Indicadores de calidad asistencial de GeSIDA para la atención de personas infectadas por el VIH/sida asociados a mortalidad e ingreso hospitalario / GeSIDA quality care indicators associated with mortality and hospital admission for the care of persons infected by HIV/AIDS

INTRODUCCIÓN: En 2010 el Grupo Español de Estudio de SIDA (GeSIDA) desarrolló 66 indicadores de calidad asistencial. Nuestro objetivo es determinar cuáles de estos indicadores se asocian a mortalidad y/o ingreso, y realizar una evaluación preliminar de la utilidad de un índice predictor de mortalidad e ingreso. MÉTODOS: Estudio de cohortes retrospectivo realizado en el Hospital Universitario Son Espases. Los pacientes con infección por el virus de la inmunodeficiencia humana incluidos fueron aquellos que iniciaron seguimiento en consultas entre el 1 de enero de2000 y el 31 de diciembre de 2012. Se realizó análisis descriptivo de las variables demográficas y de los indicadores, y un estudio de regresión logística para valorar la asociación entre los indicadores y riesgo de mortalidad/ingreso. Se calcularon índices predictores de mortalidad e ingreso para pacientes en seguimiento y en tratamiento. RESULTADOS: Fueron incluidos 1.944 pacientes (media de edad: 37 años, el 78,8% varones). En el análisis multivariante relativo a mortalidad, los indicadores asociados en pacientes en seguimiento fueron el 7, 16 y 20 y en pacientes en tratamiento se añaden el 35 y 38. En el análisis multivariante relativo a ingreso, los indicadores asociados en pacientes en seguimiento fueron los mismos que para mortalidad, además del 31, y en el grupo de pacientes en tratamiento se asociaban los indicadores 7, 16, 20, 35, 38 y 40. CONCLUSIÓN: Se han identificado varios indicadores de calidad que pueden estar relacionados con ingreso hospitalario y mortalidad. Estos indicadores hacen referencia fundamentalmente al retraso diagnóstico, seguimiento regular, prevención de las infecciones y control de comorbilidades

INTRODUCTION: In 2010, the AIDS Study Group (Grupo de Estudio del SIDA [GESIDA]) developed 66 quality care indicators. The aim of this study is to determine which of these indicators are associated with mortality and hospital admission, and to perform a preliminary assessment of a prediction rule for mortality and hospital admission in patients on treatment and follow-up. METHODS: A retrospective cohort study was conducted in the Hospital Universitario Son Espases (Palma de Mallorca, Spain). Eligible participants were patients with human immunodeficiency syndrome≥18 years old who began follow-up in the Infectious Disease Section between 1 January 2000 and 31 December 2012. A descriptive analysis was performed to evaluate anthropometric variables, and a logistic regression analysis to assess the association between GESIDA indicators and mortality/admission. The mortality probability model was built using logistic regression. RESULTS: A total of 1,944 adults were eligible (median age: 37 years old, 78.8% male). In the multivariate analysis, the quality of care indicators associated with mortality in the follow-up patient group were the items 7, 16 and 20, and in the group of patients on treatment were 7, 16, 20, 35, and 38. The quality of care indicators associated with hospital admissions in the follow-up patients group were the same as those in the mortality analysis, plus number 31. In the treatment group the associated quality of care indicators were items 7, 16, 20, 35, 38, and 40. CONCLUSIONS: Some GeSIDA quality of care indicators were associated with mortality and/or hospital admissions. These indicators are associated with delayed diagnosis, regular monitoring, prevention of infections, and control of comorbidities

[GeSIDA quality care indicators associated with mortality and hospital admission for the care of persons infected by HIV/AIDS]. / Indicadores de calidad asistencial de GeSIDA para la atención de personas infectadas por el VIH/sida asociados a mortalidad e ingreso hospitalario.

