Lipids, biomarkers, and subclinical atherosclerosis in treatment-naive HIV patients starting or not starting antiretroviral therapy: Comparison with a healthy control group in a 2-year prospective study.

OBJECTIVE: To assess the effect of HIV infection and combined antiretroviral therapy (c-ART) on various proatherogenic biomarkers and lipids and to investigate their relationship with subclinical atherosclerosis in a cohort of treatment-naive HIV-infected patients. METHODS: We performed a prospective, comparative, multicenter study of 2 groups of treatment-naive HIV-infected patients (group A, CD4>500 cells/µL, not starting c-ART; and group B, CD4<500 cells/µL, starting c-ART at baseline) and a healthy control group. Laboratory analyses and carotid ultrasound were performed at baseline and at months 12 and 24. The parameters measured were low-density lipoprotein (LDL) particle phenotype, lipoprotein-associated phospholipase A2 (Lp-PLA2), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), sCD14, sCD163, monocyte chemoattractant protein-1(MCP-1), and asymmetric dimethylarginine (ADMA). A linear mixed model based on patient clusters was used to assess differences in biomarkers between the study groups and over time. RESULTS: The study population comprised 62 HIV-infected patients (group A, n = 31; group B, n = 31) and 22 controls. Age was 37 (30-43) years, and 81% were men. At baseline, the HIV-infected patients had a worse LDL particle phenotype and higher plasma concentration of sCD14, sCD163, hs-CRP, and LDL-Lp-PLA2 than the controls. At month 12, there was an increase in total cholesterol (p = 0.002), HDL-c (p = 0.003), and Apo A-I (p = 0.049) and a decrease in sCD14 (p = <0.001) and sCD163 (p<0.001), although only in group B. LDL particle size increased in group B at month 24 (p = 0.038). No changes were observed in group A or in the healthy controls. Common carotid intima-media thickness increased in HIV-infected patients at month 24 (Group A p = 0.053; group B p = 0.048). Plasma levels of sCD14, sCD163, and hs-CRP correlated with lipid values. CONCLUSIONS: In treatment-naive HIV-infected patients, initiation of c-ART was associated with an improvement in LDL particle phenotype and inflammatory/immune biomarkers, reaching values similar to those of the controls. HIV infection was associated with progression of carotid intima-media thickness.

Infecciones nosocomiales. Evaluación de los objetivos del Plan de Salud de Cataluña para el año 2000 / Nosocomial infections. Evaluation of the objectives of the Health Plan for Catalonia for the year 2000

Fundamento y objetivos: Las infecciones nosocomiales (IN) fueron uno de los problemas prioritarios de salud incluidos en el Plan de Salud de Cataluña en 1991, y para el que se fijaron cinco objetivos a conseguir en el conjunto de hospitales de Cataluña hasta el año 2000, considerando el año 1990 como base de referencia. Cuatro de los objetivos eran de disminución de la prevalencia: la prevalencia global de IN y de infectados, por lo menos en un 15%; la de infectados en el área de atención intensiva, por lo menos en un 10%; en el área de cirugía, por lo menos en un 20%, y el quinto objetivo, situar la prevalencia en cirugía limpia por debajo del 3%. El objetivo del presente trabajo es evaluar hasta qué punto se han alcanzado estos objetivos. Población y método: La evaluación se ha realizado mediante el análisis de los datos proporcionados por el estudio de prevalencia de las IN (EPINCAT) desarrollado anualmente con carácter voluntario por un grupo de hospitales. Resultados: La prevalencia de IN disminuyó desde el 10,4% en 1990 hasta el 8,1% en el año 2000, y la de pacientes con IN desde un 9,2 hasta un 7,0%, y los dos primeros objetivos se alcanzaron ya en los primeros años de ejecución del plan. En atención intensiva la prevalencia cruda de IN no ha disminuido, aunque al estandarizar según las características de los pacientes estudiados en 1990 la prevalencia es inferior a la prevista. En cuidados intensivos se ha observado un aumento de la gravedad de los pacientes ingresados y de la proporción que recibe procedimientos asistenciales. La prevalencia en el área de cirugía descendió del 7,0 al 4,3%, y el objetivo propuesto se alcanzó en los primeros años del plan. El objetivo de reducción en cirugía limpia se alcanzó ya en 1992. Conclusiones: Según el plan de salud, en el período 1990-2000 la prevalencia de IN ha disminuido en los hospitales de Cataluña. El plan ha demostrado ser una buena herramienta para dinamizar y orientar las actividades dedicadas a la prevención y control de las infecciones nosocomiales en Cataluña (AU)

Background and objectives: Nosocomial infections (NI) were one of the priority health problems included in the Framework Document for the Development of the Health Plan for Catalonia for the year 2000 which was written in 1991. Considering 1990 as reference date, five objectives to achieve in 2000 by Catalonian hospitals were fixed. Four of them were prevalence-reduction aims: 15% reduction of overall prevalence, 15% reduction of infected patients prevalence, 10% reduction of infected patients at intensive care units prevalence, and 20% reduction of infected ones at surgical areas prevalence. The last objective was to diminish clean surgery infection prevalence under 3%. The main purpose of this paper will be to evaluate whether this objectives have been completely accomplished. Subjects and method: Data from the Study of Nosocomial Infections Prevalence were analized. Results: NI overall prevalence decrease from 10.4% in 1990 to 8.1% in 2000. Infected patient prevalence also diminished from 9.2% to 7.0%. Both objectives were achieved in the early stages of the study period. The intensive care units infection crude prevalence have not decreased. However the prevalence is lower than expected when it is standardized for specific 1990 patients variables. Surgical area infection prevalence sunk from 7.0% to 4.3%. The clean surgery objective was achieved in 1992. Conclusions: NI prevalence has decreased in Catalonian hospitals between 1990 and 2000 according to Catalonian Health Plan. The plan constitutes a good tool in order to dinamize and orient prevent activities related to control NI in Catalonia (AU)

Substitution of nevirapine, efavirenz, or abacavir for protease inhibitors in patients with human immunodeficiency virus infection.

BACKGROUND: We assessed the strategy of substituting nevirapine, efavirenz, or abacavir for a protease inhibitor in patients infected with human immunodeficiency virus type 1 (HIV-1) in whom virologic suppression had been achieved. METHODS: We randomly assigned 460 adults who were taking two nucleoside reverse-transcriptase inhibitors and at least one protease inhibitor and whose plasma HIV-1 RNA levels had been less than 200 copies per milliliter for at least the previous six months to switch from the protease inhibitor to nevirapine (155 patients), efavirenz (156), or abacavir (149). The primary end point was death, progression to the acquired immunodeficiency syndrome, or an increase in HIV-1 RNA levels to 200 copies or more per milliliter. RESULTS: At 12 months, the Kaplan-Meier estimates of the likelihood of reaching the end point were 10 percent in the nevirapine group, 6 percent in the efavirenz group, and 13 percent in the abacavir group (P=0.10 according to an intention-to-treat analysis). HIV-1 RNA could be amplified in 21 of the 29 patients in whom virologic failure developed during treatment with study medication (72 percent), and resistance mutations to the study medication and to at least one of the nucleoside reverse-transcriptase inhibitors in the regimen that failed were detected in all but 1 of the 21 patients. Twenty-three of the 29 patients with virologic failure during treatment with study medication had received prior suboptimal therapy with nucleoside reverse-transcriptase inhibitors. Fewer patients in the abacavir group (6 percent) than in the nevirapine group (17 percent) or the efavirenz group (17 percent) discontinued the study medication because of adverse events (P=0.01). The proportion of patients with fasting lipid levels warranting therapeutic intervention decreased significantly in the abacavir group, but the prevalence of clinical lipodystrophy did not change significantly in the three groups. CONCLUSIONS: When therapy was switched from a protease inhibitor to nevirapine, efavirenz, or abacavir in patients with virologic suppression, there was a trend toward a higher rate of virologic failure among those given abacavir.

[Bacteremia due to Escherichia coli: epidemiological analysis and sensitivity to antibiotics in a county hospital]. / Bacteriemia por Escherichia coli: análisis epidemiológico y de la sensibilidad a los antibióticos en un hospital comarcal.

