Time trends in the aetiology of prosthetic joint infections: a multicentre cohort study.

It is important to know the spectrum of the microbial aetiology of prosthetic joint infections (PJIs) to guide empiric treatment and establish antimicrobial prophylaxis in joint replacements. There are no available data based on large contemporary patient cohorts. We sought to characterize the causative pathogens of PJIs and to evaluate trends in the microbial aetiology. We hypothesized that the frequency of antimicrobial-resistant organisms in PJIs has increased in the recent years. We performed a cohort study in 19 hospitals in Spain, from 2003 to 2012. For each 2-year period (2003-2004 to 2011-2012), the incidence of microorganisms causing PJIs and multidrug-resistant bacteria was assessed. Temporal trends over the study period were evaluated. We included 2524 consecutive adult patients with a diagnosis of PJI. A microbiological diagnosis was obtained for 2288 cases (90.6%). Staphylococci were the most common cause of infection (1492, 65.2%). However, a statistically significant rising linear trend was observed for the proportion of infections caused by Gram-negative bacilli, mainly due to the increase in the last 2-year period (25% in 2003-2004, 33.3% in 2011-2012; p 0.024 for trend). No particular species contributed disproportionally to this overall increase. The percentage of multidrug-resistant bacteria PJIs increased from 9.3% in 2003-2004 to 15.8% in 2011-2012 (p 0.008), mainly because of the significant rise in multidrug-resistant Gram-negative bacilli (from 5.3% in 2003-2004 to 8.2% in 2011-2012; p 0.032). The observed trends have important implications for the management of PJIs and prophylaxis in joint replacements.

Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study.

We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicentre, observational study of GN-PJI diagnosed from 2003 through to 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up, leading to unplanned surgery or repeat debridement>30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analysed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range (IQR) 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, five (2%) shoulder and two (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months' follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio (aHR) 0.23; 95% CI, 0.13-0.40; p<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56; 95% CI, 1.14-5.77; p 0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.

Endocarditis polimicrobiana por Streptococcus salivarius y Pseudomonas stutzeri: buena evolución tras cirugía precoz / Polimicrobial endocarditis by Streptococcus salivarius and Pseudomonas stutzeri: good evolution after early surgery

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[Clinical and epidemiological characteristics of persons newly diagnosed of HIV infection]. / Características clinicoepidemiológicas de los nuevos diagnósticos de infección por el virus de la inmunodeficiencia humana.

BACKGROUND: We describe the characteristics of people with a recent diagnosis of HIV infection. PATIENTS AND METHOD: Series of 126 new cases of HIV infection diagnosed in an infectious diseases Service. RESULTS: Sexual transmission was the commonest form of infection (74%). Fifteen percent of individuals were aged over 50 years and 16% were immigrants. A late diagnosis (stage C) accounted for 36% of cases and it was associated with being more than 50 years old (OR: 5.1; 95% CI: 1.6-16.8). CONCLUSIONS: It is necessary to implement HIV infection surveillance systems and to improve preventive services.

Toxicidad pancreática de los anthimoniales en pacientes infectados por el VIH / Pancreatic toxicity of antimonials in patients with HIV infection

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[Pyrimethamine and sulfadoxine as a preventive treatment for Pneumocystis carinii and Toxoplasma encephalitis]. / Pirimetamina y sulfadoxina como tratamiento preventivo para la neumonía por Pneumocystis carinii y la encefalitis por Toxoplasma.

BACKGROUND: Few studies have been reported on the potential usefulness of Fansidar combination at a fixed doses of pyrimethamine and sulfadoxine as prophylaxis for pneumonia by Pneumocystis carinii and toxoplasmic encephalitis. METHODS: The clinical histories of the patients seen in our department from January, 1992 to December, 1994 who were prescribed pyrimethamine and sulfadoxine for the above prophylactic treatment were reviewed. RESULTS: One hundred fifty clinical histories fulfilled the requisites for evaluation. Thirty-seven patients (24%) had a previous diagnosis of AIDS, with the median CD4 count being of 134/mm3. The median follow up of treatment with Fansidar was of 31 months. Twenty-eight cases of pneumonia by Pneumocystis carinii (6.9 cases for 100 patients-years) and 10 cases of toxoplasmic encephalitis (2.5 cases for 100 patients-years) were diagnosed. CONCLUSIONS: These values are similar to those presented with respect to other pharmacologic interventions commonly used for the prevention of pneumonia by Pneumocystis carinii and toxoplasmic encephalitis and suggest that pyrimethamine and sulfadoxine is a useful alternative and requires consideration in individualized cases for the prophylaxis of these diseases.

[Acute pancreatitis and infection with the human immunodeficiency virus]. / Pancreatitis aguda e infección por el virus de la immunodeficiencia humana.

BACKGROUND: Retrospective study of the etiology and evolution of 40 episodes of acute pancreatitis in 28 patients infected with the human immunodeficiency virus (HIV). RESULTS: AIDS criteria were met by 89.3% of patients. The likely etiology was an opportunist infection in 32.5% of episodes, drug use in 22.5%, and biliary lithiasis in 5%. AP secondary to AIDS-associated cholangitis occurred in 35.7% of episodes. Sixty percent of episodes were severe in nature. The mortality rate reached 30%. CONCLUSIONS: AP in HIV infected patients: a) is more frequent in the advanced stages of disease; b) opportunistic infections and drugs are the most frequent causes in our environment; c) in a third of patients it is probably secondary to AIDS associated cholangitis; d) biliary lithiasis seems to be less common than in the general population, and e) it is associated with a high severity and mortality.

Stevens-Johnson syndrome caused by indinavir.

A case is presented of an HIV-infected man who developed Stevens-Johnson syndrome shortly after the initiation of treatment with indinavir. This is the first case ever reported of this adverse drug reaction occurring with an HIV protease inhibitor.

[Bacterial pneumonia as a risk marker for new bacterial diseases in patients with HIV infection]. / Neumonías bacterianas como marcador de riesgo de nuevas enfermedades bacterianas en pacientes infectados por el HIV.

BACKGROUND: Bacterial pneumonias are a main cause of morbidity and mortality among patients infected by the HIV. Furthermore, recent data suggest that, under certain circumstances, they can be prognostic markers. METHODS: The evolution of a cohort of HIV-infected patients, prospectively defined by having suffered a pneumonia, was studied with regards to the occurrence of a new pneumonia or death from a bacterial disease; the evolution of a control cohort of patients matched according to sex, CD4-cell count, previous HIV-disease and zidovudine-treatment was compared to the former cohort by means of survival-analysis techniques. RESULTS: Forty-nine patients in each group were followed up for a total of 1389 and 1893 patient-months respectively. In the first group, 17 new first pneumonia episodes were diagnosed, as compared to 7 in the second group (relative-risk: 3.23, 95% confidence interval: 1.34 to 7.79, p = 0.005). Eight of the 31 deaths that occurred in the first group were attributed to a bacterial disease, as compared to none of the 24 deaths in the second group (p = 0.007, Fisher's exact test) (in five of those cases, a bacteria was isolated which was thought to be directly related to the death). CONCLUSIONS: HIV-infected patients who suffer a bacterial pneumonia have an increased risk of suffering new severe bacterial diseases (pneumonia or fatal diseases) as compared to HIV-infected patients with similar prognostic features but no previous episodes of pneumonia.