Immune thrombotic thrombocytopenic purpura in older patients: Results from the Spanish TTP Registry (REPTT).

Immune thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare disease that seldom occurs in the elderly. Few reports have studied the clinical course of iTTP in older patients. In this study, we have analysed the clinical characteristics at presentation and response to therapy in a series of 44 patients with iTTP ≥60 years at diagnosis from the Spanish TTP Registry and compared them with 209 patients with <60 years at diagnosis from the same Registry. Similar symptoms and laboratory results were described in both groups, except for a higher incidence of renal dysfunction among older patients (23% vs. 43.1%; p = 0.008). Front-line treatment in patients ≥60 years was like that administered in younger patients. Also, no evidence of a difference in clinical response and overall survival was seen in both groups. Of note, 14 and 25 patients ≥60 years received treatment with caplacizumab and rituximab, respectively, showing a favourable safety and efficacy profile, like that observed in patients <60 years.

Serotypes and Clonal Composition of Streptococcus pneumoniae Isolates Causing IPD in Children and Adults in Catalonia before 2013 to 2015 and after 2017 to 2019 Systematic Introduction of PCV13.

The goal of this study was to investigate the distribution of serotypes and clonal composition of Streptococcus pneumoniae isolates causing invasive pneumococcal disease (IPD) in Catalonia, before and after systematic introduction of PCV13. Pneumococcal strains isolated from normally sterile sites obtained from patients of all ages with IPD received between 2013 and 2019 from 25 health centers of Catalonia were included. Two study periods were defined: presystematic vaccination period (2013 and 2015) and systematic vaccination period (SVP) (2017 to 2019). A total of 2,303 isolates were analyzed. In the SVP, there was a significant decrease in the incidence of IPD cases in children 5 to 17 years old (relative risk [RR] 0.61; 95% confidence interval [CI] 0.38 to 0.99), while there was a significant increase in the incidence of IPD cases in 18- to 64-year-old adults (RR 1.33; 95% CI 1.16 to 1.52) and adults over 65 years old (RR 1.23; 95% CI 1.09 to 1.38). Serotype 8 was the major emerging serotype in all age groups except in 5- to 17-year-old children. In children younger than 5 years old, the main serotypes in SVP were 24F, 15A, and 3, while in adults older than 65 years they were serotypes 3, 8, and 12F. A significant decrease in the proportions of clonal complexes CC156, CC191, and ST306 and an increase in those of CC180, CC53, and CC404 were observed. A steady decrease in the incidence of IPD caused by PCV13 serotypes indicates the importance and impact of systematic vaccination. The increase of non-PCV13 serotypes highlights the need to expand serotype coverage in future vaccines and rethink vaccination programs for older adults. IMPORTANCE We found that with the incorporation of the PCV13 vaccine, the numbers of IPD cases caused by serotypes included in this vaccine decreased in all of the age groups. Still, there was an unforeseen increase of the serotypes not included in this vaccine causing IPD, especially in the >65-year-old group. Moreover, a significant increase of serotype 3 included in the vaccine has been observed; this event has been reported by other researchers. These facts call for the incorporation of more serotypes in future vaccines and a more thorough surveillance of the dynamics of this microorganism.

Pediatric Multisystemic Inflammatory Syndrome Temporarily associated with COVID-19: Clinical characteristics and management in a Pediatric Critical Care Unit. / Síndrome Inflamatorio Multisistémico Pediátrico asociado a COVID-19: Características clínicas y manejo en una Unidad de Paciente Crítico Pediátrico.

