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Introduction: A possible increase in Candida resistance, especially in Candida glabrata, has been speculated according to poor diffusion of echinocandins to peritoneal fluid. Materials/methods: Peritoneal and serum concentrations of caspofungin, micafungin and anidulafungin were analysed in surgical patients with suspected candida peritonitis. After 4 days of starting therapy, serum and peritoneal samples (through peritoneal drainage) were obtained at baseline, 1, 6, 12 and 24 h of drug administration. Micafungin and anidulafungin concentrations were determined using highperformance liquid chromatography (HPLC/F), whereas caspofungin concentrations were established by bioassay. Results: Twenty-three critically ill patients with suspected abdominal fungal infection who were receiving an echinocandin were prospectively recruited. No specific criteria were applied to prescribe one specific echinocandin. No special clinical differences were observed among the three groups of patients. All were receiving antibiotic therapy, 80% required inotropic drugs, and fungal peritonitis was confirmed in 74% of them. The AUC0_24h (mg h/L) obtained in serum and peritoneal fluid were: 126.84 and 34.38, 98.52 and 18.83, and 66.9 and 8.78 for anidulafungin, micafungin and caspofungin, respectively. The median concentration in peritoneal fluid ranged from 0.66 to 1.82mg/mL for anidulafungin, 0.68–0.88mg/mL for micafungin and 0.21–0.46 mg/mL for caspofungin. Conclusion: The results showed moderate penetration of echinocandins into the peritoneal fluid of these patients. These levels are below the threshold of resistance mutant selection published by other authors. This could justify a potential risk of resistance in patients with prolonged treatment with echinocandins and suboptimal control of abdominal infection. The study received funding from the “Fondo de Investigaciones Sanitarias” of the Spanish Ministry of Health (FIS PI 15/1536). The work was supported by 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, Spanish Network for Research in Infectious Diseases (REIPI RD16), and co-financed by European Development Regional Fund “A way to achieve Europe”, Operative program Intelligent Growth 2014-2020. Sí

Summary Background Information about incidence, clinical characteristics, and outcomes of HIV-infected individuals with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is scarce. We characterised individuals with COVID-19 among a cohort of HIV-infected adults in Madrid. Methods In this observational prospective study, we included all consecutive HIV-infected individuals (aged ≥18 years) who had suspected or confirmed COVID-19 as of April 30, 2020, at the Hospital Universitario Ramon y Cajal (Madrid, Spain). We compared the characteristics of HIV-infected individuals with COVID-19 with a sample of HIV-infected individuals assessed before the COVID-19 pandemic, and described the outcomes of individuals with COVID-19. Findings 51 HIV-infected individuals were diagnosed with COVID-19 (incidence 1·8%, 95% CI 1·3–2·3). Mean age of patients was 53·3 years (SD 9·5); eight (16%) were women, and 43 (84%) men. 35 (69%) cases of co-infection had laboratory confirmed COVID-19, and 28 (55%) required hospital admission. Age and CD4 cell counts in 51 patients diagnosed with COVID-19 were similar to those in 1288 HIV-infected individuals without; however, 32 (63%) with COVID-19 had at least one comorbidity (mostly hypertension and diabetes) compared with 495 (38%) without COVID-19 (p=0·00059). 37 (73%) patients had received tenofovir before COVID-19 diagnosis compared with 487 (38%) of those without COVID-19 (p=0·0036); 11 (22%) in the COVID-19 group had previous protease inhibitor use (mostly darunavir) compared with 175 (14%; p=0·578). Clinical, analytical, and radiological presentation of COVID-19 in HIV-infected individuals was similar to that described in the general population. Six (12%) individuals were critically ill, two of whom had CD4 counts of less than 200 cells per μL, and two (4%) died. SARS-CoV-2 RT-PCR remained positive after a median of 40 days from symptoms onset in six (32%) individuals, four of whom had severe disease or low nadir CD4 cell counts. Interpretation HIV-infected individuals should not be considered to be protected from SARS-CoV-2 infection or to have lower risk of severe disease. Generally, they should receive the same treatment approach applied to the general population. Funding None.

Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Complicacions infeccioses; Càncer Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Complicaciones infecciosas; Cáncer Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Infectious complications; Cancer Background We aimed to describe the epidemiology, risk factors, and clinical outcomes of co-infections and superinfections in onco-hematological patients with COVID-19. Methods International, multicentre cohort study of cancer patients with COVID-19. All patients were included in the analysis of co-infections at diagnosis, while only patients admitted at least 48 h were included in the analysis of superinfections. Results 684 patients were included (384 with solid tumors and 300 with hematological malignancies). Co-infections and superinfections were documented in 7.8% (54/684) and 19.1% (113/590) of patients, respectively. Lower respiratory tract infections were the most frequent infectious complications, most often caused by Streptococcus pneumoniae and Pseudomonas aeruginosa . Only seven patients developed opportunistic infections. Compared to patients without infectious complications, those with infections had worse outcomes, with high rates of acute respiratory distress syndrome, intensive care unit (ICU) admission, and case-fatality rates. Neutropenia, ICU admission and high levels of C-reactive protein (CRP) were independent risk factors for infections. Conclusions Infectious complications in cancer patients with COVID-19 were lower than expected, affecting mainly neutropenic patients with high levels of CRP and/or ICU admission. The rate of opportunistic infections was unexpectedly low. The use of empiric antimicrobials in cancer patients with COVID-19 needs to be optimized. This study was supported by the Spanish Plan Nacional de IDi 2013-2016, Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Economía, Industria y Competitividad, and the Spanish Network for Research in Infectious Diseases (REIPI grant: RD16/0016/0001). It was also co-financed by the European Development Regional Fund ‘A Way to Make Europe’, Operational Programme Smart Growth 2014-2020.

OBJECTIVES: To describe and compare the main clinical characteristics and outcome measures in hospitalized patients with confirmed coronavirus disease 2019 (COVID-19) according to geographical area of origin. METHODS: A retrospective analysis of patients hospitalized with confirmed COVID-19 at a referral centre in Madrid, Spain, during March-May 2020 was performed. Recorded variables (age, gender, intensive care unit (ICU) admission, outcome), and geographical area of origin were compared for Europeans and non-Europeans (Latin Americans, Asians and Africans). RESULTS: In total, 2345 patients with confirmed COVID-19 hospitalized during the study period were included in the study. Of these, 1956 (83.4%) were European and 389 (16.6%) were non-European (of whom over 90%, 354/389, were Latin American). Non-Europeans were significantly younger than Europeans (mean 54 (SD 13.5) versus 70.4 (SD 15.1) years, p

Direct-acting antivirals have proved to be highly efficacious and safe in monoinfected liver transplant (LT) recipients who experience recurrence of hepatitis C virus (HCV) infection. However, there is a lack of data on effectiveness and tolerability of these regimens in HCV/HIV-coinfected patients who experience recurrence of HCV infection after LT. In this prospective, multicenter cohort study, the outcomes of 47 HCV/HIV-coinfected LT patients who received DAA therapy (with or without ribavirin [RBV]) were compared with those of a matched cohort of 148 HCV-monoinfected LT recipients who received similar treatment. Baseline characteristics were similar in both groups. HCV/HIV-coinfected patients had a median (IQR) CD4 T-cell count of 366 (256-467) cells/mu L. HIV-RNA was

Purpose: To analyze the influence of adding gentamicin to a regimen consisting of β-lactam or vancomycin plus rifampicin on survival in patients suffering from Staphylococcal prosthetic valve endocarditis (SPVE). Methods: From January 2008 to September 2016, 334 patients with definite SPVE were attended in the participating hospitals. Ninety-four patients (28.1%) received treatment based on β-lactam or vancomycin plus rifampicin and were included in the study. Variables were analyzed which related to patient survival during admission, including having received treatment with gentamicin. Results: Seventy-seven (81.9%) were treated with cloxacillin (or vancomycin) plus rifampicin plus gentamicin, and 17 patients (18.1%) received the same regimen without gentamicin. The causative microorganism was Staphylococcus aureus in 40 cases (42.6%) and coagulase-negative staphylococci in 54 cases (57.4%). Overall, 40 patients (42.6%) died during hospital admission, 33 patients (42.9%) in the group receiving gentamicin and 7 patients in the group that did not (41.2%, P = 0.899). Worsening renal function was observed in 42 patients (54.5%) who received gentamicin and in 9 patients (52.9%) who did not (p = 0.904). Heart failure as a complication of endocarditis (OR: 4.58; CI 95%: 1.84–11.42) and not performing surgery when indicated (OR: 2.68; CI 95%: 1.03–6.94) increased mortality. Gentamicin administration remained unrelated to mortality (OR: 1.001; CI 95%: 0.29–3.38) in the multivariable analysis. Conclusions: The addition of gentamicin to a regimen containing vancomycin or cloxacillin plus rifampicin in SPVE was not associated to better outcome.

