Respiratory tract infections are a common complaint and most of them, such as common cold and laryngitis, are viral in origin, so antibiotic use should be exceptional. However, there are other ...respiratory tract infections (sinusitis, pharyngitis, lower respiratory tract infections, and exacerbations of chronic obstructive pulmonary disease) where a bacterial etiology is responsible for a non-negligible percentage, and antibiotics are often empirically indicated. The aim of the study is to identify the strength of the data obtained from the symptoms, physical examination and rapid diagnostic methods in respiratory infections in which antibiotic use is frequently proposed in order to improve diagnosis and influence the decision to prescribe these drugs. The review concludes that history, physical examination and rapid tests are useful to guide the need for antibiotic treatment in diseases such as acute sinusitis, acute pharyngitis, exacerbation of lower respiratory tract infection and chronic obstructive pulmonary disease. However, no isolated data is accurate enough by itself to confirm or rule out the need for antibiotics. Therefore, clinical prediction rules bring together history and physical examination, thereby improving the accuracy of the decision to indicate or not antibiotics.
To analyse the characteristics and predictors of death in hospitalized patients with coronavirus disease 2019 (COVID-19) in Spain.
A retrospective observational study was performed of the first ...consecutive patients hospitalized with COVID-19 confirmed by real-time PCR assay in 127 Spanish centres until 17 March 2020. The follow-up censoring date was 17 April 2020. We collected demographic, clinical, laboratory, treatment and complications data. The primary endpoint was all-cause mortality. Univariable and multivariable Cox regression analyses were performed to identify factors associated with death.
Of the 4035 patients, male subjects accounted for 2433 (61.0%) of 3987, the median age was 70 years and 2539 (73.8%) of 3439 had one or more comorbidity. The most common symptoms were a history of fever, cough, malaise and dyspnoea. During hospitalization, 1255 (31.5%) of 3979 patients developed acute respiratory distress syndrome, 736 (18.5%) of 3988 were admitted to intensive care units and 619 (15.5%) of 3992 underwent mechanical ventilation. Virus- or host-targeted medications included lopinavir/ritonavir (2820/4005, 70.4%), hydroxychloroquine (2618/3995, 65.5%), interferon beta (1153/3950, 29.2%), corticosteroids (1109/3965, 28.0%) and tocilizumab (373/3951, 9.4%). Overall, 1131 (28%) of 4035 patients died. Mortality increased with age (85.6% occurring in older than 65 years). Seventeen factors were independently associated with an increased hazard of death, the strongest among them including advanced age, liver cirrhosis, low age-adjusted oxygen saturation, higher concentrations of C-reactive protein and lower estimated glomerular filtration rate.
Our findings provide comprehensive information about characteristics and complications of severe COVID-19, and may help clinicians identify patients at a higher risk of death.
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A Contemporary Picture of Enterococcal Endocarditis Hernández-Meneses, Marta; Ojeda-Burgos, Guillermo; Noureddine, Mariam ...
Journal of the American College of Cardiology,
02/2020, Volume:
75, Issue:
5
Journal Article
Peer reviewed
Open access
Enterococcal endocarditis (EE) is a growing entity in Western countries. However, quality data from large studies is lacking.
The purpose of this study was to describe the characteristics and analyze ...the prognostic factors of EE in the GAMES cohort.
This was a post hoc analysis of a prospectively collected cohort of patients from 35 Spanish centers from 2008 to 2016. Characteristics and outcomes of 516 cases of EE were compared with those of 3,308 cases of nonenterococcal endocarditis (NEE). Logistic regression and Cox proportional hazards regression analysis were performed to investigate risk factors for in-hospital and 1-year mortality, as well as relapses.
Patients with EE were significantly older; more frequently presented chronic lung disease, chronic heart failure, prior endocarditis, and degenerative valve disease; and had higher median age-adjusted Charlson score. EE more frequently involved the aortic valve and prosthesis (64.3% vs. 46.7%; p < 0.001; and 35.9% vs. 28.9%; p = 0.002, respectively) but less frequently pacemakers/defibrillators (1.5% vs. 10.5%; p < 0.001), and showed higher rates of acute heart failure (45% vs. 38.3%; p = 0.005). Cardiac surgery was less frequently performed in EE (40.7% vs. 45.9%; p = 0.024). No differences in in-hospital and 1-year mortality were found, whereas relapses were significantly higher in EE (3.5% vs. 1.7%; p = 0.035). Increasing Charlson score, LogEuroSCORE, acute heart failure, septic shock, and paravalvular complications were risk factors for mortality, whereas prior endocarditis was protective and persistent bacteremia constituted the sole risk factor for relapse.
