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INTRODUCTION AND OBJECTIVES In infective endocarditis (IE), decisions on surgical interventions are challenging and a high percentage of patients with surgical indication do not undergo these procedures. This study aimed to evaluate the short- and long-term prognosis of patients with surgical indication, comparing those who underwent surgery with those who did not. METHODS We included 271 patients with left-sided IE treated at our institution from 2003 to 2018 and with an indication for surgery. There were 83 (31%) surgery-indicated not undergoing surgery patients with left-sided infective endocarditis (SINUS-LSIE). The primary outcome was all-cause death by day 60 and the secondary outcome was all-cause death from day 61 to 3 years of follow-up. Multivariable Cox regression and propensity score matching were used for the analysis. RESULTS At the 60-day follow-up, 40 (21.3%) surgically-treated patients and 53 (63.9%) SINUS-LSIE patients died (P

Clostridioides difficile is the main cause of healthcare-associated diarrhoea in adults. The incidence of C.difficile infection (CDI) has increased in recent years. The risk of recurrence of CDI is 15%-25% in a first episode and this risk is increased in subsequent episodes. Toxigenic culture and cytotoxicity tests are the reference techniques for the microbiological diagnosis of CDI. These are laborious and slow techniques and therefore they have been replaced in clinical practice by the application of a multi-step algorithm that includes the detection of glutamate dehydrogenase (GDH), toxins and molecular techniques. The treatment of choice for CDI is Vancomycin. In recent years, new drugs and new treatment strategies have appeared that are especially useful in the treatment of relapses of CDI.

Predominantly antibody deficiencies are the most prevalent primary immunodeficiency (PID) in adults. These are rare diseases difficult to diagnose. Therefore, they are diagnosed late. This study aims to evaluate whether an awareness campaign of PIDs among physicians is associated with an increase in number of diagnoses, a reduction in diagnostic delay and diagnosis at earlier stages.A single centre, interventional, quasi-experimental study was designed that included 2 periods, period 1 pre-intervention (1986-2008) and period 2 post-intervention (2009-2018). A descriptive comparative study of variables was carried out in both periods.116 patients were included [27 (23.3%) in period 1 and 89 (76.7%) in period 2]. The incidence rate increased significantly (0.204 and 1.236/100,000habs./year; P 0.05), the diagnosis delay tended to be lower (4 vs. 3.73 years). The reasons for diagnostic suspicion were diverse and the burden disease at diagnosis (expressed by bronchiectasis, altered spirometry, ability to generate antibodies by thymus-independent mechanism and need for substitute treatment) tended to decrease in period 2.Given the potentially serious complications of patients with late diagnosis of PIDs, it is necessary to create specialized multidisciplinary units, to unify assistance protocols and to design interventions to increase the knowledge of these entities.

Background: Daptomycin is an optimal choice for outpatient parenteral antibiotic therapy (OPAT) because of its safety, once-daily administration and its activity against Gram-positive bacteria. Although daptomycin is increasingly being used in OPAT, limited information about its safety in this scenario is available. Methods: We performed a prospective multicentre pilot study to evaluate the safety of daptomycin in outpatients with proved or suspected Gram-positive infections (DAPTODOM). The primary objective was to evaluate the safety and the secondary objective to evaluate the efficacy in OPAT. We also looked at the development of daptomycin resistance in those cases with microbiological failure. Results: We included 54 patients from 12 Spanish hospitals, 67% male with a mean age of 67.1 years. Most patients (87%) had chronic underlying diseases. The main reason for inclusion was skin and soft-tissue infections in 52%, followed by bacteremia or endocarditis in 34%. Staphylococcus aureus accounted for 44% of the isolates (24% were methicillin-resistant), coagulase-negative staphylococci 15% and enterococci 7%. Two patients (4%) had to be readmitted because of complications; only one patient had an adverse effect related to daptomycin (increase in serum creatine kinase levels), which disappeared after discontinuation (2%). At the end of follow-up, 96% of patients had good outcome and only 4% of patients did not have a clinical or microbiological cure. The use of a 2-minute bolus in 18 cases was not associated with adverse effects. Conclusions: Daptomycin was safe and efficacious in outpatients with Gram-positive bacterial infections and can be administered in 2-minute bolus infusion.

