Six-year experience with GM test in hematological patients in a public Brazilian tertiary hospital

Abstract Invasive fungal infection (IFI) is frequent in patients with hematologic malignancies or submitted hematopoietic stem cell transplantation (HSCT). Objectives To evaluate the role of the GM (galactomannan) test in prescribing therapeutic antifungals; to determine invasive aspergillosis (IA) frequency, the factors associated with positive GM test, and the in-hospital mortality. Methods We conducted a retrospective observational study including patients aged 18 or over with hematological malignancy or submitted to HSCT. GM test was measured twice weekly. The hypothesis of IFI was considered in patients with neutropenia and persistent fever despite broad-spectrum antibiotics. Results A total of 496 patients were evaluated; the mean of GM tests performed per patient was 4.2 (+3.1), and 86 (17.3 %) had positive results. IFI was diagnosed in 166 (33.5 %) and IA in 22 (24.6 %) patients. Positive GM test was more frequent in patients with IFI (72.2 % and 25.1 %; OR 8.1; 95 % CI 4.8 - 13.8), and was associated with therapeutic antifungals prescription (52, 9 % and 20.5 %; OR 4.3, 95CI% 2.0 - 9.4), as well as lung abnormalities on HRCT (45.3% vs. 21.5 %; OR 3.0, 95 %CI 1.4 - 6.5). Mortality was 31.6 %. In the multivariate analysis, the variables associated with mortality were the hypothesis of IFI (OR 6.35; 95 % CI 3.63-11.12.0), lung abnormalities on HRCT (57.9 % and 26.9 %; OR 2 0.6; 95 % CI 1.5 - 4.4), and positive GM test (57.9 % and 26.9 %; OR 2.7 95 % CI 1.6 - 4.5). Conclusions Positive GM test was associated with lung abnormalities on HRCT and with the introduction of therapeutic antifungals. If adequate anti-mold prophylaxis is available, the GM test should not be used as screening, but to investigate IFI in high-risk patients. The diagnosis of IFI, positive GM test and lung abnormalities on HRCT were predictors of hospital mortality in patients with hematological malignancies or undergoing HSCT.

Cohort study of hospitalized patients with COVID-19 at Brazilian tertiary-care hospital: Occurrence of adverse events and mortality

ABSTRACT Introduction: Patients hospitalized with COVID-19 are often submitted to invasive procedures and they are at risk for hospital-associated adverse events. Objectives: To evaluate the epidemiological and clinical aspects of patients hospitalized with COVID-19; the occurrence of adverse events and the risk factors for mortality. Method: Cohort study that included adult patients hospitalized with a diagnosis of SAR-SCoV-2 infection, at the tertiary University Hospital of UNICAMP from March 2020 to March 2021. Patients were identified through the hospital epidemiological surveillance system and followed until discharge or death. Descriptive, comparative, and logistic regression analysis was performed. Results: 650 adult patients were included. The main adverse events identified were nosocomial infections (31.5%), renal failure (33.8%), thromboembolic and vascular events (12.6%). Mortality was higher among those with bloodstream infections (30.2% vs. 8.6%; p < 0.0001), ventilator-associated pneumonia (VAP, 52.5% vs. 12.3%; p < 0.0001), catheter associated urinary infection (27.3% vs. 7.2%; p < 0.0001); thromboembolic and vascular events (23.0% vs. 9.9%; p < 0.0001) and renal failure (81.3% vs. 20.9%; p < 0.0001). Klebsiella pneumoniae (15.6%), Pseudomonas aeruginosa (14.4%), Enterococcus faecalis (8.6%) were the most isolated bacteria. Logistic regression analysis identified age, (RR = 1.03; 95% CI 1.02 to 1.05); ICU admission (RR = 3.06; 95% CI 1.59 to 5.87), vasoactive drug use (RR = 3.1; 95% CI 1.79 to 4.82); renal failure (RR = 7.76; 95% CI 4.54 to 13.26); and VAP (RR = 2.2; 95% CI 1.23 to 3.96), independently associated with mortality. Conclusion: adverse events have an important impact on the evolution of patients with COVID-19, reinforcing the need for optimized prevention and control measures as an essential part of care for these patients.

