Long-term prognosis of HIV-infected patients with Kaposi sarcoma treated with pegylated liposomal doxorubicin.

INTRODUCTION: Incidence of Kaposi sarcoma (KS) in human immunodeficiency virus (HIV)-infected persons has dramatically decreased in the highly active antiretroviral therapy era. However, this tumor still represents the most common cancer in this population. OBJECTIVES: The objectives of this study were to evaluate long-term prognosis of HIV-infected patients with KS who had received pegylated liposomal doxorubicin (PLD) and, more specifically, to assess tumor relapse rate, mortality, and cause of death in these subjects. DESIGN: This study was a retrospective review of all patients with KS who had received PLD in centers belonging to the Caelyx/KS Spanish Group. Kaplan-Meier analysis and univariate and multivariate Cox-regression analysis were used to assess the rate of and factors associated with relapse and death through January 2006. RESULTS: A total of 98 patients received PLD from September 1997 through June 2002. Median follow-up after initiation of treatment was 28.7 months (interquartile range, 6.6-73.2 months); during follow-up, 29 patients died (a mortality rate of 14.6% per year). In 9 patients (31%), the cause of death was related to the appearance of other tumors (including 7 lymphomas, 1 gastrointestinal adenocarcinoma, and 1 tongue epidermoid cancer). Death caused by progression of KS occurred in 3 cases. Death risk was inversely related to CD4(+) cell counts at the end of follow-up (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.5-0.9). A relapse study was performed for 61 patients who had complete or partial response to PLD and who attended a control visit after treatment completion. After a median follow-up of 50 months (interquartile range, 17.2-76 months), 8 patients (13%) had experienced relapse; 5 of these patient experienced relapse within the first year after stopping PLD. The only factor that was independently related to risk of relapse was having a CD4(+) cell count >200 cells/microL at baseline (hazard ratio, 6.2; 95% confidence interval, 1.2-30). Lower CD4(+) cell count at the end of follow-up was marginally associated with relapse (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.6-1.01). CONCLUSIONS: Treatment of KS with PLD in HIV-infected patients is followed by a low relapse rate, with most relapses occurring during the first year after stopping chemotherapy. However, the mortality rate in this population was high, in part because of an unexpectedly high incidence of other tumors, mainly lymphomas.

[Major closed-space bleeding in patients on anticoagulation with acenocoumarol (TAO) or non-fractionned heparin(HS): a case-control study]. / Estudio caso-control de sangrados mayores cerrados en pacientes descoagulados con acenocumarol y heparina-no fraccionada.

