Evolving mortality and clinical outcomes of hospitalized subjects during successive COVID-19 waves in Catalonia, Spain.

BACKGROUND: The changes in shield strategies, treatments, emergence variants, and healthcare pathways might shift the profile and outcome of patients hospitalized with COVID-19 in successive waves of the outbreak. METHODS: We retrospectively analysed the characteristics and in-hospital outcomes of all patients admitted with COVID-19 in eight university hospitals of Catalonia (North-East Spain) between Feb 28, 2020 and Feb 28, 2021. Using a 7-joinpoint regression analysis, we split admissions into four waves. The main hospital outcomes included 30-day mortality and admission to intensive care unit (ICU). FINDINGS: The analysis included 17,027 subjects admitted during the first wave (6800; 39.9%), summer wave (1807; 10.6%), second wave (3804; 22.3%), and third wave (4616; 27.1%). The highest 30-day mortality rate was reported during the first wave (17%) and decreased afterwards, remaining stable at 13% in the second and third waves (overall 30% reduction); the lowest mortality was reported during the summer wave (8%, 50% reduction). ICU admission became progressively more frequent during successive waves. In Cox regression analysis, the main factors contributing to differences in 30-day mortality were the epidemic wave, followed by gender, age, diabetes, chronic kidney disease, and neoplasms. INTERPRETATION: Although in-hospital COVID-19 mortality remains high, it decreased substantially after the first wave and is highly dependent of patient's characteristics and ICU availability. Highest mortality reductions occurred during a wave characterized by younger individuals, an increasingly frequent scenario as vaccination campaigns progress. FUNDING: This work did not receive specific funding.

Infectious diseases experts as part of the antibiotic stewardship team in primary care: protocol for a cluster-randomised blinded study (IDASP).

INTRODUCTION: Antibiotic overuse is directly related to antibiotic resistance, and primary care is one of the main reasons for this overuse. This study aims to demonstrate that including experts on infectious diseases (ID) within the antimicrobial stewardship (AMS) programme team in primary care settings achieves higher reductions in overall antibiotic consumption and increases the quality of prescription. METHODS AND ANALYSIS: A multicentre, cluster-randomised, blinded clinical trial will be conducted between 2021 and 2023. Six primary care centres will be randomly assigned to an advanced or a standard AMS programme. The advanced AMS programme will consist of a standard AMS programme combined with the possibility that general practitioners (GP) will discuss patients' therapies with ID experts telephonically during working days and biweekly meetings. The main endpoint will be overall antibiotic consumption, defined as daily defined dose per 1000 inhabitants per day (DHD). Secondary end-points will be: (1) unnecessary antibiotic prescriptions in patients diagnosed with upper respiratory tract or urinary tract infection, (2) adequacy of antibiotic prescription, (3) reattendance to GP or emergency room within 30 days after the initial GP visit and (4) hospital admissions for any reason within 30 days after the GP visit. Two secondary endpoints (unnecessary antibiotic therapy and adequacy of therapy) will be evaluated by blinded investigators.We will select three clusters (centres) per arm (coverage of 147 644 inhabitants) which will allow the rejection of the null hypothesis of equal consumption with a power of 80%, assuming a moderate intracluster correlation of 0.2, an intracluster variance of 4 and a mean difference of 1 DHD. The type I error will be set at 5%. ETHICS AND DISSEMINATION: The protocol was reviewed and approved by local ethics committees. The results of this study will be published in peer-reviewed journals and presented at medical conferences. TRIAL REGISTRATION NUMBER: NCT04848883.

Current outcomes and predictors of treatment failure in patients with surgical site infection after elective colorectal surgery. A multicentre prospective cohort study.

OBJECTIVE: To determine current outcomes and predictors of treatment failure among patients with surgical site infection (SSI) after colorectal surgery. METHODS: A multicentre observational prospective cohort study of adults undergoing elective colorectal surgery in 10 Spanish hospitals (2011-2014). Treatment failure was defined as persistence of signs/symptoms of SSI or death at 30 days post-surgery. RESULTS: Of 3701 patients, 669 (18.1%) developed SSI; 336 (9.1%) were organ-space infections. Among patients with organ-space SSI, 81.2% required source control: 60.4% reoperation and 20.8% percutaneous/transrectal drainage. Overall treatment failure rate was 21.7%: 9% in incisional SSIs and 34.2% in organ-space SSIs (p < 0.001). Median length of stay was 15 days (IQR 9-22) for incisional SSIs and 24 days (IQR 17-35) for organ-space SSIs (p < 0.001). One hundred and twenty-seven patients (19%) required readmission and 35 patients died (5.2%). Risk factors for treatment failure among patients with organ-space SSI were age ≥65 years (OR 1.83, 95% CI: 1.07-1.83), laparoscopy (OR 1.7, 95% CI: 1.06-2.77), and reoperation (OR 2.8, 95% CI: 1.7-4.6). CONCLUSIONS: Rates of SSI and treatment failure in organ-space SSI after elective colorectal surgery are notably high. Careful attention should be paid to older patients with previous laparoscopy requiring reoperation for organ-space SSI, so that treatment failure can be identified early.

[Treatment of neuropathic pain in HIV-infected patients]. / Tratamiento del dolor neuropático en el enfermo con infección por el VIH.

Neuropathic pain of various etiologies is a frequent symptom in HIV-infected patients that is underdiagnosed and inadequately treated. It requires a multidisciplinary pain approach based on psychosocial factors, diet and exercise, etiologic treatment whenever possible, symptomatic medical treatment, and sometimes, interventional techniques. Medical treatment should be individualized and introduced gradually, with a mind to potential drug interactions. Neuropathic pain responds poorly to conventional analgesics, such as nonsteroidal antiinflammatory drugs and opiates; tricyclic antidepressants and anticonvulsants are the drugs of choice. Before establishing an analgesic treatment, possible drug interactions should be ruled out, mainly those occurring with antiretroviral agents.

Tratamiento del dolor neuropático en el enfermo con infección por el VIH / Treatment of neuropathic pain in HIV-infected patients

El dolor neuropático en los pacientes con infección por VIH es un síntoma frecuente y de etiología múltiple que suele estar infradiagnosticado e infratratado. Exige un abordaje multidisciplinario e individualizado. Debemos hacer un tratamiento combinado del dolor basado en aspectos psicosociales, dieta y ejercicio, también tratamiento etiológico siempre que sea posible y tratamiento farmacológico sintomático e incluso recurrir a técnicas intervencionistas. El tratamiento farmacológico del dolor neuropático debe de ser individualizado y escalonado, teniendo en cuenta las posibles interacciones medicamentosas, sobre todo en los enfermos con VIH que reciben habitualmente mucha medicación de forma simultánea. Responde mal a los analgésicos convencionales como los antiinflamatorios no esteroideos y los opioides, y son los antidepresivos tricíclicos y los anticomiciales los fármacos de elección. Antes de instaurar un tratamiento analgésico hay que descartar las posibles interacciones medicamentosas, fundamentalmente con los antirretrovirales (AU)

Neuropathic pain of various etiologies is a frequent symptom in HIV-infected patients that is underdiagnosed and inadequately treated. It requires a multidisciplinary pain approach based on psychosocial factors, diet and exercise, etiologic treatment whenever possible, symptomatic medical treatment, and sometimes, interventional techniques. Medical treatment should be individualized and introduced gradually, with a mind to potential drug interactions. Neuropathic pain responds poorly to conventional analgesics, such as nonsteroidalanti inflammatory drugs and opiates; tricyclic antidepressants and anticonvulsants are the drugs of choice. Before establishing an analgesic treatment, possible drug interactions should be ruled out, mainly those occurring with antiretroviral agents (AU)

Less lipoatrophy and better lipid profile with abacavir as compared to stavudine: 96-week results of a randomized study.

OBJECTIVE: To assess lipoatrophy, other toxicities, and efficacy associated with abacavir as compared with stavudine in HIV-infected antiretroviral-naive patients. METHODS: This was a prospective, randomized, open trial, stratified by viral load and CD4 cell count, conducted January 2001 to July 2004. Two hundred thirty-seven adult patients with HIV infection initiating antiretroviral therapy were assigned to receive abacavir (n = 115) or stavudine (n = 122), both combined with lamivudine and efavirenz. The primary endpoint was the proportion of patients with lipoatrophy as assessed by physician and patient observation at 96 weeks. RESULTS: A lower proportion of patients assigned to abacavir developed clinical signs of lipoatrophy (4.8% vs. 38.3%; P < 0.001). These observations were confirmed by anthropometric data. Dual energy x-ray absorptiometry (DEXA) scans performed in 57 patients showed significantly greater total limb fat loss in the stavudine arm (-1579 vs. 913 g; P < 0.001). The lipid profile in abacavir patients presented more favorable changes in the levels of triglycerides (P = 0.03), high-density lipoprotein cholesterol (HDLc; P < 0.001), and apolipoprotein A1 (P < 0.001) as well as in the ratio between total cholesterol and HDLc (P = 0.005). Throughout the study, a higher proportion of patients in the stavudine group received lipid-lowering agents as compared to the abacavir group (17% vs. 4%; P = 0.002). Similar virologic and immunologic responses were observed. CONCLUSIONS: Assuming the limitations inherent to clinical assessment, this study shows a notably weaker association of abacavir with lipoatrophy than stavudine. DEXA scans and anthropometric measurements supported the clinical findings. In addition, the lipid changes that occurred were more favorable in patients receiving abacavir.

Hemorragia subaracnoidea temporal izquierda producida por introducción de cuerpo extraño metálico [Imagen de la semana] / Left temporal subaracnoid hemorrhage due to a metalic foreign body [Weekly image]

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Infección por virus respiratorio sincitial en adultos ingresados por neumonía adquirida en la Comunidad / Respiratory syncytial virus infection in adults patients hospitalized with community-acquired pneumonia

Fundamento: Determinar la incidencia y distribución de la infección por el virus respiratorio sincitial en adultos ingresados por neumonía de la comunidad. Pacientes y métodos: Pacientes adultos no inmunodeprimidos, ingresados por neumonía de la comunidad en nuestro centro y estudiados de forma prospectiva. Como parte del protocolo diagnóstico, se realizaron serologías para virus respiratorio sincitial, con sueros de la fase aguda y de convalescencia, a los pacientes ingresados entre febrero de 1995 y mayo de 1997, y se compararon las características clínicas y epidemiológicas de los pacientes con y sin criterios serológicos de infección aguda por el virus respiratorio sincitial. Resultados: Se realizaron serologías en pareado para el virus respiratorio sincitial en 250 pacientes ingresados por neumonía de la comunidad. En la mayoría de ellos (97 por ciento) se detectó la presencia de anticuerpos IgG, pero sólo 17 pacientes (6,8 por ciento) tuvieron evidencia serológica de infección aguda, seroconversión en ocho e IgM positiva en nueve. Catorce pacientes (82 por ciento) con infección aguda ingresaron entre noviembre y mayo. Tres pacientes fueron diagnosticados de neumonía neumocócica, dos de neumonía por Legionella pneumophila y 12 de neumonía no filiada. No se observaron diferencias clínicas entre los pacientes con y sin infección aguda por el virus respiratorio sincitial, aunque aquellos con infección aguda presentaron afectación pulmonar bilateral con mayor frecuencia y entre ellos hubo una mayor proporción de neumonías no filiadas. Conclusiones: El virus respiratorio sincitial es causa de infección aguda entre los pacientes adultos ingresados por neumonía de la comunidad en nuestro medio, fundamentalmente entre los meses de noviembre y mayo. Deberían realizarse estudios dirigidos a dilucidar su papel como agente productor de neumonía en esta población (AU)