Estudio de casos-controles de la infección por Clostridioides difficile en un área sanitaria rural / Case-control study of Clostridioides difficile in a rural health care area

Objetivo: Determinar los factores de riesgo y factores pronósticos de la infección por Clostridioides difficile (ICD). Pacientes y métodos: Estudio prospectivo de casos-controles (61 casos y 64 controles) de 2 años o más con diarrea, atendidos en un área sanitaria manchega durante 14 meses. El diagnóstico se realizó mediante inmunocromatografía (glutamato deshidrogenasa y toxina A/B), realizando amplificación isotérmica en los casos discordantes. Se recogieron variables demográficas, comorbilidades, tipo de adquisición, administración previa de antibióticos, antiácidos e inmunosupresores y evolución. Los datos se analizaron mediante la prueba de χ2 y el efecto de los factores de riesgo y pronósticos se cuantificó mediante odds ratio con intervalos de confianza del 95%. Resultados: Como factores de riesgo independientes de ICD encontramos el ingreso hospitalario las 4 semanas previas a la infección, la hipoalbuminemia y la administración previa de antibióticos. Presentar estos 3 factores supuso un riesgo casi 3 veces mayor de infectarse. En el grupo de adquisición nosocomial se encontró mayor número de ingresos hospitalarios las 4-12 semanas previas a la ICD y, aunque hubo mayor tendencia a las recurrencias y al pronóstico desfavorable entre los casos intrahospitalarios, estas diferencias no fueron significativas. Identificamos como factores de pronóstico desfavorable la fiebre y el ingreso hospitalario las 4 semanas previas a la infección. Conclusiones:Los factores de riesgo independientes de ICD fueron: ingreso hospitalario las 4 semanas previas a la infección, hipoalbuminemia y administración previa de antibióticos. La fiebre y la hospitalización las 4 semanas anteriores se identificaron además como factores pronósticos de evolución desfavorable.(AU)

Objective: To determine the risk and prognostic factors for Clostridioides difficile infection (CDI). Patients and methods: Prospective, case-control study with 61 cases and 64 controls, aged ≥2 years with diarrhoea, carried out in Castilla-La Mancha Health Care Area for 14 months. The diagnosis was made by immunochromatography technics (glutamate dehydrogenase and toxin A/B), confirming discordant cases by isothermal amplification. Demographic variables, comorbidities, type of acquisition, previous administration of antibiotics, antacids and immunosuppressants, and evolution were collected. The data were analysed using the chi-square test and the effect of risk and prognostic factors was quantified using an odds ratio with 95% confidence intervals. Results: Hospital admission 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics were identified as independent risk factors for CDI. Presenting these 3 factors constitutes nearly 3-fold increase in the risk of becoming infected. A greater number of hospital admissions in the 4-12 weeks prior to CDI were found in the group of nosocomial acquisition. Although there was a greater tendency to recurrence and an unfavourable prognosis among nosocomial cases, these differences were not significant. We found that fever and hospital admission in the 4 weeks prior to infection were unfavourable prognostic factors of CDI. Conclusions: The independent risk factors for CDI were: Hospital admission in the 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics. Fever and hospitalisation in the previous 4 weeks were also identified as prognostic factors of unfavourable evolution.(AU)

Case-control study of Clostridioides difficile in a rural health care area. / Estudio de casos-controles de la infección por Clostridioides difficile en un área sanitaria rural.

OBJECTIVE: To determine the risk and prognostic factors for Clostridioides difficile infection (CDI). PATIENTS AND METHODS: Prospective, case-control study with 61 cases and 64 controls, aged ≥2 years with diarrhoea, carried out in Castilla-La Mancha Health Care Area for 14 months. The diagnosis was made by immunochromatography technics (glutamate dehydrogenase and toxin A/B), confirming discordant cases by isothermal amplification. Demographic variables, comorbidities, type of acquisition, previous administration of antibiotics, antacids and immunosuppressants, and evolution were collected. The data were analysed using the chi-square test and the effect of risk and prognostic factors was quantified using an odds ratio with 95% confidence intervals. RESULTS: Hospital admission 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics were identified as independent risk factors for CDI. Presenting these 3 factors constitutes nearly 3-fold increase in the risk of becoming infected. A greater number of hospital admissions in the 4-12 weeks prior to CDI were found in the group of nosocomial acquisition. Although there was a greater tendency to recurrence and an unfavourable prognosis among nosocomial cases, these differences were not significant. We found that fever and hospital admission in the 4 weeks prior to infection were unfavourable prognostic factors of CDI. CONCLUSIONS: The independent risk factors for CDI were: Hospital admission in the 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics. Fever and hospitalisation in the previous 4 weeks were also identified as prognostic factors of unfavourable evolution.

