Congenital syphilis confirmed by pcr as a result of treatment failure for syphilis in pregnancy. case report

ABSTRACT Introduction: Congenital syphilis is a major public health problem, and early diagnosis and treatment are necessary to prevent it. Penicillin G benzathine is the treatment of choice in pregnant women; however, it may fail to prevent fetal infection, as in the present case. Case presentation: Male newborn, son of an HIV negative mother with gestational syphilis (venereal disease research laboratory (VDRL) 1:4 dilution, positive treponemal test) diagnosed at week 21 of gestation and treated with three doses of 2 400 000 IU of penicillin G benzathine. At delivery, the mother presented VDRL 1:1 dilution. The newborn was diagnosed with congenital syphilis due to VDRL 1:4 dilution, positive treponemal test, elevated aspartate aminotransferases, hypos-thenuria, proteinuria, hematuria, and leukocyturia that resolved after treatment with crystalline penicillin for 10 days. The molecular testing in blood showed a high treponemal load. The VDRL test at 3 months was non-reactive. Conclusions: Preventing congenital syphilis with the recommended treatment for gestational syphilis may fail. Moreover, diagnosing this condition in an asymptomatic newborn is difficult. Therefore, clinical and serological tests are recommended to confirm whether maternal treatment was effective in the fetus.

RESUMEN Introducción. La sífilis congénita es un importante problema de salud pública y para prevenirla es necesario diagnosticar y tratar la sífilis gestacional de forma temprana. En el presente caso la gestante recibió el tratamiento de elección (penicilina benzatínica), pero este no previno la infección fetal. Presentación del caso. Recién nacido masculino, hijo de una madre con serología negativa para el virus de la inmunodeficiencia humana y positiva para sífilis gestacional diagnosticada en la semana 21 (prueba VDRL con dilución 1:4 y prueba treponémica rápida positiva) y tratada con tres dosis de 2 400 000 UI de penicilina benzatínica. En el parto, la madre presentó VDRL con dilución 1:1 y el recién nacido fue diagnosticado con sífilis congénita por presentar VDRL con dilución 1:4, prueba treponémica rápida positiva, niveles de aspartato aminotransferasa elevados, hipostenuria, proteinuria, hematuria y leucocituria, condiciones que se resolvieron luego de recibir tratamiento con penicilina cristalina durante 10 días. El estudio molecular en sangre realizado al momento del nacimiento evidenció una alta presencia de Treponema pallidum. La prueba VDRL a los 3 meses fue no reactiva. Conclusiones. Prevenir la sífilis congénita con el tratamiento recomendado para sífilis gestacional puede fallar, además, diagnosticar sífilis congénita en un recién nacido asintomático es difícil, por lo cual se recomienda hacer un seguimiento clínico y serológico para confirmar si el tratamiento materno fue efectivo en el feto.

Sífilis congénita atípica con doble VDRL negativo materno. Reporte de un caso / Atypical congenital syphilis with a double negative VDRL from the mother. A case report

Resumen INTRODUCCIÓN: La sífilis es una infección de trasmisión sexual adquirida a través de una trasfusión sanguínea, por contacto directo con una lesión activa o por vía vertical. La infección puede trasmitirse al feto en cualquier momento del embarazo. Cada año se registran en el mundo 749,000 casos de sífilis congénita. En México, del 2007 al 2017, se reportaron 1030 casos de sífilis congénita (media de 90.6 casos por año). En 50 a 80% de los casos hay complicaciones materno-fetales. OBJETIVO: Reportar un caso clínico de sífilis congénita temprana, con pénfigo bulloso y descamación al nacimiento. CASO CLÍNICO: Paciente de 25 años, con antecedente de cuatro embarazos, dos partos y un aborto, previamente sana, con control prenatal y pruebas de VDRL y VIH negativas. Los dos últimos embarazos finalizaron con recién nacido, ambos de sexo femenino, con lesiones ampollosas decapitadas, placas blanquecinas de aspecto áspero elevadas sobre una base eritematosa, eritema con descamación gruesa en las manos y pies, y descamación fina generalizada. Ante la sospecha de sífilis congénita se inició la administración de 50,000 UI/kg de penicilina G cristalina por vía intravenosa cada 12 h. La sospecha de sífilis congénita se confirmó. La paciente se dio de alta con citas de seguimiento en la consulta externa. CONCLUSIONES: El control prenatal adecuado, con una o dos pruebas para sífilis, no es suficiente para prevenir la forma congénita. Es necesario el análisis de los casos para encontrar opciones e implementar estrategias de salud pública que prevengan nuevos casos.

Abstract INTRODUCTION: Syphilis is a sexually transmitted infection acquired through blood transfusion, by direct contact with an active lesion or by the vertical route. The infection can be transmitted to the fetus at any time during pregnancy. Each year, 749,000 cases of congenital syphilis are reported worldwide. In Mexico, from 2007 to 2017, 1030 cases of congenital syphilis were reported (average of 90.6 cases per year). In 50 to 80% of cases there are maternal-fetal complications. OBJECTIVE: To report a clinical case of early congenital syphilis with bullous pemphigus and desquamation at birth. CLINICAL CASE: 25-year-old patient, with a history of four pregnancies, two deliveries and one abortion, previously healthy, with prenatal control and negative VDRL and HIV tests. The last two pregnancies ended with a newborn, both female, with decapitated blistering lesions, whitish plaques of rough appearance raised on an erythematous base, erythema with thick desquamation on the hands and feet, and generalized fine desquamation. Suspecting congenital syphilis, 50,000 IU/kg of crystalline penicillin G intravenously every 12 h was started. The suspicion of congenital syphilis was confirmed. The patient was discharged with follow-up outpatient appointments. CONCLUSIONS: Adequate prenatal screening, with one or two tests for syphilis, is not sufficient to prevent the congenital form. Case analysis is necessary to find options and implement public health strategies to prevent new cases.

