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Agathe León,
César Cáceres,
Emma Fernández,
Paloma Chausa,
Maite Martin, Carles Codina,
Araceli Rousaud,
Jordi Blanch,
Josep Mallolas,
Esteban Martinez,
Jose L Blanco,
Montserrat Laguno,
Maria Larrousse,
Ana Milinkovic,
Laura Zamora,
Neus Canal,
Josep M Miró,
Josep M Gatell,
Enrique J Gómez,
Felipe García
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ABSTRACT: Antiretroviral therapy has changed the natural history of human immunodeficiency virus (HIV) infection in developed countries, where it has become a chronic disease. This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals.
We developed a new internet-based home care model covering the entire management of chronic HIV-infected patients. This was called Virtual Hospital. We report the results of a prospective randomised study performed over two years, comparing standard care received by HIV-infected patients with Virtual Hospital care. HIV-infected patients with access to a computer and broadband were randomised to be monitored either through Virtual Hospital (Arm I) or through standard care at the day hospital (Arm II). After one year of follow up, patients switched their care to the other arm. Virtual Hospital offered four main services: Virtual Consultations, Telepharmacy, Virtual Library and Virtual Community. A technical and clinical evaluation of Virtual Hospital was carried out.
Of the 83 randomised patients, 42 were monitored during the first year through Virtual Hospital (Arm I) and 41 through standard care (Arm II). Baseline characteristics of patients were similar in the two arms. The level of technical satisfaction with the virtual system was high: 85% of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system. Neither clinical parameters [level of CD4+ T lymphocytes, proportion of patients with an undetectable level of viral load (p = 0.21) and compliance levels >90% (p = 0.58)] nor the evaluation of quality of life or psychological questionnaires changed significantly between the two types of care.
Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients. Telemedicine should be considered as an appropriate support service for the management of chronic HIV infection.
Clinical-Trials.gov: NCT01117675.
PLoS ONE 01/2011; 6(1):e14515. · 4.09 Impact Factor
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José A Martínez,
Esther Delgado,
Sara Martí,
Francesc Marco,
Jordi Vila,
Josep Mensa,
Antoni Torres, Carles Codina,
Antoni Trilla,
Alex Soriano,
Aitor Alquezar,
Pedro Castro,
José M Nicolás
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ABSTRACT: To assess the role of antipseudomonal agents on Pseudomonas aeruginosa colonization and acquisition of resistance.
Prospective cohort study.
Two medical intensive care units.
346 patients admitted for >or= 48 h.
Analysis of data from an 8-month study comparing a mixing versus a cycling strategy of antibiotic use.
Surveillance cultures from nares, pharynx, rectum, and respiratory secretions were obtained thrice weekly. Acquisition of resistance was defined as the isolation, after 48 h of ICU stay, of an isolate resistant to a given antibiotic if culture of admission samples were either negative or positive for a susceptible isolate. Emergence of resistance refers to the conversion of a defined pulsotype from susceptible to non-susceptible. Forty-four (13%) patients acquired 52 strains of P. aeruginosa. Administration of piperacillin-tazobactam for >or= 3 days (OR 2.6, 95% CI 1.09-6.27) and use of amikacin for >or= 3 days (OR 2.6, 95% CI 1.04-6.7) were positively associated with acquisition of P. aeruginosa, whereas use of quinolones (OR 0.27, 95% CI 0.1-0.7) and antipseudomonal cephalosporins (OR 0.27, 95% CI 0.08-0.9) was protective. Exposure to quinolones and cephalosporins was not associated with the acquisition of resistance, whereas it was linked with usage of all other agents. Neither quinolones nor cephalosporins were a major determinant on the emergence of resistance to themselves, as resistance to these antibiotics developed at a similar frequency in non-exposed patients.
In critically ill patients, quinolones and antipseudomonal cephalosporins may prevent the acquisition of P. aeruginosa and may have a negligible influence on the acquisition and emergence of resistance.
