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Resumen Introduccion En Espana, al igual que en otros paises donde el sarampion endemico ha sido eliminado, es necesario utilizar de forma rutinaria las herramientas diagnosticas que confirmen los casos para su prevencion y control de la diseminacion. Se describen los diferentes ensayos microbiologicos utilizados para su diagnostico durante un brote de sarampion en 2019 en la provincia de Guadalajara (Espana). Metodos Las pruebas serologicas y moleculares se realizaron en el laboratorio de Microbiologia del Hospital Universitario de Guadalajara y en el Centro Nacional de Microbiologia del Instituto de Salud Carlos III (Majadahonda, Espana). Los datos de los pacientes se obtuvieron del sistema epidemiologico de vigilancia. Resultados Se diagnosticaron de sarampion un total de 43 pacientes por metodos microbiologicos: 29 casos por PCR (exudado faringeo u orina) junto con IgM especifica positiva, 11 pacientes solamente por PCR, y 3 pacientes exclusivamente por presencia de IgM. El genotipo D8 fue identificado en 35 pacientes y el genotipo A en 2 casos descartados como postvacunal. La PCR en suero fue positiva en 11 de 14 pacientes con ausencia de IgM en su primera muestra recogida de suero. Once casos confirmados habian recibido una o 2 dosis de la vacuna. Doce adultos fueron ingresados, todos diagnosticados de hepatitis. Conclusiones La combinacion de pruebas moleculares y la presencia de IgG e IgM especificas son necesarias para un diagnostico correcto y la clasificacion de los pacientes como fallo vacunal (primario o secundario). El genotipado es una herramienta fundamental para la correcta clasificacion de los pacientes en el contexto de un programa de eliminacion del sarampion.

Infectious keratitis is a serious ocular infection that can lead to loss of vision. The aim of this study was to investigate the microbiological characteristics of this infection at the University Hospital of Guadalajara (Spain). We retrospectively reviewed all cases diagnosed between January 2010 and December 2016. During the 7-year study period, 297 corneal scrapes corresponding to 298 patients were performed. Antibiotic treatment prior to the culture was administered in 59 cases (19.9%). Contact lens wear was the most common risk factor (33.2%). Bacterial keratitis accounted for 64.6% of cases, viral keratitis for 3.4%, and fungal keratitis for 1%. A total of 241 bacterial strains were identified. Gram-positive isolates represented 87.1%, and gram-negative 12.7%. Coagulase-negative Staphylococcus strains were the most common microorganisms isolated (30.3%). When gram-positive microorganisms were analyzed, the sensitivity prevalence rates for vancomycin (VCM), levofloxacin, gentamicin (GM), and tobramycin (TO) were 99.4%, 84.6%, 87.9%, and 88.3%, respectively. For the gram-negative organisms, the sensitivity prevalence rates for ceftazidime, ciprofloxacin, GM, and TO were 83.3%, 93.5%, 96.3%, and 100%, respectively. Our study revealed strong predominance of gram-positive microorganisms. We suggest empirically treating bacterial keratitis originating in our area with VCM and TO, especially severe bacterial keratitis and pretreated cases in the community without a clinical response.

Urinary tract infection (UTI) due to Achromobacter xylosoxidans is rare. The aims were to know the frequency and clinical characteristics of this infection in our area. We performed a retrospective analysis of 9 patients with UTI caused by this organism diagnosed over a period of 13 y. The mean age was 63.1 y. All patients had underlying diseases or urological abnormalities. The most frequent underlying diseases were solid or hematological malignancies (3 cases). Seven patients (77.7%) had urological abnormalities. Eight patients had symptoms of cystitis and 1 remained asymptomatic. Seven patients had community acquired UTIs. Clinical outcome was favourable in 5 patients after antibiotic treatment and recurrence occurred in 3 patients who had urological abnormalities. All isolates were susceptible to imipenem and piperacillin-tazobactam, 88.8% were susceptible to ceftazidime and 77.7% were susceptible to trimethoprim-sulfamethoxazole. High frequencies of resistance to ampicillin (100%), amoxicillin/clavulanic acid (78%), cefuroxime (100%), cefotaxime (67%), norfloxacin (89%), ciprofloxacin (78%), nitrofurantoin (89%) and gentamicin (67%) were observed. UTI due to A. xylosoxidans was predominantly observed in elderly patients with predisposing factors, especially urological abnormalities, malignancies and immunosuppression. Treatment can be difficult due to the high level of antibiotic resistance. Trimethoprim-sulfamethoxazole may be useful for treatment, particularly in outpatients with community acquired infections.

