Obesidad y funcion renal. Datos del estudio epidemiologico: Prevalencia de la enfermedad renal cronica en España. Estudio EPIRCE / Obesity and renal function. Data from the epidemiological study: Prevalence of chronic renal disease in Spain. EPIRCE Study

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[Occult chronic kidney disease (OCKD), and cardiovascular risk factors. Epidemiologic study]. / Enfermedad renal crónica oculta (ERCO), y factores de riesgo vascular (FRV) asociádos. Estudio epidemiológico.

UNLABELLED: Vascular diseases are the first cause of mortality within the occidental world. In Spain, they represent 35.5% within the total of deceases. Vascular diseases, jointly with Diabetic Nephropaty, are the first cause of inclusion of patients in dialysis. In precocious stages of renal disease, and as a consequence of the inflammatory condition generated already exists vascular damage. But its prevention is difficult, because habitually GFR is evaluated by means of plasmatic creatinin rate impeding the suitable detection of renal disease prevailing. OBJECTIVE: The purpose of this study is to evaluate the prevailing of Occult Chronic Kidney Disease (OCKD) and its association with conventional vascular risk factors (VRF). MATERIAL AND METHODS: The epidemiologic study was made in a randomly selected population elder than 18 years. GFR was calculated using Cockcroft-Gault and MDRD methods, and the results were correlated with VRF. RESULTS: The studied population mean age is 50.49 +/- 16.28 years, hypertension prevailing is 31.5%, diabetes: 7.5%, obesity: 21.9%, dislipènic: 35.62%, anemia: 1.4%. IV degree IRCO rate (GFR: 15-30 ml/min) is 0.7 (MDRD) with 69.43 +/- 12.58 years of age, and 1.5% (C-G) with 76.25 +/- 10.64 years of age. GFR, independently on the method used in its calculation, is significantly correlated with TAS (< 0.0001), pulse pressure (< 0.0001), Hb (0.0001), obesity (< 0.0001), Total Cholesterol (< 0.0001), triglycerides (< 0.0018), c-HDL (< 0.0001), c-LDL (< 0.0001) e hiperuricemic (< 0.0001). GFR disparity depends on the equation used. It could be explained because C-G overestimate by "weigh" and it has higher deviation in lower renal function values. Whereas, using MDRD equation there is an overestimation by "age" and it has lower variability. CONCLUSIONS: In an aged population, the prevailing of OCKD and the rate of VRF are high conferring high vascular risk. It will be necessary to adopt intervention measures in order to avoid renal disease progress and its high morbid-mortality.

Determinants of health system delay among confirmed tuberculosis cases in Spain.

BACKGROUND: Health system delay (HSD) is an important issue in tuberculosis (TB) control. This report investigates HSD and associated factors in a cohort of Spanish culture-confirmed TB patients. METHODS: Data were collected from clinical records. Using logistic regression with two different cut-off points to define HSD (median and 75th percentile), adjusted odds ratios were used to estimate the association between HSD and different variables. RESULTS: A total of 5184 culture-confirmed TB cases were included. Median and 75th percentile HSD were 6 and 25 days respectively. HSD significantly greater than the median was associated with: age >44 years, past or present intravenous drug use, diagnosis at a primary-care centre, prior preventive therapy, positive histology, request for drug-sensitivity testing, presence of silicosis or neoplasia in addition to TB, presence of non-TB related symptoms, and gastrointestinal site. HSD greater than the 75th percentile was related to the same variables, with the exception of diagnosis at a primary-care centre, positive histology, silicosis, non-TB-related symptoms and gastrointestinal site, for which the association disappeared; in contrast, an association with female gender emerged. CONCLUSION: Despite free health care being universally available in Spain, there are some groups of TB patients whose treatment is unduly delayed.

Enfermedad renal crónica oculta (ERCO), y factores de riesgo vascular (FRV) asociados. Estudio epidemiológico / Occult chronic kidney disease (ockd), and cardiovascular risk factors. Epidemiologic study

Las enfermedades vasculares son la primera causa de muerte en el mundo occidental,en España representan el 35,5% del total de fallecimientos y son juntamentecon la Nefropatía Diabética, la primera causa de inclusión de pacientes en depuraciónextrarrenal. En estadios precoces de insuficiencia renal y como consecuencia delestado inflamatorio que genera, ya existe daño vascular, pero su prevención es difícilya que de forma habitual se evalúa el GFR mediante la tasa plasmática de creatinina,lo que impide detectar de forma adecuada la prevalencia de enfermedad renal.Objetivo: Evaluar la prevalencia de ERCO y su asociación a factores de riesgovascular (FRV) convencionales.Material y métodos: Estudio epidemiológico, en una muestra aleatoria al azaren una población mayor de 18 años (n = 1.059), se determinó GFR por fórmulasde Cockcroff-Gault y MDRD y se correlaccionó con los FRV.Resultados: La media de edad de la población estudiada es 50,49 ± 16,28 añosy la tasa de ERCO Grado III (GFR < 60 ml/min) es 13,1% (MDRD) con una mediade edad de 66,27 años y 17,8% (C-G) y edad 68,73 años. El Grado IV (GFR: 15-30ml/min) es 0,7 (MDRD) con edad de 69,43 ± 12,58 años y 1,5% (C-G) y 76,25 ±10,64 años. En la población general, la prevalencia de hipertensión es: 31,5%, diabetes:7,5%, obesidad: 21,9%, dislipemia: 35,62%, anemia: 1,4%. El GFR, independientedel método de medida se correlaciona significativamente con la TAS (< 0,0001),presión del pulso (< 0,0001), Hb (< 0,0001), obesidad (< 0,0001), Colesterol total(< 0,0001), Triglicéridos (< 0,0018), c-HDL (< 0,0001), c-LDL (< 0,0001) e hiperuricemia(< 0,0001).La disparidad del GFR en función de la fórmula utilizada es debido a que elC-G sobrestima por peso y tiene una mayor dispersión para valores mas bajos defunción renal y MDRD lo hace por la edad, y tiene menor variabilidad.En conclusión, la prevalencia de ERCO es elevada, en una población envejeciday con tasa elevada de FRV, lo que les confiere un alto riesgo vascular y seríapreciso adoptar medidas de intervención a fin de evitar la progresión de la enfermedadrenal y su alta morbi-mortalidad

Vascular diseases are the first cause of mortality within the occidental world. InSpain, they represent 35.5% within the total of deceases. Vascular diseases, jointlywith Diabetic Nephropaty, are the first cause of inclusion of patients in dialysis .In precocious stages of renal disease, and as a consequence of the inflammatorycondition generated already exists vascular damage. But its prevention is difficult,because habitually GFR is evaluated by means of plasmatic creatinin rate impedingthe suitable detection of renal disease prevailing.Objective: The purpose of this study is to evaluate the prevailing of Occult ChronicKidney Disease (OCKD) and its association with conventional vascular riskfactors (VRF).Material and methods: The epidemiologic study was made in a randomly selectedpopulation elder than 18 years. GFR was calculated using Cockcroft-Gaultand MDRD methods, and the results were correlated with VRF.Results: The studied population mean age is 50.49 ± 16.28 years, hypertensionprevailing is 31.5%, diabetes: 7.5%, obesity: 21,9%, dislipènic: 35,62%, anemia:1,4%. IV degree IRCO rate (GFR: 15-30 ml/min) is 0.7 (MDRD) with 69.43 ±12.58 years of age, and 1.5% (C-G) with 76.25 ± 10.64 years of age. GFR, independentlyon the method used in its calculation, is significantly correlated withTAS (< 0.0001), pulse pressure (< 0,0001), Hb (0,0001), obesity (< 0,0001), TotalCholesterol (< 0,0001), triglycerides (< 0,0018), c-HDL (< 0,0001), c-LDL (<0,0001) e hiperuricemic (< 0,0001).GFR disparity depends on the equation used. It could be explained because CGoverestimate by «weight» and it has higher deviation in lower renal functionvalues. Whereas, using MDRD equation there is an overestimation by «age» andit has lower variability.Conclusions: In an aged population, the prevailing of OCKD and the rate of VRFare high conferring high vascular risk. It will be necessary to adopt intervention measuresin order to avoid renal disease progress and its high morbid-mortality

[Monitoring protocol of native vascular accesses for haemodialysis]. / Programa de monitorización de accesos vasculares nativos para hemodiálisis.

