Current clinical spectrum of common variable immunodeficiency in Spain: The multicentric nationwide GTEM-SEMI-CVID registry.

Common variable immunodeficiency (CVID) constitutes a heterogenic group of primary immunodeficiency disorders with a wide-ranging clinical spectrum. CVID-associated non-infectious morbidity constitutes a major challenge requiring a full understanding of its pathophysiology and its clinical importance and global variability, especially considering the broad clinical, genetic, and regional heterogeneity of CVID disorders. This work aimed to develop a nationwide, multicenter, retrospective study over a 3-year period describing epidemiological, clinical, laboratory, therapeutic, and prognostic features of 250 CVID patients in Spain. The mean diagnostic delay was around 10 years and most patients initially presented with infectious complications followed by non-infectious immune disorders. However, infectious diseases were not the main cause of morbimortality. Non-infectious lung disease was extraordinarily frequent in our registry affecting approximately 60% of the patients. More than one-third of the patients in our cohort showed lymphadenopathies and splenomegaly in their follow-up, and more than 33% presented immune cytopenias, especially Evans' syndrome. Gastrointestinal disease was observed in more than 40% of the patients. Among biopsied organs in our cohort, benign lymphoproliferation was the principal histopathological alteration. Reaching 15.26%, the global prevalence of cancer in our registry was one of the highest reported to date, with non-Hodgkin B lymphoma being the most frequent. These data emphasize the importance of basic and translational research delving into the pathophysiological pathways involved in immune dysregulation and diffuse lymphocytic infiltration. This would reveal new tailored strategies to reduce immune complications, and the associated healthcare burden, and ensure a better quality of life for CVID patients.

Infective endocarditis treated in a secondary hospital: epidemiological, clinical, microbiological characteristics and prognosis, with special reference to patients transferred to a third level hospital / La endocarditis infecciosa en un hospital de 2º nivel: epidemiologia, clínica y análisis de factores pronósticos, con especial referencia a los pacientes trasladados a un hospital de tercer nivel

Introduction. To analyse the clinical and epidemiological characteristics and mortality-related factors of patients admitted to a secondary hospital with Infective Endocarditis (IE). Methods. Observational study of a cohort of patients who have been diagnosed with IE in a secondary hospital and evaluated in accordance with a pre-established protocol. Results. A total of 101 cases were evaluated (years 2000- 2017), with an average age of 64 years and a male-to-female ratio of 2:1. 76% of the cases had an age-adjusted Charlson comorbidity index of >6, with 21% having had a dental procedure and 36% with a history of heart valve disease. The most common microorganism was methicillin-susceptible S. aureus (36%), with bacterial focus of unknown origin in 54%. The diagnostic delay time was 12 days in patients who were transferred, compared to 8 days in patients who were not transferred (p=0.07); the median surgery indication delay time was 5 days (IQR 13.5). The in-hospital mortality rate was 34.6% and the prognostic factors independently associated with mortality were: cerebrovascular events (OR 98.7%, 95% CI, 70.9–164.4); heart failure (OR 27.3, 95% CI, 10.2–149.1); and unsuitable antibiotic treatment (OR 7.2, 95% CI, 1.5–10.5). The mortality rate of the patients who were transferred and who therefore underwent surgery was 20% (5/25). Conclusions. The onset of cerebrovascular events, heart failure and unsuitable antibiotic treatment are independently and significantly associated with in-hospital mortality. The mortality rate was higher than the published average (35%); the diagnostic delay was greater in patients for whom surgery was indicated. (AU)

Introducción. Analizar las características clínico-epidemiológicas y los factores asociados a mortalidad de los pacientes ingresados por endocarditis infecciosa (EI) en un Hospital de 2º nivel. Métodos. Estudio observacional de una cohorte de pacientes diagnosticados de EI en un hospital de 2º nivel y evaluados de acuerdo a un protocolo preestablecido. Resultados. Se evaluaron 101 casos (2000-2017), edad media de 64 años, relación hombre/mujer 2:1, presentando un índice de Charlson corregido por edad >6 en el 76% de los casos, antecedentes de manipulaciones dentarias en el 21% y valvulopatía previa en el 36%. El microorganismo más frecuente fue Staphylococcus aureus sensible a meticilina (36%), con foco bacteriémico de origen desconocido en el 54%. El tiempo de demora diagnóstica fue de 12 días en pacientes transferidos frente a 8 en los no transferidos (p= 0.07); el de demora de indicación de cirugía tuvo una mediana de 5 días (RIQ 13.5). La mortalidad intrahospitalaria fue del 34.6% y los factores pronósticos asociados de forma independiente fueron la presencia de eventos vasculares cerebrales (OR 98.7, IC 95% 70.9-164.4), el fallo cardiaco (OR 27.3, IC 95% 10.2 – 149.1) y el tratamiento antibiótico inadecuado (OR 7.2, IC 95% 1.5–10.5). La mortalidad intrahospitalaria de los pacientes transferidos y por tanto intervenidos fue del 20% (5/25). Conclusiones. El desarrollo de eventos vasculares cerebrales, el fallo cardiaco y el tratamiento antibiótico inadecuado se asocian de forma independiente y significativa con mortalidad intrahospitalaria. La mortalidad fue superior a la media publicada (35%); la demora diagnóstica fue mayor en los pacientes con indicación quirúrgica. (AU)

