Joan Gómez-Junyent

Clinical Features, Etiology and Outcomes of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease

Background Community-acquired pneumonia (CAP) is a frequent complication of chronic obstructive pulmonary disease (COPD), but previous studies are often contradictory. Objectives We aimed to ascertain the characteristics and outcomes of CAP in patients with COPD as well as to determine the risk factors for mortality and Pseudomonas aeruginosa pneumonia in COPD patients with CAP. We also describe the etiology and outcomes of CAP in COPD patients receiving chronic oxygen therapy at home and those receiving inhaled steroids. Methods An observational analysis of a prospective cohort of hospitalized adults with CAP (1995–2011) was performed. Results We documented 4121 CAP episodes, of which 983 (23.9%) occurred in patients with COPD; the median FEV1 value was 50%, and 57.8% were classified as stage III or IV in the GOLD classification. Fifty-eight per cent of patients were receiving inhaled steroids, and 14.6% chronic oxygen therapy at home. Patients with COPD presented specific clinical features. S. pneumoniae was the leading causative organism overall, but P. aeruginosa was more frequent in COPD (3.4 vs. 0.5%; p<0.001). Independent risk factors for case-fatality rate in patients with COPD were multilobar pneumonia, P. aeruginosa pneumonia, and high-risk PSI classes. Prior pneumococcal vaccination was found to be protective. FEV1 was an independent risk factor for P. aeruginosa pneumonia. Conclusions CAP in patients with COPD presents specific characteristics and risk factors for mortality. Prior pneumococcal vaccine has a beneficial effect on outcomes. P. aeruginosa pneumonia is associated with low FEV1 values and poor prognosis.

Management of Ventriculoperitoneal Shunt Infections in Adults: Analysis of Risk Factors Associated With Treatment Failure

Background Little is known regarding the optimal treatment of ventriculoperitoneal (VP) shunt infections in adults. Our aim was to assess the efficacy of treatment strategies and to identify factors that predict failure. Methods Retrospective, observational study of patients aged ≥12 years with VP shunt infections (1980 -2014). Therapeutic approaches were classified under 4 headings: only antibiotics (OA), one-stage shunt replacement (OSSR), two-stage shunt replacement (TSSR), and shunt removal without replacement (SR). The primary endpoint was failure of the treatment strategy, defined as the absence of definite cerebrospinal fluid (CSF) sterilization or related mortality. The parameters that predicted failure were analyzed using logistic regression. Results Of 108 episodes (51% male, median age 50 years), 86 were analyzed. Intravenous antibiotics were administered for a median of 19 days. Eighty episodes were treated using strategies that combined antibiotic and surgical treatment (37 TSSR, 24 SR, 19 OSSR) and 6 with OA. Failure occurred in 30% of episodes, mostly due to lack of CSF sterilization in OSSR and OA groups. Twelve percent died of related causes and 10% presented superinfection of the CSF temporary drainage/externalized peritoneal catheter. TSSR was the most effective strategy when VP shunt replacement was attempted. The only independent risk factor that predicted failure was retention of the VP shunt, regardless of the strategy. Conclusions This is the largest series of VP shunt infections in adults reported to date. VP shunt removal, particularly TSSR when the patient is shunt dependent, remains the optimal choice of treatment and does not increase morbidity.

Delayed haemolysis after artesunate therapy in a cohort of patients with severe imported malaria due to Plasmodium falciparum

INTRODUCTION Delayed haemolytic anaemia is one of the more frequent events after treatment with intravenous artesunate in patients with severe malaria. Little is known about its frequency and the outcomes of patients with this condition. METHODS A retrospective study was conducted to describe the incidence of delayed haemolysis in a cohort of patients with severe malaria by Plasmodium falciparum treated with artesunate between August 2013 and July 2015. RESULTS The study included 52 patients with malaria due to Plasmodium falciparum, with 21 having severe malaria. The majority were male (66.7%), and the median age was 43 years. Four patients (19%) presented post-artesunate delayed haemolysis 11-13 days from the initiation of treatment. Two patients required hospital admission and red blood cell transfusion. CONCLUSION Post-artesunate delayed haemolysis is frequent in patients with severe malaria treated with intravenous artemisinins. These patients should be monitored for 4 weeks after treatment is started.

Real-Time Polymerase Chain Reaction in Stool Detects Transmission of Strongyloides stercoralis from an Infected Donor to Solid Organ Transplant Recipients

Solid organ transplant recipients can acquire Strongyloides stercoralis from an infected donor. The diagnosis of S. stercoralis in immunocompromised individuals may be challenging due to a lower sensitivity of available parasitological and serological methods, compared with immunocompetent individuals. Recently, a real-time polymerase chain reaction (RT-PCR) in stool has been developed for S. stercoralis diagnosis. We report two cases of S. stercoralis infection transmitted by a donor to two solid organ transplant recipients, who were diagnosed with RT-PCR in stool. This test could play an important role inS. stercoralis diagnosis in immunosuppressed patients, facilitating rapid treatment initiation and reducing the risk of severe strongyloidiasis. Adherence to current recommendations of screening among donors and recipients from endemic areas is also urgently needed.

