Procalcitonin levels among patients with fever secondary to severe intracerebral infection. A cross-sectional study

ABSTRACT BACKGROUND: Making the differential diagnosis between central fever and infectious fever is critically important among intracerebral hemorrhage patients followed up in intensive care units (ICUs). Serum procalcitonin (PCT) has been found to be a promising biomarker for the initial diagnosis of infection, even before culturing results. OBJECTIVES: To investigate the relationship between PCT and both fever etiologies and C-reactive protein (CRP) levels among critically ill patients with suspected intracerebral hemorrhage. DESIGN AND SETTING: Cross-sectional study in a public university hospital in Elazig, Turkey. METHODS: ICU patients diagnosed with intracerebral hemorrhage and normal procalcitonin levels were included in this study. From clinical assessments and cultures, they were classified as presenting either infectious or central fever. The sensitivity and specificity of PCT and CRP for predicting infection were calculated using a receiver operating characteristic (ROC) curve. RESULTS: There were 98 ICU patients with diagnoses of intracerebral hemorrhage. The median (interquartile range) PCT levels of patients with infectious and central fever were 4 (0.9-11) and 0.1 (0.1-0.4) ng/ml, respectively, with a statistically significant intergroup difference (P < 0.001). The areas under the ROC curve for predicting infectious or central fever PCT and CRP were 0.958 (P < 0.001) and 0.816 (P < 0.001), respectively. A statistically significant positive correlation was detected between PCT and CRP levels in patients with infectious fever (rho: 0.461; P = 0.003), but not in patients with central fever. CONCLUSIONS: PCT can possibly be used as a biomarker to differentiate between infectious and central fever among ICU patients.

Especies rickettsiales en casos humanos con síndrome febril agudo inespecífico en Perú / Rickettsial species in human cases with non-specific acute febrile syndrome in Peru

RESUMEN Con el objetivo de caracterizar molecularmente aislamientos rickettsiales procedentes de humanos con síndrome febril agudo inespecífico se realizó un estudio descriptivo transversal, con aislamientos propagados en cultivos celulares Vero ATCC y líneas alternativas, verificando viabilidad mediante Inmunofluoresencia Indirecta (IFI). Previa extracción del ADN, se amplificó el gen gltA mediante PCR convencional, y se analizó su secuencia. Doce aislamientos fueron amplificados, cinco con suficiente ADN para secuenciarlos, evidenciando compatibilidad con R. asembonensis en cuatro, y estrecha identidad con Coxiella burnetti en uno. Al menos tres de siete líneas celulares alternativas mostraron rendimiento significativo en sub cultivos. Se identificó R. asembonensis en cuatro aislamientos de humanos con síndrome febril agudo inespecífico, procedentes de las regiones de Ayacucho, Cajamarca y Madre de Dios en Perú, y Coxiella burnetti en uno procedente de la región Loreto.

ABSTRACT With the objective of molecularly characterizing rickettsial isolates from humans with non-specific acute febrile syndrome, a cross-sectional descriptive study was conducted, with isolates propagated in Vero ATCC cellular cultures and alternative lines, verifying the viability by means of Indirect Immunofluorescence. Prior to DNA extraction, the gltA gene was amplified by means of conventional PCR, and its sequence was analyzed. Twelve isolates were amplified, five with sufficient DNA so as to sequence them, exhibiting compatibility with R. asembonensis in four, and a close identity with Coxiella burnetti in one. At least three of seven alternative cellular lines showed significant yield in sub-cultures. R. asembonensis was identified in four isolates of humans with non-specific acute febrile syndrome, coming from the regions of Ayacucho, Cajamarca, and Madre de Dios in Peru, and Coxiella burnetti in one coming from the Loreto region.

Predictive factors for disseminated histoplasmosis in AIDS patients with fever admitted to a reference hospital in Brazil

Abstract INTRODUCTION: In many settings, the lack of sensitive biomarkers of disseminated histoplasmosis (DH) leads to a clinical reliance on older diagnostic methods and delayed treatment initiation. The early recognition of DH is critical for survival, especially in patients with human immunodeficiency virus (HIV). This study aimed to identify clinical and laboratory findings associated with the definitive diagnosis of DH in low-income HIV patients in endemic areas. METHODS: Febrile AIDS patients with suspected DH who were admitted to a reference hospital in northeastern Brazil from January 2006 to January 2007 were evaluated for clinical and laboratory findings associated with DH diagnosis. RESULTS: One hundred seventeen patients with fever were included, and 48 (41%) cases of DH were determined by Histoplasma capsulatum identification. A higher fever (≥38.5ºC), maculopapular/papular rash, splenomegaly, hepatomegaly, wheezing, hemoglobin ≤9.5g/dL, platelets ≤80,000/µL, CD4 count ≤75/µL, aspartate aminotransferase (AST) level ≥2.5 times the upper limit of normal (ULN), lactate dehydrogenase (LDH) ≥5times the ULN; and international normalized ratio (INR) >2 times the ULN were significantly associated with DH. A multivariable analysis identified hepatomegaly [adjusted (a) prevalence ratio (PR)= 1.96; 95% confidence interval (CI): 1.21-3.16), CD4 count ≤75/µL (aPR = 2.02; 95% CI: 1.06-3.83), LDH ≥5 times the ULN (aPR = 2.23; 95% CI: 1.44-3.48), and maculopapular/papular rash (aPR = 1.70; 95% CI: 1.02-2.83) were independent risk factors for DH. CONCLUSIONS: These easily assessed parameters can facilitate clinical decision-making for febrile AIDS patients with suspected DH in low socioeconomic and Histoplasma-endemic regions.