Summary Background The role of galactomannan (GM) in serum or bronchoalveolar lavage fluid (BALF) for the diagnosis of invasive pulmonary aspergillosis (IPA) has been extensively evaluated in hematological patients, however its performance in non-hematological patients is not well established. Methods We performed a multicenter retrospective study in 3 university hospitals in Madrid, Spain between 2010 and 2014. The study population comprised patients with chronic obstructive pulmonary disease (COPD) and patients with immunosuppressive conditions in whom IPA was suspected and for whom BALF GM was available. Patients with hematological disorders were excluded. Results A total of 188 patients (35 with COPD and 153 with immunosuppressive conditions) were analyzed, and 31 cases of IPA (proven or probable) were identified. The global sensitivity of BALF GM (optical density index [ODI] ≥ 1.0) was 77.4%; sensitivity was higher in patients with immunosuppressive conditions than in patients with COPD (81.8% vs 66.7%; p: 0.38). In COPD patients, the best performance was obtained for BALF GM (ODI ≥ 0.5), although sensitivity (88.9%) was similar to that of BALF fungal culture (88.9%). The sensitivity of GM in serum was very poor in both populations (36.4% and 11.6%, respectively). Conclusions In the present series, the diagnostic performance of BALF GM was good for IPA in non-hematological patients, especially in patients with immunosuppressive conditions.

The immunosuppressive treatment that recipients receive from a solid organ transplantation hinders the defensive response to infection. Its transmission from the donor can cause dysfunction or loss of the graft and even death of the recipient if proper preventive measures are not established. This potential risk should be thoroughly evaluated to minimise the risk of infection transmission from donor to recipient, especially with organ transplantation from donors with infections, without increasing graft dysfunction and morbidity and mortality in the recipient. This document aims to review current knowledge about infection screening in potential donors and offer clinical and microbiological recommendations about the use of organs from donors with infection based on available scientific evidence.

Objective Previous studies on monitoring of post-transplant cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) are limited by single-centre designs and disparate risk categories. We aimed to assess the clinical value of a regular monitoring strategy in a large multicentre cohort of intermediate-risk kidney transplant (KT) recipients. Methods We recruited 124 CMV-seropositive KT recipients with no T-cell-depleting induction pre-emptively managed at four Spanish institutions. CMV-specific interferon-γ-producing CD4+ and CD8+ T cells were counted through the first post-transplant year by intracellular cytokine staining after stimulation with pp65 and immediate early-1 peptides (mean of six measurements per patient). The primary outcome was the occurrence of any CMV event (asymptomatic infection and/or disease). Optimal cut-off values for CMV-specific T cells were calculated at baseline and day 15. Results Twelve-month cumulative incidence of CMV infection and/or disease was 47.6%. Patients with pre-transplant CMV-specific CD8+ T-cell count Conclusions Monitoring for CMV-specific CMI in intermediate-risk KT recipients must be regular to reflect dynamic changes in overall immunosuppression and individual susceptibility. The early assessment at post-transplant day 15 remains particularly informative.

Solid organ transplant recipients (SOTR) are at risk of serious influenza-related complications. The impact of respiratory co-infection in SOTR with 2009 pandemic influenza A(H1N1) is unknown. A multicentre prospective study of consecutive cases of pandemic influenza A(H1N1) in SOTR was carried out to assess the clinical characteristics and outcome and the risk factors for co-infection. Overall, 51 patients were included. Median time from transplant was 3.7years, 5.9% of the cases occurred perioperatively and 7.8% were hospital-acquired. Pneumonia was diagnosed in 15 (29.4%) patients. Ten cases were severe (19.6%): 13.7% were admitted to intensive care units, 5.9% suffered septic shock, 5.9% developed acute graft rejection and 7.8% died. Co-infection was detected in 15 patients (29.4%): eight viral, six bacterial and one fungal. Viral co-infection did not affect the outcome. Patients with non-viral co-infection had a worse outcome: longer hospital stay (26.2±20.7 vs. 5.5±10.2) and higher rate of severe diseases (85.7% vs. 2.3%) and mortality (42.8% vs. 2.3%). Independent risk factors for non-viral co-infection were: diabetes mellitus and septic shock. Other factors associated with severe influenza were: delayed antiviral therapy, diabetes mellitus, time since transplantation

