La infección del tracto urinario en los servicios de medicina interna / Urinary tract infections in internal medicine

Objetivos. Análisis de las características de los pacientes ingresados en servicios de medicina interna (MI) con el diagnóstico de infección tracto urinario (ITU). Pacientes y métodos. Estudio transversal, descriptivo, retrospectivo de pacientes ingresados y diagnosticados de ITU en los informes de alta de diversos servicios de MI de nuestro país (1 de octubre al 31 de diciembre de 2007). Se registraron variables de filiación, factores de riesgo para ITU complicada, criterios diagnósticos, resultados microbiológicos y antibióticos utilizados. Resultados. Se reclutaron 992 pacientes (61,8% mujeres), de 57 hospitales, con edad media de 75,3 años. Procedían de residencia el 18,1%. Presentaban dependencia física el 53,5%. El 78,3% tenía algún factor de riesgo (diabetes mellitus 33,6%, sondaje vesical 24,1%). El tipo sindrómico de ITU más frecuente fue «ITU no especificada» (38,1%). En el 46% se llegó al diagnóstico exclusivamente por alteraciones del sedimento y/o urocultivo positivo. E. coli fue el patógeno más frecuente (64,17%), mostrando sensibilidad intermedia o resistente el 22,8% a amoxicilina-clavulánico, el 34,8 % a levofloxacino y el 40,6% a ciprofloxacino. La amoxicilina-clavulánico fue el antibiótico más utilizado (30,9%). La ITU demoró el alta en un 13,3% de los pacientes. La infección intrahospitalaria (23%) fue estadísticamente más frecuente en los pacientes sondados (50,5 vs 16,2%) y la mortalidad (3,4%) en mayores (81,2 vs 75,1 años), pacientes con P. aeruginosa (11,8 vs 4,1%) y en aquellos con sepsis urinaria (41,4 vs 16,2%). Conclusiones. Los pacientes dados de alta con ITU en los servicios de MI son de edad avanzada y frecuentemente presentan factores de riesgo. En excesivas ocasiones el diagnóstico se basa en criterios no específicos. E. coli es el patógeno más frecuente. Las quinolonas no deberían ser utilizadas en el tratamiento de primera línea en los pacientes con ITU complicada o grave, dado el alto porcentaje de resistencias(AU)

Objectives. Analysis of characteristics of patients in internal medicine (IM) hospital wards in Spain with the diagnosis of urinary tract infection (UTI). Patients and methods. Observational, descriptive, retrospective study of a population of inpatients with UTI diagnosis (October-December, 2007). Recorded variables included personal data, risk factors for complicated UTI, diagnosis criteria, microbiological results and antibiotics used. Results. A total of 992 patients (61.8% women), from 57 hospitals, were recruited. Mean age was 75.3 years old (SD 16.5), with 18.1% from nursing homes and with some physical dependence in 53.5%. The majority (78.3 %) had some risk factors (diabetes mellitus 33.6%, vesical catheterization 24.1%). Non-specific UTI was the most frequent diagnosis (38.1%). UTI was diagnosed in 46%, based exclusively on urinary sediment alterations and/or positive cultures. E. coli was the most frequent pathogen (64.17%), with intermediate sensitivity or resistance of 22.8% to amoxicillin-clavunanic, 34.8% to levofloxacin and 40.6% to ciprofloxacin. Amoxicillin-clavulanic was the most used antibiotic (30.9%). UTI delayed hospital discharge in a 13.3%. Intrahospital-UTI was statistically more frequent (23%) with vesical catheterization (50.5 vs 16.2%) and mortality (3.4%) in older patients (81.2 vs. 75.1 years old.), in patients with P. aeruginosa cultures (11.8 vs 4.1%) and in those with urinary sepsis (41.4 vs 16.2%). Conclusions. Patients in internal medicine wards with a UTI diagnosis are older and with risk factors. Frequently, UTI is diagnosed based on non-specific criteria. E. coli is the most frequent pathogen. Quinolones should not be the first-line treatment in complicated or severe UTI, due to the high percentages of resistance(AU)

[Urinary tract infections in internal medicine]. / La infección del tracto urinario en los servicios de medicina interna.