Clinical and epidemiological use of nested PCR targeting the repetitive element IS1111 associated with the transposase gene from Coxiella burnetii

ABSTRACT Q fever is a worldwide zoonosis caused by Coxiella burnetii—a small obligate intracellular Gram-negative bacterium found in a variety of animals. It is transmitted to humans by inhalation of contaminated aerosols from urine, feces, milk, amniotic fluid, placenta, abortion products, wool, and rarely by ingestion of raw milk from infected animals. Nested PCR can improve the sensitivity and specificity of testing while offering a suitable amplicon size for sequencing. Serial dilutions were performed tenfold to test the limit of detection, and the result was 10× detection of C. burnetti DNA with internal nested PCR primers relative to trans-PCR. Different biological samples were tested and identified only in nested PCR. This demonstrates the efficiency and effectiveness of the primers. Of the 19 samples, which amplify the partial sequence of C. burnetii, 12 were positive by conventional PCR and nested PCR. Seven samples—five spleen tissue samples from rodents and two tick samples—were only positive in nested PCR. With these new internal primers for trans-PCR, we demonstrate that our nested PCR assay for C. burnetii can achieve better results than conventional PCR.

Análisis de una serie de casos de tuberculosis en pacientes pediátricos atendidos en un hospital de tercer nivel / A case-series analysis of tuberculosis in pediatric patients treated in a tertiary level hospital

Resumen: Introducción: La tuberculosis (TB) continúa siendo un reto ya que las formas graves se presentan con mayor frecuencia en los menores de 5 años y el diagnóstico es complejo. El objetivo del presente trabajo fue describir las formas de presentación clínica, frecuencia, métodos de diagnóstico empleados y respuesta al tratamiento en niños con TB atendidos en un hospital de tercer nivel. Métodos: Se diseñó un estudio retrospectivo, descriptivo, de una cohorte de casos consecutivos atendidos desde enero de 2010 hasta diciembre de 2013. Se revisaron 93 expedientes clínicos de niños con diagnóstico de TB de acuerdo con la definición de la NOM-006-SSA2-2013. Se utilizó estadística descriptiva para el análisis. Resultados: El 58% de 93 niños fueron pacientes de sexo masculino con una media de edad de 7 años. El 97% contaba con antecedente de vacunación BCG; el 6% tuvo contacto con algún caso de TB. Las formas clínicas más frecuentes fueron la TB pulmonar (30.1%), ganglionar (24.7%), miliar/diseminada (16.1%), meníngea (13%) y ósea (7.5%). Los síntomas más comunes fueron fiebre y pérdida de peso (50% y 40%, respectivamente). El BAAR y el cultivo fueron positivos en el 26% y el 7% de todos los casos, respectivamente. El estudio histopatológico fue concluyente en el 90%. El tratamiento fue exitoso en el 94.6%, sin mortalidad asociada. Conclusiones: La asociación del cuadro clínico con las alteraciones en la radiografía de tórax y PPD positivo son útiles para establecer el diagnóstico presuntivo e iniciar el manejo oportuno.

Abstract: Background: Tuberculosis (TB) remains a challenge because severe forms occur most frequently in children under 5 years of age and the diagnosis is complex. The objective of this paper was to describe the clinical presentation, frequency, diagnostic methods used and response to treatment in children with TB treated at a tertiary level hospital. Methods: The study was retrospective and descriptive of a cohort of consecutive cases treated from January 2010 to December 2013. Ninety-three medical records of children diagnosed with TB according to the definition of the NOM-006-SSA2-2013 were reviewed. Descriptive statistics were used for the analysis. Results: From 93 children, 58% were male (mean age of 7 years), 97% with a history of BCG vaccination, and 6% had contact with a TB case. The most frequent clinical forms were pulmonary (30.1%), lymph node (24.7%), miliary/disseminated (16.1%), meningeal (13%), and osteal TB (7.5%). The most common symptoms were fever and weight loss (50% and 40%, respectively). BAAR and culture were positive in 26% and 7% of all cases, respectively. The histopathological study was conclusive in 90% of the cases. The treatment was successful in 94.6%, with not associated mortality. Conclusions: The association of clinical symptoms with alterations in chest radiography and positive PPD are useful in establishing the presumptive diagnosis and an early and appropriate treatment.

Prediction of Cortical Defect Using C-Reactive Protein and Urine Sodium to Potassium Ratio in Infants with Febrile Urinary Tract Infection

PURPOSE: We investigated whether C-reactive protein (CRP) levels, urine protein-creatinine ratio (uProt/Cr), and urine electrolytes can be useful for discriminating acute pyelonephritis (APN) from other febrile illnesses or the presence of a cortical defect on 99mTc dimercaptosuccinic acid (DMSA) scanning (true APN) from its absence in infants with febrile urinary tract infection (UTI). MATERIALS AND METHODS: We examined 150 infants experiencing their first febrile UTI and 100 controls with other febrile illnesses consecutively admitted to our hospital from January 2010 to December 2012. Blood (CRP, electrolytes, Cr) and urine tests [uProt/Cr, electrolytes, and sodium-potassium ratio (uNa/K)] were performed upon admission. All infants with UTI underwent DMSA scans during admission. All data were compared between infants with UTI and controls and between infants with or without a cortical defect on DMSA scans. Using multiple logistic regression analysis, the ability of the parameters to predict true APN was analyzed. RESULTS: CRP levels and uProt/Cr were significantly higher in infants with true APN than in controls. uNa levels and uNa/K were significantly lower in infants with true APN than in controls. CRP levels and uNa/K were relevant factors for predicting true APN. The method using CRP levels, u-Prot/Cr, u-Na levels, and uNa/K had a sensitivity of 94%, specificity of 65%, positive predictive value of 60%, and negative predictive value of 95% for predicting true APN. CONCLUSION: We conclude that these parameters are useful for discriminating APN from other febrile illnesses or discriminating true APN in infants with febrile UTI.