Estudio de coste-efectividad del diagnóstico microbiológico de tuberculosis mediante geneXpert MTB/RIF(R) / Cost-effectiveness study of the microbiological diagnosis of tuberculosis using geneXpert MTB/RIF(R)

Introducción/Objetivo: Evaluar mediante un análisis de coste-efectividad la aplicación de una técnica de biología molecular al diagnóstico de tuberculosis frente a la alternativa diagnóstica clásica. Métodos: Se realizó un análisis de coste-efectividad para evaluar la aplicación teórica de un procedimiento de biología molecular que incluye 2 alternativas de una técnica para la detección precoz de Mycobacterium tuberculosis Complex y resistencia a rifampicina (alternativa1: una determinación a pacientes seleccionados; alternativa2: 2 determinaciones a todos los pacientes). Ambas alternativas se compararon con el procedimiento habitual de diagnóstico microbiológico de tuberculosis realizado a 1972 pacientes durante 2008-2012 (microscopia y cultivo). La medida de la efectividad se hizo en QALY y la incertidumbre se trató mediante análisis de sensibilidad univariable, multivariable y probabilístico. Resultados: Para el método habitual se obtuvo un valor de 8.588€/QALY. En la alternativa1 el gasto fue de 8.487€/QALY, mientras que en la alternativa2 el cociente coste-efectivo ascendió a 2.960€/QALY. La alternativa2 fue la de mayor eficiencia diagnóstica, alcanzando una reducción del 75% del número de días que un paciente con tuberculosis permanece sin tratamiento adecuado, así como una reducción del 70% del número de días que un paciente sin tuberculosis permanece ingresado. Conclusión: La aplicación de una técnica microbiológica molecular en el diagnóstico de tuberculosis es sumamente coste-efectiva frente al método habitual. Su introducción en el procedimiento diagnóstico de rutina supondría una mejora en la calidad asistencial de los pacientes al evitar ingresos y tratamientos innecesarios, reflejándose en un ahorro económico al hospital (AU)

Introduction/Objective: To perform a cost-effectiveness analysis of a molecular biology technique for the diagnosis of tuberculosis compared to the classical diagnostic alternative. Methods: A cost-effectiveness analysis was performed to evaluate the theoretical implementation of a molecular biology method including two alternative techniques for early detection of Mycobacterium tuberculosis Complex, and resistance to rifampicin (alternative1: one determination in selected patients; alternative2: two determinations in all the patients). Both alternatives were compared with the usual procedure for microbiological diagnosis of tuberculosis (staining and microbiological culture), and was accomplished on 1,972 patients in the period in 2008-2012. The effectiveness was measured in QALYs, and the uncertainty was assessed by univariate, multivariate and probabilistic analysis of sensitivity. Results: A value of €8,588/QALYs was obtained by the usual method. Total expenditure with the alternative1 was €8,487/QALYs, whereas with alternative2, the cost-effectiveness ratio amounted to €2,960/QALYs. Greater diagnostic efficiency was observed by applying the alternative2, reaching a 75% reduction in the number of days that a patient with tuberculosis remains without an adequate treatment, and a 70% reduction in the number of days that a patient without tuberculosis remains in hospital. Conclusion: The implementation of a molecular microbiological technique in the diagnosis of tuberculosis is extremely cost-effective compared to the usual method. Its introduction into the routine diagnostic procedure could lead to an improvement in quality care for patients, given that it would avoid both unnecessary hospitalisations and treatments, and reflected in economic savings to the hospital (AU)

Cost-effectiveness study of the microbiological diagnosis of tuberculosis using geneXpert MTB/RIF®. / Estudio de coste-efectividad del diagnóstico microbiológico de tuberculosis mediante geneXpert MTB/RIF®.