The National Plan for the Elimination of Rubella was implemented in Spain in 2008 using the logistics of the National Plan for the Elimination of Measles that have been employed since year 2000. Molecular characterization of rubella virus (RUBV) is important for disease surveillance and for monitoring elimination of the disease throughout the world. We describe the first complete series of data regarding the circulation of RUBV genotypes in Spain. The 739-nucleotide fragment designated by the WHO for RUBV genotyping was sequenced in 88 selected cases collected from 1998 to 2014. Five genotypes were identified: 1E, 2B, 1J, 1I, and 1a. Genotype 1E was predominant between 1998 and 2003 but was replaced by genotype 2B, which was detected in sporadic cases in 2004, 2006, 2008, 2012, 2013 and 2014. There was an outbreak of genotype 2B in Algeciras (Andalusia) in 2008. Genotype 1J caused an outbreak in Madrid in 2004/2005 and sporadic cases in 2005 and 2007. Genotype 1I was found to have infected an immune-suppressed patient with neurological symptoms in 2008. Finally, vaccine strain RA 27/3 was detected in three sporadic cases, two of them immune-suppressed and without a recent history of vaccination. This suggests that during these years there were a series of imported sporadic cases and outbreaks, confirming the findings of epidemiological data analysis. The importation sources were generally consistent with our geographic and cultural ties, mainly with Europe (genotypes 1E, 2B, 1I) and Latin America (1J). This work has received financial support from the fellowship for Ph.D. Study by Republic of Panama and Acuerdo de Encomienda de Gestión entre la Dirección General de Salud Pública del Ministerio de Sanidad y Consumo y el Instituto de Salud Carlos III. N° expediente: DGVI-1429/05-3, and Fondo de Investigación Sanitaria, Instituto de Salud Carlos III (IP12/02006). Also, has been developed under the Project FIS PI12/02006 funded by the Strategic Action on Health of the Instituto de Salud Carlos III. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Sí

Resumen Introduccion Aeromonas spp. es una causa habitual de gastroenteritis pero ocasionalmente puede producir infecciones extraintestinales. El objetivo de este estudio es conocer las caracteristicas clinicas y microbiologicas de las infecciones extraintestinales producidas por este microorganismo en nuestro medio. Pacientes y metodos Se revisaron retrospectivamente las historias clinicas de los enfermos con infecciones extraintestinales por Aeromonas spp., diagnosticadas en el Hospital Universitario de Guadalajara entre enero de 1990 y diciembre de 2005. La identificacion microbiologica y la susceptibilidad antimicrobiana de las cepas aisladas se realizaron mediante el sistema automatico MicroScan WalkAway-40 (DadeBerhing). Resultados Se diagnosticaron 38 casos: 18 infecciones abdominales, 11 de piel y partes blandas, 3 del tracto urinario, 3 del aparato respiratorio y 3 bacteriemias sin foco primario. La especie mas frecuente fue A. hydrophila (16 casos). El 76,3% de los enfermos presentaron patologias de base predisponentes, siendo las de naturaleza neoplasica las mas frecuentes (34,2%), seguida de diabetes mellitus (21%). El 50% de las infecciones fueron polimicrobianas y el 21% de origen nosocomial. La mortalidad global fue del 16,2%. Los antibioticos con mayor porcentaje de sensibilidad fueron gentamicina, amikacina, cefotaxima y ciprofloxacino. Conclusiones Aeromonas spp. debe ser tenida en cuenta en infecciones del sistema biliar, infecciones de heridas quirurgicas abdominales y celulitis postraumaticas. La infeccion extraintestinal con frecuencia es polimicrobiana, suele aparecer en enfermos con patologias de base y en general el pronostico es bueno. Los antibioticos mas activos in vitro fueron gentamicina, amikacina, cefotaxima y ciprofloxacino.

