The role of wild boar (Sus scrofa) in the eco-epidemiology of R. slovaca in Northeastern Spain.

Rickettsia slovaca is considered the etiological agent of tick-borne lymphadenopathy (TIBOLA), an emerging disease transmitted by tick bites. Dermacentor marginatus constitutes the most important vector and wild boar (Sus scrofa) is the main wild host in our area. The epidemiology of this tick-borne rickettsioses has not been completely clarified. During hunting season 2004, wild boar sera sample were collected from northeastern Spain. Ticks were collected both from wild boar and from flagging vegetation in the same areas where wild boar were hunted. Serologic study was carried out using the immunofluorescent antibody (IFA) technique. Ticks were identified as D. marginatus and Rhipicephalus uranicus. Based on sequence analysis on ompA gene, R. slovaca was identified in 30.5% D. marginatus ticks removed from wild boar and in 33.3% D. marginatus collected from flagging vegetation. Rickettsia sp. RpA4 was identified in 4 specimens of D. marginatus removed from wild boar. Twelve of 23 wild boar were seropositive to R. slovaca. Results suggested wild boar are exposed to R. slovaca infection and this pathogen is well established in the wild cycle of D. marginatus in our area.

[Bacteremic pneumococcal pneumonia]. / Neumonía neumocócica bacteriémica.

BACKGROUND: Streptococcus pneumonia is the most common bacterial cause of community-acquired pneumonia in children. The reference standard for etiological diagnosis is isolation of S. pneumoniae from blood Since the advent of conjugate vaccines, disease caused by this organism can now be prevented. Many studies have been performed of the global incidence of invasive pneumococcal infections and of pneumococcal meningitis but few studies investigated bacteremic pneumococcal pneumonia and its complications in children. OBJECTIVES: To determine the incidence, patient characteristics, clinical signs, laboratory data, percentage and days of hospitalization, response to antibiotic treatment, antibiotic resistance, complications and causal serogroups of bacteremic pneumococcal pneumonia in our environment in order to estimate requirements for systematic vaccination programs. MATERIAL AND METHODS: From January 1990 to May 2001, data on all pediatric cases of invasive pneumococcal infections diagnosed in our hospital were collected. Several characteristics of patients with bacteremic pneumococcal pneumonia were analyzed. Bacteremic pneumococcal pneumonia was diagnosed in patients with positive blood or pleural fluid cultures for S. pneumoniae and radiographically evident pulmonary infiltrate. The incidence of both types of pneumonia were determined according to population census data. All S. pneumonia strains were sent to the Pneumococci Reference Laboratory of the Instituto Carlos III in Madrid for serotyping. We estimated the serotype coverage of the pneumococcal 7-valent conjugate vaccine according to the serotypes included in this vaccine and their distribution. RESULTS: Forty cases of bacteremic pneumococcal pneumonia were diagnosed, yielding an incidence of 17,10 and 5 cases per 10(5) children aged less than 2, 4 and 15 years old respectively. The mean age was 50 months and 43% were aged less than 4 years. Peaks occurred in January, March, April and May. A total of 77.5% of the patients were admitted to hospital and the mean length of stay was 9.2 days. The mean duration of fever was 2 days and was 4.2 days in patients with pleural empyema. All patients presented fever and its mean duration before admission was 4 days. Fifty-eight percent of the patients had cough. Thirty-nine percent appeared generally unwell, vomiting was present in 47% and abdominal pain in 28%. Respiratory auscultation detected rales in 30% of the patients, hypophonesis in 28% and polypnea or dyspnea in 35%. Most patients showed alveolar bilateral infiltrations and 20% had pleural empyema. Seventy-eight percent had WBC counts > 15,000 and 93% showed neutrophilia of > 60%. Erythrocyte sedimentation rate and C-reactive protein were elevated in 77% and 85% of the patients, respectively. Overall, 40% of the isolates showed intermediate susceptibility to penicillin and 5% were resistant. Eighteen percent showed intermediate susceptibility to cefotaxime and 18% were resistant to erythromycin. Thirty-four strains were resistant to erythromycin. Thirty-four strains were serogroups and in children < or = 59 months, 34% of the serogroups were included in the pneumococcal 7-valent pneumococcal conjugate vaccine. CONCLUSION: The significant morbidity of bacteremic pneumococcal pneumonia and the implicated serogroups supports the use of the new heptavalent vaccine in the pediatric age group.

