Características diferenciales en las bacteriemias según la edad en un hospital comunitario / Differential characteristics of bacteraemias according to age in a community hospital

Objetivo. Describir las características de las bacteriemias, según la edad, en un hospital comunitario. Material y método. Estudio prospectivo de las bacteriemias en el año 2011. Los pacientes se clasificaron en 3 grupos de edad: menos de 65, de 65 a 79 y 80 o más años. Se recogieron variables de los pacientes y de los episodios. Resultados. Se analizaron 233 bacteriemias en 227 pacientes (23,8% en<65; 38,3% entre 65 y 79; y 37,9% en≥80 años). La enfermedad de base más frecuente en todos los grupos fue la diabetes mellitus. En los pacientes muy ancianos el índice de Charlson fue mayor, hubo una menor proporción de factores exógenos y casi un 25% eran dependientes graves (índice de Barthel<20). Escherichia coli fue el germen más frecuente y el foco principal fue el urológico. En los pacientes≥80 años predominó el origen de la infección asociado a cuidados sanitarios, la expresividad clínica menos grave (sepsis) (66,3%) y la mortalidad más elevada (29,1%), respecto a los de menor edad. Conclusiones. Los pacientes muy ancianos con bacteriemia presentaron menos factores exógenos, más comorbilidad y una situación funcional peor; el foco más frecuente fue el urológico y el origen el asociado a cuidados sanitarios. A pesar de que su presentación clínica fue menos grave, su mortalidad fue superior, siendo el grado de dependencia una variable de riesgo independiente muy relevante (AU)

Objective. To describe the characteristics of bacteraemias, according to age, in a community hospital. Material and method. A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes. Results. The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients. Conclusions. The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients’ mortality was greater, and their degree of dependence was a highly relevant independent risk factor (AU)

Differential characteristics of bacteraemias according to age in a community hospital. / Características diferenciales en las bacteriemias según la edad en un hospital comunitario.

OBJECTIVE: To describe the characteristics of bacteraemias, according to age, in a community hospital. MATERIAL AND METHOD: A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes. RESULTS: The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients. CONCLUSIONS: The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients' mortality was greater, and their degree of dependence was a highly relevant independent risk factor.

Tuberculosis in a cohort of HIV-positive patients: epidemiology, clinical practice and treatment outcomes.

OBJECTIVE: To describe tuberculosis (TB) incidence, risk factors, clinical presentation, disease management and outcomes in human immunodeficiency virus (HIV) infected patients from the CoRIS cohort, Spain, 2004-2010. DESIGN: Open multicentre cohort of antiretroviral treatment (ART) naïve patients at entry. Incidence and risk factors were evaluated using multivariate Poisson regression. RESULTS: Among 6811 patients, 271 were eligible for the study and 198 for the estimation of the incidence rate; TB incidence ranged from 12.1 to 14.1/1000 person-years. TB was associated with low education level (rate ratio [RR] 2.65, 95%CI 1.73-4.07), being sub-Saharan African (RR 3.14, 95%CI 1.81-5.45), heterosexual (RR 2.01, 95%CI 1.22-3.29) or an injecting drug user (RR 2.11, 95%CI 1.20-3.69), not undergoing ART (RR 3.33, 95%CI 2.22-4.76), CD4 <200 cells/mm(3) (RR 5.20, 95%CI 3.25-8.33) and log-viral load of 4-5 (RR 5.44, 95%CI 3.28-9.02) or >5 (RR 13.10, 95%CI 8.27-20.76). Overall, 87% were new cases and 13% were previously treated cases; 175 (65%) were bacteriologically confirmed. Drug susceptibility testing was performed in 146 (83%) patients: resistance to first-line drugs was 11.1% in new and 36.4% in previously treated cases. Standard anti-tuberculosis treatment with four or three drugs was prescribed in respectively 55% and 36% of cases. Treatment default was 11%, and was higher among previously treated cases; 80% received ART during anti-tuberculosis treatment, 80% of new and 50% of previously treated cases were cured or completed treatment, and 18 (6.6%) died. CONCLUSION: TB incidence in HIV-infected patients remains high. Interventions should include early HIV diagnosis and access to ART, enhanced bacteriological confirmation, wider use of four-drug regimens and reduction in treatment default.

Compliance with national guidelines for HIV treatment and its association with mortality and treatment outcome: a study in a Spanish cohort.

