Infectious arthritis in patients with rheumatoid arthritis.

Eleven cases of infectious arthritis occurring in patients with rheumatoid arthritis are reported. Staphylococcus aureus was the causative organism in eight patients. Streptococcus anginosus and Streptococcus agalactiae in one patient each, and Mycobacterium tuberculosis in two patients. The mean duration of symptoms before diagnosis was 16 days in patients with pyogenic arthritis. The diagnosis of joint infection caused by Mycobacterium tuberculosis was especially delayed (57 days). Four patients died; they were found to have a longer time to diagnosis and two of them had multiple joint infection. Although Staphylococcus aureus is the microorganism most often affecting patients with rheumatoid arthritis, infection caused by Mycobacterium tuberculosis must also be considered in such patients.     

The spectrum of pneumonia in 1983 at the Riyadh Armed Forces Hospital

The agents causing pneumonia have been assessed in 112 adult patients admitted to the Armed Forces Hospital in Riyadh during a period of one year: pathogens were identified in 78 patients (69.6%). Sputum culture produced a significant isolate in 60 patients (53.5%), and in 17 (15.2%) the causative agent was suggested by serological tests. Streptococcus pneumonia was the commonest infecting agent (21.4%). Pneumonia due to Mycobacterium tuberculosis was diagnosed in eight patients, to Mycoplasma pneumoniae in seven, to Chlamydia psittaci in two and to Legionella pneumophila in one. Three renal transplant patients had pneumonia caused by Staphylococcus aureus, cytomegalovirus and Pneumocystis carinii respectively, the latter diagnosed by lung biopsy. Two patients with acute Brucella melitensis infections developed pneumonia. In 34 patients (30.4%) the causative organism was not identified. Most of the epidemiological and aetiological factors studied in this survey are inconsistent with previous reports on pneumonia from western countries. For example, the commonest age group affected was younger than in western series. Tuberculous and brucella pneumonia, not commonly seen in western countries, are diagnoses to be considered in Saudi Arabia.     

Characteristics of B. melitensis versus B. abortus bacteraemias

OBJECTIVE: To determine the epidemiological and the clinical characteristics of bacteremic brucellosis. METHODS: A prospective study, performed in the First Infectious Diseases Clinic of Ankara Numune Education and Research Hospital. All the patients had positive culture result for Brucella spp. RESULTS: Fifty-four acute bacteremic brucellosis cases were included. The majority of patients (76%) were from rural Anatolia. Brucella melitensis serotypes were more common than Brucella abortus (83% versus 17%). Fever and arthralgia were the most common symptoms. The number of patients with back pain and arthralgia was higher in B. abortus infected group (p = 0.014 and p = 0.009). CONCLUSIONS: B. melitensis is the most common subtype of Brucella infection in Turkey. The infections with B. abortus spp. are not less severe than the infections with B. melitensis.     

The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study

OBJECTIVE: To assess the clinical and microbiological characteristics of septic bursitis in those cases that required treatment at the hospital during the past 10 years in a northwestern area of Spain. METHODS: The charts of all patients diagnosed as having septic bursitis at Hospital Xeral-Calde, Lugo, Spain, from October 1987 through September 1997 were reviewed based on published criteria and graded according to severity. RESULTS: Sixty-nine patients diagnosed with definite and 6 with probable septic bursitis met the criteria for severe septic bursitis. Sixty-two were male (82.7%). The mean age at the time of diagnosis was 51 years. The most frequently involved sites were olecranon (47%) and prepatellar (44%) bursae. Among predisposing factors, the presence of prepatellar bursitis was correlated with a job that involved frequent trauma on the bursae. The main clinical and laboratory findings were cellulitis and/or erythema (94.7%), fever (77.3%), and leukocytosis (72%). Noninflammatory synovial fluid (SF, < 2,000 leukocytes/mm3) was observed in 4/32 (12.5%) cases. Positive SF cultures were obtained in 69 of 75 patients (92%). Staphylococcus aureus was the most common pathogen (84%). Blood cultures were positive in 12 of 62 patients (19.4%). Three patients had osteomyelitis. This complication was associated with a longer delay to diagnosis from the onset of symptoms (> 3 weeks vs 9.3+/-13.3 days for the group as a whole). Apart from these 3 cases, overall outcome was excellent. CONCLUSION: Severe septic bursitis is a common disease. Local trauma is the most common risk factor for this infection. Although the most common pathogen is S. aureus, other pathogens such as Brucella abortus play an important role in this infection in our area.     

