Evolution and genetic diversity of the Spain23F-ST81 clone causing adult invasive pneumococcal disease in Barcelona (1990-2012).

OBJECTIVES: We aimed to analyse the clinical epidemiology and genetic diversity of invasive pneumococcal disease (IPD) episodes attributed to the Spain(23F)-ST81 (PMEN1) clone. METHODS: Fifty-eight (2.7%) of 2117 invasive pneumococci isolated from adult patients during the 1990-2012 period shared a PFGE pattern related to the PMEN1 clone. The genotype was confirmed by multilocus sequence typing. The pbp2x, pbp1a, pbp2b and pspA genes were PCR-amplified and sequenced. Polymorphisms in the pspC gene were identified by PCR restriction fragment length polymorphism. The presence of transposons with erythromycin and tetracycline resistance determinants was detected by PCR. RESULTS: The prevalence of the PMEN1 clone increased from 0.8% in 1991 to 6.2% in 2001, and decreased to 0% in 2010-12, concomitant with the introduction of the seven-valent pneumococcal conjugate vaccine for children. A total of 93.1% of patients had pneumonia, meningitis or peritonitis; 87.9% of patients had associated underlying diseases, mainly cancer, chronic obstructive pulmonary disease and diabetes. Two closely related sequence types (STs) (ST81, n = 52; ST85, n = 6) were detected, with different serotypes: 23F (n = 42), 19A (n = 9) and 19F (n = 6). All the isolates were resistant to penicillin, co-trimoxazole and chloramphenicol. All the isolates also shared the same pbp1a allele, whereas multiple alleles of pbp2b, pbp2x, pspA and pspC were detected. Of the isolates, 89.7% were tetracycline resistant and 60.3% (n = 35) were macrolide resistant, and resistance was associated with different Tn916-like transposons. CONCLUSIONS: Adult IPD caused by this clone was mainly detected in patients with underlying conditions, and genetic variability was observed among PMEN1 isolates collected in our area over the past 20 years.

Recomendaciones de vacunación antineumocócica en el adulto por indicación médica / No disponible

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Orofacial problems in musicians: a review of the literature.

OBJECTIVE: The objective of our study was to review the different pathologies of the stomatognathic system that can present in musicians as a result of playing their instruments. DESIGN: The National Library of Medicine's PubMed database was searched to identify all peer-reviewed articles in the English literature dealing with orofacial problems in musicians, using both subject headings such as MeSH terms (PubMed) and free text words in combination (oral, musician, violin, wind instruments, vocalists, orthodontic, tooth, temporomandibular disorders [TMD]). The identified studies were assessed independently by two authors. We included any instruments that involved the orofacial area: i.e., wind and brass instruments, vocalists, and violins and violas. RESULTS: Thirty-two articles were selected that were of many different types (clinical reviews, longitudinal and transverse studies of therapeutic procedures, case-control studies). Among orofacial problems, the most common disorders that affect musicians are TMDs, herpes simplex virus infections, orthodontic problems, and problems with perioral musculature. CONCLUSIONS: Musicians may suffer from pathological conditions that are worsened by their occupation due to excessive practice and stress. These conditions can cause permanent injuries that subsequently prevent the musicians from playing. Depending on the characteristics of the musical instrument and the way it is played, professional musicians generally show a propensity for buccodental problems.

Serotype distribution and susceptibility of Streptococcus pneumoniae isolates from pleural fluid in Spain from 1997 to 2008.

Trends in serotype incidence and susceptibility (1997 to 2008) of Spanish Streptococcus pneumoniae pleural isolates (n = 831) were explored. Penicillin (oral) nonsusceptibility rates and the incidence of 7-valent pneumococcal conjugate vaccine (PCV-7) serotypes showed decreasing trends (R(2) ≥ 0.600; P ≤ 0.002). The incidence of serotypes 1 and 19A showed increasing trends (R(2) ≥ 0.759; P < 0.001), with no trends for serotype 3. Serotypes 19A, 1, and 3 represented 85% of pediatric isolates in 2008. In serotype 19A, the penicillin nonsusceptibility rate was 82.4% in 2008, associated with amoxicillin and cefotaxime nonsusceptibility in 21.4% of isolates. Inclusion of these serotypes in new vaccines offers the broadest coverage.

A retrospective clinicopathological study of 550 patients with oral lichen planus in south-eastern Spain.

