Management of disseminated histoplasmosis in a high-complexity clinic in Cali, Colombia.

Histoplasmosis presents a substantial clinical challenge globally, with a particular prevalence in South America, especially among patients with concurrent Human Immunodeficiency Virus (HIV) infection. Despite itraconazole's established efficacy, investigating alternative therapeutic approaches remains imperative. This is the largest study in our region to date, assessing the effectiveness of the less explored posaconazole treatment. This observational study, conducted at Fundación Valle del Lili (FVL) from 2016 to 2022, encompassed adults with disseminated histoplasmosis. Patients (n = 31) were treated with liposomal amphotericin B as an initial treatment, followed by consolidation treatment with posaconazole or itraconazole. Patients with single-organ cases, those lacking microbiological diagnosis, those who received initial treatment with antifungals other than liposomal Amphotericin B and those with < 6 months follow-up were excluded (Figure 1). Analyses considered population characteristics, treatments, and outcomes. Patients (average age: 45.6; 58.1% female) had common comorbidities (HIV 38.7%, solid organ transplantation 29% and oncologic disease 12.9%). Lungs (48.4%) and lymph nodes (16.1%) were commonly affected. Biopsy (64.5%) was the primary diagnostic method. Initial treatment with liposomal amphotericin B (100%) was given for 14 days on average. Follow-up indicated 71% completion with 19.4% requiring treatment modifications. Notably, 70.9% completed a posaconazole consolidation regimen over 350 days on average. Drug interactions during consolidation (80.6%) were common. No relapses occurred, and three deaths unrelated to histoplasmosis were reported. Traditionally, itraconazole has been the prevalent initial treatment; however, in our cohort, 55.9% of patients received posaconazole as the primary option. Encouragingly, posaconazole showed favorable tolerance and infection resolution, suggesting its potential as an effective and well-tolerated alternative for consolidation treatment. This finding prompts further exploration of posaconazole, potentially leading to more effective patient care and better outcomes.

Histoplasmosis is a critical concern in South America, notably among human immunodeficiency virus patients, leading to high mortality rates. This study, the largest in our region, investigates the effectiveness of posaconazole as an alternative treatment to itraconazole. The results offer the potential for enhanced patient care and improved outcomes.

A non-surgical approach: Ampicillin's success in Listeria monocytogenes endocarditis.

Background: Listeria monocytogenes, a Gram-positive bacillus, primarily affects immunocompromised individuals. Endocarditis is a rare but severe complication of L. monocytogenes bacteremia, irrespective of native or prosthetic valves. While there is no standardized treatment, the use of ampicillin proves effective in most cases. Surgical intervention is reserved for cases involving valve dehiscence, heart failure, or myocardial abscess. Case presentation: A 54-year-old female, with mitral valve replacement, presented with fever, chest pain and dyspnea at rest. Patient was initially diagnosed with bacterial pneumonia; however, subsequent evaluation revealed L. monocytogenes bacteremia, resulting in endocarditis. Surgical management was contraindicated due to multiple prior valve replacement surgeries. Symptoms resolution, along with improvements in echocardiographic and clinical parameters, was achieved through extended antibiotic treatment only with no surgical intervention. Conclusion - key takeaways: This case underscores the critical importance of individualized treatment approaches in endocarditis, particularly in patients with surgery approach contraindication, and emphasized the success achieved through ampicillin-based management.

Relación entre mortalidad y tratamiento recibido en pacientes con endocarditis infecciosa / Relationship between mortality and treatment received in patients with infective endocarditis

Resumen Introducción: La endocarditis infecciosa es una enfermedad de baja incidencia y alta morbilidad. Puede tener un curso agudo o subagudo, con complicaciones que están directamente relacionadas con la mortalidad y varían según el agente infeccioso; el más frecuente es Staphylococcus aureus. Dependiendo de la condición clínica se puede elegir una terapia antimicrobiana exclusiva o una terapia combinada (antimicrobiana y cirugía); la elección adecuada impacta en las tasas de sobrevida. Objetivo: Describir las características clínicas, microbiológicas y ecocardiográficas en pacientes con endocarditis infecciosa y analizar la mortalidad según el tratamiento recibido (terapia antimicrobiana o terapia combinada). Método: Estudio de cohorte retrospectivo, realizado en el Hospital Universitario Fundación Valle del Lili, en Cali, Colombia, en el que se incluyeron pacientes hospitalizados mayores de 18 años que cumplían los criterios de Duke modificados para diagnóstico de endocarditis infecciosa. Se evaluaron dos cohortes según hubieran recibido tratamiento antimicrobiano exclusivo o terapia combinada. Los pacientes fueron seguidos hasta el egreso hospitalario. Resultados: De 101 pacientes, 58 recibieron terapia antimicrobiana y 43 terapia combinada. La sobrevida global fue del 77.35%; el grupo de terapia combinada tuvo una hazard ratio ajustada de 0.13 (intervalo de confianza del 95%: 0.036-0.505; p = 0.003). La tasa de mortalidad calculada por 1000 días-persona fue de 25.9 con terapia antimicrobiana y de 4.33 con terapia combinada. Conclusiones: El grupo de terapia combinada tuvo más complicaciones y mayor estancia en la unidad de cuidados intensivos, pero menores tasas de mortalidad que los pacientes con terapia antimicrobiana exclusiva. De acuerdo con las indicaciones actuales de manejo quirúrgico descritas en las guías internacionales, se pueden obtener excelentes resultados en los pacientes más enfermos.

Abstract Introduction: Infective endocarditis is a disease of low incidence but high morbidity. It can have an acute or subacute course, with complications that are directly related to mortality and vary according to the infectious agent; the most common is Staphylococcus aureus. Based on the clinical condition, an exclusive antimicrobial therapy or a combined therapy (antimicrobial and surgery) can be chosen; their proper choice impacts survival rates. Objective: To describe the clinical, microbiological and echocardiographic characteristics in patients with infective endocarditis and to analyze how mortality behaved according to the treatment received (antimicrobial therapy or combined therapy). Method: A retrospective cohort study, carried out at the Fundación Valle del Lili University Hospital, Cali, Colombia, which included hospitalized patients over 18 years of age who met modified Duke criteria for the diagnosis of infective endocarditis. Two cohorts were evaluated according to treatment: exclusive antimicrobial and combined therapy. They were followed until discharge from the hospital. Results: Of 101 patients, 58 received antimicrobial therapy and 43 combined therapy. Overall survival was 77.35%, the combined therapy group had an adjusted hazard ratio of 0.13 (95% confidence interval: 0.036-0.505; p = 0.003). The mortality rate calculated per 1000 person-days was 25.9 in antimicrobial therapy and 4.33 in combination therapy. Conclusions: the combined therapy group had more complications and a longer hospital stay in the ICU, but lower mortality rates than the patients on exclusive antimicrobial therapy. According to the current indications for surgical management described in international guidelines, excellent results can be obtained in sicker patients.