Epidemiological trends of HIV/HCV coinfection in Spain, 2015-2019.

OBJECTIVES: We assessed the prevalence of anti-hepatitis C virus (HCV) antibodies and active HCV infection (HCV-RNA-positive) in people living with HIV (PLWH) in Spain in 2019 and compared the results with those of four similar studies performed during 2015-2018. METHODS: The study was performed in 41 centres. Sample size was estimated for an accuracy of 1%. Patients were selected by random sampling with proportional allocation. RESULTS: The reference population comprised 41 973 PLWH, and the sample size was 1325. HCV serostatus was known in 1316 PLWH (99.3%), of whom 376 (28.6%) were HCV antibody (Ab)-positive (78.7% were prior injection drug users); 29 were HCV-RNA-positive (2.2%). Of the 29 HCV-RNA-positive PLWH, infection was chronic in 24, it was acute/recent in one, and it was of unknown duration in four. Cirrhosis was present in 71 (5.4%) PLWH overall, three (10.3%) HCV-RNA-positive patients and 68 (23.4%) of those who cleared HCV after anti-HCV therapy (p = 0.04). The prevalence of anti-HCV antibodies decreased steadily from 37.7% in 2015 to 28.6% in 2019 (p < 0.001); the prevalence of active HCV infection decreased from 22.1% in 2015 to 2.2% in 2019 (p < 0.001). Uptake of anti-HCV treatment increased from 53.9% in 2015 to 95.0% in 2019 (p < 0.001). CONCLUSIONS: In Spain, the prevalence of active HCV infection among PLWH at the end of 2019 was 2.2%, i.e. 90.0% lower than in 2015. Increased exposure to DAAs was probably the main reason for this sharp reduction. Despite the high coverage of treatment with direct-acting antiviral agents, HCV-related cirrhosis remains significant in this population.

Tuberculosis en pacientes inmunodeprimidos / Tuberculosis in immunosuppressed patients

La tuberculosis (TB) es una de las infecciones más importantes en pacientes inmunodeprimidos debido a su elevada frecuencia y alta morbimortalidad. La TB es la principal causa de muerte entre pacientes infectados por VIH. El diagnóstico y tratamiento precoz de la infección tuberculosa latente es clave para evitar su progresión a enfermedad. Del mismo modo, el diagnóstico precoz de la TB es clave para mejorar el pronóstico de los pacientes y evitar su transmisión. La expresión clínica de la TB en pacientes inmunodeprimidos está condicionada por el grado de inmunodepresión de los pacientes. Es importante tener presente esta peculiaridad para no retrasar el diagnóstico de sospecha de TB. Las bases del tratamiento de la TB en inmunodeprimidos son las mismas que en la población general. Sus peculiaridades derivan principalmente de las interacciones farmacológicas. Examinamos las bases de diagnóstico y tratamiento de la TB y la infección tuberculosa latente en pacientes inmunodeprimidos

Tuberculosis (TB) is one of the most significant infections in immunosuppressed patients due to its high frequency and high morbidity and mortality. TB is the leading cause of death among HIV-infected patients. The diagnosis and early treatment of latent tuberculosis infection is vital to preventing it progression to disease. Similarly, the early diagnosis of TB is key to improving the prognosis of patients and preventing its transmission. The clinical expression of TB in immunosuppressed patients is conditioned by the patient's degree of immunosuppression. It is important to keep this peculiarity in mind so as not to delay the diagnosis of suspected TB. TB treatment is basically the same in immunosuppressed patients as in the general population and any differences mainly derive from pharmacological interactions. We examined the diagnosis and treatment of TB and latent tuberculosis infection in immunosuppressed patients

Tuberculosis in immunosuppressed patients. / Tuberculosis en pacientes inmunodeprimidos.

