Increasing Incidence of mucormycosis in Spanish inpatients from 1997 to 2018.

BACKGROUND: Mucormycosis is a worldwide angio-invasive fungal infection that is associated with high morbidity and mortality. A few European studies have focused on the epidemiology. METHODOLOGY: A retrospective longitudinal descriptive study was performed with inpatients diagnosed with mucormycosis (ICD-9-CM, code 117.7, cases 1997-2015; and ICD-10, code B46, cases 2016-2018; along with length of hospital stay) in Spanish public hospitals between 1 January 1997 and 31 December 2018. Data were obtained from the Minimum Basic Data Set (CMBD in Spanish). PRINCIPAL FINDINGS: A total of 962 patients were recorded; 665 were men. The mean age (±SD) was 55 ± 18.8 years. The annual incidence rate increased from 0.74 to 1.24 cases per million person-years. The lethality rate was 31.3%. Renal failure (41.6%) and haematological malignancy (36.3%) were the main factors involved. CONCLUSIONS: Mucormycosis is a rare infectious disease in Spain, but it has had a significantly increased incidence in the last two decades. Being an adult male and having diabetes, neoplasm or renal failure are the main factors associated. High mortality is usually associated mainly with haematological malignancy and renal failure. CMBD studies could be an efficient tool for assessing changes in the epidemiology of mucormycosis.

Epidemiological of cat scratch disease among inpatients in the Spanish health system (1997-2015).

Cat scratch disease, whose causative agent is Bartonella henselae, is an anthropozoonosis with a worldwide distribution that causes significant public health problems. Although it is an endemic disease in Spain, the available data are very limited. The aim of our study was to describe cat scratch disease inpatients in the National Health System (NHS) of Spain. This was a retrospective descriptive study using the minimum basic data set (CMBD in Spanish) in patients admitted to hospitals of the NHS between 1997 and 2015 with a diagnosis of cat scratch disease (ICD-9: 078.3). We found 781 hospitalized patients diagnosed with cat scratch disease. The mean age (± SD) was 30.7 ± 25.3 years old. The male/female ratio was 1.1:1. The incidence rate over the study period was 0.93 (95% CI, 0.86-0.99) cases per million person-years. The incidence rate in men was 0.98 cases per million person-years and that in women was 0.88 cases per million person-years. The cases were more frequent from September to January. A total of 652 (83.5%) cases were urgent hospital admissions. The average hospital stay was 8.4 ± 8.9 days. The overall lethality rate of the cohort was 1.3%. We have demonstrated that CSD causes a substantial burden of disease in Spain, affecting both adult and pediatric patients with a stable incidence rate. Our data suggest that CSD is benign and self-limited, with low mortality, and its incidence is possibly underestimated. Finally, there is a need for a common national strategy for data collection, monitoring, and reporting, which would facilitate a more accurate picture and the design of more strategic control measures. Hospital discharge records (HDRs) could be a good database for the epidemiological analysis of the hospital management of CSD.

Epidemiological assessment of 5598 brucellosis inpatients in Spain (1997-2015).

Brucellosis remains one of the main zoonoses worldwide. Epidemiological data on human brucellosis in Spain are scarce. The objective of this study was to assess the epidemiological characteristics of inpatient brucellosis in Spain between 1997 and 2015. A retrospective longitudinal descriptive study was performed. Data were requested from the Health Information Institute of the Ministry of Health and Equality, which provided us with the Minimum Basic Data Set of patients admitted to the National Health System. We also obtained data published in the System of Obligatory Notifiable Diseases. A total of 5598 cases were registered. The period incidence rate was 0.67 (95% CI 0.65-0.68) cases per 100 000 person-years. We observed a progressive decrease in the number of cases and annual incidence rates. A total of 3187 cases (56.9%) came from urban areas. The group most at risk comprised men around the fifth decade of life. The average (±s.d.) hospital stay was 12.6 days (±13.1). The overall lethality rate of the cohort was 1.5%. The number of inpatients diagnosed with brucellosis decreased exponentially. The group of patients with the highest risk of brucellosis in our study was males under 45 years of age and of urban origin. The lethality rate has reduced to minimum values. It is probable that hospital discharge records could be a good database for the epidemiological analysis of the hospital management of brucellosis and offer a better information collection system than the notifiable diseases system (EDO in Spanish).

