Clinical management of cUTI, cIAI, and HABP/VABP attributable to carbapenem-resistant Gram-negative infections in Spain

Introduction. Carbapenem-resistant Gram-negative (CRGN) infections are a major public health problem in Spain, often implicated in complicated, healthcare-associated infections that require the use of potentially toxic antibacterial agents of last resort. The objective of this study was to assess the clinical management of complicated infections caused by CRGN bacteria in Spanish hospitals. Methods. The study included: 1) a survey assessing the GN infection and antibacterial susceptibility profile in five participating Spanish hospitals and 2) a non-interventional, retrospective single cohort chart review of 100 patients with complicated urinary tract infection (cUTI), complicated intra-abdominal infection (cIAI), or hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia (HABP/VABP) attributable to CRGN pathogens. Results. In the participating hospitals CRGN prevalence was 9.3% amongst complicated infections. In the retrospective cohort, 92% of infections were healthcare-associated, and Klebsiella pneumoniae and Pseudomonas aeruginosa were the most common pathogens. OXA was the most frequently detected carbapenemase type (71.4%). We found that carbapenems were frequently used to treat cUTI, cIAI, HABP/VABP caused by CRGN pathogens. Carbapenem use, particularly in combination with other agents, persisted after confirmation of carbapenem resistance. Clinical cure was 66.0%, mortality during hospitalization 35.0%, mortality at the time of chart review 62.0%, and 6-months-post-discharge readmission 47.7%. Conclusion. Our results reflect the high burden and unmet needs associated with the management of complicated infections attributable to CRGN pathogens in Spain and highlight the urgent need for enhanced clinical management of these difficult-to-treat infections.

The clinical and cost impact of switching to fingolimod versus other first line injectable disease-modifying therapies in patients with relapsing multiple sclerosis

BACKGROUND

There is limited evidence on the effectiveness and healthcare costs of switching to fingolimod versus another first line injectable therapy (FLIT) in patients with relapsing multiple sclerosis (RMS) who have already been treated with FLIT.

OBJECTIVE

The objectives of the study were to assess the annualized relapse rate (ARR), socio-demographic and clinical characteristics, persistence and adherence rates, healthcare resource utilization and cost among patients with RMS who either switch to fingolimod or another FLIT in routine clinical practice.

METHODS

A multicenter, observational, retrospective chart review was conducted across eight clinics in Canada between 1 May 2011 and 30 June 2013. The data was collected from two cohorts: patients who switched to fingolimod and patients who switched to FLIT from a previous FLIT.

RESULTS AND CONCLUSIONS

A total of 124 patients were included in the study: 82 and 42 switched to fingolimod and FLIT, respectively. There were no significant differences in the patient characteristics at the date of switch except for number of previous disease-modifying therapies (DMTs) which was higher in the fingolimod cohort (fingolimod: 1.52; FLIT: 1.10, p < .001). The ARR during the first year of switching was numerically higher in the FLIT cohort compared to the fingolimod cohort (FLIT: 0.9 [95% CI 0.3-1.6]; fingolimod: 0.3 [95% CI 0.1-0.5]). The negative binomial model adjusted for the number of previous DMTs confirmed a statistically significant difference in ARR between the fingolimod and FLIT cohorts at 12 months of follow-up (p = .012). In the fingolimod cohort, 20.7% of patients experienced at least one relapse compared to 38.1% in the FLIT cohort. In both groups, a high proportion of patients (>90%) showed good treatment adherence (≥80% of prescribed doses).

Health care costs of complex perianal fistula in Crohn's disease

AIM

To evaluate the use of health care resources and the associated costs of complex perianal Crohn's disease (CD) from the National Health System perspective.

METHODS

We conducted a multicenter, retrospective, observational study in which gastroenterologists from 11 hospitals in the Community of Madrid took part. Data was collected on the direct healthcare resources (pharmacological treatments, surgical procedures, laboratory/diagnostic tests, visits to specialists and emergency departments, and hospitalizations) consumed by 97 adult patients with complex perianal CD which was active at some point between January 1, 2005, and case history review.

