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Introduction Infective endocarditis (IE) still carries high morbidity and mortality and frequently requires surgery. The benefit of mitral valve repair (MVr) in the setting of IE is yet to be proven. The goal of this study was to assess the results of MVr in patients with IE after a minimum follow-up of 1 year. Methods This study is based on a Spanish nationwide prospective registry that included patients operated on for native mitral valve IE. The collaborating Institutions pooled their pre-, peri-, and postoperative data into the database of the GAMES group [Grupo de Apoyo al Manejo de la EndocarditiS (Group for support and management of infective endocarditis)]. Results Data from 27 hospitals were recorded and 3524 cases of active IE identified between 2008 and 2016. There were 1513 cases of mitral IE, of which 898 involved native valves. Of these, 437 patients underwent surgical treatment, and 369 completed the 1-year follow-up. The valve was repaired in 68 cases (18.4%). Preoperative groups were comparable (EuroSCORE MVr 7.7 vs MVR 8.0; p = ns). Mortality in the repair group was inferior to that in the replacement group (16.2% vs 27.2%, p = 0.058). At 1 year, mortality remained higher in the replacement group: 3.7% vs 2.9%. Relapse of the infection was slightly more frequent in the repair group (7.1% vs 3.7%; p = ns), although this did not lead to higher rates of reintervention (MVr/MVR: 2.9% vs 4.9%). Conclusion MVr is an attractive option for specific patients with IE and does not seem to negatively impact on relapses.

