Adrenal insufficiency and exogenous Cushing's syndrome in a patient receiving inhaled fluticasone and ritonavir / Insuficiencia adrenal y exógenos en un paciente con síndrome de down que recibe fluticasona inhalada y ritonavir

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[Bacteremia in very elderly patients: risk factors, clinical characteristics and mortality]. / Bacteriemia en pacientes muy ancianos: factores de riesgo, características clínicas y mortalidad.

INTRODUCTION: There is little information on bacteremia in very elderly patients. This study describes the characteristics of bacteremia in this population. METHODS: This is a prospective study investigating bacteremia episodes in patients over 80 years old in comparison with episodes in patients aged 18-64 and 65-79 years. RESULTS: A total of 146 bacteremia episodes were analyzed in patients over 80 years old. Comorbidity was documented in 66.4% and immunodeficiency in 6.8% of patients. Among the total, 82.2% had no underlying disease or a disease considered non-fatal. Eighty episodes were community-acquired. The main infectious foci included primary (25.3%) and urinary tract (20.5%) infection, and the most frequent isolates were Escherichia coli (28.2%), coagulase-negative Staphylococcus (14.7%) and S. aureus (13.6%). Sepsis or septic shock occurred in 55.5% of the cases, and 31 patients died due to a bacteremia-related cause. Immunodeficiency was less frequent in patients over 80 years old, but they had a higher proportion of community-acquired infections and gram-negative infections. Bacteremia-related mortality was highest in the oldest group of patients and was associated with a fatal or ultimately fatal underlying disease, S. aureus infection, and inappropriate empirical antibiotic treatment. A lower Pitt severity score was related to lower mortality risk. CONCLUSIONS: Very elderly bacteremic patients showed a lower frequency of immunodeficiency, a higher percentage of community-acquired and gram-negative infections. Bacteremia-related mortality was greater in the most elderly group and was associated with fatal or ultimately fatal underlying disease, S. aureus infection and initiation of inappropriate empirical antibiotic treatment.

Bacteriemia en pacientes muy ancianos: factores de riesgo, características clínicas y mortalidad / Bacteremia in very elderly patients: risk factors, clinical characteristics and mortality

Introducción. Existe poca información sobre bacteriemias en pacientes muy ancianos. El objetivo del trabajo fue describir las características de éstas en esta población. Métodos. Estudio prospectivo de las bacteriemias en pacientes mayores de 80 años y comparación con pacientes de 18-64 y de 65-79 años. Resultados. Se analizaron 146 bacteriemias en pacientes mayores de 80 años. En el 66,4% hubo alguna comorbilidad y en el 6,8%, alguna causa de inmunodeficiencia. El 82,2% no tenía enfermedad de base o ésta no fue fatal. El origen fue comunitario en 80 casos. Los principales focos fueron: primario (25,3%) y urinario (20,5%); y los aislamientos más frecuentes: Escherichia coli (28,2%), Staphylococcus coagulasa negativos (14,7%) y Staphylococcus aureus (13,6%). Presentaron sepsis o shock séptico el 55,5%, y fallecieron 31 en relación con la bacteriemia. Los pacientes mayores de 80 años tuvieron menos frecuencia de inmunodeficiencia y mayor proporción de infecciones comunitarias y por gramnegativos. La mortalidad relacionada con la bacteriemia fue mayor en el grupo de más edad y se asoció con la presencia de una enfermedad de base fatal o finalmente fatal, la bacteriemia por S. aureus y con el inicio de un tratamiento empírico inapropiado. Un índice de gravedad de Pitt más bajo se mostró como una variable protectora. Conclusiones. Los pacientes muy ancianos con bacteriemia tienden a presentar menos causas de inmunodeficiencia, mayor frecuencia de infecciones comunitarias y por gérmenes gramnegativos. Existe mayor riesgo de mortalidad relacionada, sobre todo en presencia de enfermedad de base, bacteriemia por S. aureus o tras un tratamiento empírico inapropiado (AU)