Standard photopatch test battery? Proposal based on current epidemiology and experience in our Skin Allergy Unit.

BACKGROUND: The diagnosis of photoallergic contact dermatitis (PACD) is confirmed by photopatch testing (PPT). In Spain, the latest recommendation on which allergens to test in PPT dates from 1995. METHODS: In the last 4 years, we studied 455 patients with epicutaneous tests and performed PPT on 33 of those patients (7.3%). RESULTS: The most prevalent allergens in PPT were as follows: non-steroidal anti-inflammatory drugs (NSAIDs) (46%), fragrances (21%), and solar filters (18%). DISCUSSION: In our country, the most common photoallergens continue to be NSAIDs (ketoprofen). The increasingly common use of sunscreens has led to a growing involvement of solar filters in PACD, which can be also contained in other cosmetics. In our experience, PACD due to fragrances is nonetheless at least similar in frequency. CONCLUSIONS: The PPT battery must adapt to the prescription, use, and exposure habits of each country. We propose a diagnostic model to guide which allergens to test in PPT, which in our experience should also include fragrances.

Medical treatment of cystic echinococcosis: systematic review and meta-analysis.

BACKGROUND: Cystic echinococcosis (CE) is a well-known neglected parasitic disease. However, evidence supporting the four current treatment modalities is inadequate, and treatment options remain controversial. The aim of this work is to analyse the available data to answer clinical questions regarding medical treatment of CE. METHODS: A thorough electronic search of the relevant literature without language restrictions was carried out using PubMed (Medline), Cochrane Central Register of Controlled Trials, BioMed, Database of Abstracts of Reviews of Effects, and Cochrane Plus databases up to February 1, 2017. All descriptive studies reporting an assessment of CE treatment and published in a peer-reviewed journal with available full-text were considered for a qualitative analysis. Randomized controlled trials were included in a quantitative meta-analysis. We used the standard methodological procedures established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: We included 33 studies related to the pharmacological treatment of CE in humans. Of these, 22 studies with levels of evidence 2 to 4 were qualitatively analysed, and 11 randomized controlled trials were quantitatively analysed by meta-analysis. CONCLUSIONS: Treatment outcomes are better when surgery or PAIR (Puncture, Aspiration, Injection of protoscolicidal agent and Reaspiration) is combined with benzimidazole drugs given pre- and/or post-operation. Albendazole chemotherapy was found to be the primary pharmacological treatment to consider in the medical management of CE. Nevertheless, combined treatment with albendazole plus praziquantel resulted in higher scolicidal and anti-cyst activity and was more likely to result in cure or improvement relative to albendazole alone.

Recurrence of cystic echinococcosis in an endemic area: a retrospective study.

BACKGROUND: Cystic echinococcosis (CE) is a chronic, complex and neglected zoonotic disease. CE occurs worldwide. In humans, it may result in a wide spectrum of clinical manifestations, ranging from asymptomatic infection to fatal disease. Clinical management procedures have evolved over decades without adequate evaluation. Despite advances in surgical techniques and the use of chemotherapy, recurrence remains one of the major problems in the management of hydatid disease. The aim of this study was to determine the frequency of CE recurrence and the risk factors involved in recurrence. METHODS: A descriptive longitudinal-retrospective study was designed. We reviewed all patients diagnosed with CE according to ICD-9 (code 122-0 to 122-9) criteria admitted at Complejo Asistencial Universitario de Salamanca, Spain, between January 1998 and December 2015. RESULTS: Among the 217 patients studied, 25 (11.5%) had a hydatid recurrence after curative intention treatment. Median duration of recurrence's diagnosis was 12.35 years (SD: ±9.31). The likelihood of recurrence was higher [OR = 2.7; 95% CI, 1.1-7.1; p < 0.05] when the cyst was located in organs other than liver and lung, 22.6% (7/31) vs 14.2% (31/217) in the cohort. We detected a chance of recurrence [OR = 2.3; 95% CI, 1.4-6.5; p > 0.05] that was two times higher in those patients treated with a combination of antihelminthic treatments and surgical intervention (20/141, 14.2%) than in patients treated with surgical intervention alone (5/76, 6.6%). CONCLUSIONS: Despite advances in diagnosis and therapeutic techniques in hydatid disease, recurrence remains one of the major problems in the management of hydatid disease. The current management and treatment of recurrences is still largely based on expert opinion and moderate-to-poor quality of evidence. Consequently, large prospective and multicenter studies will be needed to provide definitive recommendations for its clinical management.

