Patients In Barcelona Research Articles

Report of three azole-resistant Aspergillus fumigatus cases with TR34/L98H mutation in hematological patients in Barcelona, Spain

ObjectivesWe aimed to report the emergence of azole-resistant invasive aspergillosis in hematologic patients admitted to a tertiary hospital in Spain during the last 4 months.MethodsProspective, descriptive study was performed to describe and follow all consecutive proven and probable invasive aspergillosis resistant to azoles from hematological cohort during the last 4 months. All patients had fungal cultures and antifungal susceptibility or real-time PCR detection for Aspergillus species and real-time PCR detection for azole-resistant mutation.ResultsFour cases of invasive aspergillosis were diagnosed in 4 months. Three of them had azole-resistant aspergillosis. Microbiological diagnosis was achieved in three cases by means of fungal culture isolation and subsequent antifungal susceptibility whereas one case was diagnosed by PCR-based aspergillus and azole resistance detection. All the azole-resistant aspergillosis presented TR34/L98H mutation. Patients with azole-resistant aspergillosis had different hematologic diseases: multiple myeloma, lymphoblastic acute leukemia, and angioimmunoblastic T lymphoma. Regarding risk factors, one had prolonged neutropenia, two had corticosteroids, and two had viral co-infection. Two of the patients developed aspergillosis under treatment with azoles.ConclusionWe have observed a heightened risk of azole-resistant aspergillosis caused by A. fumigatus harboring the TR34/L98H mutation in patients with hematologic malignancies. The emergence of azole-resistant aspergillosis raises concerns for the community, highlighting the urgent need for increased surveillance and the importance of susceptibility testing and new drugs development.

Pneumocystis jirovecii genetic diversity in a Spanish tertiary hospital.

A newly described MLST scheme aims at providing a standardized tool to study and compare Pneumocystis jirovecii epidemiology. A high diversity among P. jirovecii isolates from patients in Barcelona, Spain, and a potential association between specific STs and infection/colonization were identified.

Mycoplasma genitalium macrolide resistance update: Rate among a 2016–2017 cohort of patients in Barcelona, Spain

IntroductionMycoplasma genitalium is a major cause of urethritis and other genital syndromes. Antibiotic resistance, especially to macrolides, is increasing at an alarming rate worldwide. The aim of this study was to estimate the rate of macrolide resistance in M. genitalium among a 2016–2017 cohort of patients in Barcelona, Spain; and to compare this estimate with previous data from 2013 to 2014 in this region. MethodsThe study was conducted retrospectively with M. genitalium-positive samples collected between December 2016 and February 2017 at the Hospital Vall d’Hebron Microbiology Department. Genotypic markers of macrolide resistance were primarily detected using the ResistancePlus® MG molecular assay (SpeeDx). Mutations were then confirmed by sequencing. ResultsMacrolide resistance-mediating mutations were detected in 30/83 infections (36.1% [95% CI, 25.9%–47.4%]). This resistance was more frequent among men who have sex with men (55.0% [95% CI, 38.5%–70.7%]) compared to heterosexual men (27.3% [95% CI, 10.7%–50.2%]) and women (9.5% [95% CI, 1.3%–30.4%]), p<0.001. Additionally, macrolide resistance did not significantly increase in this cohort when compared with previous investigations. ConclusionDespite the current notable rate of macrolide resistance in M. genitalium, resistance did not significantly increase between 2013–2014 and 2016–2017 in our region. Nevertheless, strict local surveillance and the implementation of rapid diagnostic tests that combine the detection of the bacterium and resistance-mediating mutations may facilitate the optimization of antibiotic administration and reduce the transmission of resistance in M. genitalium.

