Clinical significance and outcome of Aeromonas spp. infections among 204 adult patients.

The objectives of this investigation were to analyze the clinical patterns, risk groups, prognostic factors, and mortality of infections caused by Aeromonas spp. This was a retrospective study of adult patients with Aeromonas spp. isolates attended at the Hospital del Mar in Barcelona, Spain, between January 2006 and December 2012. Epidemiological data, antimicrobial susceptibility, clinical patterns, underlying illnesses, type of infection, admission to the intensive care unit (ICU), number of episodes, coinfection, antimicrobial therapy, and evolution were analyzed. A total of 221 clinical samples from 204 patients were positive for Aeromonas spp. The mean age of the patients was 67.6 years. The main clinical form of presentation was gastrointestinal (78.4%). Malignancy was the main risk group in 69 (33.8%) patients, and 48 (23.5%) were previously healthy. Twenty-one patients (10.3%) were admitted to the ICU. Infections were acquired in the hospital in 52.5% of the patients, and 28.9% were polymicrobial. The overall mortality (after 1 year of follow-up from the first positive culture) was 26.5%. Univariate analysis identified an association between increased mortality and the following variables: age ≥80 years, hospitalization, admission to the ICU, malignancy, extraintestinal infection, and appropriate antimicrobial therapy. In the multivariate analysis, age ≥80 years [odds ratio (OR), 4.37 [95% confidence interval (CI), 1.68-11.35; p = 0.002]], admission to the ICU (OR, 6.59 [95% CI, 2.17-19.99; p = 0.001]), and malignancy (OR, 3.62 [95% CI, 1.32-9.90; p = 0.012]) were significantly associated with mortality. Aeromonas infections are mainly gastrointestinal. The 1-year follow-up mortality rate was high. Old age (age ≥80 years), admission to the ICU, and malignancy were identified as independent risk factors for mortality.

Timing y catéter de Swan-Ganz / Swan-Ganz catheter and timing

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Hemorragia alveolar y crioglobulinemia mixta asociada al virus de la hepatitis C. A propósito de tres casos / Alveolar haemorrhage and virus C virus-related mixed cryoglobulinemia report of three cases

La crioglobulinemia mixta asociada a virus de la hepatitis C es una entidad reconocida. Entre sus complicaciones destacan la afectación renal y pulmonar. La hemorragia alveolar es una de las formas más graves de afectación pulmonar. Su forma de presentación puede simular otro tipo de patologías. Presentamos tres casos de crioglobulinemia asociada a virus C cuyo diagnóstico final fue de hemorragia alveolar. El primer caso corresponde a una mujer de 71 años que ingresó por disnea y hemoptisis, precisando IOT y VM. Inicialmente se orientó como neumonía y ante una caída de la hemoglobina y persistencia de infiltrados radiológicos se sospechó hemorragia alveolar. Se realizó fibrobroncoscopia a las 48 horas de iniciados los corticoides, que demostró la presencia de un 6% de hemosiderófagos. El segundo caso trata de una mujer de 64 años que consultó por disnea y lesiones vasculíticas en glúteos más insuficiencia renal. Se iniciaron antibióticos bajo la sospecha clínica de neumonia grave con mala evolución, requiriendo IOT y VM. La FBS demostró un 60% de hemosiderófagos. El tercer caso corresponde a una mujer de 67 años que ingresa por fiebre, disnea y dolor en hemitórax derecho. Se orientó como neumonía ingresando en UCI. Siguió una mala evolución que obligó a IOT y VM. Se practicó fibrobroncoscopia que mostró restos hemáticos sugestivos de hemorragia alveolar

