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Background: The aim of this paper is to determine both the prevalence of community-acquired pneumonia (CAP) in the A & E Department and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients., Methods: Descriptive cross-sectional analysis at 49 Spanish A & E Departments during 12 months. All patients with infections, respiratory infection or CAP diagnosis were included. All patients attended to in A & E during the study were recorded as well., Results: CAP has increased its prevalence among patients in the A & E Departments in the past decade (0.85% to 1.35%, p <0.001). Fifty-one per cent were over 70 years old. Sixty-nine point eight per cent had some underlying disease and 17.8% had risk factors. Eleven point seven per cent met sepsis criteria, 4.6% severe sepsis and 3% septic shock. Thirty-seven per cent of patients were directly discharged from the A & E Departments., Conclusions: The impact and prevalence of CAP in A & E Departments has increased in the last decade. It is the most common cause of sepsis, severe sepsis and septic shock, admission to intensive care units and death due to infectious disease.

Background: Early antibiotic administration to patients diagnosed of community-acquired pneumonia (CAP) has been associated with a lower mortality. In the USA, its administration within four hours has been implanted as a quality standard. The objective of this work was to analyze, in a Spanish emergency department, the performance with patients with CAP, focusing on the administration of the first dose of antibiotic., Patients and Method: Clinics, welfare and organizational aspects have been analysed on 93 patients diagnosed of CAP in an emergency department in order to identify their influence on antibiotic administration within 4 hours., Results: 46.2% of patients received antibiotics within 4 hours. The fact that patients were assisted in the higher complexity level showed a positive association with the antibiotic administration within 4 hours. On the contrary, presence of more than 10 patients waiting to be admitted showed a negative association., Conclusions: Early antibiotic administration in the CAP is possible. On order to guarantee a higher number of patients taking antibiotics within 4 hours we have to improve quality of care in both the emergency department (to guarantee correct classification according to the level of complexity) and in the hospital (management of beds to avoid delay in the admission of the patients)., (Copyright (c) 2008 Sociedad Española de Calidad Asistencial. Published by Elsevier España, S.L. All rights reserved.)

Background: Characterize clinical findings and outcome of acute bacterial meningitis (ABM) in adults, with special emphasis on nosocomial meningitis and meningitis in the elderly., Methods: We reviewed the charts of all persons 14 years of age or older in whom ABM was diagnosed in our hospital during a 12 and a half-year period., Results: Ninety-seven patients were treated for 100 episodes of ABM, of which 23 percent were nosocomial and 27 percent occurred in elderly persons. Predisposing factors were present in 59 percent of the episodes. Fifty-four percent had the classic triad of fever, nuchal rigidity, and change in mental status. Cerebrospinal fluid pleocytosis with a neutrophilic predominance, hypoglycorrhachia, and elevated protein levels were present in 62 percent of the episodes. A pathogen was identified in 62 percent of the cases, in a higher frequency in elderly persons (p < 0.05) and in patients who had not received antibiotics before the lumbar puncture (p < 0.05). Causal agents more frequently identified were: Streptococcus pneumoniae (27 percent) in community-acquired meningitis, coagulase-negative Staphylococci (35 percent) in nosocomial meningitis, and Strep. pneumoniae (33 percent) in elderly persons. Central nervous system (CNS) complications occurred in 18 percent of episodes, and 15 percent developed systemic complications. The overall mortality rate was 9 percent, higher among patients in whom CNS complications began within 24 hours of admission (p < 0.05)., Conclusions: A high proportion of cases of ABM in adults are nosocomial, or affect elderly persons. The fatality rate is high, particularly among those who develop CNS complications at the onset of the disease.

Three cases of spontaneous peritonitis due to Clostridium perfringens in cirrhotic patients with a fatal outcome are reported. The diagnosis was made clinically in two patients and by post-mortem examination in the third. One patient had elevated values of serum alpha-fetoprotein. These cases are compared with three other reported cases in the literature. Blood cultures were negative in the three patients, a fact that lends support to the theory of transmural migration of bacteria. In the authors' experience C. perfringens is the third most frequent agent responsible for spontaneous peritonitis in cirrhosis, preceded by E. coli and Streptococcus and followed by Klebsiella, a surprising fact given the scarce number of reported cases. Routine abdominal paracentesis is recommended in any cirrhotic patient with ascites, followed by appropriate antibiotic treatment whenever positive cultures are obtained. The efficacy of treatment is probably doubtful. The literature on antibiotic treatment of spontaneous peritonitis in cirrhosis is reviewed.

A 79-year old female patient with antecedents of headache and fever, was admitted because of fatigue, anorexia, anemia and elevated ESR. After admission she presented with rheumatic polymyalgia and synovial effusion in the knee. A first biopsy of the temporal artery was normal. After dismissing other possible causes a second biopsy of the contralateral temporal artery was bone and confirmed giant cell arteritis. Diagnostic value of a second temporal artery biopsy is discussed and justified by: a) a confirmed diagnosis is necessary for prolonged treatment with corticosteroids, b) if it is decided to treat the rheumatic polymyalgia with lower doses of corticosteroids than for temporal arteritis the certainty that no temporal arteritis is present and c) shortening the hospital stay and lowering the cost and number of diagnostic procedures. The frequency of arthritis and synovial effusion in temporal arteritis are also discussed.

During a period of 29 months positive hemocultures to Streptococcus agalactiae corresponding to eight adult patients have been observed. These bacteria were apparently responsible for the clinical picture in five patients. In other two patients S. agalactiae appeared in the course of a sepsis caused by other germ. The remaining patient had a transient bacteremia and no treatment was required. Septic shock and bacterial endocarditis were the cause of death in two patients. Six patients cured. Literature on this subject is reviewed and the better prognosis of sepsis due to S. agalactiae in adults than in neonates is stressed. Endocarditis and meningitis occur as severe complications with poor prognosis. In patients with endocarditis the administration of penicillin and gentamicin as well as the consideration of early surgical replacement of the affected heart valve is recommended. Intravenous penicillin and gentamicin associated with intrathecal gentamicin are indicated in meningeal infections. Vancomycin is a good substitutive antibiotic in patients with penicillin hypersensibility.

A 75 year-old male presented with hyperkalemia unexplained by a moderate renal insufficiency, low basal levels of aldosterone and renin with a subnormal response to walking and saline depletion, and normal glucocorticoid function. The hyperkalemia was corrected by fluorocortisone administration. The concept of hypoaldosteronism is reviewed, defining it as an isolated aldosterone deficiency and thus excluding the combined deficiency of cortisol and aldosterone and the suprarenal enzyme deficits that simultaneously involve mineralocorticoid and glucocorticoid synthesis. Depending on the presence or absence of alterations of the renin-angiotensin axis, this infrequent syndrome can be pathophysiologically classified as low, normal or high renin hypoaldosteronism. The characteristic features of each type are described, and emphasis is made on the need for a high index of suspicion when unexplained hyperkalemia is present in order to perform the appropriate tests to confirm or rule out hypoaldosteronism.