OBJECTIVE: To study the characteristics of major bleeding episodes into a closed space (BCS) of patients under chronic anticoagulation with either unfractionated heparin (HS) or coumadin (CM), and to determine the relationship, if any, of anticoagulation parameters (INR, PT and PTT) values at the time of bleeding with the episode. Finally, to determine risk factors for BCS and mortality in this population. METHODS: Descriptive epidemiology of all cases of BCS seen in our hospital from 1995 to 2000 was obtained through the records and follow up visits of all patients under anticoagulation (HS or CM) during this period. A matched case-control study to determine risk factors for BCS was carried out. Cases and controls (1:2) were matched for age, gender, anticoagulant treatment and indication for anticoagulation. Cases were patients with a BCS while on anticoagulation (HS OR CM). Controls were patients under anticoagulation (HS or CM) without any bleeding episode during the study period that had anticoagulation parameter values (INR, PT or PTT) determined the very same day than the cases. RESULTS: During the study period, 225 patients under anticoagulation were prospectively followed (75 cases and 150 controls) amid a total of 1650 patients under anticoagulation, for a 4.5% prevalence of BCS. Reasons for anticoagulation were: atrial fibrillation in 79 (35.3%), valvular heart disease in 59 (25.9%), pulmonary embolism or deep venous thrombosis in 48 (21.4%), dilated cardiomyopathy in 26 (11.6%) and vascular cerebral stroke in 13 (5.8%). Mean age of cases was 70.5 (SD 9.5) years and 41 (55%) were women, values similar to the controls. At the time of BCS 39 patients were on CM and 36 on HS. The mean INR value in the CM group at the time of the episode of BCS was 5.3 (SD + 7.5) while the PTT value was 2,25 (SD 0.95) in the HS group. There was previous antecedent bleeding in 24 (32%) cases. The most common sites of BCS were: muscular (40%), CNS (30.6%), retroperitoneal (18,6%) and articular (10.6%). Muscular (abdominal or thoracic wall) and retroperitoneal BCS were higher in the HS group (10 and 12 in the HS group versus 5 and 2 in the CM group, respectively; p < 0.0001). In contrast, CNS bleeding was commoner in the CM group (20 in CM versus 3 in HS; p < 0.001). BCS related mortality rate was 14.6% (11/75) and higher in the CM group (p = 0.04). Comparative analysis of the case-control study revealed that anticoagulation values in the CM group at the time of bleeding were within the recommended range in 38.5% of cases vs. 75% of the controls (p < 0.001). Also, there were significant differences in mean INR values between cases and controls (5.3 + 7.5 vs. 2.6 + 0.9, p < 0.029) In the HS group no differences were present in PTT values at the time of bleeding between cases and controls. In BCS cases, a previous bleeding episode was more frequent than in the control group (32% versus 1.3%, p < 0.001). Likewise, mortality was higher in cases (18,6%) than in controls (11.4%), p = 0.01. CONCLUSIONS: In our study, the majority of patients under anticoagulation with CM had INR values above the recommended range at the time of BCS, in contrast with those on HS that had a PTT within the therapeutic range at the time of the BCS. A previous bleeding episode was an independent risk factor for a BCS episode. Bleeding was a late complication in the CM group and frequently in the CNS, while BCS was more frequently associated with muscular or retroperitoneal sites in the HS treated group. BCS related mortality was 15%. Close monitoring of INR is crucial to minimize bleeding complications.

Estudio caso-control de sangrados mayores cerrados en pacientes descoagulados con acenocumarol y heparina-no fraccionada / Major close space bleeding in patients on anticoagulation with acenocumarol (TAO) or non fractionned heparin (HS): a case-control study

Objetivos: Determinar las características de los episodios de sangrado mayor cerrado (SM). Valorar los controles de la anticoagulación mediante el INR del tiempo de protrombina (TP) y el tiempo de tromboplastina parcial (TTPA) durante los episodios. Analizar la mortalidad directamente relacionada con los episodios de SM. Comparar estos factores con un grupo control. Métodos: Estudio caso-control de los SM registrados en la base de datos de monitorización de los tratamientos anticoagulantes de nuestro centro desde enero de 1995 hasta diciembre de 2002. Se define caso como cualquier episodio de SM en paciente que recibiese tratamiento anticoagulante y control como cualquier paciente sin episodio previo o actual de SM al que se realizó una determinación de INRo TTPA el mismo día que el caso de SM, siempre que estuvieran emparejados por edad, sexo, tipo e indicación de tratamiento anticoagulante. Resultados: Análisis descriptivo: Desde enero 1995 a diciembre de 2002 se estudiaron de forma prospectiva 225 pacientes en tratamiento anticoagulante,de los cuales 75 fueron casos de SM y 155 controles. Durante este periodo se controlaron un total de 1650 pacientes por lo que la prevalencia de SM fue del 4,5%. Los motivos de descoagulación del total de 225 pacientes fueron: fibrilación auricular en 79 pacientes (35,3%), valvulopatías en 59 (25,9%), TVP-TEP en 48 (21,4%), miocardiopatía dilatada o isquémica en 26 (11,6%) y AVC en 13 (5,8%). La edad media de los casos fue de 70,5 años (DE 9,5) siendo mujeres 41 (55%). En el momento del sangrado 39 casos (52%) seguían tratamiento con TAO y 36 casos (48%) estaban tratados con HS. El INR medio en el momento del sangrado fue de 5,3 (DE 7,5) y el TTPA de 2,25 (DE 0,95). Tenían antecedentes de sangrado previo 24 (32%) de los casos. La localización del SM fue por orden de frecuencia: muscular (40%), sistema nervioso central (30,6%), retroperitoneal (18,6%) y articular (10,6%). Los pacientes tratados con TAO sangraron significativamente con más frecuencia en SNC mientras que los pacientes en tratamiento con HS lo hicieron en músculo o retroperitoneal (p < 0,0001). Murieron a causa del SM 11/75 casos (14,6%) y por otras razones 3 casos (4%). Análisis comparativo: El INR de los casos estaba dentro del rango terapéutico en el momento del sangrado en el 38.5% respecto del 75,3% de los controles (p < 0,0001). Se observaron diferencias significativas entre elvalor de INR medio de casos (5,3 ± 7,5) y de controles (2,5 ± 0,95) con una p < 0,001 y no las hubo entre el TTPA de casos y controles. En el 32% de los casos existía un episodio de sangrado previo, antecedente que sólo tenían el 1,3% de los controles (p < 0,001) siendo éste un factor de riesgo independiente para un nuevo sangrado (RR = 34,5). La mortalidad global de los casos fue del 18,6% (14/75) mientras que en los controles fue del 11,4% (18/155); p = 0,01. Conclusiones: En nuestro estudio los casos de SM tratados con TAO tiene controles de INR (TP) fuera de su rango terapéutico en una proporción mayor que los casos tratados con HS. El sangrado previo es un importante factor de riesgo para SM. El SM por TAO es tardío en el curso del tratamiento y predomina los episodios de sangrado a nivel del SNC mientras que en los pacientes tratados con HS el sangrado es a nivel muscularo retroperitoneal. La mortalidad directamente relacionada con el SM es del 14,6%. Una cuidadosa monitorización del INR del tiempo de protrombina se revela como única estrategia para disminuir el riesgo de sangrado

