Vicente Boix

Microbiology and Outcome of Iliopsoas Abscess in 124 Patients

To describe the microbiology and outcome of iliopsoas abscess (IPA) in a large case series, we analyzed 124 cases of IPA collected from 1990 through 2004 in 11 hospitals in Spain. Twenty-seven (21.8%) patients had primary and 97 (78.2%) had secondary IPA. The main sources of infection were bone (50.5%), gastrointestinal tract (24.7%), and urinary tract (17.5%). A definitive microbial diagnosis was achieved in 93 (75%) cases. Abscess culture was the most frequent procedure leading to microbial diagnosis, followed by blood cultures. Staphylococcus aureus, Escherichia coli, and Bacteroides species were the most frequent microbial causes: S. aureus was the most common organism in patients with primary abscesses (42.9%) and with abscesses of skeletal origin (35.2%), whereas E. coli was the leading organism in those with abscesses of urinary (61.5%) and gastrointestinal (42.1%) tracts. Mycobacterium tuberculosis was found in 15 patients, 4 of them associated with human immunodeficiency virus (HIV) infection. Twenty (21.5%) cases had polymicrobial infections; these were more common among patients with abscesses of gastrointestinal origin. Information on clinical outcome was available for 120 patients; 19 (15.8%) had a relapse and 6 (5%) died due to complications related to the IPA. Patients who died were older and more likely to have bacteremia and E. coli isolated from cultures. In conclusion, secondary IPA is more prevalent than primary IPA. Among those with secondary IPA, most abscesses are secondary to a skeletal source. A bacterial etiology can be identified in most cases. The overall prognosis of patients with this condition is good. Abbreviations: AIDS = acquired immunodeficiency syndrome, CI = confidence interval, CT = computed tomography, HIV = human immunodeficiency virus, IPA = iliopsoas abscess, IQR = interquartile range, MRI = magnetic resonance imaging, MRSA = methicillin-resistant S. aureus, OR = odds ratio.

Functional status determined by Barthel Index predicts community acquired pneumonia mortality in general population

BACKGROUND Barthel Index (BI) measures functional status. Our aim was to analyze if BI and other factors not included in Pneumonia Severity Index (PSI) predict mortality in general population with community acquired pneumonia (CAP). METHODS Prospective observational study including all patients with CAP diagnosed in 2006. Endpoint of study: 30-day mortality. Variables not included in PSI as BI were analyzed. Strength of association was determined by odds ratio (OR) with 95% confidence interval. RESULTS 550 patients, mean age of 60.3 ± 20.8, were included. 32 were lost during follow-up and 518 patients were finally analyzed. 44 (8.5%) patients died in the first 30 days after CAP diagnosis. In bivariate analysis, mortality was significantly more frequent in patients with PSI ≥ IV (19.2% vs 1.9%), BI≤80 points (23.9% vs 2.9%), multilobar infiltrate (20% vs 6%), diabetes mellitus (14.9% vs 6.5%), influenza vaccination (11.9% vs 6.6%) and pneumococcal vaccination (16.7% vs 6%). In multivariate analysis, mortality independently associated factors were: BI ≤80, OR: 3.9(CI95% 1.4-10.5; p < 0.001); PSI ≥ IV OR: 3.9(1.2-12.7; p < 0.05); and multilobar infiltrate OR: 2.9(1.1-7.3; p = 0.05). CONCLUSION A BI score ≤80 is associated with a higher mortality in patients with CAP independently of the PSI. BI can be a useful tool to predict CAP mortality in general population.

Acalculous Cholecystitis Associated with Plasmodium falciparum Malaria

SIR—We read with interest the report by Dylewski and AlAzragi [1] that describes a patient with acalculous cholecystitis (AC) and Plasmodium falciparum malaria, which has not been previously described. We present another patient with the same condition and comment on the pathogenesis of AC and P. falciparum malaria, an underdiagnosed condition. A 24-year-old Spanish woman was admitted to the hospital because of a 1-week history of diarrhea and fever after a 15day tourist visit to Punta Cana, Dominican Republic. On admission, she was lethargic, her temperature was 397C, her pulse 105/min, and her blood pressure 90/50 mm Hg. A general physical examination showed tenderness in the right upper abdominal quadrant without any other abnormalities. Laboratories studies disclosed the following values: hemoglobin, 8.9 g/dL; leukocytes, 6200/mm; platelets, 11.000/mm; prothrombin time, 22 s; partial thromboplastin time, 120 s; fibrinogen, 80 mg/dL; antithrombin III, 36%; total bilirubin, 6.9 mg/dL (direct bilirubin, 6.5 mg/dL); lactate dehydrogenase, 928 U/L; aspartate aminotransferase, 214 U/L; alanine aminotransferase, 254 U/L; and alkaline phosphatase, 423 U/L. A test for fibrin degradation products was positive. Other routine laboratory data and the chest x-ray were normal. Abdominal ultrasonography revealed a stone-free gallbladder with a thickened wall surrounded by a thin layer of fluid. A diagnosis of AC cholecystitis was made. Examination of 3 blood smears for parasites was negative. A hematological study revealed anemia with normal iron metabolism, a negative Coombs test, and absence of hemolysis signs. Freshly frozen plasma was administered for the severe coagulation abnormalities, and empirical therapy with ceftriaxone and metronidazole was initiated. Cultures of blood, stool specimen, and urine were negative. Two serologic studies separated by 1 week were negative for Salmonella, Yersinia, amoeba, Leptospira, and HIV. After 1 week of antibiotic treatment, although the fever continued, abdominal symptoms had improved, and the gallbladder ultrasonography was normal. A thoracic and abdominal CT showed a moderate splenomegaly. On day 21, the patient became apyretic; the antibiotics were stopped, and she was discharged. Four days later, the clinical symptoms reappeared. On readmission, 1 of 3 blood cultures grew Shigella sonnei, whereas stool cultures remained negative. Again therapy with ceftriaxone was begun. Despite a normal abdominal ultrasonography, the patient had a persistent fever, anemia, hyperbilirubinemia, and increased levels of lactate dehydrogenase without hemolysis. A second set of blood smears revealed infestation with ring trophozoites typical of Plasmodium falciparum and merozoites. Several days later, a positive serology of P. falciparum at a titer of 1:360 was received. A diagnosis of imported malaria was made, and treatment with quinine and doxicycline was started, with resolution of the diarrhea and fever, as well as normalization of the laboratory data. An enteric fever was initially suspected, despite negative cultures and serology. The patient had recently traveled to the Caribbean islands, her clinical features were compatible, and she had developed an AC and had a good response to ceftriaxone. During the second admission to the hospital, the patient’s fever and diarrhea relapsed and, although S. sonnei was isolated in a blood culture, specific treatment failed, and symptoms persisted until malaria treatment was administered. The clinical presentation with AC and the concept that Punta Cana in the Altagracia province of the Dominican Republic was not a malaria area led to the delay of the diagnosis. On 22 December 1999, the Centers for Disease Control and Prevention reported in its travel web page (www.cdc.gov/travel/blusheet.htm) an outbreak of P. falciparum malaria in the Altagracia province. This outbreak involved 1250 cases during 1999 and has been associated with climatic changes induced by Hurricane George. It has also been associated with worker emigration, usually illegal and without sanitary control, from endemic areas (Haiti) to tourist zones in the Dominican Republic. The pathogenesis of AC [2] involves a combination of bile stasis and ischemia. As in Dylewski’s patient, our patient presented hypotension that probably contributed to gallbladder damage. Etiology of AC [2] includes trauma, vascular diseases (polyarteritis nodosa), and infectious agents, such as Salmonella, cytomegalovirus, Cryptosporidium, and microsporidium. To the best of our knowledge, S. sonnei has never been associated with AC. The S. sonnei bacteremia was probably related to a transient immunosuppression induced by malaria [3]. The contribution of malaria to AC in this patient seems evident, but secondary bacterial infections are common in malaria. It remains to be determined whether AC is directly related to malaria or to a secondary gallbladder bacterial infection that could not be identified. We agree with Dylewski and Al-Azragi that malaria, although the pathogenesis remains controversial, should be included among the differential diagnoses of AC, especially in endemic zones of malaria.

