What do beta-lactams add to vancomycin or daptomycin in the treatment of patients with methicillin-resistant Staphylococcus aureus bacteraemia? A review.

Several studies have documented the synergy between vancomycin/daptomycin and various beta-lactams, and clinical studies have studied this combination therapy in humans. We review the published literature on this topic to know the utility of the combined treatment with beta-lactams in treating bacteraemia methicillin-resistant Staphylococcus aureus (MRSA) infections. Fifteen observational studies, three randomised clinical trials and three systematics reviews are analysed in this article. Observational studies used ceftaroline, cefazolin, piperacillin/tazobactam or cefepime among the beta-lactams. Clinical trials used cloxacillin or flucloxacillin as the most used beta-lactam in two trials and ceftaroline in one. Three systematic reviews are published. One of them only includes studies with vancomycin and included six studies. The other two systematic reviews include patients with daptomycin or vancomycin and included 15 and 9 studies, respectively. Adding a beta-lactam to vancomycin or daptomycin may help shorten bacteraemia and avoid recurrences in patients with MRSA bacteraemia. There is no evidence that combined therapy improves mortality. Nephrotoxicity in clinical trials precludes the use of combination therapy mainly with cloxacillin or flucloxacillin, but systematic reviews have not found a significant difference in this point in observational studies with other beta-lactams. The role of other beta-lactams such as ceftaroline should be thoroughly studied in these patients.

Current Evidence on the Antimicrobial Treatment and Chemoprophylaxis of Human Leptospirosis: A Meta-Analysis.

BACKGROUND: Leptospirosis is a worldwide zoonotic infection, and its management needs to be refined. This study aims to discern which antibiotic would be the best option to treat leptospirosis disease and analyze the efficacy of chemoprophylaxis regimens to prevent this illness. METHODS: systematic review and meta-analysis on the efficacy of antibiotic treatment and chemoprophylaxis of leptospirosis in humans. RESULTS: Ten clinical trials compared an antibiotic treatment with placebo or other antibiotic treatments in leptospirosis (the most recent one was published in 2007). The meta-analysis shows no effect of penicillin treatment on mortality compared to placebo (OR 1.65; 95% CI 0.76-3.57; p = 0.21). There are no differences between penicillin and cephalosporins or doxycycline. Penicillin does not reduce the time of defervescence (MD-0.16; 95% CI (-1.4) -1.08; p = 0.80) nor hospital stay (MD 0.15; 95% CI (-0.75)-1.06; p = 0.74). Besides, the data did not demonstrate any effectiveness of the use of penicillin in terms of the incidence of oliguria/anuria, the need for dialysis treatment, time to creatinine normalization, incidence of jaundice, or the liver function normalization time. Eight trials have assessed prophylactic treatment against leptospirosis with different strategies. A weekly dose of 200 mg of doxycycline does not show benefit versus placebo regarding the number of new cases of symptomatic leptospirosis (OR 0.20; 95% CI 0.02-1.87; p = 0.16). A single dose of doxycycline at exposure to flood water could have a beneficial effect (OR 0.23; 95% CI 0.07-0.77; p = 0.02). None of the other chemoprophylaxis regimens tested have shown a statistically significant effect on the number of new symptomatic cases. CONCLUSION: There is no evidence that antibiotics are a better treatment than placebo regarding mortality, shortening of fever, liver and kidney function, or reduction in the hospital stay. On the other hand, neither doxycycline nor penicillin, nor azithromycin have shown statistically significant differences in preventing symptomatic infection. Well-designed clinical trials, including other antibiotics such as quinolones or aminoglycosides, are urgently needed to improve our understanding of the treatment for this infection, which continues to be a neglected disease.

Drivers who tested positive for cannabis in oral fluid: a longitudinal analysis of administrative data for Spain between 2011 and 2016.

