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1.
Int J Infect Dis ; 2021 Feb 26.
Artículo en Inglés | MEDLINE | ID: mdl-33647515

RESUMEN

BACKGROUND: The role of combination immunomodulatory therapy with systemic corticosteroids and tocilizumab (TCZ) for aged patients with COVID-19-associated cytokine release syndrome remains unclear. METHODS: We conducted a retrospective single-center study including consecutive patients ≥65 years that developed severe COVID-19 between March 3 and May 1, 2020 and were treated with corticosteroids at various doses (methylprednisolone [0.5 mg/Kg/12 hours to 250 mg/24 hours]), either alone ("CS group") or associated to intravenous tocilizumab (400-600 mg, one to three doses) ("CS-TCZ group"). Primary outcome was all-cause mortality by day +14, whereas secondary outcomes included mortality by day +28 and clinical improvement (discharge and/or a ≥2-point decrease on a six-point ordinal scale) by day +14. Propensity score (PS)-based adjustment and inverse probability of treatment weights (IPTW) were applied. RESULTS: Overall, 181 and 80 patients were included in the CS and CS-TCZ groups. All-cause 14-day mortality was lower in the CS-TCZ group, both in the PS-adjusted (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.17 - 0.68; P-value = 0.002) and IPTW-weighted models (odds ratio [OR]: 0.38; 95% CI: 0.21 - 0.68; P-value = 0.001). This protective effect was also observed for 28-day mortality (PS-adjusted HR: 0.38; 95% CI: 0.21 - 0.72; P-value = 0.003). Clinical improvement by day +14 was higher in the CS-TCZ group in the IPTW analysis only (OR: 2.26; 95% CI: 1.49 - 3.41; P-value <0.001). The occurrence of secondary infection was similar between both groups. CONCLUSIONS: The combination of corticosteroids and TCZ was associated with better outcomes among patients ≥65 years with severe COVID-19.

2.
Artículo en Inglés | MEDLINE | ID: mdl-33558295

RESUMEN

Current guidelines recommend against systematic screening or treating asymptomatic bacteriuria (AB) among kidney transplant (KT) recipients, although the evidence regarding episodes occurring early after transplantation or in the presence of anatomical abnormalities is inconclusive. Oral fosfomycin may constitute a good option for the treatment of post-transplant AB, particularly due to the emergence of multidrug-resistant (MDR) uropathogens. Available clinical evidence supporting its use in this specific setting, however, remains scarce. We performed a retrospective study in 14 Spanish institutions from January 2005 to December 2017. Overall, 137 episodes of AB diagnosed in 133 KT recipients treated with oral fosfomycin (calcium and trometamol salts) with a test-of-cure urine culture within the first 30 days were included. Median time from transplantation to diagnosis was 3.1 months (interquartile range [IQR]: 1.1 - 10.5). Most episodes (96.4% [132/137]) were caused by gram-negative bacteria (GNB), and 56.9% (78/137) were categorized as MDR (extended-spectrum ß-lactamase-producing Enterobacterales [20.4%] and carbapenem-resistant GNB [2.9%]). Rate of microbiological failure at month 1 was 40.1% (95% confidence interval [95%CI]: 31.9 - 48.9) for the whole cohort and 42.3% (95%CI: 31.2 - 54.0) for episodes due to MDR pathogens. Previous urinary tract infection (odds ratio [OR]: 2.42; 95%CI: 1.11 - 5.29; P-value = 0.027) and use of fosfomycin as salvage therapy (OR: 8.31; 95%CI: 1.67 - 41.35; P-value = 0.010) were predictors of microbiological failure. No severe treatment-related adverse event were detected. Oral fosfomycin appears to be a suitable and safe alternative for the treatment (if indicated) of AB after KT, including those episodes due to MDR uropathogens.

3.
Int J Infect Dis ; 2021 Feb 13.
Artículo en Inglés | MEDLINE | ID: mdl-33592340

RESUMEN

OBJETIVES: A subgroup of patients with SARS-CoV-2 infection is considered to develop a cytokine release syndrome and have been treated with tocilizumab, but a significant percentage of patients evolve. Our objective was to determine the usefulness of anakinra as rescue treatment for patients with tocilizumab-refractory COVID-19 disease. METHODS: A prospective cohort of patients with COVID19 pneumonia who received anakinra as salvage therapy after failure of tocilizumab were compared (1:1) to selected controls in a historical cohort of patients treated with tocilizumab. Cases and controls were matched by age, comorbidities, pulse oximetry oxygen saturation to fraction of inspired oxygen (SpO2/FiO2) ratio at baseline and time elapsed since the initiation of treatment with tocilizumab. The primary outcome was the improvement in clinical status measured by a six-point ordinal scale, from baseline to day 21. RESULTS: The study included 20 cases and 20 controls (mean age 65.3±12.8 years, 65% males). No differences were found in the clinical improvement rates at 7, 14 and 21 days of follow-up. In-hospital mortality rate for patients receiving anakinra was 55% vs. 45% in the control group (P=0.527). CONCLUSIONS: Treatment with anakinra was not useful to improve the prognosis of patients with tocilizumab-refractory severe COVID-19.