European Journal of Intensive Care Medicine 10/2008; 35(3):439-47. · 5.17 Impact Factor
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Alex Soriano,
Guillem Bori,
Sebastián García-Ramiro,
Juan C Martinez-Pastor,
Teresa Miana, Carles Codina,
Francesc Maculé,
Misericordia Basora,
José A Martínez,
Josep Riba,
Santiago Suso,
Josep Mensa
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ABSTRACT: There is no clinical trial analyzing the best moment to infuse an antibiotic during knee arthroplasty performed during ischemia. We designed a single-center, randomized, double-blind, placebo-controlled trial to evaluate whether antibiotic therapy should be administered before tourniquet inflation or just before tourniquet deflation.
Patients who underwent a primary knee arthroplasty were randomized to receive (1) 1.5 g of cefuroxime 10-30 min before inflation of the tourniquet and placebo 10 min before release of the tourniquet (standard arm) or (2) placebo 10-30 min before inflation of the tourniquet and 1.5 g of cefuroxime 10 min before release of the tourniquet (experimental arm). In both arms, a postoperative dose of 1.5 g of cefuroxime was given 6 h after the surgical procedure. The main variables associated with the rate of deep-tissue infection after 3 and 12 months of follow-up were gathered. Continuous variables were compared using Student's t test, and categorical variables were compared using the chi(2) test or Fisher's exact test.
From September 2004 through December 2005, a total of 908 patients were randomized, 442 and 466 of whom were allocated to the standard and experimental arms, respectively. There were no differences between treatment arms in terms of age, sex, comorbidity, American Society of Anaesthesiologists score, duration of surgery, need of blood transfusion, or fourth-day hematocrit. The rates of deep-tissue infection among the standard and experimental groups were 3.4% and 1.9%, respectively, at 3 months of follow-up (P = .21) and 3.6% and 2.6%, respectively, at 12 months of follow-up (P = .44).
The administration of prophylactic antibiotics just before tourniquet release was not inferior to standard antibiotic prophylaxis.
Clinical Infectious Diseases 05/2008; 46(7):1009-14. · 9.15 Impact Factor
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ABSTRACT: To evaluate the relationship between perceived adverse side effects (AE) and non-adherence associated with highly active antiretroviral therapy (HAART).
For 6 consecutive months, patients taking HAART who came to the Pharmacy Department were interviewed. In the questionnaire they had to answer if they had experienced any AE over the past 6 months, what did they do in response to AE and what was the clinical evolution. Adherence was measured by pill counts or by pharmacy records (when pill counts were not possible).
Of 1,936 interviewed patients, 661 (34.1%) reported AE over the past 6 months. The type of antiretroviral drug regimen and starting, re-starting or changing HAART over the past 6 months were significantly associated with AE. Patients who reported AE were 1.4 times more likely to be non-adherents. The most frequently reported AE were diarrhea followed by central nervous system abnormalities and by other gastrointestinal disturbances. In patients starting HAART, 62% of AE improved or disappeared during the first 4 weeks of therapy.
Patients who report AE have worst adherence. AE are more frequent in patients starting HAART but in most cases they improve with time and/or symptomatic therapy.
Medicina Clínica 07/2007; 129(4):127-33. · 1.38 Impact Factor
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ABSTRACT: Hydrocephalus is usually resolved by diverting cerebrospinal fluid through a surgically implanted intra-ventricular catheter (shunt). The aim of this study was to characterize vancomycin pharmacokinetic (PK) parameters and optimal dosage in shunted patients under vancomycin treatment.
Intensive Care and Neurosurgical Units. University Hospital.
Retrospective data of vancomycin blood concentrations, demographics and biochemical parameters, from a Therapeutic Drug Monitoring (TDM) program, in ventricle-external shunted patients (Group A) and controls (Group B) were collected. In all subjects, several blood samples at steady state conditions were drawn. Individual PK parameters such as drug clearance (CL) and volume of distribution (V) were estimated by using an one-compartmental PK model and later, dosage regimens were individually adjusted by Bayesian analysis. The obtained CL and V mean +/- standard deviation were compared between both groups (A versus B). Vancomycin dosage regimens between both groups were also compared.
Patients demographics, clinical records, creatinine clearance by Cockcroft-Gault, vancomycin blood levels, vancomycin pK parameters and optimal initial IV vancomycin dosage.
