Teresa Vicente

Tuberculous meningitis in patients infected with the human immunodeficiency virus.

BACKGROUND AND METHODS Tuberculosis is a frequent complication of human immunodeficiency virus (HIV) infection. We describe the clinical manifestations and outcomes of tuberculous meningitis in patients with HIV infection, and compare them with those in non-HIV-infected patients. We reviewed the records from 1985 through 1990 at two large referral hospitals in Madrid for patients who had Mycobacterium tuberculosis isolated from cerebrospinal fluid. RESULTS Of 2205 patients with tuberculosis, 455 (21 percent) also had HIV infection, of whom 45 had M. tuberculosis isolated from the cerebrospinal fluid. Of the 37 HIV-infected patients with tuberculous meningitis for whom records were available, 24 (65 percent) had clinical or radiologic evidence of extrameningeal tuberculosis at the time of admission. In 18 of 26 patients (69 percent), a CT scan of the head was abnormal. In most patients, analysis of cerebrospinal fluid showed pleocytosis (median white-cell count, 0.234 x 10(9) per liter) and hypoglycorrhachia (median glucose level, 1.3 mmol per liter), but in 43 percent (15 of 35), the level of protein in cerebrospinal fluid was normal. In four patients with HIV infection, tuberculosis was only discovered after their deaths. Of the 33 patients who received antituberculous treatment, 7 died (in-hospital mortality, 21 percent). Illness lasting more than 14 days before admission and a CD4+ cell count of less than 0.2 x 10(9) per liter (200 per cubic millimeter) were associated with a poor prognosis. Comparison with tuberculous meningitis in patients without HIV infection showed that the presentation, clinical manifestations, cerebrospinal fluid findings, and mortality were generally similar in the two groups. However, of the 1750 patients without HIV infection, only 2 percent (38 patients) had tuberculous meningitis, as compared with 10 percent of the HIV-infected patients (P less than 0.001). CONCLUSIONS HIV-infected patients with tuberculosis are at increased risk for meningitis, but infection with HIV does not appear to change the clinical manifestations or the outcome of tuberculous meningitis.

Bloodstream Infections: Evolution and Trends in the Microbiology Workload, Incidence, and Etiology, 1985-2006

Abstract Information available on bloodstream infection (BSI) is usually restricted to short periods of time, certain clinical backgrounds, or specific pathogens, or is just outdated. We conducted the current prospective study of patients with BSI in a 1750-bed teaching hospital to evaluate workload trends and the incidence and etiology of BSI in a general hospital during the last 22 years, including the acquired immunodeficiency syndrome (AIDS) era. The main outcome measures were laboratory workload, trends in incidence per 1000 admissions and per 100,000 population of different microorganisms, and the impact of the human immunodeficiency virus (HIV) epidemic in the period 1985-2006. From 1985 to 2006 we had 27,419 episodes of significant BSI (22,626 patients). BSI incidence evolved from 16.0 episodes to 31.2/1000 admissions showing an annual increase of 0.83 episodes/1000 admissions (95% confidence interval, 0.61-1.05; p < 0.0001). The evolution of the incidence per 1000 admissions and per 100,000 population of different groups of microorganisms was as follows: Gram positives 8.2 to 15.7/1000 admissions and 66.8 to 138.3/100,000 population; Gram negatives 7.8 to 16.2/1000 admissions and 63.5 to 141.9/100,000 population; anaerobes 0.5 to 1.3/1000 admissions and 4.1 to 11.7/100,000 population; and fungi 0.2 to 1.5/1000 admissions and 1.7 to 12.5/100,000 population. All those differences were statistically significant. We observed the emergence of multiresistant Gram-positive and Gram-negative microorganisms. At least 2484 episodes of BSI (9.1%) occurred in 1822 patients infected with HIV. The incidence of BSI in HIV-infected patients increased from 1985 and reached a peak in 1995 (17.6% of BSI). Since 1995, the decrease was continuous, and in 2006 only 3.9% of all BSI episodes occurred in HIV-positive patients in our institution. We conclude that the BSI workload has increased in modern microbiology laboratories. Gram-positive pathogens have overtaken other etiologic agents of BSI. Our observation shows the remarkable escalation of some resistant pathogens, and the rise and relative fall of BSI in patients with HIV. Abbreviations: AIDS = acquired immunodeficiency syndrome, BSI = bloodstream infection, ESBL = extended-spectrum beta-lactamase, HAART = highly active antiretroviral therapy, HIV = human immunodeficiency virus, MRSA = methicillin-resistant Staphylococcus aureus.

The CLED agar option in urine culture routine: A prospective and comparative evaluation

Current recommendations for routine urine culture are still inoculation of specimens in a combination of solid media, usually blood agar (BA) plus MacConkey agar (MK). We have performed a prospective blind study comparing the accuracy of CLED agar (C), as the sole medium, with classic procedure (BA+MK). We included 1157 urine samples plated on the three culture media simultaneously. After incubation for 20-22 hr at 37 degrees C, the cultures were read by two of the authors independently. The cultures were evaluated according to standard criteria (BA+MK) considering a count above 10(4) CFU/ml as significant. The numbers of positive, negative, and contaminated cultures were 233, 764, and 160, respectively. Sensitivity and specificity of CLED were 98% and 99%, respectively. Fastidious microorganisms were accurately detected on C agar as well as on BA+MK. Morphologic differentiation of colonies was easier with C agar, and time required for inoculating and reading the plates was logically less in the C group. As the productivity of C is similar to that of standard procedures, its economy and convenience make it a medium worth using for routine culture of urine samples.

Enhanced activity of the combination of penicillin G and gentamicin against penicillin-resistant viridans group streptococci.

We evaluated the effects of the combination of penicillin G and gentamicin against 10 penicillin-resistant bacteremic isolates of viridans group streptococci for which the MICs of penicillin were 4 to 64 micrograms/ml. In time-kill studies, the combination resulted in more killing of eight isolates for which the MICs of penicillin were from 8 to 64 micrograms/ml than any of the antimicrobial agents tested alone. In general, clearly enhanced antimicrobial activity was observed with the combination.