Osteomyelitis in patients with systemic lupus erythematosus

OBJECTIVE: To investigate the clinical profile of and the risk factors for osteomyelitis in patients with systemic lupus erythematosus (SLE). METHODS: We reviewed 11 consecutive cases of patients with SLE who had also had osteomyelitis between 1981 and 2001 at a medical center in Taiwan, with special attention to predisposing factors, clinical features, laboratory values, and outcomes. RESULTS: The mean age at diagnosis of osteomyelitis was 34.5 +/- 22.0 years and the ratio of females to males was 9:2. The typical initial manifestations were nonspecific focal pain (82%) and fever (64%). The most commonly affected sites were the long bones (6 cases, 54%), followed by the vertebrae (4 cases, 36%). Salmonella (5 cases, 45%) and Staphylococcus aureus (4 cases, 36%) were the major causative organisms. Interestingly, once long bones had become involved, 5 of 6 (83%) isolates proved to be Salmonella, and for vertebral osteomyelitis, 3 of 4 (75%) isolates proved to be S. aureus. Predisposing factors include an active status of SLE (SLEDAI score >/= 4, 100%), coexistent underlying systemic disease (91%), chronic renal disease (82%), and intensified immunosuppressive agent usage (82%). Laboratory values either reflected an acute phase reaction that would be expected in an infection, such as a raised C-reactive protein (100%) and neutrophilia (55%), or reflected features consistent with active lupus disease. Four patients had longterm motor deficits and another patient died. Poor prognostic factors include delayed diagnosis, vertebral involvement, artificial implants in bones, and chronic carrier status. CONCLUSION: In patients with SLE who present with local osteoarticular pain, particularly those whose disease is active and who also have chronic renal disease and were taking intensified immunosuppressive agents, osteomyelitis must be considered seriously. Salmonella should be considered as a potential contributing pathogen for long bone osteomyelitis and S. aureus should be considered for cases of vertebral osteomyelitis when conducting empirical antimicrobial therapy. Early recognition and treatment is essential to avoid longterm sequelae or death.     

Primary sternal osteomyelitis in a healthy child due to community-acquired methicillin-resistant Staphylococcus aureus and literature review

Primary sternal osteomyelitis is a rare condition. Most of the recent cases have been reported in intravenous drug abusers. A 4-y-old male case of primary sternal osteomyelitis due to community-acquired methicillin-resistant Staphylococcus aureus with no apparent risk factors is reported. The diagnosis should be suspected in a young patient presenting with acute inflammatory swelling over the sternum. While bacteriological culture results are pending, antibiotic therapy with Staphylococcus aureus coverage should be initiated empirically and the possibility of community-acquired methicillin-resistant S. aureus must be borne in mind. In this report we also review the literature of paediatric primary sternal osteomyelitis.     