RESULTS

We recorded 527 treatments: 73.1% pharmacological (32.3% antibiotic, 20.5% immunomodulator, 20.3% biological) and 26.9% surgical. Mean annual global cost was €8,289/patient, 75.3% (€6,242) of which was accounted for by pharmacological treatments (€13.44 antibiotics; €1,136 immunomodulators; €5,093 biological agents), 12.4% (€1,027) by hospitalizations and surgery, 7.7% (€640) by medical visits, 4.2% (€350) by laboratory/diagnostic tests, and 0.4% (€30) by emergency department visits.

CONCLUSIONS

Pharmacological therapies, and in particular biological agents, are the main cost driver in complex perianal CD; costs due to surgery and hospitalizations are much lower.

Prevalence and molecular epidemiology of acquired AmpC β-lactamases and carbapenemases in Enterobacteriaceae isolates from 35 hospitals in Spain

The purpose of this investigation was to determine the prevalence of plasmid-mediated AmpC (pAmpC) and carbapenemases in Enterobacteriaceae collected from 35 hospitals in Spain and to establish their epidemiological relationships. We conducted a prospective multi-centre study on pAmpC- or carbapenemase-producing Enterobacteriaceae isolates from clinical samples collected from February to July 2009. The strains suspected to carry pAmpC were resistant or showed intermediate susceptibility to co-amoxiclav and second- or third-generation cephalosporins. Strains suspected to carry a carbapenemase were selected because they showed a minimum inhibitory concentration (MIC) to imipenem >1 mg/L. Polymerase chain reaction (PCR) and a sequencing strategy were used to characterise the enzymes. The clonal relationships between isolates was analysed by pulsed field gel electrophoresis (PFGE). Among 100,132 Enterobacteriaceae isolates collected, 1,654 were compatible with the production of pAmpC or carbapenemases. We found a prevalence of 0.64 % of pAmpC (n = 635) and 0.04 % of carbapenemases (n = 43). The most prevalent pAmpC enzymes were CMY-type (78.3 %), DHA-type (19.5 %), ACC-type (1.6 %) and FOX-type (0.6 %). The CMY-type was the most frequent in Escherichia coli and Proteus mirabilis species, whereas the DHA-type was mainly found in Klebsiella spp. The enzymes involved in carbapenem resistance were VIM-1, IMP-22 and the new IMP-28. Nine new bla genes were described: bla (CMY-54), bla (CMY-55), bla (CMY-56), bla (CMY-57), bla (CMY-96), bla (DHA-6), bla (DHA-7), bla (FOX-8) and bla (IMP-28). The prevalence of pAmpC or carbapenemases found is not negligible. The CMY-types were the predominant pAmpC, whereas the VIM or IMP enzymes were the predominant carbapenemases. Furthermore, we observed a great genetic diversity among pAmpC-producing strains and a close clonal relationship between carbapenemase-producing strains.

Paroxetine-induced increase in LDL cholesterol levels

Paroxetine is widely prescribed because it has the indication for multiple psychiatric disorders. Our objective was to assess the effect of short-term administration of paroxetine on low-density lipoprotein cholesterol (LDL-C) levels in both healthy controls (HCs) and in patients with panic disorder (PD). Blood samples for measurement of LDL-C were collected atbaseline, after 8 weeks of paroxetine administration and post-discontinuation in 24 male HCs and nine male patients suffering from PD, for a total of 33 subjects. Paroxetine treatment, both in HCs and PD patients, induced a mean 9% increase per subject in LDL-C that normalized post-discontinuation, suggesting causality. The National Cholesterol Education Program (NCEP) guidelines suggest that this paroxetine-induced increase in LDL-C is clinically significant but would not warrant therapeutic intervention in this population selected to be at low cardiovascular risk. However, the increase in LDL-C levels raised above the threshold of 2.7 mmol/L (100 mg/dL) in 36% of our low-risk subjects. The LDL-C increase in this subgroup would be associated with a minor increase in coronary heart disease (CHD) risk. A similar 9% paroxetine-induced increase in LDL-C observed in the large number of psychiatric patients suffering from comorbid established CHD would be detrimental from a cardiovascular perspective and would oppose the new NCEP therapeutic goals of decreasing LDL-C levels by 30-40% in high and moderately high-risk patients. It is possible that longer treatment duration and use of higher doses of paroxetine would lead to a greater increase in LDL-C.

