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Resumen Fundamento y objetivo La incidencia de ictus en individuos muy ancianos se halla en ascenso. Sin embargo, existen muy pocos datos sobre las diferencias en el tratamiento y la evolucion de estos pacientes en nuestro medio. Material y metodo Se analizaron las caracteristicas clinicas, los recursos diagnostico-terapeuticos empleados, las complicaciones medicas y la mortalidad intrahospitalaria en 463 sujetos ingresados por ictus isquemico entre 2009-2010. Se compararon las diferencias entre los pacientes con ≥ 85 anos («muy ancianos») y los de menor edad. Resultados Los pacientes muy ancianos presentaron al ingreso mayor frecuencia de fibrilacion auricular (34 frente a 19%, p National Institutes of Health Stroke Scale (IC 95% 1,8-38,1). Conclusiones Los sujetos muy ancianos ingresados por ictus isquemico reciben menores recursos diagnosticos y terapeuticos. Sin embargo, en nuestro estudio la edad no fue un factor independiente para la mortalidad, que vino determinada esencialmente por la situacion funcional previa y la gravedad del ictus.

Levofloxacin plus rifampicin (L+R) is the treatment of choice for acute staphylococcal prosthetic joint infection (PJI) managed with debridement and implant retention (DAIR). Long courses have been empirically recommended, but some studies have suggested that shorter treatments could be as effective. Our aim was to prove that a short treatment schedule was non-inferior to the standard long schedule. An open-label, multicentre, randomised clinical trial (RCT) was performed. Patients with an early post-surgical or haematogenous staphylococcal PJI, managed with DAIR and initiated on L+R were randomised to receive 8 weeks of treatment (short schedule) versus a long schedule (3 months or 6 months for hip or knee prostheses, respectively). The primary endpoint was cure rate. From 175 eligible patients, 63 were included (52% women; median age, 72 years): 33 patients (52%) received the long schedule and 30 (48%) received the short schedule. There were no differences between the two groups except for a higher rate of polymicrobial infection in the long-schedule group (27% vs. 7%; P = 0.031). Median follow-up was 540 days. In the intention-to-treat analysis, cure rates were 58% and 73% in patients receiving the long and short schedules, respectively (difference −15.7%, 95% CI −39.2% to 7.8%). Forty-four patients (70%) were evaluable per-protocol: cure rates were 95.0% and 91.7% for the long and short schedules, respectively (difference 3.3%, 95% CI −11.7% to 18.3%). This is the first RCT suggesting that 8 weeks of L+R could be non-inferior to longer standard treatments for acute staphylococcal PJI managed with DAIR.

The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum β-lactamases (ESBL) and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. After the selection of clinically relevant questions, this document provides evidence-based recommendations for the use of microbiological techniques for the detection of ESBL- and carbapenemase-producing Enterobacteriaceae, and for antibiotic therapy for invasive infections caused by these organisms. The absence of randomized-controlled trials is noteworthy, thus recommendations are mainly based on observational studies, that have important methodological limitations, pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified.

The incidence of stroke in the very old is increasing. However, there are very few data regarding the differences in the management and outcomes in Spain.We analyzed the clinical characteristics, diagnostic and therapeutic procedures, medical complications and intrahospitalary mortality in 463 subjects admitted because of ischemic stroke between 2009 and 2010. Very-old patients (≥ 85 year-old) were compared with younger patients.Very old patients showed on admission higher frequency of atrial fibrillation (34 vs 19%, P.001) and lower use of antiplatelet agents and oral anticoagulants (P.001). Disability and stroke severity were higher among the very old (P.001) and the use of diagnostic and therapeutic procedures was significantly lower (P.001). The length of stay was longer in the very old (12 [6-24] days vs 8 [5-15], P.001), as wells as the intrahospitalary mortality (27 vs 6%, P.001). After a multivariate analysis, independent predictive factors of mortality were previous disability, measured by the modified Rankin scale (95% confidence interval [95%CI] 1.6-10.7), impaired level of consciousness (IC95% 2.1-13.9) and stroke severity measured by the National Institutes of Health Stroke Scale (95%CI 1.8-38.1).Very old patients admitted with ischemic stroke undergo less diagnostic and therapeutic procedures. However, in our study, very old age was not an independent predictor of mortality, which was essentially determined by previous functional status and stroke severity.

Invasive aspergillosis, chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis are the clinical forms of aspergillosis. Although there is a great number of Aspergillus species, Aspergillus fumigatus-complex is the more frequent aetiological agent, regardless of clinical form or baseline condition. The increase in immunosuppressive agents and the higher use of corticosteroids in chronic obstructive pulmonary disease have led to aspergillosis becoming more prominent in recent years. Galactomannan detection and radiological diagnostic images complement the limitations of microbiology cultures in these patients. Voriconazole and liposomal amphotericin B are the gold standard in patients requiring therapy, and posaconazole, itraconazole, caspofungin and other echinocandins are effective alternatives. The prognosis depends of clinical forms and characteristics of the host, but it is particularly poor in the disseminated invasive forms.

a b s t r a c t The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum - lactamases and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. Clinically relevant questions were selected and the literature was reviewed for each of them. The information from the selected articles was extracted and recommendations were provided and graded according to the strength of the recommendations and quality of the evidence. The document was opened to comments from the members from the Spanish Society of Infectious Diseases and Clinical Microbiology, which were considered for inclusion in the final version. Evidence-based recommendations are provided for the use of microbiological techniques for the detec- tion of extended-spectrum -lactamases and carbapenemases in Enterobacteriaceae, and for antibiotic therapy for invasive/severe infections caused by these organisms. The absence of randomised controlled trials is noteworthy; thus, recommendations are mainly based on observational studies (that have impor- tant methodological limitations), pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified.