F Marco

CRESIB Barcelona Centre for International Health Research, Barcino, Catalonia, Spain

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Publications (206)896.66 Total impact

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    ABSTRACT: Infective endocarditis (IE) continues to be a serious disease with a poor prognosis and high mortality. Neither incidence rates nor mortality have decreased in recent decades. Because of this, it is important to prevent IE in patients at risk. In the past, prevention of IE has focused on antimicrobial prophylaxis, mainly for dental procedures. However, recent major changes in epidemiology, the most significant being the growing frequency and high mortality rate of health care-associated valve endocarditis (HAIE), mean that preventive strategies against IE must also change. Since intravascular catheters are the most common source of bacteremia among patients with HAIE, significant efforts must be made to minimize the risk of catheter-related bloodstream infections. Measures for preventing the infection of prosthetic valves and cardiac implantable devices at the time of implantation also need to be implemented.
    Current Infectious Disease Reports 11/2014; 16(11):439.
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    ABSTRACT: Carbapenem-resistant Acinetobacter baumannii is a major source of nosocomial infections worldwide and is mainly associated with the acquisition of OXA-type carbapenemases and, to a lesser extent, metallo-β-lactamases (MBLs). In this study, 82 non-epidemiologically related Acinetobacter strains carrying different types of OXA- or MBL-enzymes were tested using the Eazyplex® system, a LAMP-based method to rapidly detect carbapenemase carriage. The presence/absence of carbapenem-hydrolyzing enzymes was correctly determined for all isolates in less than 30 minutes.
    Antimicrobial Agents and Chemotherapy 09/2014; · 4.57 Impact Factor
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    Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 07/2014;
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    ABSTRACT: The aim of this study was to assess changes in antibiotic resistance, epidemiology, and outcome among patients with Enterococcus faecalis infective endocarditis (EFIE) and to compare the efficacy and safety of the combination of ampicillin and gentamicin (A+G) with that of ampicillin plus ceftriaxone (A+C). The study was a retrospective analysis of a prospective cohort of EFIE patients treated in our center from 1997 to 2011. Thirty patients were initially treated with A+G (ampicillin 2 g/4 h and gentamicin 3 mg/kg/d) and 39 with A+C (ampicillin 2 g/4 h and ceftriaxone 2 g/12 h) for 4-6 weeks. Increased rates of high-level aminoglycoside resistance (HLAR: gentamicin MIC ≥512 mg/L, streptomycin MIC ≥1024 mg/L or both) were observed in recent years (24% in 1997-2006 and 49% in 2007-2011; P=0.03). The use of A+C increased over time: 1997-2001, 4/18 (22%); 2002-2006, 5/16 (31%); and 2007-2011, 30/35 (86%) (P<0.001). Renal failure developed in 65% of the A+G group and in 34% of the A+C group (P=0.014). Thirteen patients (43%) in the A+G group had to discontinue treatment, whereas only 1 patient (3%) treated with A+C had to discontinue treatment (P<0.001). Only development of heart failure and previous chronic renal failure were independently associated with one-year mortality, while the individual antibiotic regimen (A+C vs. A+G) did not affect outcome (OR 0.7, 95%CI 0.2-2.2, P=0.549). Our study shows that the prevalence of HLAR EFIE has increased significantly in recent years and that alternative treatment with A+C is safer than A+G, with similar clinical outcomes, although the sample size is too small to draw firm conclusions. Randomized controlled studies are needed to confirm these results.This article is protected by copyright. All rights reserved.
    Clinical Microbiology and Infection 07/2014; · 4.58 Impact Factor
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    ABSTRACT: SUMMARY This study was part of a bloodstream infection surveillance programme that prospectively collected data on consecutive patients with bacteraemia in our institution from 1991 to 2012. We included 2092 bacteraemias in neutropenic patients. Shock and mortality accounted for 299 and 349 cases, respectively (14% and 17%). The main microorganisms isolated were coagulase-negative staphylococci (CoNS, 634, 30%), Escherichia coli (468, 22%) and Pseudomonas aeruginosa (235, 11%). During 2006-2012, there were 155 (27%) E. coli isolates; of these, 73% were fluoroquinolone resistant and 26% cefotaxime resistant. The independent risk factors for mortality were shock on presentation, rapidly fatal prognosis of underlying disease, corticosteroid use, and polymicrobial bacteraemia. Factors associated with lower mortality were the isolation of CoNS [odds ratio (OR) 0·38, 95% confidence interval (CI) 0·20-0·73, P = 0·004] and empirical therapy with amikacin (OR 0·50, 95% CI 0·29-0·88, P = 0·016). The progressive increase of Gram-negative microorganisms resistant to antibiotics influences the choice of empirical treatment in febrile neutropenia and in our experience, the addition of amikacin could be beneficial for such patients.