Objetive: To study the characteristics of major bleeding episodes into a closed space (BCS) of patients under chronic anticoagulation with either unfractionated heparin (HS) or coumadin (CM), and to determinethe relationship, if any, of anticoagulation parameters (INR, PT and PTT) values at the time of bleeding with the episode. Finally, to determine risk factors for BCS and mortality in this population. Methods: Descriptive epidemiology of all cases of BCS seen in ourhospital from 1995 to 2000 was obtained through the records and follow up visits of all patients under anticoagulation (HS or CM) during this period. A matched case-control study to determine risk factorsfor BCS was carried out. Cases and controls (1:2) were matched for age, gender, anticoagulant treatment and indication for anticoagulation. Cases were patients with a BCS while on anticoagulation (HS OR CM). Controls were patients under anticoagulation (HS or CM) without any bleeding episode during the study period that had anticoagulation parameter values (INR, PT or PTT) determined the very same day than the cases. Results: During the study period, 225 patients under anticoagulation were prospectively followed (75 cases and 150 controls) amid a total of 1650 patients under anticoagulation, for a 4.5% prevalence of BCS. Reasons for anticoagulation were: atrial fibrillation in 79 (35.3%), valvular heart disease in 59 (25.9%), pulmonary embolism or deep venous thrombosis in 48 (21.4%), dilated cardiomyopathy in 26 (11.6%) and vascular cerebral stroke in 13 (5.8%). Mean age of cases was 70.5 (SD 9.5) years and 41 (55%) were women, values similar to the controls. At the time of BCS 39 patients were on CM and 36 on HS. The mean INR value in the CM group at the time of the episode of BCS was 5.3 (SD + 7.5) while the PTT value was 2,25 (SD 0.95) in the HS group. There was previous antecedent bleeding in 24 (32%) cases. The most common sites of BCS were: muscular (40%), CNS (30.6%), retroperitoneal (18,6%) and articular (10.6%). Muscular (abdominal or thoracic wall) and retroperitoneal BCS were higher in the HS group (10 and 12 in the HS group versus 5 and 2 in the CM group, respectively; p < 0.0001). In contrast, CNS bleeding was commoner in the CM group (20 in CM versus 3 in HS; p <0.001). BCS related mortality rate was 14.6% (11/75) and higher in theCM group (p = 0.04). Comparative analysis of the case-control study revealed that anticoagulation values in the CM group at the time of bleeding were within the recommended range in 38.5% of cases vs. 75% ofthe controls (p < 0.001). Also, there were significant differences in mean INR values between cases and controls (5.3 + 7.5 vs. 2.6 + 0.9, p <0.029) In the HS group no differences were present in PTT values at thetime of bleeding between cases and controls. In BCS cases, a previous bleeding episode was more frequent than in the control group (32% versus 1.3%, p < 0.001). Like wise, mortality was higher in cases (18,6%) than in controls (11.4%), p = 0.01. Conclusions: In our study, the majority of patients under anticoagulation with CM had INR values above the recommended range at thetime of BCS, in contrast with those on HS that had a PTT within the therapeutic range at the time of the BCS. A previous bleeding episode was an independent risk factor for a BCS episode. Bleeding was a late complication in the CM group and frequently in the CNS, while BCS was more frequently associated with muscular or retroperitoneal sites in the HS treated group. BCS related mortality was 15%. Close monitoring of INR is crucial to minimize bleeding complications