Effect of benzathine penicillin combined with ceftriaxone on the results of rapid plasma reagin circle card test/toluidine red unheated serum test in the treatment of early syphilis: a meta-analysis / 中华皮肤科杂志

Objective:To systematically evaluate the efficacy of benzathine penicillin combined with ceftriaxone on the negative conversion rate of the rapid plasma reagin circle card test/toluidine red unheated serum test (RPR/TRUST) in the treatment of early syphilis.Methods:According to the search strategy, online databases (PubMed, Web of science, Embase, Cochrane Library, CNKI, Wanfang and VIP) were searched for case-control studies on benzathine penicillin combined with ceftriaxone in the treatment of early syphilis. The Newcastle Ottawa scale (NOS) was used to evaluate the quality of the included articles, and the RevMan5.3 software to analyze the negative conversion rate of RPR/TRUST.Results:A total of 14 case-control studies were included, including 1 160 syphilis patients (585 in the combination treatment group and 575 in the benzathine penicillin alone group) . According to the meta-analysis, the negative conversion rate of serum RPR/TRUST was significantly higher in the combination treatment group than in the benzathine penicillin alone group ( OR=3.70, 95% CI[2.71, 5.06], P<0.001) . Subgroup analysis based on the follow-up duration, the negative conversion rate of serum RPR/TRUST was also significantly higher in the combination treatment group than in the benzathine penicillin alone group after 3-month ( OR=3.68, 95% CI [2.26, 5.98], P<0.001) , 6-month ( OR=3.11, 95% CI[2.26, 4.27], P<0.001) and 12-month treatment ( OR=4.35, 95% CI[2.81, 6.73], P<0.001) . Conclusion:Compared with benzathine penicillin, benzathine penicillin combined with ceftriaxone can more effectively promote serum RPR/TRUST to turn negative in the treatment of early syphilis.

Factors associated with prematurity in reported cases of congenital syphilis / Fatores associados à prematuridade em casos notificados de sífilis congênita

ABSTRACT OBJECTIVE: To analyze the factors associated with prematurity in reported cases of congenital syphilis in the city of Fortaleza, Ceará, Brazil. METHODS: Cross-sectional study conducted in ten public maternity hospitals in Fortaleza, Ceará, Brazil. A total of 478 reported cases of congenital syphilis were included in 2015, and data were collected from notification forms, from mothers' and babies' medical records and from prenatal cards. For the bivariate analysis, Pearson's chi-squared and Fisher's exact tests were used, considering p < 0.05. Multiple logistic regression was conducted, presenting odds ratio (OR) with a 95% confidence interval. RESULTS: We found 15.3% prematurity in pregnant women with syphilis. The titration of the VDRL test > 1:8 at delivery (OR 2.46; 95%CI: 1.33-4.53; p = 0.004) and the non-treatment of the pregnant women or treatment with drugs other than penicillin during prenatal care (OR 3.52; 95%CI: 1.74-7.13; p< 0.001) were associated with higher chances of prematurity. CONCLUSION: The prematurity due to congenital syphilis is a preventable condition, provided that pregnant women with syphilis are treated appropriately. Weaknesses in prenatal care are associated with this outcome, which highlights the importance of public policies oriented to improve the quality of prenatal care.

RESUMO OBJETIVO: Analisar os fatores associados à prematuridade em casos notificados de sífilis congênita no município de Fortaleza, Ceará, Brasil. MÉTODOS: Estudo transversal realizado em dez maternidades públicas de Fortaleza, Ceará, Brasil. Foram incluídos 478 casos notificados de sífilis congênita em 2015, e os dados foram coletados das fichas de notificação, dos prontuários das mães e dos bebês e do cartão de pré-natal. Para a análise bivariada, foram utilizados os testes do qui-quadrado de Pearson e exato de Fisher, considerando p < 0,05. Realizou-se regressão logística múltipla, apresentando razão de chances (OR) com intervalo de confiança de 95%. RESULTADOS: Encontrou-se 15,3% de prematuridade em gestantes com sífilis. A titulação do teste VDRL > 1:8 no parto (OR 2,46; IC95%: 1,33-4,53; p = 0,004), o não tratamento da gestante ou tratamento realizado com drogas diferentes da penicilina durante o pré-natal (OR 3,52; IC95%: 1,74-7,13; p < 0,001) estiveram associados a maiores chances de prematuridade. CONCLUSÃO: A prematuridade decorrente da sífilis congênita é um agravo evitável, desde que as gestantes com sífilis sejam tratadas adequadamente. As fragilidades na assistência pré-natal estão associadas a este desfecho, o que ressalta a importância de implementar políticas públicas voltadas a melhorar a qualidade do pré-natal.

Who was affected by the shortage of penicillin for syphilis in Rio de Janeiro, 2013-2017? / A quem afetou o desabastecimento de penicilina para sífilis no Rio de Janeiro, 2013-2017?

