Efficacy and safety of fosfomycin plus imipenem as rescue therapy for complicated bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus: a multicenter clinical trial

BACKGROUND

There is an urgent need for alternative rescue therapies in invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the clinical efficacy and safety of the combination of fosfomycin and imipenem as rescue therapy for MRSA infective endocarditis and complicated bacteremia.

METHODS

The trial was conducted between 2001 and 2010 in 3 Spanish hospitals. Adult patients with complicated MRSA bacteremia or endocarditis requiring rescue therapy were eligible for the study. Treatment with fosfomycin (2 g/6 hours IV) plus imipenem (1 g/6 hours IV) was started and monitored. The primary efficacy endpoints were percentage of sterile blood cultures at 72 hours and clinical success rate assessed at the test-of-cure visit (45 days after the end of therapy).

RESULTS

The combination was administered in 12 patients with endocarditis, 2 with vascular graft infection, and 2 with complicated bacteremia. Therapy had previously failed with vancomycin in 9 patients, daptomycin in 2, and sequential antibiotics in 5. Blood cultures were negative 72 hours after the first dose of the combination in all cases. The success rate was 69%, and only 1 of 5 deaths was related to the MRSA infection. Although the combination was safe in most patients (94%), a patient with liver cirrhosis died of multiorgan failure secondary to sodium overload. There were no episodes of breakthrough bacteremia or relapse.

CONCLUSIONS

Fosfomycin plus imipenem was an effective and safe combination when used as rescue therapy for complicated MRSA bloodstream infections and deserves further clinical evaluation as initial therapy in these infections.

FTIR gas-phase kinetic study on the reactions of some acrylate esters with OH radicals and Cl atoms

Acrylate esters are α,β-unsaturated esters that contain vinyl groups directly attached to the carbonyl carbon. These compounds are widely used in the production of plastics and resins. Atmospheric degradation processes of these compounds are currently not well understood. The kinetics of the gas phase reactions of OH radicals with methyl 3-methylacrylate and methyl 3,3-dimethylacrylate were determined using the relative rate technique in a 50 L Pyrex photoreactor using in situ FTIR spectroscopy at room temperature (298 ± 2 K) and atmospheric pressure (708 ± 8 Torr) with air as the bath gas. Rate coefficients obtained were (in units cm(3) molecule(-1) s(-1)): (3.27 ± 0.33) × 10(-11) and (4.43 ± 0.42) × 10(-11), for CH3CH═CHC(O)OCH3 and (CH3)2CH═CHC(O)OCH3, respectively. The same technique was used to study the gas phase reactions of hexyl acrylate and ethyl hexyl acrylate with OH radicals and Cl atoms. In the experiments with Cl, N2 and air were used as the bath gases. The following rate coefficients were obtained (in cm(3) molecule(-1) s(-1)): k3 (CH2═CHC(O)O(CH2)5CH3 + Cl) = (3.31 ± 0.31) × 10(-10), k4(CH2═CHC(O)OCH2CH(CH2CH3)(CH2)3CH3 + Cl) = (3.46 ± 0.31) × 10(-10), k5(CH2═CHC(O)O(CH2)5CH3 + OH) = (2.28 ± 0.23) × 10(-11), and k6(CH2═CHC(O)OCH2CH(CH2CH3)(CH2)3CH3 + OH) = (2.74 ± 0.26) × 10(-11). The reactivity increased with the number of methyl substituents on the double bond and with the chain length of the alkyl group in -C(O)OR. Estimations of the atmospheric lifetimes clearly indicate that the dominant atmospheric loss process for these compounds is their daytime reaction with the hydroxyl radical. In coastal areas and in some polluted environments, Cl atom-initiated degradation of these compounds can be significant, if not dominant. Maximum Incremental Reactivity (MIR) index and global warming potential (GWP) were also calculated, and it was concluded that these compounds have significant MIR values, but they do not influence global warming.

