Varicella pneumonia associated with spontaneous popliteal arterial thrombosis in an adult: a case study and review of the literature

Introduction: Chickenpox is generally a childhood exanthematic benign self-limited disease. In contrast, most complications and fatal cases occur among adults, which is the group that suffers less commonly from this disease. The frequency of chickenpox in adults is increasing worldwide, together with the associated complications, mainly varicella pneumonia, which can lead to death. The incidence of other complications such as peripheral artery thrombosis is much lower but can cause important morbidity. Case presentation: We report the case of a 63-year-old male smoker, who was otherwise previously healthy, who was admitted to the Emergency Department with chickenpox and varicella pneumonia with respiratory insufficiency requiring mechanical ventilation and intensive care unit admission. During hospitalization, the patient developed spontaneous popliteal artery thrombosis that finally led to transfemoral amputation. Conclusions: Varicella pneumonia and peripheral artery thrombosis are two of the known complications of chickenpox. Both complications seem to be much more frequent in men with an active smoking habit. Clinicians should be aware of these complications in order to recognize them promptly and provide adequate treatment

Characteristics of febrile urinary tract infections in older male adults

Background: Urinary tract infections (UTI) are among the most frequent bacterial infections in older adults. The aim of the study was to analyse the existence of differences in clinical features, microbiological data and risk of infection by multidrug-resistant organisms (MDRO) between older and non-older men with febrile UTI (FUTI). Methods: This was an ambispective observational study involving older males with a FUTI attended in the Emergency Department. Variables collected included age, comorbidity, diagnostic of healthcare-associated (HCA)-FUTI, clinical manifestations, hospitalization, mortality, and microbiological data. Results: Five hundred fifty-two males with a FUTI, 329 (59.6%) of whom were older adults, were included. Older males had a higher frequency of HCA-FUTI (p < 0.001), increased Charlson scores (p < 0.001), had received previous antimicrobial treatment more frequently (p < 0.001) and had less lower urinary tract symptoms (p < 0.001). Older patients showed a lower frequency of FUTI caused by E. coli (p < 0.001) and a higher rate of those due to Enterobacter spp. (p = 0.003) and P. aeruginosa (p = 0.033). Resistance rates to cefuroxime (p = 0.038), gentamicin (p = 0.043), and fluoroquinolones (p < 0.001) in E. coli isolates and the prevalence of extended-spectrum beta-lactamase and AmpC producing E. coli and Klebsiella spp. strains (p = 0.041) and MDRO (p < 0.001) were increased in older males. Inadequate empirical antimicrobial treatment (p = 0.004), frequency of hospitalization (p < 0.001), and all cause in-hospital mortality (p = 0.007) were higher among older patients. In the multivariate analysis, being admitted from an long term care facility (OR 2.4; 95% CI: 1.06-5.9), having a urinary tract abnormality (OR 2.2; 95% CI: 1.2-3.8) and previous antimicrobial treatment (OR 3.2; 95% CI: 1.9-5.4) were associated to FUTI caused by MDRO. Conclusions: Older male adults with a FUTI have different clinical characteristics, present specific microbiological features, and antimicrobial resistance rates. In the multivariate analysis being an older male was not associated with an increased risk of FUTI caused by MDRO

Rotura de un aneurisma de arteria esplénica. A proposito de un caso y revisión de la literatura

La prevalencia de aneurismas esplénicos en la población general es del 0,8%, siendo más alta en mujeres que en hombres. El embarazo, la fibrodis plasia arterial y la hipertensión portal, con o sin esplenomegalia asociada, son factores de riesgo conocidos asociados al desarrollo de aneurismas esplénicos. Se presenta el caso clínico de una pa ciente nulípara de 24 años, sin factores de riesgo vasculares y con antecedentes de paludismo, que acudió al servicio de urgencias de nuestro centro por presentar dolor abdominal tras un vuelo en avión de larga distancia. La exploración física y las pruebas complementarias realizadas mostraron un shock hipovolémico por hemoperitoneo. A pe sar del tratamiento de apoyo, la paciente falleció antes de su entrada en quirófano. La necropsia mostró la rotura de un aneurisma sacular de la arteria esplénica como causa de muerte. Se discu te la posibilidad de que un barotrauma pueda ha ber sido la causa de rotura aneurismáti