Evaluation of linezolid or trimethoprim/sulfamethoxazole in combination with rifampicin as alternative oral treatments based on an in vitro pharmacodynamic model of staphylococcal biofilm

Combinations of linezolid (LZD) or trimethoprim/sulfamethoxazole (SXT) plus rifampicin (RIF) are alternative oral treatments for staphylococcal prosthetic joint infections (PJIs) when fluoroquinolones are not possible to use, but there is limited evidence regarding their activity. This study evaluated the efficacy of LZD and SXT, alone and in combination with RIF, against Staphylococcus aureus in an in vitro pharmacokinetic/pharmacodynamic biofilm model. Using the CDC Biofilm Reactor® system, simulated regimens of LZD (600 mg every 12 h), SXT (160/800 mg every 8 h) and levofloxacin (LVX) (750 mg/day), alone and in combination with RIF (600 mg/day), were evaluated against one methicillin-susceptible S. aureus (MSSA) and one methicillin-resistant S. aureus (MRSA) strain. Antibiotic efficacy was evaluated by the decrease in planktonic bacterial counts from medium and biofilm-embedded bacteria from coupons over 56 h. Resistant strains were screened. In both strains, SXT alone was ineffective and LZD presented low activity, but no resistance emerged. Combinations with RIF significantly increased the antibiofilm efficacy against MSSA (Δlog CFU/mL 56h-0h: SXT + RIF, -2.9 and LZD + RIF, -3.1), but RIF-resistant strains appeared with SXT + RIF. Against MRSA, LZD + RIF (-3.1) protected against the emergence of resistance and was more effective than SXT + RIF (-0.6; P <0.05), in which RIF-resistant strains were again detected. LVX + RIF confirmed its high efficacy against biofilm-embedded bacteria, this being the most effective therapy (-5.1 against MSSA). The emergence of RIF-resistant strains with SXT + RIF poses serious concerns for its use in clinical practice. Interestingly, LZD + RIF appears to be an appropriate alternative for PJI caused by LVX-resistant S. aureus.

High prevalence of S. Stercoralis infection among patients with Chagas disease: A retrospective case-control study

Background We evaluate the association between Trypanosoma cruzi infection and strongyloidiasis in a cohort of Latin American (LA) migrants screened for both infections in a non-endemic setting. Methodology Case-control study including LA individuals who were systematically screened for T. cruzi infection and strongyloidiasis between January 2013 and April 2015. Individuals were included as cases if they had a positive serological result for Strongyloides stercoralis. Controls were randomly selected from the cohort of individuals screened for T. cruzi infection that tested negative for S. stercoralis serology. The association between T. cruzi infection and strongyloidiasis was evaluated by logistic regression models. Principal findings During the study period, 361 individuals were screened for both infections. 52 (14.4%) individuals had a positive serological result for strongyloidiasis (cases) and 104 participants with negative results were randomly selected as controls. 76 (48.7%) indiviuals had a positive serological result for T. cruzi. Factors associated with a positive T. cruzi serology were Bolivian origin (94.7% vs 78.7%; p = 0.003), coming from a rural area (90.8% vs 68.7%; p = 0.001), having lived in an adobe house (88.2% vs 70%; p = 0.006) and a referred contact with triatomine bugs (86.7% vs 63.3%; p = 0.001). There were more patients with a positive S. stercoralis serology among those who were infected with T. cruzi (42.1% vs 25%; p = 0.023). Epidemiological variables were not associated with a positive strongyloidiasis serology. T. cruzi infection was more frequent among those with strongyloidiasis (61.5% vs 42.3%; p = 0.023). In multivariate analysis, T. cruzi infection was associated with a two-fold increase in the odds of strongyloidiasis (OR 2.23; 95% CI 1.07–4.64; p = 0.030). Conclusions T. cruzi infection was associated with strongyloidiasis in LA migrants attending a tropical diseases unit even after adjusting for epidemiological variables. These findings should encourage physicians in non-endemic settings to implement a systematic screening for both infections in LA individuals.