For the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España (GAMES) investigators: Hospital Costa del Sol, Marbella: Fernando Fernández Sánchez, Mariam Noureddine, Gabriel Rosas, Javier de la Torre Lima. Hospital Universitario de Cruces, (Bilbao): Roberto Blanco, María Victoria Boado, Marta Campaña Lázaro, Alejandro Crespo, Josune Goikoetxea, José Ramón Iruretagoyena, Josu Irurzun Zuazabal, Leire López-Soria, Miguel Montejo, Javier Nieto, David Rodrigo, Regino Rodríguez, Yolanda Vitoria, Roberto Voces. Hospital Universitario Virgen de la Victoria, Málaga: María (Mª) Victoria García López, Radka Ivanova Georgieva, Guillermo Ojeda, Isabel Rodríguez Bailón, Josefa Ruiz Morales. Hospital Universitario Donostia-Policlínica Gipuzkoa, San Sebastián: Ana María Cuende, Tomás Echeverría, Ana Fuerte, Eduardo Gaminde, Miguel Ángel Goenaga, Pedro Idígoras, José Antonio Iribarren, Alberto Izaguirre Yarza, Xabier Kortajarena Urkola, Carlos Reviejo. Hospital General Universitario de Alicante, Alicante: Rafael Carrasco, Vicente Climent, Patricio Llamas, Esperanza Merino, Joaquín Plazas, Sergio Reus. Complejo Hospitalario Universitario A Coruña, A Coruña: Nemesio Álvarez, José María Bravo-Ferrer, Laura Castelo, José Cuenca, Pedro Llinares, Enrique Miguez Rey, María Rodríguez Mayo, Efrén Sánchez, Dolores Sousa Regueiro. Complejo Hospitalario Universitario de Huelva, Huelva: Francisco Javier Martínez. Hospital Universitario de Canarias, Canarias: Mª del Mar Alonso, Beatriz Castro, Dácil García Rosado, Mª del Carmen Durán, Mª Antonia Miguel Gómez, Juan Lacalzada, Ibrahim Nassar. Hospital Regional Universitario de Málaga, Málaga: Antonio Plata Ciezar, José Mª Reguera Iglesias. Hospital Universitario Central Asturias, Oviedo: Víctor Asensi Álvarez, Carlos Costas, Jesús de la Hera, Jonnathan Fernández Suárez, Lisardo Iglesias Fraile, Víctor León Arguero, José López Menéndez, Pilar Mencia Bajo, Carlos Morales, Alfonso Moreno Torrico, Carmen Palomo, Begoña Paya Martínez, Ángeles Rodríguez Esteban, Raquel Rodríguez García, Mauricio Telenti Asensio. Hospital Clínic-IDIBAPS, Universidad de Barcelona, Barcelona: Manuel Almela, Juan Ambrosioni, Manuel Azqueta, Mercè Brunet, Marta Bodro, Ramón Cartañá, Carlos Falces, Guillermina Fita, David Fuster, Cristina García de la Mària, Laura García-Valls, Marta Hernández-Meneses, Jaume Llopis Pérez, Francesc Marco, José M. Miró, Asunción Moreno, David Nicolás, Salvador Ninot, Eduardo Quintana, Carlos Paré, Daniel Pereda, Juan M. Pericás, José L. Pomar, José Ramírez, Irene Rovira, Elena Sandoval, Marta Sala, Marta Sitges, Dolors Soy, Adrián Téllez, José M. Tolosana, Bárbara Vidal, Jordi Vila. Hospital General Universitario Gregorio Marañón, Madrid: Iván Adán, Javier Bermejo, Emilio Bouza, Daniel Celemín, Gregorio Cuerpo Caballero, Antonia Delgado Montero, Ana Fernández Cruz, Ana García Mansilla, Mª Eugenia García Leoni, Víctor González Ramallo, Martha Kestler Hernández, Amaia Mari Hualde, Mercedes Marín, Manuel Martínez-Sellés, Mª Cruz Menárguez, Patricia Muñoz, Cristina Rincón, Hugo Rodríguez-Abella, Marta Rodríguez-Créixems, Blanca Pinilla, Ángel Pinto, Maricela Valerio, Pilar Vázquez, Eduardo Verde Moreno. Hospital Universitario La Paz, Madrid: Isabel Antorrena, Belén Loeches, Alejandro Martín Quirós, Mar Moreno, Ulises Ramírez, Verónica Rial Bastón, María Romero, Araceli Saldaña. Hospital Universitario Marqués de Valdecilla, Santander: Jesús Agüero Balbín, Carlos Armiñanzas Castillo, Ana Arnaiz, Francisco Arnaiz de las Revillas, Manuel Cobo Belaustegui, María Carmen Fariñas, Concepción Fariñas-Álvarez, Rubén Gómez Izquierdo, Iván García, Claudia González Rico, Manuel Gutiérrez-Cuadra, José Gutiérrez Díez, Marcos Pajarón, José Antonio Parra, Ramón Teira, Jesús Zarauza. Hospital Universitario Puerta de Hierro, Madrid: Fernando Domínguez, Pablo García Pavía, Jesús González, Beatriz Orden, Antonio Ramos. Hospital Universitario Ramón y Cajal, (Madrid): Tomasa Centella, José Manuel Hermida, José Luis Moya, Pilar Martín-Dávila, Enrique Navas, Enrique Oliva, Alejandro del Río, Jorge Rodríguez-Roda Stuart, Soledad Ruiz Rodríguez. Hospital Universitario Virgen de las Nieves, Granada: Carmen Hidalgo Tenorio. Hospital Universitario Virgen Macarena, Sevilla: Manuel Almendro Delia, Omar Araji, José Miguel Barquero, Román Calvo Jambrina, Marina de Cueto, Juan Gálvez Acebal, Irene Méndez, Isabel Morales, Luis Eduardo López-Cortés. Hospital Universitario Virgen del Rocío, Sevilla: Arístides de Alarcón, Emilio García, Juan Luis Haro, José Antonio Lepe, Francisco López, Rafael Luque. Hospital San Pedro, Logroño: Luis Javier Alonso, Pedro Azcárate, José Manuel Azcona Gutiérrez, José Ramón Blanco, Lara García-Álvarez, José Antonio Oteo, Mercedes Sanz. Hospital de la Santa Creu i Sant Pau, Barcelona: Natividad de Benito, Mercé Gurguí, Cristina Pacho, Roser Pericas, Guillem Pons. Complejo Hospitalario Universitario de Santiago de Compostela, A Coruña: M. Álvarez, A. L. Fernández, Amparo Martínez, A. Prieto, Benito Regueiro, E. Tijeira, Marino Vega. Hospital Santiago Apóstol, Vitoria: Andrés Canut Blasco, José Cordo Mollar, Juan Carlos Gainzarain Arana, Oscar García Uriarte, Alejandro Martín López, Zuriñe Ortiz de Zárate, José Antonio Urturi Matos. Hospital SAS Línea de la Concepción, Cádiz: Gloria García Domínguez, Antonio Sánchez-Porto. Hospital Clínico Universitario Virgen de la Arrixaca, Murcia: José Mª Arribas Leal, Elisa García Vázquez, Alicia Hernández Torres, Ana Blázquez, Gonzalo de la Morena Valenzuela. Hospital de Txagorritxu, Vitoria: Ángel Alonso, Javier Aramburu, Felicitas Elena Calvo, Anai Moreno Rodríguez, Paola Tarabini-Castellani. Hospital Virgen de la Salud, Toledo: Eva Heredero Gálvez, Carolina Maicas Bellido, José Largo Pau, Mª Antonia Sepúlveda, Pilar Toledano Sierra, Sadaf Zafar Iqbal-Mirza. Hospital Rafael Méndez, Lorca-Murcia: Eva Cascales Alcolea, Pilar Egea Serrano, José Joaquín Hernández Roca, Ivan Keituqwa Yañez, Ana Peláez Ballesta, Víctor Soriano. Hospital Universitario San Cecilio, Granada: Eduardo Moreno Escobar, Alejandro Peña Monje, Valme Sánchez Cabrera, David Vinuesa García. Hospital Son Llátzer, Palma de Mallorca: María Arrizabalaga Asenjo, Carmen Cifuentes Luna, Juana Núñez Morcillo, Mª Cruz Pérez Seco, Aroa Villoslada Gelabert. Hospital Universitario Miguel Servet, Zaragoza: Carmen Aured Guallar, Nuria Fernández Abad, Pilar García Mangas, Marta Matamala Adell, Mª Pilar Palacián Ruiz, Juan Carlos Porres. Hospital General Universitario Santa Lucía, Cartagena: Begoña Alcaraz Vidal, Nazaret Cobos Trigueros, María Jesús Del Amor Espín, José Antonio Giner Caro, Roberto Jiménez Sánchez, Amaya Jimeno Almazán, Alejandro Ortín Freire, Monserrat Viqueira González. Hospital Universitario Son Espases, Palma de Mallorca: Pere Pericás Ramis, Mª Ángels Ribas Blanco, Enrique Ruiz de Gopegui Bordes, Laura Vidal Bonet. Complejo Hospitalario Universitario de Albacete, Albacete: Mª Carmen Bellón Munera, Elena Escribano Garaizabal, Antonia Tercero Martínez, Juan Carlos Segura Luque., [Background] 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). [Methods] Retrospective analysis of data from a multicenter, prospective cohort study of 2000 consecutive IE patients in 25 Spanish hospitals (2008–2012) was performed. [Results] 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. [Conclusions] OPAT provided excellent results despite the use of broader criteria than those recommended by IDSA. OPAT criteria should therefore be expanded., This work was supported by the Ministerio de Economia and Competitividad (Madrid, Spain) (FIS NCT00871104, Instituto de Salud Carlos III). J. M. P. received a “Rio Hortega” research grant from Instituto de Salud Carlos III and the Ministerio de Economia and Competitividad (Madrid, Spain) and the European Society for Clinical Microbiology and Infectious Diseases and Federation of European Microbiological Societies Research Fellowship 2016. Instituto de Salud Carlos III, Ministerio de Economía y Competitividad (Madrid, Spain) provided J. M. M. with a personal intensification research grant (INT15/00168) during 2016 and a personal 80:20 research grant from the Institut d’Investigacions Biomèdiques Pi i Sunyer for the period 2017–2019.