Musculoskeletal infections in intravenous drug addicts: report of 34 cases with analysis of microbiological aspects and pathogenic mechanisms

OBJECTIVE: To analyse characteristics of musculoskeletal infections in Spanish intravenous (i.v.) drug addicts. METHODS: A retrospective analysis of 34 medical records was carried out and the aetiologic agent was confirmed in all cases. RESULTS: The mean age was 26 years and the sex ratio was 25M/9F. Twenty-four patients were HIV-positive and 10 HIV-negative. There were no differences between the 2 subgroups. Septic arthritis, seen in 27 cases (79%), was the most common type of infection. Axial involvement was present in 23 cases (67%). The organisms isolated included Staphylococcus aureus (25 cases), Candida albicans (3 cases), Mycobacterium tuberculosis (2 cases), and Neisseria gonorrhoeae, Salmonella typhi, Staphylococcus epidermidis and Streptococcus pyogenes in one case each. Candida albicans affected the sternocostal joints. Laboratory data showed non-specific findings. The outcome was mostly good and only one patient died. CONCLUSION: Human immunodeficiency virus does not affect characteristics of musculoskeletal infections in i.v. drug addicts. Staphylococcus aureus is the most frequently isolated pathogen in this population.     

Clinical suspicion of vertebral osteomielitis: back pain in patients with hemodyalisis by catheter related infection

The overall incidence of vertebral osteomyelitis is increasing due to, the increasing rates of bacteraemia due to intravascular devices. We report a patient with end-stage renal failure under hemodialysis by internal jugular catheters who started with back pain after several episodes of Staphylococcus aureus bacteraemia, and whose magnetic resonance imaging was showed signs suggestive of spondylodiscitis. Other 4 similar cases from our service have been analysed, thereby we can conclude the most effective treatment of vertebral osteomyelitis and/or epidural abscess is premature diagnosis of these pathologies. Magnetic resonance imaging is the most sensitive radiologic technique whom we have. Treatment of vertebral osteomyelitis must be preceded by a correct bacteriological diagnosis. Surgery plays a central role in the successful treatment and should be performed as soon as neurological problems are apparent.     

Comparison of microbiological results of needle puncture vs. superficial swab in infected diabetic foot ulcer with osteomyelitis.

AIM: To study prospectively two methods for the bacteriological diagnosis of osteomyelitis related to diabetic foot ulcer: needle puncture performed across normal skin surrounding the foot ulcer and superficial swabbing of the ulcer. PATIENTS AND METHODS: Diabetic patients with a foot ulcer complicated by bone or joint infection, as detected by X-ray imaging, were included in the study. Ulcer swabbing and needle puncture were performed in each patient. To reach the tissue nearest the bone surface, needle puncture was guided by X-ray imaging and the drop of fluid obtained by aspiration was used for both aerobic and anaerobic bacterial culture. RESULTS: Twenty-one diabetic patients were included. The mean number of microorganisms isolated by needle puncture was significantly lower compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P < 0.02). Three bacterial species were isolated by needle puncture only in one patient while three or more bacterial isolates were obtained by superficial swabbing in six patients. No bacterial isolate was detected in five patients by needle puncture and in two patients by superficial swabbing. Staphylococcus aureus accounted for 70% of cases (seven patients) when a single bacterial species was obtained by needle puncture. After needle puncture, no wound complication or infection was observed. CONCLUSION: Culture of samples obtained by needle puncture revealed one or two bacterial isolates in two-thirds of diabetic patients with osteomyelitis following foot ulcer. Given the lack of complications, this invasive diagnostic technique should be considered for deep direct sampling in diabetic patients with osteomyelitis related to foot ulcer when surgical debridement is contraindicated or delayed.     

Non-tuberculous mycobacteria disease as a cause of hospitalization in HIV-infected subjects.