OBJECTIVES: Analysis of characteristics of patients in internal medicine (IM) hospital wards in Spain with the diagnosis of urinary tract infection (UTI). PATIENTS AND METHODS: Observational, descriptive, retrospective study of a population of inpatients with UTI diagnosis (October-December, 2007). Recorded variables included personal data, risk factors for complicated UTI, diagnosis criteria, microbiological results and antibiotics used. RESULTS: A total of 992 patients (61.8% women), from 57 hospitals, were recruited. Mean age was 75.3 years old (SD 16.5), with 18.1% from nursing homes and with some physical dependence in 53.5%. The majority (78.3 %) had some risk factors (diabetes mellitus 33.6%, vesical catheterization 24.1%). Non-specific UTI was the most frequent diagnosis (38.1%). UTI was diagnosed in 46%, based exclusively on urinary sediment alterations and/or positive cultures. E. coli was the most frequent pathogen (64.17%), with intermediate sensitivity or resistance of 22.8% to amoxicillin-clavunanic, 34.8% to levofloxacin and 40.6% to ciprofloxacin. Amoxicillin-clavulanic was the most used antibiotic (30.9%). UTI delayed hospital discharge in a 13.3%. Intrahospital-UTI was statistically more frequent (23%) with vesical catheterization (50.5 vs 16.2%) and mortality (3.4%) in older patients (81.2 vs. 75.1 years old.), in patients with P. aeruginosa cultures (11.8 vs 4.1%) and in those with urinary sepsis (41.4 vs 16.2%). CONCLUSIONS: Patients in internal medicine wards with a UTI diagnosis are older and with risk factors. Frequently, UTI is diagnosed based on non-specific criteria. E. coli is the most frequent pathogen. Quinolones should not be the first-line treatment in complicated or severe UTI, due to the high percentages of resistance.

[Analysis of population attended in a tuberculosis unit in Madrid. Evolution and impact of immigration from 1997 to 2006]. / Análisis de la población atendida en una unidad de tuberculosis en Madrid. Evolución e impacto de la inmigración desde 1997 a 2006.

BACKGROUND: In Spain there is a high prevalence of tuberculosis (TB). The aim of this study is to describe population attended in an Isolation Unit, analysing the changes that have occurred in 10 years, the impact of immigration and factors that may condition the loss of following. PATIENTS AND METHODS: Descriptive study of all patients admitted to the Isolation Unit of Hospital Cantoblanco-La Paz from 1997 to 2006. Univariate analysis and multiple logistic regression analysis were performed. RESULTS: 832 patients were studied, 69.4% men, with a mean age of 40.8 years 37.5% immigrants. In new cases, resistance to isoniazid was documented in 6.7% and multidrug resistance in 3.1%, and in previously treated cases, in 11.2% and 8.4%, respectively. Treatment was completed by 74.1%, 17.5% were lost, which was associated with drugs consumption (OR 3.01; CL 95% 1.18-3.41), being immigrant (OR 2.14; CL 95% 1.42-3.21) and HIV infection (OR 1.96; CL 95% 1.18-3.41). In the 10 years, percentage of immigrants and patients who proceeded from the Emergency Departments increased and results improved, while HIV infection and loss of following reduced. CONCLUSIONS: Profile of patient with TB has changed in last years in association with immigration. In spite of better results, more actions are needed in order to improve the adherence and epidemiologic control of the disease. (c) 2009 Elsevier España, S.L. All rights reserved.

Risk factors for multidrug-resistant tuberculosis in a tuberculosis unit in Madrid, Spain.

The setting for this retrospective cohort study was a specialised tuberculosis unit in Madrid, Spain. The objective was to describe the risk factors for multidrug-resistant tuberculosis (MDR-TB). The medical records of all patients admitted to the unit were reviewed retrospectively to identify factors associated with multidrug resistance. Patients with positive culture for M. tuberculosis and with available drug-susceptibility tests were included. The variables assessed were age, gender, country of origin, homelessness, alcohol consumption, intravenous drug use, methadone substitution therapy, contact with a tuberculosis patient, sputum smear, site of disease, previous tuberculosis treatment, HIV infection, history of imprisonment, diabetes mellitus and chronic obstructive pulmonary disease. Thirty patients with MDR-TB and 666 patients with non-MDR-TB were included from the years 1997 to 2006. The only factors associated with MDR-TB in multivariate analysis were previous tuberculosis treatment (OR: 3.44; 95% CI: 1.58-7.50; p = 0.003), age group 45-64 years (OR: 3.24; 95% CI: 1.34-7.81; p = 0.009) and alcohol abuse (OR: 0.12; 95% CI: 0.03 to 0.55; p = 0.003). In our study, patients who had had previous treatment for tuberculosis, who were 45-64 years of age or who had no history of alcohol abuse were more likely to have MDR-TB.