ABSTRACT OBJECTIVE To analyze the shortage of benzathine penicillin G (BPG), characterizing its temporal evolution and spatial distribution in the city of Rio de Janeiro from 2013 to 2017. METHODS This ecological study used gestational and congenital syphilis notifications, BPG distribution records, and sociodemographic data from the population of Rio de Janeiro. To quantify the shortage, a BPG supply indicator was estimated per quarter for each neighborhood between 2013 and 2017. Thematic maps were created to identify areas and periods with greater BPG shortage, described according to sociodemographic factors, health services network, and epidemiological features in the incidence of syphilis. RESULTS BPG shortage in Rio de Janeiro from 2013 to 2017 was not homogeneous in space nor in time. The temporal evolution and spatial distribution of BPG scarcity shows that the shortage affected the inhabitants of the municipality in different ways. Shortage was lower in 2013 and 2016 and more severe in 2014, 2015, and 2017, particularly in neighborhoods within the programmatic areas PA3 and PA5, poorer and with higher prevalence rates of gestational and congenital syphilis. CONCLUSIONS Analyzing BPG shortage and its temporal evolution and spatial distribution in Rio de Janeiro allowed us to realize that the inhabitants are affected in different ways. Understanding this process contributes to the planning of actions to face shortage crises, minimizing possible impacts on the management of syphilis and reducing inequality in access to treatment.

RESUMO OBJETIVO Analisar o desabastecimento da penicilina benzatina (PB), caracterizando sua evolução temporal e distribuição espacial no município do Rio de Janeiro de 2013 a 2017. MÉTODOS Trata-se de estudo ecológico misto realizado com notificações de sífilis gestacional e congênita, registros de distribuição de PB e de dados sociodemográficos da população dos bairros do município do Rio de Janeiro. Para mensurar o desabastecimento foi calculado por trimestre um indicador de abastecimento de PB para cada bairro, entre 2013 e 2017. Mapas temáticos foram produzidos para identificar áreas e períodos com maior desabastecimento de PB, o qual foi descrito segundo condições sociodemográficas, rede de serviços de saúde e aspectos epidemiológicos da incidência de sífilis por bairro. RESULTADOS O desabastecimento de PB no município do Rio de Janeiro, no período de 2013 a 2017, não foi homogêneo no espaço ou no tempo. A evolução temporal e a distribuição espacial da escassez de PB revelam que o desabastecimento afetou de formas distintas os habitantes do município, sendo menor em 2013 e 2016 e mais intenso em 2014, 2015 e 2017, principalmente nos bairros das áreas programáticas AP3 e AP5, mais pobres e com maiores taxas de sífilis gestacional e congênita. CONCLUSÕES Analisar o desabastecimento de PB e sua evolução temporal e distribuição espacial no município do Rio de Janeiro permitiu reconhecer que os habitantes do município são afetados de diferentes modos. Compreender esse processo ajuda a planejar ações para enfrentar crises de desabastecimento, minimizando possíveis impactos no controle da sífilis, além de reduzir a desigualdade no acesso ao tratamento.

Secondary syphilis: The great imitator can't be forgotten / Sífilis secundária: a grande imitadora não pode ser esquecida

Summary Syphilis is an infection caused by Treponema pallidum, mainly transmitted by sexual contact. Since 2001, primary and secondary syphilis rates started to rise, with an epidemic resurgence. The authors describe an exuberant case of secondary syphilis, presenting with annular and lichen planus-like lesions, as well as one mucocutaneous lesion. Physicians must be aware of syphilis in daily practice, since the vast spectrum of its cutaneous manifestations is rising worldwide.

Resumo A sífilis é uma infecção causada pela espiroqueta Treponema pallidum, transmitida principalmente por contato sexual. Desde 2001, houve o ressurgimento dessa epidemia, com aumento das taxas de sífilis primária e secundária. Os autores descrevem um caso exuberante de sífilis secundária apresentando lesões cutâneas anulares e lesões que lembram líquen plano, além de uma lesão mucocutânea. Médicos de todas as especialidades devem estar cientes das diversas apresentações de sífilis: o vasto espectro de manifestações cutâneas da sífilis secundária e as crescentes taxas dessa patologia representam um desafio.

Influences of improved intramuscular injection on quality of benzathine benzylpenicillin medication / 中华护理杂志

Objective To explore influences of improved intramuscular injection on quality of benzathine benzylpenicillin medication.Methods The cluster random sampling was adopted to select 178 patients who needed injection of 240U benzathine benzylpenicillin.A self-control study design was used,and benzathine benzylpenicillin was injected in both sides with each of 1 200 000 units.The left side was injected via routine method,while the right side was injected by an improved intramuscular injection.One-time success rate,degree and duration of pain during and after injection were recorded.Results The differences of one-time success rate,pain during injection,pain after injection,duration of pain after injection and incidence of induration after injection between two groups were statistically significant(P＜0.01).Conclusion The improved intramuscular injection can improve one-time success rate of benzathine benzylpenicillin,reduce pain during injection and local pain after injection,shorten duration of pain and decrease incidence of induration after injection.

