Post-surgical enterococcal meningitis: Clinical and epidemiological study of 20 cases

Enterococcal post-surgical meningitis is an uncommon disease. 20 episodes of nosocomial post-surgical enterococcal meningitis diagnosed between 1994 and 2003 were retrospectively studied. During the period of study 20 cases of post-surgical enterococcal meningitis (60% female, mean age 55+/-18 y, range 16-78 y) were reviewed. The mean time between admission at the hospital and surgery was 26 (SD = 15) d (range 7-61 d). The most frequent underlying diseases were: intracerebral haemorrhage (55%), brain neoplasms (25%), head trauma (15%) and hydrocephalus (5%). 11 patients had previously received antibiotic treatment. The isolates identified were Enterococcus faecalis (n = 18) (90%), E. faecium (1) and E. durans (1). 11 patients had polymicrobial infections. The treatment most frequently used was vancomycin alone or with other antibiotics (11). In 5 patients intrathecal vancomycin (20 mg/d) was also added. The mortality rate was not different in intrathecally treated patients. Cerebrospinal fluid (CSF) devices were removed in 8 patients. Four patients died due to the infection. Mortality was significantly associated with lack of removal of the CSF devices (p = 0.04). Enterococcal spp. are a cause of nosocomial meningitis associated with neurosurgical procedures and the presence of neurological devices.

Therapeutic immunization with an inactivated HIV-1 Immunogen plus antiretrovirals versus antiretroviral therapy alone in asymptomatic HIV-infected subjects

To determine whether the addition of an inactivated-gp120-depleted HIV-1 Immunogen to antiretrovirals (ARTs) conferred a beneficial effect on delaying time to virologic failure relative to that obtained by ARTs alone, a phase II clinical trial was performed in 243 asymptomatic, ART naïve, HIV-1 seropositive adults. The Cox model showed that HIV-1 Immunogen treatment was associated with a 34% decrease in the risk of virologic failure (P = 0.056). When the analysis incorporated baseline HIV-RNA stratification the risk of virologic failure in the HIV-1 Immunogen Arm was significantly reduced a 37% compared to the IFA placebo Arm (P = 0.034). The data suggest that therapeutic immunization plus ARTs could influence virologic control.

Eikenella corrodens brain abscess after repeated periodontal manipulations cured with imipenem and neurosurgery

Eikenella corrodens is a facultatively anaerobic gram-negative rod that colonizes the oral cavity and very rarely produces central nervous system (CNS) infections. Frontal lobe abscesses are occasionally associated with a dental source of infection. We report a case of an adult man with overzealous dental cleaning habits who developed a right frontal brain abscess caused by E. corrodens. He underwent neurosurgical drainage of the pus and was successfully treated with imipenem 4 g/i.v./day for 4 weeks with no complications. Repeated periodontal trauma could explain the Eikenella brain abscess in this case.

[Postsurgical meningitis caused by Acinetobacter baumannii: study of 22 cases and review of the literature]

BACKGROUND

Postsurgical Acinetobacter baumannii meningitis is associated with relevant morbidity and mortality. It has been related to neurosurgery, intraventricular catheters (IC) or CSF fistula. Thus, features, epidemiology and clinical course of this infection were studied.

METHODS

Retrospective analysis of 22 episodes of nosocomial postsurgical Acinetobacter baumannii meningitis. Twenty episodes occurred in males. The mean age of patients was 46 years (range: 16-83 years).

RESULTS

All patients were admitted to the ICU. In 50% of patients a history of intraventricular hemorrhage was recorded, 36% had had a skull fracture and the remaining patients had a brain tumor. In 18 cases the portal of entry was considered to be IC, in two an epidural catheter, and in two a CSF fistula. Patients showed a clinical picture indistinguishable from other types of meningitis, fever being the most common symptom (100%). CSF findings were consistent with bacterial meningitis. In one case the microorganism was recovered from blood. Fifteen patients recovered, three died as a direct result of the infection, and the remaining patients relapsed. Non recovery of patients was significantly associated with non removal of catheter (p < 0.05).

CONCLUSIONS

Postsurgical Acinetobacter baumannii meningitis occurs frequently in patients previously colonized with this microorganism in other sites and is enhanced by the presence of an IC. Catheter removal is essential for recovery of patients.

Visceral leishmaniasis and other severe infections in an adult patient with p47-phox-deficient chronic granulomatous disease

We report a rare case of a male patient without known immunodeficiency consecutively diagnosed with visceral leishmaniasis, brain abscess and cavitating pneumonia in the 3rd decade of life. Chronic granulomatous disease (CGD) was diagnosed by a nitroblue tetrazolium test. A p47-phox mutation of the NADPH oxidase of the leukocytes was suspected by immunoblotting and confirmed by DNA analysis. The patient was homozygous for this mutation while his mother and sister were heterozygous asymptomatic carriers. After the CGD diagnosis the patient started a chronic prophylactic regimen with subcutaneous interferon-gamma (0.05 mg/m2 of body surface/three times a week), and oral trimethoprim-sulfamethoxazole and itraconazole (both at 5 mg/kg/day) with no subsequent infections after 12 months of follow-up.