Intestinal transplant recipients are at high risk of cytomegalovirus (CMV) disease due to the specific characteristics of the graft and the intense cellular immunosuppression caused by immunosuppressive induction therapy in this type of transplantation. The most frequent form of CMV disease is graft enteritis. Diagnosis of this entity is not always straightforward given that antigenemia for CMV is frequently low grade or negative and the pathological findings can be confused with those of rejection. Diagnosis is aided by immunohistochemistry or molecular biological detection in biopsies of the colon. Current recommendations for the preventive management of CMV disease are based on sporadic experiences and expert opinion, given the lack of specifically-designed, high-quality studies in this type of transplant recipient. In general, universal prophylaxis against CMV is preferred in these patients, initially with intravenous ganciclovir and subsequently with oral valganciclovir for a minimum of 6 months, although this prophylaxis can be prolonged for up to 1 year depending on the type of immunosuppressive therapy used. Several groups also use CMV-specific immunoglobulin.

Introduccion La epidemiologia de los pacientes con tuberculosis ha cambiado en los hospitales europeos en los ultimos anos. Metodos Presentamos un estudio prospectivo en pacientes hospitalizados en nuestra institucion con tuberculosis confirmada por cultivo entre los anos 1997 y 2008. Resultados Se analizaron 661 pacientes con tuberculosis pulmonar. Durante el periodo de estudio se confirmo un incremento de la incidencia (p < 0,001). El porcentaje de pacientes con infeccion por VIH disminuyo desde el 26% en los anos 1997-2000 al 12% en los anos 2005-2008. Sin embargo, la proporcion de pacientes mayores de 40 anos e inmigrantes se incremento de forma significativa, desde el 37 al 59% y desde el 12 al 35% respectivamente. El analisis multivariante confirmo el tratamiento antituberculoso previo y la inmigracion como factores asociados a resistencia a isoniazida y a isoniazida-rifampicina. Despues del ano 2000 la mortalidad se asocio de forma independiente con la presencia de tuberculosis extrapulmonar (OR: 3,1; IC 95%: 1,4-7,2), infeccion por virus de la hepatitis C (OR: 6,0; IC 95%: 2,2-16,3), y diabetes (OR: 6,4; IC 95%: 2,4-16,8). Conclusion La inmigracion desde paises con elevadas incidencias de tuberculosis ha reemplazado a la infeccion por VIH como factor de riesgo de tuberculosis en nuestros pacientes. En los ultimos anos, el incremento de la edad y la presencia de otros factores de comorbilidad, especialmente hepatopatia cronica, pueden justificar una mayor morbi-mortalidad en estos pacientes

The guidelines on the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) are presented. These recommendations are focused on four clinical categories: oncology-haematology patients, solid organ transplant recipients, patients admitted to intensive care units, and children. An extensive review is made of therapeutical advances and scientific evidence in these settings. These guidelines have been prepared according the SEIMC consensus rules by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. Specific recommendations on the prevention of fungal infections in these patients are included.

Diseases of the gastrointestinal system frequently complicate immunosuppressed patients. Endogenous flora is the principal source of infection in humans, especially in patients with dysfunction of the digestive epithelial barrier due to various factors. Bacterial translocation, traumatisms, ischemia and surgery are frequent events in the general population. In addition, important risk factors for abdominal infections in specific patients include tumoral infiltration, mucositis complicating chemotherapy and/or radiotherapy, hypoproteinemia, neutropenia and lymphocyte deficiency. Clinical pictures vary according to patients' baseline condition and the environmental setting, including nosocomial infections. The differential clinical characteristics of abdominal infections observed in distinct types of immunosuppressed patients are reviewed.