Is the combination of pyrazinamide plus rifampicin safe for treating latent tuberculosis infection in persons not infected by the human immunodeficiency virus?

SETTING: Nine public health care centres in four Spanish cities. OBJECTIVE: To evaluate the efficacy and safety of 2 months of rifampicin (R) plus pyrazinamide (Z) therapy (2RZ) compared with a 6-month course of isoniazid therapy (6H) for treating latent tuberculosis infection (LTBI). DESIGN: Multicentered, randomised, comparative and prospective trial conducted in HIV-seronegative contacts of infectious pulmonary TB cases. RESULTS: Of 352 individuals, 199 received 6H and 153 2RZ; 73% of contacts receiving 6H and 71% receiving 2RZ completed treatment (P = 0.73). Treatment interruption due to hepatotoxicity (ALT/AST > 5 times upper limit of normal) was observed in 10% of contacts in the 2RZ group and in 2.5% of the 6H group (P = 0.007). This higher than expected rate of hepatotoxicity in the 2RZ arm led to premature termination of the study. Severe or fatal liver injury was not detected. Liver function tests normalised after discontinuation of treatment. We conclude that the use of RZ should only be considered when other regimens are unsuitable and intensive monitoring of liver function is feasible.

Health-related quality of life in HIV-infected naive patients treated with nelfinavir or nevirapine associated with ZDV/3TC (the COMBINE-QoL substudy).

PURPOSE: The aim of the study was to assess differences in health-related quality of life (HRQoL) in HIV-infected naive patients treated with two HAART regimens at 12 months. METHOD: The MOS-HIV questionnaire was used to measure HRQoL in a subgroup of 127 patients included in the COMBINE study, which was an open-label, randomized, multicenter study comparing zidovudine (ZDV) and lamivudine (3TC) plus nelfinavir (NFV) or nevirapine (NVP) regimens in HIV-infected naive patients. 63 patients were included in the ZDV/3TC/NFV arm and 64 in the ZDV/3TC/NVP arm. RESULTS: No statistically significant differences were observed at baseline in demographic and clinical variables and HRQoL scores between treatment groups, except that the proportion of homosexual men was higher in the ZDV/3TC/NVP arm. There were no statistically significant differences in HRQoL scores between arms at 12 months and over time; only ZDV/3TC/NVP patients showed statistically significant improvement in Physical Health Summary score (p <.01) and a trend toward a better profile in Mental Health Summary score (p =.07). Overall, patients who were treated with ZDV/3TC/NVP showed greater changes in physical dimensions and patients who were treated with ZDV/3TC/NFV showed greater changes in mental health. CONCLUSION: Differences in HRQoL between study groups at 1 year follow-up were not detected. Nevertheless, a trend toward improvement was observed in summary health scores in ZDV/3TC/NVP-treated patients.

Tuberculosis cutánea, mamaria y ganglionar sin afectación pulmonar en paciente sininmuno depresión aparente / Mammary cutaneous and nodal tuberculosis without pulmonary affectation in a patient

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[Intracranial purulent collections. Review of 34 surgically treated cases in 12 years (1989-2000)]. / Colecciones purulentas intracraneales. Revisión de 34 casos tratados quirúrgicamente a lo largo de doce años (1989-2000).