[Progressive multifocal leukoencephalopathy associated with human immunodeficiency virus infection: the clinical, neuroimaging, virological and evolutive characteristics in 35 patients]

BACKGROUND

The clinical, neuroimaging, virologic and evolutive characteristics of progressive multifocal leukoencephalopathy (PML) in 35 AIDS patients are studied.

PATIENTS AND METHODS

PML was diagnosed by clinical and neuroimaging criteria in 32 patients and by autopsy in other three. The detection of JC virus (JCV) was done by PCR and further hybridization of the amplified DNA in peripheral blood lymphocytes, urine and CSF.

RESULTS

127 of 930 HIV positive patients were admitted by neuropsychiatric symptoms and of them 35 (SD 27.6%) by PML. The PML patients had a mean CD4 lymphocytes count of 75.3 (82.0)/x 10(6)/l and a HIV viral load of 330,698 (538,971) copies of RNA/ml. Thirty patients did not receive any anti-retroviral therapy or only transcriptase inhibitors monotherapy and five triple anti-retroviral therapy, including a proteases inhibitor. Multiple hypodense lesions on CT (53.1%) and T2 hyperintense lesions on MRI (58.3%) were the most frequent neuroimaging findings. JCV was detected in 20/21 (95.2%) LMP patients: 18/19 detections in lymphocytes, 6/8 in CSF and 4/6 in urine. The mean survival without and with antiretroviral therapy were 3.0 (0.47) and 21.4 (4.4) months (p < 0.001) in 34 patients followed. PML progressed to death in 31/34 patients (91.2%), and remained stable in 3/34 (8.8%). A patient was lost for follow-up.

CONCLUSIONS

The application of clinical and neuroimaging criteria and the detection of JCV in CSF are useful for high presumption diagnosis of PML without brain biopsies. JCV detection in lymphocytes and in urine have a much lower predictive value. The evolution and survival of this disease can improve with triple anti-retroviral therapy including a protease inhibitor.

[The prognostic value of cytomegalovirus antigenemia and viremia for the development of cytomegalovirus disease and the survival of AIDS patients]

OBJECTIVES

To analyse risk factors for morbidity and survival associated with blood cytomegalovirus (CMV) detection with the antigenemia method among AIDS patients.

PATIENTS AND METHODS

CMV antigenemia and CMV blood cultures in 277 AIDS patients IgG-CMV sero-positive with a CD4 level lower than 200 x 10(6)/l under antiretroviral monotherapy were analysed. We consider cases the 116 patients with one or more positive blood samples tested for pp65 antigenemia or CMV culture. They were matched with 161 control patients with negative antigenemia or viremia.

RESULTS

Multivariate analysis pointed out a significant positive association for blood CMV reactivation with the following variables: CMV disease development and CMV urine detection, sex-acquired HIV infection, CD4+ < 50 x 10(6)/l and matched time from AIDS diagnosis to CMV blood culture correlated with positive antigenemias. Quantitative antigenemia title showed predictive value for risk of CMV disease although 23% of retinitis patients had persistent undetectable antigenemia. CMV invasive disease developed in 48% of cases and 11% of controls (relative risk [RR]: 7.9; 95% confidence interval [CI]: 4.2-14.7). Mortality after 12 months of follow-up was 73% vs 52% respectively (p < 0.001). Time survival curves after CD4+ count adjusting remained significantly lower for case patients (median, 127 days vs 355 days; p < 0.01 by log-rank test). Increased death rate was found in patients with CMV disease (74%), followed by patients with CMV antigenemia but no disease (70%) and patients without antigenemia or CMV disease (mortality 49%).

CONCLUSIONS

CMV blood detection in AIDS patients may be considered as a bad prognosis marker for CMV morbidity and survival. This risk increases with higher CMV antigenemias. Therefore, pre-emptive anti-CMV therapy should be considered in this restricted population.

Cytomegalovirus antigenemia surveillance in the treatment of cytomegalovirus disease in AIDS patients

OBJECTIVE

Surveillance of quantitative cytomegalovirus (CMV) antigenemia among AIDS patients with CMV treated complications in order to determine its value in assessing the response to treatment and survival.

METHODS

A longitudinal follow-up of antigenemia measurement at diagnosis, after induction therapy with ganciclovir or foscarnet, and every 3 months during maintenance therapy was carried out in 25 patients with CMV retinitis and in 8 with extraocular CMV disease. Positive antigenemia was defined as the presence of any amount of immunofluorescent pp65-positive leukocytes/10(5) cells.

