The impact of pipeline changes and temperature increase in a hospital historically colonised with Legionella.

Healthcare-related Legionnaires' disease has a devastating impact on high risk patients, with a case fatality rate of 30-50%. Legionella prevention and control in hospitals is therefore crucial. To control Legionella water colonisation in a hospital setting we evaluated the effect of pipeline improvements and temperature increase, analysing 237 samples over a 2-year period (first year: 129, second year: 108). In the first year, 25.58% of samples were positive for Legionella and 16.67% for amoeba. Assessing the distance of the points analysed from the hot water tank, the most distal points presented higher proportion of Legionella colonisation and lower temperatures (nearest points: 6.4% colonised, and temperature 61.4 °C; most distal points: 50% and temperature 59.1 °C). After the first year, the hot water system was repaired and the temperature stabilised. This led to a dramatic reduction in Legionella colonisation, which was negative in all the samples analysed; however, amoeba colonisation remained stable. This study shows the importance of keeping the temperature stable throughout the circuit, at around 60 °C. Special attention should be paid to the most distal points of the circuit; a fall in temperature at these weak points would favour the colonisation and spread of Legionella, because amoeba (the main Legionella reservoir) are not affected by temperature.

Clinical impact and prevalence of MRSA CC398 and differences between MRSA-TetR and MRSA-TetS in an area of Spain with a high density of pig farming: a prospective cohort study.

OBJECTIVES: Tetracycline resistance (TetR) is a phenotypic marker of the livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) CC398 clone. The aim of this study was to analyse the prevalence of MRSA CC398 in patients in contact with healthcare facilities and differences between patients with MRSA-TetR and MRSA tetracycline-susceptible (TetS) strains. METHODS: Patients diagnosed with MRSA from January 2012 to December 2015 were divided into two groups, MRSA-TetR and MRSA-TetS. Epidemiologic and clinical data were evaluated. Molecular analysis was performed (multilocus sequence typing, spa typing) on MRSA-TetR strains. RESULTS: Data from 288 MRSA patients were obtained, and 106 (36.8%) carried MRSA-TetR (93 typed as CC398 (87.7%); the remaining 13 isolates were ascribed to CC9, CC1, CC121, CC30, CC97, CC146 and CC152). The most frequent spa type was t011 (56.6%, 61/106). Detection of MRSA-TetR increased over the years (21.9%, 16/73, in 2012; 50.7%, 36/71, in 2015; p <0.001). Hospital acquisition was found in 16.7% (19/114) of MRSA-TetR patients vs. 83.3% (95/114) in MRSA-TetS patients (p <0.001). Frequency of MRSA-TetR patients in nursing homes was lower than in MRSA-TetS patients (4.7%, 5/106, vs. 27.5%, 50/182, p <0.001). MRSA-TetR as distinct from MRSA-TetS was associated with workers on pig farms (49.0%, 52/106, vs. 1.0%, 2/182; p <0.001), fewer admissions to hospital (46.2%, 49/106, vs. 68.1%, 124/182; p <0.001) and fewer comorbidities (81.1%, 86/106, vs. 59.9%, 109/182; p <0.001). Sixty cases of MRSA-CC398 infection were diagnosed, including, among others, endocarditis, septic arthritis, prosthetic joint infection, pneumonia and bacteraemia. CONCLUSIONS: Prevalence of MRSA-TetR (especially CC398) at the hospital level in a Spanish region with intensive pig farming activity is high and is responsible for severe infections. Significant differences were detected in clinical and epidemiologic characteristics among MRSA-TetR and MRSA-TetS patients.

¿La crisis económica condiciona la aparición de un nuevo perfil de riesgo en viajeros internacionales? / Has the economic crisis led to a new risk profile for international travelers?