Tuberculosis (TB) is one of the most significant infections in immunosuppressed patients due to its high frequency and high morbidity and mortality. TB is the leading cause of death among HIV-infected patients. The diagnosis and early treatment of latent tuberculosis infection is vital to preventing it progression to disease. Similarly, the early diagnosis of TB is key to improving the prognosis of patients and preventing its transmission. The clinical expression of TB in immunosuppressed patients is conditioned by the patient's degree of immunosuppression. It is important to keep this peculiarity in mind so as not to delay the diagnosis of suspected TB. TB treatment is basically the same in immunosuppressed patients as in the general population and any differences mainly derive from pharmacological interactions. We examined the diagnosis and treatment of TB and latent tuberculosis infection in immunosuppressed patients.

Executive summary: Pre-exposure prophylaxis for prevention of HIV infection in adults in Spain: July 2016 / Resumen ejecutivo: profilaxis pre-exposición en adultos para la prevención de la infección por VIH en España: Julio 2016

Administration of antiretroviral drugs to individuals exposed to, but not infected by, HIV has been shown to reduce the risk of transmission. The efficacy of pre-exposure prophylaxis (PrEP) makes it obligatory to include it in an integral program of prevention of HIV transmission, together with other measures, such as use of the condom, training, counseling, and appropriate treatment of infected individuals. In this document, the AIDS Study Group (GeSIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica [SEIMC]) provides its views on this important subject. The available evidence on the usefulness of PrEP in the prevention of transmission of HIV is presented, and the components that should make up a PrEP program and whose development and implementation are feasible in Spain are set out (AU)

Se ha demostrado que la administración de fármacos antirretrovirales a personas expuestas y no infectadas por el VIH puede reducir el riesgo de transmisión. La eficacia de la profilaxis pre-exposición obliga a considerar su inclusión en un programa integral de prevención de la transmisión del VIH, junto con otras medidas como el uso del preservativo, la formación y el consejo asistido y el tratamiento adecuado de las personas infectadas. En este documento, el Grupo de Estudio de SIDA (GeSIDA) de la SEIMC aporta su visión sobre este importante tema. Se presenta la evidencia disponible acerca de la utilidad de la PrEP en la prevención de la transmisión del VIH y se enumeran los elementos que deberían integrar un programa de PrEP, cuyo desarrollo y puesta en marcha sea factible y viable en nuestro medio (AU)

Factores de riesgo de neumonía nosocomial por Staphylococcus aureus resistente a meticilina / Risk factors of nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus

Fundamento y objetivo: Es necesario predecir una neumonía nosocomial (NN) por Staphylococcus aureus resistente a meticilina (SARM) para facilitar la inclusión de un antibiótico específico en la terapia empírica. En este estudio se desarrolla un modelo para predecir la probabilidad de NN por SARM cuando se desconoce el estado de portador y el diagnóstico microbiológico. Pacientes y método: Se diseñó un estudio de casos y controles, realizándose una regresión logística multivariable para identificar los factores de riesgo de NN por SARM. Se incluyeron factores demográficos, relacionados con la hospitalización, la inmunodepresión, neutropenia, la medicación y la gravedad.Resultados: Se estudiaron 363 pacientes (121 casos y 242 controles). Permanecieron en el modelo final la edad>14 años (odds ratio [OR] 7,4, intervalo de confianza del 95% [IC 95%] 1,5-37,4, p<0,015), la aparición de la NN>6 días después del ingreso (OR 4,1, IC 95% 2,4-7,1, p<0,001), el desarrollo de la NN fuera del verano (OR 2,5, IC 95% 1,2-5,2, p = 0,015), las enfermedades respiratorias (OR 4,9, IC 95% 1,5-15,8, p = 0,007) y la afectación multilobar (OR 4, IC 95% 2,3-7,2, p<0,001). Con estas variables se calculó la probabilidad de desarrollar neumonía por SARM para cada una de las posibles combinaciones, clasificándose en criterios mayores y menores.Conclusiones: Se debe incluir cobertura de SARM en el tratamiento empírico de la NN cuando: a) un paciente adulto (>14 años) tiene, al menos, 2 criterios mayores o un criterio mayor y 2 menores, y b) un paciente<14 años tiene los 2 criterios mayores y los 2 menores (AU)

