What do beta-lactams add to vancomycin or daptomycin in the treatment of patients with methicillin-resistant Staphylococcus aureus bacteraemia? A review.

Several studies have documented the synergy between vancomycin/daptomycin and various beta-lactams, and clinical studies have studied this combination therapy in humans. We review the published literature on this topic to know the utility of the combined treatment with beta-lactams in treating bacteraemia methicillin-resistant Staphylococcus aureus (MRSA) infections. Fifteen observational studies, three randomised clinical trials and three systematics reviews are analysed in this article. Observational studies used ceftaroline, cefazolin, piperacillin/tazobactam or cefepime among the beta-lactams. Clinical trials used cloxacillin or flucloxacillin as the most used beta-lactam in two trials and ceftaroline in one. Three systematic reviews are published. One of them only includes studies with vancomycin and included six studies. The other two systematic reviews include patients with daptomycin or vancomycin and included 15 and 9 studies, respectively. Adding a beta-lactam to vancomycin or daptomycin may help shorten bacteraemia and avoid recurrences in patients with MRSA bacteraemia. There is no evidence that combined therapy improves mortality. Nephrotoxicity in clinical trials precludes the use of combination therapy mainly with cloxacillin or flucloxacillin, but systematic reviews have not found a significant difference in this point in observational studies with other beta-lactams. The role of other beta-lactams such as ceftaroline should be thoroughly studied in these patients.

Current Evidence on the Antimicrobial Treatment and Chemoprophylaxis of Human Leptospirosis: A Meta-Analysis.

BACKGROUND: Leptospirosis is a worldwide zoonotic infection, and its management needs to be refined. This study aims to discern which antibiotic would be the best option to treat leptospirosis disease and analyze the efficacy of chemoprophylaxis regimens to prevent this illness. METHODS: systematic review and meta-analysis on the efficacy of antibiotic treatment and chemoprophylaxis of leptospirosis in humans. RESULTS: Ten clinical trials compared an antibiotic treatment with placebo or other antibiotic treatments in leptospirosis (the most recent one was published in 2007). The meta-analysis shows no effect of penicillin treatment on mortality compared to placebo (OR 1.65; 95% CI 0.76-3.57; p = 0.21). There are no differences between penicillin and cephalosporins or doxycycline. Penicillin does not reduce the time of defervescence (MD-0.16; 95% CI (-1.4) -1.08; p = 0.80) nor hospital stay (MD 0.15; 95% CI (-0.75)-1.06; p = 0.74). Besides, the data did not demonstrate any effectiveness of the use of penicillin in terms of the incidence of oliguria/anuria, the need for dialysis treatment, time to creatinine normalization, incidence of jaundice, or the liver function normalization time. Eight trials have assessed prophylactic treatment against leptospirosis with different strategies. A weekly dose of 200 mg of doxycycline does not show benefit versus placebo regarding the number of new cases of symptomatic leptospirosis (OR 0.20; 95% CI 0.02-1.87; p = 0.16). A single dose of doxycycline at exposure to flood water could have a beneficial effect (OR 0.23; 95% CI 0.07-0.77; p = 0.02). None of the other chemoprophylaxis regimens tested have shown a statistically significant effect on the number of new symptomatic cases. CONCLUSION: There is no evidence that antibiotics are a better treatment than placebo regarding mortality, shortening of fever, liver and kidney function, or reduction in the hospital stay. On the other hand, neither doxycycline nor penicillin, nor azithromycin have shown statistically significant differences in preventing symptomatic infection. Well-designed clinical trials, including other antibiotics such as quinolones or aminoglycosides, are urgently needed to improve our understanding of the treatment for this infection, which continues to be a neglected disease.