Introducción. La crisis económica mundial condiciona la migración de trabajadores europeos hacia países en vías de desarrollo con alta incidencia de enfermedades infecciosas. El objetivo de este estudio es valorar si este contexto produce un aumento de los riesgos de los viajeros internacionales que se desplazan por motivos laborales (VML). Métodos. Estudio observacional retrospectivo. La población de estudio fueron los VML atendidos antes de su viaje en una Unidad de Salud Internacional durante los años 2007 (año anterior al inicio de la crisis europea) y 2012 (con la crisis estructural establecida). Se realizó un análisis comparativo sociodemográfico y de los factores de riesgo presentes entre ambos grupos. Resultados. En 2007 y 2012 se atendieron un total de 9.197 viajeros. Los VML fueron 344 (3,4%); en 2007, 101 (2,8%) y en 2012, 243 (4,5%) (p<0,001). La edad media de los viajeros fue de 38,1 (DE: 10,57) años. El destino más frecuente fue África subsahariana con 164 (47,6%) casos. Se prescribió quimioprofilaxis antipalúdica a 152 (44%) y presentaban comorbilidades 80 (23,25%). Los VML del 2012 presentaron significativamente mayor edad (p=0,05), más comorbilidades (p=0,018), y mayor proporción de estancias en zonas rurales (p=0,009) durante periodos más largos (p=0,001). Conclusiones. A 5 años del inicio de la crisis económica, existe una variación en el perfil del VML. Su número ha aumentado significativamente, así como la proporción de los que presentan factores de riesgo para contraer enfermedades importadas. Las Unidades de Salud Internacional deberían adaptarse a las nuevas circunstancias y adoptar medidas preventivas en dicho colectivo (AU)

Introduction. The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travelers for work reasons (TWR). Methods. Observational, retrospective study. The study population included TWR who were attended before traveling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups. Results. In 2007 and 2012 a total of 9197 travelers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<.001). The average age of the travelers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travelers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=.05), more comorbidity (p=.018) and a greater proportion of stays in rural areas (p=.0009) for longer time periods (p=.001). Conclusions. At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population (AU)

Has the economic crisis led to a new risk profile for international travellers? / ¿La crisis económica condiciona la aparición de un nuevo perfil de riesgo en viajeros internacionales?

INTRODUCTION: The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travellers for work reasons (TWR). METHODS: Observational, retrospective study. The study population included TWR who were attended before travelling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups. RESULTS: In 2007 and 2012 a total of 9,197 travellers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<0.001). The average age of the travellers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travellers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=0.05), more comorbidity (p=0.018) and a greater proportion of stays in rural areas (p=0.0009) for longer time periods (p=0.001). CONCLUSIONS: At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Un estudio clínico-epidemiológico de la población infectada por Trypanosoma cruzi en la zona metropolitana norte de Barcelona / A clinical and epidemiological study of the Trypanosoma cruzi infected population in the north metropolitan area of Barcelona

Antecedentes y objetivos. Como consecuencia inevitable de la inmigración latinoamericana, España y otros países europeos deben afrontar el abordaje de la infección/enfermedad chagásica de la que epidemiológicamente persisten más interrogantes que respuestas. El objetivo del estudio es describir la población diagnosticada de infección/enfermedad chagásica residente en la zona metropolitana norte de Barcelona (406.000 habitantes). Pacientes y método. El estudio, prospectivo y multicéntrico en 3 hospitales y una unidad de salud internacional (2007-2011), incluyó a todos los pacientes con serología positiva a Trypanosoma cruzi solicitada por la razón que fuere. Resultados. Los 139 casos estudiados representan unas incidencias anuales de: a) 0,68/10.000 habitantes, y b) 73,2/10.000 inmigrantes procedentes de zonas endémicas. Estaban enfermos (presentaron alteraciones en alguna prueba complementaria) 80 (57,6%): cardiológicas 62 (44,6%), gastroenterológicas 38 (27,3%) y 20 (14,4%) ambas. Según el Consenso Brasileño de cardiopatía chagásica, se encontraban en estadio 0=84 (60,4%); a=40 (28,7%); b1=4 (2,9%), b2=10 (7,2%) y c/d=1 (0,7%) pacientes. Se indicó tratamiento (benznidazol 5mg/kg/24h durante 60 días) en 116 (83,4%) pacientes, y 89 (76,7%) lo completaron. Presentaron efectos secundarios 56 (50,9%), lo que obligó a retirarlo en 21 ocasiones (19,1%). Conclusiones. En la zona metropolitana norte de Barcelona han sido diagnosticados menos casos de infección/enfermedad chagásica de los esperables. La serie contiene un elevado número de pacientes enfermos y posiblemente haya un número elevado de inmigrantes procedentes de zonas endémicas en la fase crónica asintomática de la infección que ignoran su estado(AU)

