Antimicrobial susceptibility and molecular typing of toxigenic clinical isolates of Clostridium difficile causing infections in the south of Spain.

Antimicrobial susceptibility to 6 antimicrobial agents, PCR-ribotyping and molecular genetics of fluoroquinolone resistance was assessed in 70 toxigenic clinical isolates of C. difficile recovered from patients attended in a hospital in southern Spain with suspected Clostridium difficile infection. Moxifloxacin was the least active drug, mainly driven by the aminoacid substitution Thr82Ile in GyrA, while PCR-ribotype 078 was the most prevalent lineage identified and grouped several of the fluoroquinolone resistant isolates.

Multicenter Study of Method-Dependent Epidemiological Cutoff Values for Detection of Resistance in Candida spp. and Aspergillus spp. to Amphotericin B and Echinocandins for the Etest Agar Diffusion Method.

Method-dependent Etest epidemiological cutoff values (ECVs) are not available for susceptibility testing of either Candida or Aspergillus species with amphotericin B or echinocandins. In addition, reference caspofungin MICs for Candida spp. are unreliable. Candida and Aspergillus species wild-type (WT) Etest MIC distributions (microorganisms in a species-drug combination with no detectable phenotypic resistance) were established for 4,341 Candida albicans, 113 C. dubliniensis, 1,683 C. glabrata species complex (SC), 709 C. krusei, 767 C. parapsilosis SC, 796 C. tropicalis, 1,637 Aspergillus fumigatus SC, 238 A. flavus SC, 321 A. niger SC, and 247 A. terreus SC isolates. Etest MICs from 15 laboratories (in Argentina, Europe, Mexico, South Africa, and the United States) were pooled to establish Etest ECVs. Anidulafungin, caspofungin, micafungin, and amphotericin B ECVs (in micrograms per milliliter) encompassing ≥97.5% of the statistically modeled population were 0.016, 0.5, 0.03, and 1 for C. albicans; 0.03, 1, 0.03, and 2 for C. glabrata SC; 0.06, 1, 0.25, and 4 for C. krusei; 8, 4, 2, and 2 for C. parapsilosis SC; and 0.03, 1, 0.12, and 2 for C. tropicalis The amphotericin B ECV was 0.25 µg/ml for C. dubliniensis and 2, 8, 2, and 16 µg/ml for the complexes of A. fumigatus, A. flavus, A. niger, and A. terreus, respectively. While anidulafungin Etest ECVs classified 92% of the Candida fks mutants evaluated as non-WT, the performance was lower for caspofungin (75%) and micafungin (84%) cutoffs. Finally, although anidulafungin (as an echinocandin surrogate susceptibility marker) and amphotericin B ECVs should identify Candida and Aspergillus isolates with reduced susceptibility to these agents using the Etest, these ECVs will not categorize a fungal isolate as susceptible or resistant, as breakpoints do.

Prevalence and distribution of hepatitis C virus genotypes in Spain during the 2000-2015 period (the GEHEP 005 study).

We report the largest study on the prevalence and distribution of HCV genotypes in Spain (2000-2015), and we relate them with clinical, epidemiological and virological factors. Patients from 29 hospitals in 10 autonomous communities (Andalusia, Aragon, Castilla-Leon, Catalonia, Galicia, Canary Islands, Madrid Community, Valencian Community, Murcia Region and Basque Country) have been studied. Annual distribution of HCV genotypes and subtypes, as well as gender, age, transmission route, HIV and/or HBV coinfection, and treatment details were recorded. We included 48595 chronically HCV-infected patients with the following characteristics: median age 51 years (IQR, 44-58), 67.9% male, 19.1% HIV-coinfected, 23.5% HBV-coinfected. Parenteral transmission route was the most frequent (58.7%). Genotype distribution was 66.9% GT1 (24.9% subtype 1a and 37.9% subtype 1b), 2.8% GT2, 17.3% GT3, 11.4% GT4 and 0.1% GT5 and 0.02% GT6. LiPA was the most widely HCV genotyping test used (52.4%). HCV subtype 1a and genotypes 3 and 4 were closely associated with male gender, parenteral route of infection and HIV and HBV coinfection; in contrast, subtype 1b and genotype 2 were associated with female gender, nonparenteral route and mono-infection. Age was related to genotype distribution, and different patterns of distribution and biodiversity index were observed between different geographical areas. Finally, we describe how treatment and changes in transmission routes may have affected HCV genotype prevalence and distribution patterns. We present the most recent data on molecular epidemiology of hepatitis C virus in Spain. This study confirms that genotype distributions vary with age, sex, HIV and HBV coinfection and within geographical areas and epidemiological groups.