Screening for parasite infections in immigrant children from low-income countries.

INTRODUCTION: In Spain, minors represent approximately 20% of the immigration flow. Many of these immigrants come from countries in the tropics and sub-tropics where intestinal parasitic infections caused by helminths and protozoa are one of the major causes of human disease. The main objective of the present work was to describe parasite infections in a group of immigrant children. METHODS: A prospective evaluation was performed in 373 minors from Sub-Saharan Africa, North Africa, and Latin America. Details were collected from the medical records and physical examination. Urine, stool and peripheral blood samples were obtained for serological and routine laboratory tests. Direct and indirect parasitological tests were also performed. RESULTS: At least 1 parasitic disease was diagnosed in 176 (47.1%) immigrant children, while 77 (20.6%) minors were infected with two or more parasites. The number of parasites was highest in children from Sub-Saharan Africa compared with the rest of the areas of origin (p<.001), and in children from urban areas compared with those from rural areas (OR 1.27 [1.059-1.552], p=.011). The most frequent causes of multiple parasite infection were filariasis plus strongyloidiasis and filariasis plus schistosomiasis. Intestinal parasite infection was diagnosed in 38 cases (13.8%). Logistic regression analysis revealed that for each month of stay, the probability of a positive finding in the stool sample decreased by 0.02% [ß=-0.020, (p=.07)]. CONCLUSIONS: The high infection rates of parasite diseases in immigrant children point to the need for screening protocols for certain infectious diseases in these children according to their country of origin and their length of residence in Spain.

[Epidemiological update of hydatid disease in hospitals in the public health system of Extremadura (2003-2012)]. / Situación epidemiológica de la hidatidosis en los centros hospitalarios del sistema público de salud de Extremadura (2003-2012).

INTRODUCTION: Echinococcosis is a zoonotic infection with a worldwide distribution, and is still an important health problem in many areas of the world, including the Mediterranean basin. At present the epidemiological situation is unclear in certain regions of Spain. The aim of this study was to update the epidemiological situation in Extremadura through an analysis of hospitalised patients in the public health system diagnosed with hydatid disease. METHODS: A longitudinal retrospective study was conducted between 2003 and 2012 on hospitalised patients with a diagnosis of hydatidosis (ICD 122.0-122.9) in hospitals of the public health service of Extremadura. RESULTS: During the period of study, 876 patients were diagnosed with hydatid disease. Of these 536 (61%) of cases were male, with a mean age of 65.53±17.8 years. More importantly, 19 (2.2%) of patients were 19 years old, with 17 cases between 2003-2007 versus 2 cases between 2008-2012 (OR=7.83; 95%CI: 1.79-34.11; P=.001). A total of 141 (16.0%) were younger than 45 years. The primary diagnosis was most frequently reported in the younger population <45 years, whereas the secondary diagnosis was usually found in the elderly population >70 years (P<.05). The incidence rate of hydatid disease obtained from Hospital Discharge Records (HDRs) was significantly higher compared to the incidence that was declared in the Notifiable Disease System of Extremadura (8.02 cases per 10(5) person-years vs. 1.88 cases per 10(5) person-years [P<.05]). CONCLUSION: In Extremadura hydatid disease is still frequent. With a clear decrease in the number of paediatric cases. The number of cases obtained from HDRs regarding Notification System Diseases Extremadura suggests the need for modifications to improve surveillance and control of hydatid disease.

Pylephlebitis: incidence and prognosis in a tertiary hospital.

