The factors associated with the trend in incidence of Bacteraemia and associated mortality over 30 years.

BACKGROUND: Studies have reported increased incidence of BSI over the past decades and indicate that it is necessary to investigate the causes. The aim of this study was to determine the factors affecting trends in the incidence of bacteraemias and associated mortality. METHODS: We conducted a retrospective cohort study assessing prospectively collected data of all clinically significant bacteraemias between 1991 and 2020 in a 450-bed hospital. We determined the evolution of bacteraemia-associated incidence, adjusted 30-day mortality and performed multivariable logistic regression to compare the evolution of variables associated with mortality between 5-year periods. RESULTS: 6777 episodes were included, 59.7% males, age 66.5 ± 18.2, 39.4% ≥ 75 years. The incidence total increased: 43.8/100,000/year in 1991-1995 to 205 in 2016-2020; community-acquired bacteraemia (24.9 to 139) and hospital-acquired (0.36/1000 inpatients-days to 1.09). Bacteraemia with source in vascular catheter, urinary and biliary tract increased. The 30-day mortality rate of patients was 1179/6777 (17.4%) in the whole series and population-adjusted mortality incidence increased from 11.4/100,000 in 1991-1996 to 28.4 in 2016-2020 (RR 2.49, 95% CI 2.01-3.08). Mortality was higher in men (18.2% vs 16.3%) and those over 74 years (22.2% vs 14.3%). Appropriate empirical antimicrobial treatment improved (66.5% to 73.1%), 30-day mortality of patients decreased from 26.1 to 13.9%. When comparing the evolution of the factors associated with mortality between 1991 and 1996 vs 2016-2020, the frequency of some variables associated with higher mortality increased: male sex (OR 1.38, 95% CI 1.10-1,74), age (OR 1.02, 1.01-10.3), immunosuppressive treatment (OR 3.1, 2.09-4.6), polymicrobial bacteraemia (OR 1.76, 1.12-2.79), and others decreased: severe sepsis/septic shock (OR 0.70, 0.52-0.93), spontaneous bacterial peritonitis in cirrhosis (OR 0.06, 0.02-0.23), endocarditis (OR 0.54, 0.35-0.83); on the other hand, the frequency of factors associated with lower mortality increased: urinary (OR 1.67, 95% CI 1.23-2.27) and bile tract source (OR 1.59, 1.04-2.43), and adequate empirical treatment (OR 1.42, 95% CI 1.10-1.83). CONCLUSIONS: The incidence of bacteraemia increased due to more elderly, co-morbid patients undergoing procedures and more device related bacteraemia. The percentage of mortality decreased because adequate empirical treatment improved, decreased spontaneous bacterial peritonitis in cirrhosis and endocarditis, and increased bacteraemia of urinary and biliary tract source.

Impact of the COVID-19 pandemic on tuberculosis management in Spain.

BACKGROUND: The impact of COVID-19 on the diagnosis and management of tuberculosis (TB) patients is unknown. METHODS: Participating centres completed a structured web-based survey regarding changes to TB patient management during the COVID-19 pandemic. The study also included data from participating centres on patients aged ≥18 diagnosed with TB in 2 periods: March 15 to June 30, 2020 and March 15 to June 30, 2019. Clinical variables and information about patient household contacts were retrospectively collected. RESULTS: A total of 7 (70%) TB units reported changes in their usual TB team operations. Across both periods of study, 169 patients were diagnosed with active TB (90 in 2019, 79 in 2020). Patients diagnosed in 2020 showed more frequent bilateral lesions in chest X-ray than patients diagnosed in 2019 (P = 0.004). There was a higher percentage of latent TB infection and active TB among children in households of patients diagnosed in 2020, compared with 2019 (P = 0.001). CONCLUSIONS: The COVID-19 pandemic has caused substantial changes in TB care. TB patients diagnosed during the COVID-19 pandemic showed more extended pulmonary forms. The increase in latent TB infection and active TB in children of patient households could reflect increased household transmission due to anti-COVID-19 measures.

Correlation between Streptococcus bovis bacteremia and density of cows in Galicia, northwest of Spain.