Besides other baseline and clinical differences, EE more frequently affects prosthetic valves and less frequently pacemakers/defibrillators. EE presents higher rates of relapse than NEE.
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Outpatient parenteral antibiotic treatment (OPAT) has proven efficacious for treating infective endocarditis (IE). However, the 2001 Infectious Diseases Society of America (IDSA) criteria for OPAT in ...IE are very restrictive. We aimed to compare the outcomes of OPAT with those of hospital-based antibiotic treatment (HBAT).
Retrospective analysis of data from a multicenter, prospective cohort study of 2000 consecutive IE patients in 25 Spanish hospitals (2008-2012) was performed.
A total of 429 patients (21.5%) received OPAT, and only 21.7% fulfilled IDSA criteria. Males accounted for 70.5%, median age was 68 years (interquartile range IQR, 56-76), and 57% had native-valve IE. The most frequent causal microorganisms were viridans group streptococci (18.6%), Staphylococcus aureus (15.6%), and coagulase-negative staphylococci (14.5%). Median length of antibiotic treatment was 42 days (IQR, 32-54), and 44% of patients underwent cardiac surgery. One-year mortality was 8% (42% for HBAT; P < .001), 1.4% of patients relapsed, and 10.9% were readmitted during the first 3 months after discharge (no significant differences compared with HBAT). Charlson score (odds ratio OR, 1.21; 95% confidence interval CI, 1.04-1.42; P = .01) and cardiac surgery (OR, 0.24; 95% CI, .09-.63; P = .04) were associated with 1-year mortality, whereas aortic valve involvement (OR, 0.47; 95% CI, .22-.98; P = .007) was the only predictor of 1-year readmission. Failing to fulfill IDSA criteria was not a risk factor for mortality or readmission.
OPAT provided excellent results despite the use of broader criteria than those recommended by IDSA. OPAT criteria should therefore be expanded.
BACKGROUND // With age increases the consumption of drugs, including anticholinergics. The anticholinergic load is a predictor of falls, cognitive
impairment and mortality, and its calculation is ...useful. The objectives of this paper was to know the prevalence of anticholinergic consumption and
anticholinergic load according to different scales, and the variables that influence the prevalence and load.
METHODS // An analytical and cross-sectional study was carried out. The sample was obtained by cluster sampling (95% confidence level, 3%
precision) of patients aged sixty-five/eighty consulting an emergency department. Dependent variables were Anticholinergic drugs consumed and
anticholinergic load calculated using 10 scales: Anticholinergic Activity Scale (AAS); Anticholinergic Burden Classification (ABC); Anticholinergic
Cognitive Burden Scale (ACB); Anticholinergic Drug Scale (ADS); Anticholinergic Load Scale (ALS); Anticholinergic Risk Scale (ARS); Clinician-Rated
Anticholinergic Scale (CrAS); Chew’s scale (Chew); Drug Burden Index (DBI); and Duran’s scale (Duran). Independent variables were demographics,
chronic pathologies and drugs consumed. Statistical analysis: description of variables and analytical study through a multivariate analysis (regression
analysis) to avoid confounding factors.
RESULTS // 456 patients participated, mean consumption was seven drugs (95% CI 6.81-7.59). 75.2% (95% CI 71%-79%) were taking some
anticholinergic; mean of anticholinergics of 1.91 (95% CI 1.75%-2.08%). Using the scales simultaneously, 58.1% (95% CI 53.4%-62.5%) had a high
anticholinergic load. The scales that detected the highest anticholinergic risk were DBI (50.7%) and ALS (45.8%), and those with the highest, ABC
load (19.1%) and DBI (17.3%). Taking anticholinergics was associated in a statistically significant way with suffering nephrourological pathology
(adjusted odds ratio (ORa) 2.33, 95% CI 1.15-4.72), and psychiatric (ORa 4.45, 95% CI 1.62-12.22), and higher drug use (ORa 1.50, 95% CI 1.32-1.71). In
addition, the high anticholinergic load was associated in a statistically significant way with suffering nephrourological pathology (ORa of 2.66,
95%CI 1.49-4.74), neurological (ORa of 2.52, 95%CI 1.32-4, 79), psychiatric (ORa of 8.15, 95%CI 3.71-17.90) and was also associated with consuming
more drugs (ORa of 1.37, 95%CI 1.25-1.50).
CONCLUSIONS // A high number of anticholinergics are consumed, associating this with suffering from renourological and psychiatric pathologies
and with a greater consumption of medications. There is great variability between anticholinergic load scales. Its joint use improves the
detection of consumption and anticholinergic load.