Frecuencia de leptospirosis y características socio-demográficas en pacientes febriles del norte del Perú / Leptospirosis frequency and socio-demographic characteristics associated in febrile patients from northern Perú

Indroduction: Leptospirosis is a frequent cause of febrile illness around the world, particularly in tropical and subtropical areas such as Perú. Objective: To estimate the frequency and socio-demographic characteristics associated with leptospirosis in febrile patients in northern Perú. Materials and Methods: A cross sectional study was conducted from January to December 2014 in 143 fever cases admitted to the Hospital Regional Lambayeque, Perú. Structured for socio-demographic information and sanitation questionnaire was used. Serum samples were examined to quantitatively determine the presence of IgM antibodies to leptospira using ELISA IgM. Results: The frequency was 26.6% (95% CI 19.3 to 33.8) and independently associated features were: be between 20-54 years (OR: 3.36, 95% CI 1.17 to 9, 64), work in agriculture-livestock (OR: 6.15, 95% CI 1.99 to 19.05),contact with animals (OR: 4,13, IC 95%: 1,76-9,65) and consumption of unsafe water(OR: 3,33, IC 95%: 1,49-7,43). Conclusions: This study reveals a high frequency of leptospirosis among febrile patients from northern Perú. These results indicate the need to investigate routinely leptospirosis in febrile patients, especially those exhibiting risk characteristics.

Introducción: La leptopsirosis es causa frecuente de enfermedad febril alrededor del mundo, en particular en áreas tropicales y subtropicales como Perú. Objetivo. Estimar la frecuencia de leptospirosis y características socio-demográficas asociadas en pacientes febriles del norte del Perú. Material y Métodos: Se realizó un estudio transversal entre enero y diciembre de 2014 en 143 casos febriles admitidos en el Hospital Regional Lambayeque, Perú. Se usó un cuestionario estructurado para obtener información socio-demográfica y de saneamiento. Se examinaron muestras de suero para determinar cuantitativamente la presencia de anticuerpos IgM contra leptospira usando la técnica de ELISA IgM. Resultados: La frecuencia fue de 26,6% (IC 95%: 19,3-33,8) y las características asociadas independientemente fueron: tener entre 20 y 54 años (OR: 3,36, IC 95%: 1,17-9,64), dedicarse a la agricultura/ganadería (OR: 6,15, IC 95%: 1,99-19,05), el contacto con animales (OR: 4,13, IC 95%: 1,76-9,65) y el consumo de agua no potable (OR: 3,33, IC 95%: 1,49-7,43). Conclusiones: Este estudio revela una alta frecuencia de leptospirosis entre los pacientes febriles procedentes del norte del Perú. Estos resultados indican la necesidad de investigar la leptospirosis rutinariamente como causa de enfermedad febril, especialmente entre aquellos pacientes que presentan características de riesgo.

Agentes causantes de bacteriemia en niños con cáncer y neutropenia febril de alto riesgo en seis hospitales de Santiago, Chile, período 2004-2009 / Bloodstream infections in children with cancer and high risk fever and neutropenia episodes in six hospitals of Santiago, Chile between 2004 and 2009

Introduction: To determine the etiology of invasive bacterial infection in high risk febrile neutropenia (HRFN) episodes in children with cancer is essential because of the favorable impact on mortality of the early empiric antibiotic treatment. Objective: To determine the etiology of bacteremia in pediatric patients with cancer and HRFN in the National Child Program of Antineoplastic Drugs during the 2004-2009 period, and compare these agents and their antimicrobial susceptibility with the period 1994-1998 described in a previous study. Methods: The causative agents of bacteremia were prospectively recorded in patients less than 18 years of age receiving chemotherapy for cancer with HRFN and positive blood cultures admitted to one of the six hospitals from the Child Program of Antineoplastic Drugs network during the period 2004-2009. Results: 839 episodes of HRFN were identified; 181 blood cultures were positive in the following proportion: gram positive cocci (56%), gram negative bacilli (42%) and yeast (2%).The most common etiologic agents were Staphylococcus coagulase negative (25%), Escherichia. coli (20%), group viridans Streptococcus (14%), Staphylococcus aureus (13%) and Pseudomonas aeruginosa (9%). Comparing the two periods, the relative frequency of Streptococcus spp increased from 4 to 17%, coagulase negative Staphylococcus decreased from 44 to 25%, showing an increase in their resistance to oxacillin from 55% to 77%. Conclusions: We describe the main etiological agents from HRFN episodes in children with cancer in a 5 years period. This information could help for a better approach in the empirical antimicrobial therapy in this population.

Introducción: Conocer la etiología de los episodios de neutropenia febril de alto riesgo (NFAR) en pacientes con cáncer tiene importancia para implementar tratamientos antimicrobianos ajustados a la epidemiología local, lo que tiene impacto en la morbilidad y mortalidad. Objetivo: Describir la etiología de las bacteriemias en niños con cáncer y NFAR en el período 2004-2009, en la red PINDA de Santiago (Región Metropolitana), Chile, y comparar estos agentes y su susceptibilidad antimicrobiana con un estudio previo realizado en el período 1994-1998. Material y Métodos: Se registraron prospectivamente los agentes causantes de bacteriemia y su susceptibilidad a antimicrobianos de los pacientes bajo 18 años de edad en tratamiento quimioterápico por cáncer, ingresados con diagnóstico de NFAR a los seis hospitales de la red, durante el período 2004-2009. Resultados: De 839 episodios de NFAR, 181 tuvieron hemocultivos positivos, correspondientes a cocáceas grampositivas (56%), bacilos gramnegativos (42%) y levaduras (2%). Los agentes más frecuentemente aislados fueron: Staphylococcus coagula-sa negativa (25%), Escherichia coli (20%), Streptococcus grupo viridans (14%), Staphylococcus aureus (13%) y Pseudomonas spp (9%). Al comparar los dos períodos de tiempo, destacan los siguientes cambios significativos: disminución en frecuencia relativa de Staphylococcus coagulasa negativa (desde 44 a 25%), aumento de Streptococcus spp (desde 4 a 17%), y aumento de la resistencia de Staphylococcus coagulasa negativa a oxacilina (desde 55 a 77%). Conclusiones: Se dan a conocer los principales agentes etiológicos de los episodios de NFAR y la susceptibilidad a antimicrobianos en un período de cinco años. Esto permite racionalizar el manejo antimicrobiano empírico de los episodios de NFAR en esta población.