Background. As an inevitable consequence of Latin American immigration to Europe, Spain and other European countries, it is necessary to confront the approach to cases of Chagas infection/disease for which, epidemiologically, there are more questions than answers. This study has aimed to describe all the Chagas-infected population in the north metropolitan area of Barcelona (406,000 inhabitants). Patients and methods. A prospective and multicentric study was performed in 3 hospitals and 1 International Health Unit. It included all patients with Trypanosoma cruzi positive serology, regardless of the requesting reason.Results The 139 diagnosed cases represent an annual incidence of: a) 0.68/10,000 inhabitants and, b) 73.2/10,000 immigrants coming from endemic zones. Of the patients, 80 (57.6%) had alterations in some complementary tests: cardiologic 62 (44.6%), digestive 38 (27.3%) and 20 (14.4%) both. According to the Brazilian Consensus of Chagas cardiomyopathy, they were classified as: 0=84 (60.4%); a=40 (28.7%); b1=4 (2.9%), b2=10 (7.2%) and c/d=1 (0.7%). Treatment with benznidazole (5mg/kg/24h for 60 days) was prescribed in 116 (83.4%) patients, 89 (76.7%) of whom completed it. Secondary effects were recorded in 56 (50.9%), which made it necessary to withdraw it in 21 (19.1%). Conclusions. Fewer cases of Chagas infection/disease than expected have been diagnosed in the North Metropolitan area of Barcelona. The series contains a high number of patients and there may be an elevated number of immigrants from endemic zones who have the asymptomatic chronic stages of the infection and who were unaware of their condition(AU)

[A clinical and epidemiological study of the Trypanosoma cruzi infected population in the north metropolitan area of Barcelona]. / Un estudio clínico-epidemiológico de la población infectada por Trypanosoma cruzi en la zona metropolitana norte de Barcelona.

BACKGROUND: As an inevitable consequence of Latin American immigration to Europe, Spain and other European countries, it is necessary to confront the approach to cases of Chagas infection/disease for which, epidemiologically, there are more questions than answers. This study has aimed to describe all the Chagas-infected population in the north metropolitan area of Barcelona (406,000 inhabitants). PATIENTS AND METHODS: A prospective and multicentric study was performed in 3 hospitals and 1 International Health Unit. It included all patients with Trypanosoma cruzi positive serology, regardless of the requesting reason.Results The 139 diagnosed cases represent an annual incidence of: a) 0.68/10,000 inhabitants and, b) 73.2/10,000 immigrants coming from endemic zones. Of the patients, 80 (57.6%) had alterations in some complementary tests: cardiologic 62 (44.6%), digestive 38 (27.3%) and 20 (14.4%) both. According to the Brazilian Consensus of Chagas cardiomyopathy, they were classified as: 0=84 (60.4%); a=40 (28.7%); b1=4 (2.9%), b2=10 (7.2%) and c/d=1 (0.7%). Treatment with benznidazole (5mg/kg/24h for 60 days) was prescribed in 116 (83.4%) patients, 89 (76.7%) of whom completed it. Secondary effects were recorded in 56 (50.9%), which made it necessary to withdraw it in 21 (19.1%). CONCLUSIONS: Fewer cases of Chagas infection/disease than expected have been diagnosed in the North Metropolitan area of Barcelona. The series contains a high number of patients and there may be an elevated number of immigrants from endemic zones who have the asymptomatic chronic stages of the infection and who were unaware of their condition.

Clinical, electrocardiographic and echocardiographic abnormalities in Latin American migrants with newly diagnosed Chagas disease 2005-2009, Barcelona, Spain.

Following Latin American migration, Chagas disease has inevitably appeared in non-endemic countries in Europe and elsewhere. New policies are necessary to prevent transmission in those countries but the long, often undetected chronic period of the early stages of the disease also renders epidemiological studies important. The main objective of our study was to determine the presence of clinical, electrocardiogram (ECG) and echocardiographic abnormalities in a population of Latin American migrants infected with Trypanosoma cruzi at the moment of diagnosis. We performed a hospital-based observational study of 100 adult patients with newly diagnosed Chagas infection between January 2005 and December 2009. Thirty-seven patients were classified within the Brazilian Consensus on Chagas cardiomyopathy early cardiac stages (A or B1) and 49 presented pathological findings (stage B2) according to the Panamerican Health Organization Classification. Overall, 49 patients showed ECG and/or echocardiographic alterations. The presence of ECG and ecocardiographic alterations were significantly associated (p=0.038). The most frequent ECG and echocardiographic findings were right bundle branch block (12 cases) and impaired left ventricular wall relaxation (24 cases), respectively. In conclusion, ECG and echocardiographic alterations coherent with Chagas cardiomyopathy were found in a large proportion of newly diagnosed Latin American migrants infected with T. cruzi. In the mid-term, Chagas disease might become an important cause of chronic cadiomyopathy in our attendance area.