FUNDAMENTOS // Con la edad aumenta el consumo de fármacos, entre ellos los anticolinérgicos. La carga anticolinérgica es predictora de
caídas, deterioro cognitivo y mortalidad, y su cálculo resulta de utilidad. El objetivo de este trabajo fue conocer la prevalencia del consumo
de anticolinérgicos y la carga anticolinérgica según diferentes escalas, así como las variables que influyen en la prevalencia y en la carga.
MÉTODOS // Se llevó a cabo un estudio analítico y transversal. La muestra fue obtenida por muestreo por conglomerados (nivel de confianza del
95%, precisión del 3%) de pacientes de sesenta y cinco-ochenta años consultantes de un servicio de Urgencias. Las variables dependientes fueron
los fármacos anticolinérgicos consumidos y la carga anticolinérgica calculada mediante diez escalas: Anticholinergic Activity Scale (AAS); Anticholinergic
Burden Classification (ABC); Anticholinergic Cognitive Burden Scale (ACB); Anticholinergic Drug Scale (ADS); Anticholinergic Load Scale (ALS);
Anticholinergic Risk Scale (ARS); Clinician-Rated Anticholinergic Scale (CrAS); Chew’s scale (Chew); Drug Burden Index (DBI); y Duran’s scale (Duran).
Las variables independientes fueron demográficas, patologías crónicas y fármacos consumidos. Como análisis estadístico se realizó la descripción
de variables y el estudio analítico a través de un análisis multivariante (análisis de regresión) para evitar factores de confusión.
RESULTADOS // Participaron 456 pacientes, y el consumo medio fue de siete fármacos (IC 95% 6,81-7,59). El 75,2% (IC 95%; 71%-79%) tomaban algún
anticolinérgico; la media de anticolinérgicos fue de 1,91 (IC 95%; 1,75%-2,08%). Utilizando las escalas simultáneamente, el 58,1%, (IC 95%; 53,4%-
62,5%) tenían alta carga anticolinérgica. Las escalas que más riesgo anticolinérgico detectaron fueron DBI (50,7%) y ALS (45,8%) y las que más
alta carga, ABC (19,1%) y DBI (17,3%). Tomar anticolinérgicos se asoció de forma estadísticamente significativa con padecer patología nefrourológica
(odds ratio ajustado (ORa) de 2,33, IC95% 1,15-4,72), psiquiátrica (ORa de 4,45, IC95% 1,62-12,22), así como con un mayor consumo farmacológico (ORa
de 1,50, IC95% 1,32-1,71). Además, la alta carga anticolinérgica se asoció de forma estadísticamente significativa con padecer patología nefrourológica
(ORa de 2,66, IC95% 1,49-4,74), neurológica (ORa de 2,52, IC95% 1,32-4,79), psiquiátrica (ORa de 8,15, IC95% 3,71-17,90) y también se asoció a consumir
más fármacos (ORa de 1,37, IC95% 1,25-1,50).
CONCLUSIONES // Se consume un número elevado de anticolinérgicos, lo cual parece asociarse a padecer patología nefrourológica y psiquiátrica
y a mayor consumo de medicamentos. Existe una gran variabilidad entre las escalas de carga anticolinérgica. Su utilización conjunta
mejora la detección de consumo y carga anticolinérgica.
There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not ...recommended for these conditions.
This study sought to describe the clinical and microbiological features of IE in patients with BAV and MVP and compare them with those of IE patients with and without IEAP indication, to determine the potential benefit of IEAP in these conditions.
This analysis involved 3,208 consecutive IE patients prospectively included in the GAMES (Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España) registry at 31 Spanish hospitals. Patients were classified as high-risk IE with IEAP indication (high-risk group; n = 1,226), low- and moderate-risk IE without IEAP indication (low/moderate-risk group; n = 1,839), and IE with BAV (n = 54) or MVP (n = 89).
BAV and MVP patients had a higher incidence of viridans group streptococci IE than did high-risk group and low/moderate-risk group patients (35.2% and 39.3% vs. 12.1% and 15.0%, respectively; all p < 0.01). A similar pattern was seen for IE from suspected odontologic origin (14.8% and 18.0% vs. 5.8% and 6.0%; all p < 0.01). BAV and MVP patients had more intracardiac complications than did low/moderate-risk group (50% and 47.2% vs. 30.6%, both p < 0.01) patients and were similar to high-risk group patients.
IE in patients with BAV and MVP have higher rates of viridans group streptococci IE and IE from suspected odontologic origin than in other IE patients, with a clinical profile similar to that of high-risk IE patients. Our findings suggest that BAV and MVP should be classified as high-risk IE conditions and the case for IEAP should be reconsidered.
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The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality.
...Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk.
A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio HR:2.78;95% confidence interval CI:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality.
There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group.