We made a revision of 34 cases of intracerebral supurations (31 brain abscesses and 3 subdural empyemas) treated at our department of neurosurgery of "Mutua de Terrassa" during the period of 1989-2000. Treatment used was tapping of the abscess and aspiration in 28 cases and craneotomy and resection in only two cases. Three subdural empyemas were treated with burr-holes and aspiration. Results were evaluated using the Glasgow Outcome Scale at 6 months after discharge, resulting in 7 deaths (20.6%), 17 fully recovered patients (50%) and 10 with minor deficits (29.4%). Glasgow Coma Score at admission and the age were the unique variables significantly correlated with the final outcome. After analyzing the cost of treatment in our patients we suggest using antibiotic ambulatory treatment when the disease shows an adequate clinical and radiological response, thus permitting to shorten the usually long period of hospitalization of patients with intracerebral supurative diseases.

Experimental study of the efficacy of vancomycin, rifampicin and dexamethasone in the therapy of pneumococcal meningitis.

The object of the study was to assess the efficacy of rifampicin and the combination of rifampicin plus vancomycin in a rabbit model of experimental penicillin-resistant pneumococcal meningitis. We also studied the effect of concomitant dexamethasone on the CSF antibiotic levels and inflammatory parameters. The rabbit model of pneumococcal meningitis was used. Groups of eight rabbits were inoculated with 106 cfu/mL of a cephalosporin-resistant pneumococcal strain (MIC of cefotaxime/ceftriaxone 2 mg/L). Eighteen hours later they were treated with rifampicin 15 mg/kg/day, vancomycin 30 mg/kg/day or both plus minus dexamethasone (0.25 mg/kg/day) for 48 h. Serial CSF samples were withdrawn to carry out bacterial counts, antibiotic concentration and inflammatory parameters. Rifampicin and vancomycin promoted a reduction of >3 log cfu/mL at 6 and 24 h, and cfu were below the level of detection at 48 h. Combination therapy with vancomycin plus rifampicin was not synergic but it had similar efficacy to either antibiotic alone and it was able to reduce bacterial concentration below the level of detection at 48 h. Concomitant use of dexamethasone decreased vancomycin levels when it was used alone (P< 0.05), but not when it was used in combination with rifampicin. Rifampicin alone at 15 mg/kg/day produced a rapid bactericidal effect in this model of penicillin-resistant pneumococcal meningitis. The combination of vancomycin and rifampicin, although not synergic, proved to be equally effective. Using this combination in the clinical setting may allow rifampicin administration without emergence of resistance, and possibly concomitant dexamethasone administration without significant interference with CSF vancomycin levels.

Colecciones purulentas intracraneales. Revisión de 34 casos tratados quirúrgicamente a lo largo de doce años (1989-2000) / Intracranial Purulent Collections. A revision of 34 cases surgically treated during the last twelve years (1989-2000)

Se han revisado un total de 34 supuraciones cerebrales, 31 abscesos y 3 empiemas subdurales, tratados en el Servicio de Neurocirugía de la "Mutua de Terrassa" en el intervalo transcurrido entre 1989 y 2000. El tratamiento elegido fue quirúrgico mediante punciónaspiración en 28 casos y en sólo dos hubo de practicarse una craneotomía con resección en bloque del absceso. Los tres empiemas subdurales fueron evacuados mediante trépanos y aspiración. En lo que respecta a resultados, a los seis meses de seguimiento hubo siete exitus (20,6 por ciento), diecisiete obtuvieron una recuperación completa (50 por ciento) y diez presentaron secuelas mínimas (29,4 por ciento). El Glasgow Coma Score inicial y la edad fueron las únicas variables que obtuvieron significancia estadística en el pronóstico final. Se analizan los costes del tratamiento de estas lesiones y se propone para el futuro la posibilidad de introducir el tratamiento antibiótico ambulatorio, una vez que la enfermedad se haya controlado clínica y radiológicamente, que permite acortar la habitual prolongada hospitalización de los enfermos con enfermedades supurativas intracerebrales (AU)

Thrice-weekly sulfadiazine-pyrimethamine for maintenance therapy of toxoplasmic encephalitis in HIV-infected patients. Spanish Toxoplasmosis Study Group.