OBJECTIVES: The present study characterized and determined the prevalence of mycobacterial diseases (tuberculosis (TB) and non-tuberculous mycobacteria (NTM)) as a cause of hospitalization among HIV-infected subjects consecutively admitted to a large metropolitan hospital during 2001/2002. METHODS: Hospital discharge diagnoses were established for 521 HIV-positive patients. RESULTS: Respiratory disease accounted for 49% of the admissions. Community acquired pneumonia (CAP) was the main cause of respiratory disease (52%) followed by Pneumocystis carinii (PCP, 24%), non-tuberculous mycobacteria (NTM, 11%) and Mycobacterium tuberculosis (TB, 9%). Mycobacterium tuberculosis disease was established using bacteriological, clinical and radiographic criteria. NTM disease was defined following the American Thoracic Society criteria. NTM was disseminated in the majority of cases (19 Mycobacterium avium complex (MAC), one Mycobacterium kansasii). Nine patients had respiratory disease (seven MAC, one Mycobacterium fortuitum, one Mycobacterium kansasii) and one had gastrointestinal disease caused by MAC. Mortality was 10% for NTM disseminated cases; none of the TB patients died over the course of the study. The length of hospitalization for NTM patients was longer (15+/-13 days) than for other respiratory cases (10+/-10, p=0.04). CONCLUSIONS: NTM disease along with its related mortality is a significant pathology as a cause of hospitalization among HIV-infected individuals.     

Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95

Vertebral osteomyelitis (VO) is a rare condition and the diagnosis is often overlooked initially. Delay in diagnosis may result in vertebral destruction or perforation of the spinal canal. We suggest diagnostic criteria in order to simplify the diagnosis and classification of VO. Medical records of 58 patients with VO from G?teborg during the years 1990-95 were studied retrospectively. The incidence, clinical presentation, microbiology and treatment of VO were evaluated. The median age at the time of admission was 59 y (range 13-83 y) and the male:female ratio was 1.6:1. The incidence was 2.2/100,000 inhabitants/y. Sixty-four percent of the patients were natives of Sweden. The patients were classified as definite (67%), probable (26%) and possible (7%) VO. Staphylococcus aureus was the most common infective agent (34%), followed by Mycobacterium tuberculosis (27%). The most common risk factors included recent or current infections, immunosuppressive diseases and previous surgery. CRP and ESR were elevated in 82% and 88% respectively and plain X-ray changes indicating VO were found in 56% of the patients. Radiological changes were found in 34/44 (77%) computerized tomography scans and 10/13 (77%) magnetic resonance imaging examinations. The median duration of intravenous and oral antibiotic treatment were 10 and 179 d respectively. A delay of > I month from the onset of symptoms until diagnosis was found in 38% of the patients. This indicates the need for a standardized protocol for diagnosing VO. In this paper we suggest diagnostic criteria, which have not previously been available.     

Osteoarticular and muscle infectious lesions in patients with the human immunodeficiency virus

Summary Between 1988 and 1995, 1832 HIV positive patients were evaluated in our institution. We studied the epidemiologic, immunologic and bacteriologic data, laboratory tests, and X-Ray films in those with musculoskeletal infection. We reviewed twenty-one cases of musculoskeletal infection in twenty patients aged 23–35 years (mean 28,6 years, M:F=15:5). In all of them risk factor for HIV was intravenous drug abuse. The number of CD4 positive lymphocytes ranged from 0,003 to 0,5 10⁹/l. Staphylococcus aureus was the organism responsible of the infection in twelve cases, all active intravenous drug abusers at the time the diagnosis was done. The remaining causative agents were: Mycobacterium tuberculosis (3 cases), Candida albicans (2 cases), Salmonella subgroup 1 (1 case), Neisseria gonorrhoeae (1 case), Pseudomona aeruginosa (1 case) and Streptococcus agalactiae (1 case). Fifteen infections were diagnosed between 1988 and 1991 and 6 between 1992 and 1995. Musculoskeletal infectious lesions in HIV positive patients in our country are related in the majority of cases to intravenous drug abuse. In the last four years due to a National medical health care plan conducted to educate this group of people the number of musculoskeletal infections is decreasing.     

