Factores de riesgo de neumonía nosocomial por Staphylococcus aureus resistente a meticilina / Risk factors of nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus

Fundamento y objetivo: Es necesario predecir una neumonía nosocomial (NN) por Staphylococcus aureus resistente a meticilina (SARM) para facilitar la inclusión de un antibiótico específico en la terapia empírica. En este estudio se desarrolla un modelo para predecir la probabilidad de NN por SARM cuando se desconoce el estado de portador y el diagnóstico microbiológico. Pacientes y método: Se diseñó un estudio de casos y controles, realizándose una regresión logística multivariable para identificar los factores de riesgo de NN por SARM. Se incluyeron factores demográficos, relacionados con la hospitalización, la inmunodepresión, neutropenia, la medicación y la gravedad.Resultados: Se estudiaron 363 pacientes (121 casos y 242 controles). Permanecieron en el modelo final la edad>14 años (odds ratio [OR] 7,4, intervalo de confianza del 95% [IC 95%] 1,5-37,4, p<0,015), la aparición de la NN>6 días después del ingreso (OR 4,1, IC 95% 2,4-7,1, p<0,001), el desarrollo de la NN fuera del verano (OR 2,5, IC 95% 1,2-5,2, p = 0,015), las enfermedades respiratorias (OR 4,9, IC 95% 1,5-15,8, p = 0,007) y la afectación multilobar (OR 4, IC 95% 2,3-7,2, p<0,001). Con estas variables se calculó la probabilidad de desarrollar neumonía por SARM para cada una de las posibles combinaciones, clasificándose en criterios mayores y menores.Conclusiones: Se debe incluir cobertura de SARM en el tratamiento empírico de la NN cuando: a) un paciente adulto (>14 años) tiene, al menos, 2 criterios mayores o un criterio mayor y 2 menores, y b) un paciente<14 años tiene los 2 criterios mayores y los 2 menores (AU)

Background and objective: To include a specific antibiotic in the empiric therapy, it is necessary to predict when a nosocomial pneumonia (NP) is caused by methicillin-resistant Staphylococcus aureus (MRSA). We have developed a model for the prediction of the probability of a NP being caused by MRSA, when the carrier status and the microbiological diagnosis are unknown. Patients and methods: A retrospective case-control study (1999-2005) was designed. A univariate and multivariate logistic regression was performed to identify the risk factors for suffering a NP due to MRSA. Demographic factors, related to hospitalization, immunosuppression or neutropenia, to medication and severity were included. Results:Three hundred and sixty three patients (121 cases and 242 controls) were studied. The final model of multivariate logistic regression included an age>14 years (OR 7.4, CI 95% 1.5-37.4, P<.015), NP appearance>6 days after admittance (OR 4.1, CI 95% 2.4-7,1, P<.001), NP development excluding summers (OR 2.5, CI 95% 1.2-5.2, P<.015), respiratory diseases (OR 4.9, CI 95% 1.5-15.8, P<.007) and multilobar involvement (OR 4, CI 95% 2.3-7.2, P<.001).The probability of developing a pneumonia due to MRSA was studied for each of the possible combinations and subsequently classified in minor and major criteria. Conclusions: MRSA coverage should be included in the empirical treatment of NP when: a) an adult patient (>14 years old) presents, at least, 2 major criteria or 1 major criterion together with 2 minor criteria, and b) a patient <14 years-old has 2 major criteria as well as 2 minor criteria Ç(AU)

[Risk factors of nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus]. / Factores de riesgo de neumonía nosocomial por Staphylococcus aureus resistente a meticilina.

BACKGROUND AND OBJECTIVE: To include a specific antibiotic in the empiric therapy, it is necessary to predict when a nosocomial pneumonia (NP) is caused by methicillin-resistant Staphylococcus aureus (MRSA). We have developed a model for the prediction of the probability of a NP being caused by MRSA, when the carrier status and the microbiological diagnosis are unknown. PATIENTS AND METHODS: A retrospective case-control study (1999-2005) was designed. A univariate and multivariate logistic regression was performed to identify the risk factors for suffering a NP due to MRSA. Demographic factors, related to hospitalization, immunosuppression or neutropenia, to medication and severity were included. RESULTS: Three hundred and sixty three patients (121 cases and 242 controls) were studied. The final model of multivariate logistic regression included an age>14 years (OR 7.4, CI 95% 1.5-37.4, P<.015), NP appearance>6 days after admittance (OR 4.1, CI 95% 2.4-7,1, P<.001), NP development excluding summers (OR 2.5, CI 95% 1.2-5.2, P<.015), respiratory diseases (OR 4.9, CI 95% 1.5-15.8, P<.007) and multilobar involvement (OR 4, CI 95% 2.3-7.2, P<.001).The probability of developing a pneumonia due to MRSA was studied for each of the possible combinations and subsequently classified in minor and major criteria. CONCLUSIONS: MRSA coverage should be included in the empirical treatment of NP when: a) an adult patient (>14 years old) presents, at least, 2 major criteria or 1 major criterion together with 2 minor criteria, and b) a patient <14 years-old has 2 major criteria as well as 2 minor criteria.

