Mycobacterium africanum, an emerging disease in high-income countries?

BACKGROUND: Mycobacterium africanum is a cause of tuberculosis (TB) that has mainly been described in Africa, but immigration and travel patterns have contributed to the spread of the disease to other countries. METHODS: We retrospectively reviewed TB cases due to M. africanum during 2000-2010 in seven Spanish hospitals. Selected clinical charts were reviewed using a predefined protocol that included demographical, clinical and microbiological data and outcome. RESULTS: Although 57 cases were diagnosed, only 36 clinical charts were available for review: 82.8% were men and the mean age was 31.6 years (range 12-81). Forty-four cases were from Africa, 1 from the Philippines, 1 from India, and 4 from Spain, while the country of origin was unknown in 7 cases. The most frequent site of infection was the lung (58.3%). Four cases (6.9%) were resistant to at least one first-line anti-tuberculosis drug. CONCLUSIONS: Disease due to M. africanum in industrialised countries is mainly associated with immigration from endemic areas, although some cases also occur among native-born populations.

[Sample collection methods for urine culture and analysis]. / Métodos para la recogida de muestras de orina para urocultivo y perfil urinario.

A review of the scientific evidence available on the validity of existing sample collection methods for urine culture and analysis in childhood is presented. Few studies evaluating diagnostic tests have analyzed the various available techniques with respect to valid patterns of reference. Except for clean catch midstream urine samples, there are no estimators of validity (sensitivity, specificity, probability quotients) that can be generalized to most of the techniques and that could guide decision making. Consequently, data from descriptive studies on the risk of contamination, feasibility, safety and acceptability of each technique will have to be considered in decision making. Urine collection by means of adhesive perineal bag is the most widely used method in Spain in children who do not control urine emission. Nevertheless, this technique has a high risk of contamination and a very low positive predictive value, limiting its diagnostic utility. Urethral catheterization and suprapubic bladder aspiration are considered the tests of choice; however, because these tests are invasive, their use is restricted. Therefore, when choosing the technique to be used, the patient's circumstances and our working environment will have to be considered.

Métodos para la recogida de muestras de orina para urocultivo y perfil urinario / Sample collection methods for urine culture and analysis

Se presenta una revisión de la evidencia científica disponible sobre la validez de los métodos existentes de recogida de orina en la infancia para la realización de urocultivo y perfil urinario. Existen pocos estudios de evaluación de pruebas diagnósticas que hayan analizado las distintas técnicas disponibles con respecto a patrones de referencia válidos. Salvo las orinas recogidas de la mitad de un chorro miccional limpio, para las otras técnicas no disponemos de estimadores de validez (sensibilidad, especificidad, cocientes de probabilidades) generalizables, que nos orienten en la toma de decisiones. Por ello, tendremos que considerar información obtenida a partir de estudios descriptivos sobre riesgo de contaminación, factibilidad, seguridad y aceptabilidad de cada técnica en la toma de decisiones. La recogida de orina mediante bolsa adhesiva perineal es el método más empleado en España para la recogida de orina en niños que no controlan la micción. Sin embargo, tiene un alto riesgo de contaminación y un muy bajo valor predictivo positivo, lo que condiciona su utilidad diagnóstica. La cateterización vesical y la punción suprapúbica son consideradas las pruebas de referencia, aunque el hecho de tratarse de técnicas invasivas restringe su uso. Por ello tendremos que valorar las circunstancias del paciente y de nuestro entorno de trabajo a la hora de elegir qué técnica emplear

A review of the scientific evidence available on the validity of existing sample collection methods for urine culture and analysis in childhood is presented. Few studies evaluating diagnostic tests have analyzed the various available techniques with respect to valid patterns of reference. Except for clean catch midstream urine samples, there are no estimators of validity (sensitivity, specificity, probability quotients) that can be generalized to most of the techniques and that could guide decision making. Consequently, data from descriptive studies on the risk of contamination, feasibility, safety and acceptability of each technique will have to be considered in decision making. Urine collection by means of adhesive perineal bag is the most widely used method in Spain in children who do not control urine emission. Nevertheless, this technique has a high risk of contamination and a very low positive predictive value, limiting its diagnostic utility. Urethral catheterization and suprapubic bladder aspiration are considered the tests of choice; however, because these tests are invasive, their use is restricted. Therefore, when choosing the technique to be used, the patient's circumstances and our working environment will have to be considered

Drug-resistant tuberculosis in Castilla-León, Spain, 1996-2000.