OBJECTIVES: This study aimed to assess the association between positive roadside tests for delta-9-tetrahydrocannabinol (THC) and other driving-impairing substances and THC concentrations and the age and gender of THC-positive drivers. DESIGN: This study is based on administrative data. SETTING, PARTICIPANTS AND EXPOSURES: National administrative data on drivers who tested positive in confirmation analysis of driving-impairing substances in oral fluid were assessed (2011-2016, 179 645 tests). PRIMARY AND SECONDARY OUTCOME MEASURES: Frequencies of positivity for THC, THC alone and THC plus non-THC substances (stratification by age and gender in 2016) and THC concentration were obtained. Comparisons and univariate and multivariate regression analyses were performed. RESULTS: Of the 65 244 confirmed drug-positive tests, 51 869 were positive for THC (79.5%). In 50.8% of the THC-positive tests, cocaine and amphetamines were also detected. Positivity for THC and non-THC substances predominated among drivers with low THC concentrations and represented 58.6% of those with levels lower than 25 ng/mL. The mean±SD for age was 29.6±7.7 years (year 2016, n=24 941). Men accounted for 96.3% of all THC-positive drivers. With increasing age, positivity for THC decreased (OR 0.948; 95% CI 0.945 to 0.952; p<0.0001), and positivity for THC and non-THC substances increased (OR 1.021; 95% CI 1.017 to 1.024; p<0.0001). Men were associated with higher THC concentrations (OR 1.394; 95% CI 1.188 to 1.636; p<0.0001). CONCLUSIONS: Cannabis positivity is frequent among drivers, and polysubstance use is common. Hence, focusing on younger drivers and those with low THC concentrations is encouraged. This study provides evidence on the current implementation of roadside drug testing in Spain and aims to characterise driving under the influence (DUI) of cannabis to increase the awareness of all involved to help them avoid DUI.

Opioids in oral fluid of Spanish drivers.

BACKGROUND: Driving under the influence of certain drugs is not allowed, and roadside drug testing is being considered an important tool for deterring driving under the influence of them. This study aimed to assess the presence and concentration of opioids, as well as their combined use with other drugs (laboratory confirmation after the on-road screening) in Spanish drivers between 2011 and 2016. METHODS: In Spain, mandatory roadside breath alcohol and oral fluid drug testing (screening) are carried out by the Traffic Police using Dräger Alcotest® 6810 device, and Dräger DrugTest® 5000, DrugWipe®, or Alere™ DDS®2 Mobile Test System. For positive cases in the period covered, 65,244, confirmation analysis and quantification using chromatographic techniques were performed. RESULTS: Opioids were confirmed in 8.6% of positive cases, being 7.2% positives to 6-acetylmorphine (6-AM), 6.5% to morphine, 5.4% to codeine, and 4.1% to methadone. The majority of the confirmed tests for morphine (96.5%), codeine (88.4%) and methadone (81.9) were also positive for 6-AM. The presence of other drugs, particularly cocaine and cannabis, was very common. Concentration values reached important levels. Positive results for morphine (0.1%), codeine (0.6%) or methadone (0.4%) alone were very infrequent. CONCLUSIONS: Drivers with a confirmed positive roadside test for morphine, codeine, and methadone had also consumed heroin and/or other illicit drugs, such as cocaine and/or THC, and at relevant concentrations. Improving interventions to combat the problem of driving under the influence of driving-impairing substances is a priority.

Prevalence of psychoactive substances, alcohol and illicit drugs, in Spanish drivers: A roadside study in 2015.

A survey was conducted during 2015 to monitor psychoactive substance use in a sample of drivers in Spanish roads and cities. Traffic police officers recruited drivers at sites carefully chosen to achieve representativeness of the driver population. A brief questionnaire included the date, time, and personal and driving patterns data. Alcohol use was ascertained through ethanol breath test at the roadside and considered positive if concentrations >0.05mg alcohol/L were detected. Four drug classes were assessed on-site through an oral fluid screening test that, if positive, was confirmed through a second oral fluid sample at a reference laboratory. Laboratory confirmation analyses screened for 26 psychoactive substances. To evaluate the association between drug findings and age, sex, road type (urban/interurban), and period of the week (weekdays, weeknights, weekend days, weekend nights), logistic regression analyses were done (overall, and separately for alcohol, cannabis and cocaine). A total of 2744 drivers, mean age of 37.5 years, 77.8% men, were included. Overall, 11.6% of the drivers had at least one positive finding to the substances assessed. Substances more frequently testing positive were cannabis (7.5%), cocaine (4.7%) and alcohol (2.6%). More than one substance was detected in 4% of the subjects. The proportion of positive results decreased with age, and was more likely among men and on urban roads. The pattern for alcohol use was similar but did not change with age and increased among drivers recruited at night. Cannabis was more likely to be detected at younger ages and cocaine was associated with night driving. Alcohol use before driving has decreased over the last decade; however, the consumption of other illegal drugs seems to have increased. The pattern of illegal psychoactive substance observed is similar to that declared in surveys of the general population of adults.

Roadside opioid testing of drivers using oral fluid: the case of a country with a zero tolerance law, Spain.