La anidulafungina es una nueva equinocandina aceptada para el tratamiento de candidiasis esofagica, candidemia y otras formas de candidiasis, como peritonitis o abscesos intraabdominales en pacientes no neutropenicos. Como las otras equinocandinas, posee una elevada actividad fungicida frente a la mayoria de las especies de Candida y es fungistatico frente a Aspergillus spp. Tambien tiene buena actividad frente a Pneumocystis jirovecii y es poco activa frente a Cryptococcus neoformans, mucorales y otros hongos filamentosos diferentes a Aspergillus spp. Presenta ausencia o minima toxicidad renal y/o hepatica y, a diferencia de otras equinocandinas y azoles, no sufre metabolizacion asociada con el citocromo P450. Por tanto, carece de interacciones medicamentosas con los calcineurinicos y otros farmacos utilizados en los pacientes trasplantados. Esta caracteristica permite a la anidulafungina posicionarse como un antifungico especialmente interesante en este tipo de pacientes.

Summary Objective To assess the efficacy and toxicity of intravenous colistin in the treatment of infections due to multidrug-resistant gram-negative bacteria. Methods Retrospective cohort study. Results Sixty patients received colistin sulphomethate sodium (mean dose, 4.4mg/kg/day; median duration, 20days). The main infections were pneumonia or tracheobronchitis (63.3%), intra-abdominal (10%), urinary tract (8.3%), and surgical site infection (6.6%), primary bacteremia (5%), catheter infection (3.3%), meningitis (1.6%), and soft-tissue infection (1.6%). The responsible bacteria were Acinetobacter spp. (50%), P. aeruginosa (23.3%), K. pneumoniae (13.3%), Enterobacter spp. (10%), E. coli (1.6%), and S. maltophilia (1.6%). Eight patients (13%) received colistin monotherapy, and 52 (87%) received combination therapy with other antibiotics such as beta-lactams (15 cases), aminoglycosides (14), beta-lactams and aminoglycosides (15), or ciprofloxacin (8). A favourable response was observed in 43 cases (71.7%). Overall mortality was 26.7%. Despite the common use of combination therapy with aminoglycosides (48%), nephrotoxicity during colistin therapy was observed in only 10.9% of patients; most of them had previous renal failure. Conclusion Colistin appears to be an effective and safe drug for therapy of severe infections due to multidrug-resistant gram-negative bacteria. Despite the concomitant use of aminoglycosides in a high proportion of patients, renal toxicity was an uncommon adverse event.

Introduccion y objetivos La necesidad de retirar los electrodos endocavitarios del marcapasos o el desfibrilador es cada vez mas frecuente, aunque no esta exenta de riesgos y complejidad. Revisamos nuestra experiencia en la retirada de electrodos por via percutanea desde abril de 1989 hasta junio de 2006. Metodos Se retiraron 314 electrodos en 187 pacientes, implantados durante un periodo medio de 69,16 meses (intervalo, 0,11-234,6 meses; mediana 60,25 meses). En total, 115 fueron auriculares, 196 ventriculares y 3 de seno coronario, encontrandose 78 de ellos abandonados en el lecho vascular. Resultados Las indicaciones fueron: infeccion (26,1%), disfuncion (22,9%), decubito (25%), endocarditis (20,7%) y bacteriemia (2,7%). El 58,8% de los pacientes fue remitido desde otros servicios. El 96,8% de los electrodos se retiro completamente. Se utilizo la traccion simple en el 23,4% de los pacientes y tecnicas de contratraccion (con y sin radiofrecuencia) en el 60,7%. En caso de que hubiera electrodos abandonados, se utilizo una pinza de biopsia (4,3%) combinada con sistemas de contratraccion o lazos femorales (10,1%). Se necesito una esternotomia media en 3 pacientes de los 10 en los que quedaron restos de electrodos. El porcentaje de complicaciones fue del 4,6% (un 2,5% de complicaciones mayores). Estas se relacionaron con la edad menor de 60 anos (odds ratio [OR] = 5,38; intervalo de confianza [IC] del 95%, 1,07- 27,23), la presencia de endocarditis (OR = 4,97; IC del 95%, 1,04-23,70) y la implantacion por el lado derecho (OR = 17,09; IC del 95%, 2,15-135,70). Conclusiones La retirada de electrodos endocavitarios con los modernos sistemas de extraccion soluciona el problema en la mayoria de los casos. Debido a la posibilidad, aunque baja, de complicaciones durante la retirada, se aconseja realizar el procedimiento en centros especializados con capacidad quirurgica.