Vascular access failure is an important cause of morbidity and mortality for patients on haemodialysis. We have prospectively studied, with a 5 years follow up, a monitoring protocol of native vascular accesses, using the available methods in every haemodialysis unit. All the native vascular accesses, created from 1- 1998 to XII-2001, with a posterior follow up until XII-2002, were monitored. Monitoring was based on physical examination, dificulty for blood flow greater than 300 ml/min, and in a monthly basis: dynamic venous pressure, urea recirculation and urea kinetic model. Abnormalities suggestive of fistulogram were a priori defined. During the recruitment period, a total of 164 accesses were created in 144 patients. Of these only 3 were grafts, 28 native vascular accesses were never functioning (primary failure rate 17. 1%), and 127 native accesses created in 113 patients (age 63.3 +/- 12.4 years; 18 % diabetics), were monitored (83% cephalic vein). Monitoring findings indicated realization of fistulogram in 35% and percutaneus angioplasty in 25% of the accesses. In order to maintain patency, the surgical intervention rate was 0.03 procedures/patient/year, the radiological 0.10 and the total 0.13. During the 5 years of the study occurred 41 thrombosis episodes in 40 accesses (0.07 thrombosis/patient/year), with percutaneus repermeabilization in 30%. Primary (unassisted) survival was 30.3 months (Confidence Interval 95% 25.6, 35.0) and secondary (assisted) survival 42.8 months (Confidence Interval 95%: 38.7, 46.9). Logistic regression analysis showed that presence of a central catheter at the time of creating the vascular access posses a greater risk for thrombosis (Relative Risk 5.6 if in subclavian vein), whereas age, diabetes, time to canulation, number of previous accesses and anatomic type do not increase that risk. In conclusion, in an old haemodialysis population, with an important diabetes prevalence, it is possible to create functioning native vascular accesses in most of them. The monitoring protocol allowed the detection and posterior correction of stenosis in a great number of accesses. The main risk of thrombosis is the presence of a central catheter at the time of creating a vascular access.

Comparison of two techniques of sputum induction in the diagnosis of pulmonary tuberculosis.

SETTING: Specialised tuberculosis out-patient clinic covering a population of 350 885. OBJECTIVES: To compare two techniques, ultrasonic nebuliser (UN) and Venturi-type face mask nebuliser (VFMN), for obtaining sputum in patients suspected of having active pulmonary tuberculosis (PTB) and who cannot expectorate, and to analyse the usefulness and cost of sputum induction with UN in a specialised medical practice. DESIGN: Prospective study from October 1997 until March 2000. RESULTS: Of 94 subjects who completed all tests, at least one sample of sputum was obtained from 89 (95.6%). UN provided adequate samples in 86 (93.4%) and VFMN in 66 (71%), a significant difference (P < 0.001). Among 43 patients diagnosed with active PTB, the diagnosis was confirmed in 39 with the samples obtained by sputum induction. Direct acid-fast bacilli smear was positive in 8 (19%). Direct costs were low and the technique can be performed on the day the patient attends the outpatient clinic. CONCLUSION: Sputum induction with an ultrasonic nebuliser was well-tolerated, of low cost, allows adequate samples to be obtained in the majority of patients who cannot produce sputum, and was more effective than the Venturi-type face mask.