Background and objective: To include a specific antibiotic in the empiric therapy, it is necessary to predict when a nosocomial pneumonia (NP) is caused by methicillin-resistant Staphylococcus aureus (MRSA). We have developed a model for the prediction of the probability of a NP being caused by MRSA, when the carrier status and the microbiological diagnosis are unknown. Patients and methods: A retrospective case-control study (1999-2005) was designed. A univariate and multivariate logistic regression was performed to identify the risk factors for suffering a NP due to MRSA. Demographic factors, related to hospitalization, immunosuppression or neutropenia, to medication and severity were included. Results:Three hundred and sixty three patients (121 cases and 242 controls) were studied. The final model of multivariate logistic regression included an age>14 years (OR 7.4, CI 95% 1.5-37.4, P<.015), NP appearance>6 days after admittance (OR 4.1, CI 95% 2.4-7,1, P<.001), NP development excluding summers (OR 2.5, CI 95% 1.2-5.2, P<.015), respiratory diseases (OR 4.9, CI 95% 1.5-15.8, P<.007) and multilobar involvement (OR 4, CI 95% 2.3-7.2, P<.001).The probability of developing a pneumonia due to MRSA was studied for each of the possible combinations and subsequently classified in minor and major criteria. Conclusions: MRSA coverage should be included in the empirical treatment of NP when: a) an adult patient (>14 years old) presents, at least, 2 major criteria or 1 major criterion together with 2 minor criteria, and b) a patient <14 years-old has 2 major criteria as well as 2 minor criteria Ç(AU)

[Risk factors of nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus]. / Factores de riesgo de neumonía nosocomial por Staphylococcus aureus resistente a meticilina.

BACKGROUND AND OBJECTIVE: To include a specific antibiotic in the empiric therapy, it is necessary to predict when a nosocomial pneumonia (NP) is caused by methicillin-resistant Staphylococcus aureus (MRSA). We have developed a model for the prediction of the probability of a NP being caused by MRSA, when the carrier status and the microbiological diagnosis are unknown. PATIENTS AND METHODS: A retrospective case-control study (1999-2005) was designed. A univariate and multivariate logistic regression was performed to identify the risk factors for suffering a NP due to MRSA. Demographic factors, related to hospitalization, immunosuppression or neutropenia, to medication and severity were included. RESULTS: Three hundred and sixty three patients (121 cases and 242 controls) were studied. The final model of multivariate logistic regression included an age>14 years (OR 7.4, CI 95% 1.5-37.4, P<.015), NP appearance>6 days after admittance (OR 4.1, CI 95% 2.4-7,1, P<.001), NP development excluding summers (OR 2.5, CI 95% 1.2-5.2, P<.015), respiratory diseases (OR 4.9, CI 95% 1.5-15.8, P<.007) and multilobar involvement (OR 4, CI 95% 2.3-7.2, P<.001).The probability of developing a pneumonia due to MRSA was studied for each of the possible combinations and subsequently classified in minor and major criteria. CONCLUSIONS: MRSA coverage should be included in the empirical treatment of NP when: a) an adult patient (>14 years old) presents, at least, 2 major criteria or 1 major criterion together with 2 minor criteria, and b) a patient <14 years-old has 2 major criteria as well as 2 minor criteria.

Respuesta de los autores: «Neumonía típica y atípica: ¿utilidad clínica?» y «Neumonía adquirida en la comunidad: decisiones relacionadas con el pronóstico» / Response of the authors: «Typical and atypical pneumonia: Clinical usefulness?» and «Community-acquired pneumonia: Prognosis-related decisions»

No disponible

No disponible

Cost-effectiveness analysis of HLA-B*5701 typing in the prevention of hypersensitivity to abacavir in HIV+ patients in Spain.

