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

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

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

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

¿Sirve la escala ABCD2 del AIT para predecir y prevenir Ictus?

ABSTRACT Background and objectives: Independent validations of the ABCD2 score used to predict stroke development have reported conflicting results, yet expert opinion as to proper diagnostic approach and best treatment differs widely. A model predictive power can be modified by the concomitant use of effective diagnostic and pharmacological treatments. We aimed to determine the predictive power of the ABCD2 score while simultaneously providing patients with current urgent recommended treatments and recording their early and long term health outcomes. Methods: Data was retrospectively collected from all the patients presenting with a TIA for a whole year and were followed for another whole year. Physicians completed data forms with the ABCD2 score when patients arrived at the emergency department (ED).We calculated sensitivity, specificity for predicting stroke at 7 and 30 days after visiting the ED using the high-risk cutpoint of an ABCD2 score &#8805; 4.Univariate Cox proportional hazards regression modelling was performed for ABCD2 score to estimate the hazard ratios relative to the low-risk category and to assess the effect of the individual components of the ABCD2 score and other potential risk factors to predict stroke development. Results: We enrolled 172 patients (mean age 71 yr, 51 % women) with a new incident diagnosis of TIA. The mean (SD) ABCD2 score was 4.2 (1.4). There were 12 new TIA, 21 non fatal strokes and 3 fatal strokes. Intrahospital mortality was 1.7% and 12% during the 1 year follow up. An ABCD2 score of &#8805; 4 had a sensitivity of 88% and 82 % for a stroke at 7 and 30 days respectively, with a poor specificity of 30%. Negative predictive value at 7 days was 98%. ABCD2 score &#8805; 4 had no significant predictive value for stroke within 7 days (hazard ratio [HR], 3.49; 95%CI, 0.42 to 27.93) and 30 days (HR, 1.97; 95%CI, 0.43 to 9.13) of the event. Only diabetes predicted an increased likelihood of stroke over the first week (HR, 5.47; 95%IC 1.43 to 20.95) and over the first month (HR, 3.60; 95%IC 1.08 to 12). Conclusions: The accuracy of the ABCD2 score fails to help us make treatment decisions except for its negative predictive value (98%). It was only being diabetic that was significantly related to the probability of stroke development. TIA probably justifies early accurate identification of the underlying TIA etiology for nearly all presentations. We recommend adding a systematic Brain CT, carotid ultrasound and ECG within 24 hours while concomitantly starting urgent treatment. RESUMEN Introducción y objetivo: Las validaciones de la escala ABCD2 para predecir un Ictus después de un AIT han sido contradictorias y la opinión de los expertos sobre cual es mejor método de diagnostico y tratamiento son muy variables. Ademas los el poder predictivo de las escalas puede variar mucho si al mismo tiempo se usan procesos diagnósticos y terapéuticos efectivos en variar el curso de la enfermedad. Nuestro objetivo es evaluar el poder predictivo real de la escala ABCD2 cuando al mismo tiempo a los pacientes se les somete a métodos diagnósticos adecuados y tratamientos efectivos urgentes. Metodología: Se recogieron de manera retrospectiva todos los pacientes que acudieron a un hospital terciario durante un año y fueron seguidos prospectivamente durante 1 año. Los datos de la escala ABCD2 fueron los que presentaban al momento de llegada a urgencias. Calculamos cual era la sensibilidad, especificidad y poder discriminatorio de una puntuación &#8805; 4 para predecir la aparición de un Ictus a los 7 y 30 días. Se aplicó un modelo de regresión univariante de Cox a la escala ABCD2 para estimar el cociente de riesgo correspondiente a la categoría de bajo riesgo y valorar la capacidad predictiva de ictus de sus componentes individuales y de otros potenciales predictores de riesgo. Resultados: Incluimos 172 pacientes ( edad media 71 años, 51% mujeres) con un nuevo diagnostico de AIT. La puntuación media de la escala ABCD2 fue de 4.2 ± 1.4. Se produjeron 12 nuevos AIT, 21 Ictus no fatales y 3 ictus fatales durante el seguimiento. La mortalidad intrahospitalaria fue del 1.7% y la total durante el seguimiento de 1 año del 12 %. Una puntuación en la escala de ABCD2 de &#8805; 4 tenia una sensibilidad del 88% y del 82% para predecir un ictus a los 7 y 30 días respectivamente, con una pobre especificidad del 30%.El valor predictivo negativo a 7 dias fue del 98%. Una puntuación ABCD2 &#8805; 4 no tuvo valor predictivo significativo de ictus a los 7 días (hazard ratio [HR], 3.49; 95%CI, 0.42 to 27.93) ni a 30 días (HR, 1.97; 95%CI, 0.43 to 9.13). Como componente individual, solo la diabetes predijo la probabilidad de desarrollar un ictus en la primera semana (HR, 5.47; 95%IC 1.43 to 20.95) y durante el primer mes (HR, 3.60; 95%IC 1.08 to 12). Conclusiones: El poder discriminativo de la escala ABCD2 no ayuda a tomar decisiones de tratamiento salvo por su valor predictivo negativo del 98%. Solo la variable diabetes de la escala se asocio con una probabilidad relevante de tener un ictus.Probablemente cualquier tipo de presentación de AIT justifica la búsqueda rápida de la etiologia subyacente. Consideramos que en el AIT, independientemente de la escala ABCD2 , se debe realizar en menos de 24 horas un TAC cerebral, ECG, e imagen de carótida, mientras al mismo tiempo se inicia tratamiento preventivo urgente