Efectos indirectos de la infección por citomegalovirus / Indirect effects of cytomegalovirus infection

A pesar de la mejora en las estrategias de prevención, el citomegalovirus (CMV) continúa siendo el principal causante de infección en los pacientes trasplantados de órgano sólido. En estos pacientes, además de efectos directos, como el síndrome viral o la enfermedad invasiva de órgano, el CMV puede ocasionar efectos indirectos que resultan de la interacción del virus con el sistema inmune del huésped. Esta interacción puede desembocar en un mayor grado de inmunosupresión, con el consiguiente aumento de infecciones oportunistas, en un mayor riesgo de malignidad (enfermedad linfoproliferativa postrasplante asociada al virus de Epstein-Barr) y en un mayor riesgo de disfunción del injerto. Aunque en la actualidad no puede establecerse una relación directa de causalidad entre el CMV y la mayoría de los efectos indirectos descritos, numerosos estudios experimentales y clínicos han evidenciado una asociación entre la aparición de estos efectos y el CMV. Además, se ha evidenciado la disminución del riesgo de alguno de estos efectos, como la aparición de infecciones oportunistas, con la instauración de pautas de profilaxis frente al virus (AU)

Despite improvements in prevention strategies, cytomegalovirus (CMV) continues to be the main cause of infection in solid organ transplant recipients. In these patients, in addition to direct effects, such as viral syndrome or invasive organ disease, CMV can cause indirect effects resulting from the interaction of the virus with the host’s immune system. This interaction may increase immunosuppression, with a consequent rise in opportunistic infections and the risk of malignancies (Epstein-Barr virus-associated post- transplantation lymphoproliferative disease) and graft dysfunction. Currently, a direct causal relation between CMV and most of the indirect effects described cannot be established. However, numerous experimental and clinical studies have found an association between the development of these effects and CMV. Moreover, some of these effects, such as the development of opportunistic infections, have been reduced by CMV prophylaxis (AU)

Candidemias: análisis multicéntrico en 16 hospitales andaluces / Candidemias: multicentre analysis in 16 hospitals in Andalusia (Spain)

Introducción La candidemia es una infección nosocomial con elevada mortalidad. Los cambios clínicos y microbiológicos descritos en otras áreas y las novedades terapéuticas de los últimos años hacen preciso conocer si la epidemiología clínica de las candidemias en nuestro medio ha cambiado. Material y métodos Estudio prospectivo, multicéntrico y observacional de todos los episodios de candidemia en pacientes adultos atendidos entre el 1 octubre 2005 y el 30 septiembre 2006 en 17 hospitales de Andalucía. Resultados El número total de episodios fue de 220, la incidencia de 0,58 episodios/por cada 1.000 altas. Candida albicans fue la etiología más frecuente (53%). El 89% de las cepas fueron sensibles a fluconazol. La sepsis fue la presentación clínica más frecuente (65,7%). El tratamiento empírico fue inapropiado en el 38,7%. La mortalidad global (..) (AU)

Introduction: Candidemia is a nosocomial infection with high associated mortality. There have been changes in microbiology, epidemiology and treatment over the last few years, which has led us to analyse our own situation. Material and methods: Prospective, multicentre and observational study. All episodes of candidemia in adult patients seen in 17 Andalusian hospitals from 1 October 2005 to 30 September 2006 were included. Results: Were detected 220 cases, the incidence was 0.58 cases/1,000 hospital discharges. Candida albicans was the most frequent species (53% of cases). The majority of isolates (89%) was susceptibility to fluconazole. Sepsis was the most frequent clinical manifestation (65.7%). The treatment was inadequate in b38.7% of cases. Overall mortality was 40%.On univarite analysis (..) (AU)

[Candidemias: multicentre analysis in 16 hospitals in Andalusia (Spain)]. / Candidemias: análisis multicéntrico en 16 hospitales andaluces.