RESULTS

Mean antigenemia values were: 77+/-148/10(5) leukocytes at retinitis diagnosis; 45+/-114 after induction therapy; and 7+/-18 and 1.5+/-4 after 6 months and one year of therapy, respectively. Patients achieving undetectable antigenemia increased from 44% at baseline to 68% at postinduction and 80% during follow-up. Seven patients (28%) who remained free of relapses presented significant minor baseline antigenemias and became negative after induction therapy. Patients with extraocular disease showed erratic antigenemia values and absent therapeutic response. CMV blood cultures before and after induction therapy were positive in 39% and 21% of patients, respectively. Kaplan-Meier analysis revealed a significantly longer survival for patients with retinitis when compared to those with extraocular complications, and for patients with negative antigenemia after induction in comparison with those who failed to achieve it.

CONCLUSIONS

Low basal antigenemia and antigenemia clearance after induction therapy are variables directly related to good response to treatment and survival. Continuous surveillance of antigenemia during treatment could permit designing of individual strategies to obtain a better response.

Successful intrathecal ethanol block for intractable spasticity of AIDS-related progressive multifocal leukoencephalopathy

OBJECTIVE

To study the efficacy of intrathecal ethanol block to relieve intractable spasticity in AIDS-related progressive multifocal leukoencephalopathy (PML) when long-term intrathecal baclofen infusion cannot be used.

METHODS

A 33-year-old man with AIDS-related PML developed very severe spastic paraparesis (Ashworth rigidity score, 4) and painful muscle spasms. The patient was unable to sit in his wheelchair and remained bed bound. Combined oral baclofen and tizanidine at therapeutical doses were used without any effect on the spasticity. The patient refused the placement of an intrathecal catheter for long-term baclofen infusion. A single intrathecal ethanol (6 ml) injection in the L2-L3 intervertebral space with the patient placed in a lateral Trendelenburg (40 C) position was performed.

RESULTS

The procedure was very effective in improving the stiffness (Ashworth rigidity score. 2, after the technique) and the muscle spasms disappeared. No side effects during or after the injection were observed.

CONCLUSION

Intrathecal ethanol block is a last but very useful choice for treatment of intractable spasticity in PML and other neurologic disorders in AIDS patients when other oral treatments have failed and intrathecal baclofen infusion is not suitable.

[Pseudomonas aeruginosa bacteremia as a complication after endoscopic retrograde cholangiopancreatography]

BACKGROUND

The present was performed to describe the characteristics of bacteremias by Pseudomonas aeruginosa following cholangiopancreatography and the methods of prevention and treatment of the same.

METHODS

Twelve different episodes of bacteremia by Pseudomonas aeruginosa were retrospectively studied in patients submitted to endoscopic cholangiopancreatography (ERCP) from 1993-1997.

RESULTS

Three point six percent of the patients undergoing ERCP presented episodes of bacteremias by the microorganism in the 48 hours following the procedure. Except for one case, the patients presented obstructive disease in the form of calculi or neoplasms at the level of the biliary tree. In three cases, sphincterotomy had been carried out which was followed by clinical manifestations of hemorrhage in one case. Three patients (25%) died as a consequence of bacteremia and a hepatic abscess was developed in one case. The bacteremia appeared in successive outbreaks from 1993-1997.

CONCLUSIONS

Bacteremia by Pseudomonas aeruginosa following ERCP is more frequent in patients with obstructive disease of the biliary tract and has an important additional morbimortality. It is associated with incorrect endoscopic disinfection. The use of drugs with an antipseudomonal spectrum should be considered as preendoscopic prophylaxis.

Bactericidal effect of ADP and acetic acid on Bacillus subtilis

Bacillus subtilis is a ubiquitous soil bacterium used for measuring the beta-lysin activity and in other bioassays. We observed a complete bactericidal effect of ADP on B. subtilis at concentrations of 50-100 microM at pH values <5.5, which disappeared at pH values above 6. The effect was also found for acetic acid at concentrations >17.4 microM and similar pH values. ATP, adenosine, and HCl were not bactericidal. We used BCECF-AM, a pH-sensitive probe, and found that the killing of B. subtilis was due to a change in the intracellular pH caused by the passage across the cell membrane of these weak organic acids when incubated with B. subtilis at pH values near the pK. More experiments are needed to determine the biological meaning of these in vitro findings.

Imipenem therapy of brain abscesses

The efficacy of imipenem versus standard chemotherapy (both in addition to neurosurgery) in the treatment of brain abscess was compared in a retrospective study. Cure was obtained in 52 of 60 (86.7%) patients in the standard group, and in 15 of 15 (including 5 patients with multiple brain abscesses) in the imipenem group. Cure without neurosurgery was observed in 2 of 60 (3.3%) and 3 of 15 (20%) of the cases, respectively (p = 0.08). Levels of imipenem in blood, cerebrospinal fluid, and brain pus were above the minimum inhibitory concentrations of most of the abscess isolates. Side effects of imipenem were rare and tolerance was excellent. Imipenem monotherapy (3-4 g/day) for five weeks seems a reasonable therapeutic choice for treatment of bacterial brain abscesses.

[Severe orbital cellulitis: therapeutic results in 9 patients and review of the literature]

BACKGROUND

Orbital cellulitis can produce severe neuromeningeal infections. Modern antimicrobial agents such as imipenem can be a valid therapeutical choice.