Invasive non-type b haemophilus influenzae disease: report of eight cases / Doença invasiva causada por haemophilus influenzae não tipo b: relato de oito casos

ASTRACT Objective: To describe eight cases of invasive non-type b Haemophilus influenzae disease in children admitted to Hospital de Clínicas of Universidade Estadual de Campinas. Cases description: In 2015, there were eight cases of invasive non-type b H. influenzae disease. We tested the ampicillin sensitivity and beta-lactamase production of the strains identified and performed the genotyping. Molecular typing was determined by Pulsed-Field Gel Electrophoresis. Four patients were diagnosed with bacteremia; in two cases, H. influenzae was detected in the pleural fluid, and two patients had meningitis. Patients with comorbidities represented 37.5% of cases. Except for the strain of one patient - not sent to the reference laboratory -, all were ampicillin-sensitive and non-beta-lactamase-producing. Genotyping identified four non-capsular, one type c, and two type a strains. Molecular typing ruled out nosocomial transmission since all serotypes were distinct regarding genotype. Comments: The rise in cases of invasive non-type b H. influenzae infection was real. There was no nosocomial transmission, and we found no justification for the increase. These data indicate the need for surveillance to correctly diagnose, monitor, and understand the spectrum of non-type b H. influenzae disease.

ABSTRACT Objetivo: Descrever oito casos de doença invasiva por Haemophilus influenzae não tipo b em crianças internadas no Hospital de Clínicas da Universidade Estadual de Campinas. Descrição dos casos: Em 2015, ocorreram oito casos de doença invasiva por H. influenzae não tipo b. Nas cepas identificadas, testou-se a sensibilidade à ampicilina e a produção de betalactamase, e realizou-se a genotipagem. A tipagem molecular foi feita por Pulsed Field Gel Electrophoresis. Em quatro pacientes, o diagnóstico foi de bacteremia; em dois casos, H. influenzae foi identificado em líquido pleural, e dois pacientes tiveram meningite. Comorbidades foram encontradas em 37,5% dos pacientes. Com exceção da cepa de um dos pacientes (que não foi enviada ao laboratório de referência), todas eram sensíveis à ampicilina e não produtoras de betalactamase. A genotipagem identificou quatro cepas não capsulares, uma cepa tipo c e duas cepas tipo a. A tipagem molecular descartou a transmissão intra-hospitalar, já que todos os sorotipos eram distintos quanto ao genótipo. Comentários: O aumento dos casos de infecção invasiva por H. influenzae não tipo b foi real. Não houve transmissão intra-hospitalar e não foi encontrada justificativa para o aumento. Esses dados indicam a necessidade de vigilância para diagnosticar corretamente, monitorar e entender o espectro da doença causada por H. influenzae não tipo b.

Serum markers as an aid in the diagnosis of pulmonary fungal infections in AIDS patients

ABSTRACT Introduction: The etiology of pulmonary infections in HIV patients is determined by several variables including geographic region and availability of antiretroviral therapy. Materials and methods: A cross-sectional prospective study was conducted from 2012 to 2016 to evaluate the occurrence of pulmonary fungal infection in HIV-patients hospitalized due to pulmonary infections. Patients' serums were tested for (1-3)-β-D-Glugan, galactomannan, and lactate dehydrogenase. The association among the variables was analyzed by univariate and multivariate regression analysis. Results: 60 patients were included in the study. The patients were classified in three groups: Pneumocystis jirovecii pneumonia (19 patients), community-acquired pneumonia (18 patients), and other infections (23 patients). The overall mortality was 13.3%. The time since diagnosis of HIV infection was shorter in the pneumocystosis group (4.94 years; p = 0.001) than for the other two groups of patients. The multivariate analysis showed that higher (1-3)-β-D-Glucan level (mean: 241 pg/mL) and lactate dehydrogenase (mean: 762 U/L) were associated with the diagnosis of pneumocystosis. Pneumocystosis was the aids-defining illness in 11 out of 16 newly diagnosed HIV-infected patients. Conclusion: In the era of antiretroviral therapy, PJP was still the most prevalent pulmonary infection and (1-3)-β-D-Glucan and lactate dehydrogenase may be suitable markers to help diagnosing pneumocystosis in our HIV population.

