ABSTRACT
Há diversas terapias sendo utilizadas ou propostas para a COVID-19, muitas carecendo de apropriada avaliação de efetividade e segurança. O propósito deste documento é elaborar recomendações para subsidiar decisões sobre o tratamento farmacológico de pacientes hospitalizados com COVID-19 no Brasil. Métodos: Um grupo de 27 membros, formado por especialistas, representantes do Ministério da Saúde e metodologistas, integra essa diretriz. Foi utilizado o método de elaboração de diretrizes rápidas, tomando por base a adoção e/ou a adaptação de recomendações a partir de diretrizes internacionais existentes (GRADE ADOLOPMENT), apoiadas pela plataforma e-COVID-19 RecMap. A qualidade das evidências e a elaboração das recomendações seguiram o método GRADE. Resultados: Foram geradas 16 recomendações. Entre elas, estão recomendações fortes para o uso de corticosteroides em pacientes em uso de oxigênio suplementar, para o uso de anticoagulantes em doses de profilaxia para tromboembolismo e para não uso de antibacterianos nos pacientes sem suspeita de infecção bacteriana. Não foi possível fazer uma recomendação quanto à utilização do tocilizumabe em pacientes hospitalizados com COVID-19 em uso de oxigênio, pelas incertezas na disponibilidade e de acesso ao medicamento. Foi feita recomendação para não usar azitromicina, casirivimabe + imdevimabe, cloroquina, colchicina, hidroxicloroquina, ivermectina, lopinavir/ ritonavir, plasma convalescente e rendesivir. Conclusão: Até o momento, poucas terapias se provaram efetivas no tratamento do paciente hospitalizado com COVID-19, sendo recomendados apenas corticosteroides e profilaxia para tromboembolismo. Diversos medicamentos foram considerados ineficazes, devendo ser descartados, de forma a oferecer o melhor tratamento pelos princípios da medicina baseada em evidências e promover economia de recursos não eficazes.
Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil. Methods: A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method. Results: Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made. Conclusion: To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.
Subject(s)
Humans , SARS-CoV-2/drug effects , COVID-19/drug therapy , Oxygen Inhalation Therapy , Thromboembolism/prevention & control , Immunization, Passive , Adrenal Cortex Hormones/therapeutic use , Lopinavir/therapeutic use , Health Planning Guidelines , Hydroxychloroquine , Anti-Bacterial Agents/therapeutic useABSTRACT
RESUMO Introdução: Há diversas terapias sendo utilizadas, consideradas ou propostas para o tratamento da COVID-19, muitas carecendo de apropriada avaliação de efetividade e segurança. O propósito deste documento é fornecer recomendações baseadas nas evidências científicas disponíveis e em sua interpretação transparente, para subsidiar decisões sobre o tratamento farmacológico da COVID-19 no Brasil. Métodos: Um grupo de 27 especialistas e metodologistas integraram a força-tarefa formada pela Associação de Medicina Intensiva Brasileira (AMIB), pela Sociedade Brasileira de Infectologia (SBI) e pela Sociedade Brasileira de Pneumologia e Tisiologia (SBPT). Foram realizadas revisões sistemáticas rápidas, atualizadas até 28 de abril de 2020. A qualidade das evidências e a elaboração das recomendações seguiram o sistema GRADE. As recomendações foram elaboradas nos dias 5, 8 e 13 de maio de 2020. Resultados: Foram geradas 11 recomendações, embasadas em evidência de nível baixo ou muito baixo. Não há indicação para uso de rotina de hidroxicloroquina, cloroquina, azitromicina, lopinavir/ritonavir, corticosteroides ou tocilizumabe no tratamento da COVID-19. Heparina deve ser utilizada em doses profiláticas no paciente hospitalizado, mas não deve ser realizada anticoagulação na ausência de indicação clínica específica. Antibacterianos e oseltamivir devem ser considerados somente nos pacientes em suspeita de coinfecção bacteriana ou por influenza, respectivamente. Conclusão: Até o momento, não há intervenções farmacológicas com efetividade e segurança comprovada que justifiquem seu uso de rotina no tratamento da COVID-19, devendo os pacientes serem tratados preferencialmente no contexto de pesquisa clínica. As recomendações serão revisadas continuamente, de forma a capturar a geração de novas evidências.
ABSTRACT Introduction: Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. Methods: A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. Results: Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. Conclusion: So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.