Aim: To compare the discriminatory power of pulsed-field gel electrophoresis (PFGE) and sequence-based typing (SBT) in Legionella outbreaks for determining the infection source. Materials & methods: Twenty-five investigations of Legionnaires’ disease were analyzed by PFGE, SBT and Dresden monoclonal antibody. Results: The results suggested that monoclonal antibody could reduce the number of Legionella isolates to be characterized by molecular methods. The epidemiological concordance PFGE–SBT was 100%, while the molecular concordance was 64%. Adjusted Wallace index (AW) showed that PFGE has better discriminatory power than SBT (AWSBT→PFGE = 0.767; AWPFGE→SBT = 1). The discrepancies appeared mostly in sequence type (ST) 1, a worldwide distributed ST for which PFGE discriminated different profiles. Conclusion: SBT discriminatory power was not sufficient verifying the infection source, especially in worldwide distributed STs, which were classified into different PFGE patterns.

An outbreak of Legionnaires’ disease with 113 confirmed cases was reported in the town of Mataro, Spain, in August 2002. In this study, we compared three different typing methods and characterized the clinical isolates by comparing them with other clinical isolates with the same ST from our own database to further characterize the outbreak. In the outbreak, a total of 16 clinical (nine patients) and 32 environmental (from four environmental sources) Legionella pneumophila isolates were analyzed by pulsed-field electrophoresis (PFGE), sequence-based typing (SBT), and monoclonal antibody typing (MAb). We compared the MAb and SBT profiles of the outbreak clinical isolates and other unrelated clinical isolates showing the same ST profile. We obtained seven different PFGE and SBT profiles and six MAb patterns from the outbreak isolates. PFGE and SBT showed 100 % concordance during the outbreak. SBT proved to be highly discriminatory, particularly with the addition of the new neuA gene. One PFGE, SBT (ST-37), and Philadelphia profile was observed among the clinical isolates. Using PFGE, this ST37 Philadelphia profile was closely related to other unrelated clinical isolates. These findings suggest that the ST37 Philadelphia profile could be a virulence marker in our area. The combination of the three methodologies was useful to further characterize and obtain additional information on a very explosive outbreak. Despite the minor discrimination of PFGE versus SBT, the two genetic methods are recommended in outbreak investigations. Further studies are currently underway in this area to obtain more definitive conclusions.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of healthcare-related infection. Surveillance and prevention of MRSA is a priority in infection control programs. The aim of this study was to describe rates and trends of MRSA colonization or infection in 40 hospitals participating in the VINCat Program from 2008 to 2010. The study included all patients treated in acute care areas of participating hospitals. Hospitals were stratified into 3 groups based on size. The following annual indicators were reported: Methicillin-resistance rate, incidence density of new cases of MRSA and incidence density of MRSA bacteremia. Between 2008 and 2010, the yearly mean rate of resistance to methicillin remained stable for the study period (24%–25%), while the mean incidence of new cases of MRSA decreased from 0.65 to 0.54 cases per 1000 patient-days (p=NS) and the mean incidence of MRSA bacteremia decreased from 0.06 to 0.05 cases per 1,000 patient-days (p=NS). The implementation of a MRSA surveillance system in hospitals that participated in the VINCat Program provides information on the situation of each institution and facilitated interhospital comparisons in order to establish appropriate preventive measures.