[Partial occipital seizures as main symptom of posterior encephalopathy secondary to immunosuppresants]

INTRODUCTION

Reversible posterior leukoencephalopathy syndrome (RPLS) affects patients who are following immunosupressive treatment. It can affect children too, it can be irreversible and occipital seizures can be the main manifestation. We describe the EEG of five children who presented occipital seizures due to posterior leukoencephalopathy syndrome secondary to treatment with immunosupressives. They had different clinico- electrical evolutions.

CASES REPORTS

Five children aged from 18 months to 11 years who had been treated with bone marrow, liver or kidney transplantation and one or two immunosupressive drugs: cyclosporine, tacrolimus. 4-50 days after the transplantation they presented arterial hypertension and low conscience. Occipital seizures or status were registered in EEG. Neuroimaging showed edema lesions in posterior regions. They were treated with antihipertensives, antiepileptics and substitution or reduction of immunosupressive drugs doses. Two patients presented further episodes and three of them had persistent abnormal EEG. Two patients had more than one status even though Cys A had been replaced by Tacrolimus or because the drug dose had not been modified. The Immunosupressive drugs are necessary for the transplantation's good outcome and they cannot be easily stopped.

CONCLUSIONS

Low conscience level and oculoclonic movements may form part of the subtle clinic of the occipital seizures, that may be the main manifestation of PLS in children who are following immunosupressor treatment. The realization of an EEG is indispensable for a quick diagnose and in order to achieve the reversibility of the syndrome. If we cannot get it, EEG will be useful for the evolution follow-up too.

[Quality of life and social functioning in schizophrenic patients treated with olanzapine: 1 year follow-up naturalistic study]

OBJECTIVE

To measure health related quality of life (HRQL) and social functioning in schizophrenic patients treated with olanzapine under regular clinical practice conditions.

METHODS

Out-patients diagnosed of schizophrenia and beginning treatment with olanzapine, quetiapine, risperidone or typical oral antipsychotics were included. Information on socio-demographic characteristics was obtained and in each visit (baseline, 3, 6 and 12 months) they were administered the generic HRQL questionnaire Euro-QoL-5D (EQ-5D) and the Social Functioning Scale (SFS).

RESULTS

A total of 1,198 patients were followed-up for 12 months. Mean age (SD) was 38.6 (13.3) years and 62.9 % of them were men. In basal conditions the most affected dimensions of EQ-5D were anxiety/depression (76 %), and daily activities (73.6 %). After 12 months treatment the cohort of patients treated with olanzapine showed a better HRQL in the self-care dimension compared to all other treatments (p < 0.05), and in the dimensions of pain/discomfort, anxiety/depression and usual activities compared to the group treated with quetiapine and risperidone (p < 0.05). The Visual Analogue Scale (VAS) of the EQ-5D questionnaire showed a better health state after 12 months in the group treated with olanzapine compared to the groups of quetiapine or risperidone (p < 0.05). The SFS showed a better improvement in the cohort of olanzapine in the three studied dimensions after 12 months: isolation and social relationships in comparison to the risperidone group (p < 0.05), interpersonal communication in comparison to the risperidone and quetiapine group (p < 0.05) and independence performance in comparison to all the other treatments (p < 0,05).

CONCLUSION

Schizophrenic patients treated with olanzapine for one year show a better improvement in HRQL and social functioning than those treated with other antipsychotics.

Expression of angiogenesis factors in human umbilical vein endothelial cells and their regulation by PEDF

The VEGFs and FGF-2 stimulate angiogenesis. Pigment epithelium-derived factor (PEDF) and thrombospondin-1 (TSP-1) strongly inhibit angiogenesis. Human umbilical vein endothelial cells (HUVECs) expressed VEGF-A, -B, -C, the VEGF receptors R1, R2, and R3, PEDF, FGF-2, and TSP-1, but VEGF-D transcripts were barely detectable. Hypoxia reduced the transcript levels of VEGF-C and its cognate receptor, VEGF-R3. PEDF blocked the effect of CoCl(2) on these two factors. The expression of VEGF-A and -B as well as VEGF-R1 and VEGF-R2 remained unchanged after exposure to hypoxia, PEDF, or both. There was a marked reduction in TSP-1 transcripts in CoCl(2) treated cultures and PEDF blocked this reduction. PEDF induced a small increase in FGF-2 transcripts in HUVECs, but there was no change in FGF-2 expression in HUVECs exposed to hypoxia or hypoxia plus PEDF. PEDF may control neovascularization, in part, by restoring the negative effects of hypoxia on the expression of a potent angiogenesis inhibitor, TSP-1. PEDF may also modulate vascular leakage by maintaining the transcriptional levels of the vascular homeostasis factors, VEGF-C and VEGF-R3 in hypoxic conditions.

