Jaime abarca L

Endocarditis infecciosa: análisis de 261 casos y resultados del tratamiento con un enfoque multidisciplinario

Background: Early diagnosis, an effective treatment and prompt recognition of complications are essential to improve the prognosis of infective endocarditis (IE) Aim: To report the results of a multidisciplinary approach to diagnosis and management of patients with IE at the Universidad Catolica de Chile Hospital. Patients and methods: The clinical history, diagnosis, treatment and outcome of 261 episodes (Duke criteria) of IE admitted between January 1980 and January 1999 were analyzed. These included 185 episodes of native, 73 of prosthetic valve and 3 of nonvalvular IE. Results: Sixty nine percent of patients were men and the mean age was 49 ± 16 years. Seventy five percent had a definite diagnosis of IE (Duke). S. viridans, staphylococci and enterococci together constituted 85% of the isolated bacterial strains. Twenty seven had culture-negative IE, related to a high incidence of antibiotic therapy prior to diagnosis. Transesophageal echocardiography was performed in 102 cases and it detected vegetations in 91% of aortic and 96% of mitral IE, rupture or prosthesis dehiscence in 67% of aortic and 52% of mitral IE and abscesses in 51% of aortic and 15% of mitral IE. Fifty one percent developed heart failure and 34% had embolic events. S. aureus IE was associated to a higher incidence of embolic events, complications which contraindicated surgery and increased mortality rate (27%). Of all patients, 40% were treated exclusively with antibiotics, 52% were operated on and 8% had surgical indication but were nonoperable because of serious complications. The overall mortality was 16.3%: 13% in the medical, 9% in the surgical and 81% in the non-operable groups. The type of treatment and mortality rates did not differ between IE of native valves and prosthetic valves. Long term follow up showed survival rates of 73% at 5 years and 66% at 10 years. Conclusion: A multidisciplinary approach may be very helpful to improve the prognosis of IE. (Rev Med Chile 2000; 128: 708-20).

Perfil epidemiológico de la candidiasis invasora en unidades de pacientes críticos en un hospital universitario

La epidemiologia de candidiasis invasora (CI) ha cambiado, lo cual no ha sido suficientemente estudiado en Chile. Objetivo: Describir el perfil epidemiologico y microbiologico de CI en pacientes criticos. Metodos: Estudio observacional prospectivo entre octubre 2001 y agosto 2003, en pacientes criticos adultos con sospecha o confimnacion de CI. Resultados: 53 pacientes cumplieron criterios de CI. De ellos, 18 (33,9%) tuvieron candidemia, 22(41,5%) CI diseminada y 13(24,5%) CI local. Entre las candidemias, hubo 8 C. albicans (44,4%) y 10 Candida no albicans (55,6%), predominando C. tropicalis (27,7%). Un 88,8% de las candidemias fueron susceptibles a fluconazol. La mortalidad hospitalaria global fue 24,5%, significativamente menor en pacientes con candidemias vs CI diseminada (16,6 vs 31,8%, p = 0,02). Conclusiones: Se observo una mayor proporcion de Candida no albicans en candidemias de pacientes criticos. Sin embargo, la mayoria de estas cepas fue susceptible a fluconazol. La mortalidad global fue menor en candidemias.

Coinfecciones por virus hepatitis B, virus hepatitis C, Treponema pallidum y Toxoplasma gondii en la cohorte de pacientes VIH positivos en control en la Pontificia Universidad Católica de Chile

Three hundred ninety five patients (aged 16 to 89 years, 359males) were included in the review. Seventy nine percent had been tested for HBV status with HBsAg,and the global HIV-HBV co-infection prevalence was 6.1%. A subgroup of 190 individuals were testedfor HBV infection with HBsAg and IgM/IgG anti-HBc markers. Of these, 46% fulfilled co-infectioncriteria: eight with acute hepatitis B, 11 with chronic hepatitis B and 69 with inactive HBV infection.The frequency of HIV-HBV co-infection was 48% and 22% among men and women respectively (NS).HCV-HIV co-infection was detected in 3%, syphilis-HIV co-infection in 21% and T gondii-HIV co-infection in 26%.