SPECT/CT with radiolabeled somatostatin analogues in the evaluation of systemic granulomatous infections / SPECT/CT com análogos radiomarcados de somatostatina na avaliação de infecções granulomatosas sistêmicas

Abstract Objective: To evaluate SPECT/CT with radiolabeled somatostatin analogues (RSAs) in systemic granulomatous infections in comparison with gallium-67 (67Ga) citrate scintigraphy. Materials and Methods: We studied 28 patients with active systemic granulomatous infections, including tuberculosis, paracoccidioidomycosis, pneumocystosis, cryptococcosis, aspergillosis, leishmaniasis, infectious vasculitis, and an unspecified opportunistic infection. Of the 28 patients, 23 had started specific treatment before the study outset. All patients underwent whole-body SPECT/CT imaging: 7 after injection of 99mTc-EDDA-HYNIC-TOC, and 21 after injection of 111In-DTPA-octreotide. All patients also underwent 67Ga citrate imaging, except for one patient who died before the 67Ga was available. Results: In 20 of the 27 patients who underwent imaging with both tracers, 27 sites of active disease were detected by 67Ga citrate imaging and by SPECT/CT with an RSA. Both tracers had negative results in the other 7 patients. RSA uptake was visually lower than 67Ga uptake in 11 of the 20 patients with positive images and similar to 67Ga uptake in the other 9 patients. The only patient who did not undergo 67Ga scintigraphy underwent 99mTc-EDDA-HYNIC-TOC SPECT/CT-guided biopsy of a lung cavity with focal RSA uptake, which turned to be positive for aspergillosis. Conclusion: SPECT/CT with 99mTc-EDDA-HYNIC-TOC or 111In-DTPA-octreotide seems to be a good alternative to 67Ga citrate imaging for the evaluation of patients with systemic granulomatous disease.

Resumo Objetivo: Avaliar o estudo SPECT/CT com análogos de somatostatina radiomarcados (RSA) em infecções granulomatosas sistêmicas, em comparação com o estudo com gálio-67 (67Ga). Materiais e Métodos: Vinte e oito paciente com infecção granulomatosa sistêmica ativa foram estudados, incluindo tuberculose, paracoccidioidomicose, pneumocistose, criptococose, aspergilose, leishmaniose, vasculite infecciosa e uma infecção oportunista inespecífica. Vinte e três tinham iniciado o tratamento previamente ao estudo. Todos fizeram imagem de varredura e SPECT/CT, 7 deles pós-injeção de 99mTc-EDDA-HYNIC-TOC e os outros 21 pós-injeção de 111In-DTPA-octreotide. Todos os pacientes também fizeram cintilografia com 67Ga, exceto um, que fez biópsia guiada por 99mTc-EDDA-HYNIC-TOC. Resultados: Vinte e sete sítios de atividade foram detectados com 67Ga em 20 de 27 pacientes, também vistos nos estudos com RSA. Ambos foram negativos nos outros 7 pacientes. A captação de RSA foi visualmente menor que a de 67Ga em 11 de 20 pacientes positivos e similar nos outros 9. Um paciente que não pôde fazer cintilografia com 67Ga, fez biópsia guiada por 99mTc-EDDAHYNIC-TOC SPECT/CT em uma cavidade pulmonar com captação desse traçador, que foi positiva para aspergilose. Conclusão: SPECT/CT com 99mTc-EDDA-HYNIC-TOC ou 111In-DTPA-octreotide parece ser uma boa alternativa para o estudo com 67Ga na avaliação de pacientes com doença granulomatosa sistêmica.

Lessons from the epidemiological surveillance program, during the influenza A (H1N1) virus epidemic, in a reference university hospital of Southeastern Brazil / Lições aprendidas pelo programa de vigilância epidemiológica, durante a epidemia pelo vírus da influenza A (H1N1), em um hospital universitário na região sudeste do Brasil

INTRODUCTION: The case definition of influenza-like illness (ILI) is a powerful epidemiological tool during influenza epidemics. METHODS: A prospective cohort study was conducted to evaluate the impact of two definitions used as epidemiological tools, in adults and children, during the influenza A H1N1 epidemic. Patients were included if they had upper respiratory samples tested for influenza by real-time reverse transcriptase polymerase chain reaction during two periods, using the ILI definition (coughing + temperature ≤ 38ºC) in period 1, and the definition of severe acute respiratory infection (ARS) (coughing + temperature ≤ 38ºC and dyspnoea) in period 2. RESULTS: The study included 366 adults and 147 children, covering 243 cases of ILI and 270 cases of ARS. Laboratory confirmed cases of influenza were higher in adults (50%) than in children (21.6%) ( p < 0.0001) and influenza infection was more prevalent in the ILI definition (53%) than ARS (24.4%) (p < 0.0001). Adults reported more chills and myalgia than children (p = 0.0001). Oseltamivir was administered in 58% and 46% of adults and children with influenza A H1N1, respectively. The influenza A H1N1 case fatality rate was 7% in adults and 8.3% in children. The mean time from onset of illness until antiviral administration was 4 days. CONCLUSIONS: The modification of ILI to ARS definition resulted in less accuracy in influenza diagnosis and did not improve the appropriate time and use of antiviral medication.