Nosocomial outbreak of scabies clinically resistant to lindane.

To the Editor: Scabies is a cutaneous parasitosis transmitted mainly by skin contact. Delayed diagnosis because of atypical presentation facilitates dissemination. Crusted (Norwegian) scabies particularly is likely to lead to epidemics, because patients are infested by thousands of mites and thus are extremely contagious. Several nosocomial scabies outbreaks with secondary cases among the relatives of patients and staff have been noted in recent years.1,2 Here we report such an outbreak that was very difficult to eradicate due to clinical resistance to 1% lindane, which had been our standard treatment for scabies. In late November 1994, a patient with acquired immunodeficiency syndrome and psoriatic erythroderma with severe itching was admitted to our infectious disease unit and received topical treatment, involving frequent manipulation of the lesions and changes of dressings. When symptoms persisted, crusted scabies was suspected, proven by skin biopsy on December 14, and treated with lindane. In the following 19 weeks, six cases of scabies were diagnosed among healthcare workers, five among their family members, and five among patients with no prior contact with the index patient. Lindane treatment and prophylaxis showed no effect. An intervention program was designed by our Preventive Medicine Department and was implemented in the 20th week of 1995. All of our facilities and the fomites (including beds and wheelchairs) were cleaned intensely and fumigated, 5% permethrin was used prophylactically on every patient in the ward, all the staff, and the families of both the staff and the patients. The same day, we instituted a nurse protocol directed to pruritus. Every patient admitted to our unit was questioned systematically about itching. If pruritus was detected and it affected other relatives, appeared mainly at night, or was located in areas suggesting scabies, the patient was placed in cutaneous isolation, treated with an emulsion of 5% permethrin, and kept in cutaneous isolation until scabies had been definitely excluded. From that intervention on, no more cases of scabies were diagnosed either in the staff or in their families, and no further nosocomial transmission of scabies was observed. Control of a scabies outbreak requires good disinfestation of fomites, paying special attention to beds and wheelchairs, and simultaneous treatment of all potentially affected individuals (patients and staff) in the facility and their families.3 This may require treatment of over 500 people and expenditure of more than

Hot Immunological Topics in HIV Infection

20,000. Good coordination is essential. It is imperative that treatment be given to the entire group. The medications have to be distributed and all participants given careful directions regarding the importance of following the instructions completely. Factors contributing to the persistence of epidemics include patients with unrecognized infestations because of atypical or minimally symptomatic lesions, patients with crusted (Norwegian) scabies, carriage of scabies mites by infested staff members before they have symptoms, treatment failure due to improper use of scabicides or bad compliance, and lindane failure.4 When an epidemic proves difficult to control and scabies persists as a chronic problem over a period of months or even years, this often leads to staff demoralization. Frustration and anger are common among staff, patients, and families. An accurate information policy is very useful in allaying fears and achieving the cooperation needed to resolve the outbreak.

Safety of Switching Nevirapine Twice Daily to Nevirapine Once Daily in Virologically Suppressed Patients.

Incomplete immune reconstitution and persistent immune system hyperactivation in spite of highly active antiretroviral therapy continue to be a challenge. Both facts may lead to an increased risk for AIDS-defining and non AIDS-defining clinical conditions and may also promote atherogenesis and liver fibrogenesis in HIV and hepatitis C virus-coinfected patients. In this article, the use of new markers to assess immune reconstitution and immune activation and the incidence and clinical consequences of immunediscordant response to antiretroviral therapy are addressed. Likewise, the impact of immune dysfunction on atherogenesis and liver fibrogenesis are reviewed. Finally, it is discussed whether therapy with drugs belonging to the family of CCR5 inhibitors may provide additional immunological benefit in HIV-infected patients.

Costs and cost-efficacy analysis of the 2016 GESIDA/Spanish AIDS National Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults.