INTRODUCTION: Candidemia is a nosocomial infection with high associated mortality. There have been changes in microbiology, epidemiology and treatment over the last few years, which has led us to analyse our own situation. MATERIAL AND METHODS: Prospective, multicentre and observational study. All episodes of candidemia in adult patients seen in 17 Andalusian hospitals from 1 October 2005 to 30 September 2006 were included. RESULTS: Were detected 220 cases, the incidence was 0.58 cases/1,000 hospital discharges. Candida albicans was the most frecuent species (53% of cases). The majority of isolates (89%) was susceptibility to fluconazole. Sepsis was the most frequent clinical manifestation (65.7%). The treatment was inadequate in 38.7% of cases. Overall mortality was 40%. On univarite analysis death was found to be significantly associated with: aged > 60 years, unknown candidemia focus, Pitt score ≥ 2, APACHE II, shock at onset, persistents positive second blood cultures, non-removal of the central venous catheter and Candida species different of C. parasilopsis, among others. In the multivariate analysis death was found to be significantly associated with: aged > 60 years, Pitt score ≥ 2, Candida species different of C.parasilopsis and inadequate treatment. CONCLUSIONS: The candidemia clinical epidemiology in our region is similar to other areas and receiving inadequate treatment is the only modifiable risk factor associated with higher odds of mortality. Therefore, this modifiable factor needs to be improved to reduce the mortality.

[Indirect effects of cytomegalovirus infection]. / Efectos indirectos de la infección por citomegalovirus.

Despite improvements in prevention strategies, cytomegalovirus (CMV) continues to be the main cause of infection in solid organ transplant recipients. In these patients, in addition to direct effects, such as viral syndrome or invasive organ disease, CMV can cause indirect effects resulting from the interaction of the virus with the host's immune system. This interaction may increase immunosuppression, with a consequent rise in opportunistic infections and the risk of malignancies (Epstein-Barr virus-associated posttransplantation lymphoproliferative disease) and graft dysfunction. Currently, a direct causal relation between CMV and most of the indirect effects described cannot be established. However, numerous experimental and clinical studies have found an association between the development of these effects and CMV. Moreover, some of these effects, such as the development of opportunistic infections, have been reduced by CMV prophylaxis.

Impacto de la carga vírica inicial de citomegalovirus sobre la eficacia del tratamiento anticipado con ganciclovir en receptores de trasplante de progenitores hematopoyéticos / Impact of initial cytomegalovirus viral load on efficacy of preemptive therapy with ganciclovir in allogeneic stem cell transplant recipients

Objetivos Estudiar el impacto de la carga vírica inicial de citomegalovirus (CMV) sobre la respuesta virológica al tratamiento anticipado con ganciclovir en receptores de trasplante de progenitores hematopoyéticos (TPH) después de 4 semanas de tratamiento. Métodos Se incluyó a 81 receptores de TPH realizados consecutivamente. El tratamiento anticipado se inició ante la presencia de carga vírica de CMV en 2 semanas consecutivas o cuando la carga vírica fue superior a 5.000copias/ml en una única determinación. Si la carga vírica persistía superior a 400copias/ml después de 2 semanas de tratamiento, el tratamiento con ganciclovir se mantenía durante 2 semanas más. Se definió el fallo virológico (FV) como la presencia de carga vírica de CMV superior a 400copias/ml después de 4 semanas de tratamiento. Resultados Treinta y dos pacientes (39,5%) que presentaron un total de 39 episodios de replicación de CMV recibieron tratamiento anticipado. Se observó FV en 16 pacientes (50%) después de 18 (50%) episodios de replicación de CMV. Además, 2 episodios de replicación (5%) presentaron adicionalmente fallo clínico. La carga vírica inicial superior a 20.000copias/ml al inicio del tratamiento fue el único factor de riesgo para el FV (odds ratio [OR] de 5,88, intervalo de confianza [IC] del 95%, rango de 1,49 a 25; p = 0,03). La enfermedad del injerto contra el húesped grado ii–iv fue el principal factor de riesgo para la presencia de replicación de CMV superior a 20.000copias/ml al inicio del tratamiento (OR de 16, IC del 95%, rango de 8,5 a 45).Conclusiones La presencia de una carga vírica inicial de CMV superior a 20.000copias/ml es el principal factor de riesgo de FV después de 4 semanas de tratamiento anticipado con ganciclovir tras el TPH (AU)