Background Solid organ transplantation (SOT) implies immunosuppression and frequent health care contact. Our aim was to compare the characteristics of patients with infective endocarditis (IE) and SOT against those without SOT. Methods We used data from the Spanish Collaboration on Endocarditis during the period 2008-2018. Results We identified 4794 cases of IE, 85 (1.8%) in SOT (56 kidney, 18 liver, 8 heart, 3 lung). Thirteen patients with other transplantation types (bone marrow, hematopoietic precursors, and cornea) were excluded from the analysis. Compared with patients without SOT, patients with SOT had lower median age (61 vs. 69 years, p

Direct-acting antivirals have proved to be highly efficacious and safe in monoinfected liver transplant (LT) recipients who experience recurrence of hepatitis C virus (HCV) infection. However, there is a lack of data on effectiveness and tolerability of these regimens in HCV/HIV-coinfected patients who experience recurrence of HCV infection after LT. In this prospective, multicenter cohort study, the outcomes of 47 HCV/HIV-coinfected LT patients who received DAA therapy (with or without ribavirin [RBV]) were compared with those of a matched cohort of 148 HCV-monoinfected LT recipients who received similar treatment. Baseline characteristics were similar in both groups. HCV/HIV-coinfected patients had a median (IQR) CD4 T-cell count of 366 (256-467) cells/mu L. HIV-RNA was