Efectividad del tratamiento con agentes antivirales directos en pacientes con coinfección por VHC y VIH. Estudio de cohorte multicéntrico / Effectiveness of direct-acting antiviral therapy in patients with a HCV/HIV coinfection. A multicenter cohort study

Introducción: la eficacia de los agentes antivirales directos (AAD) ha quedado demostrada en ensayos clínicos tanto en mono como en coinfectados. Nuestro objetivo es analizar la efectividad y toxicidad de este tratamiento en vida real en pacientes con coinfección por VIH y VHC así como determinar variables asociadas a una evolución desfavorable. Métodos: estudio ambispectivo multicéntrico en una cohorte de pacientes coinfectados. Los datos fueron recogidos en ocho centros de Castilla-La Mancha entre 2014 y 2016. Se realizó un análisis por intención de tratamiento en el que cualquier pérdida de seguimiento, abandono de tratamiento o toxicidad terapéutica se consideró fracaso. Resultados: se estudiaron 229 pacientes con una mediana de edad de 49,6 años con predominio masculino (83%). Menos de un 10% presentaba carga viral (CV) detectable para el VIH. El genotipo de VHC más prevalente fue el 1 (65,1%). Un 50% tenía hepatopatía en grado de cirrosis. El 65% presentaba más de 800.000 copias/ml de CV de VHC. La respuesta viral sostenida (RVS) se alcanzó globalmente en el 91,7%. La estrategia de AAD más utilizada fue sofosbuvir/ ledipasvir. Un 52% de las pautas incluyeron ribavirina. El 65,9% completó pautas de 12 semanas y un 30%, de 24 semanas. Hubo 19 fracasos terapéuticos. No existen diferencias entre las distintas estrategias de AAD utilizadas. No se observó ningún factor predictor independiente de RVS. Conclusiones: el tratamiento del VHC en pacientes coinfectados presenta tasas de RVS muy elevadas también en vida real. La toxicidad es excepcional. No hemos identificado factores predictores específicos de evolución desfavorable (AU)

ntroduction: The effectiveness of direct-acting antiviral (DAA) agents has been demonstrated in clinical trials both in patients with mono and coinfections. The goal of the study was to analyze the effectiveness and toxicity of this therapy in real-life patients with a HIV/HCV coinfection and to identify variables that are associated with an unfavorable outcome. Methods: This was a multicenter ambispective study in a cohort of coinfected patients. Data were collected from eight centers in Castilla-La Mancha from 2014 to 2016. An intent-to-treat analysis was performed and any loss to follow-up, treatment withdrawal or toxicity was considered as a failure. Results: A total of 229 patients were included with a median age of 49.6 years and the majority were male (83%). Fewer than 10% had a detectable HIV-related viral load (VL). The most prevalent HCV genotype was 1 (65.1%). Fifty percent had cirrhotic liver disease and 65% had over 800,000 copies/ml of HCV VL. The global sustained viral response (SVR) was reached by 91.7% of cases. The most commonly used DAA regimen was sofosbuvir/ledipasvir. Ribavirin was included in 52% of regimens, 65.9% of cases completed 12-week regimens and 30% completed 24-week schemes. There were 19 therapy failures. No differences were observed between the various DAA strategies used. No independent predictor was found for SVR. Conclusions: HCV treatment in coinfected patients is highly successful in terms of SVR rate in the real-life setting and toxicity is exceptional. We identified no specific predictors of an unfavorable outcome (AU)

Effectiveness of direct-acting antiviral therapy in patients with a HCV/HIV coinfection. A multicenter cohort study.