Mycoplasma genitalium macrolide resistance update: Rate among a 2016–2017 cohort of patients in Barcelona, Spain

IntroductionMycoplasma genitalium is a major cause of urethritis and other genital syndromes. Antibiotic resistance, especially to macrolides, is increasing at an alarming rate worldwide. The aim of this study was to estimate the rate of macrolide resistance in M. genitalium among a 2016–2017 cohort of patients in Barcelona, Spain; and to compare this estimate with previous data from 2013 to 2014 in this region. MethodsThe study was conducted retrospectively with M. genitalium-positive samples collected between December 2016 and February 2017 at the Hospital Vall d’Hebron Microbiology Department. Genotypic markers of macrolide resistance were primarily detected using the ResistancePlus® MG molecular assay (SpeeDx). Mutations were then confirmed by sequencing. ResultsMacrolide resistance-mediating mutations were detected in 30/83 infections (36.1% [95% CI, 25.9%–47.4%]). This resistance was more frequent among men who have sex with men (55.0% [95% CI, 38.5%–70.7%]) compared to heterosexual men (27.3% [95% CI, 10.7%–50.2%]) and women (9.5% [95% CI, 1.3%–30.4%]), p<0.001. Additionally, macrolide resistance did not significantly increase in this cohort when compared with previous investigations. ConclusionDespite the current notable rate of macrolide resistance in M. genitalium, resistance did not significantly increase between 2013–2014 and 2016–2017 in our region. Nevertheless, strict local surveillance and the implementation of rapid diagnostic tests that combine the detection of the bacterium and resistance-mediating mutations may facilitate the optimization of antibiotic administration and reduce the transmission of resistance in M. genitalium.

Epidemiological changes of acute/recent human immunodeficiency virus type 1 infection in Barcelona, Spain (1997–2015): a prospective cohort study

ObjectiveTo describe the epidemiology of acute/recent human immunodeficiency virus (HIV) infection over two decades in Barcelona (Spain). MethodsProspective, single-centre cohort including all patients with an acute/recent HIV infection (<180 days) since 1997. Patients were stratified into four periods. Phylogenetic analysis was performed to determine clusters of transmission. ResultsA total of 346 consecutive acute/recently infected patients were included. The annual proportion of recent infections among total new HIV diagnoses increased over time from 1% (29 out of 1964) to 8% (112 out of 1474) (p <0.001). Proportion of men who have sex with men (MSM) in the cohort increased from 62% (18 out of 29) to 89% (100 out of 112) (p <0.001). The proportion of migrants showed a non-significant increasing trend (24% (7 of 29) to 40% (45 of 112)) likewise the non-B subtype (0% to 22% (22 of 112)). The mean time from infection to diagnosis was 53.6 days (interquartile range (IQR) 50–57), comparable among all periods. Mean time from infection to treatment decreased over the years from 575 (IQR 467–683) to 471 (IQR 394–549) days (p <0.001) without significant differences between migrants and non-migrants (133 (IQR 71–411) versus 208 (IQR 90–523) days p 0.089). Almost 50% (152 of 311) of recently infected individuals were included in a cluster of transmission, and 92% (137 of 149) of them were MSM. ConclusionThe MSM population has progressively grown within acutely/recently infected patients in Barcelona, and is frequently involved in transmission clusters. Although the time between diagnosis and treatment has been reduced, the time between infection and diagnosis still needs to be shortened.

Mycoplasma genitalium Macrolide and Fluoroquinolone Resistance: Prevalence and Risk Factors Among a 2013–2014 Cohort of Patients in Barcelona, Spain

Macrolide and fluoroquinolone resistance is alarmingly emerging in M. genitalium worldwide. This article provides the first estimates of the current prevalence of macrolide and fluoroquinolone resistance-mediating mutations in Barcelona, Spain, and identifies risk factors associated with the acquisition of these resistances. The study was conducted retrospectively with specimens submitted between February 2013 and March 2014 to the microbiology department of the Vall d'Hebron Hospital, Barcelona, where M. genitalium was detected using nucleic acid amplification methods. DNA sequencing of 23S ribosomal RNA gene and parC was performed in the Statens Serum Institut, Copenhagen, to detect genotypic macrolide and fluoroquinolone resistance markers, respectively. Macrolide resistance-mediating mutations were detected in 35% (95% confidence interval, 24%-47%) of the M. genitalium-positive episodes, whereas 8% (95% confidence interval, 3%-17%) carried fluoroquinolone resistance mutations. Of them, three cases harbored multidrug resistance to both classes of antibiotics. Men who had sex with men (P = 0.002) and treatment with azithromycin within the previous 12 months (P = 0.006) were strongly associated with macrolide resistance. The widespread appearance of resistances, also in Spain, makes imperative the implementation of combined diagnostic-resistance detection assays for M. genitalium to facilitate the optimization of antibiotic treatment in the management of nongonococcal urethritis and potentially reduce the transmission of resistances.