OBJECTIVES: This study describes the clinicopathological characteristics of a group of patients with oral lichen planus (OLP) in south-eastern Spain. MATERIALS AND METHODS: A retrospective descriptive study was made of 550 patients clinically and histopathologically diagnosed with OLP in the period 1991-2007. Patient gender, age, the prevalence of hepatitis C, symptoms and malignization were recorded. The clinical forms were classified as reticular-papular and atrophic-erosive. RESULTS: Of the 550 patients, 128 (23.3%) were men and 422 (76.7%) women. The mean age was 56.35 +/- 13.67 years (range 14-91). The prevalence of hepatitis C was 3.5%. The red clinical forms were the most frequent, with 359 cases (64.2%). The lesions were asymptomatic in 159 patients (28.9%). Five patients developed oral squamous cell carcinoma (0.9%); none of these subjects was smokers. CONCLUSIONS: Patients with OLP present different clinical manifestations. Women were more frequently affected by the disease, and the malignant transformation rate was under 1%.

Prevalence of temporomandibular disorder-related findings in violinists compared with control subjects.

OBJECTIVE: The aim of this study was to determine if there is an association between violin playing and the presence of signs and symptoms of temporomandibular disorder (TMD). STUDY DESIGN: We studied a group of violinists in the Murcia region of Spain, who were examined for TMD. The results were compared with those from a random control group who did not play any musical instrument. The groups were matched by age and gender. Statistical analysis was carried out using SPSS 15.0 statistical software. RESULTS: Compared with the control subjects, the violinists as a group had significantly more pain in maximum mouth opening (P < .005), parafunctional habits (P = .001), and occurrence of temporomandibular joint sounds (P < .005) as determined by chi-squared. CONCLUSIONS: Violin playing appears to be a factor associated with TMD-related findings.

Changes in antimicrobial resistance, serotypes and genotypes in Streptococcus pneumoniae over a 30-year period.

Over the past three decades, antimicrobial resistance in Streptococcus pneumoniae has dramatically increased worldwide. Non-susceptibility to penicillin in S. pneumoniae was first described in Australia in 1967, and later in New Guinea (1974), South Africa (1977), and Spain (1979). Most of these strains showed resistance to multiple antibiotics and belonged to serotypes 6A, 6B, 19A, 19F, and 23F. By the late 1980s and 1990s, the emergence and rapid dissemination of antibiotic-resistant pneumococci was observed in southern and eastern Europe, North America, South America, Africa, and Asia. Great geographical variability, both in serotype distribution and in the prevalence of resistant pneumococci, has been reported. However, the highest rates of resistance to penicillin and erythromycin worldwide were found in serotypes 6B, 6A, 9V, 14, 15A, 19F, 19A, and 23F. The introduction of the seven-valent pneumococcal conjugate vaccine (PCV7) in the 2000s and a reduction in antimicrobial use were associated with a significant decline in the incidence of invasive pneumococcal infections and in rates of antibiotic resistance in the USA. However, an increase in the incidence of infections caused by non-PCV7 serotypes, especially multiresistant serotype 19A pneumococci, has been observed in many countries over the last 5 years. The dynamic character of serotypes and antibiotic resistance in S. pneumoniae should be controlled by a policy of prudent antibiotic use and by implementation of the new generation of conjugate vaccines.

Premalignant nature of oral lichen planus. A retrospective study of 550 oral lichen planus patients from south-eastern Spain.

The most important complication of oral lichen planus (OLP) is the development of squamous cell carcinoma (SCC)--this being an association that remains subject to controversy. This study aims to examine the incidence and clinical presentation of oral malignancies associated with OLP. A retrospective study was made of 550 patients diagnosed with OLP according to the criteria of the World Health Organization, in the period between 1991 and 2007, in south-eastern Spain 128 males (23.3%) and 422 females (76.7%). A clinical protocol was applied in all cases (sociodemographic data, habits and hepatitis C markers), with histological confirmation of the disease. Five of the 550 patients (0.9%) developed SCC. The mean duration of follow-up was 24+/-20.83 months. The tongue was the most common location. The exact incidence of malignant transformation of OLP is difficult to establish, due to the possible contribution of external risk factors that may be of relevance in oral malignancy.

Temporal trends of invasive Streptococcus pneumoniae serotypes and antimicrobial resistance patterns in Spain from 1979 to 2007.

