Miguel Salavert Lletí

Los aspectos epidemiológicos cambiantes de la candidemia y sus implicaciones clinicoterapéuticas

Las especies de Candida son una causa importante de infecciones invasoras y diseminadas por via hematogena. En los estudios realizados en las ultimas 2 decadas, suponen la cuarta causa como patogenos nosocomiales aislados en hemocultivos. La incidencia de Candida se ha incrementado en este periodo debido al numero y la variedad de pacientes susceptibles a este hongo, que son especialmente frecuentes y graves en los pacientes oncohematologicos. La profilaxis antifungica con azoles instaurada en la ultima decada, junto con otros factores, han ocasionado una redistribucion en las especies de Candida causantes de infeccion. Durante el periodo revisado (1996-2005), varios trabajos han confirmado el impacto de las profilaxis con azoles en la emergencia de especies distintas de Candida albicans . El amplio uso de fluconazol ha podido reducir la prevalencia de C. albicans , con un incremento de especies menos sensibles o resistentes a fluconazol, como Candida glabrata y Candida krusei . Con los estudios de sensibilidad y de virulencia disponibles de estas especies de Candida no- albicans se han disenado estrategias de manejo especificas de especie. Todavia se necesitan muchos estudios para situarnos en la era en la que dispondremos de nuevos antifungicos (equinocandinas, nuevos azoles) para su uso clinico en el tratamiento de la candidiasis invasora y de la candidemia. El objetivo de esta revision es subrayar las diferentes tendencias en incidencia, distribucion y comportamiento de la candidemia en distintos pacientes de riesgo.

Elección del tratamiento en la diarrea asociada a Clostridium difficile: guías de práctica clínica o clasificaciones de riesgo

Clostridium difficile infection (CDI) is currently believed to be the primary cause of nosocomial diarrhoea in the developed world, and is becoming ever-more prevalent as an aetiological agent in community-acquired diarrhoea and healthcare-related infections.1 Its pathogenic action can be attributed to the production of certain strains of toxin A and/or B in the presence of abnormal gut flora. This gives rise to gastrointestinal symptoms that can range from mild or moderate diarrhoea to pseudomembranous colitis, ileus and toxic megacolon.2 This disease is particularly prevalent in certain epidemiological groups, such as hospitalised patients and the elderly, and is correlated with risk factors including the use of antibiotics and gastric acid suppressants, immunodeficiency or other gastrointestinal, neoplastic or cardiopulmonary comorbidities.3 CDI has sparked growing interest because of its association with healthcare and its impact on morbidity and mortality in immunosuppressed patients and the elderly.4 A growing number of studies on its prevalence, changes in clinical presentation and epidemiology have been published in recent years, with the identification of new risk factors. Although the frequency of CDI in Spain has not been sufficiently characterised, available data suggest that its prevalence is similar to neighbouring countries and is on the increase.5 In addition, the high and increasing use of broad-spectrum antibiotics in hospitals and in the domestic setting are factors that favour the growth of this disease. The emergence of the ribotype 027 strain has increased the incidence and severity of CDI in some countries. The recent emergence of the hypervirulent ribotype 027 strain in some Spanish hospitals led to significant, but controlled, outbreaks with a particular clinical and epidemiological profile.6 One in two episodes of CDI is not diagnosed in Spanish hospitals due to a lack of clinical suspicion or the use of insensitive diagnostic methods. In diagnos-