BACKGROUND AND OBJECTIVE: There are few studies analyzing the epidemiological characteristics of Escherichia coli bacteremia including the susceptibility to antibiotics and outcome. PATIENTS AND METHOD: E. coli bacteremia episodes were recorded from January 1989 to December 1998. Clinical variables, setting acquisition, source of bacteremia, outcome and susceptibility to antibiotics were included. The study was prospective and comparative. Descriptive and univariate analysis were performed. RESULTS: 330 episodes of E. coli bacteremia were recorded: 117 in women. The most frequent source was the urinary tract (68%), followed by an abdominal and biliary focus. E. coli bacteremia appeared mostly in groups II and III of McCabe & Jackson. In 46 cases (14%), E. coli bacteremia was nosocomial. Crude and related mortality was 6.6 and 4.2%, respectively. A significant increase in the resistance to ciprofloxacin was observed. CONCLUSIONS: The epidemiological characteristics of E. coli bacteremia have not changed, yet the mortality was lower in our series. Preventive measures in the hospital and a rational use of antibiotics, principally quinolones, are necessary.

Bacteriemia por Escherichia coli: análisis epidemiológico y de la sensibilidad a los antibióticos en un hospital comarcal / Bacteremia due to Escherichia coli: epidemiological analysis and sensitivity to antibiotics in a county hospital

FUNDAMENTO Y OBJETIVO: En España los estudios epidemiológicos de la bacteriemia por Escherichia coli que incluyan la evolución de la sensibilidad antibiótica de las cepas aisladas de los hemocultivos son escasos. PACIENTES Y MÉTODO: Desde enero de 1989 a diciembre de 1998 se recogieron los episodios de bacteriemia por E. coli. Se incluyeron variables clínicas, el lugar de adquisición, el origen, la evolución de los pacientes y la sensibilidad a los antibióticos. El estudio fue prospectivo, comparativo y se realizó un análisis descriptivo y univariante. RESULTADOS: Se analizaron 330 episodios consecutivos de bacteriemia por E. coli, de las cuales 177 ocurrieron en mujeres. El origen más frecuente fue el urinario (68 per cent), seguido por el abdominal y biliar. La bacteriemia por E. coli apareció mayoritariamente en pacientes de los grupos II y III de McCabe y Jackson. En 46 casos (14 per cent) la adquisición fue nosocomial. La mortalidad global y la relacionada fueron del 6,6 y el 4,2 per cent, respectivamente. Se observó un incremento significativo de la resistencia al ciprofloxacino. CONCLUSIONES: Las características epidemiológicas de la bacteriemia por E. coli no difieren de las conocidas, si bien la mortalidad en nuestro estudio fue inferior a la de otras series. Nuestros resultados corroboran la necesidad de adoptar medidas preventivas en el medio hospitalario y de racionalizar el consumo global de antibióticos y en especial de quinolonas (AU)

Bacteriemia en pacientes dados de alta desde el servicio de urgencias / Bacteremia in patients discharged from the emergency unit

FUNDAMENTO: Conocer las características clínicas y epidemiológicas, la evolución y la tasa de tratamiento antibiótico empírico correcto en pacientes adultos a quienes se detecta bacteriemia tras ser dados de alta del servicio de urgencias. PACIENTES Y MÉTODO: Durante 10 años (19891998) se recogieron los datos clínicos y epidemiológicos más relevantes de los pacientes con bacteriemia, y los resultados se compararon con los de los pacientes con bacteriemia comunitaria que ingresaron. RESULTADOS: Se analizó a 85 pacientes (52 varones). El 45 por ciento tenía más de 70 años. Representaron el 13,9 por ciento de las bacteriemias comunitarias detectadas en el mismo período. El origen más frecuente fue el urinario (69 por ciento), seguido por el desconocido (12 por ciento). En el 62 por ciento de los pacientes se aisló Escherichia coli. En 16 casos el tratamiento se consideró incorrecto. Tres pacientes fallecieron. CONCLUSIONES: Un número no despreciable de pacientes con bacteriemia son dados de alta desde el servicio de urgencias, un 21 por ciento de ellos con tratamiento incorrecto. La evolución fatal es rara, pero en algún caso evitable (AU)