[Show abstract][Hide abstract] ABSTRACT: The most common cause of implant failure is aseptic loosening (AL), followed by prosthetic joint infection (PJI). This study evaluates the incidence of PJI among patients operated with suspected AL and whether the diagnosis of PJI was predictive of subsequent implant failure including re-infection, at 2 years of follow up.
Patients undergoing revision hip or knee arthroplasty due to presumed AL from February 2009 to September 2011 were prospectively evaluated. A sonication fluid of prosthesis and tissue samples for microbiology and histopathology at the time of the surgery were collected. Implant failure include recurrent or persistent infection, reoperation for any reason or need for chronic antibiotic suppression.
Of 198 patients with pre-and intraoperative diagnosis of AL, 24 (12.1 %) had postoperative diagnosis of PJI. After a follow up of 31 months (IQR: 21 to 38 months), 9 (37.5 %) of 24 patients in the PJI group had implant failure compared to only 1 (1.1 %) in the 198 of AL group (p < 0.0001). Sensitivity of sonicate fluid culture (>20 CFU) and peri-prosthetic tissue culture were 87.5 % vs 66.7 %, respectively. Specificities were 100 % for both techniques (95 % CI, 97.9-100 %). A greater number of patients with PJI (79.1 %) had previous partial arthroplasty revisions than those patients in the AL group (56.9 %) (p = 0.04). In addition, 5 (55.5 %) patients with PJI and implant failure had more revision arthroplasties during the first year after the last implant placement than those patients with PJI without implant failure (1 patient; 6.7 %) (RR 3.8; 95 % CI 1.4-10.1; p = 0.015). On the other hand, 6 (25 %) patients finally diagnosed of PJI were initially diagnosed of AL in the first year after primary arthroplasty, whereas it was only 16 (9.2 %) patients in the group of true AL (RR 2.7; 95 % CI 1.2-6.1; p = 0.03).
More than one tenth of patients with suspected AL are misdiagnosed PJI. Positive histology and positive peri-implant tissue and sonicate fluid cultures are highly predictive of implant failure in patients with PJI. Patients with greater number of partial hip revisions for a presumed AL had more risk of PJI. Early loosening is more often caused by hidden PJI than late loosening.
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to describe the epidemiologic and clinical characteristics and identify the risk factors of short-term and 1-year mortality in a recent cohort of patients with infective endocarditis (IE).From January 2008, multidisciplinary teams have prospectively collected all consecutive cases of IE, diagnosed according to the Duke criteria, in 25 Spanish hospitals.Overall, 1804 patients were diagnosed. The median age was 69 years (interquartile range, 55-77), 68.0% were men, and 37.1% of the cases were nosocomial or health care-related IE. Gram-positive microorganisms accounted for 79.3% of the episodes, followed by Gram-negative (5.2%), fungi (2.4%), anaerobes (0.9%), polymicrobial infections (1.9%), and unknown etiology (9.1%). Heart surgery was performed in 44.2%, and in-hospital mortality was 28.8%. Risk factors for in-hospital mortality were age, previous heart surgery, cerebrovascular disease, atrial fibrillation, Staphylococcus or Candida etiology, intracardiac complications, heart failure, and septic shock. The 1-year independent risk factors for mortality were age (odds ratio [OR], 1.02), neoplasia (OR, 2.46), renal insufficiency (OR, 1.59), and heart failure (OR, 4.42). Surgery was an independent protective factor for 1-year mortality (OR, 0.44).IE remains a severe disease with a high rate of in-hospital (28.9%) and 1-year mortality (11.2%). Surgery was the only intervention that significantly reduced 1-year mortality.