Infective endocarditis (IE) is a rare disease that is difficult to diagnose, its treatment is complex and expensive, and mortality is high (around 20%). In the field of IE, the most recent changes are epidemiological and include an increased number of cases of IE in patients with prosthetic valves and intracardiac devices and in the population receiving health care, an increased number of cases of Staphylococcus aureus IE, and changes in antibiotic sensitivity patterns with a particular impact on vancomycin. Infective endocarditis requires prolonged hospitalization and resourceintensive treatment because antibiotic therapy, intensive care, and surgical treatment form part of the therapeutic approach. Between 40% and 50% of patients require surgical treatment in the acute phase. In the year when IE is diagnosed, mortality is 30% with or without intervention. Mortality is high among certain groups, such as patients with prosthetic valves and especially those with intracranial hemorrhage. Early diagnosis and treatment can improve outcomes. Low suspicion of IE can delay effective treatment and increase mortality. In our experience, an appropriate therapeutic approach has a mean delay of 27 days when the patient is referred from another institution. The treatment of IE is a paradigm of collaboration. Multidisciplinary teams (MDT) dedicated to IE have pioneered the organization of tertiary hospital care devoted to the disease. In the last decade, the International Collaboration in Endocarditis group has had a strong impact on understanding IE. The British Heart Valve Society has recommended the collaboration of specialists in valvular heart disease and IE and recent reports have supported this model.

Resumen Las infecciones más frecuentes en pacientes con trasplante de órgano sólido son las bacterianas, fundamentalmente durante el primer mes postrasplante, la mayoría adquiridas en el ámbito hospitalario. Las infecciones nosocomiales comportan una gran morbilidad y constituyen la causa más frecuente de mortalidad en ese periodo precoz del trasplante. Suelen ser infecciones a menudo por microorganismos multirresistentes, destacando fundamentalmente enterobacterias gramnegativas, bacilos gramnegativos no fermentadores, enterococos y estafilococos. Los pacientes más expuestos a padecer infección nosocomial por bacterias son los colonizados previamente durante la lista de espera con bacterias multirresistentes. Los focos más frecuentes son los relacionados con los catéteres intravasculares, la vía urinaria, el pulmón y la herida quirúrgica. Las medidas preventivas son las mismas que las aplicadas en los pacientes hospitalizados no inmunodeprimidos, salvo en caso de pacientes con riesgo elevado de desarrollar infección fúngica, a los que se han de administrar antifúngicos durante el tiempo de hospitalización y vacunar según recomendaciones a los pacientes en lista de espera como prevención de infección en el periodo precoz del trasplante. A pesar de que la morbimortalidad asociada a las infecciones en el trasplante de progenitores hematopoyéticos (TPH) ha disminuido considerablemente en los últimos años, estas continúan siendo una de las complicaciones más destacables en estos pacientes. Por otra parte, y al igual que en la población general, las infecciones nosocomiales han incrementado su incidencia en las diferentes fases del TPH. Es difícil establecer unas medidas preventivas generales en estos pacientes, ya que existen muchos factores que condicionan las infecciones nosocomiales: están sometidos a múltiples tratamientos antibióticos e intervenciones, el grado de neutropenia e inmunodepresión es variable de paciente a paciente y, finalmente, combinan constantemente la estancia hospitalaria y domiciliaria en el proceso del trasplante. Sin embargo, existen medidas que ayudan sin duda a mejorar la situación actual.

Enterococci are the third most common etiologic agent of infective endocarditis worldwide after staphylococci and streptococci and cause 10% to 15% of cases.1 Enterococcal infections are increasingly relevant, especially among the elderly and patients with comorbid conditions in the healthcare setting.2,3 Approximately 90% of cases of enterococcal endocarditis are caused by Enterococcus faecalis , with 3-month history of symptoms before diagnosis.4 The gentamicin dose schedule (3 mg/kg per 24 hours IV …

Although the influenza A (H1N1) 2009 virus is expected to circulate as a seasonal virus for some years after the pandemic period, its behaviour cannot be predicted. We analysed a prospective cohort study of hospitalized adults with influenza A (H1N1) 2009 pneumonia at 14 teaching hospitals in Spain to compare the epidemiology, clinical features and outcomes of influenza A (H1N1) 2009 pneumonia between the pandemic period and the first post-pandemic influenza season. A total of 348 patients were included: 234 during the pandemic period and 114 during the first post-pandemic influenza season. Patients during the post-pandemic period were older and more likely to have chronic obstructive pulmonary disease, chronic kidney disease and cancer than the others. Septic shock, altered mental status and respiratory failure on arrival at hospital were significantly more common during the post-pandemic period. Time from illness onset to receipt of antiviral therapy was also longer during this period. Early antiviral therapy was less frequently administered to patients during the post-pandemic period (22.9% versus 10.9%; p 0.009). In addition, length of stay was longer, and need for mechanical ventilation and intensive-care unit admission were significantly higher during the post-pandemic period. In-hospital mortality (5.1% versus 21.2%; p