Hepatitis C virus –related mixed cryoglobulinemia is a recognised entity. Renal and pulmonary involvements are severe potential complications of this disease. Alveolar haemorrhage is a form of pulmonary complication. The clinical features of the alveolar haemorrhage can mimic other pulmonary diseases. We present three patients with hepatitis C virus-related mixed cryoglobulinemia associated to pulmonary symptoms that turned to be caused by an alveolar haemorrhage. The first patient was a 71-year old woman that was admitted because of hemoptysis and severe dyspnea that required mechanical ventilation. Although a pneumonia was the initial diagnoses, an alveolar haemorrhage was soon suspected based on the persistence of the pulmonary radiological infiltrates despite an adequate empirical antibiotic treatment and the presence of a progressive anemization. A fibrobronchoscopy, performed 48 hours after treatment was begun, revealed the presence of a 6% of hemosiderophages. The second patient was a 64 years old woman admitted because of dyspnea, vasculitic cutaneous lesions in gluteus and kidney failure. A severe pneumonia was suspected, antibiotic treatment was started and again the patient needed mechanical ventilation. The fibrobronchoscopy demonstrated the existence of a 60% of hemosiderophages. The third case describes a 67 year old woman that complained of fever, dyspnea and right chest pain. Similarly to the previous cases a severe pneumonia was the initial diagnoses, the patient needed to be transferred to the intensive care unit and mechanical ventilation was finally required. The fibrobronchoscopy showed remains of blood suggestive of an alveolar haemorrhage

[Alveolar haemorrhage and hepatitis virus C related mixed cryoglobulinemia. Report of three cases]. / Hemorragia alveolar y crioglobulinemia mixta asociada al virus de la hepatitis C. A propósito de tres casos.

Hepatitis C virus -related mixed cryoglobulinemia is a recognised entity. Renal and pulmonary involvements are severe potential complications of this disease. Alveolar haemorrhage is a form of pulmonary complication. The clinical features of the alveolar haemorrhage can mimic other pulmonary diseases. We present three patients with hepatitis C virus-related mixed cryoglobulinemia associated to pulmonary symptoms that turned to be caused by an alveolar haemorrhage. The first patient was a 71-year old woman that was admitted because of hemoptysis and severe dyspnea that required mechanical ventilation. Although a pneumonia was the initial diagnoses, an alveolar haemorrhage was soon suspected based on the persistence of the pulmonary radiological infiltrates despite an adequate empirical antibiotic treatment and the presence of a progressive anemization. A fibrobronchoscopy, performed 48 hours after treatment was begun, revealed the presence of a 6% of hemosiderophages. The second patient was a 64 years old woman admitted because of dyspnea, vasculitic cutaneous lesions in gluteus and kidney failure. A severe pneumonia was suspected, antibiotic treatment was started and again the patient needed mechanical ventilation. The fibrobronchoscopy demonstrated the existence of a 60% of hemosiderophages. The third case describes a 67 year old woman that complained of fever, dyspnea and right chest pain. Similarly to the previous cases a severe pneumonia was the initial diagnoses, the patient needed to be transferred to the intensive care unit and mechanical ventilation was finally required. The fibrobronchoscopy showed remains of blood suggestive of an alveolar haemorrhage.

Economic impact of Candida colonization and Candida infection in the critically ill patient.

The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53-1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16-1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72-2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99-1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.

Successful treatment with liposomal amphotericin B of an intraabdomianl abscess due to Candida norvegensis associated with a Gore-Tex mesh infection.

There are few reports of severe infections caused by Candida norvegensis. We here describe a case of C. norvegensis-associated intraabdominal abscess and Gore-Tex mesh-associated infection, successfully treated with liposomal amphotericin B and removal of the mesh. This is, to our knowledge, the first report of C. norvegensis causing this type of infection.

Taponamiento cardíaco en el curso de una sepsis por Staphilococcus aureus en un paciente con SIDA / Cardiac tamponade in a Staphilococcus aureus sepsis in an AIDS patients

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In vitro activities of 22 antimicrobial agents against Listeria monocytogenes strains isolated in Barcelona, Spain. The Collaborative Study Group of Listeriosis of Barcelona.