INTRODUCTION: In April 2020, the pediatric multisystem inflammatory syndrome temporarily associated with COVID-19 (MIS-C) was described for the first time. MIS-C could have a severe course and may require critical care support. OBJECTIVE: To describe the clinical, laboratory, and management characteristics of hospitalized children who meet MIS-C criteria with severe presentation in a pediatric critical pa tient unit. PATIENTS AND METHOD: Descriptive prospective study of children with severe MIS-C mana ged by treatment phases with immunoglobulin and methylprednisolone, according to their clinical response. Epidemiological, clinical, laboratory and imaging data were obtained. Phenotypes were classified into Kawasaki and not Kawasaki, comparing their findings. RESULTS: 20 patients were analy zed, the median age was 6 years, 60% were female, and 40% presented comorbidity. SARS-CoV-2 was detected in 90% of the patients. They presented fever as the first symptom, followed by brief and early gastrointestinal symptoms (70%). 75% presented the Kawasaki phenotype. They evolved with lymphopenia, hypoalbuminemia, coagulation alterations, and elevated systemic and cardiac in flammatory parameters. 80% of the cases presented echocardiographic alterations and 90% shock that required critical care support. All the patients had a short and favorable evolution. All patients responded to the established therapy, but 40% required a second phase of treatment. There were no differences when comparing phenotypes. No deaths were reported. CONCLUSION: MIS-C is a new childhood disease whose presentation could be life-threatening. It requires early suspicion, immuno modulatory management, critical care support, and a multidisciplinary approach to obtain the best results and optimize its prognosis.

Bloqueo del plano del erector espinal bilateral para cirugía de pectus excavatum en paciente pediátrico / Bilateral spinal erector plane block for pectus excavatum surgery in pediatric patient

El bloqueo del plano del erector espinal es una técnica de anestesia regional con resultados favorables en el manejo del dolor postoperatorio en pacientes pediátricos. Los reportes son escasos en Latinoamérica. Presentamos el caso de un paciente de 5 años con diagnóstico de pectus excavatum sometido a técnica quirúrgica convencional (técnica de Ravitch). Se realiza el bloqueo del plano del erector espinal bilateral con guía ecográfica a nivel de la apófisis transversa de T5 obteniéndose una adecuada estabilidad hemodinámica intraoperatoria y analgesia postoperatoria.(AU)

The spinal erector plane block is a regional anesthesia technique with favorable results in the management of postoperative pain in pediatric patients. Reports are few in Latin America. We present the case of a 5-year-old patient with a diagnosis of Pectus Excavatum undergoing a conventional surgical technique (Ravitch technique). Bilateral erector spinae plane block is performed with ultrasound guidance at the level of the transverse process of T5, obtaining adequate intraoperative hemodynamic stability and postoperative analgesia.(AU)

Caracterización clínico-epidemiológica de las enterocolitis necrosantes neonatales de siete hospitales públicos

Resumen Introducción: Enterocolitis necrosante (ECN) representa una elevada mortalidad y morbilidad post-quirúrgica, gastrointestinal y del neuro-desarrollo. Existe limitada información en Chile. Objetivo: Describir el comportamiento clínico/epidemiológico de recién nacidos que cursaron con ECN. Pacientes y Métodos: Estudio multicéntrico descriptivo de pacientes con ECN de siete hospitales de Santiago, Chile, durante el 2016. Se realizó estadística descriptiva y análisis univariable/multivariable (software SPSS v22). Resultados: Se recolectaron 75 casos. Mediana de edad al diagnóstico fue 11 días, el promedio de edad gestacional 29 semanas y peso de nacimiento 1.285 g. La incidencia fue 2,6 por 1.000/recién nacidos vivos y letalidad de 18,6%, mayor en ≤ 750 g, ≤ 25 semanas y ECN quirúrgica. Hubo aislamiento microbiológico en 45,3% y se utilizaron 19 distintos esquemas antimicrobianos empíricos para el tratamiento de ECN. El análisis multivariable mostró tendencia a que la ECN fuese quirúrgica en usuarios de catéter umbilical arterial, PCR > 10 mg/L y aislamiento microbiológico, y hubo tendencia a fallecer en usuarios de catéter umbilical arterial. Discusión: Es el primer estudio multicéntrico que recopila información de datos locales. La incidencia fue similar a la descrita en la literatura médica, en cambio la letalidad fue algo menor. No existen consensos del tratamiento antimicrobiano a utilizar. Con estos resultados esperamos avanzar en mejorar el diagnóstico y unificar tratamientos antimicrobianos, para reducir cifras de morbimortalidad.

Abstract Background: Necrotizing enterocolitis (NEC) presents high mortality and postoperative, gastrointestinal and neurodevelopmental morbidity. There is limited information about NEC in Chile. Aim: To describe the clinical/epidemiological behavior of newborns who underwent NEC. Methods: Multicenter descriptive study of patients with NEC from seven hospitals of Santiago, Chile, during 2016. Descriptive statistics and univariate/multivariate analysis were performed (SPSS v22 software). Results: 75 cases were collected. Median days of life at diagnosis was 11, gestational age was 29 weeks, birth weight 1,114 g. The incidence was 2.6 per 1,000 live newborns and mortality was 18.6%, higher in ≤ 750 g, ≤ 25 weeks and surgical NEC. There was 45.3% microbiological isolation and 19 different empirical antibiotic schemes were used for the treatment of NEC. The multivariate analysis showed a higher risk of surgery in umbilical arterial catheter users, CRP > 10 mg/L and positive microbiological isolation. The highest risk of death was in umbilical arterial catheter users. Discussion: This ie the first multicenter study that collects local data information. The incidence was similar to that found in medical reports but with a lower mortality. There is no consensus of antibiotic treatment to use. With these results we hope to advance in improving the diagnosis and unify antimicrobial treatments, to reduce morbidity and mortality figures.

Pneumococcal serotypes in children, clinical presentation and antimicrobial susceptibility in the PCV13 era.

The aim was to analyse invasive pneumococcal disease (IPD) serotypes in children aged ⩽17 years according to clinical presentation and antimicrobial susceptibility. We conducted a prospective study (January 2012-June 2016). IPD cases were diagnosed by culture and/or real-time polymerase chain reaction (PCR). Demographic, microbiological and clinical data were analysed. Associations were assessed using the odds ratio (OR) and 95% confidence intervals (CI). Of the 253 cases, 34.4% were aged <2 years, 38.7% 2-4 years and 26.9% 5-17 years. Over 64% were 13-valent pneumococcal conjugate vaccine (PCV13) serotypes. 48% of the cases were diagnosed only by real-time PCR. Serotypes 3 and 1 were associated with complicated pneumonia (P < 0.05) and non-PCV13 serotypes with meningitis (OR 7.32, 95% CI 2.33-22.99) and occult bacteraemia (OR 3.6, 95% CI 1.56-8.76). Serotype 19A was more frequent in children aged <2 years and serotypes 3 and 1 in children aged 2-4 years and 5-17 years, respectively. 36.1% of cases were not susceptible to penicillin and 16.4% were also non-susceptible to cefotaxime. Serotypes 14, 24F and 23B were associated with non-susceptibility to penicillin (P < 0.05) and serotypes 11, 14 and 19A to cefotaxime (P < 0.05). Serotype 19A showed resistance to penicillin (P = 0.002). In conclusion, PCV13 serotypes were most frequent in children aged ⩽17 years, mainly serotypes 3, 1 and 19A. Non-PCV13 serotypes were associated with meningitis and occult bacteraemia and PCV13 serotypes with pneumonia. Non-susceptibility to antibiotics of non-PCV13 serotypes should be monitored.

Mycobacterium abscessus subspecies abscessus infection associated with cosmetic surgical procedures: Cases series.