An international trial of quantitative PCR for monitoring Legionella in artificial water systems.

AIMS: To perform an international trial to derive alert and action levels for the use of quantitative PCR (qPCR) in the monitoring of Legionella to determine the effectiveness of control measures against legionellae. METHODS AND RESULTS: Laboratories (7) participated from six countries. Legionellae were determined by culture and qPCR methods with comparable detection limits. Systems were monitored over ≥10 weeks. For cooling towers (232 samples), there was a significant difference between the log mean difference between qPCR (GU l(-1) ) and culture (CFU l(-1) ) for Legionella pneumophila (0·71) and for Legionella spp. (2·03). In hot and cold water (506 samples), the differences were less, 0·62 for Leg. pneumophila and 1·05 for Legionella spp. Results for individual systems depended on the nature of the system and its treatment. In cooling towers, Legionella spp. GU l(-1) always exceeded CFU l(-1) , and usually Legionella spp. were detected by qPCR when absent by culture. The pattern of results by qPCR for Leg. pneumophila followed the culture trend. In hot and cold water, culture and qPCR gave similar results, particularly for Leg. pneumophila. There were some marked exceptions with temperatures ≥50°C, or in the presence of supplementary biocides. Action and alert levels for qPCR were derived that gave results comparable to the application of the European Guidelines based on culture. Algorithms are proposed for the use of qPCR for routine monitoring. CONCLUSIONS: Action and alert levels for qPCR can be adjusted to ensure public health is protected with the benefit that remedial actions can be validated earlier with only a small increase in the frequency of action being required. SIGNIFICANCE AND IMPACT OF THE STUDY: This study confirms it is possible to derive guidelines on the use of qPCR for monitoring the control of legionellae with consequent improvement to response and public health protection.

Outbreak of Legionnaires' disease associated with a supermarket mist machine.

An outbreak of Legionnaires' disease affected 12 customers of a supermarket in a town in Catalonia, Spain, between August and November 2006. An epidemiological and environmental investigation was undertaken. Preliminary investigation showed that all patients had visited the same supermarket in this town where a mist machine was found in the fish section. Water samples were collected from the machine and from the supermarket's water distribution system when high-risk samples were excluded. Environmental samples from the mist machine and clinical samples from two patients tested positive for L. pneumophila serogroup 1 and had the same molecular pattern. The PFGE pattern detected in the clinical and mist-machine isolates had never previously been identified in Catalonia prior to the outbreak and has not been identified since. Four days after turning off the machine, new cases ceased appearing. Molecular study supports the hypothesis that the mist machine from the fish section of the supermarket was the source of infection. We believe it is essential to include exposure to mist machines in any legionellosis epidemiological survey.

Factors influencing the case-fatality rate of Legionnaires' disease.

SETTING: The extent of the public health problem posed by Legionnaires' disease (LD) is not always well- appreciated. OBJECTIVE: To determine the characteristics and factors associated with the case fatality rate (CFR) of LD in Catalonia, Spain. DESIGN: Confirmed cases of LD reported during 1993-2004 were studied. Age, sex, hospitalisation, the type of diagnostic confirmation test and the personal risk factors for LD of cases were collected. Comparative bivariate and multivariate analyses according to origin (community-acquired or nosocomial) and nature (sporadic or outbreaks) were performed. RESULTS: Of 1938 cases reported, 164 died (case-fatality rate [CFR] 8.5%). The CFR fell from 35% in 1993 to 5.6% in 2004, and was higher in sporadic than in outbreak-associated cases (10% vs. 4.7%) and in nosocomial than community-acquired cases (31.7% vs. 6.8%). In community-acquired cases, the CFR was associated with age >70 years (OR 3.42, 95%CI 2.02-5.79), cancer (OR 4.58, 95%CI 2.36-8.90) and diagnostic confirmation methods other than Legionella urinary antigen test. The CFR of nosocomial cases was not associated with any of these factors. CONCLUSIONS: The CFR of LD fell during the study period due to the incorporation of new diagnostic techniques and improved detection of outbreaks.