Medicine 10/2015; 94(43):e1816. DOI:10.1097/MD.0000000000001816 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Streptococcus pneumoniae is an infrequent cause of severe infectious endocarditis (IE). The aim of our study was to describe the epidemiology, clinical and microbiological characteristics, and outcome of a series of cases of S. pneumoniae IE diagnosed in Spain and in a series of cases published since 2000 in the medical literature.We prospectively collected all cases of IE diagnosed in a multicenter cohort of patients from 27 Spanish hospitals (n = 2539). We also performed a systematic review of the literature since 2000 and retrieved all cases with complete clinical data using a pre-established protocol. Predictors of mortality were identified using a logistic regression model.We collected 111 cases of pneumococcal IE: 24 patients from the Spanish cohort and 87 cases from the literature review. Median age was 51 years, and 23 patients (20.7%) were under 15 years. Men accounted for 64% of patients, and infection was community-acquired in 96.4% of cases. The most important underlying conditions were liver disease (27.9%) and immunosuppression (10.8%). A predisposing heart condition was present in only 18 patients (16.2%). Pneumococcal IE affected a native valve in 93.7% of patients. Left-sided endocarditis predominated (aortic valve 53.2% and mitral valve 40.5%). The microbiological diagnosis was obtained from blood cultures in 84.7% of cases. In the Spanish cohort, nonsusceptibility to penicillin was detected in 4.2%. The most common clinical manifestations included fever (71.2%), a new heart murmur (55%), pneumonia (45.9%), meningitis (40.5%), and Austrian syndrome (26.1%). Cardiac surgery was performed in 47.7% of patients. The in-hospital mortality rate was 20.7%. The multivariate analysis revealed the independent risk factors for mortality to be meningitis (OR, 4.3; 95% CI, 1.4-12.9; P < 0.01). Valve surgery was protective (OR, 0.1; 95% CI, 0.04-0.4; P < 0.01).Streptococcus pneumoniae IE is a community-acquired disease that mainly affects native aortic valves. Half of the cases in the present study had concomitant pneumonia, and a considerable number developed meningitis. Mortality was high, mainly in patients with central nervous system (CNS) involvement. Surgery was protective.
Medicine 10/2015; 94(39):e1562. DOI:10.1097/MD.0000000000001562 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery.
Prospective cohort study, conducted from 1984-2013 in 26 Spanish hospitals.
A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p < 0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23 - 1.85; p< 0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery.
Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.
The Journal of infection 09/2015; 71(6). DOI:10.1016/j.jinf.2015.09.005 · 4.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hydatidosis or cystic echinococcosis (CE) is a parasitic zoonosis caused by Echinococcus granulosus. Its life cycle involves dogs, sheep and sometimes other animals. CE has a worldwide distribution, with greater prevalence in temperate zones. In Spain, Castile and León, La Rioja, Navarre, Aragón, and the Mediterranean coast are the areas where it is most commonly diagnosed, although there have also been published cases in other regions, such as Cantabria. Clinical signs and symptoms of EC may be related to the mass effect of the cyst, its superinfection or anaphylactic reactions secondary to its rupture. Because of its slow growth, diagnosis is usually made in adulthood by combining clinical symptoms with imaging and serological tests. There is no universal consensus on the management of CE. Treatment is based mainly on three pillars: medical treatment (mainly albendazole), surgery, and percutaneous drainage. The choice of the most appropriate approach is based on the patient's symptoms and the characteristics of the cysts.