Prevalence of methicillin-resistant Staphylococcus aureus colonization in HIV-infected patients in Barcelona, Spain: a cross-sectional study

BackgroundColonization by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been found to be markedly more common in HIV-infected individuals in the USA. Studies evaluating the prevalence MRSA colonization in HIV-infected populations in Europe are scarce. The aim of this study was to investigate the prevalence of MRSA colonization in a cohort of HIV-infected patients in Barcelona, Spain.MethodsNasal and pharyngeal S. aureus carriage was assessed in a random sample of 190 patients from an outpatient HIV clinic. Nasal and pharyngeal swab specimens were obtained for staphylococcal culture from 190 and 110 patients respectively. All MRSA isolates were screened for Panton-Valentine leukocidin (PVL) genes by PCR. Molecular characterization of MRSA isolates was performed by multilocus sequence typing. Data related to HIV infection, healthcare exposure, and previously described risk factors for MRSA were collected from medical records and a questionnaire administered to each patient.ResultsThe patients’ characteristics were as follows: male, 83 %; median (IQR) age, 45 (39–49) years; intravenous drug users, 39 %; men who have sex with men, 32 %; heterosexual, 26 %; CD4 count, 528/μL (IQR 351–740); on antiretroviral therapy, 96 %; and undetectable plasma viral load, 80 %. Sixty-five patients (34 %) were colonized by S. aureus. MRSA colonization was found in 1 % and 2 % of nasal and pharyngeal samples respectively. No PVL positive MRSA strains were detected and all the MRSA isolates belonged to typical hospital-acquired clones.ConclusionsOur data suggest that CA-MRSA colonization is not currently a problem in HIV-infected individuals in our area.

A survey of 183 paediatric patients from Barcelona including 239 supernumerary unerupted teeth

Background and objectives: Unerupted supernumerary teeth, depending on the morphology, number and distribution can give rise to various alterations in the eruption and development of those permanent teeth to which they are related. We aimed to make an epidemiological and descriptive study of the clinical characteristics of patients in Barcelona.

Recurrences in tuberculosis in a cohort of human immunodeficiency virus-infected patients: The influence of highly active antiretroviral therapy

BackgroundLittle is known about recurrent tuberculosis (TB) among HIV-infected patients and the influence of highly active antiretroviral therapy (HAART). MethodsA population-based retrospective longitudinal study was conducted on all HIV-infected TB patients in Barcelona (Spain) notified in 1987–2003, and followed up until 2005. TB recurrence and HAART influence were analysed according to calendar period. ResultsPatients with no-treatment and those in pre-HAART had more risk of TB recurrence (RR: 2.3; CI: 1–5.8 and RR: 4.8; CI: 2–12). ConclusionsHAART decreases probability of TB recurrence and should be extended to all cases.

What is next in sepsis: current trials in sepsis

17th International Symposium on Infections in the Critically Ill PatientBarcelona, Spain, 3–4 February 2012International experts reviewed and updated the most recent and relevant scientific advances on severe sepsis during the 17th International Symposium on Infections in the Critically Ill Patients in Barcelona (Spain) in February 2012. All new pharmacological therapeutic strategies have failed to demonstrate a survival benefit. Despite the large variability among countries and hospitals, the improvement of standard care according to the Surviving Sepsis campaign recommendations reduced the 28-day mortality to 24%. These results may have implications for future clinical trials in which much larger samples sizes of patients at high risk of death will be necessary. The identification of novel proinflammatory endogeneous signals and pathways may lead to the discovery of new drugs to reduce inflammatory reactions and end-organ dysfunction in critically ill patients with sepsis. Extracorporeal blood purification stem or progenitor cells have received increasing interest for the treatment of inflammation and organ injury. A better understanding of how these therapies work is essential and its benefit should be confirmed in future prospective randomized studies.

Acculturative stress as a risk factor of depression and anxiety in the Latin American immigrant population

This study explores acculturative stress as a risk factor for depressive and anxiety disorders as well as their symptomatology. It is hypothesized that perceived discrimination and general psychosocial stress will show the greatest association with psychopathology. The sample consists of 414 Latin American immigrant primary care patients in Barcelona. The instruments used are: the Barcelona Immigration Stress Scale (BISS) to evaluate acculturative stress, the Goldberg Anxiety and Depression Scale (GADS) for anxiety and depression symptoms, the Mini International Neurological Interview (MINI), a semi-structured interview, to detect psychiatric pathology, and a questionnaire for sociodemographic and attitudinal characteristics. The most elevated levels of acculturative stress were observed in the factors homesickness and general psychosocial stress. Acculturative stress is associated with depression and anxiety. With the covariants controlled, intercultural contact stress and general psychosocial stress maintain the relationship. Acculturative stress constitutes a risk factor for both depression and anxiety. General psychosocial stress and intercultural contact stress are related to psychopathology. Perceived discrimination and homesickness are not associated with psychopathology in the Spanish context, suggesting that cultural congruity plays a key role in the relationship between immigration and mental health.

Prediction of the Clinical Outcome in Invasive Candidiasis Patients Based on Molecular Fingerprints of Five Anti-Candida Antibodies in Serum

Better prognostic predictors for invasive candidiasis (IC) are needed to tailor and individualize therapeutic decision-making and minimize its high morbidity and mortality. We investigated whether molecular profiling of IgG-antibody response to the whole soluble Candida proteome could reveal a prognostic signature that may serve to devise a clinical-outcome prediction model for IC and contribute to known IC prognostic factors. By serological proteome analysis and data-mining procedures, serum 31-IgG antibody-reactivity patterns were examined in 45 IC patients randomly split into training and test sets. Within the training cohort, unsupervised two-way hierarchical clustering and principal-component analyses segregated IC patients into two antibody-reactivity subgroups with distinct prognoses that were unbiased by traditional IC prognostic factors and other patients-related variables. Supervised discriminant analysis with leave-one-out cross-validation identified a five-IgG antibody-reactivity signature as the most simplified and accurate IC clinical-outcome predictor, from which an IC prognosis score (ICPS) was derived. Its robustness was confirmed in the test set. Multivariate logistic-regression and receiver-operating-characteristic curve analyses demonstrated that the ICPS was able to accurately discriminate IC patients at high risk for death from those at low risk and outperformed conventional IC prognostic factors. Further validation of the five-IgG antibody-reactivity signature on a multiplexed immunoassay supported the serological proteome analysis results. The five IgG antibodies incorporated in the ICPS made biologic sense and were associated either with good-prognosis and protective patterns (those to Met6p, Hsp90p, and Pgk1p, putative Candida virulence factors and antiapoptotic mediators) or with poor-prognosis and risk patterns (those to Ssb1p and Gap1p/Tdh3p, potential Candida proapoptotic mediators). We conclude that the ICPS, with additional refinement in future larger prospective cohorts, could be applicable to reliably predict patient clinical-outcome for individualized therapy of IC. Our data further provide insights into molecular mechanisms that may influence clinical outcome in IC and uncover potential targets for vaccine design and immunotherapy against IC.

Molecular characterization of macrolide- and multidrug-resistant Streptococcus pyogenes isolated from adult patients in Barcelona, Spain (1993-2008)

The increase in erythromycin resistance among Streptococcus pyogenes isolates is a cause for concern. We analysed trends in macrolide resistance, phenotypes, genotypes, resistance determinants and transposons among erythromycin-resistant S. pyogenes isolates collected from adults in a Barcelona hospital (1993-2008). Antibiotic susceptibility was studied by microdilution. Molecular typing was performed by PFGE, emm typing and multilocus sequence typing (MLST). Macrolide resistance genes and those related to the Tn916 family of transposons were detected by PCR. Ninety-nine (18.3%) of 541 isolates were erythromycin resistant. Erythromycin resistance rates progressively increased from 0% (0/24) in 1993-1994 to 34.2% (50/146, P < 0.001) in 2001-2004, then falling to 7.4% (8/108, P = 0.02) in 2007-2008. Sixty-six erythromycin-resistant isolates were available for molecular studies. Of these, 26 had an M phenotype [mef(A)] and 40 had an MLS(B) phenotype [erm(B), n = 33; and erm(TR), n = 7]. Among M-phenotype isolates, the most frequent genotypes (88.5%) were emm4-ST39, emm6-ST382 and emm75-ST49, whereas genotypes emm11-ST403, emm28-ST52 and emm25-ST350 accounted for 72.5% of MLS(B)-phenotype isolates. Twenty-five isolates harboured both erm(B) and tet(M) genes related to the Tn916 family of transposons, Tn6002 being the most frequent. Ten isolates (10.1%) were ciprofloxacin non-susceptible, related to the emm6-ST382 clone with a ParC S79A change. The peak of macrolide resistance rates among S. pyogenes observed in the 2001-2004 period was associated with an increase in the MLS(B) phenotype caused by the spread of emm11-ST403 and emm28-ST52 clones harbouring transposons of the Tn916 family. However, erythromycin resistance rates decreased significantly in the 2007-2008 period.

Epidemiology of Invasive Pneumococcal Disease among Adult Patients in Barcelona Before and After Pediatric 7-Valent Pneumococcal Conjugate Vaccine Introduction, 1997–2007

Epidemiology of Invasive Pneumococcal Disease among Adult Patients in Barcelona Before and After Pediatric 7-Valent Pneumococcal Conjugate Vaccine Introduction, 1997–2007

Epidemiology of Invasive Pneumococcal Disease among Adult Patients in Barcelona Before and After Pediatric 7-Valent Pneumococcal Conjugate Vaccine Introduction, 1997–2007

Epidemiology of Invasive Pneumococcal Disease among Adult Patients in Barcelona Before and After Pediatric 7-Valent Pneumococcal Conjugate Vaccine Introduction, 1997–2007

Epidemiology of Invasive Pneumococcal Disease among Adult Patients in Barcelona Before and After Pediatric 7‐Valent Pneumococcal Conjugate Vaccine Introduction, 1997–2007

A dramatic decrease in the incidence of invasive pneumococcal disease (IPD) was observed among children and adults in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). Little is known about the incidence of IPD after PCV7 licensure in Europe. The objective of this study was to examine changes in the prevalence of IPD among adults in the PCV7 era. We undertook a prospective study involving adults with IPD who required hospital admission in the southern area of Barcelona, Spain. Three periods were studied: the pre-PCV7 period (1997-2001), the early PCV7 period (2002-2004), and the late PCV7 period (2005-2007). A total of 1007 episodes of IPD were observed. Rates of IPD among adults increased from 13.9 to 14.6 episodes per 100,000 population between the pre-PCV7 period and the early PCV7 period (P = .6) and then to 19.55 episodes per 100,000 population in the late PCV7 period (P < .001). The rates of IPD among adults due to non-PCV7 serotypes increased from 8.4 to 9.7 episodes per 100,000 population between the pre-PCV7 period and the early PCV7 period (P = .15) and then to 15.3 episodes per 100,000 population in the late PCV7 period (P < .001); IPD due to PCV7 serotypes decreased from 5.6 to 4.9 episodes per 100,000 population between the pre-PCV7 period and the early PCV7 period (P = .3), then to 4.3 episodes per 100,000 population in the late PCV7 period (P = .056). Among people aged > or = 65 years, IPD due to PCV7 serotypes decreased from 19.5 to 14.6 episodes per 100,000 population between the pre-PCV7 period and the early PCV7 period (P = .13), then to 12.3 episodes per 100,000 population in the late PCV7 period (P = .02). A decrease in the prevalence of antibioticresistant pneumococci in the late PCV7 period was associated with a decrease in the prevalence of multidrugresistant PCV7 clones (Spain(23F)-ST81, Spain(6B)-ST90, and ST88(19F)) and an increase in the prevalence of non-PCV7 antibiotic-susceptible clones (ST306(1), ST191(7F), ST989(12F), and ST433(22F)). Rates of IPD among adults increased in Barcelona in the late PCV7 period, coinciding with a clonal expansion of non-PCV7 serotypes. In contrast, rates of IPD caused by PCV7 serotypes decreased among people aged > or = 65 years, which suggests the development of a herd immunity.