Temporal trends of serotypes from invasive pneumococcal disease (IPD) in Spain from 1979 to September 2007 under antibiotic and vaccine pressure were analyzed. A significant trend in pneumococcal conjugate 7-valent vaccine (PCV7) serotypes (except serotype 4) was found, whereby the prevalence increased from the early 1980s and decreased in the 2000s for all but serotype 23F, which began decreasing in the late 1980s. Among the major non-PCV7 serotypes, a significant decrease was observed for serotypes 1, 5, and 7F in the 1980s. From the late 1990s, serotypes 1, 5, 6A, 7F, and 19A increased significantly, while serotypes 3 and 8 showed similar but nonsignificant trends over time. The incidence of IPD cases was 10.7/100,000 for the period 1996 to 2006, with reporting coverage ranging from 18% to 43%. A significant decrease in IPD incidence due to PCV7 serotypes was observed, while the incidence of non-PCV7 serotypes increased, with the consequence that there was no clear pattern in the overall incidence of IPD. Penicillin nonsusceptibility was correlated with the proportion of PCV7 serotypes. Erythromycin nonsusceptibility increased in association with long-half-life macrolide consumption and then decreased in 2004 to 2007. The increase in PCV7 serotypes and antibiotic nonsusceptibility related to antibiotic consumption in the 1980s and 1990s was reversed in the 2000s, probably as a result of PCV7 immunization. The decrease in IPD incidence due to PCV7 serotypes was mirrored by an increase in that of non-PCV7 serotypes. The impact of various preventive/therapeutic strategies on pneumococcal evolution is serotype dependent, and the dynamics remain unpredictable.

Identification of pneumococcal serotypes from culture-negative clinical specimens by novel real-time PCR.

Pneumococcal parapneumonic empyema is an increasingly common complication in children. Conventional microbiological cultures indicate bacterial causes in as few as 8% of cases; therefore, there is a vital need for new molecular methods of detection and diagnosis. The development and clinical evaluation of real-time PCR-based assays to detect the pneumococcal capsular wzg gene of all serotypes tested are reported here, and 24 of them have been identified in clinical specimens. Using real-time PCR assays with highly specific TaqMan MGB probes that target DNA sequences within the capsular polysaccharide gene cluster, it was possible to differentiate serotypes 1, 3, 5, 4, 6A, 6B, 7F/A, 8, 9V/A/N/L, 14, 15B/C, 18C/B, 19A, 19F/B/C, 23F and 23A. These assays showed high sensitivity (five to ten pneumococcal DNA equivalents) and they were validated with 175 clinical isolates of known serotypes. The clinical value of this approach was demonstrated by analysis of 88 culture-negative pleural fluids from children diagnosed with parapneumonic empyema in three Spanish hospitals. Pneumococcal DNA was detected in 87.5% of pleural fluids, and serotypes 1, 7F and 3 were responsible for 34.3%, 16.4% and 11.9%, respectively, of cases of parapneumonic empyema in children. Such molecular methods are critical for the diagnosis of invasive pneumococcal disease and continued epidemiological surveillance in order to monitor serotype vaccine effectiveness.

Has the licensing of respiratory quinolones for adults and the 7-valent pneumococcal conjugate vaccine (PCV-7) for children had herd effects with respect to antimicrobial non-susceptibility in invasive Streptococcus pneumoniae?

OBJECTIVES: The aim of the study was to analyse the evolution of antibiotic non-susceptibility in Spanish invasive Streptococcus pneumoniae after licensure of respiratory-quinolones for adults and 7-valent pneumococcal conjugate vaccine (PCV-7) for immunization of children. METHODS: All invasive pneumococci received in the Reference Laboratory (January 2000-August 2007; n = 12 957 isolates) were serotyped, and susceptibility to penicillin/erythromycin/levofloxacin was determined. Antibiotic consumption and PCV-7 doses/year were provided by IMS and the manufacturer, respectively. RESULTS: In 2000-07, PCV-7 distribution (doses/1000 inhabitants

Antibiotic susceptibility and molecular epidemiology of nasopharyngeal pneumococci from Spanish children.

Nasopharyngeal pneumococci were collected from 635 Spanish children aged 6 months to 6 years attending four primary healthcare centres (n = 276) or two hospital emergency rooms (n = 359); 36% of the children had received >/=1 dose of pneumococcal conjugate vaccine (PCV7). Overall, the carriage rate of Streptococcus pneumoniae was 31%, with no significant differences in carriage rates according to setting. Colonization with vaccine serotypes was significantly associated with the absence of PCV7 immunization (29.4% vs. 5.9%, p <0.001). Forty-seven per cent of all isolates were penicillin- and/or erythromycin-non-susceptible; 13 international antibiotic-resistant clones were represented among non-susceptible pneumococci and were similarly distributed among vaccine and non-vaccine serotypes.