Summary Background Most available information on carbapenemase-producing Enterobacteriaceae (CPE) is usually associated with specific types of infection or patient or with descriptions of outbreaks. The aim of this study was to comprehensively analyse the clinical epidemiology, clinical features and outcomes of colonisation and infections due to CPE in Spain. Methods A multicentre prospective cohort study was carried out in 34 Spanish hospitals from February to May 2013. All new patients testing positive for CPE in clinical samples were included. Logistic regression was used to identify predictors of mortality. Results Overall, 245 cases were included. The most frequent organism was Klebsiella pneumoniae (74%) and the carbapenemases belonged to the OXA-48 (74%), metallo-β-lactamase (MBL) (24%) and KPC (2%) groups. Acquisition was nosocomial in 145 cases (60%) and healthcare-associated (HCA) in 91 (37%); 42% of the latter were nursing home residents, in whom OXA-48-producing K. pneumoniae ST405 predominated. MBLs and OXA-48 predominated in ICU and medical patients, respectively. Overall, 67% of patients had infections. The most frequent infections identified in this study were urinary tract (43%) and skin structure (21%) infections, and 10% of infections were bacteraemic. Crude mortality was 20%. Inappropriate antibiotic therapy was independently associated with an increased risk of death (OR = 3.30; 95% CI: 1.34–8.11). Conclusions We found some differences in the epidemiology of CPE depending on the type of carbapenemase produced. Although a low proportion of CPE infections were bacteraemic, active antibiotic therapy was a protective factor for reducing mortality.

Fundamento. Las hepatitis virales son uno de los grupos de enfermedades infecciosas más frecuentes en patología humana y aunque la mayoría son benignas algunas pueden evolucionar hacia formas crónicas. El objetivo del estudio fue conocer la prevalencia de la infección por los virus de la hepatitis C, Epstein-Barr y herpesvirus humano tipo 6, en los escolares de 8.º de EGB (13-14 años), y relacionarla con las variables sexo y el hábitat (rural o urbano) en el que vivían. Métodos. Estudio descriptivo de tipo transversal, en una muestra representativa de la población escolar de 8.º de EGB de la provincia de Guadalajara en 1998-1999. Muestreo aleatorio sistemático estratificado según sexo y centro escolar (diseño muestral polietápico). Se determinó la tasa de anticuerpos específicos de la clase IgG, mediante técnica de ELISA. Resultados. Se estudió a 268 escolares (46,6% varones). La prevalencia de anticuerpos frente al virus de Epstein-Barr fue de 73,5% (IC: 67,9%-78,5%); el 72% (IC: 64%-80%) entre los varones y el 74,8% (IC: 67,7%-81,9%) entre las mujeres (NS); el 65,6% (IC: 57,4%-73,8%) vivían en medio urbano y el 80,7% (IC: 74,2%-87,2%) en el rural (p < 0,05). La prevalencia de positivos para el virus de la hepatitis C fue del 0,7% -dos personas, siendo ambas del sexo femenino y viviendo una en el medio urbano y otra en el rural-. Para el virus herpes tipo 6 la prevalencia fue del 82,4% (IC: 77,9%-86,9%), el 81,5% (IC: 74,7%-88,3%) entre los varones y el 83,2% (IC: 77,1%-89,3%) entre las mujeres (NS), el 86,7% (IC: 80,4%-92,2%) vivían en medio urbano y el 78,5% (IC: 73,1%-86,5%) en el rural (p < 0,05). Conclusiones. La prevalencia por los virus de Epstein-Barr y herpes humano tipo 6 y baja frente al VHC es elevada, lo cual concuerda con las características del medio y edad de las personas estudiadas.

La infección por citomegalovirus (CMV) debe ser investigada en pacientes sanos con cuadro pseudogripal consistente en fiebre, astenia, aumento inexplicado de los niveles de transaminasas y linfomonocitosis periférica. Es un cuadro relativamente frecuente, por lo que puede pasar totalmente desapercibido o con escasas manifestaciones clínicas, sobre todo en el paciente inmunocompetente. Los síntomas faríngeos y adenomegalias son menos frecuentes que en la infección mononucleósica por virus de Epstein-Barr. Presentamos el caso de un paciente sin factores de riesgo que presenta un cuadro febril prolongado y alteraciones hepáticas, con evolución espontánea a la normalización y serología compatible con infección por CMV.