Analysis of antibiotic residues in milk from healthy dairy cows treated with bovine mastitis ointment using ultra-performance liquid chromatography coupled with electrospray tandem mass spectrometry

This study was conducted to analyze penicillin G (PEG), streptomycin (STR) and neomycin (NEO) residues in milk of healthy lactating cows. Milk samples were collected from all four quarters of 12 dairy cows 2–7 days after intramammary infusions of an ointment containing PEG, STR and NEO once (n = 4; group I) or twice (n = 4, group II) daily. Ultra-performance liquid chromatography coupled with electrospray tandem mass spectrometry was used to determine the antibiotic residues in the samples. The correlation coefficient (r 2) of the calibration curves for all antibiotics was > 0.999 and the limits of detection and quantification were 0.002–0.005 µg/mL and 0.007–0.02 µg/mL, respectively. Recovery rates were ranged from 75.5 to 92.3%. In group I, PEG, STR and NEO residues were detected in milk at 2, 3 and 2 days post-treatment, respectively, which were below the maximum residue limit (MRL). In group II, PEG, STR and NEO residues were detected in milk at 2, 3 and 3 days post-treatment, respectively, which were bellow the MRL. These results suggest that a 3-day for milk withdrawal period after the ointment treatment might be sufficient for reduction of the antibiotic residues below the MRL.

Ensaio clínico controlado randomizado: região ventro glútea, local alternativo para aplicação da benzilpenicilina benzatina G / Ventrogluteal region, an alternative location to apply benzathine penicillin

O objetivo deste estudo foi comparar o nível de dor relacionada à administração da Benzilpenicilina Benzatina G nas regiões ventro glútea (VG) e dorso glútea (DG). Ensaio clínico controlado randomizado. Participaram do estudo 61 pessoas, 31 do grupo de intervenção (região VG) e 30 do grupo controle (região DG). O teste de qui-quadrado e Mann­ Whitney foram utilizados para testar diferenças entre proporções e comparar tendências centrais entre os grupos, respectivamente. Valores de p ˂ 0,05 foram considerados estatisticamente significantes. Nos três momentos avaliados, a média do escore de dor foi maior quando a aplicação do fármaco ocorreu na região VG vs. DG. No primeiro e terceiro minuto a diferença foi estatisticamente significativa. Estes resultados ratificam a região VG como local alternativo com menor reação local para aplicação de injeções intramusculares.

The objective of this study was to compare the pain level related to the administration of benzathine penicillin on the ventrogluteal (VG) and dorsogluteal (DG) region. A randomized controlled trial. Sixty-one people participated in the study, 31 on the intervention group (VG region), and 30 on the control (DG region). The Chi-Squared and Mann-Whitney tests were used to test differences of proportions and to compare central tendencies between groups, respectively. Values of p <0.05 were considered statistically significant. At the three assessed moments, the mean score of pain was higher when the application of the drug was on the VG region vs. DG. At the first and third minute, the difference was statistically significant. These results confirm the VG region as alternative place with less local reaction to apply intra- muscular injections.

Clinical Profile and Factors Related to Compliance with Benzathine Penicillin G Prophylaxis among RF/RHD Patients at the Tarlac Provincial Hospital, Philippines.

Rheumatic fever (RF) and Rheumatic heart disease (RHD), despite a documented decrease in their incidence, remain as problems in both industrialized and industrializing countries even at the beginning of the 21st century. The most devastating effects are on children and young adults in their most productive years. To determine the clinical profiles of RF/RHD patients at Pediatric Department of Tarlac Provincial Hospital, Tarlac city, Philippines and the factors related to their compliance with Benzathine Penicillin G Prophylaxis treatment, the ex post-facto research was done using the charts of patients. Out patients and ward patients diagnosed with RF/RHD patients were identified using the Jones Criteria. They served as the subjects of the study. The onset of the RF/RHD was seen in age ranging from 6 years to 17 years old with most of them occurring at 7-15 age range. The male to female ratio was 1.3:1. The RF/RHD patients came from different towns of Tarlac, the most number of which came from the city of Tarlac. The patients, being clientele of a provincial and non- paying hospital, came from poor family with low educational attainment, and low monthly income from skilled or unskilled work. Carditis (55% of the 58 cases) and polyarthritis (43%) were the most frequent manifestations seen among patients. In the minor manifestations of RF, majority had episodes of acute tonsillopharyngitis (82%) and fever (82%). Laboratory results, showed abnormal ESR (55 or 95% of the 58 cases), ASO titers (47 or 81%), PR intervals (18 or 31%), and leukocytosis (30 or 67%). Of the 26 cases who had valvular involvement cases, 7 mitral regurgitation; 2 (7%) had mitral stenosis; and 1 had aortic regurgitation. The rest had combination or triple combinations of valvular involvement. Compliance with Benzathine Penicillin G treatment was 46.6%. Compliance to treatment is related to the occupation of father (x2= 6.643, significant at .0361 level) and family income (x2= 8.088, significant at .0175 levels. Poor families who have low paying jobs are less likely to complete the treatment of their sick children. The Department of Health must find ways to provide the secondary chemoprophylaxis to RF/RHD patients for free to improve the compliance rate, thus, provide bigger chance for the RF/RHD patients to survive their disease.