The in vitro activity of 22 antimicrobial agents against 82 human Listeria monocytogenes strains isolated in Barcelona from 1994 to 1998 was determined. Ampicillin and gentamicin showed good in vitro activity against all strains (MIC90: 1 and < or = 0.25 microg/ml, respectively). No resistance to rifampin or co-trimoxazole was detected and only one strain was resistant to tetracycline. Of the nine fluoroquinolones tested, clinafloxacin and gemifloxacin were the most active compounds (MIC90: 0.12 and 0.25 microg/ml, respectively). No increasing MICs values were observed during the five-year period.

Perinatal listeriosis: a population-based multicenter study in Barcelona, Spain (1990-1996).

The aim off this study was to describe the incidence, epidemiology, clinical presentation, and outcome of perinatal listeriosis for a 7-year period (1990-1996) based on data of an active population-based surveillance project implemented in the city of Barcelona, Spain. There were 30 cases (20.8%) associated with pregnancy (15 pregnant women, 13 neonates, and 2 fetal deaths). The incidence of perinatal listeriosis varied from 4.1 to 0 per 10,000 live births. The proportion of perinatal cases in relation to the total number of cases of listeriosis varied between 0 and 42%. Early-onset neonatal sepsis accounted for 12 of 13 live births. The mean age of infected pregnant women with listeriosis was 30.1+/-2.0 years. Chorioamnionitis was the predominant clinical form (86.7%). Only two mothers had primary bacteremia by L. monocytogenes in the second trimester of pregnancy. Both infants were born healthy, without signs of infection. One of these mothers was infected with the human immunodeficiency virus (HIV). Since January 1994, 12 strains were available for serotyping and phagotyping; 9 belonged to serovar 4b, 2 to serovar 1/2b, and 1 to serovar 1/2a. No outbreaks of L. monocytogenes infection occurred during the study period. The overall neonatal mortality rate was 7.7% among infected live births. All pregnant women were treated with ampicillin and none died. Early antenatal treatment with ampicillin improves neonatal outcome and can result in the birth of healthy babies.

Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU.

OBJECTIVE: To determine the incidence and prognosis of candidemia in non-neutropenic critically ill patients, to define mortality-related factors, and to evaluate the results of systemic antifungal therapy. DESIGN: A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated. PATIENTS: All critically ill patients with positive blood cultures for Candida species admitted to the participating ICUs over a 15-month period were included. INTERVENTIONS: Candidemia was defined as the presence of at least one positive blood culture containing Candida species. The follow-up period was defined as the time elapsed from the first positive blood culture for Candida species to discharge or death during hospitalization. Antifungal therapy was considered to be "early" when it was administered within 48 h of the date when the first positive blood culture was obtained and "late" when it was administered more than 48 h after the first positive blood culture. MEASUREMENTS AND MAIN RESULTS: Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amphotericin B alone to 10, and sequential therapy to 6. Three patients did not receive antifungal therapy. The overall mortality was 56% and the attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the onset of candidemia (p = 0.04) and with the time elapsed between the episode of candidemia and the start of antifungal therapy 48 h or more later (p < 0.02). Patients with an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously ill (p = 0.04). Patients with "early" antifungal therapy (< or = 48 h between the onset of candidemia and the start of antifungal therapy) had a higher probability of survival compared with patients with late therapy (p = 0.06). No significant differences were noted between the two groups on different antifungal therapy. CONCLUSIONS: The incidence of candidemia in ICU patients was very low. An APACHE II score > 20 at the time of candidemia was associated with a higher mortality. Further studies with a large number of patients are needed to assess the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.

Candiduria in non-neutropenic critically-ill surgical patients. Detection of IgA, IgG and IgM antibodies to Candida albicans by germ tube immunofluorescence.

The significance of indirect immunofluorescence using Candida albicans germ tube as well as blastospore antigens in the diagnosis of isolated candiduria in non-neutropenic, critically-ill surgical patients was assessed. Ten patients with isolated candiduria, 12 with systemic candidosis and 10 with multifocal muco-cutaneous candidosis were included in the study. The sera of another 10 critically-ill patients with no signs of candidosis served as controls. The patients' sera were tested for IgG, IgA and IgM antibodies. The results obtained confirmed that indirect germ tube immunofluorescence is a useful procedure for differentiating systemic candidosis from colonisation of the urinary tract. Indirect immunofluorescence with blastospores, although more sensitive than germ tube immunofluorescence, cannot distinguish muco-cutaneous candidosis from systemic candidosis. Therefore, indirect germ tube immunofluorescence is regarded a useful complementary test to evaluate candiduria in non-neutropenic, HIV-negative, critically ill patients.