BACKGROUND: Opioids can impair psychomotor performance, and driving under the influence of opioids is associated with an increased risk of accidents. The goals of this study were i) to determine the prevalence of opioids (heroin, morphine, codeine, methadone and tramadol) in Spanish drivers and ii) to explore the presence of opioids, more specifically whether they are used alone or in combination with other drugs. METHODS: The 2008/9 DRUID database regarding Spain was used, which provided information on 3302 drivers. All drivers included in the study provided a saliva sample and mass-chromatographic analyses were carried out in all cases. To determine the prevalence, the sample was weighted according to traffic intensity. In the case of opioid use combinations, the sample was not weighted. The detection limit for each substance was considered a positive result. RESULTS: The prevalence of opioids in Spanish drivers was 1.8% (95% CI, 1.4-2.3). Polydrug detection was common (56.2%): of these, in two out of three cases, two opioids were detected and cocaine was also detected in 86% of the cases. The concentration (median [Q1-Q3] ng/ml) of the substances was low: methadone 1.71 [0.10-15.30], codeine 40.55 [2.10-120.77], 6-acetylmorphine 5.71 [1.53-84.05], and morphine 37.40 [2.84-200.00]. Morphine was always detected with 6-acetylmorphine (heroin use). CONCLUSIONS: Driving under the influence of opioids is relatively infrequent, but polydrug use is common. Our study shows that 6 out of 10 drivers with methadone in their OF (likely in methadone maintenance programs) are using other substances. This should be taken into account by health professionals in order to properly inform patients about the added risks of mixing substances when driving.

Drugs, Substance Use Disorder and Driving: Intervention of Health Professionals in the Treatment of Addictions.

Editorial of vol 27-3.

Editorial del vol 27-3.

Lesiones por tráfico: un ejemplo en la salud pública / Road traffic injuries: an example of public health

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Drogas, Trastorno por Uso de Sustancias y Conducción: La intervención de los profesionales que trabajan en adicciones / Drugs, Substance Use Disorder and Driving: Intervention of Health Professionals in the Treatment of Addictions

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The relationship between observed signs of impairment and THC concentration in oral fluid.

BACKGROUND: Studies have shown that cannabis intake increases the risk of traffic accidents. Controlled experiments support these findings and have shown a positive dose-effect relationship. METHODS: In this retrospective cross-sectional study of data from a roadside survey, we investigated whether a police officer's judgment regarding signs of impairment is related to the concentration of delta-9-tetrahydrocannabinol (THC) in the oral fluid (OF). We investigated 2,632 cases from a representative sample of 3,302 Spanish drivers: 253 drivers positive for THC only, 32 positive for THC and ethanol, 201 with only ethanol detected in their breath, and 2,146 drivers who tested negative for ethanol in breath and drugs in OF. Recorded data comprised breath alcohol concentrations, THC concentrations in the OF, and the 31 observed signs of impairment. Subject groups were compared using the chi-square test, and logistic regression was used to examine the risk of being categorized as exhibiting signs of impairment. RESULTS: A relationship was found between the OF THC concentration and some observed signs of impairment. Eye signs were noticeable from a THC concentration >3.0 ng/ml in OF, and >25 ng/ml was related to behavior, facial expression, and speech signs. Alcohol and THC contribute to impairment independently and, when taken simultaneously, the effects are comparable to the sum of the effects when consumed separately. CONCLUSIONS: The observation of signs of impairment due to cannabis occurs in an OF concentration-related manner but, as a clinical test, OF has low sensitivity and specificity in a random roadside survey.

Prevalence of psychoactive substances, alcohol, illicit drugs, and medicines, in Spanish drivers: a roadside study.

Following population, geographic, road type and time criteria, Spain has carried out random, roadside controls of 3302 representative sample of Spanish drivers, including saliva analysis for 24 psychoactive substances and alcohol breath tests. The 81.4% of the drivers were male, with an average age of 34.8±11.8 (mean±SD). The 17% of the drivers were found to be positive to any of the substances analysed. The 6.6% of the drivers found positive to alcohol (>0.05 mg/l in breath), 11% were found positive to any illicit drug, and 2% were positive to one of the medicines analysed. Some drivers were positive in more than one substance. The most common illicit drugs among Spanish drivers were cannabis (7.7%), or cocaine (3.5%), either alone or combined with other substances. The most prevalent medicines were the benzodiazepines (1.6%). As a tendency, higher figures for positive cases were observed among males than in females (being statistically significant the differences for alcohol, cannabis and cocaine). Alcohol and cocaine positive cases were more frequently found among drivers of urban roads. Alcohol positive cases (alone, >0.05 mg/l), were more likely found as age increase (OR=1.02), those driving in urban roads (OR=2.13), and driving at any period than weekdays, while alcohol+drugs cases were more likely found among males (OR=2.819), those driving on urban road (OR=2.17) and driving at night periods. Finding a medicines positive case was more likely as elder the driver was (OR=1.05). There have been differences in the prevalence of positive cases of alcohol, cannabis and cocaine, in relation to the period of the week: in three cases the highest prevalence seen in night time. This study shows the high prevalence of psychoactive substances and alcohol in Spanish drivers, mainly illicit drugs (cannabis). This question requires a response from the authorities and from society, with an integral and multi-disciplinary approach that can heighten the population's awareness of the risks of driving under the influence of certain substances.