METHODS

Patients with severe or complicated orbital cellulitis admitted to our hospital from 1986 through 1994 were retrospectively studied.

RESULTS

Nine patients with severe orbital cellulitis, seven of them older than 14 years, are reported. Cellulitis was secondary to different forms of sinusitis in five of them. The incriminated microorganisms were: Streptococcus viridans alone or combined to gram negative bacilli (3 cases), Prevotella melaninogenica and other anaerobes (2 cases), Enterococcus faecalis and Staphylococcus aureus (one case each). Three patients developed brain abscesses, one an acute bacterial meningitis and another a subdural empyema. Eight patients underwent a surgical drainage. Seven patients were treated with IV imipenem at doses of 2-3 g/day with complete cure of the orbital cellulitis and of the associated infectious complications and no secondary effects. Two patients died.

CONCLUSIONS

Imipenem is an effective antibiotic in the combined medical-surgical treatment of the severe or complicated orbital cellulitis.

[Native valve endocarditis caused by Staphylococcus aureus and streptococci. A comparative study]

OBJECTIVE

To know the validity and current prognosis of clinical prototypes assigned to streptococcal endocarditis (STREPEND) and Staphylococcus aureus endocarditis (SAE).

PATIENTS AND METHODS

Fifty-four patients with SAE were compared with 43 patients with STREPEND diagnosed from 1984 to 1994 following a retrospective cohort study model.

RESULTS

The incidence of SAE and STREPEND was 0.21 and 0.17, respectively, per 1,000 hospital admissions. The acquisition of community endocarditis (non drug abusers vs. drug abusers) and nosocomial endocarditis was 74% (31% vs. 43%) and 26% for SAE; the corresponding values for STREPEND: 89% (70% vs. 19%) and 11%, respectively. The overall mortality rate for STREPEND/SAE was 9%/26% (among drug abusers there were no fatalities recorded), whereas in non drug abusers the mortality rate reached 41% and for nosocomial forms 36%. SAE was independently associated with drug abuse habits, right-sided heart infection, development of embolism and a high mortality rate. In contrast, by means of the multivariant analysis, STREPEND was independently associated with a subacute onset form, left-sided heart infection, cardiac surgery, and a low mortality rate.

CONCLUSIONS

Traditional stereotypes of the two main etiologies for endocarditis are still valid, although at present it is important to differentiate nosocomial endocarditis and in non drug abusers. Chemoprophylaxis compliance is low for STREPEND: Given the poor prognosis of SAE at the left heart side a more aggressive surgical attitude would be warranted.

[Infectious endocarditis of the native valve: its epidemiological profile and an analysis of its mortality between the years 1984 and 1993]

BACKGROUND

The description of the epidemiologic profile and analysis of the mortality of infectious endocarditis (IE) observed from 1984-1993.

METHODS

One hundred thirty episodes of IE in a native valve (30 in drug addicts [IVDA] and 20 cases of nosocomial acquisition) were analyzed with right/left/bilateral localization (42/84/4, respectively), infection of the mitral/aortic/tricuspid valve (52/47/34, respectively) and the etiology was determined as Staphylococcus aureus in 52 cases, 41 Streptococcus, 13 negative coagulase Staphylococcus, and 11 Enterococcus. High risk IE were identified by uni and multivariate analysis (MVA).

RESULTS

The incidence of IE ranged from 0.36 and 0.70 cases x 1.000 admitted adults/year (mean: 0.50). Transthoracic echocardiography detected bacterial vegetations in 67% of the cases with the validity to predict the development of embolisms being 55%. MVA showed the embolic episodes (present in 45% of the IE) to be associated with the IVDA patients and prolonged fever. The latter complication, being defined as > or = 10 days of fever under appropriate treatment, was observed in 32% of the cases and was due to mild (n = 15) and severe causes (n = 27). Postembolic septic complications were associated to fever with MVA. Twenty three patients died (18%), 2 IVDA and 5 nosocomial IE, mainly due to heart failure (n = 13). The independent risk factor predictors for death (p < 0.05) were: age > or = 60 years (mortality 34%), cerebral embolisms (55%), severe heart failure (37%), and the exclusion of the patient as a candidate for surgery (73%). To the contrary, right IE (mortality 0%) and cardiac surgery (5%) favoured survival.

CONCLUSIONS

To improve the prognosis of infectious endocarditis in high risk patients more opportune cardiac surgery accepting greater risks should be performed.

[Antiphospholipid antibodies in human immunodeficiency virus infection]

BACKGROUND

The frequency, clinical significance and prognosis of the lupic anticoagulant and the anticardiolipin antibodies were analyzed in patients with the human immunodeficiency virus infection.

METHODS

A group of 34 consecutive patients seropositive to HIV with lupic anticoagulant was studied in relation with 75 seropositive subjects without circulating anticoagulant and a control group of plasma of 23 seronegative individuals. The lengthening of thromboplastin time (relation > 1.3) was used as a screening test. The anticardiolipin antibodies IgG were studied by commercial enzymoimmunoassay.