OBJECTIVES: Septic thrombophlebitis of the portal vein or its branches, most often secondary to intra-abdominal infection is known as pylephlebitis. The frequency and the prognosis of this complication are unknown. The aim of this study was to determine the global and relative incidence of the most frequent intra-abdominal infections and the real prognosis of this disease. METHODS: An observational retrospective study was conducted in a tertiary care hospital (University Hospital of Salamanca, Spain) from January 1999 to December 2008. RESULTS: A total of 7796 patients with intra-abdominal infection were evaluated, of whom 13 (0.6%) had been diagnosed with pylephlebitis. Diverticulitis was the most frequent underlying process, followed by biliary infection. Early mortality was 23%. Survivors had no recurrences, but one of them developed portal cavernomatosis. CONCLUSIONS: Pylephlebitis is a rare complication of intra-abdominal infection, with a high early mortality, but with a good prognosis for survivors.

Fever of unknown origin as the first manifestation of colonic pathology.

Fever of unknown origin (FUO) is an entity caused by more than 200 diseases. Haematologic neoplasms are the most common malignant cause of FUO. Fever as a first symptom of colonic tumour pathology, both benign and malignant, is a rare form of presentation. Our work is a descriptive study of a series of 23 patients with colonic tumoral pathology who presented with fever of unknown origin. The mean age was 67.6 years; 56.5% of patients were men and 43.5% were women. Primary malignant neoplasia was the most common diagnosis. Blood cultures were positive in 45% of the samples. Coagulase-negative staphylococci were the most common cause of bacteraemia. Nine of 10 faecal occult blood tests performed were positive. Fever secondary to colon neoplasms, both benign and malignant, usually presents with a bacteraemic pattern, with positive results for blood-culture tests in a high percentage of cases.

Is babesiosis a rare zoonosis in Spain? Its impact on the Spanish Health System over 23 years.

BACKGROUND: Babesiosis is a zoonosis caused by an intraerythrocytic protozoan of the genus Babesia and transmitted mainly by ticks of the Ixodes spp. complex. There is no comprehensive global incidence in the literature, although the United States, Europe and Asia are considered to be endemic areas. In Europe, the percentage of ticks infected with Babesia spp. ranges from 0.78% to 51.78%. The incidence of babesiosis in hospitalized patients in Spain is 2.35 cases per 10,000,000 inhabitants/year. The mortality rate is estimated to be approximately 9% in hospitalized patients but can reach 20% if the disease is transmitted by transfusion. OBJECTIVE: To analyze the epidemiological impact of inpatients diagnosed with babesiosis on the National Health System (NHS) of Spain between 1997 and 2019. METHODOLOGY: A retrospective longitudinal descriptive study that included inpatients diagnosed with babesiosis [ICD-9-CM code 088.82, ICD-10 code B60.0, cases ap2016-2019] in public Spanish NHS hospitals between 1 January 1997 and 31 December 2019 was developed. Data were obtained from the minimum basic dataset (CMBD in Spanish), which was provided by the Ministerio de Sanidad, Servicios Sociales e Igualdad after the receipt of a duly substantiated request and the signing of a confidentiality agreement. MAIN FINDINGS: Twenty-nine inpatients diagnosed with babesiosis were identified in Spain between 1997 and 2019 (IR: 0.28 cases/10,000,000 person-years). A total of 82.8% of the cases were men from urban areas who were approximately 46 years old. The rate of primary diagnoses was 55.2% and the number of readmissions was 79.3%. The mean hospital stay was 20.3±19.2 days, with an estimated cost of €186,925.66. Two patients, both with secondary diagnoses of babesiosis, died in our study. CONCLUSIONS: Human babesiosis is still a rare zoonosis in Spain, with an incidence rate that has been increasing over the years. Most cases occurred in middle-aged men from urban areas between summer and autumn. The Castilla-La-Mancha and Extremadura regions recorded the highest number of cases. Given the low rate of primary diagnoses (55.2%) and the high number of readmissions (79.3%), a low clinical suspicion is likely. There was a 6.9% mortality in our study. Both patients who died were patients with secondary diagnoses of the disease.

Cavitary pneumonia and skin lesions.

Tularemia is a worldwide zoonosis caused by Francisella tularensis. The most frequent forms of tularemia are ulceroglandular, followed by typhoidal forms, glandular, and oculoglandular. Respiratory involvement is an uncommon presentation. Cutaneous lesions secondary to respiratory infections occur in 30% of cases. We present a case of tularemia with cavitary pneumonia and skin lesions.

Portal Hypertension as a Complication of Cystic Echinococcosis: A 20-Year Cohort Analysis.