In vitro activity of oral cephalosporins against pediatric isolates of Streptococcus pneumoniae non-susceptible to penicillin, amoxicillin or erythromycin.

The aim of this study was to evaluate the effects of penicillin, amoxicillin or erythromycin resistance on the in vitro activity of oral cephalosporins against Streptococcus pneumoniae pediatric isolates. A total of 282 pediatric isolates received during 2005 in the Spanish Reference Pneumococcal Laboratory were tested by agar dilution: 104 strains were penicillin-susceptible, 72 intermediate, and 106 resistant. Serotypes 9 and 14 were the most troublesome with <10% susceptibility to oral cephalosporins. Cefditoren exhibited the highest intrinsic activity against penicillin/amoxicillin-resistant pneumococci, with MIC(90s )of 0.5 microg/ml, followed by cefotaxime (2 microg/ml), cefpodoxime (4 microg/ml), cefuroxime (16 microg/ml), and cefaclor/cefixime (>or= 32 microg/ml), with 0% susceptibility to cefaclor, cefuroxime and cefpodoxime. Cefditoren 0.5 microg/ml inhibited 95.3%, 95.5%, and 98.6% of penicillin-, amoxicillin-, and erythromycin-resistant isolates, respectively. Susceptibility to oral cephalosporins shifted from >90% in penicillin-susceptible isolates to approximately 38% for cefuroxime/cefpodoxime and approximately 7% for cefaclor in penicillin-intermediate, and to 0% in resistant isolates. Despite the different in vitro activity of oral cephalosporins, full resistance to penicillin or amoxicillin implied lack of susceptibility to all oral cephalosporins with defined CLSI breakpoints, rendering them inadequate as empirical treatment in countries with a high prevalence of penicillin resistance.

Influence of penicillin/amoxicillin non-susceptibility on the activity of third-generation cephalosporins against Streptococcus pneumoniae.

To study the influence of penicillin/amoxicillin non-susceptibility on the activity of third-generation cephalosporins, 430 consecutive penicillin non-susceptible Streptococcus pneumoniae 2007 isolates received in the Spanish Reference Pneumococcal Laboratory were tested. For comparative purposes, 625 penicillin-susceptible 2007 isolates were also tested. Susceptibility was determined by agar dilution using Mueller-Hinton agar supplemented with 5% sheep blood. Penicillin-susceptible strains were susceptible to amoxicillin, cefotaxime and ceftriaxone, 99.8% to cefpodoxime and 99.5% to cefdinir, and were inhibited by 0.12 microg/ml of cefditoren and 4 microg/ml of cefixime. Penicillin-intermediate strains were susceptible to cefotaxime and ceftriaxone, with <50% susceptibility to cefdinir and cefpodoxime. The MIC(50) and MIC(90) values of cefditoren were 0.25 microg/ml and 0.5 microg/ml, respectively, whereas cefixime exhibited only marginal activity (MIC(90)=16 microg/ml). Penicillin-resistant strains were resistant to cefdinir and cefpodoxime, with 74.8% and 94.1% susceptibility to cefotaxime and ceftriaxone, respectively. Cefditoren MIC(50)/MIC(90) (0.5/1 microg/ml) were lower than cefotaxime and ceftriaxone. Among amoxicillin non-susceptible strains, susceptibility to cefdinir and cefpodoxime was <10%, and susceptibility to cefotaxime decreased from 87.9% in the intermediate category to 63.0% in the resistant group. Cefditoren MIC(50)/MIC(90) (0.5/1 microg/ml) were lower than cefotaxime. In conclusion, the activity of cefixime, cefdinir and cefpodoxime was highly affected by penicillin/amoxicillin non-susceptibility, while parenteral third-generation cephalosporins exhibited higher intrinsic activity (MIC(90)=1 microg/ml for penicillin-resistant and 2 microg/ml for amoxicillin-resistant strains). Cefditoren exhibited one-dilution lower MIC(90) values for these strains, even against those of the most troublesome serotypes.

Serotypes, Clones, and Mechanisms of Resistance of Erythromycin-Resistant Streptococcus pneumoniae Isolates Collected in Spain.

