Kala-azar en un paciente con artritis reumatoide tratada con metotrexato / Visceral leishmaniasis in a rheumatoid arthritis patient receiving methotrexate

Los pacientes con artritis reumatoide (AR) tratados con fármacos modificadores del curso de la enfermedad están expuestos a desarrollar infecciones potencialmente graves como la leishmaniasis. L. infantum es endémica en el Mediterráneo, hecho que obliga ante un paciente con AR que presenta fiebre y pancitopenia, a descartar este proceso. Un diagnóstico de sospecha precoz, puede evitar un curso y pronóstico fatal (AU)

Patients with rheumatoid arthritis (RA) treated with disease-modifying antirheumatic drugs are susceptible to severe infections such as leishmaniasis. As L. infantum is endemic in the Mediterranean region, it is necessary to rule this infectious process out in any RA patient presenting with fever and pancytopenia. An early diagnosis based on a high suspicion can prevent a fatal outcome (AU)

Healthcare-Associated Mycobacterium bovis-Bacille Calmette-Guérin (BCG) Infection in Cancer Patients Without Prior BCG Instillation.

Background: Bacille Calmette-Guérin (BCG), an attenuated strain of Mycobacterium bovis, is widely used as adjunctive therapy for superficial bladder cancer. Intravesical administration of BCG has been associated with systemic infection. Disseminated infection due to M. bovis is otherwise uncommon. Methods: After identification of 3 patients with healthcare-associated BCG infection who had never received intravesical BCG administration, an epidemiologic study was performed. All patients with healthcare-associated BCG infection in the Barcelona tuberculosis (TB) program were reviewed from 1 January 2005 to 31 December 2015, searching for infections caused by M. bovis-BCG. Patients with healthcare-associated BCG infection who had not received intravesical BCG instillation were selected and the source of infection was investigated. Results: Nine oncology patients with infection caused by M. bovis-BCG were studied. All had permanent central venous catheters. Catheter maintenance was performed at 4 different outpatient clinics in the same room in which other patients underwent BCG instillations for bladder cancer without required biological precautions. All patients developed pulmonary TB, either alone or with extrapulmonary disease. Catheter-related infection was considered the mechanism of acquisition based on the epidemiologic association and positive catheter cultures for BCG in patients in whom mycobacterial cultures were performed. Conclusions: Physicians should be alerted to the possibility of TB due to nosocomially acquired, catheter-related infections with M. bovis-BCG in patients with indwelling catheters. This problem may be more common than expected in centers providing BCG therapy for bladder cancer without adequate precautions.

Visceral leishmaniasis in a rheumatoid arthritis patient receiving methotrexate. / Kala-azar en un paciente con artritis reumatoide tratada con metotrexato.

Patients with rheumatoid arthritis (RA) treated with disease-modifying antirheumatic drugs are susceptible to severe infections such as leishmaniasis. As L. infantum is endemic in the Mediterranean region, it is necessary to rule this infectious process out in any RA patient presenting with fever and pancytopenia. An early diagnosis based on a high suspicion can prevent a fatal outcome.

Epidemiology of Clostridium difficile infection and risk factors for unfavorable clinical outcomes: results of a hospital-based study in Barcelona, Spain.

Prospective hospital-based surveillance for Clostridium difficile-associated disease (CDAD) was conducted in Barcelona (Spain) to describe the epidemiology of this condition and investigate the risk factors for an unfavorable outcome. All patients diagnosed with CDAD during 2009 were included. Using logistic regression modeling, we analyzed the potential risk factors associated with recurrent and complicated CDAD, defined as a need for colectomy or death within 30 days. There were 365 episodes of CDAD, yielding an incidence of 22.5 cases/10(5) person-years, 1.22 cases/10(3) hospital discharges, and 1.93 cases/10(4) patient-days. The main PCR ribotypes identified were 241 (26%), 126 (18%), 078 (7%), and 020 (5%). PCR ribotype 027 was not detected. Among the 348 cases analyzed, 232 (67%) patients were cured, 63 (18%) had a recurrence of CDAD, and 53 (15%) developed complicated CDAD. Predictors of complicated CDAD were continued use of antibiotics following CDAD diagnosis (odds ratio [OR], 2.009; 95% confidence interval [CI], 1.012 to 3.988; P = 0.046), Charlson comorbidity index score (OR, 1.265; 95% CI, 1.105 to 1.449; P = 0.001), and age (OR, 1.028; 95% CI, 1.005 to 1.053; P = 0.019). A leukocyte count of >15 × 10(3) cells/ml (OR, 2.277; 95% CI, 1.189 to 4.362; P = 0.013), continuation of proton pump inhibitor (PPI) use after CDAD diagnosis (OR, 2.168; 95% CI, 1.081 to 4.347; P = 0.029), and age (OR, 1.021; 95% CI, 1.001 to 1.041; P = 0.036) were independently associated with higher odds of recurrence. The incidence of CDAD in Barcelona during 2009 was on the lower end of the previously described range for all of Europe. Our analysis suggests that the continuation of non-C. difficile antibiotics and use of PPIs in patients diagnosed with CDAD are associated with unfavorable clinical outcomes.