Republication: Two premature neonates of congenital syphilis with severe clinical manifestations

Congenital syphilis (CS) is a public health burden in both developing and developed countries. We report two cases of CS in premature neonates with severe clinical manifestations; Patient 1 (gestational age 31 weeks, birth weight 1423 g) had disseminated idiopathic coagulation (DIC) while Patient 2 (gestational age 34 weeks and 6 days, birth weight 2299 g) had refractory syphilitic meningitis. Their mothers were single and had neither received antenatal care nor undergone syphilis screening. Both neonates were delivered via an emergency cesarean section and had birth asphyxia and transient tachypnea of newborn. Physical examination revealed massive hepatosplenomegaly. Laboratory testing of maternal and neonatal blood showed increased rapid plasma reagin (RPR) titer and positive <i>Treponema pallidum</i> hemagglutination assay. Diagnosis of CS was further supported by a positive IgM fluorescent treponemal antibody absorption test and large amounts of <i>T. pallidum</i> spirochetes detected in the placenta. Each neonate was initially treated with ampicillin and cefotaxime for early bacterial sepsis/meningitis that coexisted with CS. Patient 1 received fresh frozen plasma and antithrombin III to treat DIC. Patient 2 experienced a relapse of CS during initial antibiotic treatment, necessitating parenteral penicillin G. Treatment was effective in both neonates, as shown by reductions in RPR. Monitoring of growth and neurological development through to age 4 showed no evidence of apparent delay or complications. Without adequate antenatal care and maternal screening tests for infection, CS is difficult for non-specialists to diagnose at birth, because the clinical manifestations are similar to those of neonatal sepsis and meningitis. Ampicillin was insufficient for treating CS and penicillin G was necessary.

Republication: Two Premature Neonates of Congenital Syphilis with Severe Clinical Manifestations

Congenital syphilis (CS) is a public health burden in both developing and developed countries. We report two cases of CS in premature neonates with severe clinical manifestations; Patient 1 (gestational age 31 weeks, birth weight 1423 g) had disseminated idiopathic coagulation (DIC) while Patient 2 (gestational age 34 weeks and 6 days, birth weight 2299 g) had refractory syphilitic meningitis. Their mothers were single and had neither received antenatal care nor undergone syphilis screening. Both neonates were delivered via an emergency cesarean section and had birth asphyxia and transient tachypnea of newborn. Physical examination revealed massive hepatosplenomegaly. Laboratory testing of maternal and neonatal blood showed increased rapid plasma reagin (RPR) titer and positive <i>Treponema pallidum</i> hemagglutination assay. Diagnosis of CS was further supported by a positive IgM fluorescent treponemal antibody absorption test and large amounts of <i>T. pallidum</i> spirochetes detected in the placenta. Each neonate was initially treated with ampicillin and cefotaxime for early bacterial sepsis/meningitis that coexisted with CS. Patient 1 received fresh frozen plasma and antithrombin III to treat DIC. Patient 2 experienced a relapse of CS during initial antibiotic treatment, necessitating parenteral penicillin G. Treatment was effective in both neonates, as shown by reductions in RPR. Monitoring of growth and neurological development through to age 4 showed no evidence of apparent delay or complications. Without adequate antenatal care and maternal screening tests for infection, CS is difficult for non-specialists to diagnose at birth, because the clinical manifestations are similar to those of neonatal sepsis and meningitis. Ampicillin was insufficient for treating CS and penicillin G was necessary.

Lethality by pneumonia and factors associated to death / Letalidade por pneumonia e fatores associados ao óbito

OBJECTIVE: To describe the case-fatality rate (CFR) and risk factors of death in children with community-acquired acute pneumonia (CAP) in a pediatric university hospital. METHOD: A longitudinal study was developed with prospective data collected from 1996 to 2011. Patients aged 1 month to 12 years were included in the study. Those who left the hospital against medical orders and those transferred to ICU or other units were excluded. Demographic andclinical-etiological characteristics and the initial treatment were studied. Variables associated to death were determined by bivariate and multivariate analysis using logistic regression. RESULTS: A total of 871 patients were selected, of whom 11 were excluded; thus 860 children were included in the study. There were 26 deaths, with a CFR of 3%; in 58.7% of these, penicillin G was the initial treatment. Pneumococcus was the most common pathogen (50.4%). From 1996 to 2000, there were 24 deaths (93%), with a CFR of 5.8% (24/413). From 2001 to 2011, the age group of hospitalized patients was older (p = 0.03), and the number of deaths (p = 0.02) and the percentage of disease severity were lower (p = 0.06). Only disease severity remained associated to death in the multivariate analysis (OR = 3.2; 95%CI: 1.2-8.9; p = 0.02). CONCLUSION: When the 1996-2000 and 2001-2011 periods were compared, a significant reduction in CFR was observed in the latter, as well as a change in the clinical profile of the pediatric in patients at the institute. These findings may be related to the improvement in the socio-economical status of the population. Penicillin use did not influence CFR. .

OBJETIVO: Descrever a taxa de letalidade (TL) e os fatores de risco de óbito em crianças com pneumonia grave adquirida na comunidade (CAP) em um hospital universitário pediátrico. MÉTODO: Foi desenvolvido um estudo longitudinal com dados prospectivos coletados de 1996 a2011. Foram incluídos no estudo pacientes com idade entre 1 mês e 12 anos de idade. Foram excluídos aqueles que deixaram o hospital desconsiderando as recomendações médicas e aqueles transferidos para UTI ou outras unidades. Foram estudadas as características demográficas, clínicas e etiológicas e o tratamento inicial. As variáveis associadas a óbito foram determinadas por análise bivariada e multivariada utilizando regressão logística. RESULTADOS: Foi selecionado um total de 871 pacientes, dos quais 11 foram excluídos; assim, foram incluídas no estudo 860 crianças. Houve 26 óbitos, com uma TL de 3%; em 58,7% desses, penicilina G foi o tratamento inicial. Pneumococo foi o patógeno mais comum (50,4%). De 1996 a 2000, houve 24 óbitos (93%), com uma TL de 5,8% (24/413). De 2001 a 2011, a faixa etária de pacientes internados foi mais velha (p = 0,03) e o número de óbitos (p = 0,02) e o percentual de gravidade das doenças foram menores (p = 0,06). Apenas a gravidade das doenças continuou associada a óbito na análise multivariada (RC = 3,2; IC de 95%: 1,2-8,9; p = 0,02). CONCLUSÃO: Quando os períodos de 1996-2000 e 2001-2011 foram comparados, foi observada uma redução significativa na TL no último período, bem como uma alteração no perfil clínico dos pacientes hospitalizados no instituto. Esses achados podem estar relacionados à melhora na situação socioeconômica da população. O uso de penicilina não influenciou a TL. .