Cystic echinococcosis (CE) is a parasitic disease caused by the larval forms of species of the tapeworm Echinococcus. The most common location is the liver. To assess the frequency and clinical characteristics of portal hypertension (PH) and the risk factors for PH development, we performed a retrospective observational study of inpatients diagnosed with hepatic CE and PH from January 1998 to December 2018, at Complejo Asistencial Universitario de Salamanca, Spain. Of 362 patients analyzed with hepatic CE, 15 inpatients (4.1%) had a portal vein diameter ≥ 14 mm, and the mean diameter of the portal vein was 16.9 (standard deviation [SD] ±2.1) mm. Twelve patients were men. The mean age was 59.5 years (SD ± 17.8 years). Four patients had ascites (26.6%), four had collateral circulation (26.6%), 14 had hepatosplenomegaly (93.3%), five had esophageal varices (33.3%), four had hematemesis, and three had jaundice. Other causes of PH included hepatitis B virus (1 patient) and hepatitis C virus (1 patient) infections and alcohol abuse (1 patient). The host variables associated with PH development were male sex (odds ratio, 4.6; 95% confidence interval, 1.1-20.9; P = 0.030) and larger cyst size (10.8 ± 6.3 versus 7.6 ± 4.1; P = 0.004). Hepatic CE is an infrequent cause of PH that usually occurs without indications of liver failure. Larger cyst size and male sex were the main risk factors associated with this complication. Mortality was higher for patients with hepatic CE with PH than for patients with hepatic CE without PH.

Clinical Spectrum of Schistosomiasis: An Update.

Schistosomiasis is a helminthic infection and one of the neglected tropical diseases (NTDs). It is caused by blood flukes of the genus Schistosoma. It is an important public health problem, particularly in poverty-stricken areas, especially those within the tropics and subtropics. It is estimated that at least 236 million people worldwide are infected, 90% of them in sub-Saharan Africa, and that this disease causes approximately 300,000 deaths annually. The clinical manifestations are varied and affect practically all organs. There are substantial differences in the clinical presentation, depending on the phase and clinical form of schistosomiasis in which it occurs. Schistosomiasis can remain undiagnosed for a long period of time, with secondary clinical lesion. Here, we review the clinical profile of schistosomiasis. This information may aid in the development of more efficacious treatments and improved disease prognosis.

Delusional parasitosis. A multicenter retrospective study in Spanish infectious disease services.

INTRODUCTION: Delusional parasitosis or Ekbom syndrome is a condition described mainly in the fields of psychiatry and dermatology, with a complex diagnostic and therapeutic approach. However, it is uncommon to assess patients with this disease in infectious disease units. The objective of this work is to describe the experience of three infectious diseases departments with respect to this entity. METHODS: A retrospective descriptive study of 20 patients diagnosed with delusional parasitosis in three Infectious Diseases Services was performed between 2003 and 2017. RESULTS: The median age of the patients was 54 years, with a female/male ratio of 1.5:1. In 9 patients, an endoparasitic delirium (mainly digestive) was described, in 5 an ectoparasitic form was described, and in the remaining 6, a mixed form was described. Fourteen patients presented some type of psychiatric disorder. Four patients had alcohol or drug abuse disorder. All patients had made consultations to other specialties with a median of three per patient (range 1-7). Ten patients received "empirical" antiparasitic treatment and 8 received some type of psychopharmaceutical treatment. The evolution was very variable: in 3 patients, the delusional parasitosis was resolved; in 9 patients, the clinical manifestations persisted, and the remaining patients were lost to follow-up. CONCLUSIONS: Ekbom syndrome is a common process in infectious diseases, presenting some differences with other series evaluated by dermatologists and psychiatrists. Management of this disease should promote a multidisciplinary approach to enable a joint treatment, thus optimizing patient management and therapeutic adherence.

Eosinophilia and cystic echinococcosis: what is the relationship?

BACKGROUND: Cystic echinococcosis (CE) is a chronic, complex and neglected zoonotic disease caused by Echinococcus granulosus. Eosinophilia in CE is a classic analytic alteration, although its presentation and importance is very variable and not well established. METHODS: We performed a retrospective observational study of inpatients diagnosed with CE and eosinophilia from January 1998 to December 2017 in the Complejo Asistencial Universitario de Salamanca in western Spain. RESULTS: During the study period, 475 patients with a CE diagnosis underwent a haemogram and 118 (24.8%) patients had eosinophilia. Eighty-two (69.5%) were male and the mean age was 52.1±20.8 y, which was younger in the group with eosinophilia (p<0.001). The patients with eosinophilia had less comorbidity (33.1% vs 52.9%; p<0.001) and they were diagnosed with more complications (60.2% vs 39.8% asymptomatic; p<0.001). Clinical manifestations appeared in 71 cases (60.2%). The eosinophilia was related to the presence of pre-surgical fistulas (p=0.005). We observed significant differences when considering whether eosinophilia is a marker of the type of treatment (p<0.001). CONCLUSIONS: Eosinophilia can be an indicator for an active search in CE because as much as 40% of cases are asymptomatic at diagnosis. In patients with eosinophilia, management is usually more aggressive and is usually a combined treatment. Our work shows the importance of eosinophilia in our patients with CE and raises unresolved questions.

Epidemiological scenario of Q fever hospitalized patients in the Spanish Health System: What's new.

OBJECTIVES: The objective of this study was to assess the epidemiology and burden of Q fever (QF) in Spain. METHODS: We designed a retrospective descriptive study using the minimum basic data set in patients admitted to hospitals of the National Health System between 1998 and 2015 with a diagnosis of Q fever (ICD-9: 083.0.). RESULTS: We found 4214 hospitalized patients with a mean age (±SD) of 50.9±19.3 years. The male/female ratio was 3:1. The incidence rate was between 0.41 and 0.65 cases per 100,000 person-years over the 18-year period. The highest incidence of cases was from March to August (p=0.024). 21.1% patients had pneumonia, 17.5% had liver disease, and only 3.2% had endocarditis. The average hospital stay was 13.8 days (±12.8). A total of 117 (2.8%) patients died. The total mean cost of QF is approximately €154,232,779 (€36,600±139,422 per patient). CONCLUSIONS: QF is an important zoonosis in Spain with a stable incidence rate and high cost for hospitalization. Older patients have a more severe clinical picture and higher mortality, which can be decreased with early clinical suspicion.

Murine typhus. How does it affect us in the 21st century? The epidemiology of inpatients in Spain (1997-2015).

OBJECTIVE: The aim of this study was to analyze the epidemiological impact of murine typhus in patients who required hospitalization in the National Health System (SNS) in Spain between 1997 and 2015. BACKGROUND: Murine typhus (MT) is a zoonosis caused by Rickettsia typhi. MT is transmitted from rats, cats, dogs, and opossums to humans by their fleas. The clinical picture is characterized by headache, fever, rash, and liver function alteration. The prevalence of MT is considered underestimated since most cases are mild and self-limited. However, up to 10% of patients develop serious complications such as pneumonia or acute kidney injury and may even need admission to intensive care units. METHODS: This was a retrospective longitudinal descriptive study of inpatients diagnosed with Rickettsia typhi infection (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], 081.0) in Spanish public hospitals between January 1, 1997, and December 31, 2015. Data were obtained from the Minimum Basic Data Set (MBDS, CMBD in Spanish), which includes information about inpatients admitted to the National Health System (NHS) hospitals provided by the Health Information Institute of the Ministry of Health and Equality. RESULTS: Ninety-nine inpatients were included. The incidence rate of MT was 0.12 (95% CI, 0.09-0.14) cases per one million person-years. Cases were irregularly distributed throughout the period of study, with a slight upward trend between 2013 and 2015. The Canary Islands had the highest incidence rate: 2.17 (95% CI, 1.69-2.64) cases per one million person-years (80 cases). Most patients were men (63.6%). The mean age (±SD) was 46.4 years (±19). Five patients were under 15 years old. Approximately 85.9% of cases required urgent hospital admissions. The average hospital stay was 11 days (±9.9). Only 1 patient died. CONCLUSIONS: Although considered uncommon, the incidence of MT seems to be increasing slowly. Most cases occurred in middle-aged men between late summer and early autumn in Spain. The Canary Islands and Andalusia registered the highest number of cases. The MBDS is an appropriate approach to study MT hospital management.