Levels of outdoor PM 2.5, absorbance and sulphur as surrogates for personal exposures among post-myocardial infarction patients in Barcelona, Spain

Outdoor levels of fine particles (PM 2.5; particles <2.5 μm) have been associated with cardiovascular health. Persons with existing cardiovascular disease have been suggested to be especially vulnerable. It is unclear, how well outdoor concentrations of PM 2.5 and its constituents measured at a central site reflect personal exposures in Southern European countries. The objective of the study was to assess the relationship between outdoor and personal concentrations of PM 2.5, absorbance and sulphur among post-myocardial infarction patients in Barcelona, Spain. Thirty-eight subjects carried personal PM 2.5 monitors for 24-h once a month (2–6 repeated measurements) between November 2003 and June 2004. PM 2.5 was measured also at a central outdoor monitoring site. Light absorbance (a proxy for elemental carbon) and sulphur content of filter samples were determined as markers of combustion originating and long-range transported PM 2.5, respectively. There were 110, 162 and 88 measurements of PM 2.5, absorbance and sulphur, respectively. Levels of outdoor PM 2.5 (median 17 μg m 3) were lower than personal PM 2.5 even after excluding days with exposure to environmental tobacco smoke (ETS) (median after exclusion 27 μg m 3). However, outdoor concentrations of absorbance and sulphur were similar to personal concentrations after exclusion of ETS. When repeated measurements were taken into account, there was a statistically significant association between personal and outdoor absorbance when adjusting for ETS (slope 0.66, p<0.001), but for PM 2.5 the association was weaker (slope 0.51, p=0.066). Adjustment for ETS had little effect on the respective association of S (slope 0.69, p<0.001). Our results suggest that outdoor measurements of absorbance and sulphur can be used to estimate both the daily variation and levels of personal exposures also in Southern European countries, especially when exposure to ETS has been taken into account. For PM 2.5, indoor sources need to be carefully considered.

Rickettsia massiliaeHuman Isolation

To the Editor: The number of new rickettsial species that cause diseases in humans is rapidly increasing (1). Moreover, many of the species first described in ticks have been recently shown to be pathogenic. Of the 10 species or subspecies found to be pathogens after 1984, a total of 7 were first isolated from ticks (2). We report the first isolation of Rickettsia massiliae from a patient. The bacterium was isolated in Sicily in 1985 and identified in 2005. A 45-year-old man was hospitalized in Palermo, Italy, on June 6, 1985, for fever and a rash. He had been febrile since May 25 and did not respond to antimicrobial drug treatment using cefamezin, a first-generation cephalosporin. On examination, he had a necrotic eschar on his right ankle, a maculopapular rash on his palms and soles (Figure A1), and slight hepatomegaly. Leukocyte count was normal; he received tetracyclines for 13 days and fully recovered. He seroconverted (from 0 to 1:80 between day 11 and day 24) by indirect immunofluorescence to Rickettsia conorii (R. conorii spot, bioMerieux, Marcy l'Etoile, France). Four milliliters of heparinized blood sampled before treatment were inoculated in a 25-cm2 flask containing Vero cells and incubated at 33°C in a CO2 incubator (1). Direct immunofluorescence test on a sample of the patient's serum was positive 7 days later. The strain was stored for 20 years and tested in 2005 at the Unite des Rickettsies for identification, and R. massiliae was identified. DNA was extracted from the cell culture supernatant and used as template in 2 previously described polymerase chain reaction (PCR) assays that targeted a portion of the rickettsial ompA gene as well as a portion of the rickettsial gltA gene (3,4). Amplification products of the expected size were obtained from this extract but from no concurrently processed control materials, including 3 negative controls. DNA sequencing of the positive PCR products gave 100% identity with R. massiliae for ompA (GenBank accession no. {type:entrez-nucleotide,attrs:{text:RBU43792,term_id:1174112,term_text:gb||RBU43792}}RBU43792) and 99.9% homology for gltA (GenBank accession no. RSU 59720). R. massiliae was first isolated from Rhipicephalus ticks in Marseilles (5). It is transmitted transovarially in Rhipicephalus turanicus (2). R. massiliae is commonly found in Rhipicephalus sanguineus or R. turanicus in France, Greece, Spain (identified as Bar 29) (6), Portugal, Switzerland, Sicily (D. Raoult, unpub. data), Central Africa, and Mali (2). R. massiliae may be commonly associated with these ticks, which are distributed worldwide. R. massiliae is grouped phylogenically with Rickettsia rhipicephali and Rickettsia aeschlimannii (Figure A2). Bacteria from this group have a natural resistance to rifampin that is associated with an rpoB sequence that is different from that of other rickettsiae. This isolate was not tested for antimicrobial drug susceptibly (7). Rifampin resistance leads us to believe that this isolate may cause a Mediterranean spotted fever–like disease that was described in children in Spain (7,8). Serologic findings were recently reported that showed some patients in Barcelona, Spain, with reactions that indicate R. massiliae (B29 strain) rather than R. conorii (6). However, serologic reactions are only presumptive; isolation from a patient is the required to initially describe a new disease (9). This Sicilian index case shows that R. massiliae is a human pathogen. It contraindicates using rifampin to treat Mediterranean spotted fever in areas where R. massiliae is endemic, as it cannot as yet be differentiated from R. conorii infection. R. massiliae is a new example of a strain identified in ticks for several years before its first isolation from a human patient (10). The longest delay was observed for Rickettsia parkeri, which was isolated from ticks in 1939 but not from a patient until 2004. Many authors labeled R. parkeri a nonpathogenic rickettsia during this time (1). In the present case, the human isolate was obtained before the tick isolate but was not further identified. When this strain was isolated, R. conorii was the sole Rickettsia sp. found in ticks in southern Europe. Moreover, only 1 tickborne pathogenic Rickettsia sp. was believed to circulate in a single area. Since that time, several tickborne rickettsial diseases have been shown to exist in the same area, which prompted us to retrospectively identify this strain. The patient was reexamined in May 2005, after this identification. He is healthy and has no remaining antibodies against Rickettsia spp.