OBJECTIVES: The aim of the study was to assess the adequacy of initial antiretroviral therapy (ART), in terms of its timing and the choice of regimens, according to the Spanish national treatment guidelines [Spanish AIDS Study Group-National Plan for AIDS (GeSIDA-PNS) Guidelines] for treatment-naïve HIV-infected patients. METHODS: A prospective cohort study of HIV-positive ART-naïve subjects attending 27 centres in Spain from 2004 to 2010 was carried out. Regimens were classified as recommended, alternative or nonrecommended according to the guidelines. Delayed start of treatment was defined as starting treatment later than 12 months after the patient had fulfilled the treatment criteria. Multivariate logistic and Cox regression analyses were performed. RESULTS: A total of 6225 ART-naïve patients were included in the study. Of 4516 patients who started treatment, 91.5% started with a recommended or alternative treatment. The use of a nonrecommended treatment was associated with a CD4 count > 500 cells/µL [odds ratio (OR) 2.03; 95% confidence interval (CI) 1.14-3.59], hepatitis B (OR 2.23; 95% CI 1.50-3.33), treatment in a hospital with < 500 beds, and starting treatment in the years 2004-2006. Fourteen per cent of the patients had a delayed initiation of treatment. Delayed initiation of treatment was more likely in injecting drug users, patients with hepatitis C, patients with higher CD4 counts and during the years 2004-2006, and it was less likely in patients with viral loads > 5 log HIV-1 RNA copies/ml. The use of a nonrecommended regimen was significantly associated with mortality [hazard ratio (HR) 1.61; 95% CI 1.03-2.52; P = 0.035] and lack of virological response. CONCLUSIONS: Compliance with the recommendations of Spanish national guidelines was high with respect to the timing and choice of initial ART. The use of nonrecommended regimens was associated with a lack of virological response and higher mortality.

Documento de consenso sobre el manejo de la patología renal en pacientes con infección por VIH / Consensus document on the management of renal disease in HIV-infected patients

OBJETIVO: Actualizar las recomendaciones sobre la evaluación y el manejo de la afectación renal en pacientes con infección por el virus de la inmunodeficiencia humana (VIH). MÉTODOS: Este documento ha sido consensuado por un panel de expertos del Grupo de Estudio de Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), de la Sociedad Española de Nefrología (S.E.N.) y de la Sociedad Española de Química Clínica y Patología Molecular (SEQC). Para la valoración de la calidad de la evidencia y la graduación de las recomendaciones se ha utilizado el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTADOS: La evaluación renal debe incluir la medida de la concentración sérica de creatinina, la estimación del filtrado glomerular (ecuación chronic kidney disease epidemiological collaboration [CKD-EPI]), la medida del cociente proteína/creatinina en orina y un sedimento urinario. El estudio básico de la función tubular ha de incluir la concentración sérica de fosfato y la tira reactiva de orina (glucosuria). En ausencia de alteraciones, el cribado será anual. En pacientes tratados con tenofovir o con factores de riesgo para el desarrollo de enfermedad renal crónica (ERC), se recomienda una evaluación más frecuente. Se debe evitar el uso de antirretrovirales potencialmente nefrotóxicos en pacientes con ERC o factores de riesgo para evitar su progresión. En este documento se revisan las indicaciones de derivación del paciente a Nefrología y las de la biopsia renal, así como las indicaciones y la evaluación y el manejo del paciente en diálisis o del trasplante renal. CONCLUSIONES: La función renal debe monitorizarse en todos los pacientes con infección por el VIH y este documento pretende optimizar la evaluación y el manejo de la afectación renal.(AU)

OBJECTIVE: To update the 2010 recommendations on the evaluation and management of renal disease in HIV-infected patients. METHODS: This document was approved by a panel of experts from the AIDS Working Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Nephrology (S.E.N.), and the Spanish Society of Clinical Chemistry and Molecular Pathology (SEQC). The quality of evidence and the level of recommendation were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, Urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glucosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document advises on the optimal time for referral of a patient to the nephrologist and provides indications for renal biopsy. The indications for and evaluation and management of dialysis and renal transplantation are also addressed. CONCLUSIONS: Renal function should be monitored in all HIV-infected patients. The information provided in this document should enable clinicians to optimize the evaluation and management of HIV-infected patients with renal disease.(AU)

Critical role of ribavirin for the achievement of early virological response to HCV therapy in HCV/HIV-coinfected patients.

