The Magnificent Seven: Seven good publications in infectious disease.

The world of infectious diseases, for various reasons, before and after the COVID-19 pandemic, capture the attention of the scientific community, either due to the epidemiological data of various microbial agents that are emerging, due to the implementation with successful results of new diagnostic strategies or due to the appearance of new therapeutic options, which encourage healthcare workers to continue on the front line. Topics such as antimicrobial resistance, S. aureus bacteremia, clostridioides difficile, short treatments for tuberculosis, prosthetic joint infection or invasive fungal infections are included. In this article, we want to highlight, among many others, seven recently published articles that deserve our attention, full of useful information to keep us updated.

Mycoplasma genitalium and sexually transmitted infections: evidences and figures in a tertiary hospital.

OBJECTIVE: Mycoplasma genitalium is an emerging cause of sexually transmitted infections (STIs) and has been implicated in non-gonococcal urethritis in men and cervicitis in woman. The aim of this study is determinate the incidence and pathogenicity of M. genitalium within the diagnosis of STIs detected from clinical samples in a third level hospital. METHODS: A total of 8,473 samples from endocervix, urethra, vagina, rectum and others were processed applying Allpex STI Essential Assay. More than 190 records were reviewed to determinate M. genitalium pathogenicity. RESULTS: M. genitalium was detected in a rate 2.8%. Co-infections were detected in 20% of the patients. CONCLUSIONS: M. genitalium is considered a STI emerging pathogen thanks to the renewal of multiplex-PCR tests although with a low incidence in our approach. Emerging from our experience and the institutional recommendations both detection of acid nucleic techniques (NAATs) and gonococcal culture might be implemented accurately and coexist to adequate prescriptions.

Clostridioides difficile infection in a long-term convalescence hospital: A real tale of pitfalls and outdated therapy.

OBJECTIVE: The aim of the study was to know the characteristics and risk factors of Clostridioides difficile infection (CDI) in a long-term hospital is key to improve its management. METHODS: Retrospective study with 37 patients, along 43 months. We describe demographic variables, clinical data, time to diagnosis, treatment, and evolution. RESULTS: Analysis of 46 episodes (37 patients, mean age=82.2 years). 77.8% were absolutely dependent, 41.7% had chronic kidney disease, 64.9% had received antibiotics in the previous three months, 40.5% received antibiotics at diagnosis. It was the first episode in 78.4%, and first recurrence in 21.6%. Therapy was started in the first 24 hours after diagnosis in 89.2%, mostly metronidazole. 83.3% recovered, 3 patients died from CDI, diagnosis was registered in the discharge report in 91.1%. CONCLUSIONS: Previous antibiotic therapy, high grade of dependency and renal failure were the main risk factors. There is room for improvement in CDI management at our hospital.

Staphylococcus aureus meningitis in adults: A comparative cohort study of infections caused by meticillin-resistant and meticillin-susceptible strains.

BACKGROUND: Staphylococcus aureus meningitis is an uncommon nosocomial infection usually associated with neurosurgical procedures, but spontaneous infections may occasionally appear. AIMS: To compare the features of meningitis caused by meticillin-resistant (MRSA) and meticillin-susceptible (MSSA) S. aureus and examine the prognostic factors for mortality, including MRSA infection and combined antimicrobial therapy. METHODS: Retrospective cohort study of 350 adults with S. aureus meningitis admitted to 11 hospitals in Spain (1981-2015). Logistic regression and propensity score matching were used to analyse prognostic factors. RESULTS: There were 118 patients (34%) with MRSA and 232 (66%) with MSSA. Postoperative infection (91% vs 73%) and nosocomial acquisition (93% vs 74%) were significantly more frequent in MRSA than in MSSA meningitis (P < 0.001). Combined therapy was given to 118 (34%) patients. Overall 30-day mortality rate was 23%. On multivariate analysis, mortality was associated with severe sepsis or shock (odds ratio (OR) 9.9, 95% confidence interval (CI) 4.5-22.0, P < 0.001), spontaneous meningitis (OR 4.2, 95% CI 1.9-9.1, P < 0.001), McCabe-Jackson score rapidly or ultimately fatal (OR 2.8, 95% CI 1.4-5.4, P = 0.002), MRSA infection (OR 2.6, 95% CI 1.3-5.3, P = 0.006), and coma (OR 2.6, 95% CI 1.1-6.1, P < 0.029). In postoperative cases, mortality was related to retention of cerebrospinal devices (OR 7.9, 95% CI 3.1-20.3, P < 0.001). CONCLUSIONS: Clinical and epidemiological differences between MRSA and MSSA meningitis may be explained by the different pathogenesis of postoperative and spontaneous infection. In addition to the severity of meningitis and underlying diseases, MRSA infection was associated with increased mortality. Combined antimicrobial therapy was not associated with increased survival.