Forty-five patients were included in the study: 15 patients in group A and 30 subjects in group B. Significant differences between CL(A) and CL(B) means were observed, while not between V(A) and V(B). In shunted patients, the required vancomycin daily dose to reach target concentrations was significantly higher than the dose needed in the control group (49.25 +/- 12.28 mg/kg/day vs. 31.74 +/- 6.70 mg/kg/day; P < 0.0005).
Greater vancomycin clearance was found in our shunted patients, thus they required higher vancomycin daily doses compared to the control group. Consequently, vancomycin TDM in shunted patients should be advisable in order to guarantee antibiotic blood concentrations within the recommended therapeutic range.
Pharmacy World amp Science 08/2006; 28(4):215-21. · 1.22 Impact Factor
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Laura Gratacòs,
Montse Tuset, Carles Codina,
José M Miró,
Josep Mallolas,
Núria Miserachs,
Maria Teresa Martín-Conde,
Elena del Cacho,
Elisa de Lazzari,
Josep Ribas,
Josep M Gatell
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ABSTRACT: Different combinations of antiretroviral drugs are used as initial HIV therapy but comparative studies between them are not frequent. The objectives of this study are to determine the median duration of different therapy combinations in naive patients between 1998-2000 and the main reasons for changing or stopping this first antiretroviral therapy (ARVT).
This study included a total of 518 naive patients who began antiretroviral therapy patients from 1998-2000. Using a Kaplan-Meier analysis the median duration of different combinations was determined. In addition, the main reasons for changing or stopping this first treatment were analysed.
First ARVT median duration was 427 days (IQR: 114-890). 47% of patients stopped their first therapy due to adverse effects, 6% voluntarily withdrew from it, in 9% of patients the therapy was not effective and 15% of them were lost of follow up. Only 9% of them continued with the same ARVT at the end of the study but if we add 7% of treatment simplifications we can consider 16% of first ARVT successful.
A median duration of 427 days, similar to other studies, is shorter than we would prefer for HIV, a condition that requires continuous treatment. On the other hand, the study corroborates that secondary effects are the principal problem associated with ARVT.
Medicina Clínica 03/2006; 126(7):241-5. · 1.38 Impact Factor
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ABSTRACT: To compare a mixing vs. a cycling strategy of use of anti-Pseudomonas antibiotics on the acquisition of resistant Gram-negative bacilli in the critical care setting.
Prospective, open, comparative study of two strategies of antibiotic use.
Two medical intensive care units of a university hospital.
A total of 346 patients admitted for >or=48 hrs to two separate medical intensive care units during an 8-month period.
Patients, who according to the attending physician's judgment required an anti-Pseudomonas regimen, were assigned to receive cefepime/ceftazidime, ciprofloxacin, a carbapemen, or piperacillin-tazobactam in this order. "Cycling" was accomplished by prescribing one of these antibiotics during 1 month each. "Mixing" was accomplished by using the same order of antibiotic administration on consecutive patients. Interventions were carried out during two successive 4-month periods, starting with mixing in one unit and cycling in the other.
Swabbing of nares, pharynx, and rectum and culture of respiratory secretions were obtained thrice weekly. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention. The scheduled cycling of antibiotics was only partially successful. Although the expected antibiotic was the most prevalent anti-Pseudomonas agent used within the corresponding period, it never accounted for >45% of all anti-Pseudomonas antimicrobials administered. During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07). No differences in the rate of acquisition of potentially resistant Gram-negative bacilli or incidence of intensive care unit-acquired infections and infections due to particular organisms were observed.
In critically ill medical patients, a strategy of monthly rotation of anti-Pseudomonas beta-lactams and ciprofloxacin may perform better than a strategy of mixing in the acquisition of P. aeruginosa resistant to selected beta-lactams.
Critical Care Medicine 03/2006; 34(2):329-36. · 6.33 Impact Factor
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American Journal of Health-System Pharmacy 08/2005; 62(13):1388-9. · 1.96 Impact Factor
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ABSTRACT: Delivery of antibiotics to the lower respiratory tract could potentially achieve antimicrobial bronchial drug concentrations without toxicity.