Revista espanola de quimioterapia: publicacion oficial de la Sociedad Espanola de Quimioterapia 06/2015; 28(3):116-124. · 0.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and objectives: Among patients with bacteraemia due to S. aureus, persistence of positive blood cultures after 2-3 days of active therapy (persistent bacteraemia or PB) is considered a marker for complicated SAB. PB may be related bacterial determinants, hosts' features, or clinical management. The aim of this analysis is to investigate the hosts' and management variables associated to PB despite an adequate targeted therapy and early source control. Methods: Prospective cohort of SAB from 12 tertiary Spanish hospitals between 2008 and 2011. Two analyses were performed; (a) including only patients in whom follow-up blood cultures (FUBC) were performed 48-72 hours after start of active therapy; and (b) including all patients with SAB (those without FUBC were considered not to have PB). Those cases who died before 72 hours and those receiving palliative care for terminal conditions were excluded. Univariate analyses were performed by Chi-square test, and multivariate analyses by logistic regression. Results: 292 of the 496 (58.9%) included patients had FUBC; of them, 91 (31.2%) had PB. In the univariate analysis, PB was associated with high 14-day (RR 1.74; 95% CI 0.93-3.25, p= 0.08) and 30-day crude mortality (RR 1.77; 95% CI 1.03-3.01, p= 0.04). The variables associated with PB in multivariate analysis were a Pitt score >2 (OR 2.69; 95% CI: 1.13-6.37, p=0.03), skin and soft tissue infection as a source (OR 2.75; 95% CI: 0.87-8.65, p=0.08), and presence of septic metastasis (OR 3.45; 95% CI: 1.00-11.83, p=0.05). MRSA, early active therapy, and early source control were not associated. Among the whole series of patients with SAB (n=496), the variables associated with PB in multivariate analysis were a Pitt score >2 (OR 3.43; 95% CI: 1.62-7.27, p=0.001), skin and soft tissue infection as a source (OR 3.76; 95% CI: 1.35-10.46, p=0.01), presence of septic metastasis (OR 2.42; 95% CI: 0.90-6.46, p=0.08), and endocarditis diagnosis during the course of the SAB (OR 2.60; 95% CI: 0.99-6.84, p=0.05). Conclusion: The frequency of PB was high. The clinical variables associated with PB at the diagnosis were the severity of illness assessed by Pitt score and the skin and soft tissue source. The presence or development of septic metastasis during the bacteraemia and infectious endocarditis were also associated. It is crucial to performance FUBC because the presence of PB has clinical management and prognosis implications.
25th European Congress of Clinical Microbriology and Infectious Diseases, Copenhagen, Denmark; 04/2015
[Show abstract][Hide abstract] ABSTRACT: This cross-sectional study analyzes factors associated with the development of CMV-specific CD8+ response, measured by IFNg production after cytomegalovirus (CMV) peptide stimulation, in CMV-seropositive solid organ transplantation candidates. A total of 114 candidates were enrolled, of whom 22.8% (26/114) were nonreactive (IFNγ < 0.2 IU/mL). Multivariate logistic regression analysis showed that age, HLA alleles and organ to be transplanted were associated with developing CMV-specific CD8+ immunity (reactive; IFNγ ≥ 0.2 IU/mL). The probability of being reactive was higher in candidates over 50 than in those under 50 (OR 6.33, 95%CI 1.93–20.74). Candidates with HLA-A1 and/or HLA-A2 alleles had a higher probability of being reactive than those with non-HLA-A1/non-HLA-A2 alleles (OR 10.97, 95%CI 3.36–35.83). Renal candidates had a higher probability of being reactive than lung (adjusted OR 8.85, 95%CI 2.24–34.92) and liver candidates (OR 4.87, 95%CI 1.12–21.19). The AUC of this model was 0.84 (p < 0.001). Positive and negative predictive values were 84.8% and 76.9%, respectively. In renal candidates longer dialysis was associated with an increased frequency of reactive individuals (p = 0.040). Therefore, although the assessment of CMV-specific CD8+ response is recommended in all R+ candidates, it is essential in those with a lower probability of being reactive, such as non-renal candidates, candidates under 50 or those with non-HLA-A1/non-HLA-A2 alleles.
