Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management.

BACKGROUND: Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). AIM: To identify pVOM risk factors and evaluate management strategies. METHODS: From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. FINDINGS: Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). CONCLUSION: Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

[Health-related quality of life in patients recovered from COVID-19]. / Calidad de vida relacionada con la salud en pacientes recuperados de COVID-19.

INTRODUCTION: The presence of symptoms after acute SARS-CoV-2 infection is frequent and has an impact on patients' quality of life. The aim of this study is to assess the health-related quality of life of COVID-19 survivors and to ascertain which factors are related to worse results. METHODS: An observational, cross-sectional study has been performed, using, a telephone survey that was administered to all patients with COVID-19 from the first pandemic wave in our healthcare area 10months after the acute infection. Patients with dementia and nursing home residents were excluded. Health-related quality of life was assessed using the EQ-5D instrument and its índices EQ-VAS and EQ-Health Index. RESULTS: 443 answers were collected. Mean age was 54±16 and 38.4% of patients were male. The most affected domain was anxiety/depression (23.9% of patients) and mobility (16.5%). Mean global EQ-VAS score was 75.8±18.7, and mean EQ-Health Index was 0.884±0.174. Both VAS and Health Index scores were lower in females, patients older than 65 years, patients with comorbidities, and those who needed hospital admission during the acute infection. VAS scores in our sample were lower than in the general Spanish population, but similar to the scores in our region prior to the pandemic. Female sex, hospital admission, and a lower educational status were independently associated to lower EQ-Health Index scoring. CONCLUSION: While health self-perception is affected after COVID-19, this might not be directly related to the infection. There exist profiles of patients more prone to a worse quality of life in which interventions may be considered.

Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study.

OBJECTIVES: The aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed. METHODS: This was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present. RESULTS: In total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75-59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan-Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1-2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09-2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5-3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%). CONCLUSIONS: SAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.

Paralysis of the external popliteal sciatic nerve associated with daptomycin administration.

WHAT IS KNOWN AND OBJECTIVE: Peripheral neuropathy has been associated with the administration of certain drugs. Few reports have described the association of daptomycin with the development of peripheral neuropathy, none of them with peroneal nerve involvement. CASE SUMMARY: We report a case of a 62-year-old man who developed external popliteal sciatic nerve paralysis after 22 days of therapy with daptomycin. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events.

Differences between endocarditis caused by Streptococcus bovis and Enterococcus spp. and their association with colorectal cancer.

Streptococcus bovis group and Enterococcus spp. share phenotypic characteristics and intestinal habitat. Both have been associated with endocarditis and colorectal neoplasm (CRN). We studied all cases of endocarditis diagnosed between 1988 and 2014 in our centre and caused by S. bovis (109, 48.8 % of the bacteremia) and by Enterococcus spp. (36, 3.4 % of the bacteremia). Patients were seen until death or during a long-term follow-up, in order to rule out a concomitant CRN. The 109 cases of S. bovis endocarditis (SbIE) compared with the 36 caused by enterococci showed: a higher proportion of males (91 % vs. 72 %, p=0.005), more multivalvular involvement (28 % vs. 6 %, p=0.004), embolic complications (44 vs. 22 %, p=0.02) and colorectal neoplasm (64 % vs. 25 %, p=0.001). SbIE showed fewer co-morbidities (32 vs. 58 %, p=0.005), and less frequently urinary infection source (0 vs. 25 %, p=0.001) and healthcare-related infection (2 vs. 44 %, p=0.001). A total of 123 patients were followed up for an extended period (mean: 65.9 ± 57.5 months). During the follow-up, 6 of 28 (21 %) cases with enterococcal endocarditis and 43 of 95 (45.2 %, p=0.01) cases with SbIE developed a new CRN. These neoplasiae appeared a mean of 60.4 months later (range 12-181 months). Among the 43 cases with SbIE and CRN, 12 had had a previously normal colonoscopy and 31 had had a previous CRN and developed a second neoplasm. Cases of SbIE present important differences with those caused by Enterococcus spp. Colonoscopy must be mandatory both in the initial evaluation of SbIE, as during the follow-up period.