Role of universal 16S rRNA gene PCR and sequencing in diagnosis of prosthetic joint infection.

The etiological diagnosis of prosthetic joint infection (PJI) requires the isolation of microorganisms from periprosthetic samples. Microbiological cultures often yield false-positive and false-negative results. 16S rRNA gene PCR combined with sequencing (16SPCR) has proven useful for diagnosing various infections. We performed a prospective study to compare the utility of this approach with that of culture to diagnose PJI using intraoperative periprosthetic samples. We analyzed 176 samples from 40 patients with PJI and 321 samples from 82 noninfected patients using conventional culture and 16SPCR. Three statistical studies were undertaken following a previously validated mathematical model: sample-to-sample analysis, calculation of the number of samples to be studied, and calculation of the number of positive samples necessary to diagnose PJI. When only the number of positive samples is taken into consideration, a 16SPCR-positive result in one sample has good specificity and positive predictive value for PJI (specificity, 96.3%; positive predictive value, 91.7%; and likelihood ratio [LR], 22), while 3 positive cultures with the same microorganism are necessary to achieve similar specificity. The best combination of results for 16SPCR was observed when 5 samples were studied and the same microorganism was detected in 2 of them (sensitivity, 94%; specificity, 100%; and LR, 69.62). The results for 5 samples with 2 positive cultures were 96% and 82%, respectively, and the likelihood ratio was 1.06. 16SPCR is more specific and has a better positive predictive value than culture for diagnosis of PJI. A positive 16SPCR result is largely suggestive of PJI, even when few samples are analyzed; however, culture is generally more sensitive.

Early prosthetic joint infection: outcomes with debridement and implant retention followed by antibiotic therapy.

Recent expert reviews recommend a conservative surgical strategy - debridement and irrigation, antibiotics and implant retention (DAIR) - for most early post-surgical prosthetic joint infections (PJI). However, differences exist in published series regarding success rates with DAIR, and the size of most series is small. In this prospective multicenter cohort study of early PJI managed by DAIR, factors associated with failure of the DAIR were analyzed. Out of 139 early PJI, 117 cases managed with DAIR were studied For 67 patients (57.3%), infection was cured and the implant was salvaged with definite antimicrobial therapy. In 35 (29.9%) DAIR failed and removal of the prosthesis was necessary during follow-up. Finally, 15 patients (12.8%) needed chronic suppressive antimicrobial therapy due to suspected or confirmed persistent infection. Infections due to methicillin-resistant S. aureus (72.7% failed; p 0.05) and those treated at one of the hospitals (80.0% failed; p <0.05) had worse outcomes, but only this last variable was associated with treatment failure following multivariate analysis. Seventy-four per cent of patients who were successfully treated by DAIR and only 32.7% of the failures were able to walk without help or with one stick at the last follow-up visit (p <0.05). In conclusion, a substantial proportion of patients with an early PJI may be successfully treated with DAIR and definite antimicrobial therapy. In more than half of these, the infection can be cured. Since identification of factors associated with failure of DAIR is not simple, we recommend offering DAIR to most patients with early PJI.

Streptococcus pneumoniae skin and soft tissue infections: characterization of causative strains and clinical illness.