American Journal of Transplantation 02/2015; 15(3). DOI:10.1111/ajt.13012 · 5.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The safety and efficacy of treatment of infectious endocarditis (IE) was evaluated within a program of hospital-in-home (HIH) based on self-administered outpatient parenteral antimicrobial therapy (S-OPAT). IE episodes (n = 48 in 45 patients; 71% middle-aged males) were recruited into the HIH program between 1998 and 2012. Following treatment stabilization at the hospital they returned home for HIH in which a physician and/or a nurse supervised the S-OPAT. Safety and efficacy were evaluated as mortality, re-occurrence, and unexpected re-admission to hospital. Of the episodes of IE, 83.3% had comorbidities with a mean score of 2.3 on the Charlson index and 1.5 on the Profund index; 60.4% had pre-existing valve disease (58.6% having had surgical intervention); 8.3% of patients had suffered a previous IE episode; 62.5% of all episodes affected a native valve; 45.8% being mitral; 70.8% of infection derived from the community. In 75% of the episodes there was micro-organism growth, of which 83.3% were Gram positive. Overall duration of antibiotic treatment was 4.8 weeks; 60.4% of this time corresponding to HIH. Re-admission occurred in 12.5% of episodes of which 33.3% returned to HIH to complete the S-OPAT. No deaths occurred during HIH. One year after discharge, 2 patients had recurrence and 5 patients died, in 2 of whom previous IE as cause-of-death could not be excluded. In conclusion, the S-OPAT schedule of hospital-in-home is safe and efficacious in selected patients with IE.
European Journal of Internal Medicine 01/2015; 26(2). DOI:10.1016/j.ejim.2015.01.001 · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the results of the treatment with pegylated interferon and ribavirin for recurrence of hepatitis C after liver transplantation in HCV/HIV-coinfected patients.
Journal of Hepatology 08/2014; DOI:10.1016/j.jhep.2014.07.034 · 11.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims
Surgery for infective endocarditis (IE) is associated with high mortality. Our objectives were to describe the experience with surgical treatment for IE in Spain, and to identify predictors of in-hospital mortality.
Prospective cohort of 1000 consecutive patients with IE. Data were collected in 26 Spanish hospitals.
Surgery was performed in 437 patients (43.7%). Patients treated with surgery were younger and predominantly male. They presented fewer comorbid conditions and more often had negative blood cultures and heart failure. In-hospital mortality after surgery was lower than in the medical therapy group (24.3 vs 30.7%, p = 0.02). In patients treated with surgery, endocarditis involved a native valve in 267 patients (61.1%), a prosthetic valve in 122 (27.9%), and a pacemaker lead with no clear further valve involvement in 48 (11.0%). The most common aetiologies were Staphylococcus (186, 42.6%), Streptococcus (97, 22.2%), and Enterococcus (49, 11.2%). The main indications for surgery were heart failure and severe valve regurgitation. A risk score for in-hospital mortality was developed using 7 prognostic variables with a similar predictive value (OR between 1.7 and 2.3): PALSUSE: prosthetic valve, age ≥ 70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE ≥ 10. In-hospital mortality ranged from 0% in patients with a PALSUSE score of 0 to 45.4% in patients with PALSUSE score >3.
The prognosis of IE surgery is highly variable. The PALSUSE score could help to identify patients with higher in-hospital mortality.
International Journal of Cardiology 07/2014; DOI:10.1016/j.ijcard.2014.04.266 · 4.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Corynebacteria are mostly harmless, however, there is more and more evidence of its pathogenicity, especially as a cause of nosocomial infection in immunocompromised patients. Is the most important genus, Corynebacterium diptheriae is the most important species. Humans are the only known reservoir of diphtheria and respiratory tract the main source of transmission. The tonsillar and pharyngeal involvement is the most common clinical form. The clinical efficacy of the vaccine is 97 %. Fermentative not lipophilic corynebacteria (C. striatum, C. amycolatum) and lipophilic (C. jeikeium, C. urealyticum) are mainly related to nosocomial infections. Infections with Bacillus spp. traditionally have been limited to Bacillus anthracis anthrax responsible, a zoonosis caused by the entry of spores through skin abrasions, inhalation or ingestion of the same, which depend on its clinical forms and Bacillus cereus producing both disease as localized gastrointestinal infection. Listeria monocytogenes is an intracellular pathogen with a predilection for patients with impaired cellular immunity (pregnant and immunocompromised). The digestive tract is the most common portal of entry. The definitive diagnosis is made by culture. The clinical picture varies from meningitis, sepsis, perinatal and local infections. The treatment of choice is ampicillin to that associated gentamicin.
