Dalbavancin as suppressive antibiotic therapy in patients with prosthetic infections: efficacy and safety

Suppressive antibiotic therapy (SAT) is a strategy to alleviate symptoms and/or to reduce the progression of an infection when other treatment options cannot be used. Dalbavancin, due to its prolonged half-life, enables (bi) weekly dosing. Here, we report our multicenter real-life clinical experience with dalbavancin used as SAT in patients with prosthetic joint or vascular infections. Medical records of all adult patients with documented vascular or orthopedic chronic prosthetic infections, who received dalbavancin as SAT between 2016 and 2018 from four Spanish hospitals were reviewed for inclusion. Descriptive analysis of demographic characteristics, Charlson Comorbidity index, Barthel index, isolated pathogens and indication, concomitant antibiotic use, adverse events, and clinical outcome of SAT were performed. Eight patients were eligible for inclusion, where six patients had prosthetic vascular infections (aortic valve) and two patients had knee prosthetic joint infections. The most common pathogens were methicillin-susceptible Staphylococcus aureus and Enterococcus faecium. All patients had a history of prior antibiotic treatment for the prosthetic infection [median duration of antibiotic days 125 days (IQR, 28–203 days)]. The median number of dalbavancin doses was 29 (IQR, 9–61) and concomitant antibiotic use (n = 5, 62.5%). Clinical success was reported in 75% (n = 6) of patients. Adverse events were reported in two patients (mild renal and hepatic impairment). The median estimated cost savings due to the avoided hospital days was €60185 (IQR, 19,916–94984) per patient. Despite the limitations of our study, this preliminary data provides valuable insight to support further evaluation of dalbavancin for SAT in patients with prosthetic infections in the outpatient setting when alternative treatments are not feasible

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Recomendaciones prácticas para el diagnóstico y tratamiento de la infección urinaria en el adulto (II)

En el número anterior, se han tratado los aspectos generales en el diagnóstico y tratamiento de la infección urinaria, y las peculiaridades de los síndromes clínicos más frecuentes, cistitis y pielonefritis. En este número, se revisarán el manejo de la bacteriuria asintomática, las prostatitis y la candiduria, y las características de la infección en dos situaciones especiales, que son el sondaje y el embaraz

Peginterferón alfa-2b y Ribavirina en pacientes coinfectados VIH-VHC: eficacia y seguridad en la práctica clínica habitual

OBJECTIVE: To determine, in routine clinical practice, the efficacy and safety of peginterferon (PEG-IFN) plus ribavirin (RBV) in HCV-HIV co-infected patients in terms of sustained virologic response (SVR) and early discontinuation due to adverse effects. MATERIAL AND METHOD: Retrospective study with inclusion of all coinfected patients who started treatment with PEG-IFN �¿-2b and RBV between November/2002 and April/2007 in a specific hospital outpatient clinics. RESULTS: Forty-five patients were included (73% men; mean age: 39,8 �} 4,7 years). The median CD4 cell count was 593/mm3 and 62,3% were receiving HAART. The most common HCV genotypes were 1 (48,9%) and 3 (33,3%). HCV-RNA was . 5,7 log10 copies/ml in 85,4%. The SVR rate, in intention-to-treat analysis, was 22,2% (10/45). The SVR was significantly higher in two groups: patients with HCV genotype 3 (OR 7, p 0,021) and patients without HAART (OR 0,18, p 0,045). The toxicity leading to reduction of dose of drugs occurred in 22,2% and to discontinuation treatment occurred in 13,3%. There were no treatment-related deaths. Although HAART was discontinued in 6 patients and the absolute CD4 cell count fell by 293 CD4 cells/mm3, there were no opportunistic infections. CONCLUSIONS: In our clinical experience, SVR rate with PEG-IFN plus RBV in co-infected patients was low, even though, tolerance to treatment was acceptable with a rate of discontinuations due to toxicity similar to other series.OBJETIVO: Determinar en la practica clinica habitual, la eficacia y seguridad del tratamiento con peginterferon (PEG-IFN) y ribavirina (RBV) en pacientes coinfectados VHC-VIH, en terminos de respuesta viral sostenida (RVS) y suspension precoz por efectos adversos. MATERIAL Y METODO: Analisis retrospectivo de todos los pacientes coinfectados que iniciaron tratamiento con PEG-IFN a-2b y RBV entre Noviembre/ 2002 y Abril/2007 en una consulta monografica de VIH. RESULTADOS: Fueron incluidos 45 pacientes (73% varones; edad media: 39,8 �} 4,7 anos). La mediana de CD4 fue 593 cel/�Êl. El 62,3% recibian TARGA. Los genotipos del VHC mas frecuentes fueron el 1 (48,9%) y el 3 (33,3%). El 85,4% tenian RNA-VHC . 5,7 log10 copias/ml. La tasa de RVS, por intencion de tratar, fue de 22,2% (10/45). La RVS fue significativamente mayor en 2 grupos: pacientes con genotipo 3 del VHC (OR 7, p 0,021) y pacientes sin TARGA (OR 0,18, p 0,045). La toxicidad obligo a reducir la dosis de los farmacos en el 22,2 % y a la suspension precoz del tratamiento en el 13,3%. No hubo muertes relacionadas con el tratamiento. Aunque el TARGA tuvo que ser suspendido en 6 pacientes y el recuento de CD4 cayo una media de 293 celulas/ml, no hubo infecciones oportunistas. CONCLUSIONES: En nuestra experiencia clinica, la tasa de RVS con PEGIFN y RBV en pacientes coinfectados fue baja, a pesar de que el tratamiento fue aceptablemente tolerado, siendo la tasa de abandonos por toxicidad similar a otras series