Evidence of exogenous reinfection and mixed infection with more than one strain of Mycobacterium tuberculosis among Spanish HIV-infected inmates.

BACKGROUND: As prisons have a high prevalence of tuberculosis and HIV infection, we studied the possibility of multiple tuberculosis infections in a selected population of HIV-infected inmates. METHODS: Two groups of patients with special characteristics were selected from 226 HIV-infected inmates diagnosed with tuberculosis in the prisons of Madrid (Spain) between 1993 and 1994. The first group contained nine patients who remained culture positive 4 months after the initiation of therapy and the second group contained 28 patients with Mycobacterium tuberculosis isolated from different anatomical sites. DNA typing with IS6110 was performed on all isolates from these patients. In some patients a secondary DNA typing with the plasmid pTBN12 was performed. RESULTS: Two patients from group A had a second M. tuberculosis strain obtained 4 and 18 months after the initial isolate, with different IS6110 and pTBN12 patterns. In one patient the second strain was multidrug resistant and in the other patient both strains had the same drug-susceptible pattern. The clinical and microbiologic evidence in both patients was consistent with the presence of active tuberculosis caused by a new strain of M. tuberculosis. In group B, the isolates from 27 patients shared similar fingerprint pattern; however, in one patient isolates from sputum and urine showed different IS6110 and pTBN12 patterns, although both strains showed the same drug-susceptible phenotype. CONCLUSION: This study provides evidence that HIV-infected inmates living under conditions of high environmental infectivity can be infected with two different strains of M. tuberculosis. This finding has implications for the tuberculosis-control programs in prison.

rpoB mutations as an epidemiologic marker in rifampin-resistant Mycobacterium tuberculosis.

SETTING: Cases of rifampin-resistant Mycobacterium tuberculosis from the prison population in Madrid and from the general population in Spain. OBJECTIVE: To identify the rpoB mutations associated with resistance to rifampin and to investigate rpoB genotyping as an epidemiological marker in rifampin-resistant M. tuberculosis. DESIGN: Twenty-nine rifampin-resistant clinical isolates of M. tuberculosis, 15 obtained from the prison population in Madrid and 14 from the general population in Spain, were characterized by sequence analysis of the 81-bp core region of the rpoB gene and IS6110 DNA fingerprinting. RESULTS: All the isolates had mutations in rpoB, with those in codon 531 accounting for 41% of the total. Twenty-three (79%) isolates were highly resistant to rifampin (minimum inhibitory concentration > or = 64 mg/L). Nineteen different IS6110 fingerprints were observed: one was shared by seven isolates, one by three, two by two, and 15 were unique. Two IS6110 clusters could be divided into subclusters on the basis of rpoB analysis. Epidemiologic links were identified among patients whose isolates had identical IS6110 patterns and rpoB genotypes, but not between those with identical IS6110 patterns and different rpoB genotypes. CONCLUSION: Characterization of rpoB mutations can provide information about susceptibility to rifampin and be a useful epidemiological tool for discrimination of rifampin-resistant strains of M. tuberculosis with identical IS6110 fingerprints.

The influence of HIV infection and imprisonment on dissemination of Mycobacterium tuberculosis in a large Spanish city.

SETTING: Culture-positive cases of tuberculosis (TB) from the urban population of southern Madrid and from all the prisons located throughout the city. OBJECTIVE: To determine the frequency with which common strains of Mycobacterium tuberculosis cause disease among patients from both the urban and prison populations of a large Spanish city. DESIGN: Restriction fragment length polymorphism analysis was performed on culture-positive cases of TB identified between 1 January 1997 and 31 December 1998. Risk factors that might be associated with the dissemination of common strains of TB among the two populations were also investigated. RESULTS: Two hundred and twenty-one cases of culture-positive TB were identified, 99 (47.8%) of which were grouped in 23 clusters. Eleven were general clusters that spanned the prison and urban populations involved 69 patients (31.2%). Univariate analysis of risk factors showed that age <35 years, human immunodeficiency virus (HIV) infection, intravenous drug use and current or previous imprisonment were all associated at a statistically significant level with inclusion in general clusters. The final logistic regression model showed an interaction between HIV infection and incarceration. CONCLUSIONS: Dissemination of common strains of M. tuberculosis between prison inmates and the urban population of Madrid is significant, and involves subjects with a history of imprisonment and HIV infection.

[Transmission of tuberculosis in the prisons of Madrid]. / Transmisión de la tuberculosis en las prisiones de Madrid.

BACKGROUND: Prisons are recognized as high-risk settings for tuberculosis transmission. The purpose of this study was to describe the characteristics of prisoners with tuberculosis and to determine the extent of transmission of tuberculosis in the prison population of Madrid. PATIENTS AND METHODS: Patients with positive culture for Mycobacterium tuberculosis between 1997 and 1998 from the prison system of Madrid were included. The medical records for these patients were reviewed, and they were also interviewed. Patients were included in clusters when their isolates contained 1) six or more IS6110 bands in an identical pattern or 2) five or fewer IS6110 bands that matched identically and had an identical spoligotyping pattern. RESULTS: Culture-proven tuberculosis was diagnosed in 97 prisoners (case rate: 693 per 100.000 per year). Isolates from 73 (75%) patients were available for fingerprinting. The mean age of these patients was 33 yr (SD: 6,9), 92% were male, and 14% were immigrants. Seventy-one percent (71%) of patients were HIV-positive, 32% were active intravenous drug users and 70% nonintravenous drug users in the last two years. Primary drug resistance to isoniazid was 1,8%. Forty-one percent of prisoners (41%) were grouped in 9 clusters. Epidemiological links were found in 37% of clustered patients. Risk factors for clustering were not detected. CONCLUSION: The results suggest recent transmission of tuberculosis in the prisons of Madrid. It is essential that correctional facilities comply fully with the recomendations for prevention and control of tuberculosis.

[Resistant tuberculosis in a prison population during 1991-1993]. / Tuberculosis resistente en una población penitenciaria durante el período 1991-1993.

BACKGROUND: To know the prevalence of resistant tuberculosis and the characteristics of the same in the penitentiary medium in the Madrid area (Spain). METHODS: From March 1, 1991 to August 31, 1993 a prospective study was carried out in patients with isolations of Mycobacterium tuberculosis resistant to some of the common antituberculous drugs within the context of tuberculosis in a penitentiary population attended in the Hospital General Penitenciario (Madrid). Demographic, clinical, analytical, and microbiological data were collected as was that on the antituberculous treatment used. The study of sensitivities was performed by the proportions method. RESULTS: Tuberculosis was diagnosed in 275 patients according to strict microbiological criteria (positive Löwenstein culture). The antibiogram was performed in 218 isolations. Twenty strains resistant to some first line antituberculous drug (9%) (confidence interval [CI] p < 0.05:6-14), 9 of which were found to be multiresistant, were detected in 20 patients. Out of the patients in whom the sensitivity of the isolate was known, 173 had not previously undergone antituberculous treatment. Six of these patients were found to be resistant to isoniazide (3.5%) (CI p < 0.05:1.4-7.7) and 2 patients were resistant to rifampicin (1.2%) (CI p < 0.5:0.2-4.5). The other 45 patients had previously undergone antituberculous drugs with 8 isolates presenting resistance to isoniazide and 11 to rifampicin. Eighty-four percent of the patients with resistant tuberculosis and 90% of the sensitive cases were coinfected with HIV infection with the differences not being statistically significant. The HIV positive patients with resistant tuberculosis showed a mean CD4 positive lymphocytes of 0.76 x 10(9)/l (CI p < 0.5:0.028-0.213) and those with sensitive tuberculosis had 0.165 x 10(9)/l (CI p < 0.05:0.133-0.196) (p < 0.01). CONCLUSIONS: Tuberculosis resistant to common antituberculous drugs was detected in a Spanish penitentiary population. The level of the resistance of the isolations of Mycobacterium tuberculosis should be monitored both inside and outside of the penitentiary medium in an attempt to avoid the progression of resistant tuberculosis within the Community.

[Recent transmission of tuberculosis in Madrid (Spain): usefulness of molecular techniques]. / Transmisión reciente de la tuberculosis en Madrid: utilidad de las técnicas moleculares.

BACKGROUND: Recent studies suggest that many tuberculosis cases in urban areas result from recent transmission. The aim of this study was to determine patterns of tuberculosis transmission in Madrid. PATIENTS AND METHODS: A prospective population-based molecular epidemiological study of patients diagnosed of tuberculosis was conducted in three urban districts of Madrid (455.050 inhabitants) during 1997-1998. Clinical, demographic and epidemiological data were reviewed. Patients were included in clusters when their isolates contained: a) six or more IS6110 bands in an identical pattern, or b) five or fewer IS6110 bands that matched identically and had an identical spoligotyping pattern. RESULTS: Of 207 positive-culture patients, 148 (71,5%) were DNA fingerprinted. A total of 18 clusters which included 62 patients (41,9%) were identified. Clusters contained between 2 and 12 cases. Risk factors for clustering included: age < 35 years (OR = 4,1, 95% CI: 1,9-8,9), injection drug use (OR = 4,7, 95% CI: 1,6-14,8), HIV infection (OR = 2,7, 95% CI: 1,1-6,8), and a history of imprisonment (OR = 2,9, 95% CI: 1,2-7,2). The epidemiological investigation identified connections among 27% of clustered patients. CONCLUSIONS: A high proportion of cases of tuberculosis in urban Madrid result from recent transmission. Molecular epidemiology studies give valuable information for urban tuberculosis control.

[Fosfomycin: an underrated antibiotic for urinary tract infections due to Escherichia coli]. / Fosfomicina: un antibiótico infravalorado en infecciones urinarias por Escherichia coli.

OBJECTIVES: To evaluate the sensitivity patterns of Escherichia coli isolates obtained from urine specimens from patients with community-acquired urinary tract infections, with a special emphasis on fosfomycin trometamol for the treatment of UTI. METHODS: Retrospective analysis of the sensitivity pattern of 16,227 E. coli isolates recovered from urine cultures performed at the Microbiology Laboratory of Madrid Area 11 from 1997 to 2000. The antimicrobial agents tested included ampicillin, amoxycillin-clavulanate, cephalotin, cefuroxime, trimethoprim-sulphamethoxazol, fosfomycin trometamol, nitrofurantoin, and ciprofloxacin. Antibiotic sensitivity testing was performed with the Vitek automatic microdilution system (bioMèrieux, France). RESULTS: E. coli represented 80.1% of all uropathogens recovered. The percentages of sensitive strains to ampicillin, amoxycillin-clavulanate, cephalotin, cefuroxime, trimethoprim-sulphamethoxazol, nitrofurantoin, and ciprofloxacin were 42.25%, 81.5%, 58.75%, 87.5%, 70%, 94.75%, and 84.75%, respectively. Fosfomycin trometamol was the antibiotic with the highest activity against E. coli, with 95.5% of sensitive isolates. CONCLUSIONS: Fosfomycin trometamol (single dose) is a good alternative that should be considered for the treatment of non-complicated lower urinary tract infections.

[Microbiological study of some microorganisms implicated in sexually transmitted diseases among the female prison population]. / Estudio microbiológico de ciertos microorganismos implicados en las enfermedades de transmisión sexual de la población femenina penitenciaria.

BACKGROUND: Sexually transmitted diseases (STD) are of over greater interest, particularly since the appearance of the human immunodeficiency virus ( HIV) in the last decade. Asymptomatic or oligosymptomatic infections are very frequent, overall in women. The aim of this study was to know the prevalence of certain STD producing microorganisms in a female penitentiary population, the clinical characteristics and evaluate the risk factors which may be found in this population. METHODS: One hundred thirty-three female prisoners attended in the Gynecology Ward of the Female Penitentiary of Carabanchel of Madrid, Spain, were studied over 13 months (from 30 April 1993 to 30 May, 1994). Vaginal and endocervical samples were taken in each case for microbiologic study by the usual methods. Demographic and clinical data were collected as were possible risk factors for acquiring STD (age of first sexual relations, sexual habits, intravenous drug addiction.

[Tricuspid endocarditis caused by penicillin-resistant Staphylococcus aureus: 2 cases in parenteral drug addicts]. / Endocarditis tricúspide por Staphylococcus aureus sensible a la penicilina: 2 casos en adictos a drogas por vía parenteral.

BACKGROUND: Staphylococcus aureus is the main causal agent of infectious endocarditis (IE) in intravenous drug addicts (IVDA) with most of the strains, isolated in Spain being resistant to penicillin and sensitive to methycillin, although the latter condition varied in recent years. Two cases of IE caused by S. aureus strains sensitive to penicillin in IVDA are presented. METHODS: All bacteremia episodes diagnosed in the Hospital General Penitenciario (Madrid) over a 33-month period (March 1991 to December 1993) were prospectively studied. Special attention was given to patients diagnosed of IE. Blood cultures were processed according to the usual technique by a non radiometric system. RESULTS: One hundred and four bacteremias were detected with 14 being produced by S. aureus. Ten episodes of the total number of bacteremias fulfilled criteria for IE with 2 being produced by strains of S. aureus sensitive to penicillin (CMI < 0.06 mu/ml). Both patients had coinfection by HIV. The clinical evolution prior to diagnosis was prolonged although clinical and microbiologic cure were achieved with intravenous beta-lactam antibiotics treatment, without complications. CONCLUSIONS: Despite the low incidence of the isolation of Staphylococcus aureus sensitive to penicillin (< 3%) recently observed in Spain, strains producing severe infections, showing patterns of sensitivity such as those found during the preantibiotic era, may still be isolated.

Mutations in the rpoB gene of rifampin-resistant Mycobacterium tuberculosis isolates in Spain and their rapid detection by PCR-enzyme-linked immunosorbent assay.

Genetic alterations in the rpoB gene were characterized in 50 rifampin-resistant (Rif(r)) clinical isolates of Mycobacterium tuberculosis complex from Spain. A rapid PCR-enzyme-linked immunosorbent assay (ELISA) technique for the identification of rpoB mutations was evaluated with isolates of the M. tuberculosis complex and clinical specimens from tuberculosis patients that were positive for acid-fast bacilli (AFB). Sequence analysis demonstrated 11 different rpoB mutations among the Rif(r) isolates in the study. The most frequent mutations were those associated with codon 531 (24 of 50; 48%) and codon 526 (11 of 50; 22%). Although the PCR-ELISA does not permit characterization of the specific Rif(r) allele within each strain, 10 of the 11 Rif(r) genotypes were correctly identified by this method. We used the PCR-ELISA to predict the rifampin susceptibility of M. tuberculosis complex organisms from 30 AFB-positive sputum specimens. For 28 samples, of which 9 contained Rif(r) organisms and 19 contained susceptible strains, results were concordant with those based on culture-based drug susceptibility testing and sequencing. Results from the remaining two samples could not be interpreted because of low bacillary load (microscopy score of 1+ for 1 to 9 microorganisms/100 fields). Our results suggest that the PCR-ELISA is an easy technique to implement and could be used as a rapid procedure for detecting rifampin resistance to complement conventional culture-based methods.

[Intestinal parasitoses in the prison population in the Madrid area (1991-1993)]. / Parasitosis intestinales en la población penitenciaria del área de Madrid (1991-1993).