Infectious spondylodiscitis: A twenty-year experience from a single tertiary referral center

Aim of the workTo study microbiological, clinical and therapeutic aspects of spondylodiscitis (SD) and predisposing risk factors in Tunisian patients.Patients and methodsPatients with SD admitted to Rheumatology Departments, Southern Tunisia, were retrospectively studied. Medical records were reviewed over the last 20-years and investigations included bacterial cultures, magnetic resonance imaging (MRI) or computed-tomography percutaneous disc biopsy (CT-PDB).ResultsThere were 67 SD cases (incidence of 0.17/100,000 inhabitants/year); 38 men and 29 women and mean age was 55 ± 16 years. Advanced age, tuberculosis and brucellar contagion were the predominant risk factors. The duration from onset to diagnosis was 133.6 ± 115 days. Low back pain (LBP) was the most common symptom. Lumbar spine was the most frequent location. Neurologic symptoms (radicular pain, spinal chord compression, neurologic loss) were observed in 31 patients. C-reactive protein was elevated in 54 (52.17 ± 43.97 mg/L). MRI showed abnormalities in 60 patients and CT-PDB was performed in 39. Pathogens were isolated in 43 cases. Mycobacterium tuberculosis (MT) was the most common (55.8%) followed by staphylococcus aureus (18.6%), brucella (16.3%), Escherichia coli (EC) (4.7%) and streptococcus-β in 1 patient; 1 patient had both MT and EC. Medical treatment was prescribed in 91% and surgery performed in 6. 88% of patients improved after 24 months follow-up.ConclusionSpondylodiscitis should be considered for all patients presenting with chronic LBP with systemic symptoms and evidence inflammation. MRI is required to establish a diagnosis and evaluate the spread of infection. CT-PDB is useful to identify the causative micro-organism before antibiotic administration. These findings could to pave the way for constructing national guidelines.     

Endemic brucellar epididymo-orchitis: a 10-year experience.

OBJECTIVE: To present epidemiologic, clinical and laboratory features, treatment and outcome of patients suffering from Brucella melitensis-induced epididymo-orchitis, in comparison with cases of nonspecific epididymo-orchitis. Distinction between these two entities is essential, as treatment and outcome are entirely different. METHODS: In this retrospective study, records of 17 patients serologically diagnosed as suffering from B. melitensis epididymo-orchitis were reviewed in comparison with 141 cases of non-Brucella epididymo-orchitis. All patients presented consecutively at a tertiary hospital in southwestern Greece, from 1991 to 2000. Statistical analysis was performed using the chi-square test. RESULTS: B. melitensis epididymo-orchitis differed from nonspecific epididymo-orchitis, due to its high occupational risk, seasonal pattern, gradual onset (P<0.01), longer duration, typical undulatory fever (P<0.05), absence of serious leukocytosis (P<0.05) and lower urinary tract symptoms, and relatively minimal local signs of florid inflammation (P<0.01). Oral medication with doxycycline and rifampicin for 6 weeks was effective, and no relapses or serious side effects were recorded during the follow-up period. CONCLUSIONS: B. melitensis-induced epididymo-orchitis is a recognized clinical problem in endemic regions, requiring early detection and appropriate medication. Clinicians encountering epididymo-orchitis should consider the likelihood of brucellosis and initiate anti-Brucella medication upon clinical diagnosis and not only after serologic confirmation.     

Gastrointestinal tuberculosis: 17 cases collected in 4 hospitals in the northeastern suburb of Paris