Objective To study the impact of initial cytomegalovirus (CMV) viral load on virological response to ganciclovir preemptive therapy in allogeneic stem cell transplant (SCT) recipients after 4 weeks of treatment. Methods Eighty-one consecutive allogeneic SCT recipients were included. Preemptive therapy was initiated when CMV load was positive for 2 consecutive weeks or when a viral load >5000copies/mL was detected in 1 sample. If viral load was >400copies/mL after 2 weeks of treatment, maintenance treatment with ganciclovir was continued for 2 additional weeks. Virological failure was defined as a CMV load >400copies/mL after 4 weeks of treatment. Results Ganciclovir preemptive therapy was initiated in 32 patients (39.5%) who had 39 episodes of CMV replication. Virological failure occurred in 16 patients (50%) after 18 episodes of replication (46%). Clinical failure additionally occurred in 2 episodes (5%). The only risk factor for virological failure was a peak viral load >20 000copies/mL at the beginning of treatment (OR 5.88; 95% CI: 1.49–25, P=.03). The main risk factor for CMV replication >20 000copies/mL at the start of treatment was the presence of grade II–IV acute graft-versus-host-disease (OR 16; 95% CI: 8.5–45).Conclusion CMV viral load >20 000copies/mL is the main risk factor for virological failure after 4 weeks of ganciclovir preemptive therapy following SCT (AU)

[Impact of initial cytomegalovirus viral load on efficacy of preemptive therapy with ganciclovir in allogeneic stem cell transplant recipients]. / Impacto de la carga vírica inicial de citomegalovirus sobre la eficacia del tratamiento anticipado con ganciclovir en receptores de trasplante de progenitores hematopoyéticos.

OBJECTIVE: To study the impact of initial cytomegalovirus (CMV) viral load on virological response to ganciclovir preemptive therapy in allogeneic stem cell transplant (SCT) recipients after 4 weeks of treatment. METHODS: Eighty-one consecutive allogeneic SCT recipients were included. Preemptive therapy was initiated when CMV load was positive for 2 consecutive weeks or when a viral load >5000copies/mL was detected in 1 sample. If viral load was >400copies/mL after 2 weeks of treatment, maintenance treatment with ganciclovir was continued for 2 additional weeks. Virological failure was defined as a CMV load >400copies/mL after 4 weeks of treatment. RESULTS: Ganciclovir preemptive therapy was initiated in 32 patients (39.5%) who had 39 episodes of CMV replication. Virological failure occurred in 16 patients (50%) after 18 episodes of replication (46%). Clinical failure additionally occurred in 2 episodes (5%). The only risk factor for virological failure was a peak viral load >20,000copies/mL at the beginning of treatment (OR 5.88; 95% CI: 1.49-25, P=.03). The main risk factor for CMV replication >20,000copies/mL at the start of treatment was the presence of grade II-IV acute graft-versus-host-disease (OR 16; 95% CI: 8.5-45). CONCLUSION: CMV viral load >20,000copies/mL is the main risk factor for virological failure after 4 weeks of ganciclovir preemptive therapy following SCT.

[Variability in coronary risk assessment in HIV-infected patients]. / Variabilidad en la valoración del riesgo coronario en pacientes infectados por el virus de la inmunodeficiencia humana.

BACKGROUND AND OBJECTIVE: Antiretroviral treatment of human immunodeficiency virus (HIV)-infected patients seems to increase the coronary risk (CR) in these patients. Adequate assessment of CR has significant implications for the management of these patients. Our objective was to compare 2 systems for assessing 10-year CR in HIV-infected patients. PATIENTS AND METHOD: CR was calculated in a prospective cohort of 205 HIV-infected patients using Framingham tables and REGICOR adapted tables. Prevalence of cardiovascular risk factors in these patients was evaluated. RESULTS: Mean age (standard deviation) was 41.4 (8.2) years. Most patients were taking antiretrovirals and had a good immunological status. Current smoking was reported by 77.1% of patients, while a history of dyslipidemia, hypertension, or diabetes was found in 29.3%, 7.3%, and 4.9% of patients, respectively. Lipodystrophy was seen in 41% of patients, abdominal obesity in 21.5%, and a sedentary lifestyle in 50.7% Mean values obtained were 6.55 (6.36) in the Framingham scale and 2.85 (2.31) in the REGICOR scale. A 10-year CR greater than 10% was found in 26 patients (12.9%) with the Framingham tables and in 4 patients (2.0%) with the REGICOR tables. The difference between both methods was significant (p < 0.001). CONCLUSIONS: Application of the Framingham tables to our cohort may overestimate the CR. Studies aimed at identifying the most adequate method for measuring CR in HIV-infected patients are required. Until such data are available, estimation of CR in these patients should be taken with caution.