Background:The strategy of switching nevirapine (NVP) twice daily to once daily was evaluated. Methods:Forty-eight-week randomized, open, multicenter trial. Stable HIV-infected patients on NVP twice daily for >12-18 weeks with alanine aminotransferase (ALT) <2.5, the upper normal limit were randomized to continue their regimen or switch to NVP 400 mg once daily. Primary end point was the proportion of ALT/aspartate transaminase (AST) ≥grade 3. Results:Two hundred eighty-nine patients were included, mean CD4 620 cells per microliter. Noninferiority was demonstrated in the per protocol analysis, with 97.9% (once daily) and 99.3% (twice daily) of patients event free (difference, 1.4%; 95% confidence interval, −1.95% to 5.4%), whereas 81.8% vs. 93.8% were event free by intent-to-treat switch = toxicity analysis (difference, 12%; 95% confidence interval, 4.6% to 19.4%). Only 4 patients (3 once daily, 1 twice daily) had NVP-related grade 3/4 ALT/AST increases, but in 2 of them (once daily), transaminases decreased despite continuation with NVP. Two other once daily patients presented grade 3/4 ALT/AST increase due to well-documented acute hepatitis A virus or hepatitis C virus infection. Grade 2 ALT/AST increases occurred in 11.2% (once daily) vs. 10.3% (twice daily) of patients (P = 0.80). A larger number of once daily patients were lost to follow-up/violated protocol (15% vs. 5%). Conclusions:In patients on standard twice daily NVP-containing regimens for at least 12-18 weeks, per protocol analysis showed that switching to once daily NVP was not inferior to continued twice daily NVP in terms of the predefined noninferiority margin of 10% for hepatotoxicity.

Vitamin D insufficiency and subclinical atherosclerosis in non-diabetic males living with HIV

INTRODUCTION GESIDA and the AIDS National Plan panel of experts suggest a preferred (PR), alternative (AR) and other regimens (OR) for antiretroviral treatment (ART) as initial therapy in HIV-infected patients for 2015. The objective of this study is to evaluate the costs and the effectiveness of initiating treatment with these regimens. METHODS Economic assessment of costs and effectiveness (cost/effectiveness) based on decision tree analyses. Effectiveness was defined as the probability of reporting a viral load <50 copies/mL at week 48, in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and the costs correspond to those of 2015. A deterministic sensitivity analysis was conducted, building three scenarios for each regimen: base case, most favourable and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 4663 Euros for 3TC+LPV/r (OR) to 10,902 Euros for TDF/FTC+RAL (PR). The effectiveness varies from 0.66 for ABC/3TC+ATV/r (AR) and ABC/3TC+LPV/r (OR), to 0.89 for TDF/FTC+DTG (PR) and TDF/FTC/EVG/COBI (AR). The efficiency, in terms of cost/effectiveness, ranges from 5280 to 12,836 Euros per responder at 48 weeks, for 3TC+LPV/r (OR) and RAL+DRV/r (OR), respectively. CONCLUSION The most efficient regimen was 3TC+LPV/r (OR). Among the PR and AR, the most efficient regimen was TDF/FTC/RPV (AR). Among the PR regimes, the most efficient was ABC/3TC+DTG.

The effects of Maraviroc on liver fibrosis in HIV/HCV co-infected patients

Vitamin D insufficiency (VDI) has been associated with increased cardiovascular risk in the non‐HIV population. This study evaluates the relationship among serum 25‐hydroxyvitamin D [25(OH)D] levels, cardiovascular risk factors, adipokines, antiviral therapy (ART) and subclinical atherosclerosis in HIV‐infected males.

Infección crónica por el virus de la hepatitis C y enfermedad hepática asociada en una prisión española

The fibrogenesis analysis in quimeric CCR1 and CCR5 mice revealed that CCR5 mediates its pro‐fibrogenic effects in hepatic cells and promoting stellate cells. The blockage of co‐receptors could preserve the progression of hepatic fibrosis in HIV/HCV co‐infected patients.