Influenza A(H1N1)pdm09-related pneumonia and other complications.

Influenza A(H1N1)pdm09 virus infection was associated with significant morbidity, mainly among children and young adults. The majority of patients had self-limited mild-to-moderate uncomplicated disease. However, some patients developed severe illness and some died. In addition to respiratory complications, several complications due to direct and indirect effects on other body systems were associated with influenza A(H1N1)pdm09 virus infection. The main complications reported in hospitalized adults with influenza A(H1N1)pdm09 were pneumonia (primary influenza pneumonia and concomitant/secondary bacterial pneumonia), exacerbations of chronic pulmonary diseases (mainly chronic obstructive pulmonary disease and asthma), the need for intensive unit care admission (including mechanical ventilation, acute respiratory distress syndrome and septic shock), nosocomial infections and acute cardiac events. In experimentally infected animals, the level of pulmonary replication of the influenza A(H1N1)pdm09 virus was higher than that of seasonal influenza viruses. Pathological studies in autopsy specimens indicated that the influenza A(H1N1)pdm09 virus mainly targeted the lower respiratory tract, resulting in diffuse alveolar damage (edema, hyaline membranes, inflammation, and fibrosis), manifested clinically by severe acute respiratory distress syndrome with refractory hypoxemia. Influenza A(H1N1)pdm09-related pneumonia and other complications were associated with increased morbidity and mortality among hospitalized patients.

Influenza A(H1N1)pdm09-related pneumonia and other complications

Influenza A(H1N1)pdm09 virus infection was associated with significant morbidity, mainly among children and young adults. The majority of patients had self-limited mild-to-moderate uncomplicated disease. However, some patients developed severe illness and some died. In addition to respiratory complications, several complications due to direct and indirect effects on other body systems were associated with influenza A(H1N1)pdm09 virus infection. The main complications reported in hospitalized adults with influenza A(H1N1)pdm09 were pneumonia (primary influenza pneumonia and concomitant/secondary bacterial pneumonia), exacerbations of chronic pulmonary diseases (mainly chronic obstructive pulmonary disease and asthma), the need for intensive unit care admission (including mechanical ventilation, acute respiratory distress syndrome and septic shock), nosocomial infections and acute cardiac events. In experimentally infected animals, the level of pulmonary replication of the influenza A(H1N1)pdm09 virus was higher than that of seasonal influenza viruses. Pathological studies in autopsy specimens indicated that the influenza A(H1N1)pdm09 virus mainly targeted the lower respiratory tract, resulting in diffuse alveolar damage (edema, hyaline membranes, inflammation, and fibrosis), manifested clinically by severe acute respiratory distress syndrome with refractory hypoxemia. Influenza A(H1N1)pdm09-related pneumonia and other complications were associated with increased morbidity and mortality among hospitalized patients (AU)