    Epidemiology and infection. 06/2014;
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    ABSTRACT: Bacteraemia of unknown origin is prevalent and has a high mortality rate. However, there are no recent reports focusing on this issue. From 2005 to 2011, all episodes of community onset bacteraemia of unknown origin (CO-BSI), diagnosed at a 700-bed university hospital were prospectively included. Risk factors for Enterobactericeae resistant to third-generation cephalosporins (3GCR-E), Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus spp, and predictors of mortality were assessed by logistic regression. Out of 4,598 consecutive episodes of CO-BSI, 745 (16.2 %) were of unknown origin. Risk factors for S. aureus were male gender (OR 2.26; 1.33-3.83), diabetes mellitus (OR 1.71; 1.01-2.91) and intravenous drug addiction (OR 17.24; 1.47-202); for P. aeruginosa were male gender (OR 2.19; 1.10-4.37) and health-care associated origin (OR 9.13; 3.23-25.83); for 3GCR-E was recent antibiotic exposure (OR 2.53; 1.47-4.35), while for enterococci, it was recent hospital admission (OR 3.02; 1.64-5.55). Seven and 30-day mortality were 8.1 % and 13.4 %, respectively. Age over 65 years (OR 2.13; 1.28-3.55), an ultimately or rapidly fatal underlying disease (OR 4.15; 2.23-7.60), bone marrow transplantation (OR 4.07; 1.24-13.31), absence of fever (OR 4.45; 2.25-8.81), shock on presentation (OR 10.48; 6.05-18.15) and isolation of S. aureus (OR 2.01; 1.00-4.04) were independently associated with mortality. In patients with bacteraemia of unknown origin, a limited number of clinical characteristics may be useful to predict its aetiology and to choose the appropriate empirical treatment. Although no modifiable prognostic factors have been found, management optimization of S. aureus should be considered a priority in this setting.
    European Journal of Clinical Microbiology 06/2014; 33(11). · 3.02 Impact Factor
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    ABSTRACT: In the last decade we have witnessed a remarkable increase in the number of strains isolated in hospitals that are producing extended spectrum β-lactamases (ESBL) or, more recently, carbapenemases. This makes clear the need for a system for rapid detection of these resistance mechanisms that allow the selection of the most suitable antibiotic treatment in order to improve patient care. Recent data support the possibility of using mass spectrometry (MS), specifically MALDI -TOF (Matrix-Assisted Laser Desorption / Ionization, Time-of-Flight ) systems to identify specific resistance mechanisms and their use offers several advantages. First, the economic cost of each determination is clearly inferior to the classical molecular techniques for detection of resistance genes. Second, detection of resistance by MALDI -TOF reduces the time for obtaining results compared to the routine methods currently employed. Finally, the possibility that this method allows us to detect enzymes not previously characterized, that there is no information about the genes that encode them. Therefore, we believe that this may be a good tool to implement in clinical microbiology laboratories. This review aims to present the latest developments in this field.
    Revista espanola de quimioterapia: publicacion oficial de la Sociedad Espanola de Quimioterapia 06/2014; 27(2):87-92. · 0.84 Impact Factor
  • Revista espanola de quimioterapia: publicacion oficial de la Sociedad Espanola de Quimioterapia 06/2014; 27(2):87-140. · 0.84 Impact Factor
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    ABSTRACT: Information on the efficacy of extended meropenem administration in neutropenic patients is scarce. Our objective was to determine whether the administration of meropenem in a 4 h extended infusion (EI) leads to a better clinical outcome in patients with febrile neutropenia than the conventional short infusion (SI).