RESULTS

Lupic anticoagulant was detected in 21% of the patients with AIDS and in 3% of the seropositive patients without AIDS. The anticoagulant was found in 13 of 53 cases with tuberculosis, in 8 of 57 with pneumonia by Pneumocystis carinii, in 4 of 32 with bacteremia and in 3 out of 8 with lymphoma. In another six patients other minor processes and/or HIV seropositivity were coexistent. Thrombosis was not seen in any case, and the rate of thrombocytopenia (18%) was that to be expected in this population. The patients with anticoagulant had a greater prevalence to developing AIDS, opportunistic infections and tuberculosis with respect to the seropositive group without anticoagulant, however, no differences were observed in the prevalence and levels of anticardiolipin antibodies and other nonspecific autoimmune phenomena. Periodic follow up of the patients with anticoagulant demonstrated persistence of the anticoagulant in 31% and reappearance of the same in 23% with new infections.

CONCLUSIONS

No correlation was found between the different antiphospholipid antibodies in the patient infected by the human immunodeficiency virus. Low titers of anticardiolipin antibodies are indicative of disease progression.

[Replication indexes of the human immunodeficiency virus: predictive value of viral culture and blood antigens]

BACKGROUND

To investigate the relation between markers of load and replication of the HIV [viral culture in plasma and in mononuclear cells of peripheral blood (MCPB) and antigen p24 (p24Ag) with the number of CD4+ cells and the prognosis of the patients.

METHODS

A retrospective study was performed in 188 patients who were analyzed and followed over a mean period of 431 days. The criteria of clinical progression (AIDS related complex, and new opportunistic infections), immunologic progression (CD4+ < 0.1 and < 0.05 + 10(9)/l) and death. Cocultures of HIV in free plasma and in MCPB were performed with the detection of complete AgHIV in the supernatant of the culture being used for analysis. Circulating p24Ag was determined by an ELISA technique without previous dissociation of the immunocomplexes.

RESULTS

HIV cultures in plasma, in MCPB and p24Ag were positive in 27, 48 and 33% of the patients, respectively. The sensitivity of the indexes increased in agreement with the clinical progression of the patients and was inversely proportional to the depletion of the CD4+ lymphocytes (79% of the patients with CD4+ lymphocytes < 0.05 x 10(9)/l presented positive HIV culture in plasma). Viremia in plasma and to a lesser measure p24Ag correlated with variables recognized as bad prognosis and were found to be predictive of unfavorable evolution. Multivariate analysis demonstrated that pertenence to a symptomatic group and the presentation of a number of CD4+ lymphocytes of less than 0.2 x 10(9)/l were independent factors associated to the positivity of the viral culture in plasma and p24Ag. The culture positive in MCPB was principally related with the volume of blood analyzed. The risk of death was 6.38 fold greater in the presence of a positive plasma culture and 2.02 fold greater in the presence of positive p24Ag. In contrast, the unquantified positive HIV culture in MCPB showed no statistical significance in relation with patient survival.

CONCLUSIONS

Positive HIV culture in plasma was the greatest prognostic index in patients with a number of CD4+ lymphocytes less than 0.2 x 10(9)/l. Unquantified cell culture had no predictive significance. To establish the prognosis of patients, the indexes of viral replication should not be used in isolation.

[Hospital infection caused by enterococci. The previous use of antibiotics as risk factors in a case-control study]

BACKGROUND

Nosocomial infection by enterococci is of growing importance and recognition. The risk factors, morbidity and prognosis of the same were investigated by a case and control study in a third level university hospital.

METHODS

One hundred patients with nosocomial infection by enterococci were compared with 100 randomly selected control patients with non enterococcic nosocomial infection. Cases and controls were taken from a series of 10,926 patients examined in search of nosocomial infection by successive cut offs of prevalence.

RESULTS

The prevalence of nosocomial infection by enterococci was found to be 9.9 per 1,000 admissions. Analysis among cases and controls by the odds ratio indicated a positive association for nosocomial infection by enterococci for the following risk factors: male sex (1.8), receipt of intensive care (3.6), predisposing diseases (3.1), urinary catheter (3), abdominal-genital surgery (2.4) or nephro-urologic surgery (4.6), other previous infections (1.9) and previous exposure to antibiotics (3.7), mainly aminoglucosides (4.2). Urinary infections and those of the surgical wound predominated, 15 patients had bacteremia, with mortality related with infection being 2%, preinfection hospital stay was 34.7 days and the mean stay was of 8.3 days but these data were not statistically different in the control group. The enterococcic infections were most frequently polymicrobian (odds ratio 5.5) received worse antibiotic coverage (5.1) and presented greater number of therapeutic failures or recurrences (2.5).

CONCLUSIONS

Nosocomial infection by enterococci is relatively frequent and virulent. The risk factors identified in this study are in agreement with those found in most series. The previous use of aminoglucosides was specially capable of selecting enterococci but only 13% demonstrated high level resistance to gentamicin.