INTRODUCTION: Approximately 4% to 8% of patients with HIV-1 treated with abacavir present a hypersensitivity reaction (HSR). Various studies have shown a direct association between human leukocyte antigen (HLA)-B*5701 and HSR to abacavir. The objective of this study was to analyze whether systematic HLA-B*5701 testing to prevent HSR in patients treated with abacavir is a cost-effective option for the Spanish National Health System. METHODS: An analytical decision-making model was constructed as a decision tree model for a simulated cohort of 1000 HIV patients to evaluate whether HLA-B*5701 testing to prevent HSR to abacavir was cost effective compared with not performing the test. The parameters included in the model and the use of healthcare resources should the patient develop HSR were taken from the PREDICT-1 study and the opinion of clinical experts. The principal result obtained was the incremental cost per HSR avoided. The time horizon of the analysis was to 2 months [corrected] . All costs were expressed in 2008 Euros. RESULTS: The analysis showed that the total direct healthcare costs per patient were €1344 and €1322 with and without HLA-B*5701 testing respectively, and that 36 cases of HSR were prevented per 1000 screened patients. These results yielded a cost per HSR avoided of €630. The sensitivity analysis showed that the results were sensitive to the cost of the test, with an economic saving of €102 or a cost-effectiveness ratio of €4234. CONCLUSIONS: The model predicts that generalized use of the HLA-B*5701 test before prescribing abacavir in HIV+ patients could represent an economic saving or a limited additional cost for the National Health System which may be counterbalanced by the benefits in terms of a lower incidence of HSR.

Estudio y tratamiento de las neumonías de adquisición comunitaria en adultos / Clinical management of community- acquired pneumonia in adults

No disponible

No disponible

Formación especializada de posgrado en patología infecciosa / Post-Graduate Specialist Training in Infectious Diseases

En España, todavía no se reconoce oficialmente laespecialidad de enfermedades infecciosas, pese a que éstaha sido reconocida en la mayoría de los países desarrollados y a que existen unidades asistenciales de enfermedades infecciosas en las 17 comunidades autónomas, con estructura de servicios, secciones o unidades. La organización de un sistema formativo de posgrado en enfermedades infecciosas requiere el reconocimiento previo de la especialidad y el establecimiento oficial de un sistema formativo para futuros especialistas mediante el sistema de médicos internos residentes. Como consecuencia de la ausencia de reconocimiento oficial de la especialidad, no existe un programa específico de formación posgrado en enfermedades infecciosas. Esta situación impide la formación completa, íntegra, de calidady evaluable, de los médicos que se dedicarán al cuidadode los pacientes con enfermedades infecciosas. Estecambio debe producirse lo antes posible para garantizar,como ocurre con el resto de especialidades médicas, laformación de nuevos especialistas que posibilite elmantenimiento de una atención de calidad y eficiente a los pacientes con enfermedades infecciosas pese al relevogeneracional. Proponemos un modelo para la formación deespecialistas en enfermedades infecciosas en el quedefinimos las competencias que el futuro especialista debe adquirir, el programa de formación que permita alcanzar dichas competencias y las características que deben poseer los centros donde los futuros especialistas deben formarse

The Infectious Diseases specialty is not currentlyrecognised in Spain, despite it existing in most developed countries and there being clinical Infectious Diseases units in the 17 Autonomous Communities, as Departments, Sections or Units. Before organising a post-graduate teaching system in Infectious Diseases, it has to be officially recognised as a specialty and an official training programme established for future specialists through the Medical Residents system. As the specialty is officially recognised there is no specific post-graduate programme in his field. This situation prevents the complete, qualified and evaluable training of the physicians who are going to be dedicated to the care of patients with infectious diseases. This change must take place as soon as possible to ensure, as in the rest of the medical specialties, the training of new specialists to be able to maintain qualityand effective care of patients with infectious diseasesdespite the generational changeover. We propose a modelfor the training of specialists in Infectious Diseases, in which we define the competences that the futurespecialist must acquire, a training programme which willenable these competences to be achieved and the characteristics health centres must have for training future specialists (AU)