    Journal of Antimicrobial Chemotherapy 05/2014; · 5.34 Impact Factor
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    ABSTRACT: The incidence of candidemia by non-Candida albicans Candida species has been progressively increasing in recent years. The use of fluconazole as antifungal prophylaxis has been described as a risk factor for the development of infections by fluconazole resistant Candida strains. We report a case of Candida norvegensis bloodstream infection in a liver transplant recipient. A 61-year-old man, who received a third liver allograft that became worse with an ischemic cholangiopathy and recurrent episodes of cholangitis, was admitted to our hospital due to the development of intra-abdominal abscesses. He received multiple antibiotic schemes, and after 3 months he was discharged, maintaining parenteral antibiotic at home. While he was on fluconazole prophylaxis, a breakthrough candidemia by C. norvegensis occurred. In vitro susceptibilities of the isolate to several antifungal agents were as follows: amphotericin B MIC 0.5mg/l, flucytosine 64mg/l, fluconazole 64mg/l, itraconazole 4mg/l, voriconazole 0.75mg/l, and caspofungin 0.047mg/l. He was treated with anidulafungin with resolution of candidemia. The use of fluconazole for antifungal prophylaxis may lead to the emergence of fluconazole-resistant Candida infections, with C. norvegensis being a possible emerging pathogen in organ transplant recipients.
    Revista iberoamericana de micologia. 05/2014;
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    ABSTRACT: Background. Staphylococcus aureus endocarditis has a high mortality rate. Vancomycin minimum inhibitory concentration (MIC) has been shown to affect the outcome of methicillin-resistant S. aureus (MRSA) bacteremia, and recent data point to a similar effect on MSSA bacteremia. We aimed to evaluate the effect of vancomycin MIC on left-sided S. aureus infective endocarditis (IE) treated with cloxacillin. Methods. We analyzed a prospectively collected cohort of patients with IE in a single tertiary-care hospital. Vancomycin, daptomycin, and cloxacillin MIC was determined by E-test. S. aureus strains were categorized as low vancomycin MIC (< 1.5 µg/mL) and high vancomycin MIC (≥ 1.5 µg/mL). The primary endpoint was in-hospital mortality. Results. We analyzed 93 patients with left-sided IE treated with cloxacillin, of whom 53 (57%) had a vancomycin MIC<1.5 µg/mL and 40 (43%) a vancomycin MIC≥1.5 µg/mL. In-hospital mortality was 30% (16/53) in patients with a low vancomycin MIC and 53% (21/40) in those with a high vancomycin MIC (p=0.030). No correlation was found between oxacillin MIC and vancomycin or daptomycin MIC. Logistic regression analysis showed that higher vancomycin MIC increased in-hospital mortality 3-fold (OR 3.1, 95% CI 1.2-8.2) after adjustment for age, year of diagnosis, septic complications, and non-septic complicated endocarditis. Conclusion. Our results indicate that vancomycin MIC could be used to identify a subgroup of patients with methicillin-susceptible S. aureus IE at risk of higher mortality. The worse outcome of staphylococcal infections with a higher vancomycin MIC cannot be explained solely by suboptimal pharmacokinetics of antibiotics.
    Clinical Infectious Diseases 03/2014; · 9.37 Impact Factor
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    ABSTRACT: The aim of this study was to investigate the prevalence of ESBL producing Escherichia coli in stool samples from 457 patients with travellers' diarrhoea who had travelled to tropical and subtropical countries. Ninety-seven ESBL-producing E. coli strains were isolated in 17.9% of the patients (82/457). CTX-M-15 was the most prevalent enzyme (80%) and India was the most visited country, showing the highest prevalence of positive samples (37.4%). This article is protected by copyright. All rights reserved.
    Clinical Microbiology and Infection 02/2014; · 4.58 Impact Factor
  • International journal of antimicrobial agents 01/2014; · 3.03 Impact Factor
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    ABSTRACT: Antecedentes En los últimos años ha aumentado la incidencia de candidemia causada por especies del género Candida distintas de Candida albicans. Se ha descrito el uso de profilaxis antifúngica con fluconazol como factor de riesgo para el desarrollo de infecciones por cepas de Candida resistentes a este antifúngico. Se describe un caso de fungemia por Candida norvegensis en un receptor de un trasplante hepático. Caso clínico Un varón de 61 años, receptor de un tercer trasplante hepático que se complica con una colangiopatía isquémica y episodios de colangitis de repetición, ingresó en nuestro hospital por presentar abscesos intraabdominales. Recibió múltiples esquemas antibióticos y, tras tres meses de ingreso, se dio de alta manteniendo un tratamiento antibiótico parenteral en domicilio. Mientras recibía profilaxis con fluconazol, desarrolló una candidemia de brecha por C. norvegensis. Los valores de CMI in vitro del aislamiento para algunos antifúngicos fueron los siguientes: anfotericina B 0,5 mg/l, flucitosina 64 mg/l, fluconazol 64 mg/l, itraconazol 4 mg/l, voriconazol 0,75 mg/L y caspofungina 0,047 mg/l. El paciente recibió tratamiento con anidulafungina con resolución de la candidemia. Conclusiones El uso del fluconazol como profilaxis antifúngica puede conllevar la aparición de infecciones por especies de Candida resistentes a este antifúngico, siendo C. norvegensis un posible patógeno emergente en pacientes receptores de un órgano sólido.