An open, randomised, multicentre trial was conducted to evaluate the efficacy of thrice-weekly versus daily therapy with sulfadiazine-pyrimethamine in the prevention of relapses of toxoplasmic encephalitis in HIV-infected patients. Between February 1994 and July 1997, 124 patients with HIV infection were enrolled after resolution of the first acute episode of toxoplasmic encephalitis treated with sulfadiazine-pyrimethamine. Patients were randomly assigned to receive either a daily regimen consisting of sulfadiazine (1 g) twice a day plus 25 mg pyrimethamine and 15 mg folinic acid daily (n = 58), or a thrice-weekly regimen consisting of the same doses of sulfadiazine and folinic acid plus 50 mg pyrimethamine (n = 66). After a median follow-up period of 11 months (range 1-39 months), no differences were found in the incidence of toxoplasmic encephalitis relapses between the groups, there being 14.9 episodes per 100 patient-years (95% CI: 2.8-20.2) in the daily-regimen group versus 14.1 episodes (95% CI: 2.3-17.2) in the intermittent-regimen group. The estimated cumulative percentages of relapse at 12 months were 17% and 19%, respectively (P = 0.91). In a Cox multivariate analysis, not taking antiretroviral therapy was the only variable independently associated with relapse (adjusted risk ratio: 4.08; 95%CI: 1.32-12.66). Baseline CD4+ cell counts, prior AIDS, mental status, sequelae and allocated maintenance therapy regimen were not independent predictors of relapse. No differences were observed in the survival rate (P = 0.42), or in the incidence of severe adverse effects (P = 0.79). The efficacy of the thrice-weekly regimen was similar to that of the daily regimen in the prevention of relapses of toxoplasmic encephalitis. Administration of antiretroviral therapy was the only factor associated with a lower incidence of relapse.

Evaluation of combined ceftriaxone and dexamethasone therapy in experimental cephalosporin-resistant pneumococcal meningitis.

The treatment of meningitis caused by strains of Streptococcus pneumoniae with decreased susceptibility to third-generation cephalosporins is an increasingly frequent and difficult problem. In this study a rabbit model of meningitis was used to determine the efficacy of ceftriaxone at different dosages, and to establish the effect of the addition of dexamethasone to the chemotherapeutic regimen. Groups of eight rabbits were inoculated with 10(6) cfu/mL of a cephalosporin- resistant strain of S. pneumoniae (MIC of cefotaxime/ceftriaxone 2 mg/L). Eighteen hours after inoculation, ceftriaxone (50 or 100 mg/kg/day) with or without dexamethasone (0. 25 mg/kg/ day) was administered for a period of 48 h. The ceftriaxone dose of 50 mg/kg/day was not fully effective in this model (therapeutic failure rate 28%). With a dose of 100 mg/kg/day there were no therapeutic failures and all CSF cultures were below the level of detection at 48 h. CSF ceftriaxone concentrations, area under the time-concentration curve and time above the MIC were not significantly different with or without dexamethasone. However, concomitant use of dexamethasone resulted in higher CSF bacterial counts and a higher number of therapeutic failures (57% with the 50 mg/kg/day dose and 28% with the 100 mg/kg/day dose). Increasing doses of ceftriaxone might be an effective mode of therapy for meningitis caused by S. pneumoniae with MIC

[The role of carbapenems in the treatment of nosocomial infection]. / Papel de los carbapenémicos en el tratamiento de la infección nosocomial.