The clinical epidemiology and malignancies associated with Streptococcus bovis biotypes in 506 cases of bloodstream infections.

OBJECTIVES: To determine the incidence of Streptococcus bovis (Sb) biotypes causing bacteraemia and associated malignancies. METHODS: This is a retrospective analysis of patients with Sb bacteraemia, pulled out from a prospective surveillance protocol of bacteraemia cases, in three areas of Spain (1990-2013): a cattle area (Lugo), a fishing area (Ferrol) and an urban area (Barcelona). Colonoscopy and Sb biotypes (Sb-I and Sb-II) were determined in most cases. RESULTS: 506 patients with Sb bacteraemia; mean age 68.1 (±14.1) years, and 66.2% were males. The cattle area, compared with the fishing and urban areas, had higher incidence of bacteraemia by SbI (40.29 vs 9.38 vs 6.15 cases/10(6) person-years, P < 0.001) and bacteraemia by Sb-II (29.07 vs 9.84 vs 13.37 cases/10(6) person-years, P < 0.001). The Sb-I cases (n = 224), compared with Sb-II cases (n = 270), had greater rates of endocarditis (77.6% vs 9.6%, P < 0.001) and colorectal neoplasm (CRN) (50.9% vs 16.6%, P < 0.001), and smaller rates of biliary tract infection (2.2% vs 29.6%, P < 0.001) and non-colorectal malignancy (8.9% vs 31.4%, P < 0.001). CONCLUSION: There was a link between the cattle area and higher incidence of Sb bacteraemia. Sb-I differed from Sb-II cases in clinical findings and associated malignancies. Colonoscopy is mandatory in cases of endocarditis or bacteraemia caused by Sb-I.

Daptomycin plus fosfomycin versus daptomycin monotherapy in treating MRSA: protocol of a multicentre, randomised, phase III trial.

INTRODUCTION: Despite the availability of new antibiotics such as daptomycin, methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia continues to be associated with high clinical failure rates. Combination therapy has been proposed as an alternative to improve outcomes but there is a lack of clinical studies. The study aims to demonstrate that combination of daptomycin plus fosfomycin achieves higher clinical success rates in the treatment of MRSA bacteraemia than daptomycin alone. METHODS AND ANALYSIS: A multicentre open-label, randomised phase III study. Adult patients hospitalised with MRSA bacteraemia will be randomly assigned (1:1) to group 1: daptomycin 10 mg/kg/24 h intravenous; or group 2: daptomycin 10 mg/kg/24 h intravenous plus fosfomycin 2 gr/6 g intravenous. The main outcome will be treatment response at week 6 after stopping therapy (test-of-cure (TOC) visit). This is a composite variable with two values: Treatment success: resolution of clinical signs and symptoms (clinical success) and negative blood cultures (microbiological success) at the TOC visit. Treatment failure: if any of the following conditions apply: (1) lack of clinical improvement at 72 h or more after starting therapy; (2) persistent bacteraemia (positive blood cultures on day 7); (3) therapy is discontinued early due to adverse effects or for some other reason based on clinical judgement; (4) relapse of MRSA bacteraemia before the TOC visit; (5) death for any reason before the TOC visit. Assuming a 60% cure rate with daptomycin and a 20% difference in cure rates between the two groups, 103 patients will be needed for each group (α:0.05, ß: 0.2). Statistical analysis will be based on intention to treat, as well as per protocol and safety analysis. ETHICS AND DISSEMINATION: The protocol was approved by the Spanish Medicines and Healthcare Products Regulatory Agency (AEMPS). The sponsor commits itself to publishing the data in first quartile peer-review journals within 12 months of the completion of the study. TRIAL REGISTRATION NUMBER: NCT01898338.

Is Streptococcus bovis a urinary pathogen?