BACKGROUND: Intestinal parasitoses are frequent in populations in tropical and subtropical areas, HIV infection has favoured an increase in the prevalence of some of these parasitoses . Both conditions concur in innate populations. The aim of this study was to determine the prevalence and clinical characteristics of the intestinal parasitosis in a penitentiary population from the Madrid area. METHODS: On the basis of the data from the Laboratory of Clinical Microbiology in the Hospital General Penitenciario, patients with the diagnosis of intestinal parasitosis were retrospectively reviewed. The study period covered 29 months (from 1/8/91 to 31/12/93). Samples were taken from patients admitted to, and attended, in the outpatient area of this hospital in addition to those held in dependents prisons. Processing was done by direct macroscopic and microscopic visualization (400x) of the sediment obtained by the formol-ether concentration method (Ritchie). Modified Ziehl staining was carried out. Demographic, clinical-evolutive and microbiologic data of the patients were analyzed. RESULTS: One thousand two hundred eighty-one samples corresponding to 1,033 patients were studied 131 (10.2%) positives corresponding to 96 (9.3%) patients were observed. 88.5% (n = 85) were males. The mean age was 31.2 years (CI 95%: 29.3-32.9). The patients were from Europe in 39.7% of the cases (Spain: 94%), Africa 28.9% and Latin America 28.9%. Twenty-five patients were HIV+ (46%) with a mean CD4 count of 160/mm3 (CI 95%: 65-255) and 29 were HIV-. Globally, the most frequently found parasites were uncinaria (22%), Giardia lamblia (21%) and Cryptosporidium parvum (20%). One case of intestinal capillariasis was diagnosed. Fifteen mixed parasitoses (15.6%) were observed and the most frequent association was Trichuris trichiura and uncinaria in 8 patients (5 HIV+ and 3 unknown HIV). Clinical manifestations were present in 63.7% (42/66) of the patients with diarrhea being the most frequent (25 cases). In patients in whom the clinical evolution could be evaluated, it was favorable in most of the cases except in those with Cryptosporidium parasitosis. CONCLUSIONS: Intestinal parasites are of relevance within a prison population, presenting some differences to the intestinal parasites observed in a general population. The most frequently observed parasite was uncinaria in HIV- patients and Cryptosporidium parvum in HIV+ patients. Mixed parasitosis was not infrequent (15.6%). 25% of the intestinal parasitosis are asymptomatic. When symptomatology does exist, diarrhea is the most common clinical manifestation. The clinical evolution is usually favourable with the exception of some cases of diarrhea by Cryptosporidium in severely immunosuppressed HIV+ patients.

Clinical significance of splenic tuberculosis in patients infected with human immunodeficiency virus.

To assess the clinical significance of splenic tuberculosis in patients infected with human immunodeficiency virus (HIV) type 1, we compared 20 patients who had splenic tuberculosis with 20 randomly selected, HIV-infected patients with culture-proven tuberculosis for whom splenic involvement had been ruled out by ultrasonography. All of the patients were male prison inmates and intravenous drug users. Statistically significant differences (P < .05) were detected between patients with splenic involvement (median CD4+ cell count, 54/mm3) and those without splenic involvement (median CD4+ cell count, 92/mm3). No specific symptoms suggesting splenic involvement were detected in the patients with splenic tuberculosis. All patients received antituberculous drugs, and none of these patients required splenectomy. The median survival was similar in both groups. Splenic tuberculosis occurs in more-severely immunocompromised HIV-infected patients, the prognosis is generally good, the clinical response to therapy is usually favorable, and splenectomy is rarely necessary.

[Primary cutaneous cryptococcosis and bacterial pneumonia caused by Pseudomonas aeruginosa in AIDS: clinical case and review of the literature]. / Criptococosis cutánea primaria y neumonía bacteriémica por Pseudomonas aeruginosa en el sida: caso clínico y revisión de la literatura.

BACKGROUND: Clinically symptomatic infection due to Cryptococcus neoformans is found in 5-10% of patients with AIDS. It usually appears as meningitis with or without associated blood stream infection. In the last years, severe Pseudomonas aeruginosa infections in HIV (+) patients, with a high morbidity and mortality, are increasingly reported. MATERIALS AND METHODS: A 27 year-old male HIV (+) patient, with previous opportunistic infections, was referred because of a nodular lesion on his left wrist, with an axillar homolateral lymph node of long-term evolution. Cryptococcus neoformans var. neoformans was isolated in pure culture from the lesion. Disseminated infection or affection of other organs was ruled out. Therapy with intravenous amphotericin B was initiated, but the patient developed an early nosocomial bacteremic pneumonia due to P. aeruginosa with a fatal outcome. A review of the literature about both complications in AIDS is carried out. RESULTS: The fungal clinical picture is compatible with primary cutaneous cryptococcosis that is a rare condition (12 clinical reports until 1993), of which only one case report in an AIDS patient has been described in 1994. Since 1990 severe infections due to P. aeruginosa in HIV(+) patients are increasingly reported, and pneumonias, bacteremias, catheter-related sepsis, urinary tract infections, intraabdominal infections, central nervous system and othorrhinolaryngologic infections have been described in patients with AIDS in the English-language literature. CONCLUSIONS: Primary cutaneous cryptococcosis is another rare form of infection with C. neoformans in patients with AIDS. The increasingly reported cases of severe infections due to P. aeruginosa could have important implications in the therapy of patients with AIDS.