Medicine - Programa de Formación Médica Continuada Acreditado 06/2014; 11(59):3493–3504. DOI:10.1016/S0304-5412(14)70805-4
[Show abstract][Hide abstract] ABSTRACT: IntroductionInfections caused by resistant gram-positive cocci (GPC), especially to glycopeptides, are difficult to treat in solid organ transplant (SOT) recipients as a result of lower effectiveness and high rates of renal impairment. The aim of this study was to evaluate the use of daptomycin in this population.Methods
Over a 2-year period (March 2008–2010) in 9 Spanish centers, we enrolled all consecutive recipients who received daptomycin to treat GPC infection. The study included 43 patients, mainly liver and kidney transplant recipients.ResultsThe most frequent infections were catheter-related bacteremia caused by coagulase-negative staphylococci (23.2%), skin infection caused by Staphylococcus aureus (11.5%), and intra-abdominal abscess caused by Enterococcus faecium (20.9%). The daily daptomycin dose was 6 mg/kg in 32 patients (74.4%). On day 7 of daptomycin treatment, median estimated area under the curve was 1251 μg/mL/h. At the end of follow-up, analytical parameters were similar to the values at the start of therapy. No changes were observed in tacrolimus levels. No patient required discontinuation of daptomycin because of adverse effects. Clinical success at treatment completion was achieved in 37 (86%) patients. Three patients died while on treatment with daptomycin.Conclusion
In summary, daptomycin was a safe and useful treatment for GPC infection in SOT recipients.
[Show abstract][Hide abstract] ABSTRACT: Background. Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. Several aspects of clinical management have been shown to have significant impact on prognosis. The objective of the study was to identify evidence-based quality-of-care indicators (QCIs) for the management of SAB, and to evaluate the impact of a QCI-based bundle on the management and prognosis of SAB. Methods. A systematic review of the literature to identify QCIs in the management of SAB was performed. Then, the impact of a bundle including selected QCIs was evaluated in a quasi-experimental study in 12 tertiary Spanish hospitals. The main and secondary outcome variables were adherence to QCIs and mortality. Specific structured individualized written recommendations on 6 selected evidence-based QCIs for the management of SAB were provided. Results. A total of 287 and 221 patients were included in the preintervention and intervention periods, respectively. After controlling for potential confounders, the intervention was independently associated with improved adherence to follow-up blood cultures (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.78-4.49), early source control (OR, 4.56; 95% CI, 2.12-9.79), early intravenous cloxacillin for methicillin-susceptible isolates (OR, 1.79; 95% CI, 1.15-2.78), and appropriate duration of therapy (OR, 2.13; 95% CI, 1.24-3.64). The intervention was independently associated with a decrease in 14-day and 30-day mortality (OR, 0.47; 95% CI, .26-.85 and OR, 0.56; 95% CI, .34-.93, respectively). Conclusions. A bundle orientated to improving adherence to evidence-based QCIs improved the management of patients with SAB and was associated with reduced mortality.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine vaccination rates against influenza and pneumococcus in a large cohort of adults hospitalized with confirmed influenza A(H1N1)pdm09 infection, and to identify differences in clinical features, frequency of bacterial coinfection, and outcomes between vaccinated and non-vaccinated patients. A prospective cohort study conducted at 14 teaching hospitals in Spain. Adult patients (n=699) hospitalized with confirmed influenza A(H1N1)pdm09 infection during the pandemic and the first post
pandemic influenza periods were included. Vaccination status against influenza and pneumococcus was established in 547 and 587individuals, respectively. The vaccination rates were low: 14% for seasonal influenza and 5.4% for pneumococcus. Despite conducting whole population and subgroup multivariate analyses, we observed no beneficial effects on outcomes (intensive care unit admission and mortality) for both vaccines. However, patients who had been vaccinated, whether against influenza or pneumococcus, did tend todevelop fewer bacterial coinfections, particularly that due to S. pneumoniae.