Bacteriemia en pacientes oncológicos: Experiencia en un hospital pediátrico / Bacteremia in cancer patients: Experience in a pediatric hospital

The use of intensive chemotherapy has improved survival of children with cancer. However, this is associated to severe and maintained neutropenia, increasing risks of severe infections like bacteremia. Aim: To update information on microorganisms involved in bloodstream infections in cancer patients and their antimicrobial resistance patterns during the last 3 years in our hospital, comparing it with our previous experience and with other Chilean centres. Material and Methods: Analysis of positive blood cultures belonging to cancer patients during 2006-2008 registered in the Microbiology Lab at the Roberto Del Rio Children's Hospital. Results: In 52 patients, 96 blood cultures yielded bacteria: 59.4% gram positive cocci and 34.4%, gram negative rods. Coagulase negative Staphylococci (CNS) were the most frequent bacteria isolated and enterobacteria were in the second place. Susceptibility to cloxacillin was 11% in CNS and 70 % in Staphylococcus aureus isolates. Enterobacteria maintained susceptibility to third generation cephalosporins and aminoglycosides. Conclusion: Despite the low sensitivity of CNS to cloxacillin, the empirical antibiotic treatment in our unit must include cloxacillin because of the high susceptibility of S. aureus. Switching to vancomycin should be considered only if SCN is isolated or there is an unfavorable evolution.

El uso de quimioterapia más intensiva ha mejorado la sobrevida de los niños con cáncer. Sin embargo, esto se asocia a neutropenia intensa y mantenida, aumentando el riesgo de infecciones graves como bacteriemias. Objetivo: Actualizar la información sobre los microorganismos implicados en las infecciones del torrente circulatorio en pacientes oncológicos atendidos en nuestro hospital, comparar con la literatura médica y describir el patrón de resistencia antimicrobiana. Material y Métodos: Se revisaron los registros de hemocultivos del Laboratorio de Microbiología del Hospital de Niños Roberto Del Río entre los años 2006 y 2008, seleccionando aquellos con resultado positivo y que pertenecieran a pacientes con cáncer. Resultados: En 52 pacientes, 96 hemocultivos resultaron positivos: cocáceas grampositivas 59,4% (Staphylococcus coagulasa negativa-SCN fue el más frecuente); bacilos gramnegativos 34,4%, predominando las enterobacterias, en segundo lugar. Se observó en SCN una susceptibilidad a cloxacilina de 11% y en Staphylo-coccus aureus de 70%. Las enterobacterias mantuvieron una susceptibilidad estable para cefalosporinas de tercera generación y aminoglucósidos. Conclusión: A pesar de la baja susceptibilidad de SCN a cloxacilina, el tratamiento antimicrobiano empírico de primera línea en nuestra unidad debe incluir cloxacilina dada la alta susceptibilidad de S. aureus, y el cambio a vancomicina debería plantearse frente al aislamiento de SCN o evolución desfavorable.

Infection profile of patients undergoing autologous bone marrow transplantation in a Brazilian institution / Perfil de infecção em pacientes submetidos a transplante autólogo de medula óssea em uma instituição brasileira

CONTEXT AND OBJECTIVE: Hematopoietic stem cell transplantation (HSCT) has been widely used for treating oncological and hematological diseases. Although HSCT has helped to improve patient survival, the risk of developing infection during hospitalization is an important cause of morbidity and mortality. This study aimed to analyze the infection profile during hospitalization and the associated risk factors among patients undergoing autologous HSCT at the University Hospital, Universidade Federal de Juiz de Fora. DESIGN AND SETTING: This was a cross-sectional study on patients undergoing autologous HSCT at a public university hospital. METHODS: Patients with febrile neutropenia between 2004 and 2009 were retrospectively evaluated regarding their infection profile and associated risk factors. RESULTS: Infection occurred in 57.2 percent of 112 patients with febrile neutropenia. The main source of infection was the central venous catheter (25.9 percent). Infection was chiefly due to Gram-positive bacteria, although Gram-negative-related infections were more severe and caused a higher death rate. Sex, age, skin color, nutritional status and underlying disease were not associated with the development of infection. Patients with severe mucositis (Grades III and IV) had a higher infection rate (P < 0.001). Patients who developed pulmonary complications during hospitalization had higher infection rates (P = 0.002). Infection was the main cause of death (57.1 percent) in the study sample. CONCLUSION: Strategies aimed at reducing infection-related mortality rates among patients undergoing autologous HSCT are necessary.