Gastrointestinal tuberculosis is a rare form of extrapulmonary tuberculosis and its diagnosis can be difficult. AIMS: To analyze the diagnostic and therapeutic characteristics of gastrointestinal tuberculosis. METHODS: Retrospective study from 17 cases collected in 4 hospitals in Seine Saint-Denis between 1987 and 2002. RESULTS: Seventeen cases and 19 localizations were collected: small intestine (N = 7), ileocecum (N = 6), colon (N = 4) and gastroduodenum (N = 2). Two patients had two localizations. Mean age was 43.9 years. Subjects from immigrant populations (76.5%) were preferentially affected. Twenty-three percent of patients (13 tested) were infected by human immunodeficiency virus. Weight-loss and general weakness (88%), abdominal pain (88%), fever (59%), nausea/vomiting (53%) were the predominant symptoms. The delay in diagnosis was 82 days (range: 7-180) and time before specific treatment 31.6 days (range: 7-90). Histological evidence of caseating granuloma was found in six patients. Mycobacterium tuberculosis was detected in six. Digestive imaging was abnormal in 15 patients. Mesenteric lymph nodes were the most common associated site of tuberculosis (N = 8, 47%). Mean duration of treatment was 8.2 months (range: 6-12). Thirteen patients were cured, three died and one was lost to follow up. CONCLUSION: Gastrointestinal tuberculosis is not an uncommon diagnosis in the north-eastern Parisian area, especially among immigrant populations and immunodeficient patients. The most frequent localizations are the small intestine and ileocecum. Diagnosis can be made by pathology and/or bacteriology on endoscopic and/or surgical biopsy samples.     

Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients. 1. Diagnosis and treatment of mycobacterial diseases in a community general hospital

94 patients with tuberculosis were identified in a 236-bed community general hospital without a dedicated tuberculosis ward from June 1986 to February 1998. 69 patients had bacteriological proof of tuberculosis, and the remaining 25 had clinical evidence thereof. The mean age of all patients was 63.0 years (range: 23-89 years), and the male to female ratio was 2:1. 70 of these cases were admitted. During this same period of time, the total number of inpatients admitted to the internal medicine ward reached around 11,000. Excluding 6 cases who were referred to other hospitals with a tuberculosis ward, the mean duration of hospital stay of the remaining 64 cases was 51.6 days. Among all 94 cases, 62 had pulmonary tuberculosis and the other 32 had extrapulmonary manifestations. The latter group was comprised of 11 with miliary dissemination, 8 pleuritis, 4 osteomyelitis, 2 peritonitis, 2 urinary tract disease, 1 pericarditis, 1 intestinal disease, 1 meningitis, 1 intracranial tuberculoma and 1 genital disease. 3 cases of miliary tuberculosis with dissemination died with antemortem diagnoses of fever of unknown origin, pneumonia, and lung cancer with brain metastasis. These 3 cases illustrate the importance of heightened suspicion of tuberculosis among our patient population. Referral of patients with positive sputum smears to hospitals with a tuberculosis ward has occasionally been difficult because of inaccessibility. Critical comorbid diseases such as chronic renal failure requiring hemodialysis and malignancies are additional limiting factors to transfer to such facilities. Therefore, because of the prevalence and extent of this disease, its myriad clinical presentations, challenges associated with establishing an early diagnosis, and need to prevent spread to family, other patients, and staff, dedicated beds for care of tuberculosis in general hospitals are mandatory.     

Brucellosis: an unusual diagnosis for a seronegative patient with abscesses, osteomyelitis, and ulcerative colitis.

A 16-year-old girl developed multiple subcutaneous abscesses, osteomyelitis, and severe colitis. On the patient's second admission, a single blood culture--and, subsequently, a specimen of pus--yielded Brucella melitensis biovar 1. A second set of serologic tests, including the rose bengal test, the standard tube agglutination test, the CF test, and Coombs' test, were all negative for Brucella on the patient's second admission and 1 month later. However, a lymphocyte proliferation assay with extracted antigen of Brucella was markedly positive. Thus, this case illustrates that patients with B. melitensis infection may have a unique clinical presentation and that the lymphocyte proliferation assay is an important diagnostic tool for patients whose serologic test results are negative but for whom brucellosis is suspected.     