4.
Artículo en Inglés | MEDLINE | ID: mdl-33409832

RESUMEN

The aim of our study was to elucidate if SARS-CoV-2 viral load on admission, measured by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) cycle threshold (Ct) value on nasopharyngeal samples, was a marker of disease severity. All hospitalized adult patients with a diagnosis of SARS-CoV-2 infection by rRT-PCR performed on a nasopharingeal sample from March 1 to March 18 in our institution were included. The study population was divided according to the Ct value obtained upon admission in patients with high viral load (Ct < 25), intermediate viral load (Ct: 25-30) and low viral load (Ct > 30). Demographic, clinical and laboratory variables of the different groups were analyzed to assess the influence of viral load on the development of respiratory failure during admission. Overall, 455 sequential patients were included. The median Ct value was 28 (IQR: 24-32). One hundred and thirty patients (28.6%) had a high viral load, 175 (38.5%) an intermediate viral load and 150 (33%) a low viral load. Advanced age, male sex, presence of cardiovascular disease and laboratory markers such as lactate dehydrogenase, lymphocyte count and C-reactive protein, as well as a high viral load on admission, were predictive of respiratory failure. A Ct value < 25 was associated with a higher risk of respiratory failure during admission (OR: 2.99, 95%IC: 1.57-5.69). SARS-CoV-2 viral load, measured through the Ct value on admission, is a valuable tool to predict the development of respiratory failure in COVID-19 inpatients.

6.
Clin Infect Dis ; 2021 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-33513221

RESUMEN

BACKGROUND: Although pre-surgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing post-surgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to the lack of robust supporting evidence. We aimed to evaluate the role of pre-operative NDM in the annual incidence of S. aureus PSM at our institution. METHODS: An interrupted time-series analysis, with autoregressive error model, was applied to our single-center cohort by comparing pre-intervention (1990-2003) and post-intervention period (2005 to 2018). Logistic regression was performed to analyze risk factors for S. aureus PSM. FINDINGS: 12,236 sternotomy procedures were analyzed (6,370 [52.1%] and 5,866 [47.9%] in the pre-intervention and post-intervention periods, respectively). The mean annual percentage adherence to NDM estimated over the post-interventional period was 90.2%. Only four out of 127 total cases of S. aureus PSM occurred during the 14-years post-intervention period (0.68/1,000 sternotomies vs. 19.31/1,000 in pre-interventional period [p<0.0001]). Interrupted time-series analysis demonstrated a statistically significant annual reduction of S. aureus PSM trend of -9.85 cases per 1,000 sternotomies (-13.17 to -6.5, P-value< 0·0001) in 2005, with a decreasing trend maintained over the following five years with an estimated relative reduction of 84.8% (95% CI: 89·25 to 74·09). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio: 3.7; 95% CI: 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre or post-intervention periods. INTERPRETATION: Our experience suggests that the implementation of pre-operative NDM reduces significantly the incidence of S. aureus PSM.

7.
Cell Rep Med ; 1(8): 100130, 2020 Nov 17.
Artículo en Inglés | MEDLINE | ID: mdl-33294855

RESUMEN

Hemagglutination-inhibitory antibodies are usually highly strain specific with little effect on infection with drifted or shifted strains. The significance of broadly cross-reactive non-HAI anti-influenza antibodies against conserved domains of virus glycoproteins, such as the hemagglutinin (HA) stalk, is of great interest. We characterize a cohort of 40 H1N1pmd09 influenza-infected patients and identify lower respiratory symptoms (LRSs) as a predictor for development of pneumonia. A binomial logistic regression of log10 pre-existing antibody values shows that the probability of LRS occurrence decreased with increased anti-HA full-length and stalk antibody ELISA titers. However, a multilevel logistic regression model adjusted by other potential serocorrelates demonstrates that only antibodies directed against the stalk of HA correlate with protection from lower respiratory infection, limiting disease progression. Our predictive model indicates that a threshold of protective immunity based on broadly cross-reactive HA stalk antibodies could be feasible.