    Revista Iberoamericana de Micología 01/2014; · 1.31 Impact Factor
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    ABSTRACT: Objectives To evaluate characteristics and prognostic factors of community-onset bloodstream infection (Co-BSI) in elderly patients (≥65 years). Methods Analysis of a prospective series of Co-BSI at a tertiary hospital (2005-2011). Predictors of 30-day mortality were established by logistic regression analysis. Results A total of 2605 episodes of Co-BSI were identified and empirical antibiotic treatment was inappropriate in 404 (15.5%). Thirty-day mortality was 11.4% and was independently associated with age (75-84 years OR 1.9, 1.37-2.65; ≥85 OR 2.84, 1.92-4.19), previous hospitalization (OR 1.45, 1.05-1.99), a fatal underlying disease (OR 2.80, 2.09-3.76), neutropenia (OR 2.61, 1.54-4.42), absence of fever (OR 1.99, 1.26-3.12), shock (OR 7.96, 5.82-10.88), inappropriate empirical treatment (OR 1.48, 1.02-2.12), isolation of Staphylococcus aureus (methicillin-resistant OR 2.83, 1.38-5.78; methicillin-susceptible OR 3.24, 1.98-5.32), enterococci (OR 2.03, 1.15-3.60) or Enterobacteriaceae resistant to third-generation cephalosporin (3GCR-E) (OR 1.97, 1.16-3.33) and having endovascular non-catheter (OR 4.65, 2.52-8.61), abdominal (OR 3.65, 2.12-6.28), skin/soft tissue (OR 3.45, 1.88-6.32), respiratory (OR 2.81, 1.75-4.50) or unknown (OR 1.84, 1.18-2.88) source. Conclusions Age is a prognostic factor and appropriateness of empirical treatment is the only modifiable variable. S. aureus, enterococci and 3GCR-E may be the microorganisms with major prognostic significance; hence efforts should be made to improve their management.
    Journal of Infection. 01/2014;
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    ABSTRACT: To determine whether time-to-positivity (TTP) in aerobic and anaerobic blood culture vials is useful to predict the presence of Candida glabrata in patients with candidaemia. TTP was recorded for both aerobic and anaerobic vials for each blood culture set of monomicrobial candidaemia. We considered TTP as the shortest time registered for any positive vial. Two diagnostic criteria were evaluated: the cut-off TTP value as obtained from a receiver operating characteristic curve and the detection of growth only or with a shorter TTP in anaerobic vials. A total of 157 episodes were analysed of which 19 (12.1%) were due to C. glabrata. The TTP for C. glabrata was longer than that for other species. C. glabrata grew more frequently than other species in anaerobic vials [9/19 (47%) versus 19/138 (14%); P = 0.001] and also more often exclusively or earlier in anaerobic vials [7/19 (37%) versus 5/138 (4%); P < 0.0001]. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of a TTP >56.5 h for predicting the presence of C. glabrata were 47%, 88%, 36% and 92%, respectively. Growth detection only or earlier in anaerobic flasks had a sensitivity of 37%, a specificity of 96%, a PPV of 58% and an NPV of 92%. Using the BACTEC 9240 system, a TTP ≤56.5 h is useful to rule out C. glabrata. In addition, in settings with an ∼12% prevalence of C. glabrata candidaemia, yeast detection exclusively or earlier in anaerobic vials increases the probability of the presence of C. glabrata to 58%, which may be useful for early treatment optimization.