•The clinical presentation of IE is similar to any age of patients.•Age ≥ 80 years, high comorbidity and absence of surgery when indicated are predictors of mortality.•CCI could help identify those IE patients with less surgical risk, mainly the <65 year group.
To evaluate the effect of the type of surgical indication on mortality in infective endocarditis (IE) patients who are rejected for surgery.
From January 2008 to December 2016, 2714 patients with ...definite left-sided IE were attended in the participating hospitals. One thousand six hundred and fifty-three patients (60.9%) presented surgical indications. Five hundred and thirty-eight patients (32.5%) presented surgical indications but received medical treatment alone. The indications for surgery in these patients were uncontrolled infection (366 patients, 68%), heart failure (168 patients, 31.3%) and prevention of embolism (148 patients, 27.6%). One hundred and thirty patients (24.2%) presented more than one indication. The mortality during hospital admission was 60% (323 patients). The in-hospital mortality of patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 75.6%, 61.4% and 54.7%, respectively (p < 0.001). Surgical indications due to heart failure (OR: 3.24; CI 95%: 1.99–5.9) or uncontrolled infection (OR: 1.83; CI 95%: 1.04–3.18) were independently associated with a fatal outcome during hospital admission. Mortality during the first year was 75.4%. The mortality during the first year in patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 85.9%, 76.7% and 72.7%, respectively (p = 0.016). Surgical indication due to heart failure (OR: 3.03; CI 95%: 1.53–5.98) were independently associated with fatal outcome during the first year.
The type of surgical indication is associated with mortality in IE patients who are rejected for surgical intervention.
•Clinical guidelines allow to group patients according to the surgical indication.•Many IE patients are not operated on despite presenting a clear surgical indication.•The type surgical indication may influence the mortality of these patients.•Prevention of embolism, as surgical indication, is associated with lower mortality.•Conversely, CHF is associated with higher short- and long-term mortality.
Tropheryma whipplei has been detected in 3.5% of the blood culture-negative cases of endocarditis in Spain. Experience in the management of T. whipplei endocarditis is limited. Here we report the ...long-term outcome of the treatment of previously reported patients who were diagnosed with infective endocarditis (IE) caused by T. whipplei from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España (GAMES) and discuss potential options for antimicrobial therapy for IE caused by T. whipplei.
Seventeen patients with T. whipplei endocarditis were recruited between 2008 and 2014 in 25 Spanish hospitals. Patients were classified according to the therapeutic regimen: ceftriaxone and trimethoprim/sulfamethoxazole, doxycycline + hydroxychloroquine and other treatment options.
Follow-up data were obtained from 14 patients. The median follow-up was 46.5 months. All patients completed the antibiotic treatment prescribed, with a median duration of 13 months. Six patients were treated with ceftriaxone and trimethoprim/sulfamethoxazole (median duration 13 months), four with doxycycline + hydroxychloroquine (median duration 13.8 months) and four with other treatment options (median duration 22.3 months). The follow-up after the end of the treatments was between 5 and 84 months (median 24 months).
All treatment lines were effective and well tolerated. Therapeutic failures were not detected during the treatment. None of the patients died or experienced a relapse during the follow-up. Only six patients received antibiotic treatment in accordance with guidelines. These data suggest that shorter antimicrobial treatments could be effective.
Although
group (SAG) endocarditis is considered a severe disease associated with abscess formation and embolic events, there is limited evidence to support this assumption.
We performed a ...retrospective analysis of prospectively collected data from consecutive patients with definite SAG endocarditis in 28 centers in Spain and Italy. A comparison between cases due to SAG endocarditis and viridans group streptococci (VGS) or
group (SGG) was performed in a 1:2 matched analysis.
Of 5336 consecutive cases of definite endocarditis, 72 (1.4%) were due to SAG and matched with 144 cases due to VGS/SGG. SAG endocarditis was community acquired in 64 (88.9%) cases and affected aortic native valve in 29 (40.3%). When comparing SAG and VGS/SGG endocarditis, no significant differences were found in septic shock (8.3% vs 3.5%,
= .116); valve disorder, including perforation (22.2% vs 18.1%,
= .584), pseudoaneurysm (16.7% vs 8.3%,
= .108), or prosthesis dehiscence (1.4% vs 6.3%,
= .170); paravalvular complications, including abscess (25% vs 18.8%,
= .264) and intracardiac fistula (5.6% vs 3.5%,
= .485); heart failure (34.7% vs 38.9%,
= .655); or embolic events (41.7% vs 32.6%,
= .248). Indications for surgery (70.8% vs 70.8%;
= 1) and mortality (13.9% vs 16.7%;
= .741) were similar between groups.
SAG endocarditis is an infrequent but serious condition that presents a prognosis similar to that of VGS/SGG.
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