Nosocomial pneumonia is the second most frequent cause of nosocomial infection. Most studies have been carried out in intensive care units with patients requiring mechanical ventilation or at high risk for developing nosocomial pneumonia. However, about half of the cases of nosocomial pneumonia occu

OBJECTIVES: To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (aged ≥65) and younger patients. DESIGN: Prospective enrollment of subjects with retrospective data analysis. SETTING: A 630-bed tertiary center in Badalona (Barcelona), Spain. PARTICIPANTS: A total of 158 patients diagnosed with CAP caused by L. pneumophila from 1994 to 2004: 104 younger than 65 and 54 aged 65 and older. MEASUREMENTS: Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis. RESULTS: Underlying diseases, such as chronic pulmonary diseases, diabetes mellitus, neuromuscular diseases, and heart failure; risk of aspiration; and therapy with corticosteroids were significantly more frequent in patients aged 65 and older. Patients younger than 65 were more likely to be male and have toxic habits (cigarette smoking, alcoholism) and human immunodeficiency virus infection than older patients. Fever, nonrespiratory symptoms (diarrhea and headache), and some laboratory abnormalities (hyponatremia (serum sodium concentration

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2)

La neumonia nosocomial es una de las primeras causas de infeccion nosocomial. Aunque su incidencia es mas elevada en los enfermos intubados, alrededor de la mitad de los casos se produce en las areas de hospitalizacion convencional. Sin embargo, existen pocos estudios en este ambito, por lo que la mayoria de los datos procede de series hospitalarias que incluyen a enfermos sometidos a ventilacion mecanica. Las diferencias epidemiologicas entre los enfermos intubados y los ingresados fuera de las unidades de cuidados intensivos sugieren que la etiologia y la actitud terapeutica no son totalmente equiparables en ambos grupos. En el siguiente articulo se revisa la epidemiologia, el diagnostico, el tratamiento y la prevencion de la neumonia nosocomial en las areas de hospitalizacion general.

Background Erythromycin has been the treatment of choice for Legionnaires disease (LD). However, treatment failure and experimental evidence of its bacteriostatic effect have led to evaluation of new drugs such as fluoroquinolones. This study compared the evolution of patients with LD treated with macrolides and fluoroquinolones. Methods A prospective observational study was performed, and 130 patients from three centers were included. Diagnoses were made using Legionella urinary antigen assay in all patients. Patients receiving any antibiotic > 36 h before starting the study therapy were excluded. Group 1 included 76 patients who received macrolides (33 patients with erythromycin and 43 patients with clarithromycin), and group 2 included 54 patients treated with fluoroquinolones (50 patients with levofloxacin and 4 patients with ofloxacin). Results No significant differences were seen between the two groups regarding age, sex, smoking, alcohol intake, underlying diseases, or community/hospital acquisition. The time from onset of LD symptoms until the initiation of antibiotic treatment was 78.5 h and 92.7 h in groups 1 and 2, respectively (p = 0.1). Time to apyrexia was significantly longer in the macrolide group (77.1 h vs 48 h for groups 1 and 2, respectively; p=0.000). There were no differences according to radiology, clinical complications, or mortality. Nevertheless, a trend to a longer hospital stay was observed in the macrolide group (9.9 days vs 7.6 days in groups 1 and 2, respectively; p=0.09). Conclusions Fluoroquinolones were as effective as erythromycin in the treatment of LD. It is of note that time to apyrexia was significantly shorter and hospital stay tended to be shorter in patients receiving fluoroquinolones.