INTRODUÇÃO: A definição de síndrome gripal é uma ferramenta epidemiológica importante durante epidemias de influenza. MÉTODOS: Foi conduzido estudo de coorte prospectivo para avaliar o impacto das definições de síndrome gripal (SG) e doença respiratória aguda grave (DRAG) como ferramenta de vigilância epidemiológica, em adultos e crianças, durante a epidemia de influenza A H1N1. Os pacientes foram incluídos se tivessem coleta de secreção respiratória alta testada por PCR real time para o vírus da influenza. Os dados clínicos e epidemiológicos foram estudados comparando-se dois períodos: período 1: SG (tosse + temperatura ≤ 38ºC), e período 2: DRAG (tosse + temperatura ≤ 38 e dispnéia). RESULTADOS: Foram incluídos 366 adultos e 147 crianças, em um total de 243 casos de SG e 270 DRAG. A confirmação laboratorial de influenza em adultos (50%) foi significativamente maior do que em crianças (21,6%) (p < 0,0001) e a definição de SG foi mais confirmatória de infecção por influenza (53%) do que DRAG (24,4%) (p < 0,0001). Adultos referiam mais calafrios e mialgias do que as crianças (p = 0,0001). Oseltamivir foi prescrito, respectivamente, em 58% e 46% dos adultos e crianças com influenza A H1N1. A letalidade por influenza A H1N1 foi de 7% em adultos e 8,3% em crianças. CONCLUSÕES: A mudança de definição do critério de vigilância epidemiologia de SG para DRAG resultou em redução significativa da acurácia do diagnóstico de influenza e não contribuiu para melhor indicação do antiviral como também para a sua prescrição no tempo apropriado.

Susceptibility of Mycobacterium tuberculosis to first-line antimycobacterial agents in a Brazilian hospital: assessing the utility of the tetrazolium (MTT) microplate assay

We conducted a cross-sectional, hospital-based study between January 2006-March 2008 to estimate the resistance of Mycobacterium tuberculosis to first-line drugs in patients with tuberculosis at a Brazilian hospital. We evaluated the performance of the [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide] (MTT) microplate assay compared with the Bactec-MGIT 960™ system for mycobacteria testing. The prevalence of resistance in M. tuberculosis was 6.7 percent. Multidrug-resistance [resistance to rifampicin (RMP) and isoniazid (INH)], INH-resistance and streptomycin (SM)-resistance accounted for 1 percent, 3.8 percent and 3.8 percent of all resistance, respectively, and all isolates were susceptible to ethambutol (EM). The resistance was primary in four cases and acquired in three cases and previous treatment was associated with resistance (p = 0.0129). Among the 119 M. tuberculosis isolates, complete concordance of the results for INH and EM was observed between the MTT microplate and Bactec-MGIT 960TM methods. The observed agreement for RMP was 99 percent (sensitivity: 90 percent) and 95.8 percent for SM (sensitivity 90.9 percent), lower than those for other drugs. The MTT colourimetric method is an accurate, simple and low-cost alternative in settings with limited resources.

Aderência à profilaxia com anti-retroviral pós-exposição por profissionais de saúde e vítimas de violência sexual / Adherence to post-exposure anti-retroviral prophylaxis by health care workers and victims of sexual violence

Objetivo: Conhecer a taxa de adesão ao seguimento após exposição ocupacional e não-ocupacional (violência sexual). Um estudo foi realizado, envolvendo 1580 profissionais de saúde e 378 vítimas de violência sexual, em um hospital universitário brasileiro, de maio de 1997 a março de 2001. Os resultados encontrados revelaram que 7,2 dos profissionais de saúde e 79,2...