Efficacy and safety of direct-acting antiviral agents when combined with secukinumab

Background: The interference in the immune response induced by biological disease-modifying antirheumatic drugs (bDMARDs) increases the risk of reactivation of infections. Treatment of patients with chronic hepatitis C virus (HCV) infection and psoriasis is complex. The efficacy and safety of the new direct-acting antiviral agents (DAA) when combined with bDMARDs remain unknown. Case report: We present a case of a 44-year-old Caucasian man affected with psoriasis and HCV infection. Throughout the course of the psoriatic disease, this patient received several lines of treatment, including secukinumab, a new type of bDMARD. At the time of commencing secukinumab, new DAA agents (ledipasvir/sofosbuvir) were also initiated. At week 12 post-treatment, hepatitis C viral load was undetectable and the patient remained in remission of psoriasis. Conclusion: This case report suggests that secukinumab is a therapeutic option in patients with psoriasis, particularly in those cases with HCV infection where treatment with DAA agents is warranted

Development and validation of a prediction model for 30-day mortality in hospitalised patients with COVID-19: the COVID-19 SEIMC score

Objective To develop and validate a prediction model of mortality in patients with COVID-19 attending hospital emergency rooms. Design Multivariable prognostic prediction model. Setting 127 Spanish hospitals. Participants Derivation (DC) and external validation (VC) cohorts were obtained from multicentre and single centre databases, including 4035 and 2126 patients with confirmed COVID-19, respectively. Interventions Prognostic variables were identified using multivariable logistic regression. Main outcome measures 30-day mortality. Results Patients? characteristics in the DC and VC were median age 70 and 61 years, male sex 61.0% and 47.9%, median time from onset of symptoms to admission 5 and 8 days, and 30-day mortality 26.6% and 15.5%, respectively. Age, low age-adjusted saturation of oxygen, neutrophil-to-lymphocyte ratio, estimated glomerular filtration rate by the Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) equation, dyspnoea and sex were the strongest predictors of mortality. Calibration and discrimination were satisfactory with an area under the receiver operating characteristic curve with a 95% CI for prediction of 30-day mortality of 0.822 (0.806?0.837) in the DC and 0.845 (0.819?0.870) in the VC. A simplified score system ranging from 0 to 30 to predict 30-day mortality was also developed. The risk was considered to be low with 0?2 points (0%?2.1%), moderate with 3?5 (4.7%?6.3%), high with 6?8 (10.6%?19.5%) and very high with 9?30 (27.7%?100%). Conclusions A simple prediction score, based on readily available clinical and laboratory data, provides a useful tool to predict 30-day mortality probability with a high degree of accuracy among hospitalised patients with COVID-19.Funding. This work was supported by Fundación SEIMC/GeSIDA. The funders had no role in study design, data collection, data interpretation or writing of the manuscript. JB, JRB, IJ, JC, JP and JRA received funding for research from Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, cofinanced by the European Development Regional Fund “A way to achieve Europe”, Operative program Intelligent Growth 2014-2020. Spanish AIDS Research Network (RIS) (RD16/0025/0017 (JB), RD16/0025/0018 (JRA), RD16CIII/0002/0006 (IJ)). Spanish Network for Research in Infectious Diseases (REIPI) (RD16/0016/0001 (JRB), RD16/0016/0005 (JC) and RD16/0016/0009 (JP))

Detección en urgencias de infección por VIH en pacientes que consultan por condiciones potencialmente relacionadas con infección oculta: resultados iniciales del programa "Urgències VIHgila"

