[Epidemiological features of community- and nosocomial-acquired bacteremia in the hospitalized elderly patients]. / Características epidemiologías de la bacteriemia de origen comunitario y nosocomial en pacientes hospitalizados mayores de 65 años.

OBJECTIVES: To analyze the epidemiology and to identify associated factors for community- and nosocomial-acquired bacteremia in the elderly (BE). PATIENT AND METHODS: Elderly patients diagnosed of bacteremia were selected. Community- or acquired-bacteremia were defined according to standard criteria. The severity of underlying diseases was classified as non-fatal, ultimately fatal, or rapidly fatal, according to McCabe-Jackson criteria. Multivariate analysis by logistic regression was used to identify associated factors to bacteremia. RESULTS: Two hundred and forty-two cases of BE were selected. The mean age was 72.5 years, 50% occurred in males. One hundred and thirty cases (53.7%) were community-acquired and 112 (46.3%) cases were nosocomial-acquired BE. Most common underlying diseases were diabetes mellitus (30.6%%), chronic obstructive pulmonary disease (25.6%) and neoplasia (24%). Gram-negative bacteria were more frequently isolated in community-acquired BE, while gram-positive cocci were more common in nosocomial-acquired BE. Sources of infection were: vascular (19%), respiratory tract (18.6%), biliary tract (17.8%) and urinary tract (8.3%). The factors associated with nosocomial-acquired BE were (adjusted OR; 95%CI): underlying diseases (5.4; 2.7-10.8), neoplasia (2.5; 1.3-4.9) and vascular origin (2.2; 1.1-4.5). Fifty-two patients died (23.1%). CONCLUSIONS: BE occurs in elderly patients debilitated with well-defined underlying diseases. BE is associated to high mortality.

Modelos pronósticos en bacteriemia y sepsis / Prognosis factors in bacteremia and sepsis

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Características epidemiologías de la bacteriemia de origen comunitario y nosocomial en pacientes hospitalizados mayores de 65 años / Epidemiological features of community- and nosocomial-acquired bacteremia in the hospitalized elderly patients

Objetivos: Describir las características epidemiologías e identificar factores asociados de la bacteriemia de origen comunitario y nosocomial en el paciente anciano (BA). Pacientes y método: Se seleccionaron pacientes ancianos diagnosticados de bacteriemia significativa. La fuente de bacteriemia y la adquisición comunitaria o nosocomial fueron consideradas siguiendo definiciones estandarizadas. Según la presencia de enfermedad subyacente los pacientes fueron categorizados siguiendo los criterios de McCabe y Jackson en los siguientes grupos: rapidamente fatal, últimamente fatal, y no fatal. Se realizó análisis multivariante por regresión logística para identificar factores asociados de forma independiente a la presencia de bacteriemia. Resultados: Fueron seleccionados 242 episodios de BA, con una edad media de los pacientes de 72,5 años, siendo el 50% varones. El origen fue comunitario en 130 (53,7%) casos y nosocomial en 112 (46,3%). En el 90,9% de los casos existía alguna enfermedad subyacente, siendo las más frecuentes: diabetes mellitus (30,6%), EPOC (25,6%) y neoplasia (24%). En BA de origen comunitario los bacilos gram negativos fueron más frecuentemente aislados (60,8%) y en BA nosocomial los cocos gram positivos (58,9%). La fuente primaria de bacteriemia fue vascular (19%), respiratorio (18,6%), biliar (17,8%) y urinario (8,3%). Tras analisis multivariante el origen nosocomial de la BA se asoció a presencia de alguna enfermedad subyacente (OR: 5,4; IC95%: 2,7-10,8), neoplasia (OR: 2,5; IC95: 1,3-4,9) y fuente vascular (OR: 2,2; IC95%: 1,1-4,5). Fallecieron 56 pacientes (23,1%). Conclusiones: La BA ocurre en pacientes con enfermedades debilitantes y factores predisponentes definidos, asociandose a una alta mortalidad