Multicenter study of epidemiological cutoff values and detection of resistance in Candida spp. to anidulafungin, caspofungin, and micafungin using the Sensititre YeastOne colorimetric method.

Neither breakpoints (BPs) nor epidemiological cutoff values (ECVs) have been established for Candida spp. with anidulafungin, caspofungin, and micafungin when using the Sensititre YeastOne (SYO) broth dilution colorimetric method. In addition, reference caspofungin MICs have so far proven to be unreliable. Candida species wild-type (WT) MIC distributions (for microorganisms in a species/drug combination with no detectable phenotypic resistance) were established for 6,007 Candida albicans, 186 C. dubliniensis, 3,188 C. glabrata complex, 119 C. guilliermondii, 493 C. krusei, 205 C. lusitaniae, 3,136 C. parapsilosis complex, and 1,016 C. tropicalis isolates. SYO MIC data gathered from 38 laboratories in Australia, Canada, Europe, Mexico, New Zealand, South Africa, and the United States were pooled to statistically define SYO ECVs. ECVs for anidulafungin, caspofungin, and micafungin encompassing ≥97.5% of the statistically modeled population were, respectively, 0.12, 0.25, and 0.06 µg/ml for C. albicans, 0.12, 0.25, and 0.03 µg/ml for C. glabrata complex, 4, 2, and 4 µg/ml for C. parapsilosis complex, 0.5, 0.25, and 0.06 µg/ml for C. tropicalis, 0.25, 1, and 0.25 µg/ml for C. krusei, 0.25, 1, and 0.12 µg/ml for C. lusitaniae, 4, 2, and 2 µg/ml for C. guilliermondii, and 0.25, 0.25, and 0.12 µg/ml for C. dubliniensis. Species-specific SYO ECVs for anidulafungin, caspofungin, and micafungin correctly classified 72 (88.9%), 74 (91.4%), 76 (93.8%), respectively, of 81 Candida isolates with identified fks mutations. SYO ECVs may aid in detecting non-WT isolates with reduced susceptibility to anidulafungin, micafungin, and especially caspofungin, since testing the susceptibilities of Candida spp. to caspofungin by reference methodologies is not recommended.

Viral infections of the central nervous system in Spain: a prospective study.

The aim of the study was to determine the incidence of viruses causing aseptic meningitis, meningoencephalitis, and encephalitis in Spain. This was a prospective study, in collaboration with 17 Spanish hospitals, including 581 cases (CSF from all and sera from 280): meningitis (340), meningoencephalitis (91), encephalitis (76), febrile syndrome (7), other neurological disorders (32), and 35 cases without clinical information. CSF were assayed by PCR for enterovirus (EV), herpesvirus (herpes simplex [HSV], varicella-zoster [VZV], cytomegalovirus [CMV], Epstein-Barr [EBV], and human herpes virus-6 [HHV-6]), mumps (MV), Toscana virus (TOSV), adenovirus (HAdV), lymphocytic choriomeningitis virus (LCMV), West Nile virus (WNV), and rabies. Serology was undertaken when methodology was available. Amongst meningitis cases, 57.1% were characterized; EV was the most frequent (76.8%), followed by VZV (10.3%) and HSV (3.1%; HSV-1: 1.6%; HSV-2: 1.0%, HSV non-typed: 0.5%). Cases due to CMV, EBV, HHV-6, MV, TOSV, HAdV, and LCMV were also detected. For meningoencephalitis, 40.7% of cases were diagnosed, HSV-1 (43.2%) and VZV (27.0%) being the most frequent agents, while cases associated with HSV-2, EV, CMV, MV, and LCMV were also detected. For encephalitis, 27.6% of cases were caused by HSV-1 (71.4%), VZV (19.1%), or EV (9.5%). Other positive neurological syndromes included cerebellitis (EV and HAdV), seizures (HSV), demyelinating disease (HSV-1 and HHV-6), myelopathy (VZV), and polyradiculoneuritis (HSV). No rabies or WNV cases were identified. EVs are the most frequent cause of meningitis, as is HSV for meningoencephalitis and encephalitis. A significant number of cases (42.9% meningitis, 59.3% meningoencephalitis, 72.4% encephalitis) still have no etiological diagnosis.