Striatal volume deficits in children with ADHD who present a poor response to methylphenidate

Methylphenidate (MPH) is the first choice of medical treatment for attention-deficit/hyperactivity disorder (ADHD). Its mechanism of action is to inhibit the reuptake of dopamine and noradrenaline mainly in the region of the striatum. It has been estimated that 10-30 % of patients with ADHD do not respond adequately to MPH. The aim of this study was to evaluate whether striatal differences exist between good and poor responders to MPH. The sample included 27 treatment-naïve children with ADHD between the ages of 6 and 14. MPH administration started 1 day after the MRI acquisition. After a month, psychiatrists established the good or poor response to treatment according to clinical criteria. MRI images were analyzed using a technique based on regions of interest applied specifically to the caudate and accumbens nuclei. Sixteen patients showed good response to MPH and 11 a poor one. Regions of interest analysis showed that good responders had a higher concentration of gray matter in the head of both caudate nuclei and the right nucleus accumbens. Furthermore, a significant correlation was found between caudate and accumbens nuclei volume and the Conners' Parent Rating Scale and Continuous Performance Test improvement. These results support the hypothesis of the involvement of the caudate and accumbens nuclei in MPH response and in ADHD pathophysiology.

High levels of CD4⁺ CTLA-4⁺ Treg cells and CCR5 density in HIV-1-infected patients with visceral leishmaniasis

Visceral leishmaniasis (VL) in HIV-1-infected patients has been associated with poor immunological recovery and frequent disease relapses. The aim of this study was to analyse the role of T cell populations, Treg cells and CCR5 density in patients with VL compared to HIV-1-infected patients without leishmaniasis. A cross-sectional study of nine Leishmania-HIV-1-coinfected (LH) patients with VL receiving suppressive cART for at least 1 year were compared to 16 HIV-1-infected patients with non-immunological response (NIR, CD4 count below 250 cells/mm(3)) and 26 HIV-1-infected patients with immunological response (IR, CD4 count above 500 cells/mm(3)) without leishmaniasis. LH patients had a deep depletion of naïve T cells (p = 0.002), despite similar levels of effector T cells compared to NIR patients. CD4 Treg cells were similar compared to NIR patients, but higher compared to IR patients (p < 0.001). Interestingly, CD4 Treg CTLA-4(+) cells were higher in LH patients compared to either NIR or IR patients (p = 0.022 and p < 0.001, respectively), and the CD4 Treg/TEM ratio was similar to NIR patients, but higher compared to IR patients (p = 0.017). CCR5(+) T cell levels were higher compared to IR patients (p < 0.001), while CCR5 density on T cells were higher compared to both NIR and IR patients (p < 0.005 in both cases). Higher levels of CD4(+) CTLA-4(+) Treg cells and CCR5 density on CD8(+) T cells are strongly associated with VL in HIV-1-infected patients. Also, these patients have a poor immunological profile that might explain the persistence and relapse of the pathogen.

Tomato Yellow Leaf Curl Virus Benefits Population Growth of the Q Biotype of Bemisia tabaci (Gennadius) (Hemiptera: Aleyrodidae)

Plant viruses can directly influence their insect vectors, and indirectly through their shared host plant, altering their behavior and performance in a mutualistic or rather antagonistic manner. One of the most studied begomovirus, Tomato yellow leaf curl virus (TYLCV), may also facilitate the expansion of its vector, the whitefly Bemisia tabaci (Gennadius). Considering the likely expansion of the disease and its major vector, we studied the direct and the indirect effects of a Mediterranean isolate of this virus (TYLCV-IL) on the biological performance of the Q biotype of B. tabaci. The following parameters were examined: development time and viability of nymphs, sex ratio, fecundity, and fertility and longevity. The results varied from positive to neutral depending on the parameter and the effect studied. TYLCV accelerated nymphal developmental and increased male longevity of B. tabaci when viruliferous insects developed on TYLCV-immune eggplants (direct effects). An indirect, positive effect of TYLCV-infected plants was observed on fecundity of B. tabaci, which laid more eggs on virus-infected than on noninfected tomato plants. Our results show that TYLCV enhances the population increase of its whitefly vector and that there is a high risk of rapid expansion of both the virus and its vector-the MED species of B. tabaci-into new areas when both agents interact together.

Diabetic retinopathy

This paper describes the importance of diabetic retinopathy in the loss of visual function. We exposed the most important risk factors, such as diabetes duration, poor metabolic control, pregnancy, puberty, hypertension, poor control of blood lipids, renal disease, and sleep apnea syndrome. We describe the pathogenesis of the disease, small retinal vessel microangiopathies which produce extravasation, edema and ischemia phenomena. We put special emphasis on the vascular endothelial growth factor (VEGF) and its pathogenic importance. They are also described the main clinical symptoms as microaneurysms, intraretinal hemorrhages, hard and soft exudates, intraretinal microvascular abnormalities (IRMA), venous disorders, formation of new vessels and diabetic macular edema (the latter being the most common cause of vision loss). Finally we describe the latest diagnostic techniques and eye treatment, with special emphasis on obesity surgery importance as more important preventive factor to eliminate the predisposing and precipitating disease symptoms.

Toxoplasmic encephalitis associated with meningitis in a heart transplant recipient

Toxoplasma gondii is an opportunistic pathogen that causes neurologic and extraneurologic manifestations in immunosuppressed patients. Encephalitis and intracranial mass lesions are easily recognized as typical manifestations of toxoplasmosis. However, meningitis caused by T. gondii is a rare condition with very few cases described in the literature. We present the case of a heart transplant recipient who developed toxoplasmic encephalitis associated with meningitis. After an extensive review of the medical literature, we found only 1 case of meningitis in solid organ transplant recipients and <25 cases in immunosuppressed patients, such as patients infected with human immunodeficiency virus or those with Hodgkin's disease. In this report, we consider toxoplasmosis in the differential diagnosis of meningitis in immunocompromised individuals.

Prevention strategies for cytomegalovirus disease and long-term outcomes in the high-risk transplant patient (D+/R-): experience from the RESITRA-REIPI cohort

BACKGROUND

Cytomegalovirus (CMV)-negative recipients of a graft from a CMV-positive donor (D+/R-) are at high risk of CMV disease. Current preventive strategies include universal prophylaxis (UP) and preemptive therapy (PT). However, the best strategy to prevent CMV disease and achieve better long-term outcomes remains a matter of debate.

METHODS

We analyzed the incidence of CMV disease and long-term outcomes including graft dysfunction and patient mortality at 5 years after transplantation with both preventive strategies. High-risk (D+/R-) kidney and liver transplant recipients from the RESITRA cohort were included.

RESULTS

Of 2410 kidney or liver transplant patients, 195 (8.3%) were D+/R-. The final cohort included 58 liver and 102 kidney recipients. UP was given in 92 patients and 68 received PT; 10.9% and 36.8% developed CMV disease, respectively (P < 0.01). The independent risk factors for CMV disease were PT strategy (hazard ratio [HR], 3.30; 95% confidence interval [CI], 1.6-6.9), kidney transplantation (HR, 3.8; 95% CI, 1.4-9.9), and cyclosporine immunosuppression (HR, 2.4; 95% CI, 1.2-4.7). PT strategy was also a risk factor for CMV disease in both liver transplantation (HR, 11.0; 95% CI, 1.2-98.7) and kidney transplantation (HR, 2.7; 95% CI, 1.3-6.0), independently. The development of CMV replication during the first 2 years after transplantation was a risk factor for graft dysfunction at 5 years after transplantation (odds ratio, 3.4; 95% CI, 1.3-9.0). Nevertheless, no significant differences were seen in either graft dysfunction or mortality between the 2 strategies.

CONCLUSIONS

The study supports the benefit of the UP strategy to prevent CMV disease in D+/R- liver or kidney transplant patients. The development of CMV replication during the first 2 years after transplantation was associated with graft dysfunction at 5 years after transplantation.

Prevalence of causes of secondary osteoporosis and contribution to lower bone mineral density in HIV-infected patients

SUMMARY

Eighty-one percent of human immunodeficiency virus (HIV)-infected patients had one or more of seven evaluated causes of secondary osteoporosis, and this rate increases with age. The type and number of causes were associated with a lower bone mineral density (BMD), and with an increased rate of osteopenia/osteoporosis, regardless of age and body mass index.

