Forty years of Tuberculous meningitis: The new face of an old enemy.

BACKGROUND: Tuberculous meningitis (TBM) occurs in 1-5% of cases of tuberculosis. Without early treatment, mortality and permanent disability rates are high. METHODS: A retrospective study performed at a tertiary hospital in Madrid (Spain) to describe clinical, diagnostic, and therapeutic aspects of TBM and analyze epidemiological trends over forty years, divided into two intervals (1979-1998 and 1999-2018). RESULTS: Overall, TBM was diagnosed in 65 patients (1.8% of new tuberculosis diagnoses), 48 in the first period and 17 in the second one. Median age at diagnosis increased from 38.5 to 77 years (p = 0.003). The proportion of non-HIV immunosuppressed patients increased (from 2.1% to 29.4%, p < 0.001), while the percentage of patients with a history of drug-abuse decreased (from 33.3% to 5.9%, p = 0.027). The median time between the onset of neurological symptoms and lumbar puncture increased from seven to 15 days (p = 0.040). The time between the onset of symptoms and the initiation of tuberculostatic treatment also increased from eleven to 18 days (p = 0.555). Results from image, biochemical, and microbiological tests showed no differences between both periods. A decreasing trend was observed in survival rates at 1-week (from 97.9% to 64.7%, p < 0.001), 1-month (from 91.7% to 58.8%, p = 0.002) and 1-year (from 85.4% to 47.1%, p = 0.002) after TBM diagnosis. CONCLUSIONS: The profile of patients diagnosed with TBM has changed from a young HIV-infected patient with a history of drug addiction to an elderly patient with non-HIV immunosuppression. Diagnosis and start of treatment both experienced a noticeable delay in the second period, which could help explain the increase in mortality observed across the two periods.

Direct antimicrobial susceptibility testing from the blood culture pellet obtained for MALDI-TOF identification of Enterobacterales and Pseudomonas aeruginosa.

To standardize the methodology for conducting direct antimicrobial susceptibility testing (AST) of Enterobacterales and Pseudomonas aeruginosa causing bacteremia from positive blood culture pellets. Two methods for processing positive blood cultures with Enterobacterales and P. aeruginosa were compared: a conventional method for identification and AST versus a direct method obtaining a pellet for both matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) identification and direct AST. A total of 157 (145 Enterobacterales, 12 P. aeruginosa) positive blood cultures were included. Microorganism identification showed 100% concordance between both methods at species and genus level. Definitive AST results were obtained 24 h earlier with the rapid method than the conventional one (p < 0.001). Of the 2814 MICs generated, there were discrepancies with respect to the conventional method in 47 (1.7%), 0.3% being very major (VME) and 1.3% major (ME) errors. Better results for AST were obtained when colony counts with the pellet were ≥ 105 cfu/ml. The essential agreement (EA) for antibiotics tested in Enterobacterales was at least 97%, except for ampicillin (95%). Regardless of colony count, the greatest discrepancies were observed for first/s-generation cephalosporins and aminoglycosides. In P. aeruginosa, EA was at least 92%, except for piperacillin-tazobactam (84%) and cefepime (76%). No VME occurred except for ceftazidime (8%). ME occurred in piperacillin/tazobactam (16%), ticarcillin, ceftazidime, tobramycin, amikacin, and colistin (8% each). Direct use of the blood culture pellet permits fast AST in bacteremia of Enterobacterales, enabling the clinicians to perform an early treatment adjustment. However, for Pseudomonas aeruginosa, the data needs expanding to improve the reliability of this technique.

Bacteraemia due to OXA-48-carbapenemase-producing Enterobacteriaceae: a major clinical challenge.

Bacteraemia due to carbapenemase-producing Enterobacteriaceae is an emerging medical problem. Management of this entity is complicated by the difficulty in identifying resistance patterns and the limited therapeutic options. A cohort study was performed including all episodes of bloodstream infection due to OXA-48-producing Enterobacteriaceae (O48PE), occurring between July 2010 and April 2012. Data on predisposing factors, clinical presentation, therapy and outcome were collected from medical records. There were 40 cases of bacteraemia caused by O48PE, 35 Klebsiella pneumoniae and five Escherichia coli. Patients were elderly with significant comorbidities (57.5% underlying malignancy). Thirty-five cases (87.5%) were nosocomial, and five (12.5%) were healthcare-associated. Patients had frequently been exposed to antibiotics and to invasive procedures during hospitalization. The most common source of bacteraemia was the urinary tract followed by deep intra-abdominal surgical site infection. Clinical presentation was severe sepsis or shock in 18 cases (45%). Extended-spectrum ß-lactamase production was detected in 92.5% of isolates. MIC(90) for ertapenem, imipenem and meropenem were 32, 16 and 16 mg/L, respectively. Most frequently preserved antibiotics were amikacin, colistin, tigecycline and fosfomycin. These antibiotics combined are the basis of targeted therapies, including carbapenem in selected cases. Median delay in starting clinically adequate and microbiologically appropriate treatment was 3 days. Crude mortality during admission and within 30 days from bacteraemia was 65% and 50%, respectively. Bloodstream infections caused by O48PE have a poor prognosis. Delay in diagnosis and in initiation of optimal antimicrobial therapy is frequent. Suspicion and rapid identification could contribute to improving outcomes.

[Spontaneous infectious spondylodiscitis in an internal medicine department: epidemiological and clinical study in 41 cases]. / Espondilodiscitis infecciosa espontánea en un servicio de medicina interna: estudio epidemiológico y clínico de 41 casos.

INTRODUCTION: The clinical-epidemiological characteristics of patients who were diagnosed of spontaneous infectious spondylodiscitis (SIS) in our Internal Medicine Department are analyzed and the related factors associated with the increase of the incidence are evaluated. PATIENTS AND METHODS: A cross-sectional, retrospective study of patients diagnosed of SIS from 1996 to 2005 was conducted. The study was divided in two periods: A (1996-2000) and B (2001-2005) and two main etiologic groups (pyogenic SIS and mycobacterial SIS) were compared. RESULTS: A total of 41 patients were diagnosed of SIS: 13 (31.7%) in period A and 28 (68.3%) in period B. Mean age was 58.5 +/- 17.6 years (range: 29-89). There were 73.2% men and all women presented in period B (0 vs 11, p = 0.008). Backgrounds were: 28 (68.3%) predisposing factors for SIS, 22 (53.6%), previous infections and 23 (56.1%) spinal diseases. There were not changes in the backgrounds during the study. The etiology of SIS was: 26 (63.4%) pyogenic, 12 (29.3%) mycobacterial and 3 (7.3%) brucellar. Patients with pyogenic SIS were older (63.6 +/- 3.2 vs 51.2 +/- 5.1 years, p = 0.035) and had less from onset of symptoms to diagnosis (62 +/- 12 vs 291 +/- 66 days, p = 0.0001) than patients with mycobacterial SIS. Total incidence of SIS and incidence of pyogenic SIS increased significantly during the study: (1.7/1000 admissions/year, p = 0.0057) and (1/1000 admissions/year, p = 0.0476). In the multivariate analysis, time from onset of symptoms to diagnosis was the only variable independently associated with the pyogenic etiological group (OR: 0.985, 95% CI: 0.975, 0.996, p = 0.005). CONCLUSIONS: In our study, the increasing incidence of SIS was related to an increase in pyogenic SIS incidence. Although older age and some backgrounds could be orientative of SIS etiology, these factors did not increase during the study.