[Tuberculosis and HIV infection. Evaluation of 132 cases]

Tuberculosis is currently one the more frequent opportunistic infections in patients infected by Human Immunodeficiency Virus (HIV) in our setting. Its extrapulmonary localization is considered as diagnostic of the Acquired Immunodeficiency Syndrome (AIDS). We have evaluated the epidemiological, clinical, microbiological, histological and immunological characteristics of 120 patients in the Asturias region who had a tuberculosis diagnosed in any localization, during the period between 1984 and 1991, belonging to a series of 570 patients infected by HIV. Pulmonary types were comparatively analyzed to the extrapulmonary and disseminated ones. Tuberculosis was pulmonary only in 44 occasions (PT), in 36 it was extrapulmonary (EPT) and in 52 disseminated (DT). The more frequent risk factor for the HIV infection was the parenteral consumption of drugs (78.8%). The final diagnosis was microbiologic in 81% of the cases, while bacilloscopia was positive in 62% of the cases. The histologic study showed the presence of granulomas in 86% of the tissues studied and necrosis in 81%. EPT and DT were related with a worse immune situation, bigger mortality rates attributed to tuberculosis and worse survival (p 0.069). Tuberculosis in patients infected by HIV appears mainly in CDVP, being its symptoms the normal ones; but extrapulmonary forms are clearly predominant and within this group those with a ganglionar localization. Normal diagnostic procedures yield a good result. EPT and DT are significantly related to a more severe immunodeficiency in comparison with PT. Survival and prognosis are better in the PT group.

[Trends observed in the use of antimicrobial agents at a Spanish hospital from 1986 and 1991]

BACKGROUND

The recent introduction of new antimicrobials allows important changes in the controversial field of their prescription. Longitudinal analysis of the quality and tendencies of the use of antibiotics constitutes one of the basic tools for adapting antibiotic policy.

METHODS

This study was undertaken in a university hospital with antibiotic policy plans and institutional protocols of antibiotic prophylaxis. The use of antimicrobials with prophylactic and therapeutic aims has been analyzed by 12 prevalence studies over 6 years in a sample equivalent to 10.2% of the population admitted. A comparison between the first three counts (1986-1987) and the last three (1990-1991) was performed.

RESULTS

A mean of 26.6% of the patients admitted used antibiotics. Nonetheless, while its use as treatment grew with progressive deterioration in the quality of use, its use for prophylaxis decreased and improved. Parallel, the use of restricted antibiotics grew from 12 to 19%. The comparison of the habits of prescription between the onset and the end of the study showed the following important changes: decrease in the use of aminopenicillins and cotrimoxazole and increase in the use of first and third generation cephalosporins, antifungal drugs, tobramycin, vancomycin, the group of urinary antiseptics and quinolones and the miscellaneous group of antimicrobials of minor use.

CONCLUSIONS

Antibiotics for therapy have been used more and worse, despite the restrictive barriers. The control methods have been effective in prophylaxis with the exception of its excessive prolongation which remains the principal problem. Changes have been registered in the pattern of use of antibiotics in favor of new more effective drugs against multiresistant flora.

[The clinical significance of culturing Toxoplasma gondii on blood and other organic media]

BACKGROUND

The aim of this study was to determine the value of the Toxoplasma gondii culture in blood and in other organic fluids in HIV positive and negative patients.

METHODS

Retrospective analysis (October 1990-May 1992) was carried out including all patients with positive cultures for T. gondii admitted to the Hospital Central of Asturias. The parasite was identified by monoclonal antibodies against the tachyzoite membrane. All patients with positive cultures were treated with pyrimethamine and sulphadiazine.

RESULTS

Three hundred two samples from 256 patients, seropositive and seronegative for HIV, were analyzed. Of the seropositive group 8/45 (18%) had positive cultures for T. gondii versus 9/211 (4.3%) of the seronegative group (p = 0.002). Of the 19 positive samples, 15 were from blood, 3 from bronchoalveolar lavage and one from the vitreous fluid. Four out of 9 patients (44%) with AIDS and encephalic toxoplasmosis (ET) had blood cultures positive for T. gondii. Another 4 patients with AIDS presented toxoplasmenia without visceral involvement. Of the 9 HIV seronegative patients (3 immunodepressed patients), 4 had pulmonary toxoplasmosis, one ocular toxoplasmosis, and other clinical forms of toxoplasmosis were seen in the remaining 4. All the patients evolved to cure except 2 cases coinfected by cytomegalovirus who died.

CONCLUSIONS

The identification of Toxoplasma gondii may be performed by blood cultures in half of the patients with AIDS and encephalic toxoplasmosis and in an undetermined percentage of the other clinical forms both in immunocompetent and immunodepressed subjects. In addition, toxoplasmemia has been registered in AIDS patients preceding any other organic seating of the parasite. Early antitoxoplasma therapy may, therefore, be effective.