Study objective To know the incidence, epidemiology, etiology, and outcome of hospital-acquired pneumonia (HAP) in non-ICUs adult patients. Setting Twelve Spanish teaching hospitals. Interventions From April 1999 to November 2000, non-ICU HAP was prospectively studied by active, bimonthly 1-week surveillance. Epidemiologic data, etiology, and evolution of pneumonia were recorded. Blood and sputum cultures and Legionella pneumophila and Streptococcus pneumoniae urinary antigen tests were performed. Results We included 186 patients, with complete data available in 165 patients (70.3% male gender; mean age, 63.7 ± 16.9 years [ ± SD]) The mean incidence of HAP was 3 ± 1.4 cases/1,000 hospital admissions. Most patients (64.2%) were in medical wards, had severe underlying diseases (66.6%), and had a hospital stay > 5 days (76.4%). Blood cultures were performed in 139 patients (84.2%), sputum cultures were performed in 89 patients (53.9%), and urinary antigen detection was performed in 123 patients (74.5%). An etiologic diagnosis was obtained in 60 cases (36.4%), and 31 were definitive. The most frequent etiologies were S pneumoniae (16 cases, 14 definitive), L pneumophila (7 cases, 7 definitive), Aspergillus sp (7 cases, 3 definitive), Pseudomonas aeruginosa (7 cases, 2 definitive), and several Enterobacteriaceae (8 cases, 4 definitive). Clinical complications occurred in 52.1% of the cases, and mortality was 26% (13.9% attributed to pneumonia). Conclusions Non-ICU HAP is an important cause of hospital morbidity, observed most frequently in medical wards and elderly patients with severe underlying diseases. In this setting, S pneumoniae and Legionella sp should be considered in addition to other nosocomial pathogens; urinary antigen detection is useful in determining the prevalence of these microorganisms.

Study objectives To compare the outcome of Legionnaires disease (LD) in patients with and without HIV infection. Design Retrospective review of clinical charts. Setting Six hundred-bed university hospital. Patients We studied the clinical findings of 64 patients without HIV and 15 patients with HIV. Patients with a serologic diagnosis only were not included. Patients with previous immunosuppressive therapy or transplant recipients were excluded from the former group. In the HIV group, the mean CD4 cell count was 347.5/μL, plasma viral load was undetectable in 50% of the patients, and only one patient (7%) was receiving cotrimoxazole as prophylaxis against Pneumocystis carinii at the time of pneumonia. No differences were observed in the two groups with respect to community or nosocomial acquisition, delay in the initiation of appropriate treatment, the use of macrolides or fluoroquinolones, and Fine score in cases of community-acquired LD. Results Univariate analysis showed that time to apyrexia was longer, and respiratory symptoms, bilateral infiltrates in chest radiograph, hyponatremia, increase in aspartate aminotransferase and creatine phosphokinase (CK), and respiratory failure were more frequent in the HIV group. Mortality was greater in patients with HIV, achieving a statistically significant value of 20%; however, multivariate analysis only confirmed these differences with respect to the increase in CK. Conclusions LD has a more severe clinical presentation and worse evolution in patients with HIV.

Legionella pneumophila has been recognized as an important cause of community-and hospital-acquired pneumonia in both healthy and immunosuppressed patients since its first description in 1976. The authors have systematically used urinary antigen testing as a specific diagnostic test for Legionella infection since 1994. It should also be pointed out that the reporting of Legionnaires’ disease (LD) has been mandatory in Catalonia since 1987. This chapter describes demographic data; clinical, analytical, and radiological characteristics; diagnostic methods; and therapeutic data of a series of community- and hospital-acquired cases of LD collected from 1983 to 2005. It determines trends in demographic and clinical data, individual risk factors, diagnostic methods, and outcome over time. Mortality by nosocomial and community-acquired LD combined has almost significantly decreased over time, which may be due to the earlier diagnosis and changes in treatment.

This chapter compares the individual risk factors, clinical features, and mortality of Legionella pneumonia in hospital and community scenarios. A comparative study was performed from 1983 to 2005, with 425 cases of pneumonia due to Legionella pneumophila being diagnosed during this time. The patients were divided into two groups based on the site of acquisition. Group 1 included 197 patients with community-acquired Legionella pneumonia (CALP), and group 2 included 123 patients with hospital-acquired Legionella pneumonia (HALP). Respiratory symptoms, gastrointestinal, neurological manifestations, and laboratory abnormalities prevailed in the community setting probably for two reasons: first, the CALP patients entered the hospital late because of the lack of specificity in initial symptomatology, allowing extrapulmonary symptoms to develop. Second, in hospitals with endemic legionellosis, the diagnosis and the onset of treatment for nosocomial Legionella pneumonia is immediate because of the high level of suspicion. This makes the extrapulmonary manifestations of Legionella infection less likely to be observed. The best way to prevent HALP is by culturing the hospital water supply, and, if colonized, Legionella tests should be used in any case of hospital-acquired pneumonia.