Hepatitis C virus core protein up-regulates anergy-related genes and a new set of genes, which affects T cell homeostasis.

Hepatitis C virus (HCV) infection is the main cause for chronic hepatitis, leading to cirrhosis and hepatic carcinoma. Virally induced immune dysfunction has been called as the cause for viral persistence. Previous results demonstrate that CD4 Jurkat cells stably expressing the HCV core protein show an increased activation of NFAT transcription factor and an impaired IL-2 promoter activity, affecting intracellular signaling pathways in a manner that mimics clonal anergy. We had shown previously that NFAT activates a transcriptional program, ensuing in immunological tolerance. In the present work, we have engineered lentiviral vectors expressing the HCV core to analyze the events, which unfold in the initial phase of HCV core-induced anergy. We show that genes initially described to be up-regulated by ionomycin-induced anergy in mice are also up-regulated in humans, not only by ionomycin but also by HCV core expression. We also show that HCV core is sufficient to cause NFAT nuclear translocation and a slow-down in cell-cycle progression, and using whole genome microarrays, we identify novel genes up-regulated in Jurkat cells expressing HCV core. The relevance of our results is highlighted by the presence of HCV in CD4 T cells from HCV chronically infected patients.

Home artificial nutrition in a sanitary area of Galicia (Spain): descriptive study and proposals for the future.

OBJECTIVES: Home artificial nutrition (HAN) is a technique in increasing use, but the available data about it is limited because record-keeping in most countries is voluntary. Our objective is to describe the characteristics of HAN in our setting and to design a future proposal that improves its coordination. SUBJECTS: Retrospective review of 237 clinical histories of the patients who began with HAN in 2006 in our unit. VARIABLES: epidemiological information, indications, type of HAN, duration, complications and costs. RESULTS: Mean age: 75.4 years. Neurological and neoplasic diseases were the most frequent diagnoses (39.7% and 32.1%, respectively). Main indications were: reduction of ingestion (41.8%) and neurological dysphagia (27.8%). 48.1% presented an important functional impairment and 63.7% needed a caregiver. HAN duration was < 3 months in 43.9% and the principal cause of suspension was the lack of follow-up. Oral nutrition was the preferred route (70.9%), gastrostomy was found in only 3.4%. High-energy formulas were mostly used in patients with supplements (53.3%) and standard formulas in those with complete diets (32.4%). Complications related to this therapy were low, mainly in the oral route. The most frequent were gastrointestinal (19.3%). Mean monthly cost: 159.3 euros/patient and an average travel distance of 26 km to pick up supplies. CONCLUSION: HAN is a safe, short-term therapy, indicated in patients with diminished ingestion due to an acute situation. Our future proposal tries to improve the selection of patients, to facilitate the provision of materials and to customize follow-up to patient needs.

Approach of clinicians to candiduria and related outcome in the elderly.