Objective: To estimate the prevalence of unknown HIV infection in patients who consulted in hospital emergency services (ED) for conditions defined in the SEMES-GESIDA Consensus Document (DC), evaluate the efficiency of its im-plementation and investigate the efficiency of HIV serology determination in other conditions. Methods: Results were reviewed in 10 Catalan EDs for 12 months (July-21-June-22) after implementing CD recommendations: request HIV serology in case of suspected sexually transmitted infection, chemsex, post-exposure prophylaxis (PEP), mononucleosis syndrome, community pneumonia (18-65 y-o) or herpes zoster (18-65 y-o). Other reasons for request were included. Prevalence (%) of global seropositivity and for each circumstance was calculated, with a 95% confidence interval (95%CI). The efficient strategy was considered if the lower limit of the CI95%>0.1%. Results: A total of5,107 HIV serologies were performed: 2,847(56%) in situations specified in CD, and 2,266 (44%) in other 138 circumstances. Forty-eight unknown HIV infections were detected (prevalence=0.94%;95%CI=0.69-1.24). The prevalence was somewhat higher in DC requests (30 cas-es 1.12%) than the rest (18 cases 0.71%; p=0.16). The individualized prevalence of CD reasons ranged between 7.41% (95%CI=0.91-24.3) in chemsex and 0.42% 95%CI=0.14-0.98 in PPE, always efficient except herpes zoster (0.76%; CI95%=0.02-4.18). In other reasons, cases were detected in 12 circumstances, and in four the determination could be efficient: lymphopenia (10%;CI95%=0.25-44.5), fever with polyarthralgia-polyarthritis (7.41%;CI95% =0.91-24.3), behavioral alteration-confusion-encephalopathy (3.45%;95%CI=0.42-11.9) and fever of unknown origin (2.50%;95%CI=0.82-5.74). Conclusions: The determination of HIV serology in HES in the processes defined by DC SEMES-GESIDA is efficient. Some circumstances are identified that could be added to those previously contemplated to increase efficiency

Risk Factors and Predictive Score for Bacteremic Biliary Tract Infections Due to Enterococcus faecalis and Enterococcus faecium: a Multicenter Cohort Study from the PROBAC Project

Biliary-tract bloodstream infections (BT-BSI) caused by Enterococcus faecalis and E. faecium are associated with inappropriate empirical treatment and worse outcomes compared to other etiologies. The objective of this study was to investigate the risk factors for enterococcal BT-BSI. Patients with BT-BSI from the PROBAC cohort, including consecutive patients with BSI in 26 Spanish hospitals between October 2016 and March 2017, were selected; episodes caused by E. faecalis or E. faecium and other causes were compared. Independent predictors for enterococci were identified by logistic regression, and a predictive score was developed. Eight hundred fifty episodes of BT-BSI were included; 73 (8.5%) were due to target Enterococcus spp. (48 [66%] were E. faecium and 25 [34%] E. faecalis). By multivariate analysis, the variables independently associated with Enterococcus spp. were (OR; 95% confidence interval): cholangiocarcinoma (4.48;1.32 to 15.25), hospital acquisition (3.58;2.11 to 6.07), use of carbapenems in the previous month (3.35;1.45 to 7.78), biliary prosthesis (2.19;1.24 to 3.90), and moderate or severe chronic kidney disease (1.55;1.07 to 2.26). The AUC of the model was 0.74 [95% CI0.67 to 0.80]. A score was developed, with 7, 6, 5, 4, and 2 points for these variables, respectively, with a negative predictive value of 95% for a score ? 6. A model, including cholangiocarcinoma, biliary prosthesis, hospital acquisition, previous carbapenems, and chronic kidney disease showed moderate prediction ability for enterococcal BT-BSI. Although the score will need to be validated, this information may be useful for deciding empirical therapy in biliary tract infections when bacteremia is suspected. IMPORTANCE Biliary tract infections are frequent, and a significant cause of morbidity and mortality. Bacteremia is common in these infections, particularly in the elderly and patients with cancer. Inappropriate empirical treatment has been associated with increased risk of mortality in bacteremic cholangitis, and the probability of receiving inactive empirical treatment is higher in episodes caused by enterococci. This is because many of the antimicrobial agents recommended in guidelines for biliary tract infections lack activity against these organisms. To the best of our knowledge, this is the first study analyzing the predictive factors for enterococcal BT-BSI and deriving a predictive score

Revisiting the epidemiology of bloodstream infections and healthcare-associated episodes: results from a multicentre prospective cohort in Spain (PRO-BAC Study)