11.
Transpl Infect Dis ; : e13520, 2020 Nov 22.
Artículo en Inglés | MEDLINE | ID: mdl-33222379

RESUMEN

BACKGROUND: Whether active therapy with ß-lactam/ß-lactamase inhibitors (BLBLI) is as affective as carbapenems for extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E) bloodstream infection (BSI) secondary to urinary tract infection (UTI) in kidney transplant recipients (KTR) remains unclear. METHODS: We retrospectively evaluated 306 KTR admitted to 30 centers from January 2014 to October 2016. Therapeutic failure (lack of cure or clinical improvement and/or death from any cause) at days 7 and 30 from ESBL-E BSI onset were primary and secondary study outcomes, respectively. RESULTS: Therapeutic failure at days 7 and 30 occurred in 8.2% (25/306) and 13.4% (41/306) of patients. Hospital-acquired BSI (adjusted OR [aOR]: 4.10; 95% confidence interval [CI]: 1.50-11.20) and Pitt score (aOR: 1.47; 95% CI: 1.21-1.77) were independently associated with therapeutic failure at day 7. Age-adjusted Charlson Index (aOR: 1.25; 95% CI: 1.05-1.48), Pitt score (aOR: 1.72; 95% CI: 1.35-2.17) and lymphocyte count ≤500 cells/µL at presentation (aOR: 3.16; 95% CI: 1.42-7.06) predicted therapeutic failure at day 30. Carbapenem monotherapy (68.6%, primarily meropenem) was the most frequent active therapy, followed by BLBLI monotherapy (10.8%, mostly piperacillin-tazobactam). Propensity score-adjusted models revealed no significant impact of the choice of active therapy (carbapenem-containing versus any other regimen, BLBLI- versus carbapenem-based monotherapy) within the first 72 hours on any of the study outcomes. CONCLUSIONS: Our data suggest that active therapy based on BLBLI may be as effective as carbapenem-containing regimens for ESBL-E BSI secondary to UTI in the specific population of KTR. Potential residual confounding and unpowered sample size cannot be excluded (ClinicalTrials.gov identifier: NCT02852902).

12.
Transpl Infect Dis ; : e13501, 2020 Nov 13.
Artículo en Inglés | MEDLINE | ID: mdl-33185971

RESUMEN

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might increase the risk of invasive pulmonary aspergillosis (IPA). Although several case reports and small series have been reported in the general population, scarce information is available regarding coronavirus disease 2019 (COVID-19)-associated IPA in the setting of solid organ transplantation. We describe a case of a kidney transplant recipient with severe COVID-19 that was subsequently diagnosed with probable IPA on the basis of the repeated isolation of Aspergillus fumigatus in sputum cultures, repeatedly increased serum (1 â†’ 3)-ß-d-glucan levels, and enlarging cavitary nodules in the CT scan. The evolution was favorable after initiation of isavuconazole and nebulized liposomal amphotericin B combination therapy and the withdrawal of immunosuppression.

13.
Enferm Infecc Microbiol Clin ; 38(9): 438-443, 2020 Nov.
Artículo en Inglés, Español | MEDLINE | ID: mdl-33161954

RESUMEN

Primary immunodeficiencies (PIDs) are rare, undiagnosed and potentially fatal diseases. Clinical manifestations of PID can be fatal or leave sequelae that worsen the quality of life of patients. Traditionally, the treatment of PIDs has been largely supportive, with the exception of bone marrow transplantation and, more recently, gene therapy. The discovering of new affected pathways, the development of new molecules and biologics, and the increasing understanding of the molecular basis of these disorders have created opportunities in PIDs therapy. This document aims to review current knowledge and to provide recommendations about the diagnosis and clinical management of adults and children with PIDs based on the available scientific evidence taking in to account current practice and future challenges. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation where available.

14.
J Allergy Clin Immunol Pract ; 8(10): 3342-3347, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33161963

RESUMEN

Primary immunodeficiencies (PIDs) are rare, undiagnosed and potentially fatal diseases. Clinical manifestations of PID can be fatal or leave sequelae that worsen the quality of life of patients. Traditionally, the treatment of PIDs has been largely supportive, with the exception of bone marrow transplantation and, more recently, gene therapy. The discovering of new affected pathways, the development of new molecules and biologics, and the increasing understanding of the molecular basis of these disorders have created opportunities in PIDs therapy. This document aims to review current knowledge and to provide recommendations about the diagnosis and clinical management of adults and children with PIDs based on the available scientific evidence taking in to account current practice and future challenges. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation where available.