SETTING: During 1996-2000, a regional anti-tuberculosis drug resistance survey was conducted in Castilla-León, Spain. OBJECTIVE: To determine the incidence of drug-resistant tuberculosis (TB) in newly treated human immunodeficiency virus (HIV) negative and HIV-positive TB patients. DESIGN: Nine hundred and eighty-five Mycobacterium tuberculosis strains isolated from HIV-negative (926) and HIV-positive (59) patients were studied (one strain per patient). Univariate and multivariate analyses were used to determine the prevalence of drug resistance in high-risk groups. RESULTS: Thirty-eight isolates (3.8%) showed resistance to one of the following drugs: streptomycin (S), isoniazid (H), rifampicin (R) or ethambutol (E). Of these, 36 (3.9%) were from HIV-negative and 2 (3.4%) from HIV-positive patients. The rate of drug resistance among HIV-negative patients was 1.2%, 2.0%, 0.3% and 0.8%, respectively, for S, H, R and E, and for HIV-positive patients it was 3.4%, 0%, 0% and 1.7%. Among the HIV-negative patients, monoresistance was observed in 32 (3.4%) strains and resistance to both H and R (multi-drug resistance) was detected in one. CONCLUSION: The incidence of primary drug resistance in the surveyed area was low and increased resistance was not observed in the HIV-positive group (P = 0.99). Routine surveillance of drug resistance is recommended by the TB control programme in representative patient populations to optimise treatment regimens.

Tendencias en la sensibilidad a antimicrobianos de los uropatógenos en la infancia (1995-2001) / Tendency in sensitivity of uropathogen antimicrobians in childhood (1995-2001)

Objetivo: Estudio de la evolución del perfil etiológico y patrón de sensibilidad de los uropatógenos pediátricos en nuestro medio y sus implicaciones sobre la elección de tratamiento antibiótico. Material y métodos: Análisis retrospectivo de los resultados de los urocultivos de pacientes pediátricos atendidos en los servicios de hospitalización y consulta del Hospital Virgen de la Concha de Zamora en el período 1995-2001. Valoración de la evolución en el número e idoneidad de las muestras, tipos de microorganismos aislados, patrón de sensibilidad a antimicrobianos y su variación en función de la edad y características clínicas de los pacientes. Resultados: De los 5.967 urocultivos revisados (de 3.725 pacientes) resultaron positivos 756 (12,7 por ciento) y 948 contaminados (15,9 por ciento). En los últimos años descendió significativamente (p < 0,001) el número de muestras, a expensas de las contaminadas. Los microorganismos más frecuentes fueron Escherichia coli (68 por ciento), Proteus mirabilis (6,2 por ciento), Pseudomonas aeruginosa (4,2 por ciento), Enterobacter cloacae (3 por ciento) y Enterococcus faecalis (2,8 por ciento). Por grupos de edad, destaca un mayor predominio de E. coli en los mayores de 2 años (79,9 por ciento). La sensibilidad específica a E. coli por antibióticos fue: ampicilina: 36,7 por ciento, amoxicilina-clavulánico: 93,3 por ciento, cefalosporinas 11 generación: 95 por ciento, cefuroxima: 99,3 por ciento, cefixima: 99,2 por ciento, cefo taxima: 100 por ciento, gentamicina: 96,6 por ciento, cotrimoxazol: 77,3 por ciento, nitrofurantoina: 94,9 por ciento, fosfomicina: 100 por ciento, asociación cefotaxima-gentamicina: 100 por ciento. La mayoría de las cepas resistentes a cefalosporinas fueron de P. aeruginosa, E. cloacae y M. morganii, mientras que para nitrofurantoina, cotrimoxazol y gentamicina fueron de E. coli. En el período estudiado se experimentó una discreta recuperación de sensibilidad de E. coli a cotrimoxazol (p = 0,033). Conclusiones: E. coli es el uropatógeno predominante, frente al que mantienen una buena actividad las cefalosporinas, gentamicina, fosfomicina y nitrofurantoina. La sensibilidad a cotrimoxazol se encuentra en el límite que condiciona su utilidad como tratamiento empírico. En pacientes con criterios de riesgo las cefalosporinas de 3ª generación, asociadas o no a gentamicina, constituyen la opción más recomendable. Cefixima y fosfomicina presentan un adecuado perfil para su uso en pacientes que toleran la vía oral (AU)

Análisis de coste y rentabilidad de los cultivos superficiales en una unidad neonatal / Analysis of the cost and utility of body surface cultures in a neonatal unit