PROBAC REIPI/GEIH-SEIMC/SAEI Group.The epidemiology of bloodstream infections (BSIs) is dynamic as it depends on microbiological, host and healthcare system factors. The aim of this study was to update the information regarding the epidemiology of BSIs in Spain considering the type of acquisition. An observational, prospective cohort study in 26 Spanish hospitals from October 2016 through March 2017 including all episodes of BSI in adults was performed. Bivariate analyses stratified by type of acquisition were performed. Multivariate analyses were performed by logistic regression. Overall, 6345 BSI episodes were included; 2510 (39.8%) were community-acquired (CA), 1661 (26.3%) were healthcare-associated (HCA) and 2056 (32.6%) hospital-acquired (HA). The 30-day mortality rates were 11.6%, 19.5% and 22.0%, respectively. The median age of patients was 71 years (interquartile range 60–81 years) and 3656 (58.3%; 95% confidence interval 57.1–59.6%) occurred in males. The proportions according to patient sex varied according to age strata. Escherichia coli (43.8%), Klebsiella spp. (8.9%), Staphylococcus aureus (8.9%) and coagulase-negative staphylococci (7.4%) were the most frequent pathogens. Multivariate analyses confirmed important differences between CA and HCA episodes, but also between HCA and HA episodes, in demographics, underlying conditions and aetiology. In conclusion, we have updated the epidemiological information regarding patients’ profiles, underlying conditions, frequency of acquisition types and aetiological agents of BSI in Spain. HCA is confirmed as a distinct type of acquisition.This work was financed by grants from Plan Nacional de I+D+i 2013–2016, Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades [PI16/01432] and the Spanish Network for Research in Infectious Diseases (REIPI) [RD16/0016/0001; RD16/0016/0008], co‐financed by the European Development Regional Fund ‘A way to achieve Europe’, Operative program Intelligent Growth 2014–2020

Risk Factors and Predictive Score for Bacteremic Biliary Tract Infections Due to Enterococcus faecalis and Enterococcus faecium: a Multicenter Cohort Study from the PROBAC Project

Biliary-tract bloodstream infections (BT-BSI) caused by Enterococcus faecalis and E. faecium are associated with inappropriate empirical treatment and worse outcomes compared to other etiologies. The objective of this study was to investigate the risk factors for enterococcal BT-BSI. Patients with BT-BSI from the PROBAC cohort, including consecutive patients with BSI in 26 Spanish hospitals between October 2016 and March 2017, were selected; episodes caused by E. faecalis or E. faecium and other causes were compared. Independent predictors for enterococci were identified by logistic regression, and a predictive score was developed. Eight hundred fifty episodes of BT-BSI were included; 73 (8.5%) were due to target Enterococcus spp. (48 [66%] were E. faecium and 25 [34%] E. faecalis). By multivariate analysis, the variables independently associated with Enterococcus spp. were (OR; 95% confidence interval): cholangiocarcinoma (4.48;1.32 to 15.25), hospital acquisition (3.58;2.11 to 6.07), use of carbapenems in the previous month (3.35;1.45 to 7.78), biliary prosthesis (2.19;1.24 to 3.90), and moderate or severe chronic kidney disease (1.55;1.07 to 2.26). The AUC of the model was 0.74 [95% CI0.67 to 0.80]. A score was developed, with 7, 6, 5, 4, and 2 points for these variables, respectively, with a negative predictive value of 95% for a score # 6. A model, including cholangiocarcinoma, biliary prosthesis, hospital acquisition, previous carbapenems, and chronic kidney disease showed moderate prediction ability for enterococcal BT-BSI. Although the score will need to be validated, this information may be useful for deciding empirical therapy in biliary tract infections when bacteremia is suspected. IMPORTANCE Biliary tract infections are frequent, and a significant cause of morbidity and mortality. Bacteremia is common in these infections, particularly in the elderly and patients with cancer. Inappropriate empirical treatment has been associated with increased risk of mortality in bacteremic cholangitis, and the probability of receiving inactive empirical treatment is higher in episodes caused by enterococci. This is because many of the antimicrobial agents recommended in guidelines for biliary tract infections lack activity against these organisms. To the best of our knowledge, this is the first study analyzing the predictive factors for enterococcal BT-BSI and deriving a predictive score.8 página