Bacterial pneumonia continues to be the most frequent pulmonary complication in human immunodeficiency virus (HIV)-infected patients, although its prevalence has decreased with the use of highly active antiretroviral therapy. The most common etiologic agent of community-acquired pneumonia (CAP) in infected and uninfected patients is Streptococcus pneumoniae. Legionella is at present one of the leading causes of CAP in the general population. This chapter compares the epidemiological data, clinical features, outcome, and mortality of pneumonia by S. pneumoniae and by Legionella spp. in HIV-infected patients. An observational, comparative study was performed in 15 HIV patients with CAP by Legionella (group 1) and 46 by S. pneumoniae (group 2). No statistically significant differences were observed between the two groups in either the use of an appropriate antibiotic treatment in the emergency department or in the delay from the presentation of the symptoms until the initiation of an appropriate antibiotic therapy. Legionella pneumonia (LP) should be considered as an opportunistic infection in HIV-infected patients, and the Legionella urinary antigen test should be mandatory whenever we are faced with CAP in an HIV-positive patient.

This chapter determines variables related to mortality of Legionnaire's disease (LD). An observational, comparative study was performed from 1983 to 2005, with 408 cases of Legionella pneumonia being diagnosed during this time. The variables studied included demographic characteristics, individual and aspiration risk factors, clinical manifestations, radiological manifestations, diagnostic data, treatment, and outcome. The variables were analyzed using univariate and multivariate logistic regression analysis by SPSS version 12.0. Regarding demographic data and risk factors, patients who died had a higher frequency of underlying diseases than the control group (89.8 versus 66.9%): mainly chronic respiratory disease (42.9 versus 29.6%), chronic heart failure (22.4 versus 10.2%), neoplasm (38.8 versus 15.8%), neurological sequelae (20 versus 7.6%), and inmunosuppressive therapy-mainly corticoids (45.8 versus 14.6%). Despite the improvement in the diagnostic procedures of LD and the use of more efficacious antibiotics against Legionella, chronic heart failure, hematological cancer, and corticotherapy are still bad prognostic factors of LD. Recommendations for prevention of LD should focus on settings in which there are persons at greatest risk for illness or serious outcome.

Study objectives To prospectively assess the relative risk for phlebitis in a series of consecutive patients with pneumonia and to identify risk factors that predict an increased risk for phlebitis. Setting Internal medicine department of a tertiary teaching hospital. Patients Seven hundred sixty-six consecutive patients with acute pneumonia receiving IV therapy. Interventions Only the first catheter was taken into account. There were 308 short lines (a 51-mm, 18-gauge Teflon catheter); 307 midsized lines (a 28-cm, 16-gauge polyvinyl chloride catheter); and 151 long lines (71-cm, 14-gauge plain polyurethane catheter). Eighteen variables were prospectively evaluated in an open, nonrandomized study for their contribution to the occurrence of phlebitis. Results The overall phlebitis rate was 39%. Phlebitis developed in 53% of patients with short lines, in 41% of patients with midsized lines, and in 10% of patients with long lines, and these catheters remained in place an average (± SD) of 3.0 ± 2.4 days, 4.6 ± 3.4 days, and 7.8 ± 6.6 days, respectively. The variables that influenced the development of phlebitis, as determined by multivariate analysis, were the following: type of catheter; blood hemoglobin levels; and IV therapy with either corticosteroids or erythromycin. Conclusions According to our data, when the use of a catheter is expected to be required for ≤ 36 h, a short line can be used. If a longer duration is expected, a longer line is warranted. Ours is the first study in which the relationship between blood hemoglobin levels and phlebitis has been reported. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Fluoroquinolones are the most active drugs against Legionella in intracellular and animal models, achieving high intracellular levels and low MICs. In patients with human immunodeficiency virus infection, Legionnaires' disease (LD) has a more severe clinical presentation and worse evolution, with a mortality rate of up to 20%. This chapter presents a case of a severely inmunosuppressed woman with LD in whom treatment failed with levofloxacin and who recovered after the addition of azithromycin. The intracellular location of the pathogen is relevant to the efficacy of the antibiotic. At present, new macrolides such as clarithromycin and azithromycin and fluoroquinolones are the most active drugs in the treatment of Legionella pneumonia. Even though the advances in rapid specific diagnosis and the greater efficacy of the new macrolides and quinolones have led to a better prognosis of Legionella pneumonia, mortality continues to be very high in immunosuppressed patients. Thus, randomized trials comparing the efficacy of combination therapies with new macrolides and quinolones versus monotherapy should be performed to evaluate their real impact in reducing morbidity and mortality of Legionella pneumonia with bad prognostic factors.