Formación especializada de posgrado en patología infecciosa / Post-Graduate Specialist Training in Infectious Diseases

En España, todavía no se reconoce oficialmente laespecialidad de enfermedades infecciosas, pese a que éstaha sido reconocida en la mayoría de los países desarrolladosy a que existen unidades asistenciales de enfermedadesinfecciosas en las 17 comunidades autónomas, conestructura de servicios, secciones o unidades. Laorganización de un sistema formativo de posgrado enenfermedades infecciosas requiere el reconocimientoprevio de la especialidad y el establecimiento oficial deun sistema formativo para futuros especialistas medianteel sistema de médicos internos residentes. Comoconsecuencia de la ausencia de reconocimiento oficial dela especialidad, no existe un programa específico deformación posgrado en enfermedades infecciosas. Estasituación impide la formación completa, íntegra, de calidady evaluable, de los médicos que se dedicarán al cuidadode los pacientes con enfermedades infecciosas. Estecambio debe producirse lo antes posible para garantizar,como ocurre con el resto de especialidades médicas, laformación de nuevos especialistas que posibilite elmantenimiento de una atención de calidad y eficiente a lospacientes con enfermedades infecciosas pese al relevogeneracional. Proponemos un modelo para la formación deespecialistas en enfermedades infecciosas en el quedefinimos las competencias que el futuro especialista debeadquirir, el programa de formación que permita alcanzardichas competencias y las características que debenposeer los centros donde los futuros especialistas debenformarse(AU)

The Infectious Diseases specialty is not currentlyrecognised in Spain, despite it existing in most developedcountries and there being clinical Infectious Diseases unitsin the 17 Autonomous Communities, as Departments,Sections or Units. Before organising a post-graduateteaching system in Infectious Diseases, it has to beofficially recognised as a specialty and an official trainingprogramme established for future specialists through theMedical Residents system. As the specialty is officiallyrecognised there is no specific post-graduate programmein his field. This situation prevents the complete, qualifiedand evaluable training of the physicians who are going tobe dedicated to the care of patients with infectiousdiseases. This change must take place as soon as possibleto ensure, as in the rest of the medical specialties, thetraining of new specialists to be able to maintain qualityand effective care of patients with infectious diseasesdespite the generational changeover. We propose a modelfor the training of specialists in Infectious Diseases, inwhich we define the competences that the futurespecialist must acquire, a training programme which willenable these competences to be achieved and thecharacteristics health centres must have for training futurespecialists(AU)

[Post-graduate specialist training in infectious diseases]. / Formación especializada de posgrado en patología infecciosa.

The Infectious Diseases specialty is not currently recognised in Spain, despite it existing in most developed countries and there being clinical Infectious Diseases units in the 17 Autonomous Communities, as Departments, Sections or Units. Before organising a post-graduate teaching system in Infectious Diseases, it has to be officially recognised as a specialty and an official training programme established for future specialists through the Medical Residents system. As the specialty is officially recognised there is no specific post-graduate programme in his field. This situation prevents the complete, qualified and evaluable training of the physicians who are going to be dedicated to the care of patients with infectious diseases. This change must take place as soon as possible to ensure, as in the rest of the medical specialties, the training of new specialists to be able to maintain quality and effective care of patients with infectious diseases despite the generational changeover. We propose a model for the training of specialists in Infectious Diseases, in which we define the competences that the future specialist must acquire, a training programme which will enable these competences to be achieved and the characteristics health centres must have for training future specialists.

[Variability in coronary risk assessment in HIV-infected patients]. / Variabilidad en la valoración del riesgo coronario en pacientes infectados por el virus de la inmunodeficiencia humana.