Neumonía neumocócica bacteriémica / Bacteremic pneumococcal pneumonia

Antecedentes: Streptococcus pneumoniae es el primer agente causal de neumonía bacteriana adquirida en la comunidad en la infancia. Para su diagnóstico el aislamiento en sangre de S. pneumoniae es el único método válido. Con la aparición de las nuevas vacunas conjugadas antineumocócicas se pueden prevenir estas infecciones. Existen estudios sobre la incidencia global de la enfermedad invasiva neumocócica (EIN) y sobre sus formas más graves como la meningitis, pero muy pocos la neumonía neumocócica bacteriémica (NNB) y sus complicaciones en la infancia. Objetivos: Conocer la incidencia, forma de presentación clínica y analítica, porcentaje y días de ingreso, respuesta al tratamiento antibiótico y resistencia a éstos, complicaciones y serogrupos causales de la NNB en nuestros medio para estimar la necesidad de una vacunación sistemática. Material y métodos: Desde enero de 1990 hasta mayo de 2002 se han recogido todos los casos pediátricos de EIN diagnosticados en nuestro hospital. Del total de estos casos se analizaron diversas características en los pacientes con NNB. Se consideraron NNB los casos con radiología torácica compatible con neumonía y hemocultivo o cultivo de líquido pleural positivo para S. pneumoniae. Se calculó la incidencia, tanto de la EIN como de la NNB, según los datos de población censales. Todas las cepas de S. pneumoniae fueron enviadas para serotipificación al Laboratorio de Referencia de Neumococos del Instituto de Salud Carlos III en Majadahonda (Madrid). Se estimó la cobertura vacunal de la nueva vacuna antineumocócica conjugada heptavalente según los serotipos incluidos en ella y la distribución de los serotipos. Resultados: Se diagnosticaron 40 casos de NNB, lo que representa una incidencia de 17, 10 y 5 casos por 105 niños menores de 2, 4 y 15 años, respectivamente. La edad media fue de 50 meses, siendo el 43% menores de 4 años. El mayor número de casos se dio en enero, marzo, abril y mayo. Ingresaron el 77,5% de los casos y la estancia media fue de 9,2 días. La duración media de la fiebre fue de 2 días y en los pacientes con derrame pleural fue de 4,2 días. Presentaron fiebre todos los casos, siendo su duración media antes del ingreso de 4 días. El 58% de los pacientes tenían tos. El 39% presentaban afectación de su estado general, vómitos el 47% y dolor abdominal el 28%. En la auscultación respiratoria se detectaron estertores en el 30% de los casos, hipofonesis en el 28% y polipnea o disnea en el 35%. En la mayoría de los pacientes se observó un infiltrado alveolar unilateral y el 20% de los casos tenían un derrame pleural. El 78% de los casos tenían una leucocitosis superior a 15.000 y el 93% una neutrofilia mayores de 60%. La velocidad de sedimentación globular y la proteína C reactiva fueron elevadas en el 77 y 85% de los casos, respectivamente. El 40% de las cepas tenían una sensibilidad disminuida a la penicilina y el 5% eran resistentes. El 18% tenían una sensibilidad disminuida a cefotaxima y el 18% eran resistentes a eritromicina. Se serogruparon 34 cepas y en los menores de 59 meses, el 84% de los serogrupos eran los incluidos en la vacuna heptavalente. Conclusión: La importante morbilidad de la NNB y la distribución de los serogrupos implicados apoyaría la utilización de la nueva vacuna heptavalente en esta edad (AU)

[Pneumococcal bacteremia in patients aged over 65 years. A study of 161 cases]. / Bacteriemia neumocócica en pacientes mayores de 65 años. Estudio de 161 casos.

BACKGROUND: Here we present the results from a prospective analysis of pneumococcal bacteremia in patients older than 65 years, highlighting its differences with regard to patients aged from 15 to 64 years. PATIENTS AND METHOD: We performed a prospective follow-up study (1988-1999) of patients older than 14 years whohad blood cultures positive for Streptococcus pneumoniae(S. pneumoniae). S. pneumoniae was identified using standard techniques. The antimicrobial sensitivity was analysed using the broth midrodilution technique and the serotype was studied in a reference laboratory. Statistical analyses were performed by means of the SPSS program, version 9.0. RESULTS: 161 out of 321 bacteremias occurred in 154 patients older than 65 years (86 males). Most frequent underlying diseases were chronic obstructive pulmonary disease (COPD), diabetes and neoplasia. Most patients had pneumonia, 29.7% with ilfiltrates involving at least two lung lobes. 9.4% of bacteremias were nosocomial. Among patients older than 65 years, 32.5% of strains were resistant to penicillin, compared to 21.7% in patients younger than 65 years(p = 0.034). Mortality in patients over 65 years was higher than in younger patients (25.3% vs 11.5%; p = 0.002) and mortality predictive factors in a multivariate analysis were age, nosocomial bacteremia and multi-lobe involvement (in patients with pneumonia). CONCLUSIONS: There is a high incidence of pneumococcal bacteremia in patients over 65 years of age. These patients have a higher rate of resistance to penicillin and a higher mortality rate than younger patients. Mortality predictive factors are age, nosocomial bacteremia and multi-lobe involvement.