Streptococcus pneumoniae is an uncommon cause of skin and soft tissue infections, yet the incidence and clinical significance of its isolation in samples of skin or soft tissues in unselected hospital samples is poorly understood. In the present study, a review was conducted of the records of all patients with skin and soft tissue infections due to S. pneumoniae at a university hospital between January 1994 and December 2005. The isolates were identified by standard methods and were serotyped, and susceptibility testing was performed by the broth microdilution method following the guidelines of the Clinical and Laboratory Standards Institute. During the study period, 3,201 isolates of S. pneumoniae were recovered from several sources. Of these, 69 (2.2%) were from skin and soft tissue samples (69 patients). Complete information could not be obtained for 13 patients. Of the 56 patients remaining, 36 (64.3%) were infected and fulfilled the inclusion criteria. The following types of infections were observed: surgical wound infection (n = 11), burn infection (n = 7), pyomyositis (n = 6), cellulitis (n = 4), perineal or scrotal abscess (n = 3), and other (n = 5). Thirty-one (86%) patients had a favorable outcome, and 5 (13.8%) patients died. Mortality was directly attributable to S. pneumoniae infection in three of the five fatal cases. Of the 39 S. pneumoniae isolates obtained (36 from skin and soft tissues, three from blood cultures), 58.9% were penicillin nonsusceptible, 7.7% were cefotaxime nonsusceptible, and 20.5% were erythromycin resistant. The most frequent serotypes were 3, 19, 11, and 23. Of the overall number of isolates of S. pneumoniae recovered in a general institution, 2.2% involved skin and soft tissues (of which 64% were clinically significant). Mortality due to pneumococcal skin and soft tissue infections was low.

Tratamiento en dos tiempos de la artroplastia total de rodilla infectada: estudio comparativo entre dos tipos de espaciadores / Two step surgical treatment of infected total knee replacement: comparative study of two different types of spacers

Introducción y objetivo. La infección tras la artroplastia total de rodilla, representa la peor complicación posible de este procedimiento quirúrgico, requiriendo la combinación de tratamientos complejos, junto con una prolongada hospitalización. El tratamiento debe ser multidisciplinario y sus objetivos son erradicar la infección y preservar la función de la extremidad. El objetivo del presente estudio es analizar nuestras guías y protocolos de diagnóstico y tratamiento y realizar un estudio retrospectivo comparando los resultados de dos formas diferentes de tratamiento de una artroplastia total de rodilla infectada. Material y método. El primer grupo de tratamiento lo componen los pacientes intervenidos mediante reimplantación en dos tiempos y dejando un espaciador monobloque entre cirugías sin permitir la movilidad. En el segundo grupo de pacientes se emplearon espaciadores articulados y se les permitió una movilidad controlada en el tiempo entre las cirugías. Se analizaron las diferencias en porcentaje de reimplantación, movilidad final y resultados clínicos y funcionales entre ambos grupos y se comparan los resultados entre diferentes tipos de prótesis. Resultados y conclusiones. Los espaciadores articulados en el tiempo entre cirugías y las prótesis constreñidas en la reimplantación se asociaron con mejores resultados

Introduction and purpose. Infection of total knee replacement (TKR) surgery is the worst complication of this procedure. It requires complex treatment and prolonged hospitalisation. The treatment must be carried out by a multidisciplinary team and its goal is to eradicate infection and preserve the function of the limb. The aim of this study is to analyse our diagnostic and treatment guides and protocols, and to carry out a retrospective study comparing the results of two different types of treatment of infection of total knee replacement surgery. Material and methods. The first group of patients had a two step knee replacement surgery with a monoblock spacer left in place between operations, but during this period no movement of the joint was allowed. The second group of patients had a two step knee replacement surgery with an articulated spacer left in place between operations, and during this period controlled movement of the joint was allowed. An analysis was carried out of the differences between the two groups in: percentages of re-implantation, final range of motion (ROM), clinical and functional outcomes, and results due to the use of different prosthesis. Outcomes and conclusions. Better outcomes were observed with the use of joint spacers in two step surgery and constrained prosthesis in re-implantation procedures

Reassessment of Clostridium difficile susceptibility to metronidazole and vancomycin.

Clostridium difficile is the most frequently identified enteric pathogen in patients with nosocomially acquired, antibiotic-associated diarrhea. The drugs most commonly used to treat diseases associated with C. difficile are metronidazole and vancomycin. Most clinical laboratories assume that all C. difficile isolates are susceptible to metronidazole and vancomycin. We report on the antimicrobial susceptibilities of 415 C. difficile isolates to metronidazole and vancomycin over an 8-year period (1993 to 2000). The overall rate of resistance to metronidazole at the critical breakpoint (16 microg/ml) was 6.3%. Although full resistance to vancomycin was not observed, the overall rate of intermediate resistance was 3.1%. One isolate had a combination of resistance to metronidazole and intermediate resistance to vancomycin. Rates of resistance to metronidazole and vancomycin were higher among isolates from human immunodeficiency virus-infected patients. Molecular typing methods proved the absence of clonality among the isolates with decreased susceptibilities to the antimicrobials tested.