The Streptococcus bovis group (SBG) comprises several microorganisms associated with human infections. They have been associated with bacteremia, endocarditis, biliary tract infection, meningitis, and colorectal cancer, but their role as urinary pathogens is not well known. The objective of this investigation was to discover the incidence and clinical significance of the bacteriuria associated with this complex. A retrospective analysis of all adult patients with bacteriuria caused by SBG during the period 1995-2012 was carried out. During the study period, SBG was isolated in 153 adult patients, who had a mean age of 67 years, most of them being women (80%). Most of our patients (65%) had some underlying disease, with urologic disease being the most common (37%), followed by diabetes mellitus (27%) and neurologic disease (25%). Among the 88 patients in whom we were able to correctly assess symptoms, 45% had asymptomatic bacteriuria, 35% had lower urinary tract infection, and 20% had upper urinary tract infection. In 14 cases (9%), SBG was also isolated in blood cultures. Most of the isolates of SBG (72%) were S. gallolyticus subsp. pasteurianus. All isolates were susceptible to penicillin, 98% to nitrofurantoin, and 77% to fosfomycin. Although SBG bacteriuria is uncommon, it should not always be taken as a contaminant, mainly when S. pasteurianus is isolated, because it may cause urinary tract infections and, occasionally, sepsis, whereas when S. gallolyticus is isolated from urine, it may be a marker of underlying endocarditis and colorectal cancer.

Streptococcus bovis group and biliary tract infections: an analysis of 51 cases.

Streptococcus bovis is a well-known cause of endocarditis, but its role in other infections has not been well described. We analysed prospectively all patients with biliary tract infections caused by S. bovis group during the period 1988-2011. We selected those cases associated with cholangitis and cholecystitis, defined according to Tokyo guidelines. Identification of the strains was performed using the API 20 Strep and the GP card of the Vitek 2 system, and was confirmed by molecular methods. Our series included 51 cases (30 cholangitis and 21 cholecystitis). The associated microorganisms were: Streptococcus infantarius (biotype II/1) 29 cases (57%), Streptococcus gallolyticus subsp. pasteurianus (biotype II/2) 20 cases (39%) and Streptococcus gallolyticus subsp. gallolyticus (biotype I) two cases (4%). The only difference found between S. infantarius and S. gallolyticus subsp. pasteurianus was a greater association of the first with malignant strictures of the bile ducts: 48% (14/29) versus 5% (1/20), p <0.001. Thirty-seven of the cases also had bacteraemia, causing 20% (37/185) of all S. bovis bacteraemia, with differences between S. gallolyticus subsp. gallolyticus (2/112; 2%) and the other two microorganisms: S. infantarius and S. gallolyticus subsp. pasteurianus (35/73; 48%; p <0.001). The vast majority of biliary tract infections due to S. bovis group are caused by S. infantarius and S. gallolyticus subsp. pasteurianus (S. bovis biotype II), and nearly half of the bacteraemia due to these two species has a biliary source (43% of the S. infantarius and 56% of S. gallolyticus subsp. pasteurianus).

Is colonoscopy necessary in cases of infection by Streptococcus bovis biotype II?

The association of colorectal neoplasia (CRN) with Streptococcus bovis biotype I (SBI) infection is well recognized. However, this is not the case for Streptococcus bovis biotype II (SBII). We conducted this study in order to analyze the relationship between SBII and CRN. We analyzed all cases of bacteremia due to SBI (n = 99) and SBII (n = 36) diagnosed in our hospital (during the period 1988-2011) that were followed up with colonoscopy. In addition, we reviewed the literature (during the period 1982-2011) to select all cases of infection of SB that had undergone colonoscopy or other adequate form of colorectal examination. A multivariate analysis was performed to detect CRN risk factors in patients infected with SB. From the 223 cases of SB infection included in the analysis (135 from our institution and 88 from the literature review), 159 were due to SBI and 64 were caused by SBII. As compared with SBI, the SBII cases had a lower frequency of CRN (27 % vs. 67 %, p <0.001), advanced adenomas (8 % vs. 29 %, p <0.01), and carcinomas (6 % vs. 21 %, p <0.01). In a multivariate analysis, and after adjusting for age, sex, type of infection, and biotype, SBII infection was not associated with CRN: odds ratio (OR) = 0.17; 95 % confidence interval (CI) = 0.09 to 0.33. The only factor independently associated with CRN was SBI infection: OR = 5.7; 95 % CI = 3.0 to 10.9. The prevalence of CRN in patients infected with SBII is significantly lower than patients with SBI and does not appear to be higher than the CRN prevalence among the general population.