Objectives: To analyze the epidemiology and to identify associated factors for community- and nosocomial-acquired bacteremia in the elderly (BE). Patient and methods: Elderly patients diagnosed of bacteremia were selected. Community- or acquired-bacteremia were definided according to standard criteria. The severity of underlying diseases was classified as non-fatal, ultimately fatal, or rapidly fatal, according to McCabe-Jackson criteria. Multivariate analysis by logistic regression was used to identify associated factors to bacteremia. Results: Two hundred and forty-two cases of BE were selected. The mean age was 72,5 years, 50% occurred in males. One hundred and thirty cases (53,7%) were community-acquired and 112 (46,3%) cases were nosocomial-acquired BE. Most common underlying diseases were diabetes mellitus (30,6%%), chronic obstructive pulmonary disease (25,6%) and neoplasia (24%). Gram-negative bacteria were more frequently isolated in community-acquired BE, while gram-positive cocci were more common in nosocomial-acquired BE. Sources of infection were: vascular (19%), respiratory tract (18,6%), biliary tract (17,8%) and urinary tract (8,3%). The factors associated with nosocomial-acquired BE were (adjusted OR; 95%CI): underlying diseases (5,4; 2,7-10,8), neoplasia (2,5; 1,3-4,9) and vascular origin (2,2; 1,1-4,5). Fifty-two patients died (23,1%). Conclusions: BE occurs in elderly patients debilitated with well-defined underlying diseases. BE is associated to high mortality

[Pneumococcal bacteremia in adult patients at a university hospital]. / Bacteriemia neumocócica en el adulto en un hospital de tercer nivel.

OBJECTIVES: to analyze the epidemiology, the clinical spectrum, and to identify prognostic factors for pneumococcal bacteremia (PB). PATIENTS AND METHOD: adult patients (age>14 years) diagnosed of PB in the "Carlos Haya" University Hospital at Malaga (Spain) were selected between 1995 and 2000. A protocol was drawn up for the collection of data which included epidemiological characteristics, underlying diseases, symptoms and findings on the physical examination at admission, laboratory values, chest radiography features, and patient evolution. To identify prognostic factors was carried out multivariate analysis by logistic regression. RESULTS: One hundred twenty-three cases of PB were included. The mean age was 56.2+/-18.3 years, 71.5% occurred in males. The overall annual incidence of PB was of 5.5 cases/100,000 population. Most common underlying diseases were chronic obstructive pulmonary disease (26%), alcoholism (21.1%), liver cirrhosis (21.1%), HIV infection (19.5%), and neoplasia (25%). Lungs were more frequent source of infection (71.5%). No source of bacteremia was identified in 13 (10.6%) cases. Resistance rate to penicillin was 36.6%. Mortality rate 30.1%. In the multivariate analysis, the independent prognostic factors for mortality were hyperazotemia, multi-lobe involvement, and presence of shock CONCLUSIONS: There is a high incidence of PB in patients with underlying diseases. Lung is the most common source of bacteremia. Mortality rate was high. Prognostic factors were identified.

Bacteriemia neumocócica en el adulto en un hospital de tercer nivel / Pneumococcal bacteremia in the adult patient in a university hospital

Objetivos: describir la epidemiología y el espectro clínico, así como identificar factores pronósticos de la bacteriemia neumocócica (BN) en el paciente adulto. Pacientes y método: se seleccionaron pacientes mayores de 14 años diagnosticados de bacteriemia neumocócica en el periodo 1995-2000. Se recogieron datos epidemiológicos, enfermedades subyacentes, variables clínicas y evolutivas. Para identificar factores pronósticos se realizó análisis multivariante por regresión logística. Resultados: Se incluyeron 123 casos de BN, con una edad media de 56,2ñ18,3 años, siendo el 71,5 por ciento varones. La incidencia anual media de BN fue de 5,5 casos/100.000 habitantes. Los factores predisponentes más frecuentes fueron EPOC (26 por ciento), etilismo (21,1 por ciento), cirrosis hepática (21,1 por ciento), infección por VIH (19,5 por ciento) y neoplasia (18,7 por ciento por ciento). El origen pulmonar fue la fuente de infección más frecuente (71,5 por ciento). En el 10,6 por ciento de los casos no se pudo determinar fuente de infección. La tasa de resistencia a penicilina fue del 36,6 por ciento. La mortalidad fue del 30,1 por ciento. Los factores pronósticos asociados a mortalidad de forma independiente en la BN del adulto fueron hipierazotemia, presencia de infiltrados pulmonares multilobares y shock. Conclusiones: La BN es una entidad frecuente en pacientes con enfermedades debilitantes. El origen más común es pulmonar. Se asocia a una alta mortalidad. Se identifican factores pronósticos asociados a la severidad de la infección neumocócica y a la carga de enfermedades subyacentes de pacientes (AU)

