[Appropriate hospitalization in patients with human immunodeficiency virus infection according to the Appropriateness Evaluation Protocol criteria. Factors related to the inappropriateness]

BASIS

To know the factors associated with the inadequate admissions in patients with human immunodeficiency virus (HIV) infection.

PATIENTS AND METHODS

The adaptation of 710 hospital admissions of patients with HIV infection through the Appropriateness Evaluation Protocol criteria in two hospitals of the Comunidad Valenciana since 1995 to 1997 was analyzed.

RESULTS

One hundred twenty-eight (18%) admissions were considered inadequate. The proportion of inadequate admissions was significantly higher in patients admitted because of constitutional syndrome (OR: 4.12; CI 95%: 2.11-8.05), or because of digestive symptoms (OR: 2.33; CI 95%: 1.46-3.88), and in patients admitted in facilities without day hospital (OR: 2.38; CI 95%: 1.39-3.89). Furthermore, other situations associated with the inappropriateness were the patients with a disease not related to AIDS (OR: 3.13; CI 95%: 1.93-5.08), the patients with oral or esophageal candidiasis (OR: 6.25; CI 95%: 3.08-12.7), the patients with a hospital stay less than 8 days (OR: 2.55; CI 95%: 1.57-4.01), or the patients who no died (OR: 3.61; IC 95%: 1.20-10.82).

CONCLUSIONS

The reason for the admission and the availability of a day hospital unit had influence in the inadequate hospital admissions in this study.

[Etiology of community-acquired pneumonia in ambulatory patients. Usefulness of a diagnostic investigation protocol using detection of Streptococcus pneumoniae and Legionella pneumophila antigens in urine samples]

BACKGROUND

To determine the etiology of community-acquired pneumonia (CAP) in ambulatory patients and to assess the efficiency of a diagnostic protocol by using tests to detect bacterial antigens in urine samples.

PATIENTS AND METHOD

One-year prospective study that included blood and sputum cultures, serologic studies, and detection of Legionella pneumophila and Streptococcus pneumoniae urinary antigens.

RESULTS

49 patients were recruited and an etiological diagnosis was attained in 34 (69%). Microorganisms most frequently isolated were S. pneumoniae (12 cases), Mycoplasma pneumoniae (7), Haemophilus influenzae (4), respiratory viruses (4) and Coxiella burnetii (3 cases).

CONCLUSIONS

By means of a non-invasive protocol with urinary antigen tests, a microbial etiology can be established in two thirds of patients with mild CAP. S. pneumoniae is the main cause of mild CAP.

[The Spanish scientific production about human immunodeficiency virus infection/AIDS. A study through MedLine (1991-1999)]

BACKGROUND

To analyze the research output of Spanish authors on human immunodeficiency virus (HIV) infection/AIDS.

METHODS

Papers published over 1991-1999 which were recorder in the MedLine database (CD-ROM) were selected by using the key words Spain or Espana in the address of author field and HIV, AIDS, VIH or sida in any field. Papers were analyzed according to publication journal specialty of authors, subjecte matter of the paper, institution, center of origin and geographical distribution.

RESULTS

A total of 2,065 papers were studied. Their number doubled, from 148 in 1991 to 295 in 1999 (r = 0.917; p < 0.0001). The number of papers published in foreign journals trebled, from 51 to 182 (r = 0.933; p < 0.001). The journal with the highest number o papers published was Medicina Clínica: 241 (11.7%). Although the main topic was the clinical manifestations of HIV infection (64.6%), the proportion of papers on this subject decreased from 71.4% in 1991-93 to 58.3% in 1997-99 (p < 0.001). On the other hand, the percentage of articles on antiretroviral therapy increased from 3.6% in 1991-93 to 12.4% in 1997-99 (p < 0.001). The greatest number of contributions came from hospitals (79.8% of papers), followed by universities (9.5%). Centers with the highest output were the Hospital Clínic (Barcelona) (5.7%) and the Hospital Carlos III (Madrid) (5.5%). The Autonomous Communities of Madrid (33.1%) and Catalonia (25.3%) concentrated more than half of the total output, followed by Andalusia (11.5%) and the Valencian Community (8.1%).

CONCLUSIONS

Spanish output on HIV infection/AIDS research grew during the 1991-1999 period. There was a remarkable increase in the papers published in foreign journals. Moreover, topics changed according to the epidemiological changes observed in HIV infection during the past decade.

Determinants for the development of oropharyngeal colonization or infection by fluconazole-resistant Candida strains in HIV-infected patients