Factores dependientes del microorganismo y del huésped en la patogenia de las infecciones urinarias

[spa] A pesar de los importantes avances en el conocimiento de la patogenia de las infecciones del tracto urinario (ITU) que se han producido en los últimos años, persisten aún numerosas incógnitas por despejar. A modo de ejemplo cabe señalar que desconocemos gran parte de los mecanismos por los que algunos gérmenes consiguen acantonarse en la próstata, si existen o no factores de virulencia bacterianos y/o del huésped adicionales a los ya conocidos implicados en la aparición de infecciones urinarias recurrentes (ITURs), o el mecanismo por el que ciertas pacientes presentan cuadros de ITU más graves que otras. En relación al estudio de los factores de virulencia, la implicación de la producción de biopelícula por parte de cepas uropatógenas de Escherichia coli, el germen causal más frecuente de las ITUs, en su patogenia ha sido hasta el momento poco estudiada. Si se confirmara dicha implicación, particularmente en la patogenia de las prostatitis o de las ITURs, ello permitiría por ejemplo ajustar de forma individualizada la duración óptima de los tratamientos antibióticos en función de la producción o no de biopelícula.En relación al estudio de los factores dependientes del huésped el campo de estudio es aún mayor. A modo de ejemplo, varios estudios experimentales han evidenciado la importancia de la interleuquina 8 (IL-8) y de sus receptores (CXCR1 y CXCR2) en la patogenia de las ITU, aunque estas observaciones no han podido ser confirmados en humanos. Por otra parte, a pesar de existir numerosas evidencias científicas sobre la implicación de la proteína fijadora de manosa (MBL), otro componente de la inmunidad innata, en la mayor frecuencia y gravedad de ciertos procesos infecciosos, dicha asociación no ha sido evaluada en el caso de las ITU.El objetivo de la presente tesis ha sido analizar: 1. La expresión y la presencia de polimorfismos en el gen de los receptores de la IL-8 en mujeres con ITUR y la presencia de polimorfismos en el gen de la MBL en pacientes con pielonefritis aguda y shock séptico.2. La producción de biopelícula por cepas de UPEC en las diferentes formas de ITU, incluyendo las prostatitis agudas y las ITUR.Los resultados de la presente tesis ha permitido: 1. Conocer mejor la patogenia de la infección urinaria recurrente, tanto en lo que se refiere a los factores dependientes del huésped (disminución de la expresión de CXCR2 pero no de CXCR1 y ausencia de polimorfismos significativos en el gen CXCR1), como a la demostración de la implicación de la producción de biopelícula en el caso de las cistitis recurrentes. 2. Demostrar que aquellas pacientes con una pielonefritis aguda que presentan polimorfismos en el gen de la MBL, asociados a baja producción de MBL, tienen un riesgo mayor de desarrollar un shock séptico. 3. Que las cepas de UPEC aisladas de pacientes con prostatitis aguda producen con mayor frecuencia biopelícula.[eng] The main objective of this doctoral thesis has been to increase the knowledge on the pathogenesis of urinary tract infections (ITUs), studying not only the microorganism, Escherichia coli, but also the host. Regarding the microorganism, the mechanisms by which some remain in the prostate or cause recurrent ITUs are not well understood. Several evidence point that host genetic factors may predispose to recurrent UTIs or to severe forms of UTIs. The objective of this doctoral thesis has been to analyze: 1. The expression of CXCR1 and CXCR2 and the existence of polymorphisms in the CXCR1 gene in women with recurrent UTIs and the presence of polymorphisms in the MBL2 gene in patients with acute pyelonephritis and septic shock. 2. The synthesis of biofilm by E. coli in the different clinical forms of UTIs including acute prostatitis and recurrent ITUs.This thesis has demonstrated that: 1. Women with recurrent UTIs have a lower expression of CXCR2 but not CXCR1 and that biofilm is involved in the pathogenesis of recurrent UTIs. 2. Women with acute pyelonephritis and polymorphisms in the MBL2 gene, related low MBL concentration, have an increased risk of septic shock. 3. E. coli strains involved in acute prostatitis produce biofilm more frequently