Prevalence of antibodies to spotted fever group rickettsiae in human beings and dogs from and endemic area of mediterranean spotted fever in Catalonia, Spain.

We assessed the prevalence of antibodies to spotted fever group rickettsiae in human beings and dogs by indirect immunofluorescence in the region of 'Vallés Occidental', Barcelona (Spain). In the group of 150 serum samples from patients without former history of Mediterranean spotted fever, 12 had antibodies to Rickettsia conori. The overall seroprevalence was 8% (95% confidence interval, 4.6% to 13.5%). There were no statistically significant differences between the mean ages of patients with positive and negative antibodies to R. conorii. However, seropositivity was significantly more common among patients living in semi-rural areas. In the group of 138 dog serum samples, 36 (26.1%) sera had antibodies to R. conorii. When the present results were compared with those obtained in a previous seroepidemiological survey carried out in the same geographical region in 1987, no significant differences were found. Therefore, although the epidemiological markers have dropped, this does not absolutely confirm the decrease of the presence of R. conorii in this area.

[Antibiotic treatment of acute gastroenteritis]. / Tratamiento antibiótico de la gastroenteritis aguda.

The empiric antibiotic therapy for acute gastroenteritis (AGE) is indicated only in patients with underlying diseases or risk for bacteremia. The clinical characteristics, clinical efficiency of antibiotic therapy with pivmecillinam (52 patients) or ciprofloxacin (75 patients) and its effects on the fecal carrier state of Salmonella spp. were studied in 127 adult patients with AGE and antibiotic therapy indication. The initial stool culture was positive in 90 patients (71%). The microorganism recovered most frequently was Salmonella spp., with a bacteremia rate in these patients of 5%. The susceptibility of Salmonella spp. to ciprofloxacin and mecillinam was 100% and 90%, respectively. Therapy with ciprofloxacin or pivmecillinam showed a similar efficiency. Fecal excretion lasted no longer than five weeks and no chronic carriers were observed.

Release of soluble tumor necrosis factor receptors in Mediterranean spotted fever rickettsiosis.

Tumor necrosis factor alpha (TNF) is a key cytokine in the defense against many intracellular pathogens, including Rickettsia conorii, the causative agent of Mediterranean spotted fever (MSF). The levels of two soluble TNF receptors (sTNFR-p55 and sTNFR-p75), the extracellular domains of the two cell surface receptors for TNF, were elevated in the acute-stage plasma samples from 20 patients with serologically confirmed MSF. The median values were 3.1 and 7.8 ng/ml for sTNFR-p55 and sTNFR-p75, respectively. sTNFR values correlated significantly with plasma TNF concentrations. Patients with severe MSF had higher values for both receptor fragments than patients with nonsevere disease. The differences were statistically significant for sTNFR-p55 (median, 5.8 versus 2.0 ng/ml; P = 0.008). Given the proportionately higher values for both TNF and sTNFR-p55 in patients with severe MSF, the sTNFR-p55/TNF ratios for the two patient subgroups did not differ (P = 0.5), while the sTNFR-p75/TNF ratios were significantly different (P = 0.01), with disproportionately lower values in patients with severe disease.

Plasma levels of tumor necrosis factor alpha in patients with Mediterranean spotted fever: clinical and analytical correlations.

Twenty consecutive patients with serologically confirmed Mediterranean spotted fever were analyzed for determination of plasma levels of tumor necrosis factor alpha (TNF-alpha) by means of an ELISA. Increased levels of TNF-alpha in plasma were found during the acute phase of the disease (52.3 +/- 49.8 pg/mL) compared to levels in the convalescent phase (9.0 +/- 9.3 pg/mL; P < .001) or in healthy controls (6.5 +/- 3.2 pg/mL; P < .001). Plasma TNF-alpha levels were significantly higher in patients with severe Mediterranean spotted fever. Levels of TNF-alpha correlated significantly with serum levels of C-reactive protein and triglycerides and inversely with serum levels of sodium.

