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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Magiorakos AP, Burns K, Rodríguez Baño J, Borg M, Daikos G, Dumpis U, Lucet JC, Moro ML, Tacconelli E, Simonsen GS, Szilágyi E, Voss A, Weber JT. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control 2017; 6:113. [PMID: 29163939 PMCID: PMC5686856 DOI: 10.1186/s13756-017-0259-z] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/11/2017] [Indexed: 12/25/2022] Open
Abstract
Background Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E). The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. Methods The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings. Results Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE. Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. Conclusions Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here. This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources. Electronic supplementary material The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A P Magiorakos
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - K Burns
- Beaumont Hospital, Royal College of Surgeons in Ireland & Health Protection Surveillance Centre, Dublin, Ireland
| | - J Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - M Borg
- Departments of Infection Control & Sterile Services, Mater Dei Hospital, MSD2090, Msida, Malta
| | - G Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - U Dumpis
- Department of Infectious diseases and Infection Control. Pauls Stradins University Hospital, Riga, Latvia
| | - J C Lucet
- Infection Control Unit, Bichat Claude Bernard Hospital, AP-HP, Paris, France
| | - M L Moro
- Agenzia Sanitaria e Sociale Regione Emilia-Romagna, Bologna, Italy
| | - E Tacconelli
- Division of Infectious Diseases, Department Internal Medicine 1, DZIF Center, Tübingen University, Tübingen, Germany
| | - G Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, and UiT - The Arctic University of Norway, Tromsø, Norway
| | - E Szilágyi
- Department of Epidemiology and Hospital Hygiene, National Public Health and Medical Officer Service, Budapest, Hungary
| | - A Voss
- Department of Medical Microbiology, Radboud University Medical Centre and Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - J T Weber
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
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Tartari E, Weterings V, Gastmeier P, Rodríguez Baño J, Widmer A, Kluytmans J, Voss A. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control 2017; 6:45. [PMID: 28507731 PMCID: PMC5427557 DOI: 10.1186/s13756-017-0202-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/03/2017] [Indexed: 12/11/2022] Open
Abstract
Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.
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Affiliation(s)
- E Tartari
- Infection Control Program and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - V Weterings
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P Gastmeier
- Institute of Hygiene and Environmental Medicine, Charite ´ University Medicine in Berlin, Berlin, Germany
| | - J Rodríguez Baño
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena/Instituto de Biomedicina de Sevilla (IBiS)/CSIC/Universidad de Sevilla, Seville, Spain
| | - A Widmer
- University Hospital and University of Basel, Division of infectious diseases & hospital epidemiology, Basel, Switzerland
| | - J Kluytmans
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.,Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - A Voss
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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López-Cortés LE, Cisneros JM, Fernández-Cuenca F, Bou G, Tomás M, Garnacho-Montero J, Pascual A, Martínez-Martínez L, Vila J, Pachón J, Rodríguez Baño J. Monotherapy versus combination therapy for sepsis due to multidrug-resistant Acinetobacter baumannii: analysis of a multicentre prospective cohort. J Antimicrob Chemother 2014; 69:3119-26. [PMID: 24970742 DOI: 10.1093/jac/dku233] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment of multidrug-resistant Acinetobacter baumannii (MDRAB) infection presents a challenge because of the scarcity of available options. Even though combination therapy (CT) is frequently used in clinical practice, data are needed to support its use instead of monotherapy (MT). METHODS A prospective observational study was conducted in 28 Spanish hospitals. Patients with sepsis caused by MDRAB, defined according to strict criteria, and who received active antibiotic treatment (according to in vitro susceptibility testing) for at least 48 h, were included. The main outcome variable was all-cause 30 day mortality after initiation of targeted therapy. Multivariate analysis, including a propensity score (for receiving CT), was performed by Cox regression. RESULTS One hundred and one patients were included in the analysis; 68 (67.3%) received MT and 33 (32.7%) received CT. Pneumonia was the most common infection (50.5%), 68.6% of cases being associated with mechanical ventilation. Colistin (67.6%) and carbapenems (14.7%) were the most common drugs used in MT; colistin plus tigecycline (27.3%) and carbapenem plus tigecycline (12.1%) were the most frequent combinations. Crude 30 day mortality was 23.5% and 24.2% for the MT and CT groups, respectively (RR = 1.03; 95% CI 0.49-2.16; P = 0.94). Multivariate analysis of 30 day survival showed no trend towards reduced 30 day mortality with CT (HR = 1.35; 95% CI 0.53-3.44; P = 0.53). Subgroup analysis showed similar results. CONCLUSIONS Our data do not support an association of CT with reduced mortality in MDRAB infections. More data for specific types of infection and combinations are needed.