BACKGROUND: Mycobacterium abscessus is one of the most pathogenic and drug-resistant opportunistic microorganisms among the nontuberculous mycobacteria (NTM) involved in skin and soft tissue infections (SSTI) associated with cosmetic surgical procedures. However, NTM infection is often wrongly diagnosed initially causing prolonged suffering. Here is described the author's experience working with patients who developed M. abscessus SSTI after cosmetic procedures. METHODS: Patients who developed NTM infection after undergoing cosmetic procedures, and who presented at the Hospital Metropolitano and Hospital Vozandes (Quito, Ecuador) between 2013-2016. A review of patient medical records was performed. RESULTS: Five patients with culture proven M. abscessus subspecies abscessus SSTI after cosmetic surgeries were identified. All patients were treated with aggressive surgical debridement and antibiotics. CONCLUSIONS: A rapidly spreading wound infection presenting two or more weeks after a cosmetic procedure that fails to respond to standard antimicrobial therapy should raise suspicion for NTM infection. Samples for acid-fast bacilli smear, cultures, and PCR from infected tissue should be taken. Surgical drainage and debridement are recommended along with a long course of antibiotics. In the absence of clinical trials, a combination of amikacin, imipenem, and clarithromycin may be an adequate initial treatment for M. abscessus subspecies abscessus SSTI in immunocompetent patients.

Antimicrobianos en neonatología. Parte I: Recomendaciones de dosificaciones basadas, en la más reciente evidencia en recién nacidos Comité Consultivo de Infecciones Neonatales, Sociedad Chilena de Infectología / Antibiotics in neonatology. Part I: Dosage recommendations based on the most recent evidence in newborns Advisory Committee on Neonatal Infections, Chilean Society of Infectious Diseases

Resumen Los antimicrobianos son los medicamentos más utilizados en los neonatos durante su primer mes de vida cuando se encuentran en unidades neonatales, principalmente por el alto riesgo que presentan de adquirir infecciones graves como la sepsis. La mayoría de estos antimicrobianos se utilizan con dosis extrapoladas en base a las recomendaciones en población adulta y niños mayores, a pesar de que la fisiopatología en los recién nacidos es absolutamente diferente. Lo anterior lleva a un mayor riesgo a que ocurran más efectos adversos los que pueden conducir a una mayor toxicidad y a fallas terapéuticas, entre otros. En la última década se han realizado mayores estudios farmacocinéticos de antimicrobianos en neonatos; esta reciente evidencia ha permitido nuevas recomendaciones de dosificación considerando el peso y la edad gestacional del recién nacido, entre otras variables, de acuerdo al antimicrobiano estudiado. En base a una mayor evidencia sobre el comportamiento farmacocinético de los antimicrobianos en neonatos, se ha elaborado este documento para así facilitar y promover su correcto uso en las unidades neonatales.

Abstract Antibiotics are the most widely used medications in neonates during their first month of life in neonatal units, mainly due to the high risk they present of acquiring serious infections such as sepsis. Most of these antibiotics are used with extrapolated doses based on the suggestions in the adult population and older children, despite the fact that the pathophysiology in newborns is absolutely different. This leads to a higher risk of more adverse effects occurring, which can lead to greater toxicity and therapeutic failures, among others. In the last decade more and more pharmacokinetic studies of antibiotics have been carried out in neonates, this recent evidence has led to new dosage recommendations taking into account the weight and gestational age of the newborn, among other variables, in agreement to the antibiotic studied. Therefore, based on the need to order and summarize the most up-to-date and most evidence-based information on antibiotics in neonates, this document was prepared to facilitate and promote its correct use in neonatal units.

[Plasmatic concentracion of piperacillin/tazobactam in pediatric patients on ECMO support. Preliminary analysis]. / Concentraciones plasmáticas de piperacilina/tazobactam en pacientes pediátricos críticos sometidos a ECMO. Análisis preliminar.

BACKGROUND: Pharmacokinetics and optimal dosing of piperacillin tazobactam (PT) have not been well studied in pediatric patients undergoing extracorporeal oxygenation membrane (ECMO). AIM: To describe piperacillin plasmatic concentration and evaluate achievement of pharmaccokinetic/pharmacodinamic objective in patients on ECMO support. METHOD: We report three pediatric patients admitted to the Pediatric Intensive Care Unit, treated with PT undergoing ECMO. Plasmatic concentrations of piperacillin were obtained in the middle of the dosing interval using high performance liquid chromatography. RESULTS: Plasmatic concentrations were 51,7-14,1 and 6,5 µg/mL for patient A, B and C respectively. Only one patient reached adequate concentrations. CONCLUSION: These preliminary results suggest that availability of plasmatic concentrations of piperacillin could optimize the achievement of pharmacokinetic/pharmacodynamic objectives in pediatric patients on ECMO support.

Concentraciones plasmáticas de piperacilina/tazobactam en pacientes pediátricos críticos sometidos a ECMO: análisis preliminar / Plasmatic concentracion of piperacillin/tazobactam in pediatric patients on ECMO support: preliminary analysis

Resumen Introducción: Se desconocen las alteraciones farmacocinéticas de piperacilina/tazobactam (PT) en pacientes pediátricos que requieren de membrana de oxigenación extracorpórea (ECMO) y cómo dosificar adecuadamente dicho antimicrobiano. Objetivo: Describir las concentraciones plasmáticas (CP)y evaluar el cumplimiento del objetivo farmacocinético/famacodinámico de piperacilina en pacientes pediátricos en soporte con ECMO. Métodos: Presentamos tres pacientes pediátricos en tratamiento con PT que requirieran de ECMO en los que se midieron CP de piperacilina en la mitad del intervalo de dosificación mediante cromatografía liquida de alta resolución. Resultados: Las CP fueron 51,7-14,1 y 6,5 μg/mL para los pacientes A, B y C, respectivamente. Sólo se alcanzaron CP adecuadas en un paciente. Conclusión: Estos resultados preliminares sugieren que la disponibilidad de CP de piperacilina podría optimizar el cumplimiento de los objetivos farmacocinéticos/farmacodinámicos en pacientes pediátricos en soporte con ECMO.

Abstract Background: Pharmacokinetics and optimal dosing of piperacillin tazobactam (PT) have not been well studied in pediatric patients undergoing extracorporeal oxygenation membrane (ECMO). Aim: To describe piperacillin plasmatic concentration and evaluate achievement of pharmaccokinetic/pharmacodinamic objective in patients on ECMO support. Method: We report three pediatric patients admitted to the Pediatric Intensive Care Unit, treated with PT undergoing ECMO. Plasmatic concentrations of piperacillin were obtained in the middle of the dosing interval using high performance liquid chromatography. Results: Plasmatic concentrations were 51,7-14,1 and 6,5 μg/mL for patient A, B and C respectively. Only one patient reached adequate concentrations. Conclusion: These preliminary results suggest that availability of plasmatic concentrations of piperacillin could optimize the achievement of pharmacokinetic/pharmacodynamic objectives in pediatric patients on ECMO support.

[Clinical-epidemiological characterization of neonatal necrotizing enterocolitis of seven public hospitals]. / Caracterización clínico-epidemiológica de las enterocolitis necrosantes neonatales de siete hospitales públicos.

BACKGROUND: Necrotizing enterocolitis (NEC) presents high mortality and postoperative, gastrointestinal and neurodevelopmental morbidity. There is limited information about NEC in Chile. AIM: To describe the clinical/epidemiological behavior of newborns who underwent NEC. METHODS: Multicenter descriptive study of patients with NEC from seven hospitals of Santiago, Chile, during 2016. Descriptive statistics and univariate/multivariate analysis were performed (SPSS v22 software). RESULTS: 75 cases were collected. Median days of life at diagnosis was 11, gestational age was 29 weeks, birth weight 1,114 g. The incidence was 2.6 per 1,000 live newborns and mortality was 18.6%, higher in ≤ 750 g, ≤ 25 weeks and surgical NEC. There was 45.3% microbiological isolation and 19 different empirical antibiotic schemes were used for the treatment of NEC. The multivariate analysis showed a higher risk of surgery in umbilical arterial catheter users, CRP > 10 mg/L and positive microbiological isolation. The highest risk of death was in umbilical arterial catheter users. DISCUSSION: This ie the first multicenter study that collects local data information. The incidence was similar to that found in medical reports but with a lower mortality. There is no consensus of antibiotic treatment to use. With these results we hope to advance in improving the diagnosis and unify antimicrobial treatments, to reduce morbidity and mortality figures.