Programa de monitorización de accesos vasculares nativos para hemodiálisis / Monitoring protocol of native vascular accesses for haemodialysis

El fallo del acceso vascular es causa importante de morbimortalidad en los pacientesen hemodiálisis. Se presentan los resultados de un estudio prospectivo, durante5 años, aplicando un protocolo de monitorización de los accesos vasculares nativos.Se monitorizaron, utilizando métodos disponibles en cualquier Unidad de Diálisis,todos los accesos nativos realizados desde I-1998 hasta XII-2001, con un seguimientoposterior hasta XII-2002. La monitorización se basó en examen físico, dificultad paraflujo mayor de 300 ml/min, y mensualmente, de modo alterno: presión venosa dinámica,recirculación de urea y su modelo cinético. Se definieron a priori las alteracionesindicativas de realización de fistulografía.Durante el período de reclutamiento se realizaron 164 accesos a 144 pacientes. Deestos accesos sólo 3 fueron prótesis y 28 accesos nativos nunca funcionaron (fallo primario17,1%). Se monitorizaron 127 accesos nativos (83% vena cefálica) realizadosa 113 pacientes (edad 63,3 ± 12,4 años; 18% diabéticos).Indicadas por anomalías en la monitorización se realizaron fistulografías en el 35%de los accesos y angioplastia de estenosis en el 25%. Las tasas de intervención quirúrgicapara mantener la viabilidad fueron de 0,03 procedimientos/paciente/año, laradiológica de 0,10 y la total de 0,13. En los 5 años se produjeron 41 episodios detrombosis en 40 accesos (0,07 trombosis/paciente/año), con repermeabilización percutáneaen el 30%. El tiempo de supervivencia primaria fue de 30,3 meses (Intervalode Confianza al 95%: 25,6, 35,0) y el de la acumulativa 42,8 meses (Intervalo deConfianza al 95%: 38,7, 46,9).El análisis de regresión logística demostró que la presencia de un catéter central alcrear el acceso confiere un riesgo mayor de trombosis (Riesgo Relativo 5,6 si en subclavia),mientras que la edad, diabetes, tiempo de utilización, número de accesos vascularesprevios y tipo del mismo no lo incrementan.En conclusión, el protocolo de monitorización permitió detectar y corregir estenosisen numerosos accesos vasculares nativos. En un porcentaje elevado de trombosisse produjo la recanalización percutánea del acceso. El mayor riesgo de trombosisdetectado fue la presencia previa de un catéter en vena subclavia

Vascular access failure is an important cause of morbidity and mortality for patientson haemodialysis.We have prospectively studied, with a 5 years follow up, a monitoringprotocol of native vascular accesses, using the available methods in every haemodialysisunit.All the native vascular accesses, created from I-1998 to XII-2001, with a posteriorfollow up until XII-2002, were monitored. Monitoring was based on physical examination,dificulty for blood flow greater than 300 ml/min, and in a monthly basis: dynamicvenous pressure, urea recirculation and urea kinetic model. Abnormalities suggestiveof fistulogram were a priori defined.During the recruitment period, a total of 164 accesses were created in 144 patients.Of these only 3 were grafts, 28 native vascular accesses were never functioning (primaryfailure rate 17.1%), and 127 native accesses created in 113 patients (age 63.3 ±12.4 years; 18% diabetics), were monitored (83% cephalic vein).Monitoring findings indicated realization of fistulogram in 35% and percutaneusangioplasty in 25% of the accesses. In order to maintain patency, the surgical interventionrate was 0.03 procedures/patient/year, the radiological 0.10 and the total0.13. During the 5 years of the study occurred 41 thrombosis episodes in 40 accesses(0.07 thrombosis/patient/year), with percutaneus repermeabilization in 30%. Primary(unassisted) survival was 30.3 months (Confidence Interval 95% 25.6, 35.0)and secondary (assisted) survival 42.8 months (Confidence Interval 95%: 38.7,46.9).Logistic regression analysis showed that presence of a central catheter at the time ofcreating the vascular access posses a greater risk for thrombosis (Relative Risk 5.6 if insubclavian vein), whereas age, diabetes, time to canulation, number of previousaccesses and anatomic type do not increase that risk.In conclusion, in an old haemodialysis population, with an important diabetes prevalence,it is possible to create functioning native vascular accesses in most of them.The monitoring protocol allowed the detection and posterior correction of stenosis ina great number of accesses. The main risk of thrombosis is the presence of a centralcatheter at the time of creating a vascular access

Determinants of patient delay among tuberculosis cases in Spain.

BACKGROUND: Patient delay was investigated in a cohort of TB patients identified from May 1996 until April 1997 in 13 Autonomous Regions in Spain. The study covered almost 67% of the total Spanish population. METHODS: Data were collected from clinical records. Using unconditional logistic regression with two different cut-off points to define 'patient delay' (the median and 75th percentile), the association between patient delay and different factors was estimated. RESULTS: A total of 7,037 cases were included. Median and 75th percentile delays were 22 and 57 days respectively. Factors associated with patient delay greater than the median (p<0.05) were: non-respiratory symptoms of TB and age over 14 years, although the effect of age was not linear. Furthermore, an interaction was observed between intravenous drug user (IDU) and HIV status, in that, whereas patient delay was greater in IDUs than in non-IDUs among cases whose HIV status was either negative or unknown, among HIV-positive patients no such IDU-related differences were in evidence. Factors associated with extreme patient delay (greater than the 75th percentile) were essentially the same, but the above-described interaction disappeared, with IDU status showing no direct effect. In addition, likelihood of extreme patient delay increased in the case of alcoholism and female gender and decreased in the case of chronic renal failure, corticoid treatment, prison inmates and residents of old age homes. CONCLUSION: Although there is a universally enjoyed right to health care in Spain, some groups of TB patients could nevertheless be experiencing problems in seeking medical attention.

Neither folic nor folinic acid normalize homocysteine levels in hemodialysis patients.

AIMS: A greater decrease in total homocystein (tHcy) has been reported in patients on hemodialysis (HD) following the administration of reduced forms of folic acid (FA), however, the effect of the administration of moderated doses of oral levofolinic acid has not been compared with that of FA. We decided to perform a study to evaluate the therapeutic effectiveness of oral levofolinic acid, the pharmacologically active form of folinic acid in our population of HD patients already on treatment with oral FA and vitamin B6. MATERIAL AND METHODS: We undertook a prospective study in HD patients who had been receiving oral supplements of both FA 5 mg every 48 hours and vitamin B6 40 mg every 7 days during at least 6 months, with a 17% initial decrease of tHcy levels. Patients matched for age, sex and time on HD were assigned to 1 of 2 groups: Those in group A continued to receive their previous supplements while in group B, FA was substituted by calcium levofolinate 5 mg given orally every 48 hours. The following parameters were measured at baseline and at month 6: urea kinetic model and concentrations of plasma albumin, C-reactive protein, folate, vitamin B12, pyridoxal phosphate and tHcy. RESULTS: Group A: 30 patients aged 63.4 (57.9, 68.9) years, with a time on HD of 23.4 (15.8, 30.8) months, group B: 32 age-matched patients 66.2 (62.1, 70.3) years old, with a time on HD of 23.8 (16.7, 30.9) months. No differences were found either in folate levels (72.7 (47.9, 97.5) vs. 71.9 (44.0. 99.9) ng/ml), tHcy (23.5 (21.1, 25.9) vs. 23.3 (20.8, 25.8) micromol/l), or any other study variables. In the 2 groups a significant reduction in both residual renal function (RRF) and vitamin B12 levels was observed after supplementation, but no changes in tHcy values, folate levels or any of the other parameters were found. The prevalence of hyperhomocysteinemia in group A was 93.3% at study start and 100% at month 6, in group B the corresponding values were 93.8% and 96.9%. After 6 months, multiple regression analysis showed that tHcy levels were not influenced by the type of treatment (p = 0.543). CONCLUSIONS: After 6 months of calcium-levofolinate supplementation tHcy levels did not decrease and were similar to those in patients given the same dose of FA.

Sistema de acreditación en atención primaria (SaAP) (I): retos de la formación continuada / System of primary care accreditation (SaAP) (I): challenges of ongoing training

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Effect of long-term strength training on glucose metabolism. Implications for individual impact of high lean mass and high fat mass on relationship between BMI and insulin sensitivity.