BACKGROUND AND OBJECTIVE: Antiretroviral treatment of human immunodeficiency virus (HIV)-infected patients seems to increase the coronary risk (CR) in these patients. Adequate assessment of CR has significant implications for the management of these patients. Our objective was to compare 2 systems for assessing 10-year CR in HIV-infected patients. PATIENTS AND METHOD: CR was calculated in a prospective cohort of 205 HIV-infected patients using Framingham tables and REGICOR adapted tables. Prevalence of cardiovascular risk factors in these patients was evaluated. RESULTS: Mean age (standard deviation) was 41.4 (8.2) years. Most patients were taking antiretrovirals and had a good immunological status. Current smoking was reported by 77.1% of patients, while a history of dyslipidemia, hypertension, or diabetes was found in 29.3%, 7.3%, and 4.9% of patients, respectively. Lipodystrophy was seen in 41% of patients, abdominal obesity in 21.5%, and a sedentary lifestyle in 50.7% Mean values obtained were 6.55 (6.36) in the Framingham scale and 2.85 (2.31) in the REGICOR scale. A 10-year CR greater than 10% was found in 26 patients (12.9%) with the Framingham tables and in 4 patients (2.0%) with the REGICOR tables. The difference between both methods was significant (p < 0.001). CONCLUSIONS: Application of the Framingham tables to our cohort may overestimate the CR. Studies aimed at identifying the most adequate method for measuring CR in HIV-infected patients are required. Until such data are available, estimation of CR in these patients should be taken with caution.

[Clinical practice guidelines from the Andalusian Society of Infectious Diseases (SAEI) for the treatment of tuberculosis]. / Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis.

The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(+) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(+) patients (< or = 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy.

Variabilidad en la valoración del riesgo coronario en pacientes infectados por el virus de la inmunodeficiencia humana / Variability in coronary risk assessment in HIV-infected patients

Fundamento y objetivo: El tratamiento antirretroviral de los pacientes infectados por el virus de la inmunodeficiencia humana (VIH) parece aumentar su riesgo coronario (RC). La correcta valoración de éste tiene importantes implicaciones en el tratamiento de estos pacientes. Nuestro objetivo ha sido comparar 2 sistemas de evaluación del RC a 10 años en pacientes infectados por el VIH. Pacientes y método: Se calculó el RC en una cohorte prospectiva de 205 pacientes infectados por el VIH utilizando las tablas de Framingham y las tablas adaptadas REGICOR. Se evaluó la prevalencia de factores de riesgo cardiovascular de estos pacientes. Resultados: La edad media (desviación estándar) fue de 41,4 (8,2) años. La mayoría de los pacientes tomaba antirretrovirales y tenía buena situación inmunológica. Presentaba tabaquismo activo el 77,1%, antecedentes de dislipemia el 29,3%, de hipertensión el 7,3%, de diabetes el 4,9%, lipodistrofia el 41%, obesidad abdominal el 21,5% y sedentarismo el 50,7%. La valoración media en la escala Framingham fue de 6,55 (6,36) y en la escala REGICOR de 2,85 (2,31). El RC a 10 años fue mayor del 10% en 26 pacientes (12,9%) con las tablas de Framingham y en 4 (2,0%) con las tablas REGICOR. La diferencia entre ambos métodos resultó significativa (p < 0,001). Conclusiones: Aplicar las tablas Framingham en nuestra cohorte podría suponer una sobrestimación del RC. Son necesarios estudios que tengan como objetivo identificar el método más adecuado para medir el RC en pacientes infectados por el VIH. Mientras no dispongamos de estos datos, debemos tomar con precaución la estimación del RC en estos pacientes