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Affiliation(s)
- L E López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain
| | - J M Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - F Fernández-Cuenca
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain
| | - G Bou
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - M Tomás
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - J Garnacho-Montero
- Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain Unidad de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Pascual
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - L Martínez-Martínez
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain Departamento de Biología Molecular, Universidad de Cantabria, Santander, Spain
| | - J Vila
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain
| | - J Pachón
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - J Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
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Pulcini C, Kern W, Nathwani D, Rodríguez Baño J, Simonsen GS, Vlahović-Palĉevski V, Gyssens IC. M-03: Enquête européenne sur les programmes d’enseignement des principes de bon usage des antibiotiques aux étudiants en médecine. Med Mal Infect 2014. [DOI: 10.1016/s0399-077x(14)70240-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rodríguez-Martínez JM, Díaz de Alba P, Briales A, Machuca J, Lossa M, Fernández-Cuenca F, Rodríguez Baño J, Martínez-Martínez L, Pascual Á. Contribution of OqxAB efflux pumps to quinolone resistance in extended-spectrum-β-lactamase-producing Klebsiella pneumoniae. J Antimicrob Chemother 2012; 68:68-73. [PMID: 23011289 DOI: 10.1093/jac/dks377] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aims of this study were to analyse the presence of oqxA and oqxB genes in a collection of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae strains, to determine their chromosomal and/or plasmidic locations and to analyse expression levels in relation to susceptibility or resistance to quinolones. METHODS A collection of 114 non-repetitive isolates of ESBL-producing K. pneumoniae was used. K. pneumoniae ATCC 27799 and K. pneumoniae ATCC 700603 were also included. Detection of oqxA and oqxB genes was performed by PCR. Testing for chromosomal and/or plasmidic location was carried out using plasmid DNA and subsequent hybridization. oqxA gene expression was analysed using real-time RT-PCR. Transfer of the plasmid-encoded OqxAB was evaluated. RESULTS The prevalence of both oqxA and oqxB detected in K. pneumoniae was high: 76% and 75%, respectively. Hybridization assays showed that oqxA (16%) and oqxB (13%) were simultaneously present in locations on the chromosome and on large plasmids. The plasmids were transferable by transformation into K. pneumoniae. RT-PCR assays showed higher expression (4-fold) in strains with reduced susceptibility to quinolones than in susceptible strains. Interestingly, K. pneumoniae ATCC 700603 showed an 18-fold higher expression than K. pneumoniae ATCC 27799. These differences were in accordance with quinolone susceptibility. CONCLUSIONS The prevalence of the OqxAB efflux pump (both chromosomal and plasmid encoded) in ESBL-producing K. pneumoniae is high in Spain and represents a potential reservoir for the spread of these genes. High expression of this pump contributes to reduced susceptibility to quinolones in clinical isolates of ESBL-producing K. pneumoniae.
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Salamanca Rivera E, Rodríguez Baño J, Guzmán Robles A. [Pregnant women with complete atelectasia of the left lung and cardiac tamponade]. Rev Clin Esp 2009; 209:449-50. [PMID: 19852917 DOI: 10.1016/s0014-2565(09)72520-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- E Salamanca Rivera
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla
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Rodríguez Baño J. [How long will multiresistance be only an emerging problem?]. Rev Esp Quimioter 2006; 19:89. [PMID: 16688301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- J Rodríguez Baño
- Sección de Enfermedades Infecciosas, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Escorial Moya C, Rodríguez Baño J, Borobio MV, Izquierdo G. [Opsoclonus secondary to encephalopolyradiculoneuritis due to Mycoplasma pneumoniae]. Neurologia 2004; 19:74-6. [PMID: 14986184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Opsoclonus is characterized by sudden onset of arrhythmic, multidirectional chaotic eye movements, generally associated with a parainfectious or paraneoplasic condition. Opsoclonus is a rare manifestation with no known link with infection by Mycoplasma pneumoniae. We present a case of a 23 year old male patient who presented fever, myalgia, vomiting, respiratory failure, opsoclonus and symmetric flaccid tetraparesis with important lower limb muscle atrophy. Serology and seroreversion for M. pneumoniae were both positive. This case illustrates the possibility that M. pneumoniae may produce a predominantly neurological disease and the need to include this infection in the differential diagnosis of opsoclonus, or polyradiculoneuritis.
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Affiliation(s)
- C Escorial Moya
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, Spain.
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