Regulation of factors controlling angiogenesis in liver development: a role for PEDF in the formation and maintenance of normal vasculature

PEDF and VEGF are important inhibitors and promoters of angiogenesis, and the ratio between the two is an important indicator in many neovascular diseases. In mouse liver PEDF and VEGF(165) were co-expressed at very early stages of liver development and their expression increased as liver embryogenesis progressed, suggesting that PEDF and VEGF are both crucial to vasculogenesis as well. VEGF(189) only appears at the P0 stage in liver organogenesis and is maintained at high levels thereafter. PEDF and the two VEGF isoforms are synthesized by fresh and cultured hepatocytes. Expression of VEGF(121) and overexpression of VEGF(165) were only seen in HepG2, a well-characterized hepatocellular carcinoma line. The results suggest that hepatic vascular architecture is under the control of both PEDF and VEGF, and that VEGF(165) and VEGF(189) have distinct functions in normal vascular development of the liver. The VEGF isoforms 121 and 189 may be key regulators of increased vascularity and progression of hepatocellular carcinoma, one of the most common malignant tumors, and may be of prognostic significance for this tumor.

Retinoic acid and dexamethasone regulate the expression of PEDF in retinal and endothelial cells

Both all-trans-retinoic acid (ATRA) and pigment epithelial-derived factor (PEDF) regulate cell proliferation and differentiation. Treatment of human Y-79 retinoblastoma and A-RPE 19 pigment epithelial cells with ATRA increased the levels of PEDF protein and RNA. Endothelial cells from bovine retina and human umbilical cord expressed PEDF and the levels were also increased by ATRA. Mouse Müller glial cells and rat C6 glioma cells showed at least a 2.5 fold increase in PEDF RNA levels after ATRA treatment, as measured by quantitative PCR. The PEDF promoter contains a retinoic acid receptor element (RARE). Plasmids containing a PEDF promoter regulating a luciferase gene were transfected into D407 and C6 cells and the luciferase activity measured after incubation in the presence or absence of ATRA. In both cell types ATRA increased the level of luciferase activity suggesting the RARE is functional. Dexamethasone was also effective at increasing PEDF RNA levels in both mouse Muller glial cells and C6 rat glioma cells. To test the effects of PEDF on retinoic acid function, expression of retinoic acid receptors in Y-79 and A-RPE 19 cells was measured by PCR. In Y79 cells, PEDF treatment increased the expression levels of RARalpha and RXRgamma receptors and in the A-RPE 19 cells it resulted in a decrease in expression of the RARbeta and RXRbeta receptors. This study clearly indicates an interaction between PEDF and ATRA. The cell differentiation activities of PEDF may operate through mechanisms orchestrated by retinoids, and the converse may also be true. The differentiation, anti-mitotic, and apoptotic actions of PEDF and ATRA may utilize parallel pathways that converge at key junctional transduction molecules to coordinate cellular quiescence and maintain tissue mass in the presence of signals that stimulate abnormal cell proliferation. It will be an interesting therapeutic strategy to co-administer PEDF and retinoic acid in developing protocols for neovascular diseases in the eye and in cancer.

Current status of treatment completion and fatality among tuberculosis patients in Spain

OBJECTIVES

To determine treatment completion among patients with tuberculosis (TB), and to analyse factors associated with treatment default and fatality.

METHODS

A prospective cohort study of patients who began treatment between 1 June 1999 and 31 May 2000 in areas where members of the SEPAR Tuberculosis and Respiratory Infections Group work. Factors associated with treatment default and fatality were studied using logistic regression, calculating odds ratios (OR) and their 95% confidence intervals (95%CI).

RESULTS

The study involved 142 physicians from 76 different hospitals who provided information on 1515 cases. Eighty-two per cent of the patients completed treatment correctly, 14% defaulted, 5% died, 0.5% failed, and 8.7% interrupted treatment due to transfer or other reasons. The variables associated with default were intravenous drug use (IVDU) (OR 6.00, 95%CI 2.59-13.89) and immigration (OR 8.57, 95%CI 3.78-19.45); sex, age, homelessness, incarceration, directly observed treatment (DOT) or hospitalisation were not associated with default. Variables found to be predictive of fatality were alcoholism (OR 6.38, 95%CI 2.09-19.48), human immunodeficiency virus (HIV) infection (OR 7.08, 95%CI 2.08-29.15) and age >64 years (OR 10, 95%CI 2.9-34.07), whereas sex, IVDU, homelessness, DOT and hospitalisation were not.