CONTEXTO E OBJETIVO: O transplante de células-tronco hematopoiéticas (TCTH) vem sendo amplamente utilizado no tratamento das doenças onco-hematológicas. Embora o TCTH tenha colaborado para a melhora na sobrevida dos pacientes, o risco de desenvolver infecção no período de internação é uma importante causa de morbi-mortalidade. O presente estudo teve como objetivo analisar o perfil das infecções no período de internação e os fatores de risco associados entre os pacientes submetidos ao TCTH autólogo, no Hospital Universitário da Universidade Federal de Juiz de Fora. TIPO DE ESTUDO E LOCAL: Trata-se de um estudo transversal sobre pacientes submetidos a transplante autólogo, em um hospital público universitário. MÉTODOS: Foram analisados retrospectivamente os pacientes que apresentaram neutropenia febril no período de 2004 a 2009, com relação ao perfil infeccioso e os fatores de risco associados. RESULTADOS: A infecção foi determinada em 57,2 por cento dos 112 pacientes com neutropenia febril. A principal fonte de infecção foi o cateter venoso central (25,9 por cento). A infecção ocorreu principalmente devido a bactérias Gram-positivas, apesar de as infecções causadas por bactérias Gram-negativas terem sido mais graves e causado maior taxa de morte. Sexo, idade, cor da pele, estado nutricional e doença de base não estiveram associados com o desenvolvimento da infecção. Pacientes com mucosite grave (graus III e IV) apresentaram maior taxa de infecção (P < 0.001). Os pacientes que desenvolveram complicações pulmonares durante a internação apresentaram maiores taxas de infecção (P = 0,002). A infecção foi a principal causa do óbito (57,1 por cento) na amostra estudada. CONCLUSÃO: São necessárias estratégias voltadas para a redução da taxa de mortalidade relacionada com infecção entre pacientes submetidos ao TCTH autólogo.

Occurrence & antibiogram of Salmonella Typhi & S. Paratyphi A isolated from Rourkela, Orissa.

Background & objectives: Almost round-the-year occurrence of Salmonella Typhi and Salmonella Paratyphi A has been noticed in Rourkela since last 13 and five years respectively. The incidence of infection along with the antibiogram of these two serotypes in this area were carried out. Methods: The study was carried out at Ispat General Hospital, Rourkela, India, between January 2005 and December 2008 with 5340 blood samples collected from patients with suspected enteric fever and pyrexia of unknown origin. Isolation, identification and antibiogram of the causative organisms were performed according to standard bacteriological procedures. Results: A total of 298 Salmonella isolates showed an overall per cent positivity of 5.58. Multidrug resistance was found in 11.96 per cent and 15.62 per cent isolates of S. Typhi and S. Paratyphi A respectively. Less than 2 per cent isolates of Salmonella showed resistance to ciprofloxacin. A resistance of 3.0 to 6.25 per cent against third generation cephalosporins was observed among the salmonella isolates. Interpretation & conclusion: A round-the-year occurrence of Salmonella spp. in Rourkela might have been due to the presence of a considerable number of carriers in the locality, poor sanitation in nearby slum areas, and inadequate and contaminated community water supply at times. Higher degree of susceptibility among S. Typhi isolates against various antibiotics was encouraging, but increasing trend of resistance observed among S. Paratyphi A isolates was a matter of concern.

Factores asociados a riesgo de infección bacteriana grave en niños bajo 24 meses de edad, internados por fiebre sin foco aparente / Associated risk factors for serious bacterial illness in children less than 24 months, admitted with fever without source

Objetivo: Analizar los factores de riesgo asociados a infección bacteriana grave (IBG) en niños < 2 años internados por fiebre sin foco aparente. Población: Niños bajo 2 años de edad internados en el Servicio de Pediatría del Sanatorio Mater Dei entre mayo 2004 y diciembre 2005. Diseño: Observacional, prospectivo, longitudinal. Material y Métodos: Variables independientes: edad, sexo, hermanos, infección viral en el hogar, concurrencia a jardín maternal, vacunación, época del año, laboratorio, criterios de Rochester y escala de YIOS, tratamiento antimicrobiano, días de internación y diagnóstico final. Se utilizó un modelo de regresión logística múltiple por pasos. Resultados: Setenta IBG de 201 pacientes, 56 < 3 meses de edad. Diagnósticos principales: infección urinaria (n: 47), meningitis (n: 11), bacteriemias (n: 9). Factores predictores: recuento de leucocitos > de 15.000/ mm³ (coef. 1,05 OR: 2,17 IC 1,13-4,15) e infección viral en el hogar (coef. -0,79 OR 0,42, IC 0,23- 0,77). Conclusiones: El factor asociado a IBG fue recuento de leucocitos > 15.000/mm³. La presencia de infección viral en el hogar demostró ser un factor de protección.

Objectives: To analyze risk factors for serious bacterial illness (SBI) in children less than 2 years of age admitted with fever without source. Population: Children under 2 years admitted at the Pediatric Service of Sanatorio Mater Dei from May 2004 to December 2005. Design: Observational, prospective and longitudinal study. Materials and Methods: Independent variables: age, gender, siblings, household viral infections, day care attendance, vaccination, season, laboratory data, Rochester criteria, YIOS scale, antibacterial treatment, length of hospitalization, and final diagnosis. A multiple logistic regression stepwise model was used. Results: 70 out of 201 patients developed SBI, 56 were under 3 months of age. Predominant diagnosis were: urinary tract infection (n: 47), meningitis (n: 11) and bacteremia (n: 9). Predictive factors: white-cells count > 15.000/mm³ (coef 1.05, OR = 2.17, 95 percent CI 1.13-4.15) and household viral contact (coef -0.79, OR 0.42, CI 0.23-0.77). Conclusions: Risk factor for SBI was leucocytes count >15.000/mm³. Household viral contact proved being a protective factor.