Background Hospital-acquired pneumonia (HAP) is one of the leading nosocomial infections and is associated with high morbidity and mortality. Numerous studies on HAP have been performed in intensive care units (ICUs), whereas very few have focused on patients in general wards. This study examined the incidence of, risk factors for, and outcomes of HAP outside the ICU. Methods An incident case-control study was conducted in a 600-bed hospital between January 2006 and April 2008. Each case of HAP was randomly matched with 2 paired controls. Data on risk factors, patient characteristics, and outcomes were collected. Results The study group comprised 119 patients with HAP and 238 controls. The incidence of HAP outside the ICU was 2.45 cases per 1,000 discharges. Multivariate analysis identified malnutrition, chronic renal failure, anemia, depression of consciousness, Charlson comorbidity index ≥3, previous hospitalization, and thoracic surgery as significant risk factors for HAP. Complications occurred in 57.1% patients. The mortality attributed to HAP was 27.7%. Conclusions HAP outside the ICU prevailed in patients with malnutrition, chronic renal failure, anemia, depression of consciousness, comorbidity, recent hospitalization, and thoracic surgery. HAP in general wards carries an elevated morbidity and mortality and is associated with increased length of hospital stay and increased rate of discharge to a skilled nursing facility.

SUMMARYThe cytopathogenicity of 22Legionella pneumophilaisolates from 17 hospitals was determined by assessing the dose of bacteria necessary to produce 50% cytopathic effect (CPED50) in U937 human-derived macrophages. All isolates were able to infect and grow in macrophage-like cells (range log10CPED50: 2·67–6·73 c.f.u./ml). Five groups were established and related to the serogroup, the number of PFGE patterns coexisting in the same hospital water distribution system, and the possible reporting of hospital-acquired Legionnaires' disease cases.L. pneumophilaserogroup 1 isolates had the highest cytopathogenicity (P=0·003). Moreover, a trend to more cytopathogenic groups (groups 1–3) in hospitals with more than one PFGE pattern ofL. pneumophilain the water distribution system (60%vs. 17%) and in hospitals reporting cases of hospital-acquired Legionnaires' disease (36·3%vs. 16·6%) was observed. We conclude that the cytopathogenicty of environmentalL. pneumophilashould be taken into account in evaluating the risk of a contaminated water reservoir in a hospital and hospital acquisition of Legionnaires' disease.

The molecular epidemiology of clinical and environmental Legionella species isolates was studied in seven hospitals from 1989 to 2006. The number of environmental pulsed field gel electrophoresis (PFGE) patterns ranged from one to nine according to the hospital. Genomic PFGE pattern persistence was observed in 71% of the hospitals, even after 17 years in some hospitals, and the relationship between environmental and clinical isolates was established. The isolates associated with hospital-acquired Legionnaires' disease corresponded to the persistent environmental PFGE patterns of Legionella pneumophila in potable water supplies.