Parecer técnico da ASBAI sobre o uso da penicilina G em unidades básicas de saúde / The ASBAI technical report on the use of penicillin G at primary care health clinics

Este artigo é resultado de um Parecer Técnico solicitado pelo Ministério da Saúde (MS) sobre o posicionamento da ASBAI quanto à Portaria n° 3161, de 27/12/2011 que “Dispõe sobre a administração da Penicilina nas unidades de atenção básica à saúde (UBS), no âmbito do Sistema Único de Saúde (SUS)”. A Portaria anterior, n° 156 de 19/01/2006 do MS, enfatiza a importância da sífilis congênita, que ainda hoje constitui grave problema de saúde pública. Nesta Portaria, recomenda-se que toda UBS deve contar com os seguintes materiais para atendimento à anafilaxia: máscara e cilindro para administração de oxigênio; epinefrina; prometazina; fenoterol; cloreto de sódio 0,9%, entre outros. Em 2011, a Portaria n° 156/2006 foi revogada pelo MS, que publicou a Portaria n° 3161, de 27/12/2011. Nesta nova Portaria não são mencionados os materiais e medicamentos que constavam na Portaria n° 156/2006. De todo modo, determina que a penicilina seja administrada em todas as UBS do SUS, pela equipe de enfermagem, médicos e farmacêuticos e que em caso de reações anafiláticas, deve-se proceder de acordo com os protocolos que abordam a atenção às urgências no âmbito da Atenção Básica à Saúde. O Grupo de Assessoria da ASBAI em Alergia a Medicamentos sugere que todas as UBS do SUS disponham de pessoal capacitado para o diagnóstico e tratamento de reações alérgicas. No caso de uma reação grave, como uma anafilaxia, o diagnóstico deve ser feito na UBS e, após as medidas iniciais, o paciente deve ser encaminhado para um serviço de referência...

The present article is the result of a technical report requested by the Brazilian Ministry of Health regarding ASBAI’s position regarding Ordinance no. 3161, issued December 27, 2011,which regulates the administration of penicillin at primary health care clinics of the Brazilian Unified Health System. Previous Ordinance no. 156, issued January 19, 2006, highlighted the importance of congenital syphilis, which continues to be a serious public health problem. That Ordinance recommended that all health centers should have the following materials available for the management of anaphylaxis: face mask and oxygen cylinder; epinephrine; promethazine; fenoterol; 0.9% sodium chloride; among other materials. In 2011, Ordinance no. 156/2006 was replaced with Ordinance no. 3161/2011. This new Ordinance does not mention the materials and drugs previously included in Ordinance no. 156/2006. Conversely, it determines that penicillin should be administered at all public health clinics by nurses, doctors, and pharmacists, and that anaphylactic reactions be dealt with according to emergency protocols applicable to the primary health care setting. The Advisory Group for Drug Allergies at ASBAI recommends that all primary care heath clinics have staff trained in the diagnosis and treatment of allergic reactions. In the case of a severe reaction, such as anaphylaxis, diagnosis should be made at the health clinic, and the patient should be referred to a tertiary care center once the initial measures have been carried out...

Diagnosis and Management of Genital Ulcers.

Herpes simplex virus infection and syphilis are the most common causes of genital ulcers in the United States. Other infectious causes include chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections, and fungi. Noninfectious etiologies, including sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions, can also lead to genital ulcers. Although initial treatment of genital ulcers is generally based on clinical presentation, the following tests should be considered in all patients: serologic tests for syphilis and darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum, culture or polymerase chain reaction test for herpes simplex virus, and culture for Haemophilus ducreyi in settings with a high prevalence of chancroid. No pathogen is identified in up to 25 percent of patients with genital ulcers. The first episode of herpes simplex virus infection is usually treated with seven to 10 days of oral acyclovir (five days for recurrent episodes). Famciclovir and valacyclovir are alternative therapies. One dose of intramuscular penicillin G benzathine is recommended to treat genital ulcers caused by primary syphilis. Treatment options for chancroid include a single dose of intramuscular ceftriaxone or oral azithromycin, ciprofloxacin, or erythromycin. Lymphogranuloma venereum and donovanosis are treated with 21 days of oral doxycycline. Treatment of noninfectious causes of genital ulcers varies by etiology, and ranges from topical wound care for ulcers caused by sexual trauma to consideration of subcutaneous pegylated interferon alfa-2a for ulcers caused by Behçet syndrome.

