Meningitis aséptica en la población adulta. Etiología y utilidad de las técnicas moleculares en el manejo clínico del paciente

Objective

This study describes the epidemiological, clinical and microbiological features of acute aseptic meningitis (AAM) in an adult population, and evaluates the impact of microbiological results on the clinical management of patients.

Patients and methods

Cases of AAM were prospectively collected between 2007 and 2010 among immunocompetent patients over 14 years-old. Enteroviruses and herpes viruses were determined using nucleic acids detection in CSF. Demographic and clinical data were retrospectively collected from medical records.

Results

A total of 94 patients were included, of whom 84 were diagnosed with viral meningitis (VM). The annual incidence of VM ranged from 2.4 to 15.3 cases per 100,000 inhabitants. An aetiological diagnosis was obtained in 76.2% of the patients with VM, 55 enterovirus, 4 HSV-2, 3 VZV, one HSV-1, and one EBV. Forty five per cent of patients were admitted to hospital and 65.8% of them received antibiotic treatment. A positive result prompted immediate discharge of 80% of inpatients and discontinuation of antibiotic therapy in 94.1% of them. The median duration of admission to hospital in these patients was 2.8 ± 2.9 days. Patients without available results during admission completed the antibiotic treatment, and the median hospital stay was 11.6 ± 4.6 days.

Conclusions

The annual incidence of AAM is variable. Enteroviruses were the main aetiological agent. Molecular tests revealed the aetiology in 76.2% of cases. Almost half of the patients required hospitalisation, and in these cases a positive result can lead to the immediate discharge of patients, and the diagnostic and therapeutic interventions can be reduced.     

Distribución de fenotipos clínicos en pacientes con enfermedad pulmonar obstructiva crónica por humo de biomasa y por tabaco

Introduction

Exposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke.

Objective

To determine clinical differences between these two types of the disease.

Methods

Retrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared.

Results

There were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P < .0001) and the age was lower (70.6 vs 76.2 years, P < .0001). Body mass index and FEV₁% values were higher in the biomass group (29.4 ± 5.7 vs 28.0 ± 5.1, P = .01, and 55.6 ± 15.6 vs 47.1 ± 17.1, P < .0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P < .0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P = .009). The prevalence of the chronic bronchitis and exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups.

Conclusion

Differences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups.     

Infecciones de piel y partes blandas en pacientes hospitalizados: factores epidemiológicos,microbiológicos,clínicos y pronósticos

Introduction

Skin and soft-tissue infections (SSTIs) are a frequent cause of consultation in emergence services, and complicated cases require hospitalization. However there are few data in our setting about the clinical characteristics of these infections.

Material and methods

A retrospective review of hospital admitted patients with a diagnosis of folliculitis, cellulitis, erysipelas, abscesses, hidradenitis, furuncle, impetigo, fasciitis and Fournier's gangrene. Cases were extracted from the data base of diagnostic codes of the Archive and Clinical Documentation Department of Son Llàtzer Hospital from January 2002 to November 2011.

Results

We studied 996 episodes in 841 hospitalized patients with any diagnosis of SSTIs. Cellulitis/erysipelas (66.7%) was the most frequently diagnosed condition, with 77% of all SSTIs being community acquired, and the majority of patients had comorbidities, mainly diabetes (33%) and heart failure (17.7%). The most frequent isolated microorganism was S. aureus (35.1%), in 19 (12.9%) cases with methicillin-resistance (MRSA), 84.2% of them were nosocomial or health care acquired. Monotherapy with aminopenicillin with clavulanic acid was the empiric treatment most frequently used (35.5%). New antibiotics for Gram-positive cocci (linezolid, daptomycin, and tigecycline) were used in patients with comorbidities that presented more complications (P < .001) and more risk of mortality (P = .001). During admission 10.9% of patients died, but only in 2.7% of them mortality was related to the SSTIs.

Conclusions

SSTIs attended most frequently in hospitalized patients are mainly cellulitis/erysipela, the majority community acquired. MRSA infections are mainly health care related. Use of new antibiotic for Gram-positive cocci was limited.     