[Antibiotics in neonatology. Part I: Dosage recommendations based on the most recent evidence in newborns Advisory Committee on Neonatal Infections, Chilean Society of Infectious Diseases]. / Antimicrobianos en neonatología. Parte I: Recomendaciones de dosificaciones basadas, en la más reciente evidencia en recién nacidos Comité Consultivo de Infecciones Neonatales, Sociedad Chilena de Infectología.

Antibiotics are the most widely used medications in neonates during their first month of life in neonatal units, mainly due to the high risk they present of acquiring serious infections such as sepsis. Most of these antibiotics are used with extrapolated doses based on the suggestions in the adult population and older children, despite the fact that the pathophysiology in newborns is absolutely different. This leads to a higher risk of more adverse effects occurring, which can lead to greater toxicity and therapeutic failures, among others. In the last decade more and more pharmacokinetic studies of antibiotics have been carried out in neonates, this recent evidence has led to new dosage recommendations taking into account the weight and gestational age of the newborn, among other variables, in agreement to the antibiotic studied. Therefore, based on the need to order and summarize the most up-to-date and most evidence-based information on antibiotics in neonates, this document was prepared to facilitate and promote its correct use in neonatal units.

Production of an innovative biowaste-derived fertilizer: Rapid monitoring of physical-chemical parameters by hyperspectral imaging.

In this work the possibility to apply hyperspectral imaging as a fast and non-destructive technique for the monitoring of the production process at pilot plant scale of an innovative biowaste-derived fertilizer was explored. Different mixtures of urban organic waste, farm organic residues, biochar and vegetable active principles were selected and utilized in two different European countries, Italy and Spain, for the production of the innovative fertilizer. The biowaste-derived fertilizer samples were collected from the pilot plant piles at different curing time and acquired by the hyperspectral imaging device. Spectra have been collected in the near infrared wavelength range (1000-1700 nm). Conventional analyses were carried out on the same samples in order to find correlations between the physical-chemical parameters detected at laboratory scale, and the acquired reflectance spectra. The investigated parameters were: pH, electrical conductivity, soluble total organic carbon and soluble total nitrogen. Hyperspectral data were processed adopting chemometric strategies through the application of principal component analysis, for exploratory purposes, and partial least squares analysis to establish correlations between spectral features and measured physical-chemical parameters. Good correlations, with R2 ranging between 0.85 and 0.96, were obtained for all the investigated parameters. Results showed as the proposed approach, based on hyperspectral imaging, is suitable to be adopted for a rapid and non-destructive monitoring of waste-derived fertilizer production.

Long-term impact of temozolomide on 1p/19q-codeleted low-grade glioma growth kinetics.

Although upfront temozolomide (TMZ) has been widely-used to treat 1p/19q-codeleted diffuse low-grade gliomas (LGG), its long-term impact on the growth kinetics of these tumors has not been determined. Based on serial magnetic resonance images we retrospectively evaluated the evolution of the mean tumor diameter (MTD) in 36 progressive 1p/19q-codeleted LGG treated with upfront TMZ. After TMZ onset, all but two patients (94.4%) presented a progressive MTD decrease that lasted for a median duration of 23 months (range 3-114). In 10 patients (27%) MTD regrowth occurred during TMZ treatment and in 22 patients (66%) after TMZ discontinuation. In these patients, median time to MTD regrowth after TMZ discontinuation was 12 months (range 1-88). The rate of MTD regrowth at 3 and 5 years after TMZ onset was 77 and 94%, respectively. Time to tumor progression (TTP) based on volumetric analysis was shorter than TTP based on Response Assessment in Neuro-Oncology (RANO) bidimensional criteria (23 vs. 35 months, p = 0.05) and shorter than time to next oncological treatment (23 vs. 46 months, p = 0.001). In 10 patients (27%), absence of volumetric analysis led to continue TMZ for a median of 10 cycles after MTD had started to regrow. Volumetric analysis is important to precisely assess chemotherapy efficacy in 1p/19q-codeleted LGG, identify early tumor progression and avoid futile chemotherapy continuation. In the present series, although some long-lasting volumetric responses were observed, most tumors resumed their growth within 3 years after TMZ onset.

Impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the emergency department.

AIMS: The aim of the study was to evaluate the impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the Emergency Department (ED) by assessing prescribing appropriateness at admission. METHODS: A cross-sectional, observational, descriptive study was designed and included all adult medical patients admitted from an ED between 20 November 2012 and 26 November 2012 at a large tertiary hospital. Patients to whom anticoagulants were prescribed for therapeutic purposes, patients admitted to Intensive Care Unit or maternity wards were excluded. Prescribing appropriateness was assessed using the Padua Prediction Score (ACCP 2012 guideline) for thromboembolic risk assessment and the NICE model to determine risk of bleeding. The primary end-point was the adequacy of thromboprophylaxis prescribed at the ED according to the ACCP 2012 guideline. RESULTS: A total of 393 patients were examined and 207 patients were included in the study (53.1% were male) with a median age of 75.3 years. The most common diagnosis at admission was related to a respiratory disease (41.1%). In 34.8% of the patients (72 patients), the recommendation of prophylaxis according to ACCP 2012 guideline did not match with the prophylaxis prescribed at admission. Reasons for non-concordance were undertreatment (14.5%) and overtreatment (20.3%). CONCLUSIONS: The adequacy of thromboprophylaxis in high risk patients for VTE has improved compared with the ENDORSE study. However, the percentage of patients with discordant prescriptions remains high. Despite the existence of treatment omissions, this percentage has been overcome by patients overtreated.

Community-acquired pneumonia in immunocompromised older patients: incidence, causative organisms and outcome.

The number of elderly patients in the community with immunosuppressive conditions has increased progressively over recent decades. We sought to determine the incidence, causative organisms and outcome of community-acquired pneumonia (CAP) occurring in immunocompromised older patients. We prospectively compared cases of CAP in immunocompromised and non-immunocompromised patients admitted to five public hospitals in three Spanish regions. Of 320 cases studied, 115 (36%) occurred in immunocompromised patients, including: solid or hematological malignancy (97), corticosteroids or other immunosuppressive drugs (44), solid organ or stem cell transplant (five), and other conditions (eight). The etiology was established in 44% of immunocompromised patients vs. 32% of non-immunocompromised patients (p 0.03). Streptococcus pneumoniae was the most common causative organism in both groups (29% vs. 21%; p 0.08), followed by Legionella pneumophila (3% vs. 6%; p 0.01). Gram-negative bacilli were more frequent among immunocompromised patients (5% vs. 0.5%; p <0.01), particularly Pseudomonas aeruginosa (3% vs. 0%; p 0.04). Nocardiosis was only observed in immunocompromised patients (two cases). Bacteremia occurred similarly in the two groups. No significant differences were found with respect to ICU admission (8%, in both groups) or the length of stay (12.5 vs. 10.4 days). The early (<48 h) (3.5 vs. 0.5%; p 0.04) and overall case-fatality rates (12% vs. 3%; p <0.01) were higher in immunocompromised patients. In conclusion, a substantial number of older patients hospitalized for CAP are immunocompromised. Although relatively uncommon, CAP due to gram-negative bacilli, including P. aeruginosa, is more frequent among these patients. CAP occurring in immunocompromised patients causes significant morbidity and mortality.

External ophthalmomyiasis: a case series.

Oestrus ovis or 'sheep botfly' causes common ophthalmomyiasis in warm climates. It is a self-limited infestation with symptoms such as foreign body sensation and/or tearing. The larvae can be observed in the conjunctiva and should be extracted with forceps. The development of larvae beyond the first stage does not occur in healthy humans, although they may penetrate the ocular globe, causing so-called internal myiasis. External ophthalmomyiasis is typical of rural areas, but it may be observed occasionally in urban environments.