INTRODUCTION: The effectiveness of direct-acting antiviral (DAA) agents has been demonstrated in clinical trials both in patients with mono and coinfections. The goal of the study was to analyze the effectiveness and toxicity of this therapy in real-life patients with a HIV/HCV coinfection and to identify variables that are associated with an unfavorable outcome. METHODS: This was a multicenter ambispective study in a cohort of coinfected patients. Data were collected from eight centers in Castilla-La Mancha from 2014 to 2016. An intent-to-treat analysis was performed and any loss to follow-up, treatment withdrawal or toxicity was considered as a failure. RESULTS: A total of 229 patients were included with a median age of 49.6 years and the majority were male (83%). Fewer than 10% had a detectable HIV-related viral load (VL). The most prevalent HCV genotype was 1 (65.1%). Fifty percent had cirrhotic liver disease and 65% had over 800,000 copies/ml of HCV VL. The global sustained viral response (SVR) was reached by 91.7% of cases. The most commonly used DAA regimen was sofosbuvir/ledipasvir. Ribavirin was included in 52% of regimens, 65.9% of cases completed 12-week regimens and 30% completed 24-week schemes. There were 19 therapy failures. No differences were observed between the various DAA strategies used. No independent predictor was found for SVR. CONCLUSIONS: HCV treatment in coinfected patients is highly successful in terms of SVR rate in the real-life setting and toxicity is exceptional. We identified no specific predictors of an unfavorable outcome.

Manejo del niño inmigrante: calendario vacunal / Management of immigrant children: vaccination calendar

En Castilla-La Mancha la población extranjera se ha multiplicado en el último quinquenio. La progresión de la incorporación de inmigrantes ha sido muy rápida en los últimos años, con incremento más acusado a partir del año 2001. Los inmigrantes proceden a menudo de comunidades socioeconómicas deprimidas, siendo la población infantil la más vulnerable. Existe una alta probabilidad de que estos niños estén incorrectamente vacunados y, por lo tanto, expuestos a agentes infecciosos a los que la población autóctona es inmune. En estas situaciones, debemos realizar una valoración médica inicial y una adecuada supervisión del estado vacunal, para administrar las vacunas mediante pautas aceleradas y conseguir una actualización de su carnet de vacunación de acuerdo con el calendario de inmunizaciones de nuestra comunidad autónoma. Para elaborar este trabajo se han consultado guías de atención al inmigrante de varias comunidades autónomas de nuestro país, las recomendaciones americanas del comité de inmunizaciones y, sobretodo, se han tenido en cuenta las recomendaciones del Comité Asesor de Vacunas (CAV) de la Asociación Española de Pediatría (AEP) de 2008 (AU)

The immigrant population in Castilla-La Mancha, Spain has multiplied in the last five years. The incorporation of immigrants has progressed very rapidly in the last few years with the greatest increase being in 2001. The immigrants often come from depressed socio-economic communities and the child population is the most vulnerable. There is a high probability that these children have not been adequately vaccinated and, therefore, are exposed to infectious agents to which the indigenous population is immune. For these children, we should perform an initial medical assessment and a review of their vaccine status in order to administer vaccines in an accelerated regimen. Thus bringing their vaccination record card up to date with the immunization calendar in our autonomous community. In order to carry out this work we have consulted guidelines on immigrant care in several autonomous communities in Spain, the American recommendations of the immunization committee and, in particular, the 2008 recommendations of the Vaccine Assessment Committee (CAV) and the Spanish Paediatric Society (AEP) have been taken into account (AU)

Lesiones periungueales en un viajero procedente de Sudamérica / Periungual lesions in a traveler returning from South America

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[Clinical usefulness of biochemical markers of bone turnover in early postmenopausal women: two years longitudinal study]. / Utilidad clínica de los marcadores bioquímicos de remodelado óseo en la mujer posmenopáusica reciente: estudio longitudinal a 2 años.

BACKGROUND AND OBJECTIVE: Many studies have been performed on the ability of bone turnover markers (BTM) for the prediction of bone loss and to assess the correlation of BTM with bone mineral density (BMD). However, the results from these studies have been mixed. The aim of this study was to assess the usefulness of BTM to predict bone loss and to analize the correlation of BTM with BMD in early postmenopausal women. SUBJECTS AND METHOD: 183 healthy women, aged 50 to 55 years, with natural menopause of 6 to 36 months were randomly selected. We measured bone alkaline phosphatase (BALP), intact osteocalcine (OC) and C-telopeptide (sCTx) in serum, and calcium, deoxipiridinoline (DPD) and N-telopeptide (NTx) in urine. Bone densitometry of the spine (L(2)-L(4)) was performed at the start of the study and two years later. Student t test, ANOVA, chi2 test and ROC curves were used for the statistical analysis. RESULTS: Bone markers, mainly OC and CTx, correlated with BMD and discriminated osteoporosis, osteopenia and normal bone mass (p < 0.001). According to the ROC curves, OC had a sensitivity of 77.8% and specificity of 80.6% for the diagnosis of osteoporosis and sCTx, 83.3% and 74.5%, respectively. Regarding the relation to bone loss, only sCTx showed difference between the lowest and the highest quartile (p = 0.042), but we did not find an association between high turnover and fast bone losers. CONCLUSIONS: Bone markers, mainly OC and sCTx, are useful for identification of osteoporotic and osteopenic early postmenopausal women. However, regarding the bone loss, only CTx has a weak predictive value.

Utilidad clínica de los marcadores bioquímicos de remodelado óseo en la mujer posmenopáusica reciente: estudio longitudinal a 2 años / Clinical usefulness of biochemical markers of bone turnover in early postmenopausal women: two years longitudinal study

FUNDAMENTO Y OBJETIVO: Los estudios sobre la capacidad de los marcadores del remodelado óseo (MRO) para la predicción de la pérdida ósea y sobre la correlación de los MRO con la densidad mineral ósea (DMO) han mostrado resultados dispares. Los objetivos del trabajo han sido evaluarla utilidad de los MRO para predecir la pérdida de masa ósea y estudiar la correlación entre los MRO y la DMO en las mujeres posmenopáusicas recientes. SUJETOS Y MÉTODO: Seleccionamos al azar a 183 mujeres sanas de 50-55 años, con menopausia natural en los últimos 6-36 meses. En suero analizamos fosfatasa alcalina ósea (FAO), osteocalcinaintacta (OC) y C-telopéptido (sCTx), y en orina, calcio, de oxipiridinolina (DPD) y N-telopéptido (NTx). Realizamos una densitometría ósea (L2-L4) basal y otra de control a los 2 años. El análisis estadístico se ha hecho mediante la t de Student, ANOVA, prueba de X2 y curvas ROC. RESULTADOS: Los MRO correlacionaron con la DMO y permitieron diferenciar entre osteoporosis, osteopenia y masa ósea normal, principalmente OC y sCTx (p < 0,001). Según las curvas ROC, la OC tuvo una sensibilidad del 77,8% y una especificidad del 80,6% para el diagnóstico de osteoporosis, mientras que la de sCTx, fue del 83,3 y el 74,5%, respectivamente. En cuanto ala relación con la pérdida ósea, solamente hubo diferencia entre el cuartil inferior y el superior de sCTx (p = 0,042). No encontramos asociación entre recambio óseo alto y pérdidas rápidas de masa ósea. CONCLUSIONES: Los MRO son de utilidad para la identificación de mujeres posmenopáusicas recientes con osteoporosis y osteopenia, principalmente OC y sCTx, pero respecto a la pérdida ósea tan sólo sCTx tiene un valor predictivo débil

BACKGROUND AND OBJECTIVE: Many studies have been performed on the ability of bone turnover markers (BTM) for the prediction of bone loss and to assess the correlation of BTM with bone mineral density (BMD). However, the results from these studies have been mixed. The aim of this study was to assess the usefulness of BTM to predict bone loss and to analize the correlation of BTM with BMD in early postmenopausal women. SUBJECTS AND METHOD: 183 healthy women, aged 50 to 55 years, with natural menopause of 6 to36 months were randomly selected. We measured bone alkaline phosphatase (BALP), intact osteocalcine(OC) and C-telopeptide (sCTx) in serum, and calcium, de oxipiridinoline (DPD) and N-telopeptide (NTx) in urine. Bone densitometry of the spine (L2-L4) was performed at the start of the study and two years later. Student t test, ANOVA, X2 test and ROC curves were used for the statistical analysis. RESULTS: Bone markers, mainly OC and CTx, correlated with BMD and discriminated osteoporosis, osteopenia and normal bone mass (p < 0.001). According to the ROC curves, OC had a sensitivity of 77.8% and specificity of 80.6% for the diagnosis of osteoporosis and sCTx,83.3% and 74.5%, respectively. Regarding the relation to bone loss, only sCTx showed difference between the lowest and the highest quartile (p = 0.042), but we did not find an association between high turnover and fast bone losers. CONCLUSIONS: Bone markers, mainly OC and sCTx, are useful for identification of osteoporoticand osteopenic early postmenopausal women. However, regarding the bone loss, only CTx has a weak predictive value