Carbapenems are active beta-lactam antibiotics versus most of the gram positive and gram negative microorganisms and anaerobes although their activity is lacking in the case of Staphylococcus sp. resistant to methicillin, Enterococcus faecium and Streptococcus pneumoniae with high resistance to penicillin and some gram negative bacilli which naturally produce an methaloenzyme able to hydrolyze them such as Stenotrophomonas maltophilia. Imipenem, the first synthetized carbapenem requires administration with cilastatin to avoid inactivation by renal dehydropeptidase 1. Meropenem does not require being taken with the renal enzyme inhibitor, with its activity being similar to that of imipenem. In abdominal infection the carbapenems have shown to be the authentic monotherapy in this type of infections being as effective as the different schedules of antibiotic associations normally used. Treatment with carbapenems in bacterial meningitis should be currently limited to the cases produced by gram negative bacilli producers of wide spectrum beta-lactamases (WSBL), cases of meningitis by Pseudomonas aeruginosa or gram negative bacilli producers of inducible cephalosporinase. Meropenem is the carbapenem of choice probably in these cases because the carbapenems are often the only active antibiotics and meropenem, specifically, does not have the risk of convulsions observed with imipenem-cilastatin. The carbapenems have shown to be useful in skin and soft tissue infections as well as in obstetric and gynecologic infections as monotherapy similar to the schedules of the currently used antibiotic associations. In the case of nosocomial pneumonias, all the studies have evaluated the carbapenems in monotherapy as useful and effective, specially in the case of pneumonia by gram negative bacilli. Finally, in non filiated nosocomial sepsis and specially in the case of neutropenic patients, the use of carbapenems is particularly attractive in gram negative sepsis in intensive care units. The appearance in the last few years of strains of gram negative bacilli, producers of wide spectrum beta-lactamase or stable repressed hyperproducers of class I chromosomic cephalosporinase, as well as other multiresistant gram negative bacilli, such as Acinetobacter baumanii make the carbapenems, in many cases, the only effective antibiotic in this type of infections.

[Cerebral SPECT with thallium-201 in the differential diagnosis of focal cerebral lesions in patients with AIDS]. / SPECT cerebral con talio-201 en el diagnóstico diferencial de lesiones cerebrales focales en pacientes con SIDA.

BACKGROUND: The aim of this study was to analyze the usefulness of cerebral SPECT with thallium-201 in patients with the acquired human immunodeficiency syndrome (AIDS) and focal cerebral lesions. METHODS: Six patients with AIDS and focal cerebral lesions in whom a cerebral SPECT was performed with thallium-201 are described. Treatment was initiated with antiToxoplasma drugs in all patients. The clinical response, serology for positive toxoplasma and radiologic improvement were criteria for the diagnosis of encephalitis by Toxoplasma. In the remaining cases, cerebral biopsy and/or necropsy study were carried out. RESULTS: In the 2 patients in whom cerebral SPECT demonstrated enhancement of the lesion, the pathologic diagnosis was cerebral lymphoma. Of the 4 remaining cases in whom no enhancement was observed, three corresponded to cerebral toxoplasmosis and one to progressive multifocal leucoencephalopathy. CONCLUSIONS: Cerebral SPECT with thallium-201 is a simple, specific and useful technique for the differentiation of primary cerebral lymphoma from the remaining inflammatory cerebral lesions which may be present in AIDS patients.

[In vitro bactericide activity of different antibiotic combinations to Streptococcus pneumoniae resistant to penicillin and cefotaxime]. / Actividad bactericida in vitro de diferentes combinaciones de antibióticos frente a Streptococcus pneumoniae resistente a penicilina y cefotaxima.

BACKGROUND: To determinate the bactericidal activity of vancomycin, rifampicin, cefotaxime, ceftriaxone and their double and triple combinations against penicillin and third generation cephalosporin-resistant. Streptococcus pneumoniae strain. METHODS: A study of the bactericidal activity of antibiotics alone and in combination was performed by killing-curves with fixed concentration of 2 micrograms/ml, equivalent to 1 < MIC for cefotaxime and ceftriaxone, to 8 x MIC for vancomycin and to 32 < MIC for rifampin. RESULTS: Vancomycin was the only antibiotic with bactericidal effect at 6 hours. Cefotaxime had bactericidal effect at 12 hours. Rifampin had no bactericidal effect. The association of vancomycin plus third generation cephalosporins (cefotaxime and ceftriaxone) showed indifferent effect. Rifampin decreased the bactericidal activity of vancomycin at 12 hours, when both were studied in combination, and it demonstrated antagonistic effect in the double and triple combination in which rifampicin was included. CONCLUSIONS: All associations of vancomycin plus third generation cephalosporins were bactericidal effects, but they did no show synergistic effects against penicillin- and third generation cephalosporin S. pneumoniae strain 2349. All combinations with rifampin showed decreased bactericidal activity or antagonistic effects. However, these results may be interpreted with caution because the in vivo experience of an experimental meningitis model in rabbits showed that the associations of vancomycin plus rifampin and vancomycin plus cefotaxime and rifampin were effective combinations. More in vivo and in vitro comparative studies are needed to demonstrate the reliability of in vitro results.