BACKGROUND: There are few data on the epidemiology of infections caused by Streptococcus bovis (Sb). Some studies suggest that both residence in rural areas and contact with livestock could be potential risk factors. METHODS: We performed a retrospective study for the period 2005-2016 of all cases of bacteremia caused by Sb in Galicia (a region in the northwest of Spain). The association between the incidence rate of Sb bacteremia and the number of cattle by province and district was analyzed. RESULTS: 677 cases were included with a median age of 76 years, 69.3% males. The most frequent infections were endocarditis (234 cases, 34.5%), primary bacteremia (213 cases, 31.5%) and biliary infection (119 cases, 17.5%). In 252 patients, colon neoplasms were detected (37.2%). S. gallolyticus subsp. gallolyticus was the predominant species (52.3%). Mortality was 15.5% (105 cases). The annual incidence rate was 20.2 cases/106 inhabitants and was correlated with the density of cattle (p < 0.001), but not with rurality. When comparing the two provinces with a strong predominance of rural population, but with important differences in the number of cattle, such as Orense and Lugo, with 6% and 47.7% of Galician cattle, respectively, the rates were very different: 15.8 and 43.6 cases/106, respectively, with an RR of 2.7 (95% CI, 2.08-3.71). Some districts of the province of Lugo had rates higher than 100 cases/106 inhabitants. CONCLUSIONS: Our study shows a significant correlation between the rates of Sb bacteremia and cattle density, suggesting a possible transmission of Sb from cows to people.

Meropenem antimicrobial stewardship program: clinical, economic, and antibiotic resistance impact.

There are few prospective studies with sufficient duration in time to evaluate clinical and antibiotic resistance impact of antibiotic stewardship programs (ASP). This is a descriptive study between January 2012 and December 2017, pre-post intervention. A meropenem ASP was initiated in January 2015; in patients who started treatment with meropenem, an infectious disease physician performed treatment recommendations to prescribers. Prospective information was collected to evaluate adequacy of meropenem prescription to local guidelines and to compare results between cases with accepted or rejected intervention. Analysis was performed to verify variables associated with intervention acceptance and with any significant change in meropenem consumption, hospital-acquired multidrug-resistant (MDR) bloodstream infections (BSIs), and 30-day all-cause crude death in MDR BSIs. Adequacy of meropenem prescription and de-escalation from meropenem treatment to narrower-spectrum antibiotic improved progressively over time, after ASP implementation (p < 0.001). Interventions on prescription were performed in 330 (38.7%) patients without meropenem justified treatment; in 269, intervention was accepted and in 61 not. Intervention acceptance was associated with shorter duration of treatment, cost, and inpatient days (p < 0.05); intervention rejection was not associated with severity of patient. During the period 2015-2017, meropenem consumption decreased compared with 2012-2014 (rate ratio [RR] 0.67; 95% CI 0.58-0.77, p < 0.001). Also decreased were hospital-acquired MDR BSI rate (RR 0.63; 95% CI 0.38-1.02, p = 0,048) and 30-day all-cause crude death in MDR BSIs (RR 0.45; 95% CI 0.14-1.24, p = 0.096), coinciding in time with ASP start-up. The decrease and better use of meropenem achieved had a sustained clinical, economic, and ecological impact, reducing costs and mortality of hospital-acquired MDR BSIs.

[Scrofuloderma with osteoarticular tuberculosis in the Ferrol health district]. / Escrofulodermia con tuberculosis osteoarticular en el área sanitaria de Ferrol.

INTRODUCTION: Scrofuloderma results from direct extension of an underlying tuberculous focus such as bone, joint or even the epididymis to the overlying skin, but is more frequent over a lymph node, mainly in the cervical region. METHODS: We analysed all cases of scrofuloderma with a bone or joint focus evaluated in the sanitary area of Ferrol, with a current population of 220,000, during a 15-year period. We describe the clinical, histopathological, and microbiological data of patients. RESULTS: We found 6 cases of scrofuloderma with osteoarticular tuberculosis. This series includes five men and one woman, aged 37 to 80. Visceral involvement was found in 3 patients (50 %). CONCLUSION: Osteoarticular tuberculosis comprises 10 % of all extrapulmonary tuberculous infections. There is a high probability of visceral involvement in patients with scrofuloderma. Underlying bone involvement should be rule out in all patients with scrofuloderma, especially in those with incomplete response to medical treatment.

Cardiopatía congénita tipo tronco común: supervivencia hasta los 53 años / Congenital herat disease of common thrunk type: survival to the age of 53 years

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[Resistance of Mycobacterium tuberculosis in Ferrol, Spain. Associated factors]. / Resistencias de Mycobacterium tuberculosis en Ferrol. Factores asociados.

OBJECTIVE: To know the frequency of resistances of Mycobacterium tuberculosis and the associated factors. PATIENTS AND METHODS: Prospective study of the sensitivity of Mycobacterium tuberculosis by means of the method of the proportions of Canetti in the Hospital Arquitecto Marcide-Profesor Novoa Santos (Ferrol, Spain) among 1991 and 1998. A descriptive and multiple regression analyses were performed. RESULTS: Were studied 355 strains. Primary resistance: Isoniazid 1.1%, Streptomycin 1.1%. Secondary resistance: Isoniazid 11.6%, in the 5.2% existed multidrug-resistance. The risk factors for drug-resistant tuberculosis were previous treatment (odds ratio [OR] = 10.9; 95% CI, 2.9-39.4) and age higher than 40 years (OR = 3.9; 95% CI, 1.1-14.5). CONCLUSIONS: A low frequency of resistance was observed. The factors associated with the resistances were previous treatment and age.

