Alicia Rico

A Large Multicenter Study of Methicillin–Susceptible and Methicillin–Resistant Staphylococcus aureus Prosthetic Joint Infections Managed With Implant Retention

BACKGROUND Several series predicting the prognosis of staphylococcal prosthetic joint infection (PJI) managed with debridement, antibiotics, and implant retention (DAIR) have been published, but some of their conclusions are controversial. At present, little is known regarding the efficacy of the different antibiotics that are used or their ability to eliminate methicillin-resistant S. aureus (MRSA) infection. METHODS This was a retrospective, multicenter, observational study of cases of PJI by S. aureus that were managed with DAIR (2003-2010). Cases were classified as failures when infection persistence/relapse, death, need for salvage therapy, or prosthesis removal occurred. The parameters that predicted failure were analyzed with logistic and Cox regression. RESULTS Out of 345 episodes (41% men, 73 years), 81 episodes were caused by MRSA. Fifty-two were hematogenous, with poorer prognoses, and 88% were caused by methicillin-susceptible S. aureus (MSSA). Antibiotics were used for a median of 93 days, with similar use of rifampin-based combinations in MSSA- and MRSA-PJI. Failure occurred in 45% of episodes, often early after debridement. The median survival time was 1257 days. There were no overall prognostic differences between MSSA- and MRSA-PJI, but there was a higher incidence of MRSA-PJI treatment failure during the period of treatment (HR 2.34), while there was a higher incidence of MSSA-PJI treatment failure after therapy. Rifampin-based combinations exhibited an independent protective effect. Other independent predictors of outcome were polymicrobial, inflammatory, and bacteremic infections requiring more than 1 debridement, immunosuppressive therapy, and the exchange of removable components of the prosthesis. CONCLUSIONS This is the largest series of PJI by S. aureus managed with DAIR reported to date. The success rate was 55%. The use of rifampin may have contributed to homogenizing MSSA and MRSA prognoses, although the specific rifampin combinations may have had different efficacies.

Infecciones importadas por inmigrantes y viajeros: resultados de la Red Cooperativa para el estudio de las Enfermedades Importadas por Inmigrantes y Viajeros +Redivi

INTRODUCTION Imported diseases by travellers and immigrants are a priority in the prevention of emerging infectious diseases in the 21st century. There are international records on imported diseases, but no such records are available in Spain. MATERIAL AND METHODS The cooperative network +Redivi was created in 2009 and consists of 11 national healthcare centres. +Redivi collects demographic data relating to travel/migration and infectious diseases in brief, computerised forms. RESULTS From January 2009 to October 2011, we collected 4,570 patients and recorded the main demographic data (age, sex, presence of immunosuppression), travel data (destination, duration, time between the return trip and the consultation) and data regarding the migratory process (country of origin, time between the arrival in Spain and the first consultation), as well as preventive measures that have been taken (pre-travel advice, need for malaria chemoprophylaxis, drug that was used and whether it was correct), the reason for coming to the consultation, and final diagnoses of the travellers, immigrants and immigrants-travellers. Likewise, the most frequent diagnoses of asymptomatic patients who came for a check-up are described for each of the three groups. CONCLUSIONS The +Redivi network allows us to identify and quantify the geographical origin and the type of patients affected, as well as time pattern of infections imported by migrants and travellers. Preliminary data show the significant presence of transmissible diseases and the potential reintroduction in Spain, as well as the importance of systematic screening in patients that came from tropical areas. The objective of +Redivi is to evaluate the impact of imported diseases in Spain in order to contribute to improving the care of patients, to have an influence on prevention and treatment of the most prevalent imported diseases, and to detect possible outbreaks.

The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study

Background. Streptococci are not an infrequent cause of periprosthetic joint infection (PJI). Management by debridement, antibiotics, and implant retention (DAIR) is thought to produce a good prognosis, but little is known about the real likelihood of success. Methods. A retrospective, observational, multicenter, international study was performed during 2003-2012. Eligible patients had a streptococcal PJI that was managed with DAIR. The primary endpoint was failure, defined as death related to infection, relapse/persistence of infection, or the need for salvage therapy. Results. Overall, 462 cases were included (median age 72 years, 50% men). The most frequent species was Streptococcus agalactiae (34%), and 52% of all cases were hematogenous. Antibiotic treatment was primarily using β-lactams, and 37% of patients received rifampin. Outcomes were evaluable in 444 patients: failure occurred in 187 (42.1%; 95% confidence interval, 37.5%-46.7%) after a median of 62 days from debridement; patients without failure were followed up for a median of 802 days. Independent predictors (hazard ratios) of failure were rheumatoid arthritis (2.36), late post-surgical infection (2.20), and bacteremia (1.69). Independent predictors of success were exchange of removable components (0.60), early use of rifampin (0.98 per day of treatment within the first 30 days), and long treatments (≥21 days) with β-lactams, either as monotherapy (0.48) or in combination with rifampin (0.34). Conclusions. This is the largest series to our knowledge of streptococcal PJI managed by DAIR, showing a worse prognosis than previously reported. The beneficial effects of exchanging the removable components and of β-lactams are confirmed and maybe also a potential benefit from adding rifampin.

High MICs for Vancomycin and Daptomycin and Complicated Catheter-Related Bloodstream Infections with Methicillin-Sensitive Staphylococcus aureus

Patients infected with these bacteria were more likely to have local endovascular complications.