Subject(s)
Humans , Pneumonia, Viral/drug therapy , Coronavirus Infections/drug therapy , Pandemics , COVID-19ABSTRACT
Abstract Objectives: To estimate acute otitis media incidence among young children and impact on quality of life of parents/caregivers in a southern Brazilian city. Methods: Prospective cohort study including children 0-5 years of age registered at a private pediatric practice. Acute otitis media episodes diagnosed by a pediatrician and impact on quality of life of parents/caregivers were assessed during a 12-month follow-up. Results: During September 2008-March 2010, of 1,136 children enrolled in the study, 1074 (95%) were followed: 55.0% were ≤2 years of age, 52.3% males, 94.7% white, and 69.2% had previously received pneumococcal vaccine in private clinics. Acute otitis media incidence per 1000 person-years was 95.7 (95% confidence interval: 77.2-117.4) overall, 105.5 (95% confidence interval: 78.3-139.0) in children ≤2 years of age and 63.6 (95% confidence interval: 43.2-90.3) in children 3-5 years of age. Acute otitis media incidence per 1000 person-years was 86.3 (95% confidence interval: 65.5-111.5) and 117.1 (95% confidence interval: 80.1-165.3) among vaccinated and unvaccinated children, respectively. Nearly 68.9% of parents reported worsening of their overall quality of life. Conclusion: Acute otitis media incidence among unvaccinated children in our study may be useful as baseline data to assess impact of pneumococcal vaccine introduction in the Brazilian National Immunization Program in April 2010.
Subject(s)
Humans , Male , Female , Infant, Newborn , Infant , Child, Preschool , Otitis Media/epidemiology , Quality of Life/psychology , Caregivers/psychology , Otitis Media/psychology , Brazil/epidemiology , Acute Disease , Incidence , Prospective StudiesABSTRACT
Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.
Subject(s)
Humans , Antifungal Agents/therapeutic use , Candidiasis , Societies, Medical , Brazil , Candida/classification , Candidiasis/diagnosis , Candidiasis/drug therapy , Candidiasis/microbiologyABSTRACT
OBJECTIVE: Analyze patients with HIV infection from Curitiba, Paraná, their epidemiological characteristics and HIV RAM. METHODS: Patients regularly followed in an ID Clinic had their medical data evaluated and cases of virological failure were analyzed with genotypic report. RESULTS: Patients with complete medical charts were selected (n = 191). Demographic and clinical characteristics were compared. One hundred thirty two patients presented with subtype B infection (69.1 percent), 41 subtype C (21.5 percent), 10 subtype F (5.2 percent), 7 BF (3.7 percent) and 1 CF (0.5 percent). Patients with subtype B infection had been diagnosed earlier than patients with subtype non-B. Also, subtype B infection was more frequent in men who have sex with men, while non-B subtypes occurred more frequently in heterosexuals and women. Patients with previous history of three classes of ARVs (n = 161) intake were selected to evaluate resistance. For RT inhibitors, 41L and 210W were more frequently observed in subtype B than in non-B strains. No differences between subtypes and mutations were observed to NNTRIs. Mutations at 10, 32 and 63 position of protease were more observed in subtype B viruses than non-B, while positions 20 and 36 of showed more amino acid substitutions in subtype non-B viruses. Patients with history of NFV intake were evaluated to resistance pathway. The 90M pathway was more frequent in subtypes B and non-B. Mutations previously reported as common in non-B viruses, such as 65R and 106M, were uncommon in our study. Mutations 63P and 36I, previously reported as common in HIV-1 subtypes B and C from Brazil, respectively, were common. CONCLUSION: There is a significant frequency of HIV-1 non-B infections in Paraná state, with isolates classified as subtypes C, F, BF and BC. Patients with subtype C infection were more frequently female, heterosexual and had a longer average time of HIV diagnosis.