Gastrointestinal and wound infections are the most common clinical presentation of Aeromonas. Surgical site infections (SSIs) due to this microorganism are rare. We studied the clinical and microbiological characteristics of 9 cases that appeared at 2 Spanish hospitals and reviewed 15 cases available in the literature. All patients (including our cases) had gastrointestinal or biliary diseases. 21 patients (91.3%) developed SSIs after abdominal or pelvic surgery. The mean duration from surgery to the onset of wound infection was 2.2 d in our 9 patients. The infection was polymicrobial in 17 patients (77.2%) and 19 cases were nosocomial (95%). Clinical outcome of all cases was uniformly good after treatment except for 2 patients. Two patients were cured only with surgical drainage. In conclusion, SSIs due to Aeromonas species have a probable endogenous source after abdominal or pelvic surgery and the onset is rapid in most cases. Clinical outcome is good after antibiotic treatment but surgical drainage without antibiotic therapy can be sufficient to clear the infection in some cases.

Summary Objectives Urinary tract infection (UTI) caused by non-typhoidal Salmonella (NTS) is rare. The aims were to know the frequency and clinical characteristics of this infection in our area. Patients and methods We performed a retrospective analysis of patients with bacteriuria due to NTS diagnosed in our hospital from January 1990 to December 2005. Results Nineteen patients with bacteriuria caused by NTS were diagnosed, representing 0.07% of the UTIs diagnosed in our area over the same period. The mean age was 62.5years old. Eighteen patients (94.7%) had symptoms of UTI (12, cystitis; 6, pyelonephritis), and 1 remained asymptomatic. Fourteen patients (73.6%) had chronic diseases; diabetes mellitus was present in 8 of them (42.1%) and 7 patients (36.8%) were undergoing immunosuppressor treatment. Eight patients (42.1%) had urologic abnormalities. S. enteritidis was the most common serotype isolated (16 cases). Eleven patients required antibiotic treatment over 2 or more weeks. Four patients had recurrent Salmonella UTIs (22.2%), and in 2 of them recurrence occurred after prolonged treatment during 3.5 and 5weeks, respectively. Conclusions UTI due to NTS was predominantly observed in elderly patients with underlying diseases, especially diabetes mellitus , urologic abnormalities and immunosuppression. Prolonged antibiotic treatment should be considered due to the high frequency of complicating conditions, although the infection can be recurrent despite prolonged treatment.

Brucella spp. should be considered in the differential diagnosis of acute meningitis of children living in areas where brucellosis is endemic.