OBJECTIVE: Candiduria is increasingly frequent in hospitalized debilitated patients. We aimed to evaluate the approach of clinicians to candiduria in the oldest old, and its effect on clearance and mortality. MATERIAL AND METHODS: An observational study without intervention was carried out during 2012 and 2013 in three Spanish hospitals over patients with nosocomial candiduria aged 80 and over. Following a diagnostic algorithm, we assessed the appropriateness of antifungal therapy and analyzed the impact of the clinical approach (antifungal therapy, antibiotics discontinuation and catheter removal or replacement) on the outcome (mortality at 60 days and resolution, persistence or recurrence of candiduria). RESULTS: Hundred and forty eight patients were included. Symptomatology was attributable to candiduria in 31 instances and 19 asymptomatic patients were found at risk of developing candidemia. In response to culture-results, 77 (52%) of patients were treated with antifungals, mainly fluconazole (97.4%). The use of pharmacological therapy was appropriate (P<0.05) but subtherapeutical doses of fluconazole were widely used and follow-up samples were scarcely submitted. At 60 days of diagnosis the mortality was high (29.7%). The replacement or removal of the catheter resulted in a decrease in mortality and the use of antifungal treatment was associated with recurrence (P<0.05). CONCLUSIONS: In the absence of clinical practice guidelines with enough evidence, our study suggests that catheter removal should always be tried in the elderly with candiduria, since it reduces the mortality. The repetition of culture should help to better characterize the asymptomatic episodes, which are predominant, and to reduce the use of antifungals.

Burden assessment in caregivers of patients with home artificial nutrition: a need and a challenge.

BACKGROUND/OBJECTIVES: Caregiving can be a stressful task with severe consequences on caregivers' health. Our aim was to evaluate the profile and the burden of caregivers of patients with home artificial nutrition (HAN) in our area. SUBJECTS/METHODS: We conducted a prospective observational study of patients who had started HAN over a period of a year (n=573) and their home caregivers (n=103). Epidemiological characteristics of the patients and the type of HAN were registered. Caregivers' profile data (gender, age and degree of kinship) and Zarit Burden Assessments were recorded. RESULTS: Care recipients had a median age of 79.0 (IQR 87) years, neurological and oncological diseases in 50% and a high rate of mobility limitations (80%). Oral supplements with high-calorie formulas were predominant (60%). The usual caregiver profile was a patient's daughter with a mean age of 53.1 (s.d. 13.4) years acting as the primary caregiver. Burden was absent in 49.5%, light in 18.4% and intense in 32% of caregivers. Intense burden was more frequent in oral over enteral nutrition (42% versus 22.6%; P=0.036). Supplementary nutrition was also associated with higher caregiver burden scores compared with complete diets. In patients with functional limitations, a tendency toward a slightly higher burden was observed. No differences in caregiver burden were detected according to other patient or caregiver characteristics. CONCLUSIONS: HAN type appears to be a factor influencing caregiver burden and therefore, evaluation of caregiver burden should be part of HAN programs.

A prospective international Aspergillus terreus survey: an EFISG, ISHAM and ECMM joint study.

OBJECTIVES: A prospective international multicentre surveillance study was conducted to investigate the prevalence and amphotericin B susceptibility of Aspergillus terreus species complex infections. METHODS: A total of 370 cases from 21 countries were evaluated. RESULTS: The overall prevalence of A. terreus species complex among the investigated patients with mould-positive cultures was 5.2% (370/7116). Amphotericin B MICs ranged from 0.125 to 32 mg/L, (median 8 mg/L). CONCLUSIONS: Aspergillus terreus species complex infections cause a wide spectrum of aspergillosis and the majority of cryptic species display high amphotericin B MICs.

Detection of hepatitis E virus in patients sera in southern Spain.

The aim of the present study was to detect acute Hepatitis E virus (HEV) infection in patients with abnormal alanine transaminase (ALT) in which other viral hepatitis infections had been excluded in southern Spain, an area adjacent to regions where this disease is endemic. Of 336 sera tested 30 (8.92%) were positive for IgM antibodies against HEV (anti-HEV IgM) and 7 (2.08%) were negative in a repeated assay. Immunoblot analysis (IBA) was applied to the 37 positive sera in the first assay; its results were positivity for 26 (7.73%), ambiguous for 5 and negative for 6 sera. Amplification of ORF1 and ORF2 of HEV by means of nested RT-PCR was carried out with the 37 sera that were either positive or ambiguous by ELISA; a positive result was obtained only with one serum for the ORF2 protein. IgM antibodies against the HEV ORF2 protein could be a useful marker in the diagnosis of acute infection and a substitute for the determination of viral RNA in serum; this is of both diagnostic and epidemiological importance as it would allow the patients transmitting the infection to be recognized by means of a simple determination of antibodies. The sequence of the ORF2 fragment of HEV occurring in samples taken from both humans and animals amplified in this study has considerable homology with the sequences of HEV strains/isolates of European origin. These results demonstrate that an autochthonous HEV circulates in Spain.