A point prevalence study to document oral yeast carriage was undertaken. Risk factors for the development of oropharyngeal colonization or infection by fluconazole-resistant Candida strains in HIV-infected patients were investigated with a case-control design. Cases included all patients with fluconazole-resistant strains (MIC> or =64 microg/ml), and controls were those with susceptible (MIC< or =8 microg/ml) or susceptible-dependent-upon-dose (MIC 16-32 microg/ml) strains. One hundred sixty-eight Candida strains were isolated from 153 (88%) patients, 28 (16%) of whom had oropharyngeal candidiasis. Overall, 19 (12%) of the patients harbored at least one resistant organism (MIC > or = 64 microg/ml). Among patients with resistant strains, tuberculosis (P<0.001), esophageal candidiasis (P = 0.001), clinical thrush (P<0.001), and a CD4 + cell count < 200/mm3 (P = 0.03) were more frequent. These patients had also been treated more commonly with antituberculous drugs (adjusted odds ratio [OR] 6.13; 95% confidence interval [CI] 2.11-17.80), ciprofloxacin (OR 6.0; 95% CI 1.23-29.26), fluconazole (OR 4.59; 95% CI 1.55-13.52), and steroids (OR 4.13; 95% CI 1.11-15.39). Multivariate analysis showed that the determinants for fluconazole resistance were therapy with antituberculous drugs (OR 3.61; 95% CI 1.08-12.07; P=0.03) and one of the following: previous tuberculosis (OR 3.53; 95% CI 1.08-14.57; P=0.03) or fluconazole exposure (OR 3.41; 95% CI 1.10-10.54). Findings from this study indicate that treatment with antituberculous drugs, previous tuberculosis, and fluconazole exposure are the strongest determinants for development of oropharyngeal colonization or infection by fluconazole-resistant Candida strains in HIV-infected patients.

[Epidemiology of yeast colonization and oropharyngeal infection other than Candida albicans in patients with HIV infection]

BACKGROUND

An increasing frequency of opportunistic fungal infections in immunosuppressed patients in recent years. Concurrent with this finding, it has been noted an increasing use of fluconazole. In addition, non-Candida albicans species (NCAS), most of which are fluconazole-resistant have been increasing isolated. The aim of this study was to investigate the epidemiology of colonization and infection due to NCAS in HIV-infected patients.

PATIENTS AND METHODS

A cross sectional study was conducted with HIV-infected patients in different stages, who were attended at two hospitals in Alicante, Spain. We assessed the prevalence and microbiology of oropharyngeal colonization and infection due to Candida spp., and its fluconazole susceptibility patterns. To determine the clinical risk factors for the development of fluconazole resistance, we carried out a case-control study with prevalent cases.

RESULTS

We studied 168 strains from 153 patients. NCAS were isolated in 32 (21%) of them, 25 (77%) were colonized, and 5 (26%) had infection due to NCAS. The most common isolate was Candida glabrata (n = 15). MICs were significantly higher for NCAS than for Candida albicans species, with a MIC50 of 16 and 0.25 microgram/ml, respectively, and a MIC90 of 128 micrograms/ml and 8 micrograms/ml (p = 0.0001). The median CD4 cell count in patients with NCAS was 0.06 x 10(9)/l, and 0.19 x 10(9)/l patients with Candida albicans (p = 0.009). Overall, 56% of the patients with NCAS and 41% of the patients with Candida albicans had been treated with fluconazole (p = 0.1).

CONCLUSIONS

NCAS are isolated in a high proportion of HIV infected patients. Most of the NCAS have a decreased susceptibility to fluconazole. The only risk factor associated with the acquisition of NCAS in HIV-infected patients is an advanced immunosuppression.

Endocarditis caused by Stenotrophomonas maltophilia: case report and review

Stenotrophomonas (Xanthomonas) maltophilia is a rare cause of endocarditis. The extensive resistance of this organism to several antibiotics leaves few options for antimicrobial therapy. In vitro synergism of the combination of trimethoprim-sulfamethoxazole (TMP-SMZ) and ticarcillin/clavulanic acid (TIC/CA) has been demonstrated. To our knowledge, we report the first case of ventriculoatrial cerebrospinal fluid shunt-associated endocarditis due to S. maltophilia. The patient was cured with combination therapy with TMP-SMZ and TIC/CA along with catheter removal. This is also the first report of S. maltophilia endocarditis successfully treated with this antibiotic combination. In a review of the medical literature, only 16 cases of S. maltophilia endocarditis were found. Most patients were intravenous drug users (43.8%) or had either prosthetic heart valves (50%) or an indwelling vascular catheter (18.8%). Although S. maltophilia is usually considered a nosocomial pathogen, about one-half of the cases were community-acquired. Twelve of sixteen patients had left-sided endocarditis. Therapy with a combination of two or more antibiotics was employed in most cases. Seven patients had been given TMP-SMZ therapy, but none had been treated with TIC/CA before. One-half of the patients required cardiac surgery. The overall mortality rate was 33%. Although the optimal antibiotic treatment for S. maltophilia endocarditis remains unknown, the case reported herein reinforces in vitro findings that the combination of TMP-SMZ and TIC/CA may be effective therapy.

[Necrotizing histiocytic lymphadenitis (Kikuchi-Fujimoto disease): contribution of 2 cases]

The necrotizing lymphadenitis of Kikuchi-Fujimoto is an uncommon disease in Spain. In a review of the literature we found only five cases reported until 1995. We report here two patients with the diagnosis of this entity in an area hospital during a one-year period. This fact contrasts with the low frequency of this disease reported so far in our country. The cases were two young women who were investigated because of cervical lymph node enlargement and headache. The lymph node biopsy revealed typical findings of the necrotic phase of the Kikuchi-Fujimoto disease in one case; the histology in the other case was characteristic of the so called proliferative phase. The two patients evolved spontaneously with a favorable outcome. Lymph node enlargements resolved in less than three months. All microbiological investigations performed were negative. One of the two patients was receiving intranasal calcitonin when symptoms developed. The incidence of Kikuchi-Fujimoto disease might be higher than considered. The spontaneous resolution of the disease and the requirement of the histological examination for its diagnosis are factors limiting its identification.