Tuberculosis recurrente en pacientes coinfectados por VIH / Recurrent tuberculosis in patients with coinfection by HIV

Objetivos. Analizar e identificar factores asociados a la recurrencia de la tuberculosis (TB) en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Pacientes y métodos. Se seleccionaron pacientes infectados por VIH diagnosticados de TB entre 1995-2000 y que completaron el tratamiento correctamente. Se compararon aquellos pacientes que presentaron una recurrencia de enfermedad tuberculosa con los que no lo hicieron. Se realizó análisis multivariante por regresión logística para identificar factores asociados a un nuevo episodio de TB. Resultados. De un total de 223 pacientes infectados por VIH diagnosticados de TB, 159 (71,3 por ciento) completaron adecuadamente el tratamiento y fueron considerados curados. El resto fueron excluidos por fallecer antes de completar el tratamiento (5,8 por ciento), perdidos en el seguimiento (11,7 por ciento), abandono terapéutico (9,4 por ciento) y fracaso terapéutico (1,8 por ciento). De los 159 pacientes evaluables, 14 (8,8 por ciento) presentaron posterior recurrencia. Los pacientes con TB recurrente presentaron un mayor grado de inmunodepresión, más eventos previos diagnósticos de sida y mayor frecuencia de TB extrapulmonar en el episodio inicial. Tras el análisis multivariante, un recuento de linfocitos CD4 inferior a 100/mm3 en el primer episodio de TB se asoció con enfermedad tuberculosa recurrente (odds ratio [OR]: 4,6; intervalo de confianza [IC] 95 por ciento:1,3-18,2). En los episodios recurrentes la mortalidad fue alta (35,7 por ciento).Conclusiones. La recurrencia de TB en pacientes coinfectados por VIH ocurre en individuos con inmunodepresión profunda y se asocia a una alta mortalidad (AU)

[Recurrent tuberculosis in patients with coinfection by HIV]. / Tuberculosis recurrente en pacientes coinfectados por VIH.

OBJECTIVES: Analysis and identification of factors associated with the tuberculosis (TB) recurrence in HIV-infected patients. PATIENTS AND METHODS: The HIV-infected patients diagnosed with TB between 1995-2000 and with correct completion of the treatment were selected. There were compared those patients who presented a tuberculous disease recurrence with those which did not presented it. Multivariate analysis was carried out by logistic regression in order to identify factors associated with a new episode of TB. RESULTS: In the total sample of 223 diagnosed HIV-infected patients with TB, 159 (71.3%) patients completed adequately the treatment and were considered cured. The rest were excluded because of: death before completing the treatment (5.8%), lost in the follow-up (11.7%), therapeutic abandonment (9.4%), and therapeutic failure (1.8%). In the 159 patient final sample, 14 (8.8%) patients presented later recurrence. The patients with recurrent TB presented a greater degree of immunosuppression, more previous complications indicative of AIDS, and greater frequency of extrapulmonary TB in the initial episode. After the multivariate analysis, a count of lymphocytes CD4 lower than 100/mm3 in the first episode of TB was associated with recurrent tuberculous disease (odds ratio [OR]: 4,6; 95% confidence index [CI]: 1,3-18,2). Mortality was high (35.7%) in the patients with recurrent episodes. CONCLUSIONS: The recurrence of TB in patients coinfected by HIV occurs in individuals with profound immunossuppression and is associated to high mortality.