Variabilidad en la valoración del riesgo coronario en pacientes infectados por el virus de la inmunodeficiencia humana / Variability in coronary risk assessment in HIV-infected patients

Fundamento y objetivo: El tratamiento antirretroviral de los pacientes infectados por el virus de la inmunodeficiencia humana (VIH) parece aumentar su riesgo coronario (RC). La correcta valoración de éste tiene importantes implicaciones en el tratamiento de estos pacientes. Nuestro objetivo ha sido comparar 2 sistemas de evaluación del RC a 10 años en pacientes infectados por el VIH. Pacientes y método: Se calculó el RC en una cohorte prospectiva de 205 pacientes infectados por el VIH utilizando las tablas de Framingham y las tablas adaptadas REGICOR. Se evaluó la prevalencia de factores de riesgo cardiovascular de estos pacientes. Resultados: La edad media (desviación estándar) fue de 41,4 (8,2) años. La mayoría de los pacientes tomaba antirretrovirales y tenía buena situación inmunológica. Presentaba tabaquismo activo el 77,1%, antecedentes de dislipemia el 29,3%, de hipertensión el 7,3%, de diabetes el 4,9%, lipodistrofia el 41%, obesidad abdominal el 21,5% y sedentarismo el 50,7%. La valoración media en la escala Framingham fue de 6,55 (6,36) y en la escala REGICOR de 2,85 (2,31). El RC a 10 años fue mayor del 10% en 26 pacientes (12,9%) con las tablas de Framingham y en 4 (2,0%) con las tablas REGICOR. La diferencia entre ambos métodos resultó significativa (p < 0,001). Conclusiones: Aplicar las tablas Framingham en nuestra cohorte podría suponer una sobrestimación del RC. Son necesarios estudios que tengan como objetivo identificar el método más adecuado para medir el RC en pacientes infectados por el VIH. Mientras no dispongamos de estos datos, debemos tomar con precaución la estimación del RC en estos pacientes

Background and objective: Antiretroviral treatment of human immunodeficiency virus (HIV)-infected patients seems to increase the coronary risk (CR) in these patients. Adequate assessment of CR has significant implications for the management of these patients. Our objective was to compare 2 systems for assessing 10-year CR in HIV-infected patients. Patients and method: CR was calculated in a prospective cohort of 205 HIV-infected patients using Framingham tables and REGICOR adapted tables. Prevalence of cardiovascular risk factors in these patients was evaluated. Results: Mean age (standard deviation) was 41.4 (8.2) years. Most patients were taking antiretrovirals and had a good immunological status. Current smoking was reported by 77.1% of patients, while a history of dyslipidemia, hypertension, or diabetes was found in 29.3%, 7.3%, and 4.9% of patients, respectively. Lipodystrophy was seen in 41% of patients, abdominal obesity in 21.5%, and a sedentary lifestyle in 50.7% Mean values obtained were 6.55 (6.36) in the Framingham scale and 2.85 (2.31) in the REGICOR scale. A 10-year CR greater than 10% was found in 26 patients (12.9%) with the Framingham tables and in 4 patients (2.0%) with the REGICOR tables. The difference between both methods was significant (p < 0.001). Conclusions: Application of the Framingham tables to our cohort may overestimate the CR. Studies aimed at identifying the most adequate method for measuring CR in HIV-infected patients are required. Until such data are available, estimation of CR in these patients should be taken with caution

Espectro y factores de riesgo de la infección fúngica invasora / Spectrum and risk factors of invasive fungal infection

En los últimos años, las infecciones fúngicas invasoras han constituido un problema creciente en los pacientes inmunosuprimidos. Al mismo tiempo, los cambios en la práctica médica, como el empleo de profilaxis con azoles frente a Candida spp., han posibilitado una variación en el espectro de estas infecciones posibilitando un aumento en la incidencia de aspergilosis invasora y de infecciones por otros hongos filamentosos. Además, se han identificado nuevos factores de riesgo y diferente cronología en el comienzo de estas infecciones con respecto a lo acontecido en la última década. Por lo tanto, el conocimiento de este cambio en la epidemiología y los factores de riesgo de la infección fúngica invasora en pacientes que además reciben nuevos regímenes de inmunosupresión resulta de especial importancia para el manejo clínico de estas infecciones (AU)

In recent years, invasive fungal infection has become a growing problem in immunosuppressed patients. Simultaneously, changes in medical practice, such as the use of anti-Candida prophylaxis with azoles, has led to a shift in the epidemiology of these infections from Candida spp. to Aspergillus and other filamentous molds. Moreover, new risk factors for invasive fungal infection have been identified and the time of onset is different from that seen a decade ago. Recognition of these trends in patients receiving novel immunosuppressive regimens has important implications for the clinical management of fungal infection in this population (AU)