Impact of Aspergillus spp. isolation in the first 24 hours of admission in critically ill patients with severe influenza virus pneumonia / Impacto del aislamiento de Aspergillus spp. en las primeras 24h de ingreso en pacientes críticos con neumonía grave por el virus influenza

Objective To determine the incidence and impact of Aspergillus spp. isolation (AI) on ICU mortality in critically ill patients with severe influenza pneumonia during the first 24h of admission. Design Secondary analysis of an observational and prospective cohort study. Setting ICUs voluntary participating in the Spanish severe Influenza pneumonia registry, between June 2009 and June 2019. Patients Consecutive patients admitted to the ICU with diagnosis of severe influenza pneumonia, confirmed by real-time polymerase chain reaction. Interventions None. Main variables of interest Incidence of AI in respiratory samples. Demographic variables, comorbidities, need for mechanical ventilation and the presence of shock according at admission. Acute Physiology and Chronic Health Evaluation II (APACHE II) scale calculated on ICU admission. Results 3702 patients were analyzed in this study. AI incidence was 1.13% (n=42). Hematological malignancies (OR 4.39, 95% CI 1.92–10.04); HIV (OR 3.83, 95% CI 1.08–13.63), and other immunosuppression situations (OR 4.87, 95% CI 1.99–11.87) were factors independently associated with the presence of Aspergillus spp. The automatic CHAID decision tree showed that hematologic disease with an incidence of 3.3% was the most closely AI related variable. Hematological disease (OR 2.62 95% CI 1.95–3.51), immunosuppression (OR 2.05 95% CI 1.46–2.88) and AI (OR 3.24, 95% CI 1.60–6.53) were variables independently associated with ICU mortality. Conclusions Empirical antifungal treatment in our population may only be justified in immunocompromised patients. In moderate-high risk cases, active search for Aspergillus spp. should be implemented (AU)

Objetivo Determinar la incidencia y el impacto sobre la mortalidad del aislamiento de Aspergillus spp. (AI) en paciente críticos con neumonía por influenza en las primeras 24h de ingreso. Diseño Análisis secundario de estudio de cohortes observacional y prospectivo. Ámbito Unidades de cuidados intensivos (UCI) participantes de forma voluntaria en el registro español de neumonía por influenza grave, desde junio de 2009 hasta junio de 2019. Pacientes Pacientes consecutivos con diagnóstico de neumonía grave por influenza, confirmado por prueba de reacción en cadena de la polimerasa. Intervenciones Ninguna. Variables principales Incidencia de AI. Variables demográficas, comorbilidades, necesidad de ventilación mecánica y presencia de shock al ingreso. APACHE II. Resultados Se analizaron 3.702 pacientes. La incidencia de AI fue del 1,13% (n=42). Las neoplasias hematológicas (OR: 4,39; IC 95%: 1,92-10,04); VIH (OR: 3,83; IC 95%: 1,08-13,63) y otras situaciones de inmunosupresión (OR: 4,87; IC 95%: 1,99-11,87) fueron variables que se asociaron de forma independiente con AI. El árbol de decisión de CHAID mostró que la variable neoplasias hematológicas era la más relacionada con la variable Aspergillus spp. con una incidencia del 3,3%. Neoplasias hematológicas (OR: 2,62; IC 95%: 1,95-3,51), inmunosupresión (OR: 2,05; IC 95%: 1,46-2,88) y AI (OR: 3,24; IC 95%: 1,60-6,53) se asociaron de forma independiente con mayor mortalidad en la UCI. Conclusiones El tratamiento antifúngico empírico en nuestra población estaría justificado en los pacientes con inmunosupresión. En los pacientes con riesgo moderado-grave, la búsqueda activa de Aspergillus spp. debería implementarse (AU)

Impact of Aspergillus spp. isolation in the first 24 hours of admission in critically ill patients with severe influenza virus pneumonia.