Background and objective: Antiretroviral treatment of human immunodeficiency virus (HIV)-infected patients seems to increase the coronary risk (CR) in these patients. Adequate assessment of CR has significant implications for the management of these patients. Our objective was to compare 2 systems for assessing 10-year CR in HIV-infected patients. Patients and method: CR was calculated in a prospective cohort of 205 HIV-infected patients using Framingham tables and REGICOR adapted tables. Prevalence of cardiovascular risk factors in these patients was evaluated. Results: Mean age (standard deviation) was 41.4 (8.2) years. Most patients were taking antiretrovirals and had a good immunological status. Current smoking was reported by 77.1% of patients, while a history of dyslipidemia, hypertension, or diabetes was found in 29.3%, 7.3%, and 4.9% of patients, respectively. Lipodystrophy was seen in 41% of patients, abdominal obesity in 21.5%, and a sedentary lifestyle in 50.7% Mean values obtained were 6.55 (6.36) in the Framingham scale and 2.85 (2.31) in the REGICOR scale. A 10-year CR greater than 10% was found in 26 patients (12.9%) with the Framingham tables and in 4 patients (2.0%) with the REGICOR tables. The difference between both methods was significant (p < 0.001). Conclusions: Application of the Framingham tables to our cohort may overestimate the CR. Studies aimed at identifying the most adequate method for measuring CR in HIV-infected patients are required. Until such data are available, estimation of CR in these patients should be taken with caution

Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis / Clinical practice guidelines from the Andalusian Society of Infectious Diseases (SAEI) for the treatment of tuberculosis

El esquema terapéutico de la tuberculosis pulmonar inicial recomendado por la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) es el siguiente: En la fase inicial se usa isoniacida, rifampicina y piracinamida con administración diaria durante 2 meses. En pacientes VIH(1) e inmigrantes procedentes de zonas con tasa de resistencia primaria a isoniacida superior a 4% debe añadirse etambutol hasta disponer del estudio de resistencias. La segunda fase (continuación): rifampicina e isoniacida con administración diaria o intermitente durante 4 meses en la población general y 7 meses en pacientes VIH(1) (< 200 CD4) y/o pacientes con cultivos positivos después de 2 meses de tratamiento. La pauta de 6 meses es la más recomendada para tratar la tuberculosis extrapulmonar. Las excepciones serían la meningitis cuyo tratamiento debería durar 12 meses y la tuberculosis osteoarticular que debería tratarse durante nueve. Las pautas de tratamiento de la tuberculosis resistente se basan en opiniones de expertos. Habría que utilizar una combinación de fármacos de primera línea todavía útiles, fármacos inyectables y agentes alternativos, como las quinolonas. Se recomienda el uso de tratamiento directamente observado en aquellos pacientes que presenten especial riesgo de contagiosidad o de incumplimiento del tratamiento (AU)

The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(1) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(1) patients (< 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy (AU)

Espectro y factores de riesgo de la infección fúngica invasora / Spectrum and risk factors of invasive fungal infection

En los últimos años, las infecciones fúngicas invasoras han constituido un problema creciente en los pacientes inmunosuprimidos. Al mismo tiempo, los cambios en la práctica médica, como el empleo de profilaxis con azoles frente a Candida spp., han posibilitado una variación en el espectro de estas infecciones posibilitando un aumento en la incidencia de aspergilosis invasora y de infecciones por otros hongos filamentosos. Además, se han identificado nuevos factores de riesgo y diferente cronología en el comienzo de estas infecciones con respecto a lo acontecido en la última década. Por lo tanto, el conocimiento de este cambio en la epidemiología y los factores de riesgo de la infección fúngica invasora en pacientes que además reciben nuevos regímenes de inmunosupresión resulta de especial importancia para el manejo clínico de estas infecciones (AU)

In recent years, invasive fungal infection has become a growing problem in immunosuppressed patients. Simultaneously, changes in medical practice, such as the use of anti-Candida prophylaxis with azoles, has led to a shift in the epidemiology of these infections from Candida spp. to Aspergillus and other filamentous molds. Moreover, new risk factors for invasive fungal infection have been identified and the time of onset is different from that seen a decade ago. Recognition of these trends in patients receiving novel immunosuppressive regimens has important implications for the clinical management of fungal infection in this population (AU)

Metadona y efavirenz / No disponible

La interacción de fármacos antirretrovirales con metadona puede producir síntomas de síndrome de abstinencia a metadona (SAM). Este hecho se ha descrito con fármacos de la familia de los inhibidores de la proteasa y con inhibidores de la transcriptas a inversano análogos de los nucleósidos. Efavirenz puede inducir el metabolismo de otros fármacos, que como metadona, son metabolizados en el citocromo P-450, disminuyendo los niveles plasmáticos de los mismos. El manejo de los pacientes con SAM consiste en una escalada de dosis de metadona hasta revertir el cuadro clínico. Los estudios realizados han permitido conocer que la mayor parte de los pacientes con efavirenz y metadona requieren ajuste de dosis de este fármaco, que el incremento medio de metadona para obtener una reversión del SAM es del 25% de la dosis basal, que el control clínico es suficiente para dirigir la escalada de dosis y que la determinación de niveles plasmáticos de metadona no es necesaria para el manejo de los pacientes. La utilización de una estrategia de revertir el SAM supone aceptar que éste se produzca. Ello entraña el riesgo abandono del TARGA por muchos pacientes para evitar la reaparición de un SAM. Por eso, en la actualidad en los centros de terapias aditivas se plantea una estrategia de prevención del SAM en pacientes en programa de metadona que inician tratamiento con efavirenz, mediante un aumento “preventivo” de la dosis de metadona (AU)

The pharmacokinetic interaction between antirretrovirals drugs and methadone can produce an opiods abstinence syndrome (OAS). This fact has been described as protease inhibitors as non-nucleoside transcriptase inverse inhibitors. Efavirenz can induce the metabolism of other drugs, that like methadone, are metabolized in the cytocrome P-450, diminishing the plasmatics levels of such. The treatment of the patients with OAS consists of a scaling of dose of methadone until reverting the symptons. Studies have allowed to know that most of the patients with efavirenz and methadone require adjustment of dose of this drug, the average increase of methadone required to obtain a reversion of AMS is a 25% of the basal dose and that the clinical control is sufficient and the determination of plasmatics levels of methadone is not necessary to direct the scaling of dose of methadone of the patients. The use of a strategy to revert AMS supposes to accept that this one takes place. It involves the risk abandonment of the HAART by many patients to avoid the reappearance of AMS. So, at the present time a strategy of prevention of AMS in patients in program of methadone who initiate treatment with efavirenz, by means of "a preventive" increase of the dose of metadona can be considered (AU)

Use of noninvasive markers to detect Leishmania infection in asymptomatic human immunodeficiency virus-infected patients.

Visceral leishmaniasis (VL) caused by Leishmania infantum is a common disease in human immunodeficiency virus (HIV)-infected people in the Mediterranean basin. However, most such cases are asymptomatic, and little information about the prevalence of these infections in HIV-infected individuals is available. The aim of this study was to assess the prevalence of subclinical infection and the relationship between several Leishmania infection markers by noninvasive methods in asymptomatic HIV-infected patients from Southern Spain. Ninety-two HIV-infected patients, who were consecutively attended at the participant hospitals in 2004, were invited to participate in this study. These patients were asymptomatic and without any history of cutaneous or visceral leishmaniasis. Leishmania kinetoplast DNA (kDNA) was amplified from peripheral blood samples from 28 (30.4%) of these HIV-infected subjects. Sera from three (3.5%) patients tested positive for Leishmania by an enzyme-linked immunoassay. Two patients (2.4%) showed a specific 16-kDa band by Western blotting. In contrast, none of the patients showed a positive agglutination of urine. The leishmanin skin test was positive for four (4.3%) patients. None of the patients with a PCR-positive result showed a positive reaction by enzyme-linked immunoassay or by specific bands in Western blotting or had a positive leishmanin skin test. In conclusion, L. infantum kDNA was detected in a large proportion of asymptomatic HIV-infected patients, although a demonstrable cellular or humoral immune response to this parasite was not shown. Conversely, Leishmania antigen in urine was not detected in these patients.