Prevalencia de sepsis neonatal confirmada microbiológicamente en una maternidad de la Ciudad Autó noma de Buenos Aires / Prevalence of microbiologically confirmed neonatal sepsis at a maternity center in the City of Buenos Aires

Introducción. En neonatos internados es frecuente sospechar sepsis neonatal, pero solo en el 25 % al 30 % se confirma con cultivos positivos. La selección del esquema antibiótico basándose en la epidemiología local favorece el uso racional y minimiza sus efectos colaterales. Objetivo primario. Describir la prevalencia de sepsis precoz y tardía con rescate microbiológico y sus características clínicas. Población y método. Estudio transversal retrospectivo, realizado del 1 de enero de 2013 al 31 de diciembre de 2017, en una maternidad pública de Argentina, que incluyó todos los recién nacidos internados en la unidad con diagnóstico de sepsis precoz y tardía con rescate microbiológico, y aquellos reingresados dentro del mes de vida. Resultados. Ingresaron 3322 recién nacidos, 1296 evaluados por sospecha de sepsis precoz, cultivos positivos en 25 (1,9 %; tasa: 0,86 ‰). El 52 % eran menores de 33 semanas de edad gestacional. Microorganismos: Escherichia coli 5, Listeria monocytogenes 4, Streptococcus agalactiae (SGB) 3, Streptococcus pneumoniae 3. Sepsis tardía (tasa 8,73 ‰), el 68 % ocurridas en menores de 33 semanas. Microorganismos intrahospitalarios: Staphylococcus coagulasa negativos 115, Staphylococcus aureus 47, Escherichia coli 30, Cándida spp. 16, Enterococcus faecalis 13, Klebsiella pneumoniae 11 y Streptococcus agalactiae 10. En los reingresos: E. coli 11, S. aureus 12, SGB 3 y Haemophilus influenzae 3. Conclusiones. Se observa en el período estudiado una frecuencia de sepsis precoz similar a los reportes internacionales, con predominio de E. coli y L. monocytogenes. La tasa de sepsis tardía presentó una tendencia descendente en los años analizados, con predominio de los cocos grampositivos

Introduction. Neonatal sepsis is often suspected in hospitalized newborn infants, but only in 25­30% of cases it is confirmed via a positive culture. Selecting the antibiotics based on local epidemiology favors their rational use and minimizes their side effects. Primary objective. To describe the prevalence of early- and late-onset sepsis with microorganism isolation and their clinical characteristics. Population and method. Retrospective, cross-sectional study conducted between 01-01-2013 and 12-31-2017 in a public maternity center of Argentina in all hospitalized newborn infants with a diagnosis of early- and late-onset sepsis with microorganism isolation, and those re-admitted in their first month of life. Results. A total of 3322 newborn infants were admitted; 1296 were assessed for suspected early- onset sepsis; 25 had a positive culture (1.9%; rate: 0.86‰). Of these, 52% were born before 33 weeks of gestation. Microorganisms: Escherichia coli 5, Listeria monocytogenes 4, Streptococcus agalactiae (SGB) 3, Streptococcus pneumoniae 3. Also, 68% of late-onset sepsis cases (rate: 8.73‰) occurred in infants born before 33 weeks of gestation. Hospital-acquired microorganisms: coagulase-negative Staphylococcus 115, Staphylococcus aureus 47, Escherichia coli 30, Candida spp. 16, Enterococcus faecalis 13, Klebsiella pneumoniae 11, and Streptococcus agalactiae 10. In re-admissions: E. coli 11, S. aureus 12, SGB 3, and Haemophilus influenzae 3. Conclusions. During the study period, the frequency of early-onset sepsis was similar to international reports, with a predominance of E. coli and L. monocytogenes. The rate of late-onset sepsis showed a downward trend in the analyzed years, with a predominance of Gram-positive cocci.