Febre do viajante associada com adenite cervical e sororreatividade para Bartonella sp em paciente brasileira, após retorno da África do Sul / Traveler's fever associated with cervical adenomegaly and antibodies for Bartonella sp in a Brazilian patient returning from South Africa

Um grande número de viajantes visita anualmente, por estudo, turismo ou trabalho o continente africano. Um caso de adenomegalia cervical e hepatoesplenomegalia associado à febre de duas semanas de duração com teste sorológico positivo para Bartonella sp em uma paciente de 22 anos do sexo feminino que retornou da África do Sul após realização de trabalho de campo com primatas em área silvestre é apresentado.

A large number of travelers visit the African continent annually for studying, tourism or business reasons. The authors report a case of cervical adenomegaly, hepatomegaly and splenomegaly associated with a two-week history of fever and seropositivity for Bartonella sp in a 22-year-old female patient who returned from South Africa after field work with primates in a wild area.

Antibiotic-resistant bacteria in hospitalized patients with bloodstream infections: analysis of some associated factors

Blood infections are life-threatening if not detected and managed properly. This study investigates the correlation between fever and previous antibiotics therapy with differential time to positivrty [DTP] at admitted patients at Nemazee Hospital in Shiraz, southern Iran. From January 2005 to December 2006, 985 positive blood samples in Bactec bottles from the admitted patients at Nemazee Hospital were analyzed. Sensitivity patterns of the bacteria to a panel of antibiotics were determined by the disk diffusion method. S. epidermidis, S. aureus and Acinetobacter were the most prevalent isolates respectively. However, only 100 [20.7%] S. epidermidis samples were the true infections. The most susceptible Gram positive and negative bacteria were S. viridance, S. aureus, H. influenzae, and Brucella spp., respectively. Imipenem, amikacin and ciprofloxacin were the effective ones against Gram negative bacteria, while vancomycin, co-amoxiclav and chloramphenicol were effective against Gram positive ones. Cefuroxime and penicillin G were less effective antibiotics against both Gram negative and positive bacteria. As demonstrated, the combined prescription of vancomycin and imipenem seems to cover the majority of infective agents in the blood whenever an empirical therapy is to be initiated. Moreover, periodic surveillance of antibacterial susceptibility patterns is warranted

Significance of C-reactive protein during febrile neutropenia in pediatric malignancies.

Fifty episodes of febrile neutropenia (FN) in 33 children with malignancies were studied to evaluate the usefulness of C-reactive protein (CRP) levels as an indicator of infection, and the efficacy of antibiotic therapy. Nineteen FN episodes occurred in children with documented infection whereas, 9 and 22 episodes occurred with probable infection and fever of unknown origin, respectively. CRP positivity during episodes of documented and probable infection was significantly higher than with febrile episodes of unknown origin. Blood culture was positive in 15 episodes; of these, CRP was positive in 11. CRP declined to normal on 7th day of antibiotic therapy. CRP is a useful indicator of infection in neutropenic children and also in determining the efficacy of antibiotic therapy.

Manejo de la infección del tracto urinario en lactantes febriles: experiencia de tratamiento antimicrobiano intravenoso ambulatorio / Treatment of urinary tract infections in febrile infants: experience of outpatient intravenous antibiotic treatment

Objective: To describe the feasibility, effectiveness and safety of intravenous (iv) outpatient treatment in 2 to 24 month-old children with febrile urinary tract infection (UTI). Method: Children presenting to the ER, between April 2003-2005, with fever and no identifiable focus who had a diagnosis of UTI were randomized to receive iv antibiotic in the hospital or in an outpatient facility. Children were started on amikacin or ceftriaxona according to physician criteria followed by antimicrobial adjustment based on uriñe culture result and a later switch to an oral antimicrobial. Uriñe cultures were performed during and after completing the antimicrobial course. Adherence and effectiveness of antimicrobial treatment and treatment-associated complications were analyzed. Results: The study included 112 patients, 58 inpatient children and 54 outpatient children, with an average age of 7.7 months. Duration of iv treatment didnot differ among groups (2.8 days (SD 1.2) 2.7 +0.91 days ininpatients vs 2.9 + 1.9 days in outpatients (p = 0.22). In 100 percent of outpatient children and 100 percent of inpatient children (overall 101/101) uriñe cultures were negative on day 5. None of the children had a treatment-associated complication. Cost analysis yielded 73 percent of saving money (overall cost for inpatient treatment US 9,815 vs outpatient treatment US 2,650). Conclusions: Outpatient iv treatment in patients between 2 and 24 months with UTI and fever was effective, safe and of lower cost.

Objetivo: Describir la factibilidad, efectividad y seguridad del tratamiento intravenoso (iv) ambulatorio en niños de 2 meses a 2 años con infección del tracto urinario (ITU) y fiebre. Método: Entre abril 2003 y abril 2005 se realizó un estudio prospectivo en pacientes con fiebre sin foco derivados de Emergencia Infantil, finalmente diagnosticados como ITU, estableciéndose dos grupos con tratamiento iv: uno hospitalizado y otro ambulatorio. Se administró amikacina o ceftriaxona según criterio del médico de turno, hasta obtener resultado del urocultivo, y posteriormente se cambió a tratamiento oral. Se controló urocultivo intra y post tratamiento registrándose adherencia, efectividad y complicaciones. Resultados: Se incluyeron 112 pacientes (58 hospitalizados y 54 ambulatorios), con edad promedio de 7,8 meses. El promedio de días de tratamiento iv fue 2,8 días (SD 1,2) sin diferencias significativas entre ambos grupos 2,7 +0,91 días en los internados vs 2,9 + 1,9 días en los ambulatorios (p = 0,22). En 100 por ciento de ambos grupos de pacientes (en globo 101/101) el urocultivo obtenido al día 5 fue estéril. No hubo complicaciones del tratamiento o sobre la vía venosa. El análisis de costos concluyó que en globo, el manejo ambulatorio representó un 73 por ciento de ahorro económico (1.430.000 pesos chilenos vs 5.300.000 pesos en el sólo rubro de día-cama Conclusiones: El tratamiento iv ambulatorio en pacientes con ITU febril entre 2 y 24 meses fue efectivo, seguro y a un menor costo.

Etiología de episodios de neutropenia febril en pacientes adultos con cáncer hematológico y de órganos sólidos en el Hospital Clínico Universidad Católica, Santiago-Chile / Etiology of febrile neutropenia episodes among cancer patients from Hospital Clinico Universidad Catolica, Santiago-Chile

Introduction: The surveillance of febrile neutropenia (FN) episodes in every center allows adapt the antibiotic therapy guidelines to local epidemiology. Aim: To characterize clinical features and compare the FN etiology between hematological cáncer (HC) and solid organ cancer (SOC) in our center. Patients and Methods: Surveillance study in adult patients with FN admitted to Hospital Clinico Universidad Católica, in Santiago, Chile, from January 2004 to August 2007. Results: 154 FN episodes corresponding to 87 patients were included. Mean age: 47 ± 6 years-old; 71 percent had HC and 29 percent SOC. A clinical and/or microbiologically documented infection was recognized in 76 percent. Gastrointestinal 31.5 percent, upper respiratory 30.3 percent and lower respiratory 16.9 percent were the more frequent clinical focus. In 30.5 percent blood culture resulted positive: gram negative rods 51 percent, gram positive cocci 41 percent and yeasts 8 percent; being Escherichia coli 22 percent, S. coagulase negative (SCoN) 20 percent and Klebsiella pneumoniae 12 percent most frequent bacteria; 22.2 percent Enterobacteriaceae were ESBL producers and 55.6 percent 5CoN were methicillin resistant. In 18.3 percent of FN episodes the etiology was not established. Highest mortality was observed in episodes with microbiologically documented infection (14.5 percent vs 1.3 percent, p < 0.005). A clinical observed focus and positive blood cultures were more frequently obtamed among HC than SOC associated episodes: 37.3 percent vs 13.6 percent; (p < 0.01) and 67.2 percent vs 50 percent; (p = 0.045), respectively. Conclusions: The etiological profile of FN in our center and the necessity to continue the surveillance was described. Future studies are needed regarding risk factors of invasive infection that have worst prognosis.

Introducción: La vigilancia de la etiología de los episodios de neutropenia febril (NF) en cada centro permite adaptar guías de antibioterapia a la epidemiología local. Objetivo: Caracterizar y comparar la etiología de la NF en pacientes con cáncer hematológico (CH) y de órganos sólidos (COS). Pacientes y Métodos: Estudio de vigilancia de NF de pacientes adultos en el Hospital Clínico Universidad Católica, en Santiago, Chile, entre enero 2004 y agosto 2007. Resultados: 154 episodios de NF correspondientes a 87 pacientes: 47 ± 6 años; 71 por ciento CH y 29 por ciento COS. Se documentó infección clínica y/o microbiológicamente en 76 por cientoo. Más frecuente fueron: foco gastrointestinal 31,5 por ciento, respiratorio alto 30,3 por cientoo y respiratorio bajo 16,9 por cientoo. En 30,5 por cientoo hubo hemocultivos positivos: bacilos gramne-gativos en 51 por ciento, cocáceas grampositivas en 41 por ciento, levaduras en 8 por cientoo; predominando: Escherichia coli 22 por cientoo, Staphylococcus coagulasa negativa (SCoN) 20 por cientoo y Klebsiella pneumoniae 12 por ciento; 22,2 por cientoo de las entero-bacterias eran productoras de (3-lactamasa de espectro expandido y 55,6 por cientoo >SCoN meticilina resistentes. En 18,3 por cientoo de los episodios no se identificó causa de fiebre. Hubo mayor mortalidad en episodios con documentación microbiológica (14,5 por ciento vs 1,3 por ciento, p < 0,005). En los pacientes con CH fue más frecuente obtener hemocultivos positivos (37,3 por cientoo vs 13,6 por ciento; p < 0,01) e identificar foco clínico (67,2 por ciento vs 50 por ciento; p = 0,045). Conclusiones: Se establece el perfil etiológico de las NF en nuestro centro y la necesidad de mantener vigilancia. En futuros estudios será necesario evaluar factores de riesgo de pacientes con infecciones invasores que tendrían peor pronóstico.

Tratamiento antimicrobiano en niños con neutropenia febril de alto riesgo / Antibiotic treatment in children with high risk febrile neutropenia

Background: In children with cancer and high risk febrile neutropenia (HRFN), the initial empirical treatment used in our hospital for 5 years includes the association of Cloxacillin + Ceftazidime + Amikacin. There is no chilean literature that reviews the effectiveness of this therapy. Objective: Evalúate the clinical and microbiological effectiveness of this associated therapy in children with HRFN. Method: A prospective-descriptive study evaluating children with HRFN admitted at Hospital Luis Calvo Mackenna between January 2005-August 2006. Results: 100 HRFN episodes were evaluated. In 48 percent of cases, the antimicrobial treatment was considered effective, whereas in 52 percent of episodes the therapy required modifications (15 percent cases within the first 72 hours). The most frequent diagnoses were fever without clinical focus (51 percent) and sepsis (13 percent). 36 percent had microbiological identification and the most frequently isolated bacteria were Escherichia coli (9 percent) and Staphylococcus aureus (9 percent). Conclusions: A favorable answer with the initial empirical therapy was obtained for 48 percent of cases; meanwhile in the remaining episodes, 28 percent required antibiotics modifications without justification. This fact remarks the importance of following the established guidelines for antimicrobial treatment modification in these patients.