INTRODUCTION/OBJECTIVE: To perform a cost-effectiveness analysis of a molecular biology technique for the diagnosis of tuberculosis compared to the classical diagnostic alternative. METHODS: A cost-effectiveness analysis was performed to evaluate the theoretical implementation of a molecular biology method including two alternative techniques for early detection of Mycobacterium tuberculosis Complex, and resistance to rifampicin (alternative1: one determination in selected patients; alternative2: two determinations in all the patients). Both alternatives were compared with the usual procedure for microbiological diagnosis of tuberculosis (staining and microbiological culture), and was accomplished on 1,972 patients in the period in 2008-2012. The effectiveness was measured in QALYs, and the uncertainty was assessed by univariate, multivariate and probabilistic analysis of sensitivity. RESULTS: A value of €8,588/QALYs was obtained by the usual method. Total expenditure with the alternative1 was €8,487/QALYs, whereas with alternative2, the cost-effectiveness ratio amounted to €2,960/QALYs. Greater diagnostic efficiency was observed by applying the alternative2, reaching a 75% reduction in the number of days that a patient with tuberculosis remains without an adequate treatment, and a 70% reduction in the number of days that a patient without tuberculosis remains in hospital. CONCLUSION: The implementation of a molecular microbiological technique in the diagnosis of tuberculosis is extremely cost-effective compared to the usual method. Its introduction into the routine diagnostic procedure could lead to an improvement in quality care for patients, given that it would avoid both unnecessary hospitalisations and treatments, and reflected in economic savings to the hospital.

[Economic impact of the introduction of a technique for early detection of Mycobacterium tuberculosis Complex in clinical samples in a Spanish hospital]. / Impacto económico de la introducción de una técnica de detección precoz de Mycobacterium tuberculosis Complex en las muestras clínicas de un hospital español.

BACKGROUND: Tuberculosis (TB) remains an important public health problem worldwide. Our objective was to estimate the economic and health care impact of the introduction of an early diagnosis tecnique of TB, the Xpert MTB/RIF® assay (Xpert). METHODS: The savings was estimated on the basis of reduction in the time of TB hospitalization at avoid the false-negative (FN) and false-positive (FP) TB cases diagnosed by auramine staining that could have been detected by Xpert between 2008-2012 in our hospital. The costs analysis was made by adding the cost arising from FN (hospitalization, special tests and equipment for respiratory isolation) and FP (TB treatment, successive medical consultations, analytical and microbiological controls). RESULTS: We detected 19 FP and 22 FN during the 5-year study. Xpert would have detected 19 FP and 15 FN. It was estimated a minimum cost of 3217 euros per FP (treatment, successive medical consultations, analytical and microbiological controls), while each FN has required an extension of hospitalization from 7 days on average (62229 euros), both translated into a global cost of 62229 euros. After an initial investment of 16250 euros (50 cases with high suspicion of TB at 65 euros/test), the hospital would have saved 45979 euros overall in five years. CONCLUSIONS: The introduction of Xpert would improve the quality of health care of patients, avoiding both unnecessary hospitalizations and treatments. Also, Xpert carries a saving for our hospital.

Impacto económico de la introducción de una técnica de detección precoz de Mycobacterium tuberculosis complex en muestras clínicas de un hospital español / Economic impact of the introduction of a technique for early detection of mycobacterium tuberculosis complex in clinical samples in a Spanih hospital

Fundamentos: La tuberculosis (TB) continúa siendo un problema importante de salud pública a nivel mundial. El objetivo del estudio fue estimar el impacto económico y asistencial de la introducción de Xpert MTB/RIF® (Xpert), técnica de diagnóstico rápido de TB. Métodos: Se estimó el ahorro en base a la reducción del tiempo de ingreso por TB al evitar los falsos negativos (FN) y falsos positivos (FP) de la baciloscopia que se habrían detectado por Xpert en el periodo 2008-2012. El análisis y cálculo de gastos se hizo sumando el coste de los FN (estancias más pruebas especiales y aislamiento respiratorio) y los FP (tratamiento antituberculoso, consultas sucesivas, analíticas y controles microbiológicos). Resultados: Durante los 5 años de estudio se detectaron 19 FP y 22 FN. Xpert habría detectado los 19 FP y 15 FN. El gasto mínimo estimado para los FP fue de 3.217 euros (tratamiento, consultas sucesivas, analíticas y controles microbiológicos), mientras que cada FN supuso una prolongación de una estancia media de 7 días (59.012 euros), traducidos ambos en un coste total de 62.229 euros. Con una inversión inicial de 16.250 euros (50 casos con elevada sospecha de TB a 65 euros/prueba) el hospital habría ahorrado un global de 45.979 euros en 5 años. Conclusión: La introducción de Xpert supondría un ahorro económico para el hospital y una mejora en la calidad asistencial, evitando estancias y tratamientos innecesarios(AU)