Prevalencia de infecciones de piel y tejidos blandos producidas por Staphylococcus aureus resistente a Meticilina Comunitario en Madrid

Introduction

Since it was first described in the 1990s, Methicillin-Resistant Staphylococcus aureus infection among people with no contact with a hospital setting or with no traditional risk factors, has spread worldwide and is now an important epidemiological and public health problem.

Methods

The present prospective and observational study was carried out from April to November 2010. All adult patients with community-acquired suppurative skin and soft tissue infection (SSTI) attending the Emergency Department were enrolled. Clinical, microbiological and epidemiological features of the infection were assessed.

Results

A total of 59 samples were collected from 59 patients and CA-MRSA was isolated in 13 of them. Prevalence of CA-MRSA in patients with suppurative SSTI seen in the emergency department was 22.03%, and was 33.3% in patients with staphylococcal infection. Is worth noting the greater presence of necrosis detected in CA-MRSA lesions. Only 3 patients required hospital admission. Eleven of the 13 strains were Panton-Valentine leucocidin producers, and 5 were resistant to non-betalactam antibiotics. CA MRSA infection is still more frequent in the immigrant population.

Conclusion

Data on CA-MRSA prevalence in Spain are sparse. This study aims to emphasise the current importance of this emergent pathogen in our area. About one third of suppurative staphylococcal SSTI presenting in our emergency department are caused by this agent, confirming a rapid spread in our country. Some clinical features, such as the high presence of necrosis, are closely related to CA-MRSA.     

Efectos de la antibioterapia y la técnica fisioterápica respiratoria en pacientes con fibrosis quística tratados por exacerbación pulmonar aguda: estudio experimental

Introduction

Intravenous antibiotics in combination with intensive respiratory physiotherapy were evaluated for acute lung exacerbations in chronic infections of Pseudomonas aeruginosa in cystic fibrosis patients. Forced expiratory technique (FET) was assessed during hospital stay and discharge. The aim of this study was 1) to evaluate the immediate effects of FET and of 2) Intravenous antibiotics in combination with daily respiratory physiotherapy (IA+RPT) on parameters of lung function, body anthropometry and clinical scores of cystic fibrosis patients with acute lung exacerbation with chronic infection by Pseudomonas aeruginosa, during hospital stay and at hospital discharge after clearing the infection.

Patients and method

Eighteen patients between 7–28 years old were included in a prospective non-controlled clinical study. Body anthropometry values, Cystic Fibrosis Clinical Score (CFCS) exacerbation, Cystic Fibrosis Foundation Score (CFFS), and severity scores (SS) were evaluated before and after admission. Oxygen saturation (SpO₂), heart (HR) and respiratory rate (RR) were evaluated before and after FET.

Results

CFCS (32.4+7.2) and CFFS (6.4+1.7) had decreased at hospital discharge for 18.9+3.3 and 0.3+0.5, respectively (p<0.001). IA+ RPT reduced RR means (p=0.003) and increased SpO₂ (p=0.006), forced expiration volume at 1 min (FEV₁) (p=0.021) and nutritional values (p=0.002). During admission, FET immediately improved HR (p=0.028), RR (p=0.001) and SpO₂ (p=0.015), despite significant maximum voluntary ventilation reduction (p=0.028); after the infection was treated the FET did not significantly alter parameters.

Conclusion

IA+RPT improved clinical conditions of cystic fibrosis patients. FET improved cardiorespiratory variables of patients at risk for infection.     

Características clínicas y pronóstico de la neumonía adquirida en la comunidad causada por Staphylococcus aureus resistente a la meticilina

Introduction

The aim of this study is to describe the epidemiological and clinical features, treatment and prognosis of community-acquired pneumonia (CAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in two different geographic regions where community-acquired MRSA (CA-MRSA) infections have different frequencies.

Methods

Observational study of patients admitted to two hospitals (one in Argentina, the other in Spain) between March 2008 and June 2012.

Results

We documented 16 cases of CAP caused by MRSA. MRSA accounted for 15 of 547 (2.7%) cases of CAP in Hospital Rodolfo Rossi and 1 of 1258 (0,08%) cases at the Hospital Universitari de Bellvitge (P ≤ .001). Most patients were young and previously healthy. Multilobar infiltrates, cavitation and skin and soft tissue involvement were frequent. All patients had positive blood cultures. Five patients required admission to the intensive care unit. Early mortality (≤ 48 hours) was 19%, and overall mortality (≤ 30 days) was 25%.

Conclusion

CAP caused by MRSA causes high morbidity and mortality rates. It should be suspected in areas with a high prevalence of CA-MRSA infections, and especially in young and healthy patients who present with multilobar pneumonia with cavitation. Mortality is mainly related to septic shock and respiratory failure and occurs early in most cases.     

Epidemiología y características clínicas de los episodios de bacteriemia por Streptococcus pyogenes en Cartagena (Murcia)

Introduction

A gradual increase in severe cases due to Streptococcus pyogenes or Streptococcus beta-hemolytic group A (SGA), has been detected in the last few decades.

Methods

Retrospective study of bacteremia due to S. pyogenes detected between January 2009 and January 2013 in Cartagena. The annual incidence for severe bacteremia has been estimated.

Results

Thirteen cases of SGA bacteremia were recorded. The incidence increased from 0.37 in 2009 to 2.5 cases/100,000 inhabitants in 2012. The predominant focus was skin and soft tissue infections (53%). Early mortality was 20%.

Conclusion

Severe streptococcal disease is rare, but affects individuals with good functional status, and is associated with a high mortality.     

Trastornos por cocaína e infarto agudo de miocardio,prolongación de estancias y exceso de costes hospitalarios

Introduction and objectives

To investigate the relationship between the prevalence of cocaine use disorders and acute myocardial infarction in patients aged ≥ 18 years and to estimate the influence of cocaine use disorders on mortality, excess length of stay, and overexpenditure among hospitalized patients with acute myocardial infarction.

Methods

Retrospective study of the minimum basic data set of 87 Spanish hospitals from 2008 to 2010.

Results

Among 5 575 325 admissions reviewed, there were 24 126 patients with cocaine use disorders and 79 076 cases of acute myocardial infarction. The incidence of acute myocardial infarction among patients with cocaine use disorders increased with age and reached a peak at 55 years to 64 years (P < .0001). Multivariate analysis showed that cocaine use disorders were more prevalent among patients with acute myocardial infarction independently of age, sex, other addictive disorders, and 30 other comorbidities (odds ratio = 3.0). Among patients with acute myocardial infarction, those with cocaine use disorders did not show an increase of in-hospital death, but did show excess length of hospital stay (1.5 days) and overexpenditure (382 euros).

Conclusions

Cocaine use disorders are associated with acute myocardial infarction and increase the length of hospital stay and overexpenditure among acute myocardial infarction patients. Cessation of cocaine use among these patients should be one of the primary therapeutic goals after hospital discharge.Full English text available from:www.revespcardiol.org/en     

Exposición prenatal y posnatal al tabaco y síntomas respiratorios y alérgicos en los primeros años de vida

Background and objectives

To analyse the relationship between prenatal and postnatal tobacco exposure and the development of respiratory and allergy symptoms during the first 4 years of life.

Patients and methods

Prospective and multicentred cohort study that included the subjects belonging to AMICS (Asthma Multicentred Infant Cohort Study) located in Ashford (England), Barcelona and Minorca (Spain). We recruited 1611 children, followed from the pregnancy to the 4th year of life, whose parents annually answered a questionnaire on their tobacco consumption and their children's respiratory and allergy health. In the Barcelona cohort (n=487) a tobacco exposure biomarker (cotinine) was analysed on several matrices.

Results

Prenatal tobacco exposure is associated with a greater risk of hospitalisation due to respiratory infection, particularly in the second year of life, whereas postnatal tobacco exposure is associated more strongly with the presence of late wheezing presence and increases in the chance of being diagnosed with asthma at 4 years of age. The children prenatally and postnatally exposed had more persistent wheezing, persistent rhoncus, early cough, a higher number of upper respiratory infections per year and a greater number were diagnosed with asthma. The higher the levels of cotinine measured, the higher was the risk for wheezing. No relationship was seen between tobacco exposure and atopic symptoms.

Conclusions

Passive smoke exposure during pregnancy and childhood has very distinct clinical respiratory effects in children. Therefore, smoking cessation of childbearing age women must be a priority of preventive medicine.     

Tos ferina en lactantes y niños bien vacunados. ¿Son necesarias nuevas estrategias de vacunación?