Extra-intestinal infections caused by Clostridium difficile.

The objective of this paper was to investigate the incidence of extra-intestinal infections caused by Clostridium difficile. During a 10-year period, the microbiology laboratory of our institution isolated 2034 isolates of C. difficile. Of the 2034 isolates, 21 (1.08%) were obtained from extra-intestinal sources. This represents an incidence of extra-intestinal isolation of four cases per 100 000 admissions. We were able to review the records of 17 patients for our study. The isolates in 12 patients were obtained from structures or fluids anatomically close to the colon and included the following infections: peritonitis in five cases (three primary and two secondary), intra-abdominal abscesses in three patients and abdominal wound infections in four cases. The infections in the other five patients were not in the anatomic vicinity of the colon. They included one case with a brain abscess, two episodes of bacteremia and two cases of foot infections (one chronic osteomyelitis). In all but one case, C. difficile isolation was obtained as part of a polymicrobial flora. The isolates were frequently non-toxigenic and the extra-intestinal infections occurred without concomitant diarrhea or prior anti-microbial therapy. Out of the 17 patients, eight died and nine survived. Death could not be directly attributed to C. difficile in any of the cases. The isolation of C. difficile outside the intestinal tract is very uncommon. Its clinical significance should be interpreted with caution.

Feculent meningitis: polymicrobial meningitis in colorectal surgery.

Polymicrobial anaerobic meningitis is a rare event secondary to a contiguous infection in the head or neck. Anaerobic meningitis due to a meningo-intestinal fistula is a rare event with only two cases reported in the literature. We describe a new case of adult polymicrobial anaerobic meningitis after colorectal surgery and radiotherapy and review the previous two cases.

Differences in curable STDs between HIV and non-HIV populations in Spain.

The pandemic impact of HIV has changed the clinical spectrum of STDs all over the world. The incidence and frequency of STDs in the different global geographic areas demonstrate the diagnostic and treatment capabilities of various local and national health systems and is simultaneously informing about the sexual behaviours of the population. The purpose of this study was to determine the frequency of curable STDs (herpes, chlamydia, gonorrhoea, syphilis, trichomoniasis) in a hospital-based STD clinic in Madrid, Spain during a 4-year period. Patients were referred mainly from the emergency department, gynecological wards, and family planning (61%) as well as from the HIV-hospital unit (31 beds) and outpatient department (39%). The total number of patients seen was 952 (243 men, 709 women) with an annual average of 238 patients per year. Of these, 139 (14.6%) were HIV-patients and 813 (85.4%) non-HIV patients. In non-HIV patients, STDs were identified in 493 cases (54.2%). In HIV-patients, STDs were diagnosed in 108 cases (77.7%; p < or = 0.001). Two or more STDs were more prevalent in HIV than non-HIV patients. The frequency of STDs in both HIV and non-HIV patients were vulvovaginal candidiasis, 47.8%:57.2%; syphilis, 11.7%:1.4% (p < or = 0.05); gonorrhea, 5.3%:3.9%; Gardnerella vaginosis, 6.3%:4.8%; genital chlamydia, 6.3%:9.06%; trichomoniasis, 17%:6.5% (p < or = 0.05); and genital herpes, 20.2%:5.3% (p < or = 0.05).

[Cerebral abscess as a complication of chronic otitis media]. / Absceso cerebral como complicación de una otitis media crónica.

A case is reported of chronic otitis media and cholesteatoma in an adult patient with behavioral disorders who developed a pyogenic brain abscess. Initially, clinical management focused on the otogenic disease in view of the patient's symptoms and medical history. Finally, less easily recognized discriminating signs and symptoms, and the results of imaging studies were emphasized. These data confirmed the clinical diagnosis of pyogenic brain abscess secondary to cholesteatoma. The case illustrates how one of the most severe infective complications related with cholesteatoma may appear and its a remainder to clinicians to take this possibility into consideration.