Idoneidad de las derivaciones de Atención Primaria a especialidades médicas hospitalarias / Adequacy of primary care referrals to medical specialities

INTRODUCCIÓN. El objetivo de este estudio es conocer la idoneidad de las interconsultas dirigidas desde Atención Primaria a especialidades médicas hospitalarias analizando sus características desde el punto de vista de las dos partes implicadas. MÉTODOS. Cuatro médicos (2 de Atención Primaria y 2 Internistas hospitalarios) analizaron retrospectivamente las peticiones de interconsulta y las notas de la primera consulta de 225 pacientes seleccionados aleatoriamente entre las consultas realizadas entre enero y julio de 2003 en un hospital de carácter provincial. RESULTADOS. El 26% de las interconsultas se consideraron innecesarias si se exige el acuerdo de los cuatro observadores (el 26,6% adecuadas y sin acuerdo en el 47,2% restante), y 37% cuando sólo se requiere que coincidan tres de los cuatro investigadores. La categoría en la que se alcanza un mayor grado de acuerdo es la de las consultas inadecuadas. Estas interconsultas corresponden a pacientes más jóvenes, procedentes del medio urbano, se acompañan de hojas de solicitud de consulta de peor calidad y generan un menor número de revisiones. CONCLUSIONES. Las consultas externas médicas hospitalarias están lastradas por un número muy elevado de IC no adecuadas o innecesarias, a las que se remiten pacientes con características diferentes de aquellos remitidos para consultas consideradas adecuadas

INTRODUCTION. This study aims to know the adequacy of specialized care referrals from Primary Care to hospital medical specialities, analyzing their characteristics from the point of view of the two parties involved. METHODS. Four doctors (2 from primary care and 2 hospital internists) retrospectively analyzed the specialized care requests and notes of the first consultation of 225 patients randomly selected among the consultations made between January and July 2003 in a provincial Hospital. RESULTS. A total of 26% of the specialized care referrals were considered unnecessary if agreement of four observers is required (26.6% adequate and no agreement in the remaining 47.2%) and 37% were considered unnecessary when three of the four investigators had to agree. The category that reaches the highest degree of agreement is that of inadequate consultations. These referrals correspond to younger patients, from urban setting. They are accompanied by consultation request sheets having worse quality and generate fewer reviews. CONCLUSIONS. The hospital out-patient visits are hindered by a very high number of inadequate or unnecessary specialized care consultations, to which patients are sent with characteristics different from those sent with consultations that are considered to be adequate

[The internist's role in the medical evaluation of surgical patients]. / Papel del internista como consultor de servicios quirúrgicos.

OBJECTIVE: To describe the characteristics of the consultations carried out by surgical services to an Internal Medicine service and to determine what factors influence the prognosis of these patients. METHODS: A prospective study of the consultations carried out by the surgical services of a 540-bed hospital to an Internal Medicine service. Analyzed variables were: age, sex, service of reference, reason for consultation, medical and admission diagnoses done during the admission, and clinical evolution. RESULTS: In the study 453 interconsultations were included, corresponding to 0.96 new interconsultations by working day and to 4.05 interconsultations per every 100 admissions in surgical services during the period study. The reasons for the more common consultations were dyspnea, fever, electrolytic and metabolic disorders, assessment of multiple conditions and acute confusional syndrome. Two or more diagnoses were carried out in 257 patients (56.7%). The average number of visits carried out by patient was 3.9 +/- 3.9. The average hospital stay in the study group was 28 +/- 33.05 days, while the average hospital stay of patients admitted in the surgical services during the same period was 11.6 days. Fifty patients (11%) had died at the time of the "medical discharge", and this percentage amounted to 20.5% (93 cases) upon considering the end of the hospital admission, compared with the global mortality of 3.7% registered during that period in the surgical services. The number of medical diagnoses and the age were independent predictors of mortality in the multivariate analysis. CONCLUSIONS: The interconsultations of the surgical services to an Internal Medicine service imply an important workload. The patients are complex from the medical standpoint. The average hospital stay and mortality of these patients are different from that of the patients cared in surgical services.