Rhinosinusitis and atopy in patients infected with HIV.

HYPOTHESIS: Rhinosinusitis is common during HIV infection; its prevalence is uncertain and could probably be related to clinical features, immunoallergological status, and diagnostic criteria METHODS: Seventy-four patients hospitalized with HIV infection were prospectively evaluated for the presence of rhinosinusitis based on clinical findings, nasal endoscopy, or paranasal sinus computed tomography (CT). Immune status, nasal smear, features of atopy (based on the prick test), and its contribution to sinusal inflammatory pathology were also evaluated. RESULTS: Most patients were severely immunosuppressed: CD4+ 155+/-201 cells/mL and 12+/-11% (mean +/- SD). Thirty-five percent of the patients presented at least two criteria of rhinosinusitis (clinical findings, nasal endoscopy, and CT: 35%; clinical findings and CT: 50%; nasal endoscopy and CT: 15%). CT scan showed multiple sinus involvement, opacification over 25% of the total volume of the maxillary sinus in 50% of patients, and opacification of the sphenoidal sinus in 40% of cases. Atopy was present in 18% of patients, a figure which reflects the expected prevalence in our geographic area. Two independent predictors were associated with a higher probability of rhinosinusitis: bilateral absence of maxillary infundibular patency (odds ratio, 7.5; 95% CI = 2.03-27.9) and low total count (odds ratio, 0.99; 95% CI = 0.99-1.00) or percentage of CD4+ (odds ratio, 0.93; 95% CI = 0.88-1.00). CONCLUSIONS: There is a high prevalence of rhinosinusitis in HIV-infected individuals. This finding is related to a decreased cellular immunity, but it does not appear to be related to IgE-related immediate hypersensitivity. Nasal endoscopy should be the first-step diagnostic test. However, when clinical suspicion exists and endoscopy fails to explain symptoms, CT scan is a valuable adjunct to establish this diagnosis.

[Thrombophlebitis of the lateral sinus. A more frequent complication than expected]. / Tromboflebitis del seno lateral. Una complicación más frecuente de lo esperado.

At present, the frequency of intracranial complications of middle ear infections has decreased sharply as a result of the use of more effective antibiotics. We report two cases of lateral sinus thrombosis, in a 2-year-old male and a 14-year-old male respectively, after middle ear infection that progressed to mastoiditis with osteitis. The severity of these complications underlines the importance of clinical awareness and early diagnosis by angiographic magnetic resonance imaging so that suitable treatment can be begun.

[Lost opportunities for preventing tuberculosis and derived costs; comment]. / Oportunidades perdidas para prevenir la tuberculosis y costes derivados.

BACKGROUND: We determined the extent to which opportunities for prevention were missed among patients with tuberculosis and the costs derived from the lack of prevention. METHOD: Descriptive study of patients with active tuberculosis were studied in the hospital ward of tuberculosis at the A. Marcide-Novoa Santos Centre (Ferrol, Spain), from September of 1991 to August of 1995. Risk factors to develop tuberculosis, vaccination with BCG, previous tuberculin skin test and previous history of drug prophylaxis or tuberculosis therapy were determined. Then, we determined whether they had undergone prevention procedures in accordance with current recommendations of the American Thoracic Society. An evaluation of the direct and indirect derived costs was carried out in patients with any missed opportunity for tuberculosis prevention. RESULTS: Out of 433 studied patients, 167 (38.6%) got missed any opportunity for prevention. Out of 167, 29 patients (6.7%) did not complete a previous treatment; 9 (2.1%) did not complete drug prophylaxis; 12 (2.8%) with known previous positive tuberculin skin test and an indication for drug prophylaxis never received it, and 117 (27%) with known indications for screening never received a skin test. 62 patients (53%) with known exposure to active pulmonary tuberculosis, and 65 (55.6%) with predisposing medical conditions. From the missed opportunities for prevention we calculated some direct costs of 116,909,911 pesetas and some indirect costs derived from the absence to work (141.9 +/- 114.3 days) and from the death of 6 patients for tuberculosis. CONCLUSIONS: A large percentage of missed opportunities to prevent the disease was found among patients with tuberculosis. This means a considerable expense that could have been avoided.

[The epidemiology of tuberculosis in El Ferrol]. / Epidemiología de la tuberculosis en El Ferrol.