The response to hepatitis C virus (HCV) therapy seems to be lower in HCV/HIV-coinfected patients than in HCV-monoinfected individuals. Given that most pivotal trials conducted in coinfected patients have used the combination of pegylated interferon (pegIFN) along with fixed low doses (800 mg/day) of ribavirin (RBV), it is unclear whether HIV itself and/or suboptimal RBV exposure could explain this poorer outcome. Two well-defined end points of early virological response were evaluated in Peginterferon Ribavirina España Coinfección (PRESCO), a multicentre trial in which the combination of pegIFN plus RBV (1000 mg if body weight <75 kg and 1200 mg if >75 kg) was prescribed to coinfected patients. For comparisons, we used unpublished data from early kinetics in two other large trials, one performed in HIV-negative patients [Pegasys International Study Group (PISG)] in which RBV 1000-1200 mg/day was used and another [AIDS Pegasys Ribavirin Coinfection Trial (APRICOT)] in which HIV-positive patients received fixed low RBV doses (800 mg/day). A total of 348 HCV/HIV-coinfected patients from the PRESCO trial were analysed as well as all patients treated with pegIFN plus RBV, who completed 12 weeks of therapy in the comparative studies (435 in PISG and 268 in APRICOT). Negative serum HCV-RNA at week 4 (which has the highest positive predictive value of sustained virological response, SVR) was attained in 33.3%, 31.2% and 13% of treated patients with HCV genotype 1, respectively, in PRESCO, PISG and APRICOT. For HCV genotypes 2/3, responses were 83.7%, 84.2% and 37%, respectively. A decline lower than 2 log(10) at week 12 (which has the highest negative predictive value of SVR) was seen in 25.5%, 19.5% and 37% of HCV genotype-1-infected patients, and in 2.1%, 2.9% and 12% of genotypes-2/3-infected patients, respectively. Prescription of high RBV doses enhances the early virological response to HCV therapy in HCV/HIV-coinfected patients, with results approaching those seen in HCV-monoinfected patients.

Enfermedad pulmonar por M. Kansasii: Análisis de 33 casos / No disponible

No disponible

Enfermedad pulmonar por M. Avium complex en Zaragoza / No disponible

No disponible

Estudio del retraso diagnóstico en pacientes con tuberculosis / Delayed diagnosis study in tuberculous patients

Fundamento: Estudiar el tiempo que tarda en ser diagnosticado un paciente de tuberculosis en el área de salud del Hospital Universitario Miguel Servet de Zaragoza. Pacientes y método: Estudio transversal del retraso diagnóstico observado en 428 pacientes en los que se aisló Mycobacterium tuberculosis entre los años 1993 y 1997. Se realizó un análisis estadístico con pruebas convencionales utilizando un nivel de significación p<0,05. Resultados: Se estudiaron 428 pacientes con cultivo positivos frente a Mycobacterium tuberculosis: 136 (31,8%) VIH positivos, 121 (28,3%) VIH negativos y en 171 (39,9%) no constaba la serología. El tiempo medio que tardó en diagnosticarse un paciente con tuberculosis fue de 37 días (IC 95%: 32,83-42,07), con una mediana de 22 días; el 60% fueron diagnosticados en los 30 primeros días de iniciada la clínica y en el 40% el retraso diagnóstico fue superior a un mes. No se observaron diferencias significativas entre los pacientes mayores y menores de 60 años, aunque fue ligeramente superior en los primeros (p=0,686). Cuando se compararon los pacientes infectados por el VIH y no infectados tampoco se observaron diferencias significativas (p=0,944). Se observó un mayor retraso diagnóstico en las formas clínicas más solapadas, en los pacientes con TB extrapulmonar y en aquellos con baciloscopia en esputo negativa. Conclusiones: El retraso diagnóstico de la enfermedad tuberculosa en nuestra área sanitaria es importante. Sería necesario pensar con mayor frecuencia en ella con la finalidad de intentar cortar, de alguna manera, la cadena epidemiológica y evitar así nuevos contagios (AU)