Bacteriemia neumocócica en el anciano: características clínicas y factores pronósticos / Pneumococcal bacteriemia in the elderly. Clinical features and prognostic factors

Objetivos: Analizar la epidemiología y el espectro clínico, así como identificar factores pronósticos de la bacteriemia neumocócica en el paciente anciano. Pacientes y método: De forma prospectiva, se seleccionó a pacientes ancianos diagnosticados de bacteriemia neumocócica en dos hospitales de la provincia de Málaga durante el período 1995-2001 y se compararon con un grupo control de pacientes de menos de 65 años diagnosticados consecutivamente de bacteriemia neumocócica. Para identificar factores pronósticos se realizó un análisis multivariante por regresión logística. Resultados: Se seleccionaron 72 casos de bacteriemia neumocócica en ancianos, con una edad media (desviación estándar) de 73,4 (6,9) años, el 61,1 por ciento varones. La incidencia anual media de bacteriemia neumocócica en los ancianos fue de 15,1 casos/100.000 habitantes. Ningún paciente había recibido previamente vacunación neumocócica. Los factores predisponentes más frecuentes fueron: enfermedad pulmonar obstructiva crónica (40,3 por ciento) y diabetes mellitus (25 por ciento). El origen pulmonar fue la fuente de infección más frecuente en los ancianos (el 81,9 por ciento frente al 65,3 por ciento; p < 0,05; odds ratio [OR]: 2,5; intervalo de confianza [IC]: 1,1-5,6). En el 13,9 por ciento de los casos no se pudo determinar la fuente de infección. La tasa de resistencia a penicilina fue del 23,6 por ciento. La mortalidad fue superior entre los ancianos (el 34,7 frente al 18,1 por ciento; p < 0,05; OR: 2,4; IC: 1,1-5,7 por ciento). Los factores pronósticos asociados con mortalidad de forma independiente en la bacteriemia neumocócica del anciano fueron hipoalbuminemia, presencia de infiltrados pulmonares multilobares y confusión, lo que generó un modelo con una especificidad del 97,9 por ciento y un valor predictivo positivo del 88,9 por ciento. Conclusiones: La bacteriemia neumocócica en el anciano es una entidad frecuente, cuyo origen más común es el pulmonar, y se asocia con una alta mortalidad. Se describe un modelo pronóstico con alto poder predictivo (AU)

[The cost effectiveness of the study of the familial contacts of tuberculosis patients coinfected with the human immunodeficiency virus]. / Rentabilidad del estudio de los contactos familiares de enfermos con tuberculosis coinfectados por el virus de la inmunodeficiencia humana.

The investigation of contacts of patients with tuberculosis is a highly cost-effective measure to detect new cases of disease and infected individuals; nevertheless, its efficacy has not been contrasted with persons living with patients with tuberculosis (TB) coinfected with HIV. A total of 152 family contacts were studied corresponding to 84 HIV-positive tuberculosis patients. As a control group, 516 persons living with HIV-negative TB patients were included. Contacts were classified according to the bacteriologic status of the index case (IC): group I, contacts of patients with negative bacterioscopy and positive culture of respiratory specimens; group II, contacts of patients with negative bacterioscopy and positive culture of respiratory specimens, and group III, contacts of pulmonary and/or extrapulmonary TB patients with negative bacterioscopy and culture. Among IC coinfected with HIV there was a higher percentage of extrapulmonary clinical forms and therefore a lower proportion of bacillary forms, which accounted for a lower rate of infection among contacts of HIV-positive patients than among contacts of HIV-negative patients (20.4% vs 48.8%; OR: 3.7; 95% CI: 2.4-5.9). After controlling for bacteriologic status of the IC, differences remained when bacillary (group I) of HIV-coinfected patients were compared with those of patients not coinfected with HIV (35.9% vs 52.3%; OR: 2.1%; 95% CI: 1.2-5.9). Overall, 28 new TB cases were detected (4.2% of the total of studied persons living with TB patients) with no differences among contacts of both groups. The lower rate of infections among persons living with HIV-positive patients might be due not only to a lower number of pulmonary forms in HIV-coinfected IC and therefore less bacillary forms but also to a lower degree of crowding and a higher protection against exposure to their contacts.

[The clinical and evolutional characteristics of visceral leishmaniasis in patients with HIV infection]. / Características clínicas y evolutivas de la leishmaniasis visceral en pacientes con infección por VIH.