[Pulmonary toxoplasmosis. Study of 4 cases and review of the literature]

BACKGROUND

Description of four cases of pulmonary toxoplasmosis and review of the literature.

METHODS

A retrospective analysis (October 1990-December 1992) was carried out of the patients with samples of tracheal aspirate, bronchoalveolar lavage (BAL) and lung biopsy positive for T. gondii by immunofluorescence with anti-P30 monoclonal antibodies and cell cultures.

RESULTS

Four patients were diagnosed of pulmonary toxoplasmosis, three being immunosuppressed (one renal transplant, one with chronic lymphoid leukemia and one intravenous drug user HIV seronegative) and the remaining one healthy. All the patients developed progressive dyspnea and a radiologic pattern of interstitial pneumonitis (3) or alveolar condensation (1). Three of the patients were cured with pyrimethamine and sulphadiazine. One patient had coinfection by CMV and died. Another 52 cases of this rare condition have been reported in the literature.

CONCLUSIONS

In the authors experience, bronchoalveolar lavage material and lung biopsy for T. gondii culture should be performed in immunosuppressed patients with an unclear interstitial radiologic pattern to rule out pulmonary toxoplasmosis.

[Acute-phase reactants in sepsis]

In 71 patients with fever and bacteremia without complications, a prospective study of acute-phase reactants is done. Raises in haptoglobin, ceruloplasmin, alpha-1-antitrypsin, protein C, beta-2-microglobulin, IgA and ferritin serum levels, together with leucocytosis and GSR, were very significant when diagnosis was done. Fibronectin, sideremia and transferrin were lowered. After 3 and 6 days of treatment haptoglobins, alpha-1-antitrypsin, protein C, ferritin, leucocytosis and GSR are lowered, while immunoglobulins, sideremia, transferrin and fibronectin raised, the latter until normalization. Fibronectin as well as changes in iron metabolism were very reliable parameters of inflammation and favorable evolution.

Diabetes mellitus and bacteraemia: a comparative study between diabetic and non-diabetic patients

OBJECTIVES

To compare the incidence, mortality, clinical characteristics and outcome between bacteraemias in diabetic and non-diabetic patients.

METHODS

A prospective study of all adult patients with bacteraemia admitted to a large Spanish teaching hospital during six consecutive years (1984-1990); 152 were diabetics and 1488 non-diabetics.

RESULTS

Rates per 1000 admissions when bacteraemic diabetic patients were compared with non-diabetics (p < 0.001) were respectively as follows: incidence 26.8/15.5, acquisition in the community 18.4/6.2, urinary tract source 8.7/2.2, and E. coli aetiology 8.9/3.4. Diabetes mellitus type II was found in 138 episodes. Glycosylated haemoglobin levels were 13 +/- 3%. Bacteraemia developed in association with hyperosmolar status in 14.5% of patients and with ketoacidosis in 5%. Patients in the diabetic group developed septic shock in 22% of the episodes, acute renal failure in 40%, superinfections in 22% and had an inappropriate empirical antibiotic treatment in 6%, vs 15.6%, 20%, 11% and 25% respectively of the non-diabetic bacteraemic patients (p < 0.05 for all comparisons). Overall mortality and bacteraemia-related mortality were similar in both groups. Multivariate analysis showed that the association with fatal diseases, shock and renal insufficiency negatively influenced the outcome of diabetic patients, while the nephro-urologic source and an appropriate therapy were accompanied by a better prognosis.

CONCLUSIONS

A higher incidence of bacteraemia, mainly of urinary source, community-acquired, and due to E. coli was found in the diabetic patients compared to non-diabetics. The common use of rapidly effective drugs for this predominant bacteraemia conditioned similar outcome and prognosis factors in both populations, in spite of the higher incidence of septic shock and acute renal failure in the diabetic population.

Comparative study of community versus hospital-acquired Staphylococcus aureus bacteraemia

OBJECTIVES

We prospectively investigated 274 consecutive Staphylococcus aureus septicaemias in adult patients between January 1983 and December 1989 to evaluate outcome in hospital acquired and community acquired episodes.

METHODS

Epidemiologic, clinical, laboratory and therapeutic parameters were analyzed with univariate and multivariate statistical tests.

RESULTS AND CONCLUSIONS

Ninety episodes of Staphylococcus aureus bacteraemia were acquired in the community and 184 in hospital. Diabetes mellitus and renal failure were accompanied by a clear increase in bacteraemia related death in the community-acquired category. Correct antibiotic therapy showed a better response in the community-acquired group. Bacteraemia related death was 22.6% for episodes acquired in the hospital and 18.8% for those originating in the community.