    Journal of Antimicrobial Chemotherapy 07/2013; · 5.34 Impact Factor
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    ABSTRACT: OBJECTIVES: To determine the epidemiology of bacteraemic Catheter-Acquired Urinary Tract Infection (CA-UTI) and to identify independent predictors of mortality. METHODS: This study was part of a bloodstream infection surveillance study that prospectively collected data on consecutive patients with bacteraemia in our institution from 1991 to 2010. Factors associated with 30 day mortality were determined. RESULTS: CA-UTI was the confirmed source of 1,007 bacteraemias. The most common microorganisms isolated were E. coli (42%), Klebsiella spp (15%), E. faecalis (12%) and P. aeruginosa (12%). Along the 2006-2010 periods, antibiotic- resistant E. coli and Klebsiella spp isolates accounted for 49% of the bacteraemia due to CA-UTI. Shock and mortality accounted for 125 and 92 cases, respectively (12% and 9%). Factors associated with mortality were: inappropriate empirical treatment (OR: 1.86, 95%CI: 1.48 - 2.44), ultimately or rapidly fatal prognosis of underlying disease (OR: 2.56, 95%CI: 1.48 - 4.44) and shock on presentation (OR: 12.62, 95%CI: 7.61 - 20.95). Inappropriate empirical treatment was most frequent in cases of bacteraemia produced by antibiotic-resistant E. coli or Klebsiella spp, Enterococcus spp. and P. aeruginosa. Factors associated with the isolation of a microorganism of this type were previous antibiotic therapy and healthcare-associated bacteraemia (OR: 1.50, 95%CI: 1.16 - 2.14 and OR: 3.03, 95%CI: 2.22 - 4.01, respectively). CONCLUSIONS: In cases of previous antibiotic therapy or healthcare-associated bacteraemic CA-UTI may indicate the need to initiate empirical therapy activity against antibiotic-resistant Enterobacteriaceae, E. faecalis and P. aeruginosa.
    The Journal of infection 06/2013; · 4.13 Impact Factor
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    ABSTRACT: Development of high-level daptomycin resistance (HLDR; MIC ≥256 mg/L) after exposure to daptomycin has recently been reported in viridans-group streptococci (VGS) isolates. Our study objectives were as follows: to know whether in vitro development of HLDR after exposure to daptomycin was common among clinical isolates of VGS and Streptococcus bovis; to determine whether HLDR also developed during administration of daptomycin to treat experimental endocarditis caused by the daptomycin-susceptible penicillin-resistant Streptococcus mitis strain S. mitis-351; and to establish whether combination with gentamicin prevented development of HLDR in vitro and in vivo. In vitro studies were performed in 114 VGS strains (Mitis group, 92; Anginosus group, 10; Mutans group, 8; Salivarius group, 4) and 54 S. bovis strains isolated from 168 consecutive patients with infective endocarditis diagnosed between 1995 and 2010. HLDR was only observed after 24 hours of exposure to daptomycin in 27% of the Mitis group: S. mitis (27%), S. oralis (47%), and S. sanguis (13%). In our experimental model, HLDR was detected in 7/11 (63%) and 8/12 (67%) isolates recovered from vegetations after 48 hours of daptomycin administered at 6 mg/kg/24 h and 10 mg/kg/24 h, respectively. In vitro, time-kill experiments showed that daptomycin plus gentamicin was bactericidal against S. mitis-351 at concentrations tested of 0.5, and 1 times the MIC and prevented the development of HLDR. In vivo, the addition of gentamicin at 1 mg/kg/8 h to both daptomycin arms prevented HLDR in 21 out of 23 (91%) rabbits. Daptomycin plus gentamicin was at least as effective as that of vancomycin plus gentamicin. In conclusion, HLDR develops rapidly and frequently in vitro and in vivo among Mitis-group streptococci. Combination with gentamicin enhanced the activity of daptomycin and prevented development of HLDR in most cases.