[Campylobacter jejuni infections in a prison population coinfected with the human immunodeficiency virus]. / Infecciones por Campylobacter jejuni en población reclusa coinfectada por el virus de la immunodeficiencia humana.

BACKGROUND: Campylobacter jejuni is a common etiological agent of diarrhea in the general population. In recent years it has also been involved as etiological agent of intestinal and extraintestinal infections in patients infected with the human immunodeficiency virus (HIV). The clinical and microbiological features in a series of HIV+ patients infected with C. jejuni in a correctional facility are here reported. METHODS: Retrospective analysis of clinical records of patients who had C. jejuni recovered from clinical samples diagnosed at the Hospital General Penitenciario (HGP), Madrid, for 2 years (10-1-1991 to 9-30-1993). C. jejuni strains were identified at the Clinical Microbiology Department at the HGP following standard methods. Antibiotic sensitivity testing was performed by the agar dilution and microdilution methods. RESULTS: Twenty-eight patients were diagnosed as being infected with C. jejuni. The mean age was 32.4 years (95% CI: 30.1-34.7). Twenty-seven patients (96%) were males. Twenty-five patients (90%) were intravenous drug users (IVDU). Sixty-one percent of cases clustered in the september and october months. The main clinical symptoms were diarrhea with no pathological products and fever. Mean lymphocyte CD4+ count was 103/mm3 (95% CI: 45-162). Blood cultures were obtained from 13 patients, and bacteremia was detected in three of them (23%), with no associated mortality. Forty-eight percent of C. jejuni strains were resistant to fluorquinolones, and all of them were susceptible to erythromycin. The latter antibiotic was used as therapy in 82% of patients and clinical and microbiological cure was achieved in all 17 patients who were evaluated at follow-up. CONCLUSIONS: Campylobacter jejuni is an important enteropathogen in correctional facility population infected with HIV, which in this study involved severely immunosuppressed patients. The main clinical presentation was acute enterocolitis and bacteremia (detected in 23%), a higher percentage than that reported in the literature. An increased quinolone-resistance rate was detected (48%). Erythromycin, and possibly the new macrolides, are currently the antibiotics of choice.

Mixed oropharyngeal candidiasis due to Candida albicans and non-albicans Candida strains in HIV-infected patients.

In order to determine the clinical significance of mixed oropharyngeal candidiasis (Candida albicans plus a non-albicans strain of Candida) in patients infected with HIV-1, a retrospective chart review was done in 12 HIV-1-infected patients with a clinical episode of oropharyngeal candidiasis, in whom a mixed culture of Candida albicans (found to be fluconazole-sensitive) plus a non-albicans species of Candida was obtained from their oral cavities. This group was compared with 26 HIV-positive patients (control group) with oropharyngeal candidiasis due to Candida albicans (found to be fluconazole-sensitive). Antifungal susceptibility testing was performed by a broth microdilution test with RPMI-2% glucose. A fungal strain was considered fluconazole-sensitive if its MIC was < 0.5 micrograms/ml. Both the study and control groups had similar clinical and demographic characteristics. All the patients were severely immunocompromised, with a mean CD4+ lymphocyte count of 63/mm3 (95% CI 41-84) and 80/mm3 (95% CI 25-135) in the study and control groups, respectively. In the study group, seven patients had Candida albicans and Candida krusei in their oral cavity, four had Candida albicans and Candida glabrata, and one had Candida albicans and Candida tropicalis. Antifungal therapy consisted of ketoconazole (5 patients in the study group, 14 in the control group) or fluconazole (7 patients in the study group, 12 in the control group); no statistically significant difference in clinical outcome was observed. Fungal strain persistence after therapy was frequently observed in both groups. It is concluded that non-albicans strains of Candida, less sensitive to azole drugs than their Candida albicans counterparts, are not clinically relevant in episodes of mixed oropharyngeal candidiasis in HIV-1-infected patients.