Background: To know the delayed diagnosis observed in tuberculous patients in the Miguel Servet Universitary Hospital, Zaragoza (Spain). Patients and methods: Transversal study of the delayed diagnosis observed in 428 tuberculous patients diagnosed in the Miguel Servet Universitary Hospital (Zaragoza, Spain) between 1993-1997. Statistical analysis of conventional tests and significance level at p<0,05 were performed. Results: Four hundred and twenty height patients with culture-positive to Mycobacterium tuberculosis were studied; 136 (31,8%) were HIV+, 121 (28,3%) were HIV- and in 171 (39,9%) this situation was unknow. The mean of the delayed diagnosis was 37 days (95% CI, 32,83-42,07) with a medium of 22 days. The 60% of the patients was diagnosed in the first 30 days of the symptomatology beginning and in 40% the delayed diagnosis was higher than one month. We haven`t found significant differences between both older and younger than 60 years patients (p=0,686). When we compared both seropositive and seronegative patients we didn`t found signifficant differences (p=0,944). A higher diagnostic delay was observed in the tuberculosis atipical forms, in extrapulmonar tuberculosis and in those patients with a negative sputum baciloscopie. Conclusions: Tuberculosis delayed diagnosis in our sanitary area is important. It would be necessary to think in tuberculosis because to try to cut epidemic chain and avoid new contacts and new infecctions (AU)

Evaluación y manejo de la neumonía de la comunidad (II) / Evaluation and management of pneumonia in society (II)

Este trabajo, continuación de la revisión del mismo título, que trataba de la etiología y criterios de ingreso, se ocupa ahora de analizar las posibilidades de tratamiento y la estrategia en el manejo de la neumonía adquirida en la comunidad (NAC) en medio extrahospitalario. Ante una sospecha clínica de existencia de neumonía se debe confirmar clínica y radiológicamente , una vez establecido el diagnóstico, valorar la necesidad de ingreso o manejo extrahospitalario y considerar el tratamiento antibiótico que se debe administar al paciente. Las recomendaciones apoyan el tratamiento de las enfermedaes basado en la premisa del uso del "fármaco correcto para el paciente correcto" teniendo en cuenta que los perfiles de los pacientes exigen diferentes terapéuticas para diferentes marcos clínicos (AU)

Evaluación y manejo de la neumonía de la comunidad (I) / Evaluation and management of pneumonia in society (I)

La neumonía es una de las patologías más frecuentes en nuestro medio, con una morbilidad y mortalidad considerable, siendo la infección que provoca mayor número de ingresos hospitalarios. El pronóstico de esta enfermedad ha mejorado en la últimas décadas gracias al tratamiento antibiótico aunque sigue siendo potencialmente grave, por ello, la hospitalización es necesaria en determinados pacientes, mientras que en otros pueden ser correctamente tratados en el medio extrahospitalario. Por otro lado existe preocupación por aspectos tan importantes com el problema de las resistencias del S. pneumoniae, prescripción razonada de los antimicrobianos, la relación costo/eficacia y la incorporación de nuevos antibióticos al arsenal terapéutico clásico de las neumonías. Todos estos factores justifican esta revisión con el fin de aportar información reciente haciendo uso de las recomendaciones publicadas en los últimos años (AU)

[Resistance of Mycobacterium tuberculosis in Zaragoza, Spain (1993-1997) and related factors]. / Resistencia de Mycobacterium tuberculosis en Zaragoza (1993-1997) y factores asociados.

BACKGROUND: To know the frequency of resistance of Mycobacterium tuberculosis in a general hospital and the related factors. PATIENTS AND METHOD: Transversal study of the sensitivity of Mycobacterium tuberculosis in the Hospital Miguel Servet (Zaragoza, Spain) between 1993-1997; the proportions method was used to study the susceptibility. Statistical analysis of conventional tests and significance level at p < 0.05 were performed. RESULTS: Four hundred and twenty height patients with culture-positive to Mycobacterium tuberculosis were studied; 136 (31.8%) were HIV+, 121 (28.3%) were HIV and in 171 (39.9%) this situation was unknown. In 47 patients (10.9%) the strains isolated were resistant at least to one drug. Primary resistance was 5.9% (22 patients) and acquired resistance was 42.4% (25 patients). Primary resistance in HIV+ patients was 9. 2% and in HIV patients was 7.5%; acquired resistance in HIV+ patients was greater than in HIV patients (51.8% vs 42.8%). When we compared the resistances between both HIV+ and HIV patients we did not find significant differences. Twenty isolates (4.7%) were resistant to more than one drug and 10 (2.3%) were resistant to at least isoniazid and rifampin. The risk factors for acquired resistance were alcohol (odds ratio [OR] = 2.65; 95% CI, 1.24-5.65), drugs users (OR = 2.33; 95% CI, 1.05-5.17), previous episodes of tuberculosis (OR = 109.40; 95% CI, 15.02-796.43) and homeless (OR = 3.75; 95% CI, 1.26-11.17); we did not find significant differences between the different risk factors according to primary resistance. CONCLUSIONS: On one study, the resistance of M. tuberculosis is similar to other described in Spain. We haven't found significant differences between both seropositive and seronegative patients. The risk factors for acquired resistance were alcoholism, drug users, previous episodes of tuberculosis and homeless.