Amat-Santos et al1 assessed the incidence, clinical features, and outcomes of infective endocarditis (IE) during the first year after transcatheter aortic valve replacement (TAVR). The incidence of IE reported was lower than in the largest recent studies, including that of our group.2,3 Also significant was the lower rate of periannular complications. Abscesses, fistulas, and pseudoaneurysms were more common in the study performed by our group (45% versus 22.7%).2 In addition, only 4 patients (7.5%) with IE underwent valve surgery with no impact on outcomes1; we found that 32% of patients had undergone surgery.2 Although this finding could be due to publication bias, a relevant point we covered that is not addressed by Amat-Santos et al1 is the question of whether patients with heart failure should undergo surgery. In our study, only 1 of the 18 heart failure–free patients …

Information about infections unrelated to acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus (HIV)-infected liver recipients is scarce. The aims of this study were to describe the prevalence, clinical characteristics, time of onset, and outcomes of bacterial, viral, and fungal infections in HIV/hepatitis C virus (HCV)-coinfected orthotopic liver transplant recipients and to identify risk factors for developing severe infections. We studied 84 consecutive HIV/HCV-coinfected patients who underwent liver transplantation at 17 sites in Spain between 2002 and 2006 and were followed until December 2009. The median age was 42 years, and 76% were men. The median follow-up was 2.6 years (interquartile range = 1.25-3.53 years), and 54 recipients (64%) developed at least 1 infection. Thirty-eight (45%) patients had bacterial infections, 21 (25%) had cytomegalovirus (CMV) infections (2 had CMV disease), 13 (15%) had herpes simplex virus infections, and 16 (19%) had fungal infections (7 cases were invasive). Nine patients (11%) developed 10 opportunistic infections with a 44% mortality rate. Forty-three of 119 infectious episodes (36%) occurred in the first month after transplantation, and 53 (45%) occurred after the sixth month. Thirty-six patients (43%) had severe infections. Overall, 36 patients (43%) died, and the deaths were related to severe infections in 7 cases (19%). Severe infections increased the mortality rate almost 3-fold [hazard ratio (HR) = 2.9, 95% confidence interval (CI) = 1.5-5.8]. Independent factors for severe infections included a pretransplant Model for End-Stage Liver Disease (MELD) score >15 (HR = 3.5, 95% CI = 1.70-7.1), a history of AIDS-defining events before transplantation (HR = 4.0, 95% CI = 1.9-8.6), and non-tacrolimus-based immunosuppression (HR = 2.5, 95% CI = 1.3-4.8). In conclusion, the rates of severe and opportunistic infections are high in HIV/HCV-coinfected liver recipients and especially in those with a history of AIDS, a high MELD score, or non-tacrolimus-based immunosuppression.

Pancreatic transplantation carries a higher risk of cytomegalovirus (CMV) infection than renal transplantation alone. The management of CMV disease in pancreatic transplantation depends on the risk indicated by the donor's and recipient's serological profiles (CMV IgG) and the use of antibodies as immunosuppressive therapy (especially thymoglobulin). Most clinical guidelines recommend the use of prophylaxis in preference to preemptive therapy in both donor (D)+/recipient (R)- and D+/R+ pancreatic transplantations. In combinations with highest risk (D+/R-), prophylaxis with valganciclovir 900mg per day for 3 to 6 months is recommended, adjusted to renal funtion. In D+/R+ combinations, if antibody therapy was used in the transplant or in rejection, valgancioclovir prophylaxis is also recommended for 1 to 3 months. When prophylaxis is finished, in both cases, viral load determination (quantitative polymerase chain reaction of CMV) or antigenemia should be carried out for the first year. In D-/R-combinations, preemptive therapy can be considered with determinations of viral load or antigenemia at each follow-up visit during the first year. Once prophylaxis has been suspended, special attention should be paid to the development of delayed CMV disease.

The substantial immigration into Spain from endemic areas of Chagas disease such as Latin America has increased the number of potential donors of organs and tissues. In addition, an increasing number of patients with advanced Chagas heart disease may eventually be eligible to receive a heart transplant, a universally accepted therapeutic strategy for the advanced stages of this disease. Therefore, it is necessary to establish protocols for disease management. This document is intended to establish the guidelines to be followed when a potential donor or a tissue or organ recipient is potentially affected by Chagas disease and summarizes the action criteria against the possibility of Chagas disease transmission through the donation of organs, tissues, or hematopoietic stem cells and aims to help professionals working in this field. A single registry of transplants in Trypanosoma cruzi infected donors and/or recipients will provide and disseminate experience in this area, which has shown a low recorded incidence to date.

The guidelines on the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) are presented. These recommendations are focused on four clinical categories: oncology-haematology patients, solid organ transplant recipients, patients admitted to intensive care units, and children. An extensive review is made of therapeutical advances and scientific evidence in these settings. These guidelines have been prepared according the SEIMC consensus rules by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. Specific recommendations on the prevention of fungal infections in these patients are included.

The rate of compliance with antifungal drug use guidelines by transplant physicians is mostly unknown. We performed a nationwide electronic survey to assess antifungal use by different types of transplant physicians. Sixty-one percent (53/87) of the transplant programs responded (accounting for 85% of heart transplant procedures, 65% of kidney transplantations, and 71.5% of liver transplantations). Antifungal prophylaxis was used in 41.5% programs (liver 93.3%, heart 30.8%, and kidney 16%). Prophylaxis was universal in 32% of the programs and targeted only to selected patients in 68%, mainly indicated after re-transplantation (73.3%), re-intervention (66.7%) and hemodialysis (60%). Main drugs for universal prophylaxis were fluconazole and itraconazole (42.9% each), while fluconazole (60%), L-amphotericin B (AMB), and caspofungin (13.4% each) were preferred for targeted prophylaxis. Overall, 84.9% of the programs used galactomannan for the diagnosis of invasive aspergillosis (only 34% in BAL) and 66.6% used voriconazole as first-line monotherapy. Combination first-line therapy for invasive aspergillosis was used by 31.3%, mainly with voriconazole with caspofungin (40%) or anidulafungin (26.7%) or L-AMB-caspofungin (26.7%). Adherence of transplant physicians to current recommendations on antifungal treatment and prophylaxis is poor. An international consensus that responds to differences in patients and centers and emphasizes patient safety is clearly needed.

International audience; Background : Nearly half of patients require cardiac surgery during the acute phase of infective endocarditis (IE). We describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and examine whether the type of prosthesis was associated with in-hospital and 1-year mortality.Methods and results : Among 5591 patients included in the International Collaboration on Endocarditis Prospective Cohort Study, 1467 patients with definite IE were operated on during the active phase and had a biological (37%) or mechanical (63%) valve replacement.Patients who received bioprostheses were older (62 vs 54 years), more often had a history of cancer (9% vs 6%), and had moderate or severe renal disease (9% vs 4%); proportion of health care-associated IE was higher (26% vs 17%); intracardiac abscesses were more frequent (30% vs 23%). In-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p = 0.0009) and 25.3% vs 16.6% (p < .0001), respectively.In multivariable analysis, mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10 years), and in patients with a history of cancer (0.72), but were more commonly implanted in mitral position (1.60).Bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298).Conclusions :Patients with IE who receive a biological valve replacement have significant differences in clinical characteristics compared to patients who receive a mechanical prosthesis. Biological valve replacement is independently associated with a higher in-hospital and 1-year mortality, a result which is possibly related to patient characteristics rather than valve dysfunction.

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

Aims Surgery for infective endocarditis (IE) is associated with high mortality. Our objectives were to describe the experience with surgical treatment for IE in Spain, and to identify predictors of in-hospital mortality. Methods Prospective cohort of 1000 consecutive patients with IE. Data were collected in 26 Spanish hospitals. Results Surgery was performed in 437 patients (43.7%). Patients treated with surgery were younger and predominantly male. They presented fewer comorbid conditions and more often had negative blood cultures and heart failure. In-hospital mortality after surgery was lower than in the medical therapy group (24.3 vs 30.7%, p = 0.02). In patients treated with surgery, endocarditis involved a native valve in 267 patients (61.1%), a prosthetic valve in 122 (27.9%), and a pacemaker lead with no clear further valve involvement in 48 (11.0%). The most common aetiologies were Staphylococcus (186, 42.6%), Streptococcus (97, 22.2%), and Enterococcus (49, 11.2%). The main indications for surgery were heart failure and severe valve regurgitation. A risk score for in-hospital mortality was developed using 7 prognostic variables with a similar predictive value (OR between 1.7 and 2.3): PALSUSE: prosthetic valve, age ≥ 70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE ≥ 10. In-hospital mortality ranged from 0% in patients with a PALSUSE score of 0 to 45.4% in patients with PALSUSE score > 3. Conclusions The prognosis of IE surgery is highly variable. The PALSUSE score could help to identify patients with higher in-hospital mortality. 4.036 JCR (2014) Q1, 29/123 Cardiac and cardiovascular systems UEM

International audience; IMPORTANCE: There are limited prospective, controlled data evaluating survival in patients receiving early surgery vs medical therapy for prosthetic valve endocarditis (PVE). OBJECTIVE: To determine the in-hospital and 1-year mortality in patients with PVE who undergo valve replacement during index hospitalization compared with patients who receive medical therapy alone, after controlling for survival and treatment selection bias. DESIGN, SETTING, AND PARTICIPANTS: Participants were enrolled between June 2000 and December 2006 in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. We evaluated the effect of treatment assignment on mortality, after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum. INTERVENTIONS: Valve replacement during index hospitalization (early surgery) vs medical therapy. MAIN OUTCOMES AND MEASURES: In-hospital and 1-year mortality. RESULTS: Of the 1025 patients with PVE, 490 patients (47.8%) underwent early surgery and 535 individuals (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44 [95% CI, 0.38-0.52] and lower 1-year mortality: HR, 0.57 [95% CI, 0.49-0.67]). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90 [95% CI, 0.76-1.07] and 1-year mortality: HR, 1.04 [95% CI, 0.89-1.23]). Subgroup analysis indicated a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21.2% vs 37.5%; P = .03). At 1-year follow-up, the reduced mortality with surgery was observed in the fourth (24.8% vs 42.9%; P = .007) and fifth (27.9% vs 50.0%; P = .007) quintiles of surgical propensity. CONCLUSIONS AND RELEVANCE: Prosthetic valve endocarditis remains associated with a high 1-year mortality rate. After adjustment for differences in clinical characteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. Further studies are needed to define the effect and timing of surgery in patients with PVE who have indications for surgery.

International audience; Enterococci are reportedly the third most common group of endocarditis-causing pathogens but data on enterococcal infective endocarditis (IE) are limited. The aim of this study was to analyse the characteristics and prognostic factors of enterococcal IE within the International Collaboration on Endocarditis. In this multicentre, prospective observational cohort study of 4974 adults with definite IE recorded from June 2000 to September 2006, 500 patients had enterococcal IE. Their characteristics were described and compared with those of oral and group D streptococcal IE. Prognostic factors for enterococcal IE were analysed using multivariable Cox regression models. The patients' mean age was 65 years and 361/500 were male. Twenty-three per cent (117/500) of cases were healthcare related. Enterococcal IE were more frequent than oral and group D streptococcal IE in North America. The 1-year mortality rate was 28.9% (144/500). E. faecalis accounted for 90% (453/500) of enterococcal IE. Resistance to vancomycin was observed in 12 strains, eight of which were observed in North America, where they accounted for 10% (8/79) of enterococcal strains, and was more frequent in E. faecium than in E. faecalis (3/16 vs. 7/364 , p 0.01). Variables significantly associated with 1-year mortality were heart failure (HR 2.4, 95% CI 1.7--3.5, p

Pancreatic transplantation carries a higher risk of cytomegalovirus (CMV) infection than renal transplantation alone. The management of CMV disease in pancreatic transplantation depends on the risk indicated by the donor's and recipient's serological profiles (CMV IgG) and the use of antibodies as immunosuppressive therapy (especially thymoglobulin). Most clinical guidelines recommend the use of prophylaxis in preference to preemptive therapy in both donor (D)+/recipient (R)- and D+/R+ pancreatic transplantations. In combinations with highest risk (D+/R-), prophylaxis with valganciclovir 900mg per day for 3 to 6 months is recommended, adjusted to renal funtion. In D+/R+ combinations, if antibody therapy was used in the transplant or in rejection, valgancioclovir prophylaxis is also recommended for 1 to 3 months. When prophylaxis is finished, in both cases, viral load determination (quantitative polymerase chain reaction of CMV) or antigenemia should be carried out for the first year. In D-/R-combinations, preemptive therapy can be considered with determinations of viral load or antigenemia at each follow-up visit during the first year. Once prophylaxis has been suspended, special attention should be paid to the development of delayed CMV disease.