The aim of this study was to examine the independent effect of high lean mass on glucose metabolism, as well as its consequences on the classic relationship between BMI and insulin sensitivity (SI) in 3 groups: 1) 8 strength-trained males with BMI >27 kg/m2 (athletes); 2) 10 sedentary males with BMI >27 kg/m2 (obese); and 3) 12 sedentary males with BMI 22-25 kg/m2 (control). Body composition was measured with impedance analysis. Iv glucose tolerance test was performed at 09:00 h after overnight fast. Estimation of insulin sensitivity and glucose effectiveness by Minimal Model Approach. Plasma glucose and insulin determination by glucose-oxidase and RIA respectively. BMI and lean mass (LM) were greater in athletes than in controls, but there were no differences in fat mass (FM), basal glucose (Gb), basal insulin (Ib), glucose tolerance (Kg), SI, glucose effectiveness (Sg), acute insulin response to glucose (AIRG) and leptin. Obese showed greater FM, leptin, lb and AIRG than athletes, while SI was lower; BMI, LM, Gb, Kg and Sg were similar. BMI, FM, LM, Ib, AIRG and leptin were lower in controls than in obese, while SI index was greater; Gb, Sg and Kg were similar. We found that: 1) Resistance exercise does not modify glucose effectiveness, but can improve insulin sensitivity through FM reduction (LM augmentation alone has no effect on glucose metabolism); and 2) High BMI causes insulin resistance only if it depends on adipose tissue hypertrophy.

Tuberculosis in Spain: epidemiological pattern and clinical practice.

SETTING: Thirteen Autonomous Regions in Spain. OBJECTIVE: To study the incidence of all forms of tuberculosis (TB) and investigate clinical practice in TB. DESIGN: Cases of all forms of tuberculosis diagnosed in the study setting from May 1986 to April 1997 were identified though active search of different databases. Clinical and epidemiological information on cases was collected from clinical records or by interview with physicians. RESULTS: The overall incidence of all forms of tuberculosis was 38.5/100,000 and the incidence of smear-positive disease was 13.83/100,000. Most cases (97.1%) were Spanish nationals, with rates higher in men than in women (52.7/100,000 vs. 24.87/100,000) and in groups aged 25-34 and 75 years and over (61.35/100,000 and 59.35/100,000, respectively). Disseminated forms were frequent (6.6%), and the most common risk factor was human immunodeficiency virus (HIV) infection (17.7% of cases). Hospitalisation was common (71.6%). Microbiological confirmation of diagnosis was sought for 87.7% of the cases (91.8% of pulmonary vs. 75.5% of extra-pulmonary cases), and 65.2% were culture-positive (73.8% of pulmonary vs. 39.7% of extra-pulmonary cases). HIV-infected patients were treated in almost equal proportions with three or four drugs (49.7% and 48.2%, respectively), while HIV-negative cases or those whose HIV status was unknown were usually treated with three drugs. CONCLUSION: The epidemiological pattern of TB in Spain is different to other industrialised countries in the age distribution of cases and the proportions of foreigners and cases with HIV infection. Microbiological confirmation of diagnosis is more common in pulmonary than in extra-pulmonary disease, and treatment with four drugs more frequent in HIV-positive cases.

Acción hipouricemiante de Losartan® en el trasplante renal

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Sistema de acreditación en atención primaria (SaAP) (III): retos de la formación continuada / system of accreditation in primary care (SaAP) (III): challenges in going training

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[Prognostic factors of bacteremia: prospective study]. / Factores pronósticos de la bacteriemia: estudio prospectivo.