INTRODUCTION: In 2010, the AIDS Study Group (Grupo de Estudio del SIDA [GESIDA]) developed 66 quality care indicators. The aim of this study is to determine which of these indicators are associated with mortality and hospital admission, and to perform a preliminary assessment of a prediction rule for mortality and hospital admission in patients on treatment and follow-up. METHODS: A retrospective cohort study was conducted in the Hospital Universitario Son Espases (Palma de Mallorca, Spain). Eligible participants were patients with human immunodeficiency syndrome≥18 years old who began follow-up in the Infectious Disease Section between 1 January 2000 and 31 December 2012. A descriptive analysis was performed to evaluate anthropometric variables, and a logistic regression analysis to assess the association between GESIDA indicators and mortality/admission. The mortality probability model was built using logistic regression. RESULTS: A total of 1,944 adults were eligible (median age: 37 years old, 78.8% male). In the multivariate analysis, the quality of care indicators associated with mortality in the follow-up patient group were the items 7, 16 and 20, and in the group of patients on treatment were 7, 16, 20, 35, and 38. The quality of care indicators associated with hospital admissions in the follow-up patients group were the same as those in the mortality analysis, plus number 31. In the treatment group the associated quality of care indicators were items 7, 16, 20, 35, 38, and 40. CONCLUSIONS: Some GeSIDA quality of care indicators were associated with mortality and/or hospital admissions. These indicators are associated with delayed diagnosis, regular monitoring, prevention of infections, and control of comorbidities.

Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH / Programs for optimizing the use of antibiotics (PROA) in Spanish hospitals: GEIH-SEIMC, SEFH and SEMPSPH consensus document

Los antimicrobianos son fármacos distintos al resto. Su eficacia en la reducción de la morbilidad y la mortalidad es muy superior a la de otros grupos de medicamentos. Por otra parte, son los únicos fármacos con efectos ecológicos, de manera que su administración puede contribuir a la aparición y diseminación de resistencias microbianas. Finalmente, son utilizados por médicos de prácticamente todas las especialidades. La actual complejidad en el manejo de las enfermedades infecciosas y del aumento de las resistencias hace imprescindible el establecimiento de programas de optimización del uso de antimicrobianos en los hospitales (PROA).Este documento de consenso define los objetivos de los PROA (mejorar los resultados clínicos de los pacientes con infecciones, minimizar los efectos adversos asociados a la utilización de antimicrobianos, incluyendo aquí las resistencias, y garantizar la utilización de tratamientos coste-eficaces) y establece recomendaciones para su implantación en los hospitales españoles. Las líneas maestras de las recomendaciones son: la constitución de un equipo multidisciplinario de antibióticos, dependiente de la Comisión de Infecciones. Los PROA necesitan ser considerados programas institucionales de los hospitales donde se desarrollen. Deben incluir objetivos específicos y resultados cuantificables en función de indicadores, y basarse en la realización de actividades encaminadas a mejorar el uso de antimicrobianos, principalmente mediante actividades formativas y medidas no impositivas de ayuda a la prescripción (AU)

The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary. This consensus document defines the objectives of the PROA (namely, to improve the clinical results of patients with infections, to minimise the adverse events associated to the use of antimicrobials including the emergence and spread of antibiotic resistance, and to ensure the use of the most cost-efficacious treatments), and provides recommendations for the implementation of these programs in Spanish hospitals. The key aspects of the recommendations are as follows. Multidisciplinary antibiotic teams should be formed, under the auspices of the Infection Committees. The PROA need to be considered as part of institutional programs and the strategic objectives of the hospital. The PROA should include specific objectives based on measurable indicators, and activities aimed at improving the use of antimicrobials, mainly through educational activities and interventions based more on training activities directed to prescribers than just on restrictive measures (AU)

[Programs for optimizing the use of antibiotics (PROA) in Spanish hospitals: GEIH-SEIMC, SEFH and SEMPSPH consensus document]. / Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH.