Bacteriemia, absceso cerebral y meningitis por Listeria monocytogenes / Bacteremia, brain abscess, and meningitis caused by Listeria monocytogenes

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Prevalencia de Obesidad en escolares / Prevalence of obesity in school children

Objetivos. Conocer la prevalencia de obesidad en los niños de 6 a 8 años. Valorar si la asistencia alcomedor escolar y las vacaciones del periodo estival infl uyen de manera signifi cativa en la obesidadde los niños.Diseño. Estudio observacional longitudinal.Emplazamiento. Un colegio público urbano de la Zona Básica de Salud número 1 de Albacete.Participantes. 102 niños de primero y segundo cursos de educación primaria.Mediciones principales. Las medidas antropométricas peso, talla e índice de masa corporal (IMC)fueron evaluadas en los sujetos de estudio durante el mes de mayo de 2007. De nuevo, en septiembre,se obtuvieron estos datos somatométricos en los mismos niños, así como la medición delperímetro abdominal en los que resultaron obesos. Para el cálculo de los percentiles se utilizaron lastablas de peso, talla, IMC y perímetro abdominal según edad y sexo de la fundación Orbegozo.Resultados. La prevalencia de obesidad en la primera evaluación fue del 23,5% y la de sobrepesodel 33,3%. En la segunda medición los valores ascendieron a 28,2 y 36,4% respectivamente. Comparandoel valor medio del IMC antes y después del verano, se observó una diferencia estadísticamentesignifi cativa, siendo superior después del verano (18,3 vs 18,7 Kg/m2; p = 0,005).Conclusiones. Encontramos una alta prevalencia de obesidad en nuestros escolares, sin relacióncon la asistencia al comedor escolar, sin embargo, tras el periodo estival, se comprobó un aumentoestadísticamente signifi cativo en el IMC

Objectives. To determine the prevalence of obesity in children from 6 to 8 years old. To determine ifschool dinners and the holiday period signifi cantly affect obesity in children.Design. Longitudinal, observational study.Setting. A state school in an urban area in Basic Health Area number 1 in Albacete.Participants. 102 children in the fi rst and second year of primary school.Main measurements. The anthropometric measurements of weight, height and body mass index(BMI) of the subjects were taken during May 2007. In September these measurements were takenagain and the abdominal perimeter was also measured in subjects who were obese. The percentileswere calculated using the Fundación Orbegozo charts for weight, height, BMI and abdominal perimeteraccording to age and gender.Results. The prevalence of obesity in the fi rst evaluation was 23.5% and the prevalence of beingoverweight was 33.3%. In the second evaluation these values increased to 28.1% and 36.4%, respectively.There was a statistically signifi cant difference in the BMI index before and after the summerholidays, the BMI being higher after the summer holidays (18.3 vs 18.7 Kg/m2; p = 0.005).Conclusions. We found a high prevalence of obesity in our school children. Obesity was not relatedto school dinners. However, after the summer holidays there was a signifi cantly increase in BMI

Tuberculosis intestinal en paciente con linfocitopenia CD4 idiopática / Intestinal tuberculosis in a patient with idiopathic CD4+ T-lymphocytopenia

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