Introducción: La infección continúa siendo una preocupación en las unidades neonatales. El elevado coste de los cultivos superficiales utilizados en su estudio y su utilidad es objeto de debate. Material y métodos: Se revisan retrospectivamente las historias de los recién nacidos ingresados en 1999 con sospecha de infección. Se analizan los criterios de petición, el gasto y la rentabilidad clínica de los cultivos superficiales. Resultados: En 1999 se estudiaron con cultivos superficiales 204 recién nacidos ingresados (70 por ciento de todos los ingresados), en seis de ellos se diagnosticó una bacteriemia (6,23/1.000; intervalo de confianza del 95 por ciento [IC 95 por ciento], 5,9-6,5). Los microorganismos más frecuentemente aislados fueron Escherichia coli y Streptococcus agalactiae. El coste total de los cultivos superficiales ascendió a 6.510,95 1. En el 25 por ciento de los casos los resultados de los cultivos produjeron algún impacto en la toma de decisiones clínicas. El coste necesario para conseguir repercusión clínica en un caso fue de 191,50 1. Si sólo se solicitaran, como cultivos superficiales, el frotis ótico y el umbilical, el gasto se podría reducir a la mitad sin disminuir su rentabilidad diagnóstica. Conclusiones: Un importante porcentaje de recién nacidos ingresados presenta sospecha de infección neonatal y requiere estudios microbiológicos. Si bien el uso de cultivos superficiales supone un elevado coste económico, su resultado influye en las decisiones diagnóstico-terapéuticas en la cuarta parte de los casos. No creemos que sea beneficioso eliminar su utilización, pero sí es de gran trascendencia disminuir su coste, perfilando de manera cuidadosa los criterios de petición y reduciendo estos cultivos a dos muestras (frotis ótico y umbilical) (AU)

[Cost benefit analysis of body surface cultures at a neonatal unit]. / Análisis de coste y rentabilidad de los cultivos superficiales en una unidad neonatal.

INTRODUCTION: Infection continues to be a cause of concern in neonatal units. The high cost of the body surface cultures used to study infection and their limited utility is controversial. MATERIAL AND METHODS: The medical records of newborns admitted for suspected infection in 1999 were retrospectively reviewed. Request criteria, cost, and the clinical utility of body surface cultures were analyzed. RESULTS: In 1999, body surface cultures were requested in 204 newborns admitted to hospital (70 % of all admitted newborns). Of these, six were diagnosed with bacteremia (6.23/1000; 95 % CI: 5.9-6.5). The most frequently isolated microorganisms were Escherichia coli and Streptococcus agalactiae. The total cost of body surface cultures was 6,510.95 euros (1,083,331 pesetas). In 25 % of cases the results of cultures influenced clinical decision making. The cost necessary to obtain clinical repercussion in a patient was 191.50 euros (31,863 pesetas). Requesting two body surface cultures only (otic and umbilical) halved the cost without diminishing their clinical utility. CONCLUSIONS: A considerable percentage of newborns admitted to hospital present suspected infection requiring microbiological studies. Although the cost of body surface cultures is high, the results of these cultures influence diagnostic and therapeutic decisions in a quarter of patients. We do not believe that eliminating the use of these cultures would be beneficial. However, their cost can be reduced by carefully selecting request criteria and by limiting cultures to two samples (otic and umbilical).

Evaluación económica de los servicios sanitarios / Economic assessment of health services

Está bien asumido que el objetivo de los servicios sanitarios es mejorar la salud del individuo y de la sociedad en su conjunto. Para ello es importante lograr en primer término una óptima relación entre los recursos consumidos y los resultados obtenidos. En segundo lugar parece esencial proveer los servicios de forma equitativa. De acuerdo con estos principios de eficacia y equidad se revisa la implantación de un nuevo modelo de gestión. Este parte de la identificación de la estructura de los centros asistenciales: productos que se generan, gastos en que se incurre y gestión de los mismos. Su diseño persigue en un primer escalón poder imputar los costes por servicios, y por episodios, como objetivo final. En el presente artículo se detalla la estructura del proyecto de gestión analítica hospitalaria, denominado SIGNO, cuyo ámbito de implantación abarca la práctica totalidad de los hospitales de la red pública. Se desarrollan los términos que reflejan la organización hospitalaria vigente, tales como grupo funcional homogéneo, servicio funcional y área funcional. Para ello se desglosa el concepto de coste por servicio, a partir de la identificación de la estructura hospitalaria, la imputación de costes a partir de un grupo funcional homogéneo y de la facturación interna de servicios. Finalmente, se aborda el coste por episodio (coste por proceso), como herramienta depurada para optimizar la gestión hospitalaria (AU)

[Treatment review in rhinocerebral mucormycosis]. / Revisión del tratamiento en la mucormicosis rinocerebral.

The rhinocerebral mucormycosis is the more common form produced by Rhizopus, a genus of fungi. It's a serious infective disease with high mortality, that needs a precocious medical treatment. Amphotericin B is the choice medical treatment, but liposomal amphotericine B in recent years is a better drug, due to minor renal toxicity and greater tisular diffusion. Even can not to treat all affected areas it's necessary an extensive surgical treatment according to individual characteristics and disease evolution. A 56-year-old man with rhinocerebral mucormycosis, caused by Rhizopus, who was treated with liposomal-amphotericin B and extensive rhino-orbital surgery is presented.