Objective

To analyse the vaccination status of children diagnosed with pertussis and to compare the clinical manifestations of fully vaccinated with unvaccinated, or incompletely-vaccinated, children.

Methods

The clinical histories and vaccination cards of patients under 16 years of age seen in the Emergency Room of the University Hospital Vall d’Hebron, Barcelona (Spain), for pertussis confirmed by a microbiological study were reviewed. The study period lasted from January 1, 2009 to December 31, 2011.

Results

Two hundred and twelve cases were studied: 35 in 2009, 28 in 2010 and 149 in 2011. RT-PCR was positive in 210 patients, and 73 had a positive culture. Infants under 6 months of age account for 36.8% of all cases. Forty-four patients (21.5%) were not vaccinated. Forty-four (21.5%) children were between 2 and 5 months of age and had received 1-2 vaccine doses. One hundred and seventeen (57%) children were fully vaccinated; 76.9% (90 cases) had received the last dose less than 4 years ago. When clinical manifestations of the fully vaccinated patients were compared with those of the non-vaccinated or incompletely-vaccinated children, only cyanosis was found with a higher frequency in the latter group (P < .001). The age-adjusted probability of hospitalisation was significantly associated with non-vaccination (P = .001). The case mortality rate among inpatients was 1.3%.

Conclusions

The number of pertussis cases seen in our centre has risen significantly in the last year. More than half (57%) of the patients were fully vaccinated, and 76.9% had received the last dose in the previous 4 years. Other vaccination strategies, such as vaccination of adolescents, adults, and pregnant women, as well as a cocoon strategy are required to protect infants under 6 months of age. More effective vaccines need to be developed.     

Variantes pequeñas de Staphylococcus aureus: utilidad de distintas pruebas para su diagnóstico y estudio de sensibilidad

Introduction

Small colony variants of Staphylococcus aureus (SCVSA) are a sub-population with special features.

Methods

The phenotypic features and antibiotic susceptibility of four clinical isolates SCVSA were studied.

Results

Colonies grew in the usual culture media, except in Mueller Hinton. All isolates were resistant to ciprofloxacin and co-trimoxazole.

Discussion

As SCVSA are isolated with low frequency, it is necessary to determine the optimal methods for their identification and antibiotic susceptibility study.     

Tratamiento antirretroviral de inicio en pacientes infectados por el virus de la inmunodeficiencia humana en España: decisiones con relación a características inmunovirológicas específicas (estudio PERFIL-es)

Introduction

The purpose of Perfil-es study was to identify the proportion of patients starting ARV treatment based on NNRTIs or PI/r, and to identify the variables involved in the therapeutic decision-making in standard clinical practice.

Methods

An observational restrospective study performed in 65 Spanish hospitals.

Results

Was a total of 1,687 starts: 53% with NNRTI-based regimen and 42% with PI/r, and of the 642 patients analyzed, 72% had a CD4 count < 350 cells/μl.

Conclusion

The initiation of ARV treatment is still late in Spain. NNRTIs are the more frequent choice, although PI/r plays an important role.     

Cáncer de pulmón y EPOC: una asociación frecuente

Background and objective

To analyse frequency, characteristics and patient survival with lung cancer (LC) and COPD, comparing them with patients without COPD.

Material and methods

A retrospective study, of patients diagnosed by means of cytohistology. Survival was estimated by the Kaplan-Meier method. The statistical analysis was carried out using SPSS 15.0.

Results

A total of 996 patients were diagnosed, 39.8% COPD. Mean age70±9.19 years. GOLD stages: I 18.2%, II 53.6%, III 24%, IV 4.2%. The histological types: squamous cell carcinoma 48.2%, adenocarcinoma 22%, small cell carcinoma 22.5%. Survival was longer in the COPD group.

Conclusions

LC and COPD are combined in 39.8%. Squamous cell type is more frequent and survival was longer in the COPD group.     

Caracterización genética por reacción en cadena de la polimerasa de Giardia intestinalis en muestras de humanos y perros del Caribe colombiano

Introduction

Giardia intestinalis (G. Intestinalis) is a protozoan that causes diarrheal disease and malabsorption syndrome in humans and other mammals. It presents a high genetic diversity evidenced in the recognition of 7 genotypes (A-G). Genotypes A and B are commonly associated to humans and domestic animals such as dogs. The aim of this study was to conduct a preliminary genetic characterization of G. intestinalis in humans and dogs from two cities on the Caribbean coast of Colombia.