Course of depression, health services costs, and work productivity in an international primary care study

The Longitudinal Investigation of Depression Outcomes ( LIDO) Study examined the outcomes and economic correlates of previously untreated depression among primary care patients in Barcelona, Spain; Be'er Sheva, Israel; Melbourne, Australia; Porto Alegre, Brazil; St. Petersburg, Russia; and Seattle, USA. Across all sites, 968 patients with current depressive disorder completed assessments of depression severity (Composite International Diagnostic Interview and Center for Epidemiologic Studies Depression Scale) at baseline and 9 months, and assessments of health services utilization and work days missed at baseline, 9 months, and 12 months. Follow-up depression status was characterized as persistent depression ( n = 345), partial remission ( n = 283), or full remission ( n = 340). At each site, patients with more favorable depression outcomes had fewer days missed from work; however, this relationship did not reach the 5% level of statistical significance at any site, and reached the 10% significance level only at Porto Alegre. Patients with more favorable depression outcomes also had lower health services costs, but this relationship reached the 5% significance level only in St. Petersburg. While the lack of statistical precision does not permit definitive conclusions, our findings are consistent with recent studies showing that recovery from depression is associated with lower health services costs and less time missed from work due to illness.

Course of depression, health services costs, and work productivity in an international primary care study

The The Longitudinal Investigation of Depression Outcomes ( LIDO) Study examined the outcomes and economic correlates of previously untreated depression among primary care patients in Barcelona, Spain; Be’er Sheva, Israel; Melbourne, Australia; Porto Alegre, Brazil; St. Petersburg, Russia; and Seattle, USA. Across all sites, 968 patients with current depressive disorder completed assessments of depression severity (Composite International Diagnostic Interview and Center for Epidemiologic Studies Depression Scale) at baseline and 9 months, and assessments of health services utilization and work days missed at baseline, 9 months, and 12 months. Follow-up depression status was characterized as persistent depression ( n=345), partial remission ( n=283), or full remission ( n=340). At each site, patients with more favorable depression outcomes had fewer days missed from work; however, this relationship did not reach the 5% level of statistical significance at any site, and reached the 10% significance level only at Porto Alegre. Patients with more favorable depression outcomes also had lower health services costs, but this relationship reached the 5% significance level only in St. Petersburg. While the lack of statistical precision does not permit definitive conclusions, our findings are consistent with recent studies showing that recovery from depression is associated with lower health services costs and less time missed from work due to illness.