[Familial outbreaks of fascioliasis: usefulness of serologic investigation by enzyme immunoassay]. / Brotes familiares de fascioliasis: utilidad del estudio serológico por enzimoinmunoanálisis.

BACKGROUND: To assess the usefulness of an enzyme immuno-assay test for the diagnosis of two familial outbreaks of Fasciola hepatica parasitosis in the Zamora area, where watercress are a normal part of the diet. PATIENTS AND METHODS: The microbiological diagnosis of two familial outbreaks of fascioliasis was analyzed, which included the search for eggs in feces by the Kato technique and two serologic tests, one screening test by indirect hemagglutination, and a confirmatory test by enzyme-immunoassay in 12 patients. RESULTS: Five out of the six seropositive patients had eggs detected in their feces. To note that two of the patients with eosinophilia that excreted eggs--one asymptomatic and the other with abdominal pain--had a positive result in the EIA test only and with high titers. CONCLUSIONS: The EIA test is useful for the diagnosis and study of fascioliasis outbreaks to interpret the significance of low titers in the screening test in patients with eosinophilia.

[Comments on the treatment of rhinocerebral mucormycosis]. / Comentarios sobre el tratamiento en la mucormicosis rinocerebral.

Rhinocerebral mucormycosis is a serious infectious disease with a high mortality rate that requires early medical treatment. Liposomal amphotericin B is the medical treatment of choice because of its low renal toxicity and good tissue diffusion. Surgical treatment is necessary, even if all affected areas cannot be reached. The surgical indication should be based on individual characteristics and disease evolution. The case of a 56-year-old man with rhinocerebral mucormycosis caused by Rhizopus and treated with liposomal amphotericin B and extensive rhino-orbital surgical treatment is commented.

Pediatric parenteral nutrition mixtures design program: validity and stability study.

The formulation and elaboration of a correct parenteral nutrition (PN) in infancy requires the use of many parameters, the realization of complicated mathematical calculations, and repeated and individualized adjustments of the final constituents. The use of computer programs in the confection of PN has simplified the whole process, but, to our understanding, the programs being used at the moment lack the flexibility needed to generalize its use in the pediatric age. The aim of this work is to present a new computer program able to make up complete pediatric units of PN by itself, which follow the nutritional requirements and the marketed preparations established for each clinical situation. The program provides, automatically, standard amounts for each nutrient, according to age, water needs, and route of administration. The program turns these amounts, which can be modified before or after knowing the final composition, into milliliters of each commercial product and provides a complete analysis of the PN solution. It is also possible to adapt the basic configuration of the program to the needs of each patient, modifying the nutritional requirements and the products that the program will use. In order to assess the validity of the program, we made up a series of PN solutions, for a simulated sample of patients, which represented different clinical situations and age groups. We analyzed the composition of the mixtures and its physical-chemical stability. No problems in the PN solutions generated by the program when using our standard configuration were found. A study of reproducibility was carried out and no difficulties of execution, errors, or differences in the composition of the PN solutions designed by the different physicians were found. Average time needed for the design of a PN was less than 5 min. The use of computer programs in the design of mixtures of PN reduces errors and time, allowing a better use of this technique of nutritional support.

[Focal infections caused by non-typhi Salmonella: a review of our case series and comparison with other series]. / Infecciones focales por Salmonella no typhi: revisión de nuestra casuística y comparación con otras series.

Nine cases of local infection due to non typhi Salmonella enterica, some of them of unusual localization, in 8 patients (mean age 64.9 +/- 12.4 years) attended in Zamora's Virgen de la Concha Hospital over a period of five years, are described. Focal salmonellosis represented 1.5% of non-typhi salmonellosis cases in that period (9 out of 606 detected cases). 6 of the 8 patients (75%) showed a predisposing disease. In two patients the previous existence of gastroenteritis due to Salmonella was assessed and only in one of them concomitant bacteremia was detected. Soft-tissue infections were the more frequent clinical feature: plantar abscess, two abdominal wall abscesses--one of them after cholecystectomy--post-pericardiotomy thoracic wall abscess and perianal abscess. Three soft-tissue infections were due to group B serotypes. 4 out of five soft-tissue infections evolved favorably with surgical treatment. The rest of the series is formed by two cases with acute cholecystitis in patients with previous cholelithiasis (one of whom relapsed originating an abdominal wall abscess), a recurrent pleural empyema and a purulent pericarditis. The pericarditis was produced by S. enteritidis. Patient showed signs of cardiac tamponade, his condition improving after pericardial drainage and parenteral and intrapericardial administration of ciprofloxacin. Epidemiologic and clinic characteristic of our series are compared with other series of focal salmonellosis.