Evaluación del medio xilosa galactosidasa (XG®) para el aislamiento de enteropatógenos

Introduccion Evaluar y comparar el medio cromogenico XG® con respecto a los medios habituales utilizados en coprocultivos para el aislamiento de Salmonella spp., Shigella spp., Yersinia enterocolitica y Aeromonas spp. Metodos Se estudiaron un total de 1.226 muestras de heces que se inocularon en los medios XG®, MacConkey, Salmonella-Shigella (SS), caldo selenito, agar sangre-ampicilina y cefsulodina-irgasan-novobiocina (CIN). Resultados Se obtuvieron 235 cultivos positivos: Salmonella spp. (229), Shigella spp. (3), Yersinia enterocolitica (2) y Aeromonas spp. (1). De los 229 aislamientos de Salmonella spp., cien procedian del medio XG® como de los medios habituales y los 129 restantes se recuperaron solo en estos ultimos, encontrandose diferencias estadisticamente significativas (p Conclusiones El medio cromogenico XG® mostro baja sensibilidad (64%) y especificidad (69%) para el aislamiento de Salmonella spp. Los tres aislamientos de Shigella spp. recuperados del medio XG® pudieron deberse al inmediato procesamiento de la muestra. Consideramos que el medio cromogenico XG® no puede sustituir a los medios habituales utilizados en coprocultivo.

Pathogen-related factors affecting outcome of catheter-related bacteremia due to methicillin-susceptible Staphylococcus aureus in a Spanish multicenter study

Even with appropriate clinical management, complicated methicillin-susceptible Staphylococcus aureus (MSSA) catheter-related bacteremia (CRB) is frequent. We investigated the influence of molecular characteristics of MSSA strains on the risk of complicated bacteremia (CB) in MSSA-CRB. A multicenter prospective study was conducted in Spain between 2011 and 2014 on MSSA-CRB. Optimized protocol-guided clinical management was required. CB included endocarditis, septic thrombophlebitis, persistent bacteremia and/or end-organ hematogenous spread. Molecular typing, agr functionality and DNA microarray analysis of virulence factors were performed in all MSSA isolates. Out of 83 MSSA-CRB episodes included, 26 (31.3%) developed CB. MSSA isolates belonged to 16 clonal complexes (CCs), with CC30 (32.5%), CC5 (15.7%) and CC45 (13.3) being the most common. Comparison between MSSA isolates in episodes with or without CB revealed no differences regarding agr type and functionality. However, our results showed that CC15 and the presence of genes like cna, chp and cap8 were associated with the development of CB. The multivariate analysis highlighted that the presence of cna (Hazard ratio 2.9; 95% CI 1.14–7.6) was associated with the development of CB. Our results suggest that particular CCs and specific genes may influence the outcome of MSSA-CRB.

Lesión osteolítica vertebral en un varón joven

Varon de 24 anos que acudio a nuestro hospital por presentar desde hace siete meses una fistula productiva en region lumbar, con ausencia de sintomatologia general ni dolor a ese nivel. Como unico antecedente de interes referia vivir en el campo en contacto con animales. Tras su ingreso para estudio se realizo una radiografia, una fistulografia y una tomografia axial computarizada (TAC) lumbar (figs. 1 y 2) que mostraron una imagen litica (afectando a la apofisis transversa, lamina, pediculo y cuerpo vertebral derechos) con reborde escleroso a nivel de L3 y una comunicacion con absceso que se extendia por el musculo psoas hasta la pelvis. Se decidio intervencion quirurgica con fines diagnostico-terapeuticos, realizandose una biopsia intraoperatoria que se remitio al laboratorio de Microbiologia para su estudio. La muestra se proceso para bacterias y micobacterias. El examen en fresco de la misma revelo abundantes leucocitos polimorfonucleares y presencia de escolex (fig. 3). Los resultados serologicos por hemaglutinacion indirecta arrojaron unos titulos de 1/2.560, compatibles con el diagnostico de la enfermedad.

Varón homosexual con virus de la inmunodeficiencia humana con fiebre y lesión cutánea

Varón homosexual de 27 años español no inmigrante y sin historia de viajes recientes, diagnosticado de virus de la inmunodeficiencia humana (VIH) en el año 2000, estadio B2. Se inició tratamiento antirretroviral en octubre de 2007 con tenofovir, emtricitabina y efavirenz. En el momento del inicio de los sı́ntomas, la carga vı́rica de VIH era indetectable (inferior a 50 cop/ml) y la cifra de linfocitos CD4 era de 545 cel/mm. El paciente no tenı́a historia de enfermedades oportunistas previas, aunque sı́ varios episodios documentados de enfermedades de transmisión sexual correctamente tratadas entre 2000 y 2008: sı́filis y varios episodios de uretritis gonocócica y no gonocócica. El paciente reconocı́a haber tenido múltiples parejas sexuales en los últimos meses y manifestó no tener pareja estable en el momento de su evaluación. Tres dı́as antes de acudir a esta consulta habı́a comenzado con eritema, dolor e induración en el tercio medio de muslo izquierdo. A las 24 h de la aparición de la lesión, notó fiebre, malestar general y escalofrı́os, motivo por el que tras haber sido evaluado por su médico de Atención Primaria, se inició tratamiento con cloxacilina oral (500 mg/6 h). El paciente acudió a consulta 24 h tras el inicio del tratamiento antibiótico oral debido a la persistencia de sus sı́ntomas (figs. 1–3). No contaba traumatismos cerrados ni heridas previas en el área afectada. Su temperatura era de 37,5 1C. Presentaba en el tercio medio del muslo izquierdo un área celulı́tica de unos 5 cm de diámetro con mı́nima pérdida de integridad de la epidermis en su centro y un componente significativo de induración más allá de los lı́mites del eritema, pero sin signos de fluctuación. Al presionar la lesión, se observó la salida de escaso material purulento. Se solicitó analı́tica, que mostró leucocitosis con aumento de reactantes de fase aguda: leucocitos 18,3 10/ml (72% de neutrófilos) y proteı́na C reactiva