Subject(s)
Adult , Female , Humans , Male , HIV , HIV Infections/virology , HIV-1 , Mutation/genetics , Brazil/epidemiology , Genotype , Genetic Variation/genetics , HIV Infections/epidemiology , HIV-1 , Polymerase Chain ReactionABSTRACT
Antiretroviral therapy (ART) has reduced morbidity and mortality related to human immunodeficiency virus (HIV) infection, but in spite of this advance, HIV mutations decrease antiretroviral susceptibility, thus contributing to treatment failure in patients. Genotyping HIV-1 allows the selection of new drugs after initial drug failure. This study evaluated the genotypic profile of HIV-1 isolates from treated (drug-experienced) patients in Paraná, Brazil. The prevalence of mutations in reverse transcriptase (RT) and protease (PR) genes were assessed. We analyzed 467 genotypes of patients with HIV-1 viral loads above 1,000 copies/mL. Mutations at HIV-1 RT and PR genes and previously used ART regimens were recorded. The most prevalent RT mutations were: 184V (68.31 percent), 215YF (51.6 percent), 103NS (46 percent), 41L (39.4 percent), 67N (38.54 percent), 210W (23.5 percent), 190ASE (23.2 percent), and 181C (17.4 percent). PR mutations were 90M (33.33 percent), 82ATFS (29 percent), 46I (26.8 percent) and 54V (22.2 percent). The prevalence of mutations was in line with previous national and international reports, except to nonnucleoside analogue reverse transcriptase inhibitors related mutations, which were more prevalent in this study. Previous exposure to antiretroviral drugs was associated with genotypic resistance to specific drugs, leading to treatment failure in HIV patients.
Subject(s)
Adult , Female , Humans , Male , Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , HIV Protease/genetics , HIV Reverse Transcriptase/genetics , HIV-1 , Mutation/genetics , Antiretroviral Therapy, Highly Active , Brazil , Drug Resistance, Viral/genetics , Genotype , HIV Infections/virology , HIV-1 , Treatment Failure , Viral LoadABSTRACT
Invasive aspergillosis (IA) currently is an important cause of mortality in subjects undergoing hematopoietic stem cell transplants (HSCT) and is also an important cause of opportunistic respiratory and disseminated infections in other types of immunocompromised patients. We examined the medical records of 24 cases of proven and probable invasive aspergillosis (IA) at the Hospital de Clinicas of the Federal University of Parana, Brazil, from January 1996 to October 2006. During this period occurred a mean of 2.2 cases per year or 3.0 cases per 100 HSTC transplants. There was a significant relationship between structural changes in the bone marrow transplant (BMT) Unit and the occurrence of IA cases (p=0.034, relative risk (RR) = 2.47). Approximately 83 percent of the patients died due to invasive fungal infection within 60 days of follow up. Some factors tended to be associated with mortality, but these associations were not significant. These included corticosteroid use, neutropenia (<100 cells/mm³) at diagnosis, patients that needed to change antifungal therapy because of toxicity of the initial first-line regimen and disseminated disease. These factors should be monitored in BMT units to help prevent IA. Physicians should be aware of the risk factors for developing invasive fungal infections and try to reduce or eliminate them. However, once this invasive disease begins, appropriate diagnostic and treatment measures must be implemented as soon as possible in order to prevent the high mortality rates associated with this condition.
Subject(s)
Adolescent , Adult , Child , Humans , Aspergillosis/mortality , Hematopoietic Stem Cell Transplantation/mortality , Immunocompromised Host , Aspergillosis/immunology , Aspergillosis/microbiology , Brazil/epidemiology , Hematopoietic Stem Cell Transplantation/adverse effects , Regression Analysis , Retrospective Studies , Risk FactorsABSTRACT
Vancomycin has been used with increased frequency during the past 15 years and the most common toxicity with this drug is the red man syndrome . Other adverse effects include neutropenia, fever, phlebitis, nephrotoxicity, ototoxicity, thrombocytopenia, interstitial nephritis, lacrimation, linear IgA bullous dermatosis, necrotizing cutaneous vasculitis and toxic epidermal necrolysis. Only two cases of vancomycin-induced Stevens-Johnson syndrome and one case of pancytopenia have been reported in the medical literature. The treatment for both situations is based on cessation of the vancomycin therapy; in cases of Stevens-Johnson syndrome, antihistamine and/or steroid agents can be used. This article reports a case of pancytopenia and a case of erythema major associated with neutropenia.