The aim of this study was to analyze the distributions of antibiotic susceptibility patterns, serotypes, phenotypes, genotypes, and macrolide resistance genes among 125 nonduplicated erythromycin-resistant Streptococcus pneumoniae clinical isolates collected in a Spanish point prevalence study. The prevalence of resistance to macrolides in this study was 34.7%. Multiresistance (to three or more antimicrobials) was observed in 81.6% of these strains. Among 15 antimicrobials studied, cefotaxime, moxifloxacin, telithromycin, and quinupristin-dalfopristin were the most active drugs. The most frequent serotypes of erythromycin-resistant isolates were 19F (25%), 19A (17%), 6B (12%), 14 (10%), and 23F (10%). Of the 125 strains, 109 (87.2%) showed the MLS(B) phenotype [103 had the erm(B) gene and 6 had both erm(B) and mef(E) genes]. Sixteen (12.8%) strains showed the M phenotype [14 with mef(E) and 2 with mef(A)]. All isolates were tested by PCR for the presence of the int, xis, tnpR, and tnpA genes associated with conjugative transposons (Tn916 family and Tn917). Positive detection of erm(B), tet(M), int, and xis genes related to the Tn916 family was found in 77.1% of MLS(B) phenotype strains. In 16 strains, only the tndX, erm(B), and tet(M) genes were detected, suggesting the presence of Tn1116, a transposon recently described for Streptococcus pyogenes. Five clones, namely, Sweden(15A)-25, clone(19F) ST87, Spain(23F)-1, Spain(6B)-2, and clone(19A) ST276, accounted for half of the MLS(B) strains. In conclusion, the majority of erythromycin-resistant pneumococci isolated in Spain had the MLS(B) phenotype, belonged to multiresistant international clones, and carried the erm(B), tet(M), xis, and int genes, suggesting the spread of transposons of the Tn916 family.

Very high resistance to amoxicillin in Streptococcus pneumoniae: an epidemiological fact or a technical issue?

To explore reproducibility of high amoxicillin minimum inhibitory concentrations (MIC(AMX) ), isolates received during 2002 and 2003 in the National Reference Laboratory of Streptococcus pneumoniae with an amoxicillin MIC of 16 microg/ml (43 strains) and 8 g/ml (12 strains) when singly determined on a routine basis in this center by agar dilution, were retested 10 times by agar dilution and microdilution following NCCLS guidelines, not only using double dilutions but also dilution steps of 2 microg/ml (i.e, 2, 4, 6, 8, 10, 12, 14 and 16 microg/ml). A significant (p<0.05) shift to a higher MIC(AMX )was obtained with microdilution vs. agar dilution. Routine MIC(AMX )of 16 microg/ml were confirmed in 0 strains by agar dilution and in 6 by microdilution, when retested. These 6 strains presented a modal MIC(AMX )value of 10 microg/ml (5 cases) and of 14 micro g/ml (1 case) when using 2 microg/ml microdilution steps. There is low reproducibility of the highest MIC(AMX )values.

Increase of the M phenotype among erythromycin-resistant Streptococcus pneumoniae isolates from Spain related to the serotype 14 variant of the Spain9V-3 clone.

Between 1998 and 2003 the rate of erythromycin resistance among pneumococci in Spain was 34.4%. Although the MLS(B) phenotype was prevalent (94.7%), the rate of the M phenotype increased from 3.3% to 8.9% (P < 0.01). Clonal dissemination of mef(E)-carrying strains of serotype 14 variant of the Spain(9V)-3 clone was the major contributor to this increase.

[Activity of cefpodoxime and other oral beta-lactams against Haemophilus influenzae and Streptococcus pneumoniae with different susceptibilities to penicillin]. / Actividad de cefpodoxima y otros betalactámicos orales frente a Haemophilus influenzae y Streptococcus pneumoniae con distinta sensibilidad a la penicilina.

This study explores the influence on the intrinsic activity of different oral beta-lactams of beta-lactamase production in Haemophilus influenzae and penicillin resistance in Streptococcus pneumoniae. Three substudies were performed: a) a general susceptibility study, analyzing 550 strains received by the Spanish Laboratorio de Referencia de Neumococos throughout February and March 2005; b) a study on the influence of penicillin resistance on the activity of beta-lactams, analyzing 251 penicillin-susceptible strains (MICor=2 mg/l) randomly chosen among those received by the Spanish Laboratorio de Referencia de Neumococos throughout 2005; and c) an H. influenzae susceptibility study analyzing 150 strains received by Instituto Valenciano de Microbiologia throughout 2005. A total of 71% of S. pneumoniae strains were susceptible to penicillin, 21% exhibited intermediate resistance and 8% strains presented full resistance. H. influenzae beta-lactamase production rate was 18.6%. Of the non-beta-lactamase-producing strains, 3% were not susceptible to ampicillin. Cefpodoxime and cefixime exhibited the highest intrinsic activity against H. influenzae, while amoxicillin and cefpodoxime were the most active compounds against S. pneumoniae. All H. influenzae strains were susceptible to oral cephalosporins and amoxicillin/clavulanic acid. The increase in penicillin resistance in S. pneumoniae influenced cefixime, cefaclor and cefuroxime to a higher degree than amoxicillin and cefpodoxime.