Evaluation of screening tests for antimicrobial residues in milk from individual cows treated with a combination of penicillins G and streptomycin / Valoración de pruebas de campo para detección rápida de residuos antimicrobianos en leche individual de vacas tratadas con una combinación de penicilinas y estreptomicina / Valoração de testes de campo para detecção rápida de resíduos antimicrobianos em leite individual de vacas tratadas com uma mistura de penicilinas e estreptomicina

Abstract Background: in Colombia, the law (Resolution 1382, 2013) prohibits the sale of milk that contains any antimicrobial drug residues, although no specific official screening tests and detection limits have been specified. At present, milk with positive results to both the Delvotest® and Snap® assays is simply rejected. To avoid contaminating bulk tanks with milk from individually treated cows, producers would benefit from having on-farm screening tests to conduct their own quality controls. In addition, on-site testing would allow farmers to check if the withdrawal times of commercially-available generic products are in accordance with labeled recommendations. Material and Methods: In this study, two commonly used rapid detection tests (Delvotest® and SNAP® specific for beta-lactams) were used on milk from 39 subclinical mastitic Holstein cows that were prescribed with daily intramuscular injections of a commercial suspension containing 8.000.000 IU of penicilin G (75% procaine penicilin G, 25% potasium penicillin) and 8 g of streptomycin sulfate, for a total of 4 days. Cows were individually milked and samples collected every 12 hours the day before, and for 3 days after the recommended withdrawal time of three days post-treatment. To inactivate the potential action of natural inhibitors of microbial growth that may be present in milk (ie., lysozyme and lactoferrin), the results of the Delvotest® were compared before and after milk samples were subjected to heat treatment (82°C for 5 minutes). Results: When the Delvotest® was used as per manufacturer's instructions (i.e., without heating), 7 of 39 cows were positive for one more day past the recommended withdrawal period. However, the results of the Snap® specific for beta-lactams and Delvotest® post-heating showed that only 2 of those 7 cows were positive, suggesting that 5 animals gave false positive results. For the 312 milk samples analyzed, a high degree of concordance was observed (Kappa coefficient=0.74±0.1) between the Snap® and Delvotest® post-heating. Conclusions: Considering that the streptomycin in this product is known to be eliminated faster than penicillin-G, the results suggest that the efficacy of the Delvotest® (after heat treatment) is similar to that of the Snap® beta-lactams for the detection of penicillin residues. However, when the Delvotest® was not preceded by heat treatment to inactivate potential natural inhibitors, it yielded a high number of false-positive results. The results also showed that in 95% (37/39) of the cows treated with this commercial product, the labeled instructions of a 3 day withdrawal period were adequate for compliance within the law.

Resumen En Colombia, la ley (Resolución 1382, 2013) prohíbe la venta de leche que contenga residuos de cualquier medicamento antimicrobiano, aunque no se especifican pruebas oficiales ni límites de detección que deban cumplir. Actualmente, la leche que emite resultados positivos a los kits del Delvotest® y Snap® simplemente es rechazada. Para evitar contaminar tanques de acopio con leche de vacas tratadas, los productores se beneficiarían de tener pruebas in situ que les permitan hacer sus propios controles. Además, ello permitiría comprobar si los tiempos de descarte de productos comerciales cumplen con las recomendaciones de los insertos. En este estudio se evaluaron dos pruebas de detección rápida (Delvotest® y SNAP® específico parar beta-lactámicos) en leche de 39 vacas con mastitis subclínica que fueron tratadas con inyecciones diarias intramusculares de una suspensión comercial de 8.000.000 UI de penicilina G (75% penicilina procaínica G, 25% penicilina potásica) y 8 g de sulfato de estreptomicina, durante 4 días. Las vacas se ordeñaron manualmente y recolectaron muestras de leche, cada 12 horas, por 1 día antes y 3 después del tiempo de retiro recomendable de 3 días post-tratamiento. Para inactivar la acción de inhibidores naturales del crecimiento bacteriano que pueden estar presentes en leche (ej, lisozima y lactoferrina), los resultados del Delvotest® se compararon antes y después de que las muestras de leche fuesen sometidas a calentamiento (82°C por 5 minutos). Cuando el Delvotest® se usó de acuerdo a las instrucciones de la compañía, es decir, sin calentamiento, 7 de 39 vacas dieron positivas por ≥ 1 días pasado el tiempo de retiro recomendado. Sin embargo, los resultados del Snap® y Delvotest® post-calentamiento mostraron que sólo 2 de las 7 vacas eran positivas, sugiriendo que 5 animales estaban dando falsos positivos. En las 312 muestras de leche analizadas se obtuvo un alto grado de concordancia (coeficiente Kappa = 0.74±0.1) entre el Snap® y el Delvotest® post-calentamiento. En conclusión, los resultados sugieren que la eficacia del Delvotest® (post-calentamiento) es similar a la del Snap® específico para beta-lactámicos en lo que respecta a detección de residuos de penicilina. Sin embargo, cuando el Delvotest® no iba precedido de calentamiento para inactivar inhibidores naturales, se produjeron demasiados falsos positivos. Los resultados también mostraron que en el 95% (37/39) de las vacas tratadas con este producto, la recomendación de descarte por 3 días cumplía con la legislación vigente de no contener residuos.

