antibiotics like cathelicidin and β2-defensin while inhibiting hepcidin. These pluripotent peptides have an important role in innate immunity, and their regulation is abnormal in hypovitaminosis D. The literature on their secretion mechanisms, levels in different organic fluids, mechanism of action, and relationship with vitamin D is reviewed here (AU)

Calcitriol-modulated human antibiotics: New pathophysiological aspects of vitamin D.

Traditionally, calcitriol has been considered a calcium and phosphate regulating hormone, but has recently been shown to play a pivotal role in innate immunity. Many barrier and immune cells have membrane and intracellular receptors that recognize different microbial antigens. Activation of these receptors induces synthesis of 1α-hydroxylase, which acts on 25 hydroxyvitamin D to generate intracellular calcitriol. Calcitriol activates its receptor and enhances the synthesis of important human antibiotics like cathelicidin and ß2-defensin while inhibiting hepcidin. These pluripotent peptides have an important role in innate immunity, and their regulation is abnormal in hypovitaminosis D. The literature on their secretion mechanisms, levels in different organic fluids, mechanism of action, and relationship with vitamin D is reviewed here.

Q fever endocarditis in Spain. Clinical characteristics and outcome.

OBJECTIVES: To describe the clinical presentation of a large number of Q fever endocarditis (QFE) and its management considering the role of serology. PATIENTS AND METHODS: Eighty-three patients with definite QFE (56 native and 27 prosthetic valve) with a long-term follow-up after stopping treatment (median: 48 months) were included. Final outcome (cure or relapse) was compared according with the serological titre at the end of therapy: less than 1:400 of phase I Ig G antibodies by indirect immunofluorescence (group 1, N=23) or more than 1:400 (group 2, N=30). RESULTS: Eleven patients (13.2%) died from QFE and other 8 died for other reasons not related to endocarditis during follow-up. Surgery was performed in 61 (73.5%) patients and combined antimicrobial treatment was long (median: 23 months, IQR: 12 - 36). Seven relapses were observed, but five of them had received an initial incomplete antibiotic regimen. In patients who completed the programmed treatment (range: 12 - 89 months), serological titres at the end of therapy were not useful for predicting the final outcome: one relapse in each group. CONCLUSIONS: QFE requires a prolonged antimicrobial treatment, but serological titres are not useful for determining its duration.

Q fever endocarditis in Spain. Clinical characteristics and outcome

Objectives To describe the clinical presentation of a large number of Q fever endocarditis (QFE) and its management considering the role of serology. Patients and methods Eighty-three patients with definite QFE (56 native and 27 prosthetic valve) with a long-term follow-up after stopping treatment (median: 48 months) were included. Final outcome (cure or relapse) was compared according with the serological titre at the end of therapy: less than 1:400 of phase I Ig G antibodies by indirect immunofluorescence (group 1, N=23) or more than 1:400 (group 2, N=30).Results Eleven patients (13.2%) died from QFE and other 8 died for other reasons not related to endocarditis during follow-up. Surgery was performed in 61 (73.5%) patients and combined antimicrobial treatment was long (median: 23 months, IQR: 12 – 36). Seven relapses were observed, but five of them had received an initial incomplete antibiotic regimen. In patients who completed the programmed treatment (range: 12 – 89 months), serological titres at the end of therapy were not useful for predicting the final outcome: one relapse in each group. Conclusions QFE requires a prolonged antimicrobial treatment, but serological titres are not useful for determining its duration (AU)

Objetivos Describir la presentación clínica de la endocarditis por fiebre Q (EFQ) y su manejo terapéutico, así como el papel de la serología en este aspecto. Pacientes y método Se incluyeron 83 casos de EFQ definidas (56 nativas y 27 protésicas) con un seguimiento prolongado después de la finalización del tratamiento (mediana de 48 meses). La evolución final (curación o recidiva) se comparó dividiendo los casos en dos grupos según el título serológico al final del tratamiento: menos de 1:400 para Ac Ig G en fase I mediante inmunofluorescencia indirecta (grupo 1, N=23) o más de 1:400 (grupo 2, N=30).Resultados Once pacientes (13.2%) murieron por EFQ y otros 8 lo hicieron durante el seguimiento por diversas razones no relacionadas con la endocarditis. Fueron operados 61 (73.5%) pacientes y el tratamiento antimicrobiano fue muy prolongado (mediana: 23 meses, RIQ: 12 – 36). Siete pacientes recidivaron al cesar el tratamiento, pero cinco de ellos no habían completado el inicialmente programado. En los pacientes que sí completaron el tratamiento antimicrobiano (rango: 12 – 89 meses), los títulos serológicos observados al final del mismo no fueron útiles para predecir la evolución final, observándose una recidiva en cada uno de los grupos. Conclusiones La EFQ requiere un tratamiento antimicrobiano prolongado, pero los títulos serológicos no son un instrumento útil para determinar su duración (AU)

Implicaciones de las resistencias bacterianas en las infecciones urinarias adquiridas en la comunidad / Involvement of bacterial resistances in community-acquired urinary infections

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