Actividad de cefpodoxima y otros betalactámicos orales frente a Haemophilus influenzae y Streptococcus pneumoniae con distinta sensibilidad a la penicilina / Activity of cefpodoxime and other oral beta-lactams against Haemophilus influenzae and Streptococcus pneumoniae with different susceptibilities to penicillin

Estudiamos la influencia de la producción de betalactamasas en Haemophilus influenzae y del grado de sensibilidad a la penicilina en Streptococcus pneumoniae sobre la actividad intrínseca de distintos betalactámicos orales. Realizamos tres subestudios: 1) un estudio general de sensibilidad, analizando 550 aislamientos consecutivos recibidos en el Laboratorio de Referencia de Neumococos durante los meses de febrero y marzo de 2005; 2) un estudio de la influencia de la sensibilidad a la penicilina sobre la actividad del resto de los betalactámicos, analizando la sensibilidad de 251 cepas sensibles a la penicilina (CMI ≤0,06 mg/l), 165 cepas con resistencia intermedia (CMI 0,12-1 mg/l) y 139 resistentes (CMI ≥2 mg/l), elegidas aleatoriamente entre todos los aislamientos recibidos durante el año 2005; y 3) un estudio de sensibilidad de H. influenzae, analizando 150 cepas recibidas por el Instituto Valenciano de Microbiología a lo largo del año 2005. El 71% de las cepas de S. pneumoniae fueron sensibles a la penicilina, el 21% presentaron baja resistencia o resistencia intermedia, y un 8% alta resistencia. La tasa de producción de betalactamasas fue del 18,6% en H. influenzae. El 3% de las cepas no productoras de betalactamasas fueron no sensibles a la ampicilina. La cefpodoxima y la cefixima presentaron la mayor actividad intrínseca frente a H. influenzae, mientras que frente a S. pneumoniae ésta correspondió a la amoxicilina y la cefpodoxima. Mientras que el 100% de las cepas de H. influenzae fueron sensibles a las cefalosporinas orales y a amoxicilina-ácido clavulánico, el aumento de la resistencia a la penicilina en S. pneumoniae afectó en mayor grado a la actividad de la cefixima, el cefaclor y la cefuroxima que a la amoxicilina y la cefpodoxima

This study explores the influence on the intrinsic activity of different oral β-lactams of β-lactamase production in Haemophilus influenzae and penicillin resistance in Streptococcus pneumoniae. Three substudies were performed: a) a general susceptibility study, analyzing 550 strains received by the Spanish Laboratorio de Referencia de Neumococos throughout February and March 2005; b) a study on the influence of penicillin resistance on the activity of β-lactams, analyzing 251 penicillin-susceptible strains (MIC ≤0.06 mg/l), 165 penicillin intermediateresistant strains (MIC 0.12–1 mg/l) and 139 penicillin-resistant strains (MIC ≥2 mg/l) randomly chosen among those received by the Spanish Laboratorio de Referencia de Neumococos throughout 2005; and c) an H. influenzae susceptibility study analyzing 150 strains received by Instituto Valenciano de Microbiología throughout 2005. A total of 71% of S. pneumoniae strains were susceptible to penicillin, 21% exhibited intermediate resistance and 8% strains presented full resistance. H. influenzae β-lactamase production rate was 18.6%. Of the non–β-lactamase-producing strains, 3% were not susceptible to ampicillin. Cefpodoxime and cefixime exhibited the highest intrinsic activity against H. influenzae, while amoxicillin and cefpodoxime were the most active compounds against S. pneumoniae. All H. influenzae strains were susceptible to oral cephalosporins and amoxicillin/clavulanic acid. The increase in penicillin resistance in S. pneumoniae influenced cefixime, cefaclor and cefuroxime to a higher degree than amoxicillin and cefpodoxime

Diagnóstico diferencial de los desórdenes temporomandibulares (DTM) / Diferential diagnosis of temporomandibular disorders (TMD)

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