Resumo Na Colômbia, a lei (Resolução 1382 de 2013) proíbe a venda do leite que tenha resíduos de qualquer medicamento antimicrobiano, embora não se especifiquem testes oficiais nem limites de detecção que devam se cumprir. Atualmente, o leite que emite resultados positivos aos Kits de Delvotest® e Snap® simplesmente é rejeitado. Para evitar contaminar os tanques de armazenamento com leite de vacas tratadas, os produtores beneficiar-se-iam de ter os testes in situ que lhes permita fazer seus próprios controles. Além, isto permitiria comprovar se os tempos de retiro do leite ao utilizar produtos comerciais cumprem com as recomendações da vide bula. Neste estudo avaliaram-se dois testes de detecção rápida (Delvotest® e SNAP® especifico parar beta-lactâmicos) no leite de 39 vacas com mastite subclínica que foram tratadas com injeções diárias intramusculares de uma suspensão comercial de 8.000.000 UI de penicilina G (75% penicilina procaína G, 25% penicilina potássica) e 8g de sulfato de estreptomicina durante quatro dias. Extraiu-se o leite das vacas com ordenha manual e se fez uma amostragem de leite (cada 12 horas) um dia antes e três dias depois do tempo de retiro do leite, que tinha como recomendável, na vide bula, três dias após final do tratamento. Para inativar a ação de inibidores naturais do crescimento bacteriano, que possam estar presentes no leite (ex. lisozima e lactoferrina), os resultados do Delvotest® compararam-se antes e depois de que as amostras de leite fossem sometidas a aquecimento (82°C durante 5 minutos). Quando o Delvotest® usou-se de acordo com as instruções da companhia, quer dizer, sem aquecimento, sete das 39 vacas deram positivas por ≥ 1 dia passado o tempo de retiro recomendado. Embora, os resultados do Snap® e Delvotest® após aquecimento do leite mostraram que só dois das sete vacas eram positivas, sugerindo que cinco animais estavam apresentando falsos positivos. Nas 312 amostras de leite analisadas obteve-se um alto grau de concordância (coeficiente Kappa = 0.74±0.1) entre o Snap® e o Delvotest® após aquecer o leite. Em conclusão, os resultados sugerem que a eficácia do Delvotest® (após o aquecimento do leite) é similar á do Snap ou especifico para beta-lactâmicos no que respeita a detecção de resíduos de penicilina. Embora, quando o Delvotest® não ia precedido do aquecimento do leite para inativar inibidores naturais, produziram-se muitos falsos positivos. Os resultados também demonstraram que o 95% (37/39) das vacas tratadas com este produto, estavam de acordo com a recomendação de descarte por três dias e cumpria com a legislação vigente de não conter resíduos.

Penicillin G-induced hemorrhagic cystitis: a case and review of the literature

No abstract available.

Streptococcus pneumoniae: sensibilidade a penicilina e moxifloxacina / Streptococcus pneumoniae: susceptibility to penicillin and moxifloxacin

OBJETIVO: Determinar a concentração inibitória mínima (CIM) de penicilina parenteral e moxifloxacina contra cepas de Streptococcus pneumoniae isoladas em um centro hospitalar. Métodos: Estudo in vitro prospectivo de 100 isolados de S. pneumoniae coletados de pacientes tratados entre outubro de 2008 e julho de 2010 no complexo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, em São Paulo (SP). Os isolados foram obtidos de culturas do trato respiratório e de amostras de sangue não relacionadas a infecções meníngeas e foram testados quanto à suscetibilidade a penicilina e moxifloxacina por E test. As interpretações categóricas de CIM foram baseadas em padrões atualizados. RESULTADOS: Todos os isolados foram suscetíveis a penicilina parenteral (CIM < 2 µg/mL) e, consequentemente, eram também suscetíveis a amoxicilina, ampicilina, cefalosporinas de terceira e quarta geração e ertapenem. Quanto à moxifloxacina, 99 por cento das cepas de S. pneumoniae também foram suscetíveis, e somente uma teve CIM = 1,5 µg/mL (intermediário). Conclusões: Nossos resultados mostraram altas taxas de sensibilidade a penicilina parenteral e moxifloxacin nos isolados de S. pneumoniae não relacionados a meningite, o que difere de relatos internacionais. Relatos sobre resistência a penicilina devem ser baseados em pontos de corte atualizados para isolados não relacionados a meningite a fim de guiar a escolha terapêutica antimicrobiana e melhorar a predição dos desfechos clínicos.

OBJECTIVE: To determine the minimum inhibitory concentrations (MICs) of parenteral penicillin and moxifloxacin against Streptococcus pneumoniae strains isolated at a hospital center. METHODS: In-vitro, prospective study involving 100 S. pneumoniae isolates collected from patients who had been treated, between October of 2008 and July of 2010, at the Hospital das Clínicas complex of the University of São Paulo School of Medicine, located in the city of São Paulo, Brazil. The isolates were obtained from respiratory tract cultures or blood samples unrelated to meningeal infections, and they were tested for penicillin and moxifloxacin susceptibility by E-test. The MIC category interpretations were based on updated standards. RESULTS: All isolates were fully susceptible to parenteral penicillin (MIC < 2 µg/mL), and, consequently, they were also susceptible to amoxicillin, ampicillin, third/fourth generation cephalosporins, and ertapenem. Of the S. pneumoniae strains, 99 percent were also susceptible to moxifloxacin, and only one strain showed an MIC = 1.5 µg/mL (intermediate). CONCLUSIONS: Our results showed high susceptibility rates to parenteral penicillin and moxifloxacin among S. pneumoniae isolates unrelated to meningitis, which differs from international reports. Reports on penicillin resistance should be based on updated breakpoints for non-meningitis isolates in order to guide the selection of an antimicrobial therapy and to improve the prediction of the clinical outcomes.