To assess bronchial and serum concentrations of imipenem or tobramycin obtained by nebulization or instillation in critically ill mechanically ventilated patients.
Prospective randomized open trial. Eighteen patients ventilated for more than 48 h were included. Two doses of imipenem/cilastatin (1000/500 mg) separated by 8 h, or two doses of tobramycin 200 mg separated by 12 h were randomly nebulized or instilled into the tracheal tube. Five bronchoaspirates (two bronchoscopic, three blind) and five blood samples were collected on a timed schedule after the second dose. Respiratory and serum samples were analysed by HPLC, and a subset of blood samples was also evaluated by enzyme-immunoassay.
When instilled, imipenem/cilastatin obtained higher concentrations in respiratory secretions than when nebulized (P=0.022, 1 h after the last dose; P=0.029, 2 h after the last dose). Tobramycin showed equally high concentrations when nebulized or instilled. Instillation of tobramycin may result in significant accumulation in patients with renal failure.
High bronchial concentrations of imipenem could only be achieved by instillation, whereas tobramycin seems suitable for both modes of administration. Instillation of these antibiotics is a safe procedure that achieves high drug concentrations in respiratory secretions.
Journal of Antimicrobial Chemotherapy 09/2004; 54(2):508-14. · 5.07 Impact Factor
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ABSTRACT: This article summarizes the principal characteristics of the drugs used to treat viral infections, with the exception of human immunodeficiency virus infection. It includes antiviral agents active against herpes virus, cytomegalovirus, hepatitis B and C virus, and respiratory viruses, such as influenza and respiratory syncytial virus. Dosage according to the indication, dose adjustment in the case of renal or hepatic insufficiency, significant pharmacokinetic characteristics, and the main adverse effects and interactions are described.
Enfermedades Infecciosas y Microbiología Clínica 11/2003; 21(8):433-57; quiz 458, 467. · 1.49 Impact Factor
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ABSTRACT: The goals of the present study were: a) to identify and characterize drug-related problems (adverse drug reactions, non-compliance and intentional overdose) leading to admissions to our hospital (Hospital Clínic) through the Emergency Department, b) to know the most frequently involved medications, c) to identify risk factors for hospital admissions due to drug-related problems, and d) to determine the avoidability of these admissions.
Prospective study carried out from August 1999 to November 1999 and from January 2000 to May 2000. The study included 1,800 admissions corresponding to 1,663 patients.
Including definitive, probable and possible cases, 215 hospital admissions (11.9%) were drug-related ones. Of these cases, 108 (50.2%) corresponded to adverse drug reactions, 100 (46.5%) to dose-related therapeutic failures (mainly non-compliance) and 7 (3.3%) corresponded to intentional overdose. When 'possible' cases were excluded in order to achieve a better defined causative relationship, drug-related admissions dropped to 139 (7.7%). According to Schumock and Thornton criteria, 68.4% hospital admissions due to drug-related problems were considered 'avoidable'. Most avoidable admissions were due to non-compliance, absence of preventive therapy and inappropriate monitoring.
Hospital admissions due to drug-related problems are frequent and often preventable.
Medicina Clínica 03/2002; 118(6):205-10. · 1.38 Impact Factor
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ABSTRACT: Numerous studies on continuous intravenous infusion of betalactam antibiotics have indicated that this could be a useful strategy for treating nosocomial infections as well as exacerbations of pulmonary infections in patients with cystic fibrosis and episodes of febrile neutropenia. From the pharmacodynamic viewpoint, betalactam antibiotics have a time-dependent behavior. Thus, the pharmacokinetic/pharmacodynamic index that best correlates with therapeutic efficacy appears to be the time during which free antibiotic concentrations remain above the minimum inhibitory concentration (MIC) of the infecting microorganism. Continuous infusion of betalactams successfully optimizes this pharmacokinetic/ pharmacodynamic index. Furthermore, some studies have shown that this therapeutic strategy may be favorable economically.
Enfermedades Infecciosas y Microbiología Clínica 24(7):445-52. · 1.49 Impact Factor