[Prevalence of hepatocellular carcinoma in cirrhotic patients with with portosystemic shunt. Cohort analysis]. / Prevalencia del carcinoma hepatocelular en pacientes cirróticos portadores de una derivación portosistémica. Análisis de cohortes.

The development of hepatocellular carcinoma is frequent in patients with hepatic cirrhosis of any etiology. Despite the suggestion that portosystemic shunt may increase the risk of developing this neoplasm there are scarce clinical evidence to confirm this suggestion. The present cohort study was aimed at analyzing the follow up data of 232 patients included in 3 prospective randomized controlled studies in which the efficacy of shunt procedures (group I: portocaval or splenorenal anastomosis) versus techniques other than shunt (group II: esophageal transection or variceal sclerosis) in the treatment of upper-6I bleeding secondary to rupture of esophageal-gastric varices were compared. After a mean follow up of 50 months, no differences were observed between the two groups in relation with the prevalence of hepatocellular carcinoma (group I: 17%; group II: 12%; relative risk: 1.41 [CI 95%: 0.72 - 2.75]; p = 0.41) or the actuarial probability of developing this neoplasm (group I: 2% at 2 years, 21% at 5 years; group II: 7% at 2 years, 14% at 5 years; p = 0.42). The results of this analysis suggest that the performance of portosystemic shunt does not increase the risk of developing hepatocellular carcinoma in patients with hepatic cirrhosis.

[Viral infections]. / Infecciones víricas.

Viruses cause disease after they break through the natural protective barriers of the body, evade immune control, and either kill cells of an important tissue or trigger a destructive immune and inflammatory response. The outcome of a viral infection is determined by the nature of the virushost interaction and the host's response to the infection. Viral infections can be lytic or persistent (latency, recurrence and / or transformation of the the cell). Immune response is the best treatment, but it often contributes to the pathogenesis of a viral infection. The laboratory methods accomplish the following results: description of virus-induced cytopathologic effects (CPEs) on cells, electron microscopic detection of viral particles, isolation and growth of the virus, detection of viral components (proteins and nucleic acids) and evaluation of the patient's immune response to the virus.

[Antifungal susceptibility of clinical isolates of Scopulariopsis species]. / Sensibilidad a antifúngicos de especies de Scopulariopsis de origen clínico.

INTRODUCTION: Scopulariopsis is a common soil saprophyte. In the last years the infections caused by Scopulariopsis species have increased, included superficial and invasive mycoses. This fungi has been reported resistant in vitro to some antifungal agents, although there is little information about this. The aim of the study was to establish in vitro antifungal susceptibility of clinical isolates of Scopulariopsis species against to broad-spectrum antifungal agents. METHODS: A total of 28 Scopulariopsis strains (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii and 1 S. fusca) were tested using Sensititre Yeast One and broth microdilution methods to determine the minimum inhibitory concentrations (MICs) to amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and 5-fluorocytosine, and minimun effective concentration (MECs) to anidulafungin, caspofungin and micafungin. RESULTS: Our data confirm the high in vitro resistance of Scopulariopsis to antifungal agents. Anidulafungin, caspofungin, micafungin (MICs ≥ 8 mg/L), 5-fluorocytosine (MICs ≥ 64 mg/L), and fluconazole (MICs ≥ 128 mg/L) were inactive in vitro in all species. MICs of amphotericin B (range 2 to ≥ 8 mg/L) and itraconazole (0.5 to ≥ 16 mg/L) were high. The best antifungal activity was observed for posaconazole and voriconazole (0.5 to ≥ 8 mg/L). With Sensititre Yeast One method MICs obtained slightly lower. Scopulariopsis candida, S. flava and S. fusca were the most resistant species, while S. acremonium and S. brevicaulis showed the lowest MICs. CONCLUSIONS: MICs of all tested antifungal agents for Scopulariopsis were very high. Infections caused by Scopulariopsis species may not respond to antifungal treatment. Voriconazole is the drug of choice for treatment. We consider it appropriate to add amphotericin B in serious infections.