[Mediterranean boutonneuse fever. Study of 246 cases]. / Fiebre botonosa mediterránea. Estudio de 246 casos.

The clinical and epidemiological feature of 246 cases of Mediterranean boutonneuse fever diagnosed in 1983-1988 were evaluated. It was found that the clinical and epidemiological profile of the disease remained stable as compared with previous studies. The frequent muscle involvement, with increase in serum muscular enzymes in up to 32% of patients and with histologically documented myositis in 2 patients is emphasized. 7% of patients had severe forms of the disease. The risk factors of these forms were evaluated, and the different features in adults and children were compared. The outcome was favourable in all patients.

Seroepidemiological survey of Mediterranean spotted fever in an endemic area ('Vallés Occidental', Barcelona, Spain).

A seroepidemiological survey of Mediterranean spotted fever was carried out in the region of 'Vallés Occidental', Barcelona (Spain). The prevalence of antibodies to Rickettsia conorii in human beings and dogs was determined by indirect immunofluorescence. In 200 samples of sera from subjects without former history of boutonneuse fever, an overall prevalence of antibodies to R. conorii of 11.6% was found. Seropositivity was significantly higher in the age group greater than 50 years. A significant correlation between seropositivity and habitat, social status, contact with dogs or risky practices was not found. In 48 sera from subjects with a history of Mediterranean spotted fever in the previous 10 years, the overall prevalence of antibodies was 68.7%, being 56.2% among those individuals who had suffered from the disease between 5 and 10 years earlier. In 103 dog serum samples collected during the summer, seropositivity was 36.8%. Positive sera were only detected in 1 of the 97 samples collected in winter, which suggests a relatively short duration of the canine immune response after contact with R. conorii.

New trends in Mediterranean spotted fever.

Mediterranean Spotted Fever is a disease caused by Rickettsia conorii. It is endemic to the Mediterranean area, where, for the last few years, the number of cases has increased, possibly due, in part, to climatic factors. The main clinical aspects of a prospective series of 246 cases diagnosed from 1983 to 1988 are presented. The most characteristic manifestations were fever, exanthema and tache noire. Other frequent manifestations were headache, myalgia and arthralgia, and with lesser frequency, hepatomegaly, splenomegaly, gastrointestinal symptoms and conjunctivitis. Notable analytical changes are the rise of hepatic and muscular enzymes in a large number of patients. In some cases we have found signs of myositis in muscular biopsy. The evolution of our patients was usually favorable though serious and even deadly forms of the disease have been described. One of the factors that seems to greatly influence the appearance of these forms is delay in the initiation of effective treatment.

[Mediterranean spotted fever in childhood. Prospective study of 130 cases]. / Fiebre botonosa mediterránea en la infancia. Estudio prospectivo de 130 casos.

Authors present a prospective study of 130 cases of Mediterranean spotted fever treated between 1983 and 1985 in two Departments of Paediatrics of the Valles Occidental, area near Barcelona. Thirty-eight percent of the children came from suburban areas, an urban areas, an urban or rural origin being less frequent. Previous contacts with dogs existed in 86% of the cases. Most frequent clinical signs were fever (100%) maculo-papular rash (97%) and arthromyalgias (70%). The "tache noire" was found in 87% of the cases. Presence of arthritis in two patients is underlined. Indirect immunofluorescence to Rickettsia conorii was positive (much greater than 1/40) in 75% of the cases. All patients improved after treatment with tetracycline or erythromycin. There were no relapse.

Erythromycin versus tetracycline for treatment of Mediterranean spotted fever.

Eighty one children aged between 1 and 13 years participated in a randomised comparative trial of tetracycline hydrochloride and erythromycin stearate for treatment of Mediterranean spotted fever. Both therapeutic regimens proved effective, but in patients treated with tetracycline both clinical symptoms and fever disappeared significantly more quickly. Likewise, when those patients who began treatment within the first 72 hours of illness are considered the febrile period had a significantly shorter duration in the group treated with tetracycline. One patient was switched to tetracycline because there was no improvement of clinical manifestations, with persistence of fever, myalgias, and prostration, after receiving eight days of treatment with erythromycin. These results suggest that tetracyclines are superior to erythromycin in the treatment of Mediterranean spotted fever.