Cytopathogenicity and molecular subtyping of Legionella pneumophila environmental isolates from 17 hospitals.

The cytopathogenicity of 22 Legionella pneumophila isolates from 17 hospitals was determined by assessing the dose of bacteria necessary to produce 50% cytopathic effect (CPED50) in U937 human-derived macrophages. All isolates were able to infect and grow in macrophage-like cells (range log10 CPED50: 2.67-6.73 c.f.u./ml). Five groups were established and related to the serogroup, the number of PFGE patterns coexisting in the same hospital water distribution system, and the possible reporting of hospital-acquired Legionnaires' disease cases. L. pneumophila serogroup 1 isolates had the highest cytopathogenicity (P=0.003). Moreover, a trend to more cytopathogenic groups (groups 1-3) in hospitals with more than one PFGE pattern of L. pneumophila in the water distribution system (60% vs. 17%) and in hospitals reporting cases of hospital-acquired Legionnaires' disease (36.3% vs. 16.6%) was observed. We conclude that the cytopathogenicty of environmental L. pneumophila should be taken into account in evaluating the risk of a contaminated water reservoir in a hospital and hospital acquisition of Legionnaires' disease.

Sporadic and epidemic community legionellosis: two faces of the same illness.

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2) <7.98 KPa (60 mmHg) were also more frequent in sporadic cases, while headache prevailed in outbreak cases. Sporadic cases had a greater delay in treatment, were more severe and had a worse outcome than epidemic cases. Multivariate analysis showed significant differences in sex, chronic lung disease, HIV infection and headache. The clinical and outcome differences between the two groups may be explained by the detection of milder forms of legionnaires' disease, the earlier treatment and the lower severity of underlying disease in the outbreak cases.

A community outbreak of Legionnaires' disease: evidence of a cooling tower as the source.

A community outbreak of Legionella pneumonia in the district of Cerdanyola, Mataró (Catalonia, Spain) was investigated in an epidemiological, environmental and molecular study. Each patient was interviewed to ascertain personal risk-factors and the clinical and epidemiological data. Isolates of Legionella from patients and water samples were subtyped by pulsed-field gel electrophoresis. Between 7 August and 25 August 2002, 113 cases of Legionella pneumonia fulfilling the outbreak case definition criteria were reported, with 84 (74%) cases being located within a 500-m radius of the suspected cooling tower source. In this area, the relative risk of being infected was 54.6 (95% CI 25.3-118.1) compared with individuals living far from the cooling tower. Considering the population residing in the Cerdanyola district (28,256 inhabitants) as a reference population, the attack rate for the outbreak was 399.9 cases/100,000 inhabitants, and the case fatality rate was 1.8%. A single DNA subtype was observed among the ten clinical isolates, and one of the subtypes from the cooling tower matched exactly with the clinical subtype. Nine days after closing the cooling tower, new cases of pneumonia caused by Legionella ceased to appear. The epidemiological features of the outbreak, and the microbiological and molecular investigations, implicated the cooling tower as the source of infection.

Efficacy and safety of twice-daily pharmacokinetically enhanced amoxicillin/clavulanate (2000/125 mg) in the treatment of adults with community-acquired pneumonia in a country with a high prevalence of penicillin-resistant Streptococcus pneumoniae.

OBJECTIVES: This randomized, double-blind, non-inferiority trial evaluated the efficacy and safety of pharmacokinetically enhanced amoxicillin/clavulanate 2000/125 mg twice daily versus amoxicillin/clavulanate 875/125 mg three times daily, both given orally for 7 or 10 days, in the treatment of adults with community-acquired pneumonia in Spain, a country with a high prevalence of penicillin-resistant Streptococcus pneumoniae. PATIENTS AND METHODS: Following 2:1 randomization, 566 patients (intent-to-treat population) received either amoxicillin/clavulanate 2000/125 mg (n = 374) or amoxicillin/clavulanate 875/125 mg (n = 192). RESULTS: Among the patients who did not deviate from the protocol (clinical per-protocol population), clinical success at day 21-28 post-therapy (test of cure; primary efficacy endpoint) was 92.4% (266/288) for amoxicillin/clavulanate 2000/125 mg and 91.2% (135/148) for amoxicillin/clavulanate 875/125 mg (treatment difference, 1.1; 95% confidence interval, -4.4, 6.6). Bacteriological success at test of cure in the bacteriology per-protocol population was 90.8% (79/87) with amoxicillin/clavulanate 2000/125 mg and 86.0% (43/50) with amoxicillin/clavulanate 875/125 mg (treatment difference 4.8; 95% confidence interval, -6.6, 16.2). At test of cure, amoxicillin/clavulanate 2000/125 mg was clinically and bacteriologically effective against 7/7 penicillin-resistant Streptococcus pneumoniae (MIC > or = 2 mg/L) isolates (including three amoxicillin non-susceptible strains) and amoxicillin/clavulanate 875/125 mg against 5/5 isolates (including one amoxicillin non-susceptible strain). CONCLUSIONS: Both treatment regimens were well tolerated. Amoxicillin/clavulanate 2000/125 mg was at least as effective clinically and as safe as amoxicillin/clavulanate 875/125 mg in the treatment of community-acquired pneumonia in adults in a country with a high prevalence of penicillin-resistant S. pneumoniae and has a more convenient twice daily posology.