Subject(s)
Adult , Female , Humans , Middle Aged , Anti-Bacterial Agents/adverse effects , Erythema , Neutropenia , Vancomycin , Anti-Infective Agents , Anti-Bacterial Agents/therapeutic use , Eosinophilia , Fever , Hip Prosthesis , Prosthesis-Related Infections/drug therapy , Methicillin Resistance , Ofloxacin , Pruritus , Staphylococcus , Syndrome , VancomycinABSTRACT
This is part of the series of practice guidelines commissioned by the Brazilian Society for Infectious Diseases through its Practice Guidelines Committee. The purpose of these guidelines is to provide assistance to clinicians in the antimicrobial treatment of community-acquired pneumonia (CAP) in immunocompetent adults. Panel members and consultants are experts in adult infectious diseases. The guidelines are evidence based where possible. The recommendations included in this document were elaborated based on the most frequently isolated pathogens and their antimicrobial susceptibilities. The etiology was based mainly on international studies, since there are very few regional data. On the other hand, the antimicrobial susceptibilities of main bacterial causes of CAP were based on the results of several antimicrobial resistance surveillance studies recently performed in Brazil. Other reference guidelines for the treatment of CAP, such as those elaborated by the Infectious Diseases Society of America and by the Canadian Infectious Diseases Society, were also discussed by the group during the elaboration of this document.
Subject(s)
Humans , Male , Female , Adult , Community-Acquired Infections/diagnosis , Community-Acquired Infections/drug therapy , Pneumonia , Anti-Infective Agents , Hospitalization , Community-Acquired Infections/classification , Community-Acquired Infections/microbiology , Intensive Care Units , Pneumonia , Risk FactorsABSTRACT
Our objective is to report a case of a patient with necrosis limited to the pre-peritoneal fascia and fat tissue of the abdomen and pelvis. A 34-year-old female presented with fever, chills, nausea, diarrhea and abdominal pain. She denies history of trauma, diabetes mellitus, use of immunosuppressive drugs, smoking, and drug dependence. Laboratory tests revealed hematocrit of 28.7 por cento, white blood count of 12.200/mmÝ with 49 por cento of bands, platelets of 317.000/mmÝ, and sedimentation rate of 65 mm/hr. She was subjected to an abdominal ultrasonography and computed tomography that showed hepatosplenomegaly and muscular thichening on the left flank. Surgical debridment was performed. There was necrosis limited to the pre-peritoneal fascia and fat tissue extending from the pelvis to the left flank. The fascia of the superficial muscles and the subcutaneous fat were normal. The pathologic examination showed suppuration and necrosis of the tissues. Antibiotics were administered and ten debridments were performed. The patient was discharged 30 days after the admission
Subject(s)
Humans , Female , Adult , Debridement , Fasciitis, Necrotizing/diagnosis , Fasciitis, Necrotizing/therapy , Bacterial Infections/complicationsABSTRACT
Angiomyolipoma is a rare tumor of the kidney. It consists of smooth muscle, thickwall blood vessels and adipose tissue. It has two distinct clinical presentations. One more common associated with tuberous sclerosis, with small, bilateral and assymptomatic tumors. The tumors not associated with tuberous sclerosis are large and symptomatic. We describe a patient with spontaneous rupture, with infra-abdominal hemorrhage, of a large angiomyolipoma of the left kidney. The diagnosis and treatment of this rare tumor are discussed
Subject(s)
Humans , Female , Adult , Angiomyolipoma/diagnosis , Hemorrhage , Kidney Neoplasms , Kidney/pathology , Angiomyolipoma/pathology , Angiomyolipoma/surgeryABSTRACT
Cinarizina e flunarizina säo amplamente utilizados em alguns países para tratamento de enxaqueca, vertigem central e periférica, doença vascular cerebral e periférica, e mais raramente, epilepsia. Parkinsonismo relacionado a estas drogas é bem conhecido desde 1986. Nós apresentamos 8 mulheres e 3 homens de 67 anos (média) de idade, que desenvolveram parkinsonismo clínico diretamente relacionado com exposiçäo a flunarizina (10-30mg ao dia) e cinarizina (75-225mg). O tempo de exposiçäo foi de 3 meses a 7 anos (média 24 meses). Ambas as drogas e algum eventual tratamento antiparkinsonismo foram suspensos; tratamento antidepressivo foi utilizado em 7 casos. Todos os pacientes recuperaram-se em períodos de 1 a 4 meses (média 2). Estes casos representam uma minoria dos observados durante um período de 5 anos num concultório neurológico, e foram selecionados segundo critérios específicos para este relatório. O uso indiscriminado de flunarizina e cinarizina, especialmente por períodos de mais de 2 semanas e em pessoas com mais de 50 anos de idade é uma das causas mais comuns de parkinsonismo no Brasil