Background: Tuberculosis (TB) remains an important public health problem worldwide. Our objective was to estimate the economic and health care impact of the introduction of an early diagnosis tecnique of TB, the Xpert MTB/RIF® assay (Xpert). Methods: The savings was estimated on the basis of reduction in the time of TB hospitalization at avoid the false-negative (FN) and false-positive (FP) TB cases diagnosed by auramine staining that could have been detected by Xpert between 2008-2012 in our hospital. The costs analysis was made by adding the cost arising from FN (hospitalization, special tests and equipment for respiratory isolation) and FP (TB treatment, successive medical consultations, analytical and microbiological controls). Results: We detected 19 FP and 22 FN during the 5-year study. Xpert would have detected 19 FP and 15 FN. It was estimated a minimum cost of 3217 euros per FP (treatment, successive medical consultations, analytical and microbiological controls), while each FN has required an extension of hospitalization from 7 days on average (62229 euros), both translated into a global cost of 62229 euros. After an initial investment of 16250 euros (50 cases with high suspicion of TB at 65 euros/test), the hospital would have saved 45979 euros overall in five years. Conclusions: The introduction of Xpert would improve the quality of health care of patients, avoiding both unnecessary hospitalizations and treatments. Also, Xpert carries a saving for our hospital(AU)

Epiteliopatía pigmentaria placoide multifocal posterior aguda. Una rara causa de ictus isquémico / Acute posterior multifocal placoid pigment epitheliopathy. A rare cause of ischaemic stroke

Introducción. La epiteliopatía pigmentaria placoide multifocal posterior aguda (EPPMPA) es una enfermedad inflamatoria rara, generalmente de etiología indeterminada, de la coriocapilar, el epitelio pigmentario y la retina externa. Afecta predominantemente a pacientes jóvenes y en algunos casos puede involucrar al sistema nervioso central en forma de ictus o de meningoencefalitis. Presentamos el caso clínico de una mujer joven con EPPMPA complicada con ictus e hipertensión intracraneal. Caso clínico. Mujer de 16 años que comienza con cefalea intensa sugestiva de hipertensión intracraneal, así como con un déficit agudo hemisférico izquierdo. La resonancia magnética craneal ponía de manifiesto lesiones embólicas o vasculíticas en diferentes territorios. No se evidenciaron datos de meningoencefalitis en el estudio del líquido cefalorraquídeo, pero sí de hipertensión intracraneal asociada. La presencia de lesiones muy específicas en el polo ocular posterior permitió el diagnóstico de EPPMPA complicada con ictus isquémico, probablemente por mecanismo vasculítico. Un amplio estudio etiológico fue negativo para identificar un factor desencadenante claro del proceso. Se inició tratamiento corticoideo con buena evolución clínica y radiológica. Conclusiones. La EPPMPA es una entidad rara que generalmente entraña buen pronóstico; sin embargo, en algunos casos puede complicarse con afectación del sistema nervioso central, y el ictus isquémico secundario a vasculitis es la complicación más grave. Ante un paciente joven con ictus que presente sintomatología visual y lesiones coriorretinianas, debe considerarse la EPPMPA en su diagnóstico etiológico (AU)

Introduction. Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory disease, generally of unknown aetiology, affecting the choriocapillaris, the pigment epithelium and the outer retina. It predominantly affects young patients and in some cases may involve the central nervous system in the form of strokes or meningoencephalitis. We report the clinical case of a young female with APMPPE that was complicated by stroke and intracranial hypertension. Case report. Our patient was a 16-year-old female who began with intense headaches suggesting intracranial hypertension, as well as with an acute deficit in the left hemisphere. A magnetic resonance scan of the head revealed embolic or vasculitic lesions in different territories. No evidence of meningoencephalitis was found in the cerebrospinal fluid analysis, but signs of associated intracranial hypertension were observed. The presence of very specific lesions in the posterior pole of the eye led to a diagnosis of APMPPE complicated by ischaemic stroke, probably caused by a vasculitic mechanism. An extensive aetiological study failed to identify a clear precipitating factor underlying the process. Treatment with corticoids was established, with good clinical and radiological progression. Conclusions. APMPPE is an infrequent condition that generally has a good prognosis. In some cases, however, complications may arise owing to involvement of the central nervous system, and ischaemic stroke secondary to vasculitis is the most severe complication. In young patients with stroke who present visual symptoms and chorioretinital lesions, APMPPE must be considered in the aetiological diagnosis (AU)

[Acute posterior multifocal placoid pigment epitheliopathy. A rare cause of ischaemic stroke]. / Epiteliopatía pigmentaria placoide multifocal posterior aguda. Una rara causa de ictus isquémico.

INTRODUCTION: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory disease, generally of unknown aetiology, affecting the choriocapillaris, the pigment epithelium and the outer retina. It predominantly affects young patients and in some cases may involve the central nervous system in the form of strokes or meningoencephalitis. We report the clinical case of a young female with APMPPE that was complicated by stroke and intracranial hypertension. CASE REPORT: Our patient was a 16-year-old female who began with intense headaches suggesting intracranial hyper-tension, as well as with an acute deficit in the left hemisphere. A magnetic resonance scan of the head revealed embolic or vasculitic lesions in different territories. No evidence of meningoencephalitis was found in the cerebrospinal fluid analysis, but signs of associated intracranial hypertension were observed. The presence of very specific lesions in the posterior pole of the eye led to a diagnosis of APMPPE complicated by ischaemic stroke, probably caused by a vasculitic mechanism. An extensive aetiological study failed to identify a clear precipitating factor underlying the process. Treatment with corticoids was established, with good clinical and radiological progression. CONCLUSIONS: APMPPE is an infrequent condition that generally has a good prognosis. In some cases, however, complications may arise owing to involvement of the central nervous system, and ischaemic stroke secondary to vasculitis is the most severe complication. In young patients with stroke who present visual symptoms and chorioretinital lesions, APMPPE must be considered in the aetiological diagnosis.

TITLE: Epiteliopatia pigmentaria placoide multifocal posterior aguda. Una rara causa de ictus isquemico.Introduccion. La epiteliopatia pigmentaria placoide multifocal posterior aguda (EPPMPA) es una enfermedad inflamatoria rara, generalmente de etiologia indeterminada, de la coriocapilar, el epitelio pigmentario y la retina externa. Afecta predominantemente a pacientes jovenes y en algunos casos puede involucrar al sistema nervioso central en forma de ictus o de meningoencefalitis. Presentamos el caso clinico de una mujer joven con EPPMPA complicada con ictus e hipertension intracraneal. Caso clinico. Mujer de 16 anos que comienza con cefalea intensa sugestiva de hipertension intracraneal, asi como con un deficit agudo hemisferico izquierdo. La resonancia magnetica craneal ponia de manifiesto lesiones embolicas o vasculiticas en diferentes territorios. No se evidenciaron datos de meningoencefalitis en el estudio del liquido cefalorraquideo, pero si de hipertension intracraneal asociada. La presencia de lesiones muy especificas en el polo ocular posterior permitio el diagnostico de EPPMPA complicada con ictus isquemico, probablemente por mecanismo vasculitico. Un amplio estudio etiologico fue negativo para identificar un factor desencadenante claro del proceso. Se inicio tratamiento corticoideo con buena evolucion clinica y radiologica. Conclusiones. La EPPMPA es una entidad rara que generalmente entrana buen pronostico; sin embargo, en algunos casos puede complicarse con afectacion del sistema nervioso central, y el ictus isquemico secundario a vasculitis es la complicacion mas grave. Ante un paciente joven con ictus que presente sintomatologia visual y lesiones coriorretinianas, debe considerarse la EPPMPA en su diagnostico etiologico.