Spinal cord injury and traumatic brain injury: a cost-of-illness study.

BACKGROUND: Among traumatic injuries, spinal cord injuries (SCI) and traumatic brain injuries (TBI) are of major importance because of their epidemiological and economic impact on society. The overall objective of this study was to estimate the economic cost associated with people with SCI and TBI in Spain in 2007. METHODS: A cost-of-illness analysis was performed, considering the perspective of society, using a 1-year time horizon. Medical costs, adaptation costs, material costs, administrative costs, and costs of police, firefighters and roadside assistance, productivity losses due to institutionalization and sick leave, as well as an estimate of productivity losses of carers, and productivity losses due to death were included. RESULTS: The economic cost associated with people with SCI is between EUR 92,087,080.97 and 212,496,196.41 (USD 131 million and 302 million) according to the injury mechanism, and between EUR 1,079,223,688.66 and 3,833,752,692.78 (USD 1,536 million and 5,458 million) for people with TBI. CONCLUSIONS: There is an urgent need to develop effective interventions known to prevent SCI and TBI, and to evaluate their effectiveness and efficiency.

Incidence trends of traumatic spinal cord injury and traumatic brain injury in Spain, 2000-2009.

AIMS: The aim of the present study was to estimate the incidence of hospital discharges for traumatic spinal cord injury (TSCI) and traumatic brain injury (TBI) in Spain by injury circumstances (traffic crashes and others), injury severity, gender and age group and to describe its trends over the period 2000-2009. METHODS: It is a study of trends that includes hospital discharges with a primary diagnosis of TSCI or TBI. Crude and age-standardised rates were calculated per million inhabitants. Changes in rates between 2000 and 2009 were assessed through calculation of the relative risk adjusted for age, using Poisson regression. RESULTS: Between 2000 and 2009 in Spain, 10,274 patients were admitted for traumatic TSCI, and 206,503 for TBI. The annual incidence rate for TSCI was 23.5 per million, that for TBI was 472.6 per million. The overall incidence rate for TSCI fell significantly between 2000 and 2009 by 24.2% (traffic-related 40.9%, other 12.9%), as did that for TBI (23.8% overall, 60.2% traffic-related, with no change for other circumstances). Among people aged 65 years and over, no change was observed for TSCI, incidence of TBI fell significantly when due to traffic crashes, but there was a dramatic increase of 87% in men and 89.3% in women when due to other circumstances. CONCLUSIONS: Over the last decade the incidence of these types of injury has fallen significantly when the injury resulted from traffic crashes, and to a lesser extent when from other circumstances. However TBI incidence among people aged 65 and over injured in non-traffic-related circumstances has risen dramatically.

Drogas ilegales y conducción de vehículos / Illicit drugs and driving

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Pancreatitis Aguda Recidivante por Ascaris Lumbricoides / Acute necrotising pancreatitis by ascaris lumbricoides

La ascariasis es la parasitosis más frecuente de todas las helmintiasis en humanos. Los efectos patológicosproducidos por los áscaris en el hombre se presentan en lugares diversos, de acuerdo con la localizaciónde sus distintas formas evolutivas. La ascariasis biliar en una de las complicaciones más severas.Presentamos un caso de pancreatitis aguda producida por infestación por Áscaris

Ascariasis is the commonest parasitosis of all human helminths. The pathological effects that ascaris producesin man manifest in different locations, in accordance with the location of its different evolutionaryforms. Biliary ascaris is one of the severest complications. We present a case of acute pancreatitis produced by Ascaris infestation

Neumonía recurrente como manifestación de infección por Nocardia / Recurrent pneumonia as a manifestation of Norcardia infection

La nocardiosis es una enfermedad invasiva producida por especies del género Nocardia, bien a travésde la inhalación o la inoculación cutánea. Se presentan dos casos de neumonía por Nocardia en pacientes inmunodeprimidos

Nocardiosis is an invasive disease caused by the Norcardia species, either through inhalation orcutaneous inoculation. We report two cases of pneumonia caused by Norcadia in immunodepressed patients