Candida endophthalmitis in non-neutropenic critically ill patients.

Six non-neutropenic critically ill patients who developed hematogenous endophthalmitis due to Candida spp. were studied prospectively. In all cases the yeast was isolated in blood cultures. The incidence of endophthalmitis in patients with candidemia was 13%, the predominant species being Candida albicans. Four patients were treated with fluconazole, but its efficacy could not be evaluated because three of the patients died. In patients at risk of candidemia, regular ophthalmoscopic examinations are recommended in order to enable early initiation of systemic antifungal therapy in those who develop endophthalmitis.

[Methanol and ethylene glycol poisoning. Study of 18 cases]. / Intoxicación por metanol y etilenglicol. Estudio de 18 observaciones.

BACKGROUND: The present study reviews acute intoxication by methanol and ethylenglycol analyzing its form of presentation, treatment applied and prognosis. METHODS: A retrospective study performed in 5 hospitals from the Barcelona area (Spain) from January 1984 to December 1993 is reported. RESULTS: Eighteen patients, 16 intoxicated by methanol and 2 by ethylenglycol were reviewed. The blood levels of methanol on admission ranged from 350 to 4,600 mg/l (mean = 1,649 +/- 1,220 mg/l). The clinical course was initially characterized by alteration of the level of consciousness (in 61% the index of Glasgow of coma was < or = 7) and development of metabolic acidosis (pH < or = 6.80 in 44% of cases). Eighty-seven percent of patients intoxicated by methanol had visual disorders. Treatment consisted in the administration of ethanol, bicarbonate and extrarenal exchange. Mortality was 44%, being greater among patients with the lowest initial pH (p = 0.0001) and with the lowest concentration of bicarbonates (p < 0.03). The patients with lower pH (r2 = 0.65, p < 0.002) and with a lower value of blood bicarbonate (r2 = 0.87; p < 0.0001) on admission were significantly more severe. Sequelae are present in 55% of the survivors. CONCLUSIONS: Intoxication by methanol and ethylenglycol cause severe metabolic acidosis, with high anion and osmolar gaps which may rapidly lead to death or to sequelae in survivors if diagnosis is delayed and specific treatment is not initiated early.

[Clinico-epidemiologic study of human listeriosis in Barcelona (1990-1991)]. / Estudio clinicoepidemiológico de la listeriosis humana en Barcelona (1990-1991).

BACKGROUND: The aim of this study was to determine the incidence of human listeriosis in Barcelona in addition to its clinical form of presentation, seasonability, risk groups and evolution. METHODS: A prospective study of the cases of listeriosis registered in the city of Barcelona, Spain (population of 1,643,542 inhabitants) over the period from January 1, 1990 to December 31, 1991 was carried out. RESULTS: Fifty-five cases were reviewed with a global rate of incidence of listeriosis of 9.4 per one million inhabitants per year with predominance being observed in the summer months (39% in 1990, 42% in 1991). Ninety-one percent of the cases were observed in non pregnant adults, with 86% of the patients being immunosuppressed. Nosocomial listeriosis, diagnosed in 23 patients (42%), was predominant in the group with immunosuppressive treatment (p = 0.0005). The main site of isolation was blood in 45 cases (82%), in the form of primary listeriosis (p < 0.0005). Global mortality was 49%, being greater in the group of patients with nosocomial infection (p = 0.01) and with primary bacteremia (p < 0.001). No patients without known risk factors or pertaining to the perinatal group have died. CONCLUSIONS: The use of an active system of registration of listeriosis facilitates better knowledge of its incidence, distribution and infection pattern thus allowing the early detection of epidemic outbreaks with the aim of controlling such an infection, given the social implications and morbidity of this disease.