Introducción: En los niños con cáncer y netropenia febril (NF) de alto riesgo, se utiliza en nuestro centro hace 5 años, como esquema empírico inicial, la asociación de ceftazidima-amikacina-cloxacilina. No hay literatura nacional que analice la eficacia de este esquema. Objetivo: Evaluar la eficacia clínica y microbiológica de la asociación de ceftazidima, amikacina y cloxacilina en niños con NF de alto riesgo. Método: Protocolo descriptivo, prospectivo. Evaluar niños con NF de alto riesgo hospitalizados en el HLCM entre enero 2005 y agosto 2006. Resultados: 100 episodios de NF de alto riesgo. El tratamiento antimicrobiano fue considerado eficaz en 48 por ciento de los casos, y requirió ajustes en 52 por ciento de los casos. En 13 por ciento se cambia tratamiento sin justificación y en 15 por ciento se realiza antes de 72 horas de iniciado el tratamiento antimicrobiano. Foco mßs frecuente fue: ausencia de foco clínico 51 por ciento, presentando sepsis 13 por ciento de los niños. Hubo identificación microbiológica en 36 por ciento, microorganismos mßs frecuentemente aislados Echerichia coli (9 por ciento) y Staphylococcus aureus (9 por ciento). Conclusiones: Se obtuvo una respuesta favorable de 48 por ciento con el esquema antimicrobiano empírico inicial, de el 52 por ciento restante, en un 28 por ciento se efectúan cambios de antibióticos no justificados, esto recalca la importancia de seguir las pautas ya establecidas para cambio de esquema antimicrobiano en estos pacientes.

Neutropenia febril de bajo riesgo en pacientes oncológicos / Low risk febrile neutropenia in oncological pediatric patients: clinical experience

Background: Infections constitute the major cause of morbimortality in pediatric patients treated with chemotherapy. The PINDA Infectology Committee (National Program of Antineoplasic Drugs) validated a model to predict the risk of invasive bacterial infection (IBI) in oncological patients with febrile neutropenia (FN), in order to differentiate episodes of low risk (LRFN) versus high risk (HRFN) of IBI. Objective: Characterize LRFN episodes in patients treated at the Oncology Unit of Hospital Roberto del Rio, between 2003-2006. Method: Retrospective study of clinical charts of patients with cancer and LRFN in the period of time selected. Results: 185 patients with 202 FN episodes registered, where 47 correspond to LRFN (23 percent). 8.5 percent of LRFN episodes had an unfavourable outcome (not statistically significant). In these patients, cultures were negative and required more days of hospitalization. No patients were readmitted and had no infection associated mortality. Conclusion: The selective management of patients with LRFN following the current criteria is safe and effective.

Las infecciones son la principal causa de morbimortalidad en pacientes oncológicos en quimioterapia. El Comité de Infectología del PINDA (Programa Infantil Nacional de Drogas Antineoplásicas) validó un modelo de predicción de riesgo de infección bacteriana invasora (IBI) en niños oncológicos con neutropenia febril (NF), que discrimina episodios de bajo (NFBR) y alto riesgo (NFAR) de IBI. Objetivo: Caracterizar los episodios de NFBR de pacientes atendidos en la Unidad de Oncología del Hospital de Niños Roberto del Río (2003-2006). Pacientes y Métodos: Revisión retrospectiva de fichas clínicas de pacientes que debutaron con patología oncológica en ese período que presentaron episodios de NFBR consignando edad, sexo, diagnóstico oncológico de base, catéter venoso central, foco infeccioso, quimioterapia y cultivos. Se evaluó la evolución clínica por parámetros clínicos y de laboratorio, y se analizaron las variables mediante prueba de X cuadrado, con un p < 0,05. Resultados: En 185 pacientes, se registraron 202 episodios de NF, 47 fueron NFBR (23 por ciento). Presentaron evolución desfavorable un 8,5 por ciento de NFBR (p > 0,05). En ellos no se logró aislamiento microbiológico y tuvieron mayor número de días de hospitalización. No hubo en este grupo reingresos ni mortalidad asociada. Conclusión: El manejo selectivo de los pacientes con NFBR, según criterios actuales, es seguro y efectivo.

Changing profile of prostatic abscess

PURPOSE: To compare the clinical presentation of prostatic abscess and treatment outcome in two different time frames with regards to etiologies, co-morbid factors and the impact of multidrug resistant organism. MATERIALS AND METHODS: We retrospectively assessed the charts of 48 patients with the diagnosis of prostatic abscess from 1991 to 2005. The period was divided arbitrarily into two different time frames; phase I (1991-1997) and phase II (1998-2005). Factors analyzed included presenting features, predisposing factors, imaging, bacteriological and antibiotic susceptibility profile, treatment and its outcome. RESULTS: The mean patient age in phase I (n = 18) and phase II (n = 30) were 59.22 ± 11.02 yrs and 49.14 ± 15.67 respectively (p = 0.013). Diabetes mellitus was most common predisposing factor in both phases. Eleven patients in phase II had no co-morbid factor, of which nine were in the younger age group (22 - 44 years). Of these eleven patients, five presented with pyrexia of unknown origin and had no lower urinary tract symptoms LUTS Two patients with HIV had tuberculous prostatic abscess along with cryptococcal abscess in one in phase II. Two patients had melioidotic prostatic abscess in phase II. The organisms cultured were predominantly susceptible to first line antibiotics in phase I whereas second or third line in phase II. CONCLUSION: The incidence of prostatic abscess is increasing in younger patients without co-morbid factors. The bacteriological profile remained generally unchanged, but recently multi drug resistant organisms have emerged. A worrying trend of HIV infection with tuberculous prostatic abscess and other rare organism is also emerging.