INTRODUCTION

The objective of this study was to determine whether factors of secondary osteoporosis were associated with lower BMD in HIV.

METHODS

This was a cross-sectional study of 285 HIV-infected patients (25 % females) evaluating the impact of seven different factors of reduced BMD: hyperthyroidism, diabetes, chronic viral hepatitis, chronic kidney disease (CKD), hypovitaminosis D, secondary hyperparathyroidism, and hypogonadism. Dual-energy X-ray absorptiometry scan of the femoral neck was obtained at the clinical visit.

RESULTS

Mean age was 45.7 years; osteopenia and osteoporosis were diagnosed in 38 and 6 %, respectively. Overall, 230 patients (81 %) had secondary factors; 107 (38 %) had only 1 cause, 94 (33 %) had 2, and 28 (10 %) had 3 or more, predominantly vitamin D deficiency in 61 %, hepatitis C virus coinfection in 45 %, and secondary hyperparathyroidism in 27 %. The number of secondary factors was closely related to a lower BMD, which is statistically significant for patients having ≥2 causes (0.77 vs 0.73 g/cm(2), p = 0.02). The rate of osteopenia ranged from 36 % without any cause to 57 % with three or more, osteoporosis from 0 to 19 %, and Z-score <-2 SD from 0 to 27 %, respectively. In a multivariate linear regression, adjusting by age, body mass index, and HIV-related factors, the number of secondary factors was independently associated with a lower BMD (ß coefficient -0.134; p = 0.02), mainly due to patients with hepatitis C virus (HCV) coinfection, secondary hyperparathyroidism, and CKD.

CONCLUSIONS

A high prevalence of secondary causes of osteoporosis is observed in HIV-infected patients, and its type and cumulative number determine a lower BMD, after adjusting by age and body mass index.

Regression of liver fibrosis is progressive after sustained virological response to HCV therapy in patients with hepatitis C and HIV coinfection

There are few data about the long-term histological outcome of HIV-/HCV-coinfected patients after therapy with interferon and ribavirin. We performed an observational study of 216 patients who received therapy against HCV and who had at least three successive transient elastographies (TE) during the follow-up. The primary endpoint was confirmed fibrosis regression, defined as a reduction of at least 1 point in Metavir fibrosis score, confirmed and without worsening in successive TE. At baseline, 23% had fibrosis stage 4 or cirrhosis. Overall, 82 (38%) achieved sustained virological response (SVR), without differences in baseline fibrosis or time of follow-up. Confirmed fibrosis regression was observed in 55% of patients, higher for SVR (71% vs 44%; P < 0.01), and the likelihood of achieving fibrosis regression at 3, 5 and 7 years was 0.17, 0.51 and 0.67, respectively, for SVR patients, in comparison with 0.02, 0.23 and 0.41 for no SVR patients (P < 0.01, log-rank test at any time point). Progressive regression, defined as continuous improvement in successive TE, was observed in 62% of patients with advanced liver fibrosis or cirrhosis who achieved SVR. In a Cox regression model, only SVR (HR, 4.01; 95% CI, 2.33-7.57; P < 0.01) and a younger age (HR, 1.14; 95% CI, 1.05-1.25; P < 0.01; per year) were associated with fibrosis regression. This study confirms that the rate of liver fibrosis regression increases during the follow-up after SVR to interferon therapy in HIV-/HCV-coinfected patients.

[IMSIII, SYNTHESIS, and MR-RESCUE studies: the end of endovascular treatment for stroke?]

Last March, in a single issue New England Journal of Medicine published 3 studies that evaluated the efficacy of endovascular treatment for ischemic stroke, leading to a heated controversy between neurologists and interventional neuroradiologists. The negative results have resulted in numerous reviews pointing out serious methodological defects. In this article, we analyze the outcomes of thrombolytic treatment for stroke and discuss the strengths and weaknesses of the three above-mentioned studies. Despite the negative results, these studies can point the way for new trials that will justify this treatment modality that is backed up by scientific evidence.