The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary. This consensus document defines the objectives of the PROA (namely, to improve the clinical results of patients with infections, to minimise the adverse events associated to the use of antimicrobials including the emergence and spread of antibiotic resistance, and to ensure the use of the most cost-efficacious treatments), and provides recommendations for the implementation of these programs in Spanish hospitals. The key aspects of the recommendations are as follows. Multidisciplinary antibiotic teams should be formed, under the auspices of the Infection Committees. The PROA need to be considered as part of institutional programs and the strategic objectives of the hospital. The PROA should include specific objectives based on measurable indicators, and activities aimed at improving the use of antimicrobials, mainly through educational activities and interventions based more on training activities directed to prescribers than just on restrictive measures.

Sífilis e infección por el virus de la inmunodeficiencia humana / Syphilis and HIV infection

La sífilis y la infección por el virus de la inmunodeficiencia humana (VIH) son enfermedades de transmisión sexual (ETS) que afectan a colectivos con prácticas de riesgo similares, por lo que la coinfección no es rara. Recientemente se han documentado brotes de sífilis en varones jóvenes homosexuales con infección por el VIH, lo que tiene trascendencia clínica y epidemiológica. Al igual que ocurre con otras ETS, la sífilis facilita la transmisión del VIH, por lo que los brotes referidos podrían conducir a un incremento de la incidencia de infección por el VIH. La presentación clínica, el diagnóstico serológico y el tratamiento de la sífilis tienen una serie de peculiaridades en los pacientes VIH positivos. Otro aspecto importante a tener en cuenta es el posible impacto que la sífilis puede ejercer en la infección por el VIH; además, se ha descrito un descenso de los linfocitos CD4 y un incremento de la carga viral en estos pacientes

Because syphilis and HIV infections are both sexually transmitted diseases (STD) that affect collectives with similar risk behaviors, coinfection is not unusual. Recent outbreaks of syphilis among HIV-infected men who have sex with men have been reported, with epidemiological and clinical importance. Like other STD, syphilis facilitates HIV transmission, and therefore these syphilis epidemics have generated concerns about potential increases in the incidence of HIV. Clinical features, serological diagnosis, and the therapeutic management of syphilis present certain peculiarities in HIV-infected individuals. Another important issue is the possible impact of syphilis on HIV infection; recent reports have described a decrease in CD4 cell count and an increase in HIV viral load in coinfected patients

[Clinical use of HIV-1 resistance genotyping. Predictive factors of poor virological evolution in salvage treatments]. / Utilización en la práctica clínica de los tests de resistencia genotípica al VIH-1. Factores predictivos de mala evolución virológica en tratamientos de rescate.

OBJECTIVES: To describe the use of genotype resistance testing (GRT) for virological failure in clinical practice, and the long-term clinical and virological evolution in patients for whom it is requested. To identify the predictive factors of virological failure in patients with antiretroviral (ARV) salvage therapy. METHODS: Observational study in HIV-infected patients for whom GRT was requested for virological failure (VF) in the period of 1 October 1999 to 31 December 2001. Logistic regression analysis was used to determine the predictive factors of virological progression. RESULTS: Over the period studied, 196 patients required GRT for VF (15%) among those monitored in specific units. GRT was mainly requested for patients who had been extensively pretreated for a mean of 5 years and with a median of 5 ARV combinations. Half the patients presented 3 or more mutations associated with thymidine analogs (TAMs), mutations associated with non-nucleoside analogs (NNRTIs), and 5 or more mutations associated with protease inhibitors (PIs). In 143 (74%) patients, the RTV regimen was changed on the basis of GRT results. In the intent-to-treat analysis, the percentage of patients with plasma VL < 400 cop/mL at 6, 12 and 18 months was 41%, 29% and 17%, respectively. In the on-treatment analysis, the results were 50%, 48% and 46%, respectively. Mean CD4 lymphocyte increase was 59.74 and 94 cells/mm 3. The variables predicting virological failure (plasma VL > 400 cop/mL) at 12 months were plasma VL > 30,000 cop/mL (OR 6, 1.8-19.5) and accumulation of 3 or more TAMs (OR 4.4, 1.3-15) at the start of ARV salvage therapy. CONCLUSION: Even though in clinical practice GRT is requested for patients with various treatment failures, when ART salvage treatment was started, plasma VL was undetectable and immunological response persisted in 40% of patients followed-up for 18 months. The factors best predicting virological evolution were VL and the number of baseline TAMs.

Utilización en la práctica clínica de los tests de resistencia genotípica al VIH-1. Factores predictivos de mala evolución virológica en tratamientos de rescate / Clinical use of HIV-1 resistance genotyping. Predictive factors of poor virological evolution in salvage treatments

Objetivos. Describir la utilización de los tests de resistencia genotípica (TRG) por fracaso virológico en la práctica clínica y la evolución clínica y virológica a largo plazo de los pacientes en los que se solicitaron. Establecer los factores predictivos de fracaso virológico con tratamientos antirretrovirales (TARV) de rescate. Métodos. Estudio observacional de los pacientes con infección por el virus de la inmunodeficiencia humana (VIH) a los que se solicitó TRG por fracaso virológico (FV) en el período comprendido entre el 1/10/1999 y 31/12/2001. Se determinaron los factores predictivos de mala evolución virológica mediante un análisis de regresión logística. Resultados. En el período de estudio, 196 pacientes precisaron TRG por FV (15%) de los seguidos en unas consultas específicas. Los TRG se solicitaron mayoritariamente a pacientes extensamente pretratados, con una media de 5 años y una mediana de cinco combinaciones TARV. La mitad de los pacientes presentaban tres o más mutaciones asociadas a análogos de la timidina (TAM), alguna mutación asociada a análogos no nucleósidos (ANNTI) y cinco o más mutaciones asociadas a inhibidores de proteasas (IP). En 143 (74%) se realizó un cambio de TARV en base al TRG recibido. En el análisis por intención de tratar, el porcentaje de pacientes con carga viral (CV) plasmática 400 cop./ml a los 12 meses, fueron tener una CV > 30.000 cop./ml odds ratio (OR) 6 (1,8-19,5) y haber acumulado tres o más TAM OR 4,4 (1,3-15) al iniciar el TARV de rescate. Conclusión. A pesar de que los TRG se solicitan en la práctica clínica en pacientes en multifracaso, al instaurar TARV de rescate se consiguen mantener la CV plasmática indetectables en el 40% de los pacientes en seguimiento a los 18 meses y con una respuesta inmunológica mantenida. Los factores que mejor predicen la evolución virológica son la CV plasmática y el número de TAMbasales (AU)

Objectives. To describe the use of genotype resistance testing (GRT) for virological failure in clinical practice, and the long-term clinical and virological evolution in patients for whom it is requested. To identify the predictive factors of virological failure in patients with antiretroviral (ARV) salvage therapy. Methods. Observational study in HIV-infected patients for whom GRT was requested for virological failure (VF) in the period of 1 October 1999 to 31 December 2001. Logistic regression analysis was used to determine the predictive factors of virological progression. Results. Over the period studied, 196 patients required GRT for VF (15%) among those monitored in specific units. GRT was mainly requested for patients who had been extensively pretreated for a mean of 5 years and with a median of 5 ARV combinations. Half the patients presented 3 or more mutations associated with thymidine analogs (TAMs), mutations associated with non-nucleoside analogs (NNRTIs), and 5 or more mutations associated with protease inhibitors (PIs). In 143 (74%) patients, the RTV regimen was changed on the basis of GRT results. In the intent-to-treat analysis, the percentage of patients with plasma VL 400 cop/mL) at 12 months were plasma VL > 30,000 cop/mL (OR 6, 1.8-19.5) and accumulation of 3 or more TAMs (OR 4.4, 1.3-15) at the start of ARV salvage therapy. Conclusion. Even though in clinical practice GRT is requested for patients with various treatment failures, when ART salvage treatment was started, plasma VL was undetectable and immunological response persisted in 40% of patients followed-up for 18 months. The factors best predicting virological evolution were VL and the number of baseline TAMs (AU)