[Rol of thallium-201/gallium-67 cerebral tomogammography in the differential diagnosis of cerebral space occupying lesions]. / Valor de la tomogammagrafía cerebral Talio-201/Galio-67 en el diagnóstico diferencial de las lesiones cerebrales ocupantes de espacio.

INTRODUCTION: Central nervous system (CNS) neoplasms are 10% of all tumors. A metastasis of an unknown primary neoplasm should be suspected in an adult with a cerebral tumor. In this location, the origin of most of metastases (62%) is lung, breast, skin and kidney. However, a differentiation of CNS focal infection and brain tumor, based on clinical status and morphologic imaging, may be difficult. A positive Tl-201 next to a negative Ga-67 SPECT brain scans is entirely in accord with brain metastatic tumor. CLINICAL CASE: A 72-year-old man, with history of excised bladder cancer, was admitted for neurological symptoms associated with a left occipital mass demonstrated by cranial CT and brain MRI. Clinicoradiological findings suggested a neoplastic process. Two cerebral biopsies just showed inflammatory cells. Tl-201 and Ga-67 SPECT brain scans were performed and their findings, an abnormal uptake of Tl-201 in the left occipital cortex and a negative Ga-67 scan, favored a neoplastic process. Radical exeresis of the lesion showed a metastatic adenosquamous carcinoma of probably lung origin. CONCLUSION: Tl-201 in addition to Ga-67 brain SPECT scans are a valuable tool for differential diagnosis between cerebral infection and brain tumour in patients with a sole cerebral mass lesion, especially when clinicoradiological findings and biopsy results are conflicting.

[An epidemiological and social study of 127 patients with AIDS IN Aragon]. / Estudio epidemiológico y social de 127 pacientes con sida en Aragón.

OBJECTIVE: To evaluate the profile epidemiology and social of the patient with AIDS in our environment and the direct relation with primary care. DESIGN: A descriptive, analytic and retrospective study. SETTING: The study was carried out in the Miguel Servet Hospital in Zaragoza. PARTICIPANTS: Patients with AIDS between January 1991 and june 1993 and who fulfilled the requisite diagnostic criteria. MEASUREMENTS AND MAIN RESULTS: Out of the 127 patients studied, 74.8% were male and the age was 20 to 30 years old. The transmission mechanism was blood way in drug addicts in 63.8% and heterosexual way in 14.8%. It was socioeconomic problems in 40.94%, and 69.23% of them were drug addicts. The familiar support were proved in 29.13% and had relation with primary care only 15.74%. CONCLUSIONS: An increase of the incidence of AIDS is observed, prevailing men between 31-40 years old. The heterosexual way transmission is increasing, but the blood way in drug addicts is more frequently. The majority presents socioeconomic problems and they haven't familiar support.

[Pneumonia diagnosed with bronchoscopy in HIV-positive patients]. / Neumonías diagnosticadas por broncoscopia en pacientes HIV-positivos.

BACKGROUND: The object of our research is to analyse the microbiological results of the samples which have been obtained by means of fibronchoscopy (FB) from HIV positive patients from 1991 until 1993. METHODS: Sixty fibrobronchoscopies were carried out on fifty-seven HIV positive patients. In every case, samples of bronchoaspirate (BAS), bronchoalveolar lavage (BAL) and telescoping plugged catheter (TPC) were cultured; the last two in a quantitative way. Pneumocystis carinii was investigated in BAL by means of immunofluorescence with monoclonal antibodies. RESULTS: Some microorganisms were isolated in forty-seven bronchoscopies. Thirteen episodes resulted negative. The most frequent etiologic agent was Pneumocystis carinii (seventeen cases). The etiology of fifteen episodes was polymicrobial. The intersticial radiological pattern was the predominant one. It was observed in twenty-seven cases. With regard to immunity, 91% of the patients showed CD4 < 200. CONCLUSIONS: In our research work, the samples that have been obtained by means of FB showed a high percentage of diagnoses; that is the reason why we regard this technique as very useful for the diagnosis of pneumonia in patients with AIDS. Due to the large number of bacterian pneumonia, we consider necessary not only the use of BAL, but also that of TPC in these processes.