International audience; CONTEXT: Infection of implantable cardiac devices is an emerging disease with significant morbidity, mortality, and health care costs. OBJECTIVES: To describe the clinical characteristics and outcome of cardiac device infective endocarditis (CDIE) with attention to its health care association and to evaluate the association between device removal during index hospitalization and outcome. DESIGN, SETTING, AND PATIENTS: Prospective cohort study using data from the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), conducted June 2000 through August 2006 in 61 centers in 28 countries. Patients were hospitalized adults with definite endocarditis as defined by modified Duke endocarditis criteria. MAIN OUTCOME MEASURES: In-hospital and 1-year mortality. RESULTS: CDIE was diagnosed in 177 (6.4% [95% CI, 5.5%-7.4%]) of a total cohort of 2760 patients with definite infective endocarditis. The clinical profile of CDIE included advanced patient age (median, 71.2 years [interquartile range, 59.8-77.6]); causation by staphylococci (62 [35.0% {95% CI, 28.0%-42.5%}] Staphylococcus aureus and 56 [31.6% {95% CI, 24.9%-39.0%}] coagulase-negative staphylococci); and a high prevalence of health care-associated infection (81 [45.8% {95% CI, 38.3%-53.4%}]). There was coexisting valve involvement in 66 (37.3% [95% CI, 30.2%-44.9%]) patients, predominantly tricuspid valve infection (43/177 [24.3%]), with associated higher mortality. In-hospital and 1-year mortality rates were 14.7% (26/177 [95% CI, 9.8%-20.8%]) and 23.2% (41/177 [95% CI, 17.2%-30.1%]), respectively. Proportional hazards regression analysis showed a survival benefit at 1 year for device removal during the initial hospitalization (28/141 patients [19.9%] who underwent device removal during the index hospitalization had died at 1 year, vs 13/34 [38.2%] who did not undergo device removal; hazard ratio, 0.42 [95% CI, 0.22-0.82]). CONCLUSIONS: Among patients with CDIE, the rate of concomitant valve infection is high, as is mortality, particularly if there is valve involvement. Early device removal is associated with improved survival at 1 year.

Objectives: To describe the clinical presentation and prognosis of elderly adults hospitalized with pandemic 2009 A(H1N1) influenza infection and to compare these data with those of younger patients. Design: Prospective, observational, multicenter study. Setting: Thirteen hospitals in Spain. Participants: Adults admitted to the hospital with confirmed pandemic 2009 A(H1N1) influenza infection. Measurements: Demographic, clinical, laboratory, radiological, and outcome variables. Results: Between June 12 and November 10, 2009, 585 adults with confirmed 2009 A(H1N1) influenza were hospitalized, of whom 50 (8.5%) were aged 65 and older (median age 72, range 65�87). Older adults (?65) were more likely to have associated comorbidities (88.0% vs 51.2%; P < .001), primarily chronic pulmonary diseases (46.0% vs 27.3%; P < .001). Lower respiratory tract symptoms and signs such as dyspnea (60.0% vs 45.6%) and wheezing (46.0% vs 27.8%; P = .007) were also more common in these elderly adults, although pulmonary infiltrates were present in just 14 (28.0%) of the older adults, compared with 221 (41.3%) of the younger adults (P = .06). Multilobar involvement was less frequent in elderly adults with pulmonary infiltrates than younger adults with pulmonary infiltrates (21.4% vs 60.0%; P = .05). Rhinorrhea (4.0% vs 21.9%; P = .003), myalgias (42.0% vs 59.1%; P = .01), and sore throat (14.0% vs 29.2%; P = .02) were more frequent in younger adults. Early antiviral therapy (

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

We thank Dr. Friaza and colleagues for their letter. We share their interest in gaining a better understanding of the prevalence of dihydropteroate synthase (DHPS) mutations in Spanish patients with Pneumocystis jirovecii pneumonia (PcP). The reported prevalences of DHPS mutations, possibly associated with drug resistance, vary widely geographically (Kazanjian et al., 1998, 2000, 2004; Beard et al., 2000; Huang et al., 2000). Knowing the prevalence of these mutations in Spanish PCP patients could have important public health implications. As pointed out by Dr. Friaza, we incorrectly cited their reported prevalence of Pneumocystis DHPS mutations (Alvarez-Martinez et al., 2008). Nevertheless, their reported prevalence of DHPS mutations was 35.5% overall and 45.5% in HIV-infected patients (Montes-Cano et al., 2004). This prevalence is much higher than the 3.7% reported in our study (Alvarez-Martinez et al., 2008). Dr. Friaza and colleagues suggested that this difference was due to analytical methods. However, both studies used purified PCR amplicon, not subcloned DNA, so it is unlikely that minority variants (either wild type or mutant) were overrepresented in either study (Alvarez et al., 2006; Montes-Cano et al., 2004). Previous studies have not found disparities between the RFLP method used in their study and direct DNA sequence analysis (used in our study) when conducted on the same samples. We suspect that the disparity is due to sampling bias. The study by Montes-Cano et al. (2004) included only 19 HIVpositive patients at a single health facility. Our study was conducted on 188 HIV-positive patients in 12 sites throughout Spain. Thus, we suspect that our results may be more representative of the overall Spanish HIV patient population. The results of both papers can be harmonized most easily considering another recent observation. We recently showed that there was a very high prevalence of DHPS mutations in PcP episodes in Spanish HIV patients diagnosed before the introduction of cART. The prevalence of DHPS mutations in 163 PcP episodes in HIV-1–infected patients diagnosed between 1989 and 1995 was 33% compared to only 6% in the cART period between 2001 and 2004 (Alvarez et al., 2005). This difference was probably