Norovirus: a growing cause of gastroenteritis in catalonia (Spain)?

Infectious acute gastroenteritis (AGE) is a major health problem worldwide. Salmonella is a leading cause of AGE outbreaks, but viruses may be responsible for up to 80% of cases. We compared the frequency and characteristics of AGE out breaks in Catalonia due to norovirus and Salmonella and the changes in these outbreaks from 2000 through 2010. In 2006 through 2010, we also investigated the distribution by season, setting, and implicated food, the incidence rates of cases associated, and the hospitalization rates. Differences in proportions were estimated by Pearson's chi-square test, and the odds ratio (OR) and 95% confidence interval (CI) were calculated. In 2000 through 2010, the number of AGE outbreaks caused by Salmonella decreased and those caused by norovirus significantly increased. From 2006 onward, norovirus was the most common etiology in AGE outbreaks, but in foodborne outbreaks, Salmonella was the more common cause until 2010. The incidence rate per 10(5) inhabitants was greater for norovirus (20.81 versus 3.97, P < 0.001), and the hospitalization rate was lower for norovirus (0.84 versus 4.69, P < 0.001). Salmonella infections occurred more frequently in the warmer months, and norovirus infections were more common in the colder months, both in terms of total outbreaks (OR = 4.50; 95% CI, 2.85 to 7.11; P < 0.001) and foodborne outbreaks (OR = 4.38; 95% CI, 2.42 to 7.95; P < 0.001). Norovirus infections were less common in private homes (OR = 0.08; 95% CI, 0.04 to 0.14; P < 0.001) and more common in nursing homes (P < 0.001) and hospitals or long-term care facilities (OR = 14.09; 95% CI, 3.35 to 59.33; P < 0.001). Foods most frequently implicated in norovirus infection outbreaks were seafood (22% ; OR = 7.89; 95% CI, 2.59 to 24.3; P < 0.001), and those most common in Salmonella infection outbreaks were mayonnaise and similar items (30.2%; OR = 0.05; 95% CI, 0.01 to 0.22; P < 0.001). Foodborne outbreaks in which the vehicle was not identified were more frequent in cases of norovirus infection (OR = 4.59; 95% CI, 2.54 to 8.30; P < 0.001). Our results indicate that norovirus rather than Salmonella is the most common cause of AGE outbreaks in Catalonia. Foodborne AGE outbreaks were more commonly caused by norovirus than by Salmonella only in 2010, the last year of the study.

A web-based intervention to improve and prevent low back pain among office workers: a randomized controlled trial

OBJECTIVES

To test the feasibility, safety, and efficacy of a web-based multidisciplinary intervention for office workers with subacute, nonspecific low back pain.

METHODS

The randomized controlled trial included 100 office workers with subacute low back pain. The intervention group had access to both the study intervention and standard care. The control group had access to standard care only. Standard care was defined as all existing non-web-based interventions offered by the University of Extremadura's Preventive Medicine Service. The web-based program was offered via the Preventive Medicine Service website. The participants in the intervention group were asked to engage in the web-based program at their work site for 11 minutes each day, 5 days a week. Primary outcomes were functional disability, as measured by the Roland-Morris Disability Questionnarie, and health-related quality of life, as measured by the European Quality of Life-5 Dimensions-3 Levels. Secondary outcomes were the number of episodes of low back pain and trunk muscles endurance. Outcomes were measured before and after the 9-month intervention period.

RESULTS

Over the 9-month study, the score on the Roland-Morris Disability Questionnaire for the participants in the web-based intervention group improved by a mean of -7.36 points (95% confidence interval [CI]:-8.41, -6.31) compared to a worsening of 1.89 points (95% CI: 0.71, 2.65) in the control group. The between-group difference in change on the Roland-Morris Disability Questionnarie over the study period was -9.25 points (95% CI:-10.57, -7.89). Similarly, over the compared to the control group.

CONCLUSIONS

A 9 month web-based intervention is feasible and effective to improve function and health-related quality of life and to decrease episodes of low back pain among office workers with a history of subacute, nonspecific low back pain.