Legionellosis.

Community-acquired legionnaires' disease (CALD) has dramatically increased in the Legionella urinary antigen (LUA) era. However, its incidence in each country depends on the specific techniques used for the diagnosis of LD and the mandatory reporting of cases to the local health surveillance system. Moreover, the most recent studies have demonstrated that no clinical data are discriminative enough for the diagnosis of LD. Clinical differences have been observed in sporadic and outbreak-reported cases demonstrating that the earlier the diagnosis of Legionella infection, the more nonspecific the clinical appearance. Fluoroquinolones are the most efficacious drugs against Legionella. The combination of these drugs with azithromycin seems to be promising in the treatment of patients with severe LD. Although outbreaks of LD will continue, the most important objective of the public health authorities should be to reduce their number and size.

[Travelling immigrants]. / Los inmigrantes viajeros.

OBJECTIVES: To characterise travelling immigrants and the international movements they undertake. To identify the risk journeys that this population makes and to assess the international preventive activities for them compared with those for autochthonous travellers. DESIGN: Retrospective, observational study. SETTING: Unit of International Health (UIH) Santa Coloma de Gramenet (Barcelona), in the Barcelonès Nord i Maresme Health Area, Primary Care Division of the Catalan Institute of Health. PARTICIPANTS: Patients seen between June 1999 and June 2002 (n=1163) at the UIH. They were divided into two groups, depending on their origins: those born inside (autochthonous group; no=1019) or outside (immigrant group; n1=144) the European Union. MAIN MEASUREMENTS: Age, country of origin, length of residence in Spain, interval between consultation and journey, reason for journey, destination, duration of the journey, kind of journey, stay in rural or isolated area, exposure to malaria, vaccinations and anti-malaria chemoprophylaxis prescribed, and overall risk of journey. RESULTS: Immigrants spent more time abroad than autochthonous people (mean 43.5 days; 95% CI, 37.9-49.1; and 15.8 days, 95% CI, 14.9-16.7, respectively; P<.0001). Periods between the journey and the consultation at the UIH were generally similar in the two groups (mean of 26.8 days for immigrants and 30.41 days for autochthonous people; ns), although the immigrants consulted more often in periods of less than 15 and 7 days (P<.005). 31.9% of immigrants stayed in areas of high malaria transmission (95% CI, 24.4%-39.6%) vs 21.3% (95% CI, 18.8%-23.8%) of autochthonous people (P=.04). Overall, immigrants made more risk journeys than autochthonous people (54.8% vs 43.1%; P<.01). No significant differences between the two groups were found in terms of quality in the administration of the international vaccinations prescribed. Compliance with the guidelines for anti-malaria chemoprophylaxis was less in the immigrant group than in the autochthonous one (36% vs 84%; P<.005). CONCLUSIONS: The immigrant group in our environment needs to be thought of as a risk group for catching and importing tropical diseases during their international movements. They form a population for whom international preventive measures should be prioritized.