Human African Trypanosomiasis in a Spanish traveler returning from Tanzania

Human African Trypanosomiasis (HAT) is a parasitic disease usually confined to endemic areas in sub-Saharan Africa, but it occasionally may occur among travelers, migrants, or expatriates. Although it is an uncommon diagnosis in returning travelers attending travel and tropical medicine clinics [1], the number of HAT diagnoses in travelers has been rising in recent years [2], most likely in connection with an increase of tourists visiting endemic areas and improved reporting systems. Trypanosoma brucei is the etiological agent of HAT, and is transmitted by tsetse flies of the genus Glossina. Two species can cause the disease: T. brucei gambiense in West and Central Africa (g-HAT) and T. brucei rhodesiense (r-HAT) in Eastern and Southern Africa. The disease usually presents in two stages: a first or hemolymphatic stage, where the parasite is located in the lymphatic system and blood; and a second or meningo-encephalitic stage, which occurs when trypanosomes penetrate the central nervous system. Although a vast majority of sleeping sickness cases are caused by infection with T. brucei gambiense [3], most cases of HAT reported in nonendemic countries are caused by T. brucei rhodesiense [4]. These cases occur mainly in tourists, who are usually diagnosed in the first stage, shortly after returning from their visit. Tourists commonly contract the disease after visiting game parks in sub-Saharan Africa [5], including those in Tanzania, where outbreaks in travelers have been described [6]. In contrast, g-HAT cases in nonendemic countries mainly occur in expatriates or refugees, who are usually diagnosed in the second stage and after a protracted diagnostic process [4]. Since it is rare in nonendemic countries, physicians may not suspect or find it difficult to diagnose this disease, especially if fever and/or unspecific complaints are the only presenting symptoms. Neuropsychiatric disorders are rarely present in travelers with r-HAT [7]. An accurate anamnesis, including travel history and incubation and prodromal periods, together with a thorough physical examination, is helpful to guide the diagnostic workup. r-HAT is usually easy to diagnose by blood smear examination, as parasitaemia in these patients tends to be high [8]. Examination of chancre or lymph node fluid should also be performed, if possible. Despite its uncommon occurrence in travel clinics in nonendemic settings, clinicians should be aware of the potential presentation of patients with this disease. Here, we report a

Nefritis lúpica mesangial proliferativa, descripción de una cohorte de 27 pacientes

BACKGROUND AND OBJECTIVE To describe our cohort of 27 biopsy-proven patients and their long-term follow-up, with special attention to prognostic factors. PATIENTS AND METHODS Twenty seven patients were retrospectively collected. They were controlled in the Internal Medicine Department of the Bellvitges Hospital (Spain) between 1974 and 2010. Evaluation was performed at one, 3 and 5 year follow-up. RESULTS There were 22 women (81.5%). Mean age at onset of nephritis was 34.83 years (SD 13.45). Partial or complete remission was achieved by 21 patients (80.77%) in the one-year follow-up, 22 patients (84.61%) in the third-year follow-up and 21 patients (77.77%) in the fifth-year follow-up. A change in the histology class was diagnosed in 4 patients. Seven patients suffered flares of nephritis. Seven patients died in the long term follow-up, 3 out of this 7 died because of systemic erythematosus lupus. CONCLUSION Nephritis onset beyond 45 years old is the factor mostly related with a poor prognosis. That is the reason why we recommend co-therapy with immunosuppressors from the beginning in such patients.

Leptospirosis in Spanish travelers returning from Chiang Mai: A case series

BACKGROUND Leptospirosis is an important zoonosis worldwide, nevertheless is often poor recognized in non tropical settings. In Thailand is becoming an emerging disease and Chiang Mai could become a popular spot to acquire the disease amongst travelers. METHODS We describe three cases of imported leptospirosis undifferentiated fever after travelling to Thailand during the summer of 2015 diagnosed at two Spanish hospitals. RESULTS Our three patients probably acquired leptospirosis while swimming in freshwater around Chiang Mai, a Thailands northern region with moderate incidence of leptopirosis. Travelers had normal white blood cell counts and low platelets, suggesting leptospirosis after ruling out other imported diseases such as malaria, dengue or typhoid. CONCLUSION As recent findings point out, low platelets and normal white blood cell counts are clinical features that could help the clinician to suspect Leptospirosis infection. It should be always considered as a cause of fever, particularly if travelers come from a tropical country and have had contact with water or flooding, especially during rainy season.

Analysis of mortality in a cohort of 650 cases of bacteremic osteoarticular infections

OBJECTIVES The mortality of patients with bacteremic osteoarticular infections (B-OAIs) is poorly understood. Whether certain types of OAIs carry higher mortality or interventions like surgical debridement can improve prognosis, are unclarified questions. METHODS Retrospective analysis of a prospective cohort of patients with B-OAIs treated at a teaching hospital in Barcelona (1985-2014), analyzing mortality (30-day case-fatality rate). B-OAIs were categorized as peripheral septic arthritis or other OAIs. Factors influencing mortality were analyzed using logistic regression models. The association of surgical debridement with mortality in patients with peripheral septic arthritis was evaluated with a multivariate logistic regression model and a propensity score matching analysis. RESULTS Among 650 cases of B-OAIs, mortality was 12.2% (41.8% of deaths within 7 days). Compared with other B-OAI, cases of peripheral septic arthritis were associated with higher mortality (18.6% vs 8.3%, p < 0.001). In a multiple logistic regression model, peripheral septic arthritis was an independent predictor of mortality (adjusted odds ratio [OR] 2.12; 95% CI: 1.22-3.69; p = 0.008). Cases with peripheral septic arthritis managed with surgical debridement had lower mortality than those managed without surgery (14.7% vs 33.3%; p = 0.003). Surgical debridement was associated with reduced mortality after adjusting for covariates (adjusted OR 0.23; 95% CI: 0.09-0.57; p = 0.002) and in the propensity score matching analysis (OR 0.81; 95% CI: 0.68-0.96; p = 0.014). CONCLUSIONS Among patients with B-OAIs, mortality was greater in those with peripheral septic arthritis. Surgical debridement was associated with decreased mortality in cases of peripheral septic arthritis.