We compared the epidemiological data, clinical features and mortality of community-acquired pneumonia (CAP) by Streptococcus pneumoniae and Legionella in HIV-infected patients and determined discriminative features. An observational, comparative study was performed (January 1994 to December 2004) in 15 HIV patients with CAP by Legionella and 46 by S. pneumoniae. No significant differences were observed in delay until initiation of appropriate antibiotic therapy. Smoking, cancer and chemotherapy were more frequent in patients with Legionella pneumonia (p=0.03, p=0.00009 and p=0.01). Patients with Legionella pneumonia had a higher mean CD4 count (p=0.04), undetectable viral load (p=0.01) and received highly active antiretroviral therapy more frequently (p=0.004). AIDS was more frequent in patients with S. pneumoniae pneumonia (p=0.03). Legionella pneumonia was more severe (p=0.007). Extrarespiratory symptoms, hyponatraemia and increased creatine phosphokinase were more frequent in Legionella pneumonia (p=0.02, p=0.002 and p=0.006). Respiratory failure, need for ventilation and bilateral chest X-ray involvement were of note in the Legionella group (p=0.003, p=0.002 and p=0.002). Mortality tended to be higher in the Legionella group (6.7 vs 2.2%). In conclusion, CAP by Legionella has a higher morbimortality than CAP by S. pneumoniae in HIV-infected patients. Detailed analysis of CAP presentation features allows suspicion of Legionnaires' disease in this subset.

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

The objective of this study was to compare epidemiological data and clinical presentation of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. From May 1994 to February 1996, 157 patients with S. pneumoniae (n = 68), L. pneumophila (n = 48) and C. pneumoniae (n = 41) pneumonia with definitive diagnosis, were prospectively studied. The following comparisons showed differences at a level of at least p0.05. Patients with S. pneumoniae pneumonia had more frequently underlying diseases (HIV infection and neoplasm) and those with C. pneumoniae pneumonia were older and had a higher frequency of chronic obstructive pulmonary disease (COPD), while L. pneumophila pneumonia prevailed in patients without comorbidity, but with alcohol intake. Presentation with cough and expectoration were significantly more frequent in patients with S. pneumoniae or C. pneumoniae pneumonia, while headache, diarrhoea and no response to betalactam antibiotics prevailed in L. pneumophila pneumonia. However, duration of symptomsor = 7 d was more frequent in C. pneumoniae pneumonia. Patients with CAP caused by L. pneumophila presented hyponatraemia and an increase in CK more frequently, while AST elevation prevailed in L. pneumophila and C. pneumoniae pneumonia. In conclusion, some risk factors and clinical characteristics of patients with CAP may help to broaden empirical therapy against atypical pathogens until rapid diagnostic tests are available.

Diagnosis of community acquired legionella pneumonia (CALP) is currently performed by means of laboratory techniques which may delay diagnosis several hours. To determine whether ANN can categorize CALP and non-legionella community-acquired pneumonia (NLCAP) and be standard for use by clinicians, we prospectively studied 203 patients with community-acquired pneumonia (CAP) diagnosed by laboratory tests. Twenty one clinical and analytical variables were recorded to train a neural net with two classes (LCAP or NLCAP class). In this paper we deal with the problem of diagnosis, feature selection, and ranking of the features as a function of their classification importance, and the design of a classifier the criteria of maximizing the ROC (Receiving operating characteristics) area, which gives a good trade-off between true positives and false negatives. In order to guarantee the validity of the statistics; the train-validation-test databases were rotated by the jackknife technique, and a multistarting procedure was done in order to make the system insensitive to local maxima.

The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age > or =60 years (28% vs. 13%, P = 0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs. 9%, P = 0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests.