15.
Enferm. infecc. microbiol. clín. (Ed. impr.) ; 38(9): 425-430, nov. 2020. tab
Artículo en Inglés | IBECS-Express | IBECS | ID: ibc-ET6-1460

RESUMEN

INTRODUCTION: Data concerning the use of peripherally inserted central catheters (PICC) for the administration of intravenous (IV) antimicrobials in the acute care setting is scarce. METHODS: We performed a single-center retrospective case-control study (1:1). Case subjects were defined as patients who received IV antimicrobial treatment through a PICC line placed and maintained by specifically trained nurses (PICC group). Control subjects were defined as patients who received antimicrobial therapy by a peripheral or a central venous catheter (CVC) (control group). Control subjects were matched by type of antimicrobial, causative microorganism of the infection that was being treated and duration of treatment. An event leading to undesired catheter removal (ELUCR) was defined as any circumstance which lead to the removal of the indwelling catheter other than the completion of the scheduled course of antimicrobial therapy. RESULTS: The study included 50 patients in each group. The total follow-up time was 1376 catheter-days for the PICC group and 1362 catheter-days for the control group. We observed a significantly lower incidence of ELUCR in the PICC group (0.2 versus 7.7 events per 100 catheter-days; P < 0.001). When the incidence of ELUCR was analyzed according to the duration of indwelling catheterisation for each type of catheter (divided into one-week intervals), differences between both groups were also significant (P-values ≤ 0.001 for the first three weeks of treatment). During the second week of IV treatment, only one patient in the PICC group (2.1%) developed an ELUCR compared to 19 (38.8%) in the control group (P < 0.001). CONCLUSIONS: A PICC placed and maintained by a dedicated nursing team is an excellent alternative to peripheral venous catheters or CVCs for administrating antimicrobial therapy for both short and long periods of treatment


INTRODUCCIÓN: Existe escasa información disponible sobre el empleo de catéteres venosos centrales de inserción periférica (PICC en sus siglas en inglés) para la administración de antimicrobianos por vía intravenosa (IV) en la atención a pacientes con procesos agudos. MÉTODOS: Realizamos un estudio unicéntrico retrospectivo de casos y controles (1:1). Los casos estaban constituidos por pacientes que recibieron tratamiento antimicrobiano IV a través de un catéter tipo PICC que fue insertado y cuidado por un equipo de enfermería especialmente entrenado a tal efecto (grupo PICC). Los controles estaban constituidos por pacientes que recibieron el tratamiento antimicrobiano a través de un catéter venoso periférico o a través de un catéter venoso central (CVC) (grupo control). Los controles fueron emparejados con los casos considerando el tipo de antimicrobiano administrado, el microorganismo causal de la infección que se estaba tratando y la duración del tratamiento. Se definió como un evento que condujo a la retirada no deseada del catéter (ECRDC) a cualquier circunstancia que obligara a la retirada del catéter insertado antes del tiempo programado para completar el tratamiento antimicrobiano establecido. RESULTADOS: El estudio incluyó 50 pacientes en cada grupo. El tiempo total de seguimiento fue de 1.376 días de catéter en el grupo PICC y de 1.362 días de catéter en el grupo control. Se observó una incidencia de ECRDC significativamente menor en el grupo PICC que en el grupo control (0,2 versus 7,7 eventos por cada 100 días de catéter; P < 0,001). Cuando la incidencia de ECRDC se analizó según la duración del tiempo de inserción de cada tipo de catéter (dividido en intervalos de una semana), se pudo constatar que las diferencias entre ambos grupos también eran significativas (P ≤ 0.001 para las tres primeras semanas de tratamiento). Durante la segunda semana de tratamiento IV, solamente un paciente en el grupo PICC (2,1%) desarrolló un ECRDC en comparación con 19 (38,8%) en el grupo control (P (P < 0,001). CONCLUSIONES: Un catéter tipo PICC insertado y cuidado por un equipo de enfermería entrenado es una excelente alternativa a los catéteres venosos periféricos o a los CVC para la administración de antimicrobianos tanto para periodos cortos como para periodos largos de tiempo

16.
Artículo en Inglés | IBECS-Express | IBECS | ID: ibc-ET6-1463

RESUMEN

Primary immunodeficiencies (PIDs) are rare, undiagnosed and potentially fatal diseases. Clinical manifestations of PID can be fatal or leave sequelae that worsen the quality of life of patients. Traditionally, the treatment of PIDs has been largely supportive, with the exception of bone marrow transplantation and, more recently, gene therapy. The discovering of new affected pathways, the development of new molecules and biologics, and the increasing understanding of the molecular basis of these disorders have created opportunities in PIDs therapy. This document aims to review current knowledge and to provide recommendations about the diagnosis and clinical management of adults and children with PIDs based on the available scientific evidence taking in to account current practice and future challenges. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation where available


Las inmunodeficiencias primarias (IDP) son unas enfermedades raras, frecuentemente infradiagnosticadas y potencialmente fatales. Las manifestaciones clínicas de las IDP pueden ser muy graves y ocasionar secuelas que empeoran la calidad de vida de los pacientes. Tradicionalmente, el tratamiento de las IDP ha sido fundamentalmente de soporte, con excepción del trasplante de progenitores hematopoyéticos y, más recientemente, la terapia génica. El descubrimiento de nuevos mecanismos patogénicos, el desarrollo de nuevas moléculas y fármacos biológicos y los avances en el conocimiento de las bases moleculares de estas enfermedades han abierto oportunidades para el tratamiento de esta afección. El objetivo de este documento es revisar el conocimiento actual y aportar recomendaciones para el diagnóstico y el tratamiento clínico de los pacientes adultos y pediátricos con IDP basado en la evidencia científica disponible y teniendo en cuenta la actual práctica y los retos futuros. Se realizó una revisión sistemática, que justifica los niveles de evidencia para cada recomendación

19.
Eur J Hosp Pharm ; 2020 Oct 05.
Artículo en Inglés | MEDLINE | ID: mdl-33020060

RESUMEN

OBJECTIVES: Dalbavancin is approved for the treatment of complicated skin and soft tissue infections. However, there is growing evidence that other gram-positive infections could be treated with this antibiotic. A study was undertaken in a tertiary hospital in Spain to evaluate the effectiveness and safety of dalbavancin in off-label indications and the potential healthcare cost savings. METHODS: A retrospective observational study including all patients treated with dalbavancin in our hospital from October 2016 to August 2019 was carried out. Demographic, clinical and safety variables were collected. Effectiveness was assessed using the clinical and microbiological resolution of the infection and the absence of hospital admissions due to the same infection in the following 3 months. RESULTS: A total of 102 patients were included (69.9% men, n=71; median age 72.5 years (range 56.0-84.0)). Treatment was off label in 71 cases (69.6%). The most frequent off-label indications were catheter-related bacteraemia (15.7%, n=16) and endocarditis (13.6%, n=14). All patients had previously received antibiotics. The main reason for switching to dalbavancin was patient discharge (79.4%, n=81). Dalbavancin was administered during hospitalisation in 66.7% of the patients and in the outpatient setting in 13.7%. The median reduction in length of hospital stay was 14 days per patient. A saving of about 4550 Euros per patient was estimated. 89 patients (93.7%) had clinical and microbiological resolution of the infection at the end of the study. One patient did not finish the dalbavancin infusion due to an allergic reaction. CONCLUSIONS: Our results suggest that dalbavancin is a safe and effective alternative to the off-label treatment of gram-positive infections. Its dosage facilitates early discharge and outpatient management of these patients.

20.
Front Immunol ; 11: 1917, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33123119

RESUMEN

Introduction: Our goal was to study whether influenza vaccination induced antibody mediated rejection in a large cohort of solid organ transplant recipients (SOTR). Methods: Serum anti-Human Leukocyte Antigen (HLA) antibodies were determined using class I and class II antibody-coated latex beads (FlowPRATM Screening Test) by flow cytometry. Anti-HLA antibody specificity was determined using the single-antigen bead flow cytometry (SAFC) assay and assignation of donor specific antibodies (DSA) was performed by virtual-crossmatch. Results: We studied a cohort of 490 SOTR that received an influenza vaccination from 2009 to 2013: 110 (22.4%) received the pandemic adjuvanted vaccine, 59 (12%) within the first 6 months post-transplantation, 185 (37.7%) more than 6 months after transplantation and 136 (27.7%) received two vaccination doses. Overall, no differences of anti-HLA antibodies were found after immunization in patients that received the adjuvanted vaccine, within the first 6 months post-transplantation, or based on the type of organ transplanted. However, the second immunization dose increased the percentage of patients positive for anti-HLA class I significantly compared with patients with one dose (14.6% vs. 3.8%; P = 0.003). Patients with pre-existing antibodies before vaccination (15.7% for anti-HLA class I and 15.9% for class II) did not increase reactivity after immunization. A group of 75 (14.4%) patients developed de novo anti-HLA antibodies, however, only 5 (1.02%) of them were DSA, and none experienced allograft rejection. Only two (0.4%) patients were diagnosed with graft rejection with favorable outcomes and neither of them developed DSA. Conclusion: Our results suggest that influenza vaccination is not associated with graft rejection in this cohort of SOTR.

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