Los inmigrantes viajeros / Travelling immigrants

Objetivos. Caracterizar a los inmigrantes viajeros y los desplazamientos internacionales que realizan. Identificar los viajes de riesgo que efectúa dicha población, así como valorar las actividades preventivas internacionales que reciben en relación con las aplicadas a viajeros autóctonos. Diseño. Estudio observacional retrospectivo. Emplazamiento. Unidad de Salud Internacional (USAI) de Santa Coloma de Gramenet (Barcelona). Ámbito Sanitario del Barcelonès Nord i Maresme. División de Atención Primaria. Institut Català de la Salut. Participantes. Pacientes visitados desde junio de 1999 a junio de 2002 (n = 1.163) en la USAI. Se definieron dos grupos según su procedencia: nacidos en la Unión Europea (grupo autóctono; n0 = 1.019) o fuera de ella (grupo inmigrante; n1 = 144).Medidas principales. Edad, país de origen, tiempo de residencia en España, intervalo entre consulta/viaje, motivo del viaje, destino, duración del viaje, tipo de viaje, estancia en zona rural o aislada, exposición a paludismo, vacunaciones y quimioprofilaxis antipalúdica prescritas y riesgo global del viaje. Resultados. Los inmigrantes residen en el extranjero durante más tiempo que los autóctonos (media, 43,5 días; intervalo de confianza [IC] del 95 por ciento, 37,9-49,1 y 15,8 días; IC del 95 por ciento, 14,9-16,7, respectivamente; p < 0,0001). Los períodos comprendidos entre el viaje y la consulta a la USAI son globalmente similares en ambos grupos (media de 26,8 días para inmigrantes y 30,41 días para autóctonos; p = NS), aunque los inmigrantes consultan con mayor frecuencia para períodos menores de 15 y 7 días (p < 0,005). Residieron en zonas de alta transmisión palúdica el 31,9 por ciento (IC del 95 por ciento, 24,4-39,6) de los inmigrantes frente al 21,3 por ciento (IC del 95 por ciento, 18,8-23,8) de los autóctonos (p = 0,04). En conjunto, los inmigrantes realizaron un mayor número de viajes de riesgo que los autóctonos (un 54,8 frente al 43,1 por ciento; p < 0,01). No se hallaron diferencias significativas entre ambos grupos en cuanto a la calidad en la administración de las vacunaciones internacionales prescritas. El cumplimiento de la pauta de quimioprofilaxis antipalúdica fue menor en el grupo de inmigrantes respecto al de autóctonos (el 36 frente al 84 por ciento; p < 0,005). Conclusiones. Cabe considerar el colectivo inmigrante de nuestro ámbito como un grupo de riesgo para la adquisición e importación de enfermedades tropicales durante sus desplazamientos internacionales. Conforman una población en la que se debería priorizar la recepción de medidas preventivas internacionales (AU)

Changes in bloodstream infections in HIV-positive patients in a university hospital in Spain (1995-1997).

OBJECTIVES: The Hospital Universitario Germans Trias i Pujol is a 600-bed center serving 700,000 inhabitants including 1800 patients with HIV infection in Catalonia (Spain). Highly active antiretroviral therapy (HAART) became available at the end of 1996. Thus, the period 1995 1997 was considered appropriate for evaluating possible epidemiological changes in bloodstream infections (BSI) in HIV-infected patients. METHODS: All significant bloodstream infections, including mycobacteremia and fungemia, observed in HIV-positive patients from January, 1995 to December, 1997 have been included in the study. RESULTS: One hundred and eighty six cases were evaluated, in whom a decrease in BSI was observed (68 in 1995, 86 in 1996, 32 in 1997). Over time, we observed an improvement in the immunologic situation of the patients (1995: CD4 <50/mm3 73.8% vs 1997: CD4 <50/mm3 45.5% (P=0.05)). The source of BSI was known in 80.7% of the episodes. BSI secondary to catheter and respiratory infections prevailed in 1995, whereas an increase in bacteremias related to intravenous drug use, with or without endocarditis, was seen in 1997. The most frequent isolates were Mycobacterium avium intracellulare (23) (MAI), M. tuberculosis (20), Staphylococcus aureus (20), coagulase-negative staphylococci (16), Salmonella spp. (16) and Streptococcus pneumoniae (15). In 1997, a decrease was observed in the isolation of Gram-negatives and Mycobacterium spp. with S. aureus and enterococci prevailing. CONCLUSIONS: The prevalence of bloodstream infections in HIV-positive patients has decreased since the introduction of HAART and the immunologic state has improved. Furthermore there is a trend to a decrease or disappearance of microorganisms, such as Pseudomonas spp., Mycobacterium tuberculosis, MAI or fungi related to severe immunosuppression. Lastly, bacteremia caused by the active use of intravenous drugs remains stable with the highest percentage in Spain.