OBJECTIVE: To analyze the clinical features, yield of the diagnostic techniques, and therapeutic response of HIV-associated visceral leishmaniasis (VL), and compare the initial episodes to the relapses. METHODS: Forty-one episodes of leishmaniasis visceral, diagnosed in 31 HIV-positive patients between 1st February 1992 and 31st January 1996 were reviewed. RESULTS: The prevalence of VL in HIV-positive patients in our center was 4.2%. Fifty-eight percent of the patients had AIDS prior to the diagnosis of VL. Fever was more frequent in the initial episodes than in the relapses (90.3% versus 60%; p < 0.05; OR: 6.2; IC 95%: 0.8-51.5), splenomegaly was more frequent in the relapses (100% versus 71%; p = 0.05). The diagnostic delay was longer in the initial episodes (27.2 +/- 22.7 versus 5 +/- 4.8 days; p < 0.05). The diagnostic yield of bone marrow biopsy was 82.1%, of liver biopsy 72.7% and of splenic fine-needle aspiration 87.5%. The indirect immunofluorescence test for Leishmania antibodies was positive in 5.9% of cases. Therapeutic failure occurred in 47.6% of patients treated with antimonials and 3.3% of patients treated with amphotericin B. Those patients who received secondary prophylaxis had less relapses than those who did not (17.6% versus 66.7%; p < 0.05; OR: 0.11; IC 95%: 0.01-1.28). Of the 31 patients, twenty-six (83.8%) died, and in none of them was the cause of the death directly related to LV. CONCLUSION: HIV-associated VL manifests clinically in a similar fashion to the immunocompetent's disease. It appears in advanced immunosuppression phases, behaving like other AIDS-defining illnesses. In spite of a good therapeutic response the relapse rate is high.

[Percutaneous liver biopsy: comparative study on the efficacy of and tolerance to the automatic tru-cut technique]. / Biopsia hepática percutánea: estudio comparativo sobre la eficacia y tolerancia de la técnica de tru-cut automática.

Percutaneous liver biopsy (PLB) is an useful tool in accurately diagnosing difuse hepatopathy and systemic procedures like fever of unknown origin (FUO) and human immunodeficiency virus infection. Present job compares two different PLB procedures, automatic tru-cut needle versus Menghini needle. We have achieved 143 PLBs,74 of them through Menghini needle and 69 with automatic tru-cut technique. No differences were observed about diagnostic efficiency and secondary complications but we have noted a significant presence of pain reactions when Menghini needle is used. So we conclude that tru-cut technique is as safe as Menghini needle with the same diagnostic efficiency and better tolerance.

[Socioeconomic effects of human brucellosis]. / Repercusión socioeconómica de la brucelosis humana.

The socio-economic cost of human brucellosis is analyzed. One hundred and seven patients are included in this study, 75 males (70.09%) and 32 females (29.91), diagnosed of brucellosis in the Internal Medicine Department of the Regional Hospital "Carlos Haya" in Málaga from the 1st of October 1984 to the 31st of December 1986. Thirty seven patients (34.57%) presented some kind of complication. Seventy eight cases (72.89%) were admitted to the hospital resulting in a total of 1.005 hospital admissions with a mean hospital stay of 12.88 days. The total economic cost was 30.724.962 pesetas with a mean patient cost of 287.149 pesetas. The total number of work absence days was 5.291 with a mean 101.7 days per patient and with an accumulated cost in this respect of 49.053.151 pesetas. The total money loss was 84.307.488 pesetas with a mean of 787.920 pesetas per patient. This high cost, together with the high incidence of the disease throughout most of our national territory, clearly justify the need for aggressive preventive measures.

Comparative trial of doxycycline plus streptomycin versus doxycycline plus rifampin for the therapy of human brucellosis.

Effectiveness and therapeutic value of the doxycycline plus streptomycin and doxycycline plus rifampin schedules of treatment of human brucellosis have been assessed by carrying out a prospective study on 111 patients randomly distributed into two groups. Patients in group A were treated with doxycycline plus streptomycin sulphate and those in group B with doxycycline plus rifampin. The temperature of all patients reverted to normal, and 54 patients from group A (91.6%) and 45 from group B (86.5%) achieved total recovery with a single therapeutic cycle. Two therapeutic failures and 3 relapses in group A (8.4%) and 7 relapses in group B (13.46%) were observed. The tolerance to both regimens was good. Although the combination doxycycline plus rifampin offers a more convenient oral administration, in the light of these results, until more extensive research is carried out, it should be considered as an alternative rather than a first choice in the treatment of human brucellosis.