Reconocimiento de influenza-A como etiología de síndrome febril e insuficiencia respiratoria en adultos hospitalizados durante brote en la comunidad

: Adults subjects, with Influenza A confirmed by antigen detection test, hospitalized in theclinical hospital of the «Hospital Clinico de la Universidad Catolica de Chile» between May and June,with fever or respiratory symptoms were studied. A special record was designed to register clinical,microbiological and therapeutic data.

Presencia de metalo-ß-lactamasas en Pseudomonas aeruginosa resistente a imipenem

Background: Metallo-s-lactamases (MBL) confer high resistance to carbapenems in Pseudomonas aeruginosa (Psae). They are encoded in mobile elements of different genes (VIM, IMP, SMP, GIM), along with other resistance genes. Aim: To detect the presence of MBL in imipenem resistant Psae strains. Material and methods: Fifty-nine imipenem resistant Psae strains isolated from January 2004 to August 2005 in a University Clinical Hospital, were included. The presence of MBL was studied by Etest (phenotypic) and genotypic polymerase chain reaction (PCR) methods. To rule out a nosocomial outbreak, MBL positive strains, were studied by pulse field gel electrophoresis. Results: The presente of MBL was detected in eleven strains. AH were type VIM and were not clonally related. There was no concordance between phenotypic and genotypic MBL detecting methods. AH the strains were also multiresistant. Conclusions: The presence of MBL was detected in 19% of imipenem resistant Psae strains

Etiología de la neumonía en pacientes chilenos infectados por el virus de la inmunodeficiencia humana

Objetivos: Establecer la etiologia de la neumonia y comparar el rendimiento de diferentes tecnicas para el diagnostico de las infecciones por Pneumocystis jiroveci y Mycobacterium tuberculosis en pacientes con infeccion por virus de inmunodeficiencia humana (VIH). Material y Metodos: De cada paciente se obtuvo esputo inducido y se efectuo LBA. A las muestras obtenidas se les realizo tinciones de Gram, Ziehl-Neelsen, plata e inmunofluores-cencia (IF) para P. jiroveci y M. tuberculosis; reaccion de polimerasa en cadena (RPC) para ambos microorganismos; cultivos aerobicos, fungicos, para micobacterias, virus respiratorios y citomegalovirus. Tambien se realizo determinacion de IgM de Mycoplasma pneumoniae y Chlamydophyla pneumoniae y antigeno urinario de Legionella pneumophila. Resultados: Se incluyeron 60 pacientes, lograndose diagnostico etiologico en 97% de los casos. Pneumocystis jiroveci fue la etiologia mas frecuente (58%), seguida por Streptococcus pneumoniae (12%) y Mycobacterium avium complex (MAC) (12%). Mycobacterium tuberculosis fue encontrado en 5%. Conclusiones: La comparacion de los metodos diagnosticos para P. jiroveci mostro una mayor sensibilidad de la IF y tincion de plata en LBA que en esputo; sin embargo, la RPC fue igualmente sensible en ambos tipos de muestras. Con esta estrategia se logro establecer etiologia en la gran mayoria de los pacientes. La etiologia mas comun fue P. jiroveci. IF en LBA sigue siendo el estandar para el diagnostico de la neumonia por P. jiroveci.