Utilización de heparinas de bajo peso molecular en pacientes hospitalizados en Medicina Interna / Use of low molecular heparins in inpatients of Internal Medicine

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Risk of lipodystrophy in HIV-1-infected patients treated with protease inhibitors: a prospective cohort study.

BACKGROUND: Risk factors for lipodystrophy in patients infected with HIV-1 treated with highly active antiretroviral therapy (HAART) containing HIV-1 protease inhibitors are poorly understood. We aimed to identify the risk factors for lipodystrophy in antiretroviral-naive HIV-1-infected adults on HAART. METHODS: Moderate or severe body-fat changes were clinically assessed and categorised as subcutaneous lipoatrophy, central obesity, or both, in all consecutive antiretroviral-naïve HIV-1-infected adults who began HAART with two nucleoside reverse transcriptase inhibitors plus at least one protease inhibitor from October, 1996, to September, 1999. A person-years analysis was used to calculate the incidence of types of lipodystrophy, and Cox proportional hazards models were used to describe the univariate and multivariate factors associated with progression to any lipodystrophy. FINDINGS: After a median follow-up of 18 months, 85 (17%) of the 494 patients developed some type of lipodystrophy. The incidences of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and lipodystrophy with central obesity were 11.7 (95% CI 9.2-14.2), 9.2 (7.0-11.4), and 7.7 (5.7-9.7) per 100 patient-years. An increased risk for any lipodystrophy was found among women as compared with men (relative hazard 1.87 [1.07-3.28]), heterosexuals (2.86 [1.50-5.48]), and homosexuals (2.17 [1.07-4.42]) as compared with intravenous drug users, with increasing age (1.33 per 10 years older [1.08-1.62]), and with the duration of exposure to antiretroviral therapy (1.57 per 6 months extra [1.30-1.88]) but not with any individual antiretroviral agent. The factors associated with an increased risk for lipodystrophy with subcutaneous lipoatrophy or lipodystrophy with central obesity were very similar to those associated with any lipodystrophy. The duration of indinavir use may represent an additional contribution for the development of lipodystrophy with central obesity (1.26 per 6 months extra [0.99-1.60]); p=0.064). INTERPRETATION: Risk factors associated with development of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and tipodystrophy with central obesity in patients infected with HIV-1 who were receiving HAART containing protease inhibitors are multifactorial and overlapping, and cannot be exclusively ascribed to the duration of exposure to an particular antiretroviral agent.

Hepatotoxicity in HIV-1-infected patients receiving nevirapine-containing antiretroviral therapy.

OBJECTIVES: To assess the incidence and risk factors for hepatotoxicity associated with nevirapine. DESIGN: A prospective cohort study in a teaching and referral hospital involving all consecutive patients who were prescribed a nevirapine-containing antiretroviral regimen between September 1997 and May 2000. METHOD: Cutaneous and hepatic adverse reactions and clinical hepatitis were assessed. Blood analysis including plasma HIV-1 RNA CD4 cell counts, liver chemistry tests, and serology for hepatitis B and C viruses. Hepatotoxicity was defined as an increase of at least threefold in serum alanine aminotransferase or aspartate aminotransferase levels compared with baseline values. RESULTS: Of a total of 610 patients, 82 (13.4%) were antiretroviral naive when commencing nevirapine, and 46.2 and 8.9% were coinfected with hepatitis C and B viruses, respectively. Median duration of exposure to nevirapine was 8.7 months (interquartile range 3.4--14.3). Hepatotoxicity developed in 76 (12.5%), an incidence of 13.1/100 person-years. Kaplan--Meier estimated incidence of hepatotoxicity at 3, 6 and 12 months was 3.7, 9.7 and 20.1%, respectively. In seven (1.1%) patients, hepatotoxicity was associated with clinical hepatitis, which was reversible upon discontinuation of therapy. Multivariate analysis identified the duration of prior exposure to antiretroviral drugs, hepatitis C virus, and higher baseline levels of alanine aminotransferase as independent risk factors for hepatotoxicity. CONCLUSIONS: Hepatotoxicity but not clinical hepatitis was common in HIV-1-infected patients receiving nevirapine-containing regimens and the incidence steadily increased over time. Prolonged exposure to any antiretroviral therapy, coinfection with hepatitis C virus and abnormal baseline levels of alanine aminotransferase identified patients at a higher risk.

Lipodystrophy syndrome in patients with HIV infection: quality of life issues.