BACKGROUND: This study was undertaken to know the frequency of tuberculosis in El Ferrol and to contribute to the knowledge of the situation in Spain. METHODS: A retrospective study of all the cases of tuberculosis diagnosed in the Hospital A. Marcide-Novoa Santos (El Ferrol, Spain) from 1990 to 1993 was performed. RESULTS: Seven hundred twenty-four patients were diagnosed, with a mean annual prevalence of 83.3/100,000 inhabitants. Six hundred sixty-four cases (430 males [64.8%]) were evaluated. The mean age was 35.5 +/- 19 years with 58.9% under the age of 35. 98.7% of the patients lived in the health care area and 73.2% were admitted, with 13.7% having previous history of tuberculosis. Sixty-one cases (11.1%; Cl: 8.25-13.7) had HIV infection. Diagnosis was microbiological in 505 cases (76%), anatomopathological in 60 (9%) and in 99 (14.9%) diagnosis was achieved by clinical and radiological criteria. Pulmonary localization (67.2%) was the most frequent form and was predominant in males, while lymph node and osteoarticular localizations were more frequent in women. The incidence of bacilliferous patients was 30.7/100,000 inhabitants. A delay of more than one month took place in the diagnosis of 66.4% of the bacilliferous patients. CONCLUSIONS: The incidence of tuberculosis in El Ferrol is very high with an important delay in the diagnosis of bacilliferous patients. The high percentage of patients admitted to hospital carries considerable costs in the treatment of the disease.

[Clinicoepidemiologic study of tuberculosis in the Ferrol area (1990-1991)]. / Estudio clinicoepidemiológico de la tuberculosis en el área de Ferrol (1990-1991).

BACKGROUND: To know about the main characteristics of tuberculous disease in our county. METHOD: A two-year period (1990-91), retrospective survey of the patients diagnosed of tuberculosis at a hospital from the north of La Coruña (Spain) was performed. A total of 322 cases were found, 165 diagnosed at the hospital and the remaining cases at the clinic. In the latter group, microbiological findings were the only diagnostic criteria considered. On the hospital-diagnosed cases three diagnostic categories were established: 1) definite; 2) probable, and 3) clinical diagnosis. RESULTS: The 1991 annual rate was 73.8 cases/100.000 inhabitants and the estimate rate was 80 cases/100.000. On analysis of the hospital-based diagnosed subgroup (165 patients), there was a male predominance (112/165), mean age was 35 years and 75% of patients were 44-year-old or younger. The most common clinical presentation was pulmonary (94 cases), pleural (33 cases) and pleuro-pulmonary disease (18 cases). Nine patients had concurrent infection with the human immunodeficiency virus. There was a culture-proven diagnosis of infection by Mycobacterium tuberculosis on 117/165 cases. A total of 115 cases (69.7%) received a three-drugs, 9 months therapy. The clinical outcome was fully satisfactory in 79/101 patients (78.2%) with a follow-up longer than 6 months. Only in one case there was a tuberculosis-related death. CONCLUSIONS: The high incidence rate, as well as age distribution and the frequency of pleural disease suggest a high tuberculous endemy at our region, over the rates from other parts of Spain.

[How many cases of tuberculosis are not reported?]. / Cuántos casos de tuberculosis no son declarados?

BACKGROUND: The aim of this study was to evaluate the degree of registry of tuberculosis and the factors associated to the same. METHODS: A retrospective study of the cases of respiratory tuberculosis diagnosed in the hospital A. Marcide-Novoa Santos (El Ferrol. La Coruña. Spain) from 1990 to 1992 was carried out. Identification was obtained from the registries of microbiology and pathology and the clinical history files. Registered cases were obtained from the nominal notifications to the Epidemiology Department of the local health service department. Sex, age, place of residence, previous history of tuberculosis, HIV, diagnostic method, localization of the tuberculosis, registration and reporting physician were evaluated for each patient. RESULTS: Three hundred ninety-three cases were identified of which 78 (19.8%) had been registered. Age and pulmonary localization were the variable influencing the degree of registration. Reporting was greater in the age group from 0 to 10 years (p < 0.05). Pulmonary tuberculosis was the most reported type although only 22.4% of the cases were declared. Bacilloscopy was positive in sputum in 190 patients and declared in 46 (24.2%). The degree of registration increased significantly over three years (p < 0.000001). Sex, previous history of tuberculosis, infection by the HIV and diagnostic method did not influence the degree of registration. CONCLUSIONS: Seventy-five percent of the cases with positive bacilloscopy in sputum were not declared. The degree of declaration has improved over time, however, remains deficient being 2.7 fold lower than the total number of cases diagnosed in 1992.