Neurological manifestations of cardiac myxoma: experience in a referral hospital

INTRODUCTION

Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma.

OBJECTIVE

To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years.

PATIENTS AND METHODS

We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012.

RESULTS

Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths.

CONCLUSIONS

Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.

Opportunistic pulmonary infections in solid organ transplant recipients

BACKGROUND

Opportunistic pulmonary infections (OPI) represent common life-threatening complications after solid organ transplantation. Our objective was to describe pulmonary infections caused by opportunistic pathogens in solid-organ transplant patients.

METHODS

We analyzed all adult solid organ recipients (liver, heart, kidney, and pancreas) between July 2003 and June 2010, reporting all episodes of pulmonary opportunistic infection.

RESULTS

During the study period, 1656 solid organ transplants were performed and 188 opportunistic infections were diagnosed in 163 patients (incidence 10%). In 40 cases, the site of infection was the lung (21%) with 57.5% occurring between the first and sixth month posttransplantation. The most frequently isolated microorganism was Aspergillus spp (n = 25, 63%), followed by Pneumocystis jirovecii (n = 6 cs, 15%). Twenty-five patients with an opportunistic pulmonary infections died during the follow-up including, 16 related to the infection (40%). The causative organism responsible for the highest mortality was Aspergillus spp (n = 12; 48%). Twenty-one patients with an opportunistic nonrespiratory infection died, five of them related to it (4%). Opportunistic pulmonary infection was associated with an increased mortality rate (P < .001). There was a trend toward a higher mortality among patients who developed OPI during the first 6 months after transplantation.

CONCLUSIONS

Opportunistic pulmonary infections after solid organ transplantation are not infrequent. The period of risk for developing this infectious complications goes beyond the first 6 months posttransplantation. Mortality due to these infections was high in comparison to that of opportunistic nonrespiratory infections. It is important to keep a high index of suspicion for infectious complications during all posttransplant periods, as this is the first step toward a rapid diagnosis and adequate treatment.

Viral infections of the central nervous system in Spain: a prospective study

The aim of the study was to determine the incidence of viruses causing aseptic meningitis, meningoencephalitis, and encephalitis in Spain. This was a prospective study, in collaboration with 17 Spanish hospitals, including 581 cases (CSF from all and sera from 280): meningitis (340), meningoencephalitis (91), encephalitis (76), febrile syndrome (7), other neurological disorders (32), and 35 cases without clinical information. CSF were assayed by PCR for enterovirus (EV), herpesvirus (herpes simplex [HSV], varicella-zoster [VZV], cytomegalovirus [CMV], Epstein-Barr [EBV], and human herpes virus-6 [HHV-6]), mumps (MV), Toscana virus (TOSV), adenovirus (HAdV), lymphocytic choriomeningitis virus (LCMV), West Nile virus (WNV), and rabies. Serology was undertaken when methodology was available. Amongst meningitis cases, 57.1% were characterized; EV was the most frequent (76.8%), followed by VZV (10.3%) and HSV (3.1%; HSV-1: 1.6%; HSV-2: 1.0%, HSV non-typed: 0.5%). Cases due to CMV, EBV, HHV-6, MV, TOSV, HAdV, and LCMV were also detected. For meningoencephalitis, 40.7% of cases were diagnosed, HSV-1 (43.2%) and VZV (27.0%) being the most frequent agents, while cases associated with HSV-2, EV, CMV, MV, and LCMV were also detected. For encephalitis, 27.6% of cases were caused by HSV-1 (71.4%), VZV (19.1%), or EV (9.5%). Other positive neurological syndromes included cerebellitis (EV and HAdV), seizures (HSV), demyelinating disease (HSV-1 and HHV-6), myelopathy (VZV), and polyradiculoneuritis (HSV). No rabies or WNV cases were identified. EVs are the most frequent cause of meningitis, as is HSV for meningoencephalitis and encephalitis. A significant number of cases (42.9% meningitis, 59.3% meningoencephalitis, 72.4% encephalitis) still have no etiological diagnosis.