Cirugía valvular reparadora en endocarditis infecciosa

Background: Valve replacement has been the treatment of choice for patients with valvular complications of infectious endocarditis (IE). However, excellent results with valve repair allowed it to become a new therapeutic alternative for these patients. Aim: To evaluate the results of valve repair in patients with valvular complications of IE. Patients and Methods: From January 1991 to December 2000, 14 patients with valvular complications of IE underwent valve repair. Mean age was 37.9 ± 14.9. Results: New York Heart Association (NYHA) class was 2.8 ± 0.9. IE was located in the aortic in 6 (42%), in the mitral valve in 4 (29%) and in both valves in 4 cases (29%). Surgical indication was hemodynamic in 50% of the cases, echocardiographic in 29% and septic in 21%. Five aortic valves were bicuspid, 3 mitral valves were myxomatous and the rest were normal. The most common septic lesions were vegetations and leaflet perforations. A total of 23 aortic and 21 mitral valve repair procedures were performed. There were no deaths. Only 1 patient had a surgical complication (renal failure and prolonged mechanical ventilation). Follow-up was 100% complete. There was not late mortality. One patient with bone marrow aplasia required reoperation for a new episode of IE 19 months later. At the end of the follow-up NYHA class was 1.3 ± 0.6 and echocardiography showed a mild or absence of valve regurgitation in most patients. Conclusions: Valve repair surgery in IE has good results, with advantages over valve replacement (Rev Med Chile 2004; 132: 307-15). (Key Words: Cardiovascular surgical procedures; Endocarditis, bacterial; Surgical procedures, operative)

Diagnóstico de diarrea por Clostridium difficile: en busca de un enfoque clínico más eficiente

Background: The clinical parameters for the suspicion of Clostridium difficile infections, namely the use of antimicrobials and diarrhea, have a low predictive value for the diagnosis. Aim: To search other clinical variables and determine a clinical prediction model for (Clostridium difficile diarrhea. Patients and methods: All patients to whom a Clostridium difficile study was requested, were prospectively studied during 5 months. Clinical variables of these patients were registered. The diagnosis of Clostridium difficile was done using the cytotoxicity test in fibroblast cultures. Results: Ninety two patients were analyzed and in 26, the diagnosis of Clostridium difficile was confirmed. A logistic regression model disclosed an age over 60 years old, the presence of mucus in the stools and a temperature over 37.8 °C in the previous 24 h, as significant predictors of the infection. The correlation of the model, between the predicted probability and the observed condition, was 81.5%. Conclusions: The presence of the clinical variables identified in this study are associated with a high probability of an infection by Clostridium difficile in patients with diarrhea and the recent use of antimicrobials (Rev Med Chile 2001; 129: 620-625)

Utilización del antibiotipo como marcador epidemiológico en infecciones intrahospitalarias: Comparación con la epidemiología molecular

INTRODUCCIONUna de las preguntas mas frecuentes para losepidemiologos, clinicos y microbiologos es sabersi dos bacterias son iguales o diferentes, o sea, laevaluacion de clonalidad. Hay multiples herra-mientas para responder esta pregunta, tantodesde el punto de vista fenotipico, comogenotipico; sin embargo, solo pocas de ellas seutilizan en la practica y habitualmente esta pre-gunta queda sin respuesta. Las tecnicas emplea-das con mayor frecuencia para evaluar clonalidadse muestran en la Tabla 1. Generalmente laprimera aproximacion para evaluar un origenclonal comun entre dos bacterias esta dada porlas caracteristicas fenotipicas de ellas mismas,entre las cuales el perfil de susceptibilidad a losantimicrobianos o antibiotipo es el mas usado.Por otro lado, el

Tratamiento de la neumonía del adulto adquirida en la comunidad

Appropriate antibiotic treatment reduces the duration of symptoms associated to pneumonia, the risk of complications and mortality. In most cases, it is not possible to identify the etiologic agent so antibiotic treatment is empirically prescribed. In Chile, one third of Streptococcus pneumoniae strain isolates has diminished susceptibility to penicillin; in-vitro erythromycin resistance is about 10-15% and cefotaxime resistance 2-10%. It is recommended to classify patients with community acquired pneumonia in four risk categories: Group 1: patients under 65 years without co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin 1 g TID, 7 days. Group 2: patients over 65 years and / or co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days. Group 3: patients admitted to general wards with criteria of moderate severity. Treatment: ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days. Group 4: patients with severe CAP that must be interned into ICU. Treatment: ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days. In the presence of allergy to or treatment failure with betalactam drugs and/or positive serology for Mycoplasma, Chlamydia or Legionella sp it is recommended to add: erythromycin 500 mg QID, IV or oral, oral clarithromycin 500 mg BID, or oral azythromycin 500 mg once a day