Diseño, estandarización e implementación de una nueva técnica en Guatemala, para el diagnóstico rápido de hemocultivos positivos, utilizando la tecnología Maldi-tof / Design, standardization and implementation of a new technique in Guatemala, for the rapid diagnosis of positive blood cultures, using Maldi-tof technology

Las enfermedades infecciosas son un problema de salud que a pesar de los avances médicos siguen cobrando vi-das en todo el mundo; como las septicemias. La presente investigación tuvo por objetivo diseñar, estandarizar e implementar un protocolo inexistente en Guatemala, para el diagnóstico rutinario de hemocultivos positivos dentro de las instalaciones del Laboratorio Clínico del Hospital General San Juan de Dios, lugar en donde se encuentra el único espectrómetro de masas de tipo Maldi-tof (Matrix Assisted Laser Desorption Ionization-Time of flight-mass spectrometry).Se utilizaron 240 muestras de pacientes de los diferentes servicios. El diagnóstico se realizó compa-rando las identificaciones obtenidas a partir de cultivos microbiológicos puros con muestras directas de botellas con caldo BHI(Brain Heart Infusion).Los resultados de las dos metodologías fueron evaluados con el diseño estadístico "apareado o emparejado en grupo". La comparación no evidenció discordancia en las identificaciones; pero sí en los tiempos de respuesta. La reducción de tiempo fue de 42.9 h para bacterias Gram positivo, 45.0 h para bacterias Gram negativo y 126.2 h para levaduras, todos a favor de identificaciones a partir de muestras directas. Con esta investigación se pretende ofrecer una nueva alternativa que permitirá brindar un diagnóstico rápido, confiable y certero a la población guatemalteca. También permitirá reducir la morbimortalidad de los pacientes con septicemias, promover el ahorro de insumos hospitalarios, disminuir el tiempo de estancia hospitalaria, ahorrar el consumo de antibióticos innecesarios y contribuir indirectamente a combatir la resistencia antimicrobiana; un problema actual de gran importancia a nivel mundial.

Infectious diseases are a health problem that despite medical advances in terms of diagnosis continue to take lives worldwide, such is the case of sepsis. The purpose of this research was to design, standardize and implement a non-existent protocol in Guatemala, for the routine diagnosis of positive blood cultures, within the facilities of the clinical laboratory of the San Juan de Dios General Hospital; where the only Maldi-tof (Matrix Assisted Laser Desorp-tion Ionization-Time of flight-mass spectrometry) type mass spectrometer is located. For this, 240 samples of positive blood cultures were used, coming from patients of the different services. The microbiological diagnosis was made by comparing the identification data obtained from pure microbiological cultures and direct samples of BHI broth (Brain Heart Infusion) bottles. The results of the two methodologies were evaluated based on "paired or matched in groups" statistical design. The Maldi-tof technique did not show disagreement regarding identification between the two types of samples; but it did in the response time. The time reduction was 42.9 h for Gram positive bacteria, 45.0 h for Gram negative and 126.2 h for yeasts, supporting identification from direct samples. This research aims to provide a new diagnostic alternative that will allow access to fast, reliable, and accurate results for the Guatemalan population. It will also help to reduce e morbidity and mortality rates of patients with sepsis, to promote hospital supplies savings, decrease the patient length of stay, save unnecessary antibiotics and indirectly contribute to combating antimicrobial resistance; a critical problem faced by the world today.

Clinical and microbiological characteristics of dogs in sepsis in an academic veterinary hospital in the north of Paraná / Características clínicas e microbiológicas de cães em sepse de um hospital veterinário escola do norte do Paraná

Sepsis is a life-threatening organ dysfunction caused by a patient's unregulated response to an infectious process. In veterinary medicine, the exact incidence of sepsis is unknown. Early recognition of sepsis in critically ill patients is essential for rapid and effective therapeutic intervention. The present study aimed to apply the criteria of an adapted sepsis assessment protocol based on the Second International Consensus Definition for Sepsis and Septic Shock or Sepsis-2 of human medicine, in canine patients with suspected systemic inflammatory response syndrome (SIRS) and/or organ dysfunction, and to identify infectious agents as well as their antimicrobial resistance profile in the focus of infection, in the bloodstream and colonizing the rectal mucosa. Patients were evaluated for survival and severity of sepsis. Of the 37/42 dogs that met the sepsis criteria, six presented septic shock, 26 (70.2%) had at least two signs of SIRS, and sepsis with organ dysfunction was diagnosed in 27 (73%) dogs. The primary dysfunctions observed were decreased level of consciousness in 21/37 (56.8%), hyperlactatemia in 19/37 (51.4%), and hypoalbuminemia in 18/37 (48.6%). Two or more SIRS signs associated with hypotension and hypoalbuminemia were related to more than half of the deaths. The most frequent infectious focus was skin and soft tissue in 20/37 (54%), followed by organs and cavities in 8/37 (21.6%). The survival rate was 56.7%. Blood culture confirmed bacteremia in nine patients (24.3%), with a predominance of Gram-positive microorganisms (Staphylococcus intermedius, Streptococcus spp.) in 66.6% of dogs and one yeast (Candida glabrata). The most frequent bacteria in the focus of infection were gram-negative bacteria (46.2%), mainly Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, in 19.5%, 14.6%, and 12.1%, respectively. We observed colonization by gram-negative bacteria such as E. coli-ESBL (31.5%), K. pneumoniae-ESBL (15.7%), and P. aeruginosa (15.7%), and the presence of ESBL bacteria was more associated with death when compared with other microorganisms. Vancomycin-resistant Enterococcus (VRE) were isolated from rectal mucosa in four dogs. Gram-negative microorganisms were the most frequent in both infections and colonization, and most of them were resistant to fluoroquinolones, sulfonamides, tetracyclines, and cephalosporins. Based on this information, it can be concluded that mortality due to sepsis in dogs was high. Due to the presence of multi-resistant bacteria, the use of antimicrobials should be judicious, suggesting the implementation of the same precautions used in human hospitals to prevent the spread of multi-resistant microorganisms.(AU)

A sepse é uma disfunção orgânica ameaçadora à vida, causada por uma resposta desregulada do hospedeiro à infecção e na medicina veterinária sua incidência exata é desconhecida. O reconhecimento precoce da sepse nos pacientes críticos é essencial para que a intervenção terapêutica seja rápida e eficaz. Assim, os objetivos do presente estudo foram aplicar os critérios de um protocolo de avaliação da sepse adaptado com base no Segundo Consenso Internacional para Sepse e Choque Séptico, ou Sepse-2, da medicina humana, em pacientes caninos com suspeita de infecção e/ou Síndrome da Resposta Inflamatória Sistêmica e/ou disfunção orgânica e identificar os agentes infecciosos bem como seu perfil de resistência a antimicrobianos no foco de infecção, na corrente sanguínea e colonizando a mucosa retal. Os pacientes foram avaliados quanto à sobrevivência e severidade da sepse. Dos 37/42 cães que se enquadraram nos critérios de sepse, seis estavam em choque séptico, 26 (70,2%) apresentaram pelo menos dois sinais de SIRS, e a sepse com disfunção orgânica foi diagnosticada em 27 (73%) cães. As principais disfunções verificadas foram diminuição do nível de consciência em 21/37 (56,8%), hiperlactatemia em 19/37 (51,4%) e hipoalbuminemia em 18/37 (48,6%). A presença de dois ou mais sinais de SIRS associados com hipotensão e hipoalbuminemia estiveram relacionadas com mais da metade dos óbitos. O foco infeccioso mais frequente foi pele e partes moles em 20/37 (54%) seguido por órgãos e cavidades em 8/37 (21,6%). A taxa de sobrevivência foi de 56,7%. Na hemocultura confirmou-se bacteremia em nove pacientes (24,3%), com predominância de microrganismos gram-positivos (Staphylococcus intermedius, Streptococcus spp.) em 66,6% dos cães e uma levedura (Candida glabrata). As bactérias mais frequentes no foco de infecção foram as gram-negativas (46,2%) principalmente Escherichia coli, Klebsiella pneumoniae e Pseudomonas aeruginosa, em 19,5%, 14,6% e 12,1% respectivamente. Foi constatada colonização por bactérias gram-negativas como E. coli-ESBL (31,5%), K. pneumoniae-ESBL (15,7%) e P. aeruginosa (15,7%), sendo que a colonização de cães por bactérias ESBL foi associada ao óbito quando comparada com outros microrganismos. Foram também isolados da mucosa retal Enterococcus resistentes à vancomicina (VRE) em quatro cães. Os microrganismos gram-negativos foram os mais frequentes, tanto nas infecções quanto nas colonizações e a maioria apresentava resistência à fluorquinolonas, sulfonamidas, tetraciclinas e cefalosporinas. Com base nestas informações, conclui-se que a mortalidade em decorrência da sepse em cães foi alta, e devido à presença de bactérias multirresistentes, o uso de antimicrobianos deve ser criterioso, sugerindo-se ainda a implantação das mesmas precauções utilizadas em hospitais humanos para evitar disseminação de microrganismos multirresistentes.(AU)

Caracterización clínica, epidemiológica y microbiológica de pacientes con sepsis en una unidad de cuidados intensivos / Clinical, epidemiological and microbiological characterization of patients with sepsis in an intensive cares unit

Introducción: La incidencia, morbilidad y mortalidad de la sepsis la convierten en un importante problema sanitario que requiere la adopción de medidas específicas, a fin de tomar conciencia del problema. Objetivo: Caracterizar a los pacientes con sepsis según variables clínicas, epidemiológicas y microbiológicas seleccionadas. Métodos: Se realizó un estudio descriptivo y transversal de 119 pacientes con sepsis, egresados de la Unidad de Cuidados Intensivos del Hospital General Orlando Pantoja Tamayo, del municipio de Contramaestre, desde enero de 2014 hasta julio de 2017. Se aplicó la prueba de Ji al cuadrado de independencia, para identificar asociación estadísticamente significativa entre las variables, con un nivel de significación de α= 0,05. Resultados: Prevalecieron las féminas (54,6 %), el grupo etario de 66-80 años de edad para ambos sexos (33,6 %) y la neumonía asociada a la ventilación como la forma de presentación más frecuente de la sepsis (51,6 %), principalmente la producida por Enterobacter sp. (34,4 %). Conclusiones: La sepsis se presenta fundamentalmente por infecciones respiratorias producidas por gérmenes gramnegativos en pacientes que requirieren procederes invasivos como parte del tratamiento.

Introduction: The incidence, morbidity and mortality of sepsis transforms it into an important health care problem that requires the adoption of specific measures, in order to take conscience of the problem. Objectives: To characterize the patients with sepsis according to selected clinical, epidemiological and microbiological variables. Methods: A descriptive and cross-sectional study of 119 patients with sepsis, discharged from the Intensive Cares Unit of Orlando Pantoja Tamayo General Hospital, in Contramaestre was carried out, from January, 2014 to July, 2017. The chi-square test was applied, to identify association statistically significant between the variables, with a significance level of α = 0.05. Results: There was a prevalence of females (54.6 %), 66-80 years age group for both sexes (33.6 %) and pneumonia associated to ventilation as the most frequent form of presentation of sepsis (51.6 %), mainly the one produced by Enterobacter sp. (34.4 %). Conclusions: Sepsis is presented fundamentally by breathing infections produced by gramnegative germs in patients who required invasive procedures as part of the treatment.

Septicemia por Chromobacterium Violaceum en pediatría / Septicemia due to Chromobacterium Violaceum in pediatrics

Chromobacterium violaceum es una bacteria gram negativa anaerobia facultativa, que se encuentra ampliamente distribuida en el agua y el suelo en regiones tropicales y subtropicales, que se asocia con infecciones respiratorias, gastrointestinales, abscesos hepáticos, meningitis, endocarditis, síndrome hemofagocítico y sepsis fulminante. Se presentan 2 casos en niños: el primero es un varón de 8 años con lesiones en piel, fiebre y adenitis inguinal, que ingresó con un cuadro de sepsis severa, síndrome de distrés respiratorio agudo (SDRA) y falleció a las 3 h del ingreso. De los hemocultivos se aisló Chromobacterium violaceum. El segundo caso, es una niña de 12 años con antecedente de fiebre y adenopatía inguinal secundaria a herida cortopunzante en el pie homolateral, que ingresó con un cuadro de sepsis, con desarrollo de abscesos múltiples profundos. De la colección obtenida de piel y partes blandas y de un aspirado traqueal se aisló Chromobacterium violaceum. Recibió tratamiento antibiótico adecuado y posteriormente fue dada de alta. Se realizó una revisión bibliográfica de esta infección en niños y se encontraron 44 casos en todo el mundo. Algunos de éstos, se relacionaron con inmunodeficiencia de base, como la enfermedad granulomatosa crónica. La infección por esta bacteria es rara y se presenta como un cuadro grave que no responde a antibióticos habituales de uso empírico y tiene una alta tasa de mortalidad (AU)

Chromobacterium violaceum is a facultative anaerobic Gramnegative bacillus, widely distributed in water and soil in tropical and subtropical regions and associated with respiratory and gastrointestinal infections, liver abscesses, meningitis, endocarditis, hemophagocytic syndrome, and fulminant sepsis. Here two pediatric cases are presented: The first was an 8-year-old boy with skin lesions, fever, and inguinal adenitis, who was admitted with severe sepsis, acute respiratory distress syndrome (ARDS) and died three hours after. Chromobacterium violaceum was isolated from blood cultures. The second case was a 12-year-old girl with a history of fever and inguinal adenopathy secondary to a wound in the homolateral foot, who was admitted because of sepsis and multiple deep abscesses. From samples collected from the skin and soft tissues as well as tracheal aspirate Chromobacterium violaceum was isolated. Adequate antibiotic treatment was started and the patient was subsequently discharged. In a review of the literature, 44 cases worldwide were identified. Some of these cases were related to underlying immunodeficiency, such as chronic granulomatous disease. Infection with this bacterium is rare and presents with severe manifestations that do not respond to the common empirical antibiotics and are associated with a high mortality rate (AU)

Análisis clínico y microbiológico de la sepsis grave y el choque séptico por Escherichia coli en Medellín, Colombia / Severe sepsis and septic shock by Escherichia coli, clinical and microbiological analysis in Medellin, Colombia

Resumen Introducción: Escherichia coli es causa frecuente de un amplio espectro de infecciones, desde una infeccion urinaria no complicada hasta la sepsis grave y el choque septico, asociadas con desenlaces de alto impacto como ingreso a UCI y mortalidad. Objetivos: Determinar las diferencias en mortalidad. ingreso a UCI/UCE, presencia de cepas BLEE y tratamiento antimicrobiano en pacientes con sepsis grave y choque séptico por E. coli, con o sin bacteriemia, asi como su variabilidad dependiendo del foco infeccioso. Material y Métodos: Análisis secundario de estudio de cohorte prospective multicéntrico. Resultados: De 458 pacientes que tenian infeccion por E. coli, 123 tenian aislamiento solo en hemocultivo, 222 solo en urocultivo y 113 en ambas muestras. El aislamiento solo en hemocultivo se asocio mayor frecuencia de ingreso a UCI (n = 63; 5,2%). mayor necesidad de ventilacion mecánica (n = 19; 15,5%), mayor mortalidad y estancia hospitalaria (n = 22; 18%; mediana de 12 dias, RIQ= 7-17, respectivamente), pero con menor presencia de cepas productoras de BLEE en comparacion con urocultivos y hemocultivo, urocultivo (n = 20; 17,7% y n = 46; 20,7%, respectivamente). Recibieron tratamiento antimicrobiano en las primeras 24 h 424 pacientes (92,6%), con mas frecuencia piperacilina/ tazobactam (n = 256,60,3%). La proporcion de pacientes tratados empiricamente con carbapenemicos vs no carbapenemicos fue similar en los tres grupos. Discusión: El foco infeccioso. sumado a factores de nesgo para cepas productoras de BLEE, son herramientas utiles para definir pronostico y tratamiento en esta población, debido a la variabilidad clínica y microbiologica en los distintos aislados. Conclusión: Los pacientes con aislamiento de E. coli solo en hemocultivo presentan con mayor frecuencia desenlaces desfavorables en comparación con los pacientes con E. coli en urocultivo, con o sin bacteriemia. Llama la atencion en nuestro medio la menor cantidad de cepas productoras de BLEE en los pacientes con solo hemocultivo positivo.

Background: Escherichia coli is a common cause of a broad spectrum of infections, from non-complicated urinary tract infection, to severe sepsis and septic shock, that are associated to high impact outcomes, such as ICU admission and mortality. Aims: To establish differences in mortality, ICU admission, ESBL positive strains and antibiotic treatment, between patients with E. coli related severe sepsis and septic shock, with or without bacteremia and its variability based on the source of infection. Method: Secondary data analysis of a multicentric prospective cohort study. Results: From 458 patients with E. coli isolation, 123 had E. coli exclusively in blood culture, 222 solely in urine culture, and 113 in both samples. Escherichia coli isolation exclusively in blood culture was associated with higher frequency of ICU admission (n = 63; 51.2%), higher rate of mechanical ventilation requirement (n = 19; 15.5%), higher mortality and longer hospital stay (n = 22; 18%; median of 12 days, IQR= 7 - 17, respectively); but with a lower occurrence of ESBL strains, compared to patients with positive urine culture and positive blood/urine cultures (n = 20; 17.7% and n = 46; 20.7%, respectively). 424 patients (92.6%) received antibiotic treatment in the first 24 hours. The most commonly prescribed was piperacilin/tazobactam (n = 256;60.3%). The proportion of patients empirically treated with carbapenems vs non-carbapenems was similar in the three groups. Discussion: The source of infection, associated with ESBL strains risk factors, are useful tools to define prognosis and treatment in this population, because of their clinical and microbiological variability. Conclusion: Patients with E. coli isolation exclusively in the blood culture had higher frequency of non-favorable outcomes in comparison to patients with E. coli in urine culture with or without bacteremia. Additionally, in our population patients with E. coli solely in blood culture have lower prevalence of ESBL positive strains.

Surgical treatment for congenital heart defects in down syndrome patients

Abstract Objective: To analyze data related to surgical treatment in patients with congenital heart defects (CHD) and Down syndrome (DS) based on information from International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). Methods: Between July 1, 2010 and December 31, 2017, 139 patients with CHD and DS underwent surgery at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME)/Faculdade de Medicina de São José do Rio Preto - SP (FAMERP). A quantitative, observational and cross-sectional study was performed in which the pre, intra and postoperative data were analyzed in an IQIC database. The data included gender, age, prematurity, weight, preoperative procedures, diagnosis, associated cardiac and non-cardiac anomalies, Risk Adjustment for Congenital Heart Surgery (RACHS-1), type of surgery, cardiopulmonary bypass (CPB), perfusion time, aortic clamping time and CPB temperature, bacterial sepsis, surgical site infection and other infections, length of stay in intensive care unit (ICU), length of hospital stay and in-hospital mortality. Results: The most prevalent procedures were complete atrioventricular septal defect repair (58 - 39.45%), followed by closure of ventricular septal defect (36 - 24.49%). The RACHS-1 categories 1, 2, 3 and 4 were distributed as 22 (15%); 49 (33.3%); 72 (49%) and 4 (2.7%), respectively. There were no procedures classified as categories 5 or 6. Bacterial sepsis occurred in 10.2% of cases, surgical site infection in 6.1%, other infections in