To the Editor: Increased atmospheric CO2 concentrations promote the growth of fastidious microorganisms. However, the possibility that a strain of Escherichia coli can be CO2 dependent is exceptional (1). An isolate of capnophilic E. coli was responsible for a urinary tract infection (UTI) in a 77-year-old woman at the University Hospital of Guadalajara (Spain) in November 2002. Urine was cultured on a cystine-lactose-electrolyte-deficient agar plate and incubated at 37°C in an atmosphere containing 6% CO2 for 1 day. After 24 hours, the culture yielded gram-negative rods (>105 CFU/mL) in pure culture. The organism was motile, catalase positive, and oxidase negative. The strain could not be identified by using the MicroScan WalkAway-40 system (DadeBerhing, Inc., West Sacramento, CA, USA). A subculture was performed, and the organism did not grow on sheep blood agar and MacConkey agar plates at 37°C in ambient air. However, a subculture incubated at 37°C for 24 hours in an atmosphere of 6% CO2 produced smooth colonies 2–3 mm in diameter on sheep blood agar and MacConkey agar plates. The organism fermented lactose, and the indole reaction (BBL DrySlidet, Becton Dickinson Co., Sparks, MD, USA) performed on sheep blood agar was negative. The strain grew well on Schaedler agar plates after anaerobic incubation for 48 hours. The isolate remained capnophilic after 5 subcultures. The strain was identified as E. coli by using the Biolog GN2 panel (Biolog, Inc., Hayward, CA, USA) (100%, T = 0,534), after incubation of the panel in an atmosphere containing 6% CO2 for 1 day. The API 20E system (bioMerieux, Marcy-l’Etoile, France) according to the manufacturer’s instructions without C02 incubation also identified E. coli (profile 5004512). The identification was confirmed by means of 16S rDNA sequence analysis (1,472 bp obtained by PCR amplification by a previously reported method [2]), which showed 99% similarity with E. coli sequence (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"CP000802","term_id":"157065147"}}CP000802). The 16S sequence showed similarity with Shigella species; however, this identification was not considered because the strain fermented lactose on MacConkey agar and agglutinations with Shigella antiserum were negative. The original 16S rDNA sequence was deposited in GenBank (accession no. {"type":"entrez-nucleotide","attrs":{"text":"EU555536","term_id":"171262526"}}EU555536). The antimicrobial drug susceptibility profile was determined by incubating Mueller-Hinton agar plates at 37°C in an atmosphere containing 6% CO2 by the disk diffusion method, according to National Committee for Clinical Laboratory Standards recommendations (3). The isolate was susceptible to ampicillin, amoxicillin/clavulanic acid, piperacillin, cefazolin, cefuroxime, cefotaxime, nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, gentamicin, tobramycin, amikacin, norfloxacin, and ciprofloxacin. MICs were obtained for the following antimicrobial agents with the E-test method (AB Biodisk, Solna, Sweden), performed on Mueller-Hinton agar plates incubated in a 6% CO2 atmosphere: ampicillin (1.5 μg/mL), amoxicillin (3 μg/mL), cefotaxime (0.064 μg/mL), imipenem (0.094 μg/mL), piperacillin (2 μg/mL), and ciprofloxacin (0.008 μg/mL). E. coli is the most common pathogen among patients with uncomplicated UTIs (4). Two cases of UTIs due to carbon dioxide–dependent strains of E. coli have been reported (1). The mechanisms for development of CO2 dependence are unknown (5). CO2 can play a role in the growth of E. coli as a substrate for carboxylation reactions (6). Other members of the family Enterobacteriaceae (such as some strains of Klebsiella spp.) and other organisms (such as Staphylococcus aureus), can have similar requirements (7,8). There is not 1 best way of performing urine cultures. Guidelines for the diagnosis of UTI includes the use of sheep blood agar and either MacConkey agar or a similar selective medium for routine urine culture. The plates should be incubated overnight (at least 16 hours) at 37°C in ambient air; alternatively, the blood agar plate can be incubated in elevated (3%–8%) CO2 (9). For fastidious microorganisms, chocolate agar can be added to the MacConkey agar and the plates incubated in 5% CO2 for 2 days (9). The real incidence of these infections is unknown, but the rarity of these strains suggests that the incidence is low. However, the real incidence of UTI caused by capnophilic E. coli may be underestimated because urine cultures are not usually incubated in CO2. In addition, urine cultures are not performed for many women with uncomplicated cystitis. Other fastidious uropathogens such as Haemophilus influenzae and H. parainfluenzae, also require special media and incubation in an atmosphere of CO2 (9). The low frequency of these strains suggests that incubation of routine urine cultures in an atmosphere containing CO2 is not necessary. Incubation in CO2 should be ordered only if the patient has pyuria and a previous negative urine culture after incubation in ambient air or if the patient is unresponsive to empiric therapy and routine urine culture is negative. Good clinician–laboratory communication is vital. Further studies should be performed to ascertain the real incidence of UTIs caused by capnophilic strains of E. coli. Because no breakpoints are available for antimicrobial agents against capnophilic strains of E. coli, we used published interpretative criteria or Enterobacteriaceae (3). The strain was susceptible to all antimicrobial agents that we tested. The impact of CO2 on the susceptibility of capnophilic strains of E. coli is unknown. Susceptibility of some antimicrobial agents such as quinolones can be influenced by the pH change and enhanced growth that occur during CO2 incubation when testing capnophilic organisms (10).