Si bien la mayoría de los pacientes infectados por el virus de la gripe A(H1N1)pdm09 tuvieron enfermedad no complicada, autolimitada, leve a moderada, la infección se caracterizó por una morbilidad significativa, especialmente entre niños y adultos jóvenes, de forma que algunos pacientes desarrollaron una enfermedad grave y algunos murieron. La infección por virus de la gripe A(H1N1)pdm09 se asoció no sólo con complicaciones respiratorias, sino también con complicaciones debidas a los efectos directos e indirectos sobre otros sistemas del organismo. En los pacientes adultos hospitalizados las complicaciones principales fueron neumonía (neumonía primaria por gripe y neumonía bacteriana concomitante/secundaria), exacerbaciones de enfermedades pulmonares crónicas (principalmente enfermedad pulmonar obstructiva crónica y asma), necesidad para la admisión en unidad de cuidados intensivos (incluso ventilación mecánica, síndrome de dolor respiratorio agudo y shock séptico), infecciones nosocomiales y acontecimientos cardíacos agudos. En los animales de experimentación infectados con virus de la gripe A(H1N1)pdm09 el nivel de replicación del virus a nivel pulmonar era más alto que el de los virus de la gripe estacional. Los estudios anatomopatológicos de muestras de autopsia mostraron que el virus de la gripe A(H1N1)pdm09 actúa principalmente sobre el tracto respiratorio inferior, provocando lesión difusa del alveolo (edema, membranas hialinas, inflamación y fibrosis), lo que se traduce clínicamente en un síndrome de distrés respiratorio agudo grave con hipoxemia refractaria. La neumonía y otras complicaciones relacionadas con la gripe por virus A(H1N1)pdm09 se asociaron a una mayor morbilidad y mortalidad en los pacientes hospitalizados (AU)

Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial.

BACKGROUND: The length of hospital stay (LOS) for community-acquired pneumonia (CAP) varies considerably, even though this factor has a major impact on the cost of care. We aimed to determine whether the use of a 3-step critical pathway is safe and effective in reducing duration of intravenous antibiotic therapy and length of stay in hospitalized patients with CAP. METHODS: We randomly assigned 401 adults who required hospitalization for CAP to follow a 3-step critical pathway including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge or usual care. The primary end point was LOS. Secondary end points were the duration of intravenous antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patients' satisfaction. RESULTS: Median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (difference, -2.1 days; 95% CI, -2.7 to -1.7; P < .001). Median duration of intravenous antibiotic therapy was 2.0 days in the 3-step group and 4.0 days in the usual care group (difference, -2.0 days; 95% CI, -2.0 to -1.0; P < .001). More patients assigned to usual care experienced adverse drug reactions (4.5% vs 15.9% [difference, -11.4 percentage points; 95% CI, -17.2 to -5.6 percentage points; P < .001]). No significant differences were observed regarding subsequent readmissions, case fatality rate, and patients' satisfaction with care. CONCLUSIONS: The use of a 3-step critical pathway was safe and effective in reducing the duration of intravenous antibiotic therapy and LOS for CAP and did not adversely affect patient outcomes. Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN17875607.

Pandemic 2009 A(H1N1) infection requiring hospitalization of elderly Spanish adults.

OBJECTIVES: To describe the clinical presentation and prognosis of elderly adults hospitalized with pandemic 2009 A(H1N1) influenza infection and to compare these data with those of younger patients. DESIGN: Prospective, observational, multicenter study. SETTING: Thirteen hospitals in Spain. PARTICIPANTS: Adults admitted to the hospital with confirmed pandemic 2009 A(H1N1) influenza infection. MEASUREMENTS: Demographic, clinical, laboratory, radiological, and outcome variables. RESULTS: Between June 12 and November 10, 2009, 585 adults with confirmed 2009 A(H1N1) influenza were hospitalized, of whom 50 (8.5%) were aged 65 and older (median age 72, range 65-87). Older adults (≥ 65) were more likely to have associated comorbidities (88.0% vs 51.2%; P < .001), primarily chronic pulmonary diseases (46.0% vs 27.3%; P < .001). Lower respiratory tract symptoms and signs such as dyspnea (60.0% vs 45.6%) and wheezing (46.0% vs 27.8%; P = .007) were also more common in these elderly adults, although pulmonary infiltrates were present in just 14 (28.0%) of the older adults, compared with 221 (41.3%) of the younger adults (P = .06). Multilobar involvement was less frequent in elderly adults with pulmonary infiltrates than younger adults with pulmonary infiltrates (21.4% vs 60.0%; P = .05). Rhinorrhea (4.0% vs 21.9%; P = .003), myalgias (42.0% vs 59.1%; P = .01), and sore throat (14.0% vs 29.2%; P = .02) were more frequent in younger adults. Early antiviral therapy (<48 hours) was similar in the two groups (34.0% vs 37.9%; P = .58). Two older adults (4.0%) died during hospitalization, compared with 11 (2.1%) younger adults (P = .30). CONCLUSION: Elderly adults with 2009 A(H1N1) influenza had fewer viral-like upper respiratory symptoms than did younger adults. Pneumonia was more frequent in younger adults. No significant differences were observed in hospital mortality.

Pneumonia complicating pandemic (H1N1) 2009: risk factors, clinical features, and outcomes.

We performed an observational analysis of a prospective cohort of adults hospitalized for pandemic (H1N1) 2009 at 13 Spanish hospitals, from June to November 2009, to determine the risk factors, clinical features, and outcomes of pneumonia. Of 585 patients requiring hospitalization, chest radiography was obtained in 542. A total of 234 (43.1%) patients had pneumonia, of whom 210 underwent bacterial microbiologic studies. Of these patients, 174 (82.8%) had primary viral pneumonia and 36 (17.2%) had concomitant/secondary bacterial pneumonia. Bilateral pneumonia occurred in 48.3% of patients. Streptococcus pneumoniae was the most frequent pathogen among patients with bacterial pneumonia (26 of 36 patients). None of them had received pneumococcal vaccine. Compared with patients without pneumonia, those with pneumonia more frequently had shock during hospitalization (9.8% vs. 1%; p < 0.001), required intensive care unit admission (22.6% vs. 5.8%; p < 0.001), underwent mechanical ventilation (17.9% vs. 3.2%; p < 0.001), and had longer length of hospital stay (median, 7 d vs. 5 d; p < 0.001). In-hospital mortality was higher in patients with pneumonia than in the others (5.2% vs. 0%; p < 0.001). Absence of comorbid conditions (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.32-3.24) was found to be an independent risk factor for pneumonia, whereas early (≤ 48 h) oseltamivir therapy (OR, 0.29; 95% CI, 0.19-0.46) was a protective factor. In conclusion, pneumonia is a frequent complication among adults hospitalized for pandemic (H1N1) 2009 and causes significant morbidity. Mortality in pandemic (H1N1) 2009 is low, but occurs mainly in patients with pneumonia. Early oseltamivir therapy is a protective factor for this complication.

Effect of immunomodulatory therapies in patients with pandemic influenza A (H1N1) 2009 complicated by pneumonia.

OBJECTIVE: To determine the effect of immunomodulatory therapies on the development of severe disease in hospitalized adults with laboratory-confirmed pandemic influenza A (H1N1) 2009 complicated by pneumonia. METHODS: Observational, prospective cohort study at thirteen tertiary hospitals in Spain. The use of corticosteroids, macrolides and statins was recorded. The outcome of interest was severe disease, defined as the composite of intensive care unit admission or death after the first day of hospitalization. RESULTS: Of the 197 patients with pandemic influenza A (H1N1) 2009 complicated by pneumonia, 68 (34.5%) received some anti-inflammatory therapy since hospital admission (corticosteroids in 37, macrolides in 31 and statins in 12). Severe disease occurred in 29 (14.7%) patients. After adjustment for confounding factors, immunomodulatory therapies as a group were not associated with a lower risk for developing severe disease (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.22-1.86). In a further a priori analysis, corticosteroids, macrolides and statins were included in a multivariate model. None of these therapies was found to be associated with a lower risk for developing severe disease. CONCLUSIONS: Immunomodulatory therapies use since hospital admission did not prevent the development of severe disease in adults with pandemic influenza A (H1N1) 2009 complicated by pneumonia.

An unusual case of spondylodiscitis.

STUDY DESIGN: A case report of spontaneous pyogenic spondylodiscitis and epidural abscess in vertebral fracture by an uncommon pathogen is described. OBJECTIVE: The uncommon presentation of spondylodiscitis with epidural abscess due to Gemella morbillorum after an acute lumbar vertebral fracture treated conservatively is discussed. SUMMARY OF BACKGROUND DATA: Spontaneous spondylodiscitis and epidural abscess in nonsurgical fractures is exceptionally rare. To date its colonization with Gemella morbillorum is not described in the literature. Its resistance to penicillin is also uncommon. METHODS: Diagnosis was based on clinical history, hemocultures, samples from CT-scan guided punction and, supported by magnetic resonance imaging. RESULTS: Clinical and radiologic improvement were observed after treatment based on a combined specific antimicrobial therapy and surgical drainage of epidural abscess. CONCLUSION: Spondylodiscitis and epidural abscess secondary to an acute nonsurgical vertebral fracture are rare manifestations. Microbiology and MRI are vital components in diagnosis. An emergency decompression and appropriate antibiotic regimen is the solution for a favorable outcome.

[The final week of life in an acute care hospital: review of 401 consecutive patients]. / Ultima semana de vida en un hospital de agudos: revisión de 401 pacientes consecutivos.

INTRODUCTION: because of population ageing and sociocultural changes related to death, increasing the numbers of patients are dying in hospitals. OBJECTIVES: to analyze patient characteristics and end-of-life care in the final week of life in patients dying in an acute-care hospital. MATERIAL AND METHODS: all patients older than 18 years old who died in the hospital over a 1-year period were analyzed. Patients dying in intensive care and emergency units were excluded. The following variables were evaluated: demographic data, main illness, cause of admission, comorbidity, terminal illness, medication, delay in beginning palliative sedation, use of devices, adverse events, and do not attempt resuscitation orders. RESULTS: a total of 401 patients (mean age: 78 +/- 11 years) with numerous comorbidities were evaluated. Of these, 348 patients (87%) were considered to be terminal. The reason for admission was related to the main disease in 207 patients (52%). Terminal sedation was applied in 311 patients (78%), and informed consent from the relatives was documented in 294 patients (73%). Intervention by on-call physician was required to control symptom aggravation in 214 patients (55%). Active medication was maintained in addition to sedation in 145 patients (36%). Complementary examinations were performed in 109 patients (40%), but did not modify prognosis. CONCLUSIONS: reasonable therapeutics objectives relating to the patient's situation and guidelines to improve quality of life at the end of life should be established.

Última semana de vida en un hospital de agudos: revisión de 401 pacientes consecutivos / The final week of life in an acute care hospital: review of 401 consecutive patients

Introducción: el envejecimiento y el cambio sociocultural frente a la muerte hacen que cada vez sea mayor el número de personas que fallecen en los hospitales. Objetivos: analizar aspectos relacionados con la última semana de vida de los pacientes que fallecen en un hospital de agudos. Material y métodos: se evaluó a los pacientes mayores de 18 años que fallecieron en el hospital durante un año, excluyendo los fallecidos en cuidados intensivos y en urgencias. Se analizaron: datos demográficos, enfermedad principal, motivo de ingreso, enfermedad terminal, comorbilidad, medicación, inicio de sedación, instrumentaciones, incidencias y órdenes de no iniciar reanimación cardiopulmonar. Resultados: se evaluó a 401 pacientes, con una edad media ± desviación estándar de 78 ± 11 años y elevada comorbilidad. Eran terminales 348 (87%) pacientes y en 207 (52%) pacientes el motivo de ingreso estaba relacionado con su enfermedad principal. La sedación terminal fue necesaria en 311 (78%) pacientes y constaba en la historia clínica que se había consensuado con sus familiares en 294 (73%) pacientes. Para el control de síntomas, 214 (55%) pacientes requirieron la intervención del médico de guardia. En 145 (36%) pacientes se mantuvo la medicación activa además de la sedativa, y en 109 (40%) pacientes se realizaron exploraciones complementarias sin que éstas modificaran el pronóstico. Conclusiones: es preciso establecer objetivos terapéuticos razonables en relación con la situación del paciente y protocolizar las intervenciones para mejorar la calidad de vida al final de la vida

Introduction: because of population ageing and sociocultural changes related to death, increasing the numbers of patients are dying in hospitals. Objectives: to analyze patient characteristics and end-of-life care in the final week of life in patients dying in an acute-care hospital. Material and methods: all patients older than 18 years old who died in the hospital over a 1-year period were analyzed. Patients dying in intensive care and emergency units were excluded. The following variables were evaluated: demographic data, main illness, cause of admission, comorbidity, terminal illness, medication, delay in beginning palliative sedation, use of devices, adverse events, and ¿do not attempt resuscitation orders¿. Results: a total of 401 patients (mean age: 78 ± 11 years) with numerous comorbidities were evaluated. Of these, 348 patients (87%) were considered to be terminal. The reason for admission was related to the main disease in 207 patients (52%). Terminal sedation was applied in 311 patients (78%), and informed consent from the relatives was documented in 294 patients (73%). Intervention by on-call physician was required to control symptom aggravation in 214 patients (55%). Active medication was maintained in addition to sedation in 145 patients (36%). Complementary examinations were performed in 109 patients (40%), but did not modify prognosis. Conclusions: reasonable therapeutics objectives relating to the patient's situation and guidelines to improve quality of life at the end of life should be established (AU)