Recognizing a foreign element is an inherent characteristic of living beings and guarantees their survival. Evading this defense mechanism is one of the most difficult requirements for transplant success, but it leads to a series of consequences, mainly related to infection. T lymphocytes are the cornerstone of the allogenic response. These cells recognize intracellular and extracellular antigens over HLA molecules in host cells. As a consequence, lymphocytic expansion occurring on several levels is produced, and a humoral or cellular response is the final result. The immunosuppression regimens used in transplantation include induction, maintenance and rescue therapy. Induction therapy serves primarily to decrease the proportion of T-cell precursors and to lower the efficacy of antigen presentation. With respect to maintenance therapy, cyclosporine and tacrolimus inhibit cytokine transcription, azathioprine, and mycophenolate mofetil inhibit nucleotide synthesis, and sirolimus and everolimus inhibit transduction of growth factor signals. As a consequence of immunosuppression, opportunistic microorganisms may appear with endogenic reactivation of latent infection or from an exogenous origin. Prevention of these infections by proper knowledge of the risk factors, rapid diagnosis, and adequate management are fundamental to guarantee the survival of the patient.

The capabilities of 2 quantitative polymerase chain reaction (PCR) assays for detecting pulmonary aspergillosis were analyzed. Both methodologies were real-time (RT) based and were compared with quantitative cultures and galactomannan (GM) antigen detection in a rabbit model of invasive aspergillosis. A total of 106 samples including blood, serum, lung, and brain from 3 controls and 9 infected New Zealand rabbits were analyzed. The RT-PCR methodologies were an Aspergillus fumigatus-specific assay using fluorescent resonance energy transfer technology targeting a highly conserved region of the fungal 18S rRNA gene and a panfungal assay to amplify the internal transcribed spacer regions 1 and 2 from fungal rRNA gene complex, employing SYBRGreen fluorescent dye as a detector. The specificity for both PCR base assays, culture, and GM determination was 100%. The sensitivity of the specific PCR assay was 88.9% in lung samples, 66.6% in serum, 55.5% in blood, and 33.3 in brain specimens. The panfungal assay had a sensitivity of 33.3% in lung and serum samples, being brain and blood specimens invariably negative. Otherwise, 100% of the lungs resulted positive for culture, and all serum samples showed a GM index above 1.0 after 2 days of infection. The specific RT-PCR assay is a reliable technique to detect A. fumigatus DNA in vivo comparable to cultures and GM determination. The panfungal RT-PCR assay exhibited low sensitivity to diagnose invasive aspergillosis in rabbits advising against its clinical introduction.

Background/Aims Differences in HCV-RNA clearance during therapy might explain the lower efficacy of peg-IFN/RBV in HIV/HCV-coinfection. There are limited data on HCV-RNA clearance and treatment outcomes in liver transplanted (LT) patients. Methods To assess the rates of SVR and baseline predictors of failure after 48 weeks of weight-adjusted peg-IFN-α-2b/RBV in 120 patients with HCV genotype 1: 61 HCV-monoinfected, 40 HIV-coinfected and 19 LT-patients. Viral clearance was evaluated in patients completing 24 weeks of therapy ( n =112, 93%). Results SVR was significantly lower in HIV-coinfection than in HCV-monoinfection or LT (18 vs. 39 vs. 42%, P P =0.027), baseline HCV-RNA over 800,000IU/ml (OR 2.800; 95% CI 1.121–6.993, P =0.027) and higher AST values (OR 1.009; 95% CI 1.001–1.018; P =0.028) were significantly associated to failure. Despite similar baseline HCV load (5.67 vs. 5.75 vs. 5.90log 10 IU/ml), HIV-coinfection showed significantly lower HCV-RNA decreases than HCV-monoinfection at weeks 4 ( P =0.015), 12 ( P =0.015) and 24 ( P =0.0003), and than LT at weeks 12 ( P =0.003) and 24 ( P =0.023). 36/60 subjects (60%) reaching EVR by week 12 obtained SVR vs. 3/60 (5%) who did not. Conclusions HIV-coinfection was independently associated to treatment failure, and led to a significantly slower HCV-RNA clearance.