Indicadores relacionados ao retardo no diagnóstico e na instituição das precauções para aerossóis entre pacientes com tuberculose pulmonar bacilífera em um hospital terciário / Indicators related to delays in diagnosis and in implementation of measures to control airborne infection among patients with pulmonary tuberculosis in a tertiary-care hospital

INTRODUÇÃO: Há risco de transmissão de tuberculose em instituições de cuidados à saúde. OBJETIVO: Avaliar indicadores relacionados ao risco de transmissão entre pacientes com tuberculose pulmonar bacilífera atendidos em um hospital universitário. MÉTODO: Estudo retrospectivo, descritivo, de 01/1997 a 09/1999. Foram estudados os pacientes internados com tuberculose pulmonar bacilífera no Hospital de Clínicas da Universidade Estadual de Campinas. Foram avaliados três intervalos: entre admissão e coleta da pesquisa de BAAR no escarro; entre admissão e instituição das precauções para aerossóis; entre coleta do escarro e início do tratamento. RESULTADOS: Foram incluídos 63 casos. Associação ao vírus da imunodeficiência humana ocorreu em 31,7 por cento. Quarenta pacientes foram admitidos pelo pronto-socorro (63,5 por cento). Suspeita de tuberculose esteve presente na admissão em 42 pacientes (66,7 por cento). O intervalo entre admissão e coleta de escarro excedeu 12 horas em 27,5 por cento dos casos admitidos pelo pronto-socorro e em 30,4 por cento dos internados nas enfermarias (p = 0,803). Retardo no isolamento respiratório ocorreu em 31 casos (49,2 por cento). Os fatores associados ao retardo de isolamento foram ausência de tuberculose no diagnóstico de admissão (p < 0,000) e carga bacilar mais baixa no escarro (p = 0,032). Infecção pelo vírus da imunodeficiência humana (p = 0,530), enfermaria de hospitalização (p = 0,284) e presença de co-morbidades (p = 0,541) não foram associados ao retardo de isolamento. O intervalo entre coleta e início de tratamento foi superior a 24 horas em 15,9 por cento dos casos. CONCLUSÃO: Observou-se retardo de isolamento em muitos casos. São necessárias políticas de educação continuada, sobretudo nas áreas de maior risco.

Bacterial meningitis in the elderly: an 8-year review of cases in a University Hospital

The clinical and laboratory characteristics of bacterial meningitis in subjects over 59 years-old were evaluated to establish variables related to prognosis. All patients with clinical and laboratory findings of acute meningitis were included. Sixty-four episodes in 64 patients were registered. S.pneumoniae was responsible for 19 cases (27.5 percent); L.monocytogens - 3; S.aureus -1; S.bovis - 1; S.agalactie - 1 and Corynebacterium jeikeium - 1. Gram negative bacilli caused seven cases; two cases were due to N.meningitidis and one to H.influenzae. In 50 percent of the cases no microorganisms were isolated. The main symptom was fever (67.8 percent). Headache and neck rigidity were absent in about one-half of the cases and the predominant symptoms were psychomotor agitation, stupor or coma. The presence of concomitant diseases, such as diabetes mellitus (26.6 percent) and pneumonia (17.2 percent), were common. The mortality was high (51.5 percent). This poor prognosis was related to L.monocytogens (100 percent), Gram negatives rods (83 percent) and S.pneumoniae (58 percent). The univariate analysis showed that absence of headache (p=0.002), presence of coma (p=0.04), pneumonia (p=0.01) and immunocompromised status (p=0.01) were associated with risk of death. The type of the microorganisms isolated in the elderly patients with meningitis were often unusual ones. The clinical symptoms were minimal and in many cases, the only clinical presentation was change in mental status. Poor prognosis was observed in spite of intensive care. A high index of suspicion for miningitis while caring for elderly with changes in mental status must be maintained to avoid delays in initiating appropriate therapy.

Comprometimento osteoarticular na blastomicose sul-americana: sua importância em reumatologia

Com o presente trabalho conseguimos demonstrar a grande importância da agressäo osteoarticular ana blastomicose sul-americana em nosso meio, já que 35% dos blastomicóticos a apresentavam, motivo pelo qual os reumatologistas devem estar atentos para estas manifestaçöes, a fim de que possam ser devidamente diagnosticadas e tratadas, principalmente nas formas em que as lesöes säo aparentemente primitivas