BACKGROUND: To identify the epidemiology and risk factors with influence in the outcome and mortality of a series of bacteriemic patients. MATERIAL AND METHODS: A prospective study of bloodstream infections with clinical significance detected in a secondary hospital of 650 beds over period from May 1998 to May 1999. The true bacteriemia was defined in basis to the criteria both the physician and microbiologist. A total of 16 variables were defined and categorized such as clinical-epidemiologic, intrinsic risk factor, extrinsic risk factor, outcome and survival. We used SPSS statistical package: For cuantitative variables we carried out with the mean with confidence interval of 95%, for cualitative variables: number and %. Univariate analysis of the results was carried out with the X2 test and t Student, the survival was expressed with Kaplan Meyer graphics and the logistic regression model. RESULTS: A total of 320 positive blood cultures were studied but only 272 blood cultures were considered true bacteriemia in 259 patients. The calculated incidence of significant episodes of bacteriemia per 1000 admissions/year was 13. The overall mortality was 22% whereas death attributable to bacteriemia was 16%. The mean age was 66.9 years (IC 95% 65-69), 59% episodes occurred in men. The 78% episodes occurred in patients hospitalized in medical services. 52% episodes were of nosocomial infection and 48% of community acquired infection. According to the severity of the underlying disease, 15% had fatal diseases and 35% episodes occurred in patients without underlying disease. According to the univariant analysis, the variables which where significantly associated with greater risk death were: etiology (fungus), septic shock, the inadequate antibiotic therapy, presence of extrinsic factors (central intravenous catheter, performance of invasive procedures, previous antimicrobial therapy) and the hospital stay of less than 10 days. According to the multivariable analysis showed that the factors remaining independent predictors of mortality were: septic shock (p < 0.0001, OR: 8), inadequate antimicrobial therapy (p < 0.005, OR: 6.7), existence of two or more extrinsic risk factors (p < 0.04). CONCLUSIONS: The presence of septic shock was the most important variable which influenced in the mortality in our serie, together with inappropriate antimicrobian therapy and the association of various extrinsic risk factors. These variables could be modified partly, for this reason the aggressive hemodynamic control and the early and appropriate antibiotic therapy would be the support of the successful bacteriemia management.

Factores pronóstico de la bacterimia: estudio prospectivo / Pronostic factors of the bloodstream infections: prospective study

Objetivo : Conocer la epidemiología e identificar los factores de riesgo que influyeron en la mortalidad de nuestros pacientes con bacteriemia.Material y métodos: Estudio prospectivo de las bacteriemias significativas detectadas en un hospital secundario de 650 camas en el período de mayo de 1998 a mayo de 1999. La catalogación como significativa se realizó de acuerdo con el criterio del clínico y microbiólogo implicados.Se analizaron 16 variables categorizadas como clínico-epidemiológicas, factores de riesgo intrínseco y extrínseco, evolución y supervivencia. El análisis estadístico se hizo en base al programa informático SPSS; para variables cuantitativas se utilizó la media con IC del 95 por ciento, y para las variables cualitativas: nº y por ciento. El análisis bivariante se realizó con t Student y X2; la supervivencia se expresó con gráficas de Kaplan-Meyer y el índice de regresión logística de Cox.Resultados: Se analizaron 320 hemocultivos que tras la valoración del clínico se redujeron a 272 episodios de bacteriemia clínicamente significativa en 259 pacientes, con una incidencia de 13 casos/1000 admisiones/año. La mortalidad global fue del 22 por ciento, mientras la directamente relacionada con la bacteriemia fue del 16 por ciento. La edad media fue 66,9 años (IC 95 por ciento: 65-69) con predominio de varones(59 por ciento), localizándose en el área médica hasta un 78 por ciento de los casos, siendo de origen nosocomial el 52 por ciento y comunitario el 48 por ciento. Un 15 por ciento de los casos eran portadores de enfermedad fatal y hasta un 35 por ciento carecían de enfermedad de base.Según el análisis univariante se asoció con mayor de riesgo de muerte (p<0,05): la etiología (fungemias), la presencia de shock, adecuación de tratamiento, existencia de factores extrínsecos (catéter central, antibioticoterapia previa y procedimientos invasivos) y estancia hospitalaria menor de 10 días. Con el análisis multivariante sólo se identificaron como factores pronósticos independientes: Shock séptico (p<0,0001 con RR. 8), adecuación de tratamiento (p<0,001 con RR 6,67), presencia de más de 2 factores extrínsecos (p<0,04).Conclusiones: La aparición de shock al diagnóstico fue la variable que más influyó en la mortalidad de nuestros pacientes, seguida de la inadecuación del tratamiento antibiótico y la existencia de factores de riesgo extrínsecos. Estas variables modificables en cierto grado obligan a incidir sobre la necesidad de un control hemodinámico agresivo y el establecimiento de un tratamiento antibiótico precoz adecuado (AU)