Diseño y puesta en marcha de un protocolo de tratamiento antimicrobiano domiciliario endovenoso en atención primaria: experiencia en un hospital de segundo nivel / Design and implementation of an outpatient parenteral antimicrobial therapy program in primary care: the experience at a second level hospital

Introducción. Los programas de tratamiento antimicrobiano domiciliario endovenoso (TADE) suponen una buena opción asistencial para una gran variedad de enfermedades infecciosas. Nuestro objetivo fue diseñar e implementar un programa TADE en el área de influencia de un hospital de segundo nivel, en el que no se dispone de una Unidad de Hospitalización a domicilio (UHD), siendo necesario la estrecha colaboración entre los equipos de atención hospitalaria y primaria, describir la cohorte de pacientes, analizar las pautas de tratamiento antimicrobiano y evaluar los factores de riesgo asociados al reingreso y la mortalidad. Métodos. Estudio de cohortes prospectivo de los pacientes incluidos en el TADE entre el 1 de Enero de 2012 al 31 mayo de 2015. Resultados. Se registraron un total de 98 episodios. La edad media fue 66 años. La comorbilidad más frecuente fue la inmunosupresión (33,67%), con una media global del índice de Charlson de 5,21 ± 3,09. El foco de infección más frecuente fue el respiratorio (33,67%). Se consiguió aislamiento microbiológico en 58 pacientes (59,18%), siendo Escherichia coli el más frecuentemente aislado (25%). La media de días de administración de antimicrobianos fue 10,42 (± 6,02 DE, rango 2-40), siendo los carbapenémicos (43,48%) los más usados. Ochenta y seis pacientes (87,75%) cumplimentaron el tratamiento. Treinta y dos pacientes (32,65%) reingresaron en los siguientes 30 días al alta y siete (7,14%) fallecieron. Se encontró asociación estadísticamente significativa con el reingreso con las variables edad (p = 0,03), portador de reservorios (p = 0,04) e interrupción del tratamiento RI (p<0,05). Conclusiones. Este programa es pionero en España en la administración de TADE sin el soporte de una UHD, lo que podría permitir optimizar la red de recursos hospitalarios y de Atención Primaria disponibles. No obstante, los datos del proyecto piloto son pobres en optimización de la elección del antibiótico, secuenciación, desescalamiento y duración (AU)

Introduction. Outpatient parenteral antimicrobial therapy (OPAT) programs are a good assistance option in a wide variety of infectious diseases. Our aim was to design and implement an OPAT program in the area of influence of a second-level hospital, with no Home Hospitalization Service available, being necessary close collaboration between hospitalization and Primary Care teams, describe our cohort, analyse the antimicrobial treatment indicated and evaluate the prognostic and risk factors associated with readmission and mortality. Material and methods. Prospective study cohorts of patients admitted to the OPAT programme, from 1 January 2012 to 31 May 2015. Results. During the period of study a total of 98 episodes were recorded. The average age of the cohort was 66 years. The most frequent comorbidity was immunosuppression (33.67 %), with an overall average of Charlson index of 5.21 ± 3.09. The most common source of infection was respiratory (33.67 %). Microbiological isolation was achieved in fifty-eight patients (59.18 %) being Escherichia coli the most frequently isolated (25%). The average number of days of antibiotics administration at home was 10.42 ± 6.02 (SD), being carbapenems (43.48%) the more administered. Eighty-six patients (87.75%) completed the treatment successfully. Thirty-two patients (32.65%) were readmitted within 30 days after being discharged and seven patients (7.14%) died. A statistically significant association was only found in the readmission with variables: elderly patients (p=0.03), being carriers of Porth-a-Cath (p=0.04) and treatment termination related with infection (p<0.05). Conclusions. This is the first programme of OPAT administration not dependent on Home Hospitalization Service in Spain, which could allow to optimize the hospital and primary care resources available. Nevertheless this pilot study results are poor in terms of optimization of antibiotics choice, transition to oral administration, de-escalation and duration (AU)