CONCLUSIONS

In industrialised countries, IVDU patients and immigrants should be targeted for DOT, while to reduce fatality rates stricter monitoring is required for patients who are alcoholic, HIV-infected, or aged >64 years.

Evaluation of tuberculosis trends in Spain, 1991-1999

SETTING

There are no reliable official data available on tuberculosis (TB) in Spain.

OBJECTIVE

To ascertain the epidemiological trends of TB in Spain from 1991-1999.

METHODS

In an annual survey conducted by the Tuberculosis and Respiratory Infections (TRI) Working Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), data on tuberculosis disease and infection were solicited from two information sources: 1) the public health services of the 17 Autonomous Regions (AR), and 2) 60 TRI members in different parts of Spain.

RESULTS

TB incidence declined from 36.4/100,000 in 1991 to 26.7 in 1999 according to the AR (average annual decline 3.3%), and from 45.6 to 26.8 according to TRI members (annual decline 5.1%). A similar observation was made for smear-positive cases (AR annual decline: 3.0%; TRI: 5.6%). Tuberculosis infection at 6 years of age also decreased according to both information sources (AR: 0.87% in 1991 to 0.5% in 1998, annual decline 6%, and TRI members: 1.00% in 1991 and 0.9% in 1997, annual decline 4.2%).

CONCLUSIONS

The observed rates of TB are higher than stated in official figures. In spite of the decreasing trend, observed declines are small and the current rates continue to be among the highest among industrialised countries.

Effect of medroxyprogesterone pretreatment on pentagastrin-induced panic symptoms in females with panic disorder

Clinical observation, as well as epidemiological and research data, suggest that female gonadal hormones influence the course of panic disorder (PD). Panicogenic agents such as pentagastrin are useful tools with which to study the pathophysiology of panic attacks. Nine women with PD were randomly assigned to receive, in a crossover design, a 3-day pretreatment with medroxyprogesterone acetate (MP) prior to an injection of pentagastrin, and a 3-day pretreatment with a placebo prior to another injection of pentagastrin. The panic response and the anxiety response to pentagastrin were decreased after MP pretreatment. These preliminary results support the use of laboratory models for investigations of the interactions between progestins and anxiety.

Simultaneous determination of ascorbic acid and acetylsalicylic acid in pharmaceutical formulations

A direct, simple, and practical first-derivative spectrophotometric method is described for simultaneous determination of ascorbic acid and acetylsalicylic acid. The effects of the solvent, excipients, and spectral variables on the analytical signal were investigated. The drugs were determined simultaneously with a 0.01 M methanolic hydrochloric acid solution as the solvent, and the signals were evaluated directly by using the zero-crossing method at 245.0 and 256.0 nm for acetylsalicylic acid and ascorbic acid, respectively. The method allows the simultaneous determinations of acetylsalicylic acid and ascorbic acid in the ranges of 6.6 x 10(-6) to 1.5 x 10(-4)M and 3.4 x 10(-6) to 2.0 x 10(-4)M, respectively, with standard deviation of <2.0%. The proposed method was applied to determinations of these drugs in tablets.

Simultaneous determination of chlordiazepoxide and clidinium bromide in pharmaceutical formulations by derivative spectrophotometry

A direct and simple first derivative spectrophotometric method has been developed for the simultaneous determination of clidinium bromide and chlordiazepoxide in pharmaceutical formulations. Acetonitrile was used as solvent for extracting the drugs from the formulations and subsequently the samples were evaluated directly by derivative spectrophotometry. Simultaneous determination of the drugs can be carried out using the zero-crossing method for clidinium bromide at 220.8 nm and the graphical method for chlordiazepoxide at 283.6 nm. The calibration graphs were linear in the ranges from 0.983 to 21.62 mg/l of clidinium bromide and from 0. 740 to 12.0 mg/l of chlordiazepoxide. The ingredients commonly found in commercial pharmaceutical formulations do not interfere. The proposed method was applied to the determination of these drugs in tablets.