Current antiretroviral therapy has lead to longer survival in patients infected with HIV, but it is also associated with new and important problems. Body fat redistribution and metabolic abnormalities, the so-called lipodystrophy syndrome, are among the most prevalent and worrisome ones. While an increasing number of patients infected with HIV are becoming affected by this syndrome, the pathogenesis of this syndrome and how to prevent and treat the problem all remain largely unknown. Body fat changes stigmatise the bodies of patients infected with HIV giving them a similar look to that seen in patients some years ago when the wasting syndrome was more prevalent and HIV infection was ultimately fatal. The psychological impact of body fat changes may be severe enough to affect a patients' desire to continue with antiretroviral therapy. Metabolic abnormalities, probably with the exception of symptomatic diabetes mellitus and hypertriglyceridaemia-induced pancreatitis, do not have an immediate impact on the quality of the lives of patients with HIV. However, their potential long term cardiovascular and bone consequences may increase the morbidity and the mortality of patients infected with HIV through noninfectious diseases. The impact of lipodystrophy on patients infected with HIV is not readily captured with the classic instruments used to measure quality of life and hence it is necessary to modify them urgently. Though treating lipodystrophy seems fully justified, there is no proven treatment for this problem, although a number of treatments have been used with varying success. Despite the recognition that lipodystrophy may have important psychological repercussions, the best psychological approach for this problem is not known at present. Although lipodystrophy has its own peculiarities, existing knowledge about how to psychologically help other patients with deforming body changes might be of help for patients infected with HIV, or at least may act as a starting point.

Strategies for treating HIV-related lipodystrophy.

HIV-related lipodystrophy has emerged as one of the most prevalent problems for patients with HIV, since this infection can now be seen as a chronic disease. Despite its growing importance, crucial issues such as aetiopathogenesis, diagnosis, prevention and therapy remain largely unknown and unexplored. Current evidence suggests that aetiology is multifactorial. HIV infection, antiretroviral therapy and patient-related factors probably all contribute to the development of lipodystrophy. The lack of a formal definition and the nature of wasting syndromes that affect HIV-infected patients can hinder the diagnosis and treatment of lipodystrophy. Body fat changes have a major negative impact on the quality of life of patients. Metabolic abnormalities are also well known cardiovascular risk factors that can increase the morbidity and mortality due to cardiovascular disorders in a relatively young population. As yet, we do not know whether lipodystrophy is preventable or reversible. Several therapeutic approaches have been tested with limited success, however potential complications must be considered. These therapeutic approaches include general health measures (diet, exercise and discontinuation of smoking), switching antiretrovirals (from protease inhibitors to non-nucleoside reverse transcriptase inhibitors or abacavir, or from stavudine to other nucleoside reverse transcriptase inhibitors) and use of drugs with metabolic effects (metformin, thiazolidinediones, recombinant growth hormone and anabolic steroids). A judicious use of available data, and opting for an individualised approach seems the best option for management of this problem at present.

Dose-finding study of once-daily indinavir/ritonavir plus zidovudine and lamivudine in HIV-infected patients.

BACKGROUND: Strategies for treatment of HIV need to be considered in terms of combining potency, safety, and convenience of dosage. However, regimens including once-daily protease inhibitors are not yet available. We have performed a pilot study to determine an indinavir/ritonavir (IND/RTV) regimen for once-daily dosing, by monitoring plasma levels. METHODS: Antiretroviral-naive HIV-infected adults were eligible. Therapy was zidovudine/lamivudine 1 pill twice daily plus IND/RIT (liquid formulation) 800/100 mg twice daily with food. At 4-week intervals, plasma levels were measured and dosage of IND/RIT switched to 1000/100 mg daily and then 800/200 mg daily. If 12-hour minimum concentrations (Cmin12h) of IND were too low (<0.1 microg/ml) with IND/RIT 1000/100 mg once daily in the first half of the patients, it was planned to switch directly to 800/200 mg once daily in the other half. RESULTS: In all, 27 patients were recruited. Mean baseline CD4+ lymphocyte count was 107 x 106/L (range, 4-623 x 106/L). Eleven patients (40%) discontinued the study medication within the first 4 weeks due to clinical progression (n = 3) or grade 1-2 RTV related side effects (n = 8). Nine patients (group A) switched from 800/100 mg twice daily to 1000/100 mg once daily and then to 800/200 mg once daily. Seven patients (group B) switched directly to 800/200 mg once daily. At week 32, viral load was <5 copies/ml in 15 of 16 patients (94%). RTV levels were always <2.1 microg/ml. The mean and 95% confidence interval for IND Cmin and Cmax in microg/ml was: using IND/RTV 800/100 mg twice daily (n = 16) 1.4 (0.5-2.3) and 6.7 (4.4-9.1), respectively; using IND/RTV 1000/100 mg once daily (n = 9) 0.18 (0-0.41) and 8.6 (3.3-14), respectively; and using 800/200 mg once daily (n = 16) 0.38 (0-0.9), and 7.5 (0.8-14.8). For all 16 patients who received IND/RTV 800/100 mg twice daily, the Cmin value for IND was >/=0.1 microg/ml. Conversely, IND Cmin was <0.1 microg/ml in 4 of 9 receiving 1000/100 mg once daily but in only 1 of 16 receiving 800/200 mg once daily. CONCLUSION: Once-daily regimen of IND/RIT is feasible and deserves further evaluation in larger randomized trials. Liquid formulation of RIT was not well tolerated by our antiretroviral-naive patients despite lower than suggested doses.