Strangulated volvulus of the sigmoid colon with inviable mucosal appearance in a non-surgical patient. Endoscopic devolvulation.

Colonoscopy is presently always performed before surgical management of a volvulus in the sigmoid colon. It leads to know the viability of the mucosa and, when possible, to resolve the volvulus conservatively. Besides, with endoscopic control, we can place a decompression tube proximal to the volvulated sigmoid colon, favouring a non-surgical resolution. With this conservative approach it is possible to overcome the acute period, and to restore the viability of the sigmoid wall, waiting for a definitive surgical management with less morbidity and mortality. Only with endoscopy, revolvulation does occur in 35-50% of cases. We present the clinical case of a sigmoid volvulus with compromised sigmoid wall in an 82-year-old man with several clinical problems contraindicating surgery. Endoscopic devolvulation with tube placement was adequate to resolve this sigmoid volvulus.

[Centenarian patients attended at a general hospital]. / Pacientes centenarios atendidos en un hospital general.

BACKGROUND: To report the social and medical situation of centenarian patients who required emergency hospital care during the last 8 years. METHOD: Retrospective study of patients aged over 100 years attended at the Emergency Department of a general hospital. The percentages of admissions and mortality rates were then compared with those among patients aged over 65. RESULTS: A total of 51 consultations from 41 patients were recorded, with a mean age of 101.2 years. The number of consultations increased gradually with time (p = 0.008). Ninety-three percent of patients lived with their families, predominantly in the rural setting. The most prevalent conditions included the prostatic syndrome (among males), heart failure and chronic obstruction to the airflow. Only 20% of patients had dementia. Sixty-four percent of consultations required hospital admission, with a mortality rate of 20.5% in this group of patients. The most common discharge diagnoses were heart failure and acute cerebrovascular accident. CONCLUSIONS: A gradual increase in hospital care is likely to be excepted among centenarians, who have an acceptable health status, although with a high risk of mortality during hospital admission.

Mujer de 77 años con estreñimiento y un hematoma en el tórax / 77-year old woman with constipation and chest hematoma

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Vólvulo de sigma estrangulado con mucosa de apariencia inviable en paciente no subsidiario de tratamiento quirúrgico. Devolvulación endoscópica / Strangulated volvulus of the sigmoid colon with inviable mucosal appearence in a non-surgical patient. Endoscopic devolvulation

Actualmente la colonoscopia se realiza previamente al manejo quirúrgico de los vólvulos de sigma. Ello permite conocer el estado de la mucosa del colon volvulado, su viabilidad y, en ocasiones, resolver la volvulación de forma conservadora. Asimismo, mediante control endoscópico se puede dejar en posición un tubo de descompresión, colocado proximalmente al área volvulada, favoreciendo la resolución sin cirugía. Mediante este manejo conservador es posible superar el periodo agudo y recuperar la viabilidad de la pared del colon, evitando la cirugía urgente donde la morbimortalidad es mayor. El tratamiento endoscópico solamente no suele ser suficiente como solución definitiva apareciendo recidiva de la volvulación en el 3050 por ciento de los casos. Presentamos el caso de un vólvulo de sigma estrangulado, con compromiso de la pared colónica, en un paciente de 82 años de edad, con múltiples patologías de base que contraindicaban la cirugía. La devolvulación endoscópica, dejando en posición un tubo de descompresión, permitió la resolución del cuadro, sin recidiva posterior (AU)

Mujer de 71 años con dolor abdominal y estreñimiento / 71-year-old woman with abdominal pain and constipation

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