    Antimicrobial Agents and Chemotherapy 03/2013; · 4.57 Impact Factor
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    ABSTRACT: Objective The objective of this study was to analyse the genotypic characteristics of all Enterococcus isolates with acquired vancomycin resistance (VRE) recovered in the Hospital Clinic (Barcelona, Spain) in a period of three years and two months.Methods All VRE isolated in the referred Hospital in the period January 2004-March 2007 were included in the study. The vancomycin resistance mechanism was investigated, as well as other antibiotic resistance mechanisms. Isolates were also typed by pulsed-field-gel-electrophoresis (PFGE) and multi-locus-sequence-typing (MLST).ResultsThirty-nine VRE were recovered, all being identified as E. faecium, representing 2% of total enterococci obtained in that period. Thirty-eight of them carried the vanA gene, and one isolate the vanB2 gene. The 39 VRE were classified into 13 different pulsotypes (A-M), with one main pulsotype, A, which included 13 isolates. The sequence type was identified by MLST in 24 VRE (with unrelated or closely-related PFGE patterns), and they were ascribed to the clonal complex CC17, but two classified as CC9. All VRE showed a multiresistance phenotype, including, in most cases ampicillin, ciprofloxacin, erythromycin, streptomycin, gentamicin, kanamycin and chloramphenicol, harbouring multiple antibiotic resistance genes. The presence of esp and/or hyl genes was identified in 37 VRE.Conclusion All VRE, but one, showed the vanA genotype and they were mostly ascribed to the high-risk clonal complex CC17.
    Enfermedades Infecciosas y Microbiología Clínica 01/2013; 31(1):10–14. · 1.48 Impact Factor
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    ABSTRACT: There is scarce information about the incidence, associated factors and prognosis of pericardial effusion (PE) in patients with infective endocarditis (IE). From 1990 to 2007, patients with native valve IE in our center were prospectively follow-up. A logistic regression analysis was performed to identify independent variables associated to PE and mortality. We included 479 episodes of IE in 459 patients (70% men and mean age 51 years). Small-moderate PE was observed in 109 episodes (23%) and large-very large in 9 episodes (2%). Patient with small-moderate PE when compared with patients without PE had a higher prevalence of intravenous drug abuse history (38% vs. 23%) and had more frequently right-side IE than patients without PE (33% vs. 17%). Patients with large-very large PE had a higher rate of systemic emboli (22% vs. 18%) and periannular abscess (22% vs 6%) than patients without PE. Renal failure (OR 2.1, 95%CI, 1.3-3.3) was associated with a higher risk for PE, while age (OR 0.98, 95%CI, 0.97-0.99) with a lower frequency of PE. One-year mortality of IE patients with large or very large PE was higher than that for small-moderate or absence of PE (56%, 18% and 24% respectively, p=0.033). Large-very large PE increases the one-year mortality of IE (OR 3.0, 95%CI, 1.2-7.9). In conclusion, renal failure and a younger age are associated with a higher risk of PE. Large-very large PE was associated with an increase in one-year mortality.
    The American Journal of Cardiology 01/2013; · 3.21 Impact Factor

Publication Stats

4k Citations
896.66 Total Impact Points


  • 2014
    • CRESIB Barcelona Centre for International Health Research
      Barcino, Catalonia, Spain
  • 2008–2014
    • IDIBAPS August Pi i Sunyer Biomedical Research Institute
      Barcino, Catalonia, Spain
    • Hospital Clínico, Maracaibo
      Maracaibo, Estado Zulia, Venezuela
  • 1993–2014
    • University of Barcelona
      • • Department of Medicine
      • • Departament de Microbiologia
      • • Facultad de Medicina
      Barcino, Catalonia, Spain
  • 1992–2013
    • Hospital Clínic de Barcelona
      • • Servicio de Microbiología
      • • Servicio de Enfermedades Infecciosas
      Barcino, Catalonia, Spain
  • 2010–2012
    • Universidad de La Rioja (Spain)
      • Agriculture and Food
      Logroño, La Rioja, Spain
  • 2008–2011
    • Hospital Universitario Marques de Valdecilla
      • Servicio de Microbiología
      Santander, Cantabria, Spain
  • 2007
    • Hospital Universitario Ramón y Cajal
      Madrid, Madrid, Spain
    • Universidad de Las Palmas de Gran Canaria
      Las Palmas, Canary Islands, Spain
  • 2005
    • Corporació Sanitària Parc Taulí
      • Department of Cardiology
      Catalonia, Spain
  • 1999–2005
    • Universitat Rovira i Virgili
      • Faculty of Medicine and Science of Health
      Tarraco, Catalonia, Spain
  • 2003
    • Hospital Universitario Fundacion Alcorcon
      Madrid, Madrid, Spain
  • 1998–2003
    • Southern Medical Clinic
      San Fernando, City of San Fernando, Trinidad and Tobago