Methods

Sampling areas were selected according to the highest numbers of acute diarrheal disease. Stool samples were collected from children under 7 years old, with positive medical tests for G. intestinalis. Cysts were purified by sucrose gradient and DNA samples were isolated by extraction with organic solvents. Molecular characterization was performed by amplifying the gene triose phosphate isomerase (tpi) by using a semi-nested PCR.

Results

A total of 202 samples of DNA were obtained; of these, 111 were positive in coproparasitological analysis (13 dogs and 98 children). Genotype distribution in positive samples was: 5.1% belonged to genotype A and 92.3% to genotype B. Genotype B was present in humans and animals.

Conclusions

The most common genotype in both human and animal samples was genotype B, suggesting a zoonotic transmission cycle.     

Aportación del bloque celular en el diagnóstico de adenopatías y masas mediastínicas o hiliares realizado por ecobroncoscopia

Background

Cell block material from puncture can be obtained with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in many cases. The aim of this study was to analyse the value of additional information from cell blocks obtained with EBUS-TBNA samples from mediastinal and hilar lymph nodes and masses.

Methods

Review of pathology reports with a specific diagnosis obtained from EBUS-TBNA samples of mediastinal or hilar lesions, prospectively obtained over a two-year period. The generation of cell blocks from cytology needle samples, the contribution to morphological diagnosis, and the possible use of samples for immunohistochemistry were analysed.

Results

One hundred and twenty-nine samples corresponding to 110 patients were reviewed. The diagnosis was lung cancer in 81% of cases, extrapulmonary carcinoma in 10%, sarcoidosis in 4%, lymphoma in 2.7%, and tuberculosis in 0.9%. Cell blocks could be obtained in 72% of cases. Immunohistochemistry studies on the cell blocks were significantly easier to perform than on conventional smears (52.6% vs. 14%, P < .0001). In 4 cases, the cell block provided an exclusive morphological diagnosis (3 sarcoidosis and one metastasis from prostatic carcinoma) and in 3 carcinomas, subtype and origin could be identified. Exclusive diagnoses from the cell block were significantly more frequent in benign disease than in malignant disease (25% vs 0.9%, P = .002).

Conclusions

Cell blocks were obtained from 72% of EBUS-TBNA diagnostic procedures. The main contributions of cell blocks to pathology examinations were the possibility of carrying out immunohistochemical staining for the better classification of neoplasms, especially extrapulmonary metastatic tumours, and the improved diagnosis of benign lesions.     

Ventilación mecánica no invasiva en una población anciana que ingresa en una unidad de monitorización respiratoria: causas,complicaciones y evolución al año de seguimiento

Objective

To determine the usefulness of non-invasive ventilation (NIV) in elderly patients (≥75) admitted to a respiratory monitoring unit (RMU) during hospitalization and one year later in comparison with the results from the younger age group (<75).

Material and methods

Ours is a prospective observational study carried out at the Hospital Universitario La Princesa (Madrid, Spain). We recruited all patients who were ≥75 years old and were admitted to our RMU during the period 2008-2009 with respiratory acidosis (pH <7.35 and PaCO₂ >45 mmHg) requiring NIV. We gathered data for basic variables as well as sociodemographics, history of previous pathologies, reason for hospitalization and severity, analysis upon admission and the evolution of blood gases at the start of NIV (within the first hour and after 24 hours), complications and evolution at the one-year follow-up.

Results

Mean age of the sample was 80.6 years. The Charlson index was 3.27. About half of the patients had some limitation for performing daily activities. The main reasons for admission were COPD exacerbation and heart failure. There were complications in 36% of the cases (11 renal failure and 6 atrial fibrillation). The survival rate at the one-year follow-up was 63.21%.

Conclusions

NIV is a good alternative in elderly patients admitted to the hospital with respiratory acidosis. We did not detect differences in mortality during admission between the two groups. The elderly patients were more frequently re-admitted than the younger group in the 6-12 months after hospital discharge. This could be due to their poorer functional state after hospitalization requiring NIV.