Pandemic influenza A(H1N1) virus infection in solid organ transplant recipients: impact of viral and non-viral co-infection.

Solid organ transplant recipients (SOTR) are at risk of serious influenza-related complications. The impact of respiratory co-infection in SOTR with 2009 pandemic influenza A(H1N1) is unknown. A multicentre prospective study of consecutive cases of pandemic influenza A(H1N1) in SOTR was carried out to assess the clinical characteristics and outcome and the risk factors for co-infection. Overall, 51 patients were included. Median time from transplant was 3.7 years, 5.9% of the cases occurred perioperatively and 7.8% were hospital-acquired. Pneumonia was diagnosed in 15 (29.4%) patients. Ten cases were severe (19.6%): 13.7% were admitted to intensive care units, 5.9% suffered septic shock, 5.9% developed acute graft rejection and 7.8% died. Co-infection was detected in 15 patients (29.4%): eight viral, six bacterial and one fungal. Viral co-infection did not affect the outcome. Patients with non-viral co-infection had a worse outcome: longer hospital stay (26.2 ± 20.7 vs. 5.5 ± 10.2) and higher rate of severe diseases (85.7% vs. 2.3%) and mortality (42.8% vs. 2.3%). Independent risk factors for non-viral co-infection were: diabetes mellitus and septic shock. Other factors associated with severe influenza were: delayed antiviral therapy, diabetes mellitus, time since transplantation <90 days and pneumonia. In conclusion, pandemic influenza A can cause significant direct and indirect effects in SOTR, especially in the early post-transplant period, and should be treated early. Clinicians should be aware of the possibility of non-viral co-infection, mainly in diabetic patients and severe cases. An effort should be made to prevent influenza with immunization of the patient and the environment.

Disseminated adiaspiromycosis: case report of a liver transplant patient with human immunodeficiency infection, and literature review.

Disseminated adiaspiromycosis is a rare infection that is sometimes associated with immunocompromised situations. We report the case of a patient, infected with human immunodeficiency virus and receiving highly active antiretroviral therapy, who had a liver transplant for hepatocellular carcinoma. The patient presented skin and pulmonary lesions due to adiaspiromycosis during immunosuppressive therapy. A review of >60 cases in the literature shows that adiaspiromycosis is a rare infection and Emmonsia is a dimorphic fungus that is difficult to grow. It should be considered a possible diagnosis in case of fungal infection and pulmonary granulomatosis. We should be aware of emerging adiaspiromycosis in patients with risk factors of immunosuppression, particularly transplant recipients. In these patients in particular, liposomal amphotericin B therapy should be considered.

Effect of statins on outcomes in immunosuppressed patients with bloodstream infection.

Although it has been suggested that statins have a beneficial effect on the outcome of bloodstream infection (BSI) in immunosuppressed patients, prospective studies testing this hypothesis are lacking. We performed an observational analysis of consecutive cancer patients and transplant recipients hospitalized at two tertiary hospitals in Spain (2006-2009). The first episode of BSI occurring in statin users was compared with those occurring in non-statin users. During the study period, 668 consecutive episodes of BSI in 476 immunosuppressed patients were recorded. Underlying diseases were solid tumor (46.2%), hematologic malignancy (35.1%), and transplantation (18.7%). Fifty-nine (12.4%) patients were receiving statins at the onset of BSI. Comparing with statin non-users, patients on statin treatment were older (67.3 vs. 58.7 years; p < 0.001) and had higher frequency of comorbidities (74.6% vs. 40.6%; p < 0.001). There were no significant differences in intensive care unit admission (6.8% vs. 7.7%; p = 1) and overall mortality (15.3% vs. 24%; p = 0.13) between groups. In a multivariate analysis, prior statin use was not associated with increased survival (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.22-1.23; p = 0.14). In conclusion, prior statin use is not associated with increased survival in immunosuppressed patients with BSI. Caution is warranted in attributing beneficial effects to statin use in infections among immunocompromised patients.

Aetiology of, and risk factors for, recurrent community-acquired pneumonia.

Recurrent community-acquired pneumonia (CAP) requiring hospitalization is a matter of particular concern. However, current information on its prevalence, aetiology and risk factors is lacking. To address these issues, we performed an observational analysis of a prospective cohort of hospitalized adults with CAP. Recurrence was defined as two or more episodes of CAP 1 month apart within 3 years. Patients with severe immunosuppression or local predisposing factors were excluded. Of the 1556 patients, 146 (9.4%) had recurrent CAP. The most frequent causative organism was Streptococcus pneumoniae, both in patients with recurrent CAP and in those without recurrence. Haemophilus influenzae, other Gram-negative bacilli and aspiration pneumonia were more frequent among patients with recurrent CAP, whereas Legionella pneumophila was rarely identified in this group. Independent factors associated with recurrent CAP were greater age, lack of pneumococcal vaccination, chronic obstructive pulmonary disease (COPD) and corticosteroid therapy. In a sub-analysis of 389 episodes of pneumococcal pneumonia, the only independent risk factor for recurrence was lack of pneumococcal vaccination. Recurrence of CAP is not a rare clinical problem and it occurs mainly in the elderly, patients with COPD, and those receiving corticosteroids. Our study provides support for recommending pneumococcal vaccination for adults at risk of pneumonia, including those with a first episode of CAP.