The clinical course of legionella pneumonia in immunosuppressed patients is uncertain. This study was undertaken to determine the clinical evolution of legionellosis on the basis of the immune state and to establish the variables associated with death directly related to legionellosis. The study included 78 patients: 28 with chronic disease who had received immunosuppressive treatment (group 1), 24 with chronic disease without immunosuppressive treatment (group 2), and 26 controls. Inclusion criteria were the occurrence of nosocomially acquired pneumonia, Legionella pneumophila infection, and erythromycin therapy that was initiated within 72 hours following diagnosis. Respiratory and extrarespiratory complications were observed more frequently in groups 1 and 2. Bilateral radiological involvement was most frequent in group 1, and recurrence of legionella pneumonia was observed exclusively in group 1. None of these variables achieved statistical significance. The global mortality of the series was 11.5% (17.9%, 12.5%, and 3.8% in groups 1, 2, and 3, respectively). Variables statistically related to mortality were acute renal failure, shock, and need for mechanical ventilation. Although many of the variables analyzed lacked statistical significance, a trend was seen between complications and basal immunosuppression, as previously suggested.

In February 1996, an 18-year-old girl was admitted to hospital with hemoptysis and a local lesion in the right lower lobe. She was asymptomatic until December 1995, when she developed an unproductive cough. She had dental caries, and 1 month later presented periodontitis and was treated with antibiotics. On admission, she was apyrexial, and chest radiography showed cavitationwithin the right lower lobe. Zhiel^Neelsen staining was negative in several sputum smears, and oropharyngeal contamination was observed on sputum Gram stain. Tuberculin test was negative. A diagnosis of lung abscess was made, and she initially received amoxycillin^clavulanate. Hemoptysis disappeared, lung cavitation reduced and she was discharged. Three months later the pulmonary lesion remained, although the patient was asymptomatic. In June 1996, hemoptysis reappeared and the chest radiography worsened. Bronchoscopic examination showed no endobronchial lesions, and the Zhiel^Neelsen staining and the Lo« wenstein culture of the bronchoalveolar lavage (BAL) were negative. Furthermore, BAL contained no malignant cells. Computed tomographywas performed and is shown above.

Objectives: The Hospital Universitario Germans Trias i Pujol is a 600-bed center serving 700,000 inhabitants including 1800 patients with HIV infection in Catalonia (Spain). Highly active antiretroviral therapy (HAART) became available at the end of 1996. Thus, the period 1995–1997 was considered appropriate for evaluating possible epidemiological changes in bloodstream infections (BSI) in HIV-infected patients.Methods: All significant bloodstream infections, including mycobacteremia and fungemia, observed in HIV-positive patients from January, 1995 to December, 1997 have been included in the study.Results: One hundred and eighty six cases were evaluated, in whom a decrease in BSI was observed (68 in 1995, 86 in 1996, 32 in 1997). Over time, we observed an improvement in the immunologic situation of the patients (1995: CD4

The aim of this prospective study was to compare patient characteristics, clinical data, and evolution of Legionella pneumophila pneumonia according to the duration of Legionella urinary antigen excretion. Urine samples from 61 patients with Legionella pneumonia diagnosed by detection of urinary antigen were obtained periodically until urinary antigen could no longer be detected. Cases were divided into two groups based on the duration of urinary antigen excretion: group I (46 patients,60 days) and group II (15 patients,or=60 days). Groups were compared for patient characteristics, clinical data, and evolution of pneumonia. Antigen excretionor=60 days was observed significantly more frequently in immunosuppressed patients ( P=0.001) in whom the time to apyrexia was72 h ( P=0.002), although only the time to apyrexia remained significant on multivariate analysis ( P=0.006). In conclusion, the duration of Legionella urinary antigen excretion was60 days in most patients but was longer in immunosuppressed patients with a longer time to defervescence of fever.

We evaluated a commercial enzyme immunoassay (EIA) kit for detection of Legionella pneumophila serogroup 1 soluble antigen by comparing it to radioimmunoassay (RIA), using both concentrated and nonconcentrated urine samples. The sensitivity of EIA was 67.4% in nonconcentrated urine samples and 82.6% in concentrated urine samples. The sensitivity of RIA was 60.9% and 84.8% in nonconcentrated and concentrated urine samples, respectively. Our study indicates that the sensitivity and specificity of EIA are comparable to those of RIA, and that concentrating the antigen by selective ultrafiltration increases sensitivity for both EIA and RIA, with no significant decrease in specificity.