Impact of switching from human immunodeficiency virus type 1 protease inhibitors to efavirenz in successfully treated adults with lipodystrophy.

We prospectively followed 20 consecutive patients with human immunodeficiency virus type 1 (HIV-1) with viral loads of <200 RNA copies/mL. These patients had been treated with 2 nucleoside reverse transcriptase inhibitors and > or =1 HIV-1 protease inhibitor for > or =3 months; they developed body changes consistent with lipodystrophy and requested they be switched from protease inhibitor to efavirenz. At baseline and every 3 months, we assessed the following: body mass index, waist-to-hip ratio, regional fat thickness (assessed by sonography), fasting total and high-density lipoprotein cholesterol, triglycerides, glucose, insulin, CD4(+) cells, and viral load. At baseline, hypertriglyceridemia (> or =200 mg/dL) was present in 17 (85%) patients, hypercholesterolemia (> or =200 mg/dL) in 14 (70%), and impaired fasting glucose (> or =110 mg/dL) in 8 (40%); CD4(+) T cells were 280x10(6) cells/L (range, 64-942x10(6) cells/L). HIV-1 RNA had been at <200 copies/mL for a median of 14 months (range, 3-24 months). Six months after switching to efavirenz, there was a reduction in triglyceride levels (a decrease of 31%; P=.03) and fasting insulin resistance index (a decrease of 28%; P=.03), but total and high-density lipoprotein cholesterol and glucose did not change. Waist-to-hip ratio decreased from 0.92 to 0.87 (P=.06). Subcutaneous fat thickness did not change. CD4(+) cells remained stable (363x10(6) cells/L; range, 102-741x10(6) cells/L; P=.65). Nineteen patients (95%) had HIV-1 RNA levels that remained at <200 copies/mL. Although CD4(+) response and viral suppression remained preserved after 6 months of switching from protease inhibitor to efavirenz, the benefits of this approach on the evolution of lipodystrophy were limited, and our findings do not support its routine recommendation to treat lipodystrophy.

Sonographic assessment of regional fat in HIV-1-infected people.

The routine clinical assessment of lipodystrophy in HIV-1-infected patients is hindered by the absence of easy and reliable methods to measure regional fat. We used sonography to measure subcutaneous fat thickness at three reference skin points (periumbilical, brachial, and malar) and intra-abdominal fat thickness in HIV-1-infected patients with and without lipodystrophy and in healthy controls. Patients without lipodystrophy had less subcutaneous fat than uninfected controls. Sonographic assessment of subcutaneous malar and brachial fat in patients with lipodystrophy was more sensitive and specific than that of intra-abdominal fat in the diagnosis of abnormal fat distribution.

Diagnosis of X-adrenoleucodystrophy phenotypic variants.

We report the radiological and biochemical data of a familial X-adrenoleucodystrophy with an extreme phenotypic variability, in which the diagnosis of several affected members was delayed for several years. The propositus developed a progressive dementia, while two of his brothers were diagnosed of primary Addison's disease several years previously. MRI in two cases with different phenotypes revealed hyperintense diffuse white matter lesions, and the diagnosis was confirmed by increased serum levels of very long chain fatty acids. We conclude that X-adrenoleucodystrophy should be included in the differential diagnosis of adult Addison's disease even though no neurological involvement or family history is recorded, and that MRI is a useful tool for diagnosis and follow-up of neurological involvement in this disease.