Introduction. There is little information on bacteremia in very elderly patients. This study describes the characteristics of bacteremia in this population. Methods. This is a prospective study investigating bacteremia episodes in patients over 80 years old in comparison with episodes in patients aged 18-64 and 65-79 years. Results. A total of 146 bacteremia episodes were analyzed in patients over 80 years old. Comorbidity was documented in 66.4% and immunodeficiency in 6.8% of patients. Among the total, 82.2% had no underlying disease or a disease considered non-fatal. Eighty episodes were community-acquired. The main infectious foci included primary (25.3%) and urinary tract (20.5%) infection, and the most frequent isolates were Escherichia coli (28.2%), coagulase-negative Staphylococcus (14.7%) and S. aureus (13.6%). Sepsis or septic shock occurred in 55.5% of the cases, and 31 patients died due to a bacteremia-related cause. Immunodeficiency was less frequent in patients over 80 years old, but they had a higher proportion of community-acquired infections and gram-negative infections. Bacteremia-related mortality was highest in the oldest group of patients and was associated with a fatal or ultimately fatal underlying disease, S. aureus infection, and inappropriate empirical antibiotic treatment. A lower Pitt severity score was related to lower mortality risk. Conclusions. Very elderly bacteremic patients showed a lower frequency of immunodeficiency, a higher percentage of community-acquired and gram-negative infections. Bacteremia-related mortality was greater in the most elderly group and was associated with fatal or ultimately fatal underlying disease, S. aureus infection and initiation of inappropriate empirical antibiotic treatment (AU)

Effects of escin on indinavir crystallization time in the urine of patients with HIV-I infection: a multicenter, randomized, open-label, controlled, four-period crossover trial.

BACKGROUND: The combination of indinavir, a protease inhibitor, and reverse-transcriptase inhibitors is widely used in the treatment of HIV-1 infection. However, precipitation of indinavir crystals in the renal tubular lumen due to the drug's aqueous insolubility may result in characteristic symptoms of flank pain or classic renal colic. An in vitro study has shown that addition of escin to synthetic urine containing indinavir delayed the crystallization time of indinavir. OBJECTIVE: This study examined the efficacy and tolerability of the addition of escin to highly active antiretroviral therapy containing indinavir to delay the crystallization time of indinavir in urine. METHODS: This was a multicenter, randomized, open-label, controlled, 4-period crossover trial in which each period lasted 4 weeks. HIV-1-infected adults receiving treatment with indinavir plus 2 nucleoside analogue reverse-transcriptase inhibitors in whom plasma viral loads had been undetectable (HIV-1 RNA <200 copies/mL) for at least 6 months were randomly assigned to 1 of 2 groups based on the timing of the initiation of escin. Group I received escin during the second and third treatment periods, and group II received escin during the first and fourth treatment periods. The primary end point was the in vitro crystallization time of indinavir in 24-hour urine specimens, determined at the end of each 4-week period. Tolerability was assessed based on the number of patients with a rebound in plasma viral load and on the numbers of clinically and biologically relevant adverse events (including those requiring discontinuation of treatment). Clinical and laboratory evaluations were performed throughout each 4-week period. RESULTS: Fifty HIV-1-infected patients were enrolled, 47 were randomized to treatment (40 [85.1%] men, 7 [14.9%] women; median [interquartile range] age, 36 [34-45] years), and 30 completed the study. Urine pH and plasma and urine indinavir concentrations were unaffected by the addition of escin to antiretroviral treatment. The mean time to the onset of crystallization was 14.7 minutes with escin (95% Cl, 11.8-17.5) and 9.9 minutes without it (95% Cl, 6.7-13.1). Therefore, the addition of escin increased the mean crystallization time by 5.5 minutes (95% Cl, 1.5-9.5; P = 0.008), representing the overall capacity of study treatment to inhibit indinavir crystallization in the urine. Three of 47 patients had mild gastrointestinal symptoms associated with escin treatment. No episodes of nephrolithiasis were recorded during the study or after the completion of study treatment. CONCLUSION: The results of this prospective clinical trial of the effect of escin on indinavir crystallization time support the possibility that indinavir-associated nephrolithiasis may be prevented by means other than overhydration. Further research is needed in greater numbers of patients over longer follow-up times.