Espondilodiscitis infecciosa espontánea en un servicio de medicina interna: estudio epidemiológico y clínico de 41 casos / Spontaneous Infectious Spondylodiscitis in an Internal Medicine Department: epidemiological and clinical study in 41 cases

Introducción. Se analizan las características epidemiológicas y clínicas de los pacientes diagnosticados de espondilodiscitis infecciosa espontánea (EIE) en nuestro Servicio de Medicina Interna, y valoramos los posibles factores relacionados con el aumento de su incidencia. Pacientes y métodos. Estudio transversal, retrospectivo de los pacientes diagnosticados de EIE desde 1996 hasta 2005. Se ha dividido el tiempo de estudio en dos períodos (A: 1996-2000 y B: 2001-2005) y se compararon los principales grupos etiológicos (EIE piógenas y EIE micobacterianas). Resultados. Se diagnosticaron 41 casos de EIE: 13 (31,7%) en el período A y 28 (68,3%) en el período B. La edad media era 58,5 ± 17,6 años (rango: 29-89). Un 73,2% eran varones; todas las mujeres se presentaron en el período B (0 frente a 11, p = 0,008). Los antecedentes fueron: 28 (68,3%) factores predisponentes de EIE, 22 (53,6%) infecciones previas y 23 (56,1%) patologías de columna. No se observaron modificaciones en los antecedentes a lo largo del estudio. La etiología de la EIE fue: piógena en 26 casos (63,4%), micobacteriana en 12 (29,3%) y brucelar en 3 (7,3%). Los pacientes con EIE piógenas tenían más edad (63,6 ± 3,2 frente a 51,2 ± 5,1 años, p = 0,035) y un menor tiempo de demora desde el inicio de los síntomas hasta el diagnóstico (62 ± 12 frente a 291 ± 66 días, p = 0,0001) que los pacientes con EIE micobacteriana. Se observó un aumento significativo de la incidencia total de EIE (1,7 casos por cada 1.000 ingresos al año, p = 0,0057) y de la incidencia de EIE piógenas (uno de cada 1.000 ingresos al año, p = 0,0476). En el estudio multivariante, el tiempo desde el inicio de los síntomas hasta el diagnóstico fue la única variable independientemente asociada al grupo etiológico piógeno (OR: 0,985, IC95%: 0,975; 0,996, p = 0,005). Conclusiones. El aumento significativo en la incidencia de EIE observada en nuestro estudio ha sido a expensas de un aumento significativo en la incidencia del grupo etiológico piógeno. Aunque la edad avanzada y algunos antecedentes puedan ser orientativos de la etiología de la EIE, este tipo de factores no se incrementaron durante el estudio (AU)

Introduction. The clinical-epidemiological characteristics of patients who were diagnosed of spontaneous infectious spondylodiscitis (SIS) in our Internal Medicine Department are analyzed and the related factors associated with the increase of the incidence are evaluated. Patients and methods. A cross-sectional, retrospective study of patients diagnosed of SIS from 1996 to 2005 was conducted. The study was divided in two periods: A (1996-2000) and B (2001-2005) and two main etiologic groups (pyogenic SIS and mycobacterial SIS) were compared. Results. A total of 41 patients were diagnosed of SIS: 13 (31.7%) in period A and 28 (68.3%) in period B. Mean age was 58.5 ± 17.6 years (range: 29-89). There were 73.2% men and all women presented in period B (0 vs 11, p = 0.008). Backgrounds were: 28 (68.3%) predisposing factors for SIS, 22 (53.6%), previous infections and 23 (56.1%) spinal diseases. There were not changes in the backgrounds during the study. The etiology of SIS was: 26 (63.4%) pyogenic, 12 (29.3%) mycobacterial and 3 (7.3%) brucellar. Patients with pyogenic SIS were older (63.6 ± 3.2 vs 51.2 ± 5.1 years, p = 0.035) and had less from onset of symptoms to diagnosis (62 ± 12 vs 291 ± 66 days, p = 0.0001) than patients with mycobacterial SIS. Total incidence of SIS and incidence of pyogenic SIS increased significantly during the study: (1.7/1000 admissions/year, p = 0.0057) and (1/1000 admissions/year, p = 0.0476). In the multivariate analysis, time from onset of symptoms to diagnosis was the only variable independently associated with the pyogenic etiological group (OR: 0.985, 95% CI: 0.975, 0.996, p = 0.005). Conclusions. In our study, the increasing incidence of SIS was related to an increase in pyogenic SIS incidence. Although older age and some backgrounds could be orientative of SIS etiology, these factors did not increase during the study (AU)