Clinical and laboratory features of brucellosis in two university hospitals in Southeast Turkey

This prospective study was carried out in two university hospitals between January 2000 and December 2002. The diagnosis of brucellosis was made with compatible clinical findings, positive Brucella agglutination > or =1/160 titres, and/or the isolation of Brucella species. The patients were followed up without intervention. One hundred and thirty-eight patients with active brucellosis were evaluated. Of the participants, 79 (57.2%) cases were acute, 23 (16.7%) sub-acute and 36 (26.1%) chronic. Brucella melitensis was isolated in the specimens of 24 (26.9%) out of 89 patients. The most frequent symptoms were fever (78.3%), arthralgia (77.5%) and sweating (72.5%). The most common physical findings were fever (40.6%), splenomegaly (36.2%), and hepatomegaly (26.8%). The osteoarticular involvement was found in 64 patients (46.4%). Ten (7.5%) patients had orchiepididymitis. Meningitis, pulmonary involvement, endocarditis, and hepatitis were found in five (3.6%), three (2.1%), two (1.5%) and one (0.7%) patient, respectively. Relative lymphomonocytosis was found in 80 cases (58.8%), anaemia in 46 (33.3%) and leucopoenia in 30 cases (21.7%). Clinical relapse was observed in 14 patients (10.1%).     

Changes in bloodstream infections in HIV-positive patients in a university hospital in Spain (1995-1997).

OBJECTIVES: The Hospital Universitario Germans Trias i Pujol is a 600-bed center serving 700,000 inhabitants including 1800 patients with HIV infection in Catalonia (Spain). Highly active antiretroviral therapy (HAART) became available at the end of 1996. Thus, the period 1995 1997 was considered appropriate for evaluating possible epidemiological changes in bloodstream infections (BSI) in HIV-infected patients. METHODS: All significant bloodstream infections, including mycobacteremia and fungemia, observed in HIV-positive patients from January, 1995 to December, 1997 have been included in the study. RESULTS: One hundred and eighty six cases were evaluated, in whom a decrease in BSI was observed (68 in 1995, 86 in 1996, 32 in 1997). Over time, we observed an improvement in the immunologic situation of the patients (1995: CD4 <50/mm3 73.8% vs 1997: CD4 <50/mm3 45.5% (P=0.05)). The source of BSI was known in 80.7% of the episodes. BSI secondary to catheter and respiratory infections prevailed in 1995, whereas an increase in bacteremias related to intravenous drug use, with or without endocarditis, was seen in 1997. The most frequent isolates were Mycobacterium avium intracellulare (23) (MAI), M. tuberculosis (20), Staphylococcus aureus (20), coagulase-negative staphylococci (16), Salmonella spp. (16) and Streptococcus pneumoniae (15). In 1997, a decrease was observed in the isolation of Gram-negatives and Mycobacterium spp. with S. aureus and enterococci prevailing. CONCLUSIONS: The prevalence of bloodstream infections in HIV-positive patients has decreased since the introduction of HAART and the immunologic state has improved. Furthermore there is a trend to a decrease or disappearance of microorganisms, such as Pseudomonas spp., Mycobacterium tuberculosis, MAI or fungi related to severe immunosuppression. Lastly, bacteremia caused by the active use of intravenous drugs remains stable with the highest percentage in Spain.     

Osteoarticular infection associated with the human immunodeficiency virus

An analysis is presented of 20 patients with the human immunodeficiency virus (HIV) infection who were treated for skeletal infection in our hospital. Seventeen cases of septic arthritis and three of osteomyelitis were found. All patients were intravenous drug abusers, 75% were male and all were younger than 40 years old. Eighty-eight percent of the septic arthritis cases were monarticular, the hip joint being the area most commonly affected (29%), and Staphylococcus aureus and Candida albicans were the most frequently isolated agents (60% and 20%, respectively). Gram negative bacteria were not found. No correlation between the number of CD4 lymphocytes, affected joints, isolated microorganism or functional capacity was found. Four of 17 patients with septic arthritis and 2 of 3 with osteomyelitis fulfilled the CDC criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). All cases except one responded to conventional therapy. We conclude that skeletal infection in HIV-infected patients is more closely associated with the risk-group than with HIV itself.