[Surgical bacteremia. Analysis of 210 episodes with special attention to factors influencing prognosis]

From January 1984 to April 1987, we have prospectively studied 210 consecutive episodes of bacteremia recorded in patients who underwent major surgical procedures. The incidence rate was 6.4 episodes/1000 surgical procedures. Men were responsible of 73.8% of episodes. The highest incidence was recorded in general surgery patients and the lowest in Ob & Gyn patients. Bacteremia-related mortality was 15.2% (overall mortality 29.5%). The five most common microorganisms isolated were: Staphylococcus epidermidis (17.7%), Staphylococcus aureus (14.7%), polymicrobial flora (13.3%), Escherichia coli (11.4%) and Pseudomonas sp. (9.5%). The common sources of bacteremia were intravascular devices (34.7%), surgical wound infection (28.5%) and urinary tract infection (12.8%). Multivariant analysis identified six variables that influence an adverse prognosis: complications, source of sepsis in a joint or unknown, admission in trauma or vascular surgery department, development of sepsis between the second and eight postoperative day, chronic illness or fatal underlying disease and sepsis after clean surgical procedures.

[Simultaneous acute infection with human immunodeficiency virus and cytomegalovirus]

2 cases of simultaneous acute infection caused by HIV and CV that showed clinical features of infectious mononucleosis with spontaneous resolution and good evolution is presented. After 12 months following them up, both are symptom free carriers of HIV and without clinical features of CV infection. These cases had a good evolution, which is contrary to what is described in other medical literature.

[Nosocomially acquired infection of the urinary tract]

We have evaluated 283 consecutive hospital acquired urinary tract infections (HAUTI) in a University hospital (incidence 5.6% of admissions). In females, spontaneous, symptomatic and younger patient infections predominated, while in males HAUTI were mostly asymptomatic, after catheterization and in elderly patients. Chronic nonfatal diseases--particularly neurologic disease and diabetes--, old age, previous antibiotic use, the postoperative period, and cancer were the major general predisposing factors, mostly because they involved urological procedures. There was an urethral catheter in 78% of cases, with questionable indication or maintenance in 37%. In 65% of cases there were clinical data attributable to HAUTI; however, on strict criteria only 5% of pyelonephritis and 24% of cystitis were detected. Mortality rate was 0.4%. Etiology was E. coli in 29%, Proteus in 13%, Enterobacter in 12%, enterococcus in 11.5%, Serratia in 7%, Pseudomonas in 6.5%, and Klebsiella in 6.5%. There were differences regarding endogenous and hospital flora on the basis of sex, hospital situation, catheterization, mobility, and previous duration of hospitalization. The microbial resistance pattern was high in the hospital flora. The major therapeutical problem was the high number of unnecessary treatments representing the automatic medical response to the finding of a positive urine culture.

[Use of aminopenicillins: first cause of error in the prescription of antimicrobial agents at a hospital]

The patterns of use and quality of prescription of ampicillin and amoxycillin (A/A) as compared with the rest of antimicrobials (AM) was evaluated by means of the review of the therapeutic sheets of 4572 admitted patients, in coincidence with 5 calculations of prevalence in a university hospital. 25.7% of patients received AM. These were used in 865 instances, and 6% were disqualified. A/A participated in 57% of these errors (p = 0.002 as related with the rest of AM). 309 patients received AM as prophylactic drugs, and 70% of them did not comply with the standard rules. The election of A/A for prophylaxis was associated with 71% of these errors (p less than 0.0001). Nine out of every 10 prophylactic administrations of A/A were abnormal owing to incorrect indication (77%), dosage (10%), oral route (62%) or excessive duration (82%). The high prevalence of prescription of aminopenicillins (30%) was associated with 68% of the errors in the use of AM, owing, among other reasons, to the high resistance rates of the major recovered organisms excluding enterococci. The nonjustified overuse of aminopenicillins was the leading detected problem; it can be managed by a restrictive antibiotic policy and educational measures oriented to an adequate medical prescription.

Successful treatment of recurrent cerebral empyema and brain abscesses with imipenem

Imipenem was successfully used to treat a case of subdural empyema complicated by multiple cerebral abscesses, in which surgery and therapy with other antibiotics had previously failed. Imipenem concentrations in serum, cerebrospinal fluid and the cerebral abscess were much higher than the MICs for the infecting organisms, qualifying this antibiotic as an effective option in therapy of suppurative intracranial infections.

Acute-subacute lead poisoning. Clinical findings and comparative study of diagnostic tests

A prospective study of an epidemic outbreak of acute lead poisoning characterized by unusual clinical and analytic manifestations was carried out. Its source was traced to lead-contaminated flour. Thirty-two adult patients presented with classic clinical symptoms of saturnism; however, 13 severely poisoned patients simultaneously manifested unusual clinical features such as hemolytic anemia and multiorgan dysfunction. We compared the diagnostic value of the different toxicity markers in 68 of 136 adults exposed to lead. Porphyrin precursors, urine levels of lead, and results from an edetic acid-provocative test gave poor diagnostic information and low correlation values with lead levels in blood. However, erythrocyte delta-aminolevulinic acid dehydratase activity showed a closer correlation with lead levels in blood, although we observed a frequent overlap of results in severe cases. The test for levels of lead in blood was the most reliable, suitable, and simplest test performed, and gave the best correlation with the external dose of lead, the clinical situation, and the toxicologic effects described by 12 different analytic data.