Long-term follow-up trial of oral rifampin-cotrimoxazole combination versus intravenous cloxacillin in treatment of chronic staphylococcal osteomyelitis.

Oral therapies alternative to fluoroquinolones against staphylococcal chronic osteomyelitis have not been evaluated in comparative studies. Consecutive nonaxial Staphylococcus aureus chronic osteomyelitis cases were included in a comparative trial after debridement. Fifty patients were randomized: group A (n = 22) was treated with cloxacillin for 6 weeks intravenously plus 2 weeks orally (p.o.), and group B (n = 28) was treated with rifampin-cotrimoxazole for 8 weeks p.o. During follow-up (10 years), five relapses occurred: two (10%) in group A and three (11%) in group B. Foreign-body maintenance was associated with relapse (P = 0.016). Oral rifampin-cotrimoxazole treatment showed outcomes comparable to those for intravenous cloxacillin treatment.

Clinical features and outcomes of Legionnaires' disease in solid organ transplant recipients.

We identified 14 cases of Legionnaires' disease occurring in 2946 solid organ transplant recipients from 1985 to 2007. Most cases were sporadic and community acquired. The recent introduction of the urinary antigen test has accelerated diagnosis and allows prompt institution of adequate therapy. The overall mortality rate in our series was 14.3%.

Early mortality in patients with community-acquired pneumonia: causes and risk factors.

The first 48 h of evolution of patients with community-acquired pneumonia (CAP) are critical. The aim of the present study was to determine the frequency, causes and factors associated with early mortality in CAP. Nonimmunocompromised adults hospitalised with CAP were prospectively observed from 1995 to 2005. Early deaths, defined as death due to any cause < or = 48 h after admission, were compared with all patients who survived > 48 h. Furthermore, early deaths were compared with late deaths (patients who died > 48 h) and with survivors. Of 2,457 patients, 57 (2.3%) died < or = 48 h after admission. Overall mortality was 7.7%. The main causes of early mortality were respiratory failure and septic shock/multiorgan failure. Independent factors associated with early deaths were increased age, altered mental status at presentation, multilobar pneumonia, shock at admission, pneumococcal bacteraemia and discordant empiric antibiotic therapy. Currently, early mortality is relatively low and is caused by pneumonia-related factors. It occurs mainly among the elderly and in patients presenting with altered mental status, multilobar pneumonia and septic shock. Pneumococcal bacteraemia and discordant antibiotic therapy, mainly due to lack of coverage against Pseudomonas aeruginosa are also significant risk factors.

Effect of prior pneumococcal vaccination on clinical outcome of hospitalized adults with community-acquired pneumococcal pneumonia.

The aim of this study was to evaluate the effect of prior pneumococcal vaccination on the clinical outcome of 554 consecutive hospitalized adults with community-acquired pneumococcal pneumonia from 1995 to 2004, 61 of whom had been vaccinated in the 5 years before admission. Outcome variables that were compared in vaccinated and unvaccinated adults included the occurrence of bacteremia, the time to resolution of pneumonia symptoms, the length of hospital stay, and mortality. Prior pneumococcal vaccination was associated with a lower risk of bacteremia (odds ratio 0.46, 95% CI 0.22-0.98). Compared with unvaccinated patients, vaccine recipients had better clinical outcomes, which included a faster resolution of pneumonia symptoms. The median length of hospital stay was shorter in vaccinated patients (8.0 vs. 9.0 days; p=0.032). Overall case-fatality rates did not differ significantly between groups (1.6% vs. 6.2%; p=0.233). In conclusion, prior pneumococcal vaccination appears to be associated with a lower risk of bacteremia, a faster time to resolution of symptoms, and a shorter hospital stay in adults with pneumococcal pneumonia. The findings presented here provide additional support to the current vaccine recommendations and should encourage healthcare providers to increase pneumococcal vaccine coverage among targeted adult populations.

Staphylococcus aureus nasal carriage in patients on haemodialysis: role of cutaneous colonization.

We performed a prospective study of Staphylococcus aureus nasal carriage in patients on chronic haemodialysis to determine the role of cutaneous colonization in the aetiology of recurrent nasal colonization. From February 2000 to September 2001, 71 patients on chronic haemodialysis in the dialysis unit at a university hospital were screened monthly for S. aureus nasal carriage. Carriers received nasal mupirocin for five days and were tested for nasal and cutaneous carriage two days later and monthly thereafter. Using genotyping results, recurrence was defined as relapse if pretreatment and subsequent nasal isolates were clonally identical; if the isolates were different, it was considered recolonization. Thirty-nine patients (55%) were nasal carriers: 11 initially and 28 during follow-up. Among the mupirocin-treated patients, the eradication of S. aureus nasal carriage rate was 88.5%. Nasal recurrence was documented in 17 patients (43.5%), and S. aureus nasal strains were available for molecular typing in 14 patients with a total of 23 recurrence episodes. On the basis of pulsed-field gel electrophoresis analysis, 16 (70%) recurrence episodes were considered relapses and seven were considered (30%) recolonizations. Among the episodes of relapse, prior cutaneous colonization was detected in only three cases. In haemodialysis patients, the majority of nasal carriage recurrences after mupirocin therapy were due to relapses. Cutaneous colonization does not appear to be relevant in the development of these relapses.

Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis.

The aim of this study was to analyze medical outcomes, including risks for complications and mortality, in 332 adult patients hospitalized for cellulitis. The infection was documented microbiologically in 128 cases (39%). Staphylococcus aureus (46 cases) and Streptococcus pyogenes (22 cases) were the most frequent causative pathogens. Overall, 63 patients (19%) were discharged early (< or =4 days) and 166 patients (50%) were hospitalized for more than 4 days without developing any complications. One hundred three patients (31%) had one or more complications or died. Of these, 78 required surgical debridement, 10 required plastic surgery, 7 underwent amputation, and 15 had shock on presentation. When comparing the three study groups (patients discharged early, patients hospitalized for < or =4 days without complications, and patients who developed 1 or more complication or who died), patients who were discharged early (low risk) were more frequently female and were less likely to have multiple comorbid conditions, hypoalbuminemia, renal insufficiency, and/or cutaneous necrosis at presentation. Overall mortality (<30 days) was 5% (16/332 patients). Factors associated with death were male sex, presence of multiple comorbid conditions, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency, shock, and Pseudomonas aeruginosa cellulitis. These findings can be used to stratify patients with acute cellulitis according to risks for complications and mortality and may be helpful when deciding the most appropriate means of care, i.e. outpatient treatment or hospitalization.

Efficacy and safety of sequential amoxicillin-clavulanate in the treatment of anaerobic lung infections.

In order to assess the efficacy and safety of amoxicillin-clavulanate for the treatment of anaerobic lung infection, 40 patients with lung abscess or necrotizing pneumonia were given sequential amoxicillin-clavulanate therapy. All patients received intravenous amoxicillin-clavulanate (2 g/200 mg/8 h), which was switched to oral form (1 g/125 mg/8 h) after clinical improvement. Mean duration of antibiotic therapy was 43.5 days. Microbiological documentation was obtained in 53% of cases. All but 1 of the 48 microorganisms isolated were susceptible to amoxicillin-clavulanate. The drug was well tolerated by the patients and no severe adverse effects were observed. At the end of treatment all patients were considered cured. The 35 patients assessed at long-term follow-up visit remained disease-free.

Hierro protein-succinilato para el tratamiento de la anemia ferropénica del adulto / Iron protein-succinylate in the treatment of adult iron-deficency anemia

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[Acute cerebrovascular accident in the primary antiphospholipid syndrome]. / Accidente cerebrovascular agudo en el síndrome antifosfolipídico primario.

OBJECTIVE: To report the prevalence of acute cerebrovascular accidents (ACVA) and risk factors for thrombosis among patients diagnosed of primary antiphospholipid syndrome (PAPLS) and to compare this group with that of patients with PAPLS but not ACVA. PATIENTS AND METHODS: Retrospective data analysis of 30 patients consecutively diagnosed of PAPLS. Episodes of ACVA were quantitated and other cardiovascular risk factors were determined. RESULTS: Thirty percent of patients (9/30) had one or more ACVA. No significant differences were found when the presence of other cardiovascular risk factors in both groups was compared. CONCLUSIONS: Antiphospholipid antibodies in young patients with ACVA should be determined, although some other cardiovascular risk factors may coexist.

Accidente cerebrovascular agudo en el síndrome antifosfolipídico primario / Acute cerebrovascular accident in the primary antiphospholipid syndrome

Fundamento. Describir la prevalencia de accidentes cerebrovasculares agudos (ACV) y los factores de riesgo trombótico existentes en pacientes diagnosticados de síndrome antifosfolipídico primario (SAFP) y comparar este grupo con el de los pacientes que estando afectados de SAFP no presentaron ACV.Material y métodos. Se revisaron retrospectivamente los datos de 30 pacientes diagnosticados consecutivamente de SAFP. Se cuantificaron los episodios de ACV y se determinaron otros factores de riesgo cardiovascular. Resultados. El 30 por ciento de los pacientes (9/30) presentaron uno o más ACV. Al comparar la existencia de otros factores de riesgo cardiovascular en ambos grupos no se encontraron diferencias significativas.Conclusiones. En los pacientes jóvenes que sufren un ACV deben determinarse anticuerpos antifosfolipídicos, a pesar de que coexistan otros factores de riesgo cardiovascular (AU)

Varón de 38 años con anemia perniciosa y formaciones polipoides gástricas / Thirty-eight-year-old male with pernicious anemia and gastric polyps

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