Background Native valve endocarditis in drug-user patients had a microbiology, a frequency of involvement of different cardiac valves, and a prognosis that differ from those in non–drug users. A retrospective study of native valve endocarditis cases in intravenous drug users diagnosed from 1985 to 1999 in our institution was performed to analyze the inhospital mortality of drug users with native valve endocarditis and to identify factors predictive of mortality. Methods All patients fulfilled the Duke's criteria for definite or probable endocarditis. Analysis of predictors of inhospital mortality was restricted to right-sided infective endocarditis (IE) with definite diagnosis and echocardiographic data. The following variables were analyzed: sex, HIV serostatus, CD4 cell count 3 , time of IE diagnosis (before 1993 or after 1993), previous valvulopathy, polymicrobial IE, fungal etiology (mixed or alone), neurological complication, arterial emboli, pulmonary emboli, congestive heart failure, vegetation size (VS) >2 cm, and inhospital cardiac surgery. Logistic regression was used in a multivariate model to identify factors independently associated with mortality. Adjusted odds ratios (OR) and 95% CIs were examined. Results Four hundred ninety-three cases of IE were diagnosed in this period. Two hundred twenty cases of native valve endocarditis in intravenous drug users were identified. Fourteen cases in this group died (6%). Mean time from diagnosis to death was 18.5 ± 15 days (range, 3-52). Vegetation size was available in 111 cases. Univariate analysis identified the following variables associated with inhospital mortality in right-sided cases: VS >2 cm and fungal etiology. In multivariate analysis, the variables associated with mortality that achieved statistical significance were size of vegetation >2 cm ( P = .014, OR 10.2, 95% CI 1.6-78.0) and fungal etiology ( P = .009, OR 46.2, 95% CI 2.4-1100.9). Conclusions The main prognostic factors of inhospital mortality in right-sided IE in drug users in our series were VS >2 cm and fungal etiology. The role of early surgery in these patients should be reevaluated.

Introduction Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999 Material and methods Cases included were those classified as “probable” or “definite” by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases ( Results Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study Conclusions In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients

Cytomegalovirus (CMV) infection remains an important complication of transplantation. The last decade has been characterized by improvements to management that has reduced its morbidity and mortality. The advance has been particularly important in the diagnosis and prevention. Several techniques have been developed that allow the increasingly rapid and sensitive diagnosis. The different preventive strategies include use of appropriate blood products, immune globulin, and antiviral agents either as prophylaxis or pre-emptive therapy. The development of effective oral drugs as valganciclovir also represents a new advance. It is necessary to summarize these advances to facilitate the development of local policies reflecting recent changes. The Group of Study of Infections in Transplantation (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has therefore produced actual recommendations in the management of CMV infection after transplantation.

Presentamos un varon de 43 anos, con infeccion por el virus de la inmunodeficiencia humana (VIH), sin seguimiento ni tratamiento antirretroviral, adicto a drogas por via parenteral, que acudio a urgencias por 7 dias de astenia, fiebre y disnea progresiva. Presentaba multiples signos de venopuncion y, aunque afebril, estaba afectado, sudoroso, taquicardico y taquipneico, con crepitantes gruesos bibasales en la auscultacion. La exploracion neurologica inicial fue normal. En la analitica destacaba leucocitosis con neutrofilia, 37.000 plaquetas, actividad de protrombina del 55%, indice normalizado internacional (INR) de 1,6, y elevacion de creatinfosfocinasa, transaminasas y bilirrubina. El electrocardiograma mostro taquicardia sinusal. La gasometria arterial inicial mostraba hipoxemia, con posterior evolucion a insuficiencia respiratoria global y acidosis, iniciandose tratamiento con broncodilatadores y corticoides. En Urgencias el paciente sufrio deterioro brusco del nivel de conciencia con anisocoria, y fue preciso canalizar via central y proceder a intubacion orotraqueal. Se realizo tomografia computarizada (TC) craneal sin contraste (fig. 1), que mostraba hematoma subdural agudo frontoparietal izquierdo, hemorragia subaracnoidea en hemisferio cerebral izquierdo y tentorio, hematoma en lobulo occipital izquierdo con edema periferico y herniacion transtentorial y subfalcina. Tras extraccion de hemocultivos se inicio tratamiento parenteral con cefotaxima (2 g) y clindamicina (600 mg) para cubrir posible aspiracion.