OBJECTIVE: To determine the incidence and impact of Aspergillus spp. isolation (AI) on ICU mortality in critically ill patients with severe influenza pneumonia during the first 24h of admission. DESIGN: Secondary analysis of an observational and prospective cohort study. SETTING: ICUs voluntary participating in the Spanish severe Influenza pneumonia registry, between June 2009 and June 2019. PATIENTS: Consecutive patients admitted to the ICU with diagnosis of severe influenza pneumonia, confirmed by real-time polymerase chain reaction. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Incidence of AI in respiratory samples. Demographic variables, comorbidities, need for mechanical ventilation and the presence of shock according at admission. Acute Physiology and Chronic Health Evaluation II (APACHE II) scale calculated on ICU admission. RESULTS: 3702 patients were analyzed in this study. AI incidence was 1.13% (n=42). Hematological malignancies (OR 4.39, 95% CI 1.92-10.04); HIV (OR 3.83, 95% CI 1.08-13.63), and other immunosuppression situations (OR 4.87, 95% CI 1.99-11.87) were factors independently associated with the presence of Aspergillus spp. The automatic CHAID decision tree showed that hematologic disease with an incidence of 3.3% was the most closely AI related variable. Hematological disease (OR 2.62 95% CI 1.95-3.51), immunosuppression (OR 2.05 95% CI 1.46-2.88) and AI (OR 3.24, 95% CI 1.60-6.53) were variables independently associated with ICU mortality. CONCLUSIONS: Empirical antifungal treatment in our population may only be justified in immunocompromised patients. In moderate-high risk cases, active search for Aspergillus spp. should be implemented.

Serotypes and Clonal Composition of Streptococcus pneumoniae Isolates Causing IPD in Children and Adults in Catalonia before 2013 to 2015 and after 2017 to 2019 Systematic Introduction of PCV13.

The goal of this study was to investigate the distribution of serotypes and clonal composition of Streptococcus pneumoniae isolates causing invasive pneumococcal disease (IPD) in Catalonia, before and after systematic introduction of PCV13. Pneumococcal strains isolated from normally sterile sites obtained from patients of all ages with IPD received between 2013 and 2019 from 25 health centers of Catalonia were included. Two study periods were defined: presystematic vaccination period (2013 and 2015) and systematic vaccination period (SVP) (2017 to 2019). A total of 2,303 isolates were analyzed. In the SVP, there was a significant decrease in the incidence of IPD cases in children 5 to 17 years old (relative risk [RR] 0.61; 95% confidence interval [CI] 0.38 to 0.99), while there was a significant increase in the incidence of IPD cases in 18- to 64-year-old adults (RR 1.33; 95% CI 1.16 to 1.52) and adults over 65 years old (RR 1.23; 95% CI 1.09 to 1.38). Serotype 8 was the major emerging serotype in all age groups except in 5- to 17-year-old children. In children younger than 5 years old, the main serotypes in SVP were 24F, 15A, and 3, while in adults older than 65 years they were serotypes 3, 8, and 12F. A significant decrease in the proportions of clonal complexes CC156, CC191, and ST306 and an increase in those of CC180, CC53, and CC404 were observed. A steady decrease in the incidence of IPD caused by PCV13 serotypes indicates the importance and impact of systematic vaccination. The increase of non-PCV13 serotypes highlights the need to expand serotype coverage in future vaccines and rethink vaccination programs for older adults. IMPORTANCE We found that with the incorporation of the PCV13 vaccine, the numbers of IPD cases caused by serotypes included in this vaccine decreased in all of the age groups. Still, there was an unforeseen increase of the serotypes not included in this vaccine causing IPD, especially in the >65-year-old group. Moreover, a significant increase of serotype 3 included in the vaccine has been observed; this event has been reported by other researchers. These facts call for the incorporation of more serotypes in future vaccines and a more thorough surveillance of the dynamics of this microorganism.

Incidence and Risk of Pneumococcal Pneumonia in Adults with Distinct Underlying Medical Conditions: A Population-Based Study.

PURPOSE: This study investigated the incidence of pneumococcal pneumonia requiring hospitalisation among middle-aged and older adults with and without specific underlying medical conditions, evaluating the influence of these conditions in the risk of developing pneumonia. METHODS: Population-based prospective cohort study included 2,025,730 individuals ≥ 50 years around Catalonia, Spain. The Catalonian information system for the development of research in primary care (SIDIAP) was used to establish baseline characteristics of the cohort (comorbidities and underlying medical conditions). Hospitalisations from pneumococcal pneumonia occurred among cohort members between 01/01/2015 and 31/12/2015 were collected from hospital discharge codes of 68 reference Catalonian hospitals. Cox regression was used to estimate the association between baseline conditions and the risk of developing pneumonia. RESULTS: Global incidence rate (IR) of hospitalised pneumococcal pneumonia was 82.8 cases per 100,000 persons-year. Maximum IRs (per 100,000 persons-year) emerged among persons with haematological neoplasia (837.4), immunodeficiency (709.2), HIV infection (474.7), severe renal disease (407.5) and chronic pulmonary disease (305.7). In the multivariable analyses, apart from increasing age, HIV infection (hazard ratio [HR] 6.78), haematological neoplasia (HR 6.30), prior all-cause pneumonia (HR 5.27), immunodeficiency (HR 4.57) and chronic pulmonary disease (HR 2.89) were the conditions most strongly associated with an increasing risk. Pneumococcal vaccination did not emerge associated with a reduced risk in our study population (nor PPsV23 neither PCV13). CONCLUSION: Old age, immunocompromising conditions and chronic pulmonary/respiratory disease are major risk factors for pneumococcal pneumonia in adults. Our data underline the need for better prevention strategies in these persons.

A severe case of persistent diarrhoea associated with Arcobacter cryaerophilus but attributed to Campylobacter sp. and a review of the clinical incidence of Arcobacter spp.

Although rarely, Arcobacter spp. have been associated with diarrhoea and bacteraemia. We report a persistent case in a healthy 26-year-old Spanish male of bloody diarrhoea, which was attributed to Campylobacter but in fact was caused by Arcobacter cryaerophilus, as determined by sequencing of the rpoB gene. The isolate was re-identified by matrix-assisted laser desorption ionization time of flight (MALDI-TOF) and genotyped for five putative virulence genes and for seven genes included in the Arcobacter multilocus sequence typing database. The low score obtained by MALDI-TOF indicates the need to complement the database with more isolates. Only the ciaB gene, which encodes for an invasin, was detected. Despite the isolate belonging to a new sequence type, three of the alleles (glnA, pgm and tkt) had been found previously in isolates from faeces of patients with diarrhoea. This study, together with the reviewed literature, indicates that Arcobacter can produce bacteraemia and that the isolation from patients with diarrhoea range from 0.11% to 1.25%. This study also demonstrates that Arcobacter species are confused with Campylobacter spp., as previously suggested. This is one of the factors that leads to underestimation of their incidence together with the use of inappropriate detection and identification methods.

Incidence of pneumococcal infections among children under 15 years in southern Catalonia throughout the heptavalent conjugate vaccine era, 2002-2009.

PURPOSE: Updating epidemiological studies to document current incidences of pneumococcal diseases are greatly needed in the current era of new pneumococcal conjugate vaccines (PCVs). The aim of this study is to analyze the incidence and distribution of different serotypes causing pneumococcal infections among the pediatric population in southern Catalonia, Spain, throughout the 2002-2009 PCV7 eras. METHODS: A population-based surveillance study was conducted among children aged ≤ 14 years in the region of Tarragona (Catalonia, Spain) during the period 2002-2009. All cases of pneumococcal infections (invasive and non-invasive cases) were included in the study. Incidence rates (per 100,000 population-year) and prevalence of infections caused by serotypes included in different PCV formulations were calculated for the 2002-2005 and 2006-2009 periods. RESULTS: Globally, across the total 2002-2009 period, the incidence of pneumococcal infections was 48.2 per 100,000 children-year (22.4 and 25.8 for invasive and non-invasive infections, respectively). Between 2002-2005 and 2006-2009, the incidence rates largely decreased among children aged <2 years (from 171 to 111 per 100,000 children-year; p = 0.059), but they did not substantially vary among children aged 2-14 years. The percentages of cases caused by serotypes included in PCV7 (60.0 vs. 16.7 %; p < 0.001), PCV10 (75.0 vs. 47.4 %; p = 0.028), and PCV13 (85.0 vs. 70.5 %; p = 0.190) decreased in both periods. CONCLUSION: In this study, which was conducted in a setting with intermediate PCV7 uptakes, a considerable protective direct effect of vaccination occurred among young infants, but an indirect protective effect did not emerge in the rest of the pediatric population. Despite new PCVs with higher serotype coverage, an important proportion of pneumococcal infections is still not covered by these vaccines.

An unusual adverse drug reaction?

INTRODUCTION: Adult Still Disease (ASD) is a rare (incidence 1-1,6/1,000,000 in Europe) seronegative polyarthropathy diagnosed with clinical criteria, excluding other etiologies. Minocycline, a semisynthetic derivative of tetracycline, has been associated with many adverse effects. We present the case of a 18-years-old man with a high suspicion of an adverse drug reaction (ADR), that was finally diagnosed of ASD. MATERIAL AND METHODS: In order to exclude other diseases, laboratory test, radiology and allergological studies were performed. The results of the allergological studies excluded the possibility of an ADR. The rest of the results determined the diagnosis of ASD. CONCLUSION: It's necessary to emphasize the importance of an accurate differential diagnosis in cases like this, because many diseases may mimic an ADR, and may be underdiagnosed (or misdiagnosed).

An unusual adverse drug reaction?

Introduction: Adult Still Disease (ASD) is a rare (incidence 1-1,6/1.000.000 in Europe) seronegative polyarthropathy diagnosed with clinical criteria, excluding other etiologies. Minocycline, a semisynthetic derivative of tetracycline, has been associated with many adverse effects. We present the case of a 18-years-old man with a high suspiction of an adverse drug reaction (ADR), that was finally diagnosed of ASD. Material and methods: In order to exclude other diseases, laboratory test, radiology and allergological studies were performed. The results of the allergological studies excluded the possibility of an ADR. The rest of the results determined the diagnosis of ASD. Conclusion: It's necessary to emphasize the importance of an accurate differential diagnosis in cases like this, because many diseases may mimic an ADR, and may be underdiagnosed (or misdiagnosed)

Introducción: La Enfermedad de Still del Adulto (ESA) es una poliartropatía seronegativa con muy baja incidencia (1-1,6 casos/1.000.000 en Europa). Es de diagnóstico clínico, excluyendo otras patologías. La minociclina es derivado semisintético de la tetraciclina y se ha asociado a efectos adversos muy variados. Presentamos en caso de un varón de 18 años con un diagnóstico de sospecha de reacción adversa a medicamentos (RAM), que fue diagnosticado finalmente de ESA. Material y métodos: Con el fin de excluir otras enfermedades se efectuaron estudios de laboratorio, radiológicos y alergológicos. Por el estudio alergológico se descartó la causa medicamentosa del cuadro clínico. El resto de los resultados determinaron el diagnóstico definitivo de ESA. Conclusión: Es clave un correcto diagnóstico diferencial en casos como este, porque muchas enfermedades pueden simular cuadros de RAM, y pueden pasar inicialmente desapercibidas

Non-pigmenting cutaneous-mucosal fixed drug eruption due to piroxicam.

BACKGROUND: Piroxicam is a widely used anti-inflammatory drug. Most adverse reactions affect gastrointestinal system, liver and skin. Fixed drug eruption although very unusual, has also been described, but with cutaneous involvement exclusively. We present the case of a 49-year-old man who suffered three episodes of fixed drug eruption with cutaneous-mucosal involvement, even simulating an autoimmune disease, whenever he was treated with oral piroxicam. METHODS AND RESULTS: He was patch tested on normal skin with the GEIDC standard series and an NSAIDs series. He was patch tested on normal skin and on fixed eruption with piroxicam, meloxicam and tenoxicam (all of them 1 % pet). Oral challenge test was not performed due to the severity and reproducibility in previous reactions. Results showed a positive patch test to piroxicam (1 % pet) on fixed eruption, with negative results to the rest. CONCLUSIONS: Adverse drug reactions may present a wide variability of clinical symptoms. In these situations an accurate clinical history is necessary. To our knowledge this is the 1st report of non-pigmenting fixed drug eruption with cutaneous-mucosal involvement due to piroxicam. Cross-reactivity between oxicams could not be demonstrated by patch test on fixed eruption.

Non-pigmenting cutaneous-mucosal fixed drug eruption due to piroxicam

Background: Piroxicam is a widely used anti-inflammatory drug. Most adverse reactions affect gastrointestinal system, liver and skin. Fixed drug eruption although very unusual, has also been described, but with cutaneous involvement exclusively. We present the case of a 49-year-old man who suffered three episodes of fixed drug eruption with cutaneous-mucosal involvement, even simulating an autoimmune disease, whenever he was treated with oral piroxicam. Methods and results: He was patch tested on normal skin with the GEIDC standard series and an NSAIDs series. He was patch tested on normal skin and on fixed eruption with piroxicam, meloxicam and tenoxicam (all of them 1 % pet). Oral challenge test was not performed due to the severity and reproducibility in previous reactions. Results showed a positive patch test to piroxicam (1 % pet) on fixed eruption, with negative results to the rest. Conclusions: Adverse drug reactions may present a wide variability of clinical symptoms. In these situations an accurate clinical history is necessary. To our knowledge this is the 1st report of non-pigmenting fixed drug eruption with cutaneous-mucosal involvement due to piroxicam. Cross-reactivity between oxicams could not be demonstrated by patch test on fixed eruption (AU)

Introducción: El piroxicam es un fármaco antiinflamatorio ampliamente utilizado. La mayor parte de las reacciones adversas producidas por él afectan al aparato digestivo, al hígado y a la piel. La erupción fija medicamentosa, con una frecuencia de aparición muy escasa, también se ha descrito, aunque con afectación exclusivamente cutánea. Presentamos el caso de un varón de 49 años que tuvo tres episodios de erupción fija con afectación cutáneo-mucosa, simulando una enfermedad autoinmune, coincidiendo con la administración oral de piroxicam. Material y método: Se realizaron pruebas epicutáneas con la batería estándar del GEIDC y una batería de AINE sobre piel sana. Sobre la erupción fija y también sobre piel sana se aplicaron parches con piroxicam, tenoxicam y meloxicam (todos ellos al 1 per cent vaselina).No se realizó prueba de exposición oral a causa de la gravedad y reproducibilidad de las reacciones previas. Los resultados fueron positivos, de forma exclusiva, con el parche de piroxicam (1 per cent vaselina) sobre la erupción fija. Conclusiones: Las reacciones adversas medicamentosas pueden presentar una amplia variabilidad en sus manifestaciones clínicas. En estas situaciones es necesario realizar una anamnesis muy minuciosa. De acuerdo con la bibliografía existente, este es el primer caso descrito de erupción fija no pigmentaria por piroxicam con afectación cutáneo-mucosa. La reactividad cruzada entre oxicams no pudo demostrarse mediante la aplicación del patch test sobre la erupción fija (AU)

[Noninvasive ventilator support in patients with chronic obstructive pulmonary disease. A comparison of 2 methods]. / Apoyo ventilatorio no invasivo en pacientes con enfermedad pulmonar obstructiva crónica. Comparación de dos métodos.

The external high frequency oscillation around a negative baseline (EHFO-NB) is a new mode of non-invasive ventilatory support which could replace or complement nasal intermittent positive pressure ventilation (NIPPV) for treatment of patients with chronic obstructive pulmonary disease, both in the decompensation phases and as preventive measure in intercrisis periods. This was a prospective study in which tolerance and short term effects on acid-base balance and gas interchange of both NIPPV and EHFO-NB in twenty patients with severe chronic obstructive pulmonary disease were compared. With both methods similar decrease in PaCO2 and increases in pH were observed, with decrease and increase in respiratory frequency when using NIPPV and EHFO-NB, respectively; the latter in association with the high oscillation frequencies used. While an improvement of SaO2 and no changes in PaO2 and intrapulmonary shunt were observed on NIPPV, a decrease was observed in the SaO2 and an increase in the shunt on EHFO-NB. Comfort of patients, improvement of perceived sensation of dyspnea, and the absence of complications were similar with both methods. While on NIPPV, 75 per cent of patients required a short period of training and continuous supervision.

[Value of the measurement of gases in the diagnosis of pleural effusion (author's transl)]. / Valor de los gases en el diagnóstico de los derrames pleurales.

Determination of pH and measurement of pCO2 and pO2 have been systematically included in the study of 183 patients with pleural effusion. According to selective etiologic criteria the effusions were divided into four categories: those of cardiac origin (42), non-specific infectious (14), tuberculous (22) and neoplastic (20). A pH inferior to 6.30 seemed to be characteristic of non-tuberculous pleural effusion, and in these circumstances an associated pCO2 greater than 135 mm Hg and pO2 less than 21 mm Hg were noticed. Results in tuberculous and neoplastic cases were similar, pO2 being the only differential datum (pO2 less than 49 mm Hg and pO2 greater than 52 mm Hg, respectively). Overall results are compared to those obtained in the subgroup of pleural effusions of cardiac origin. Determination of pH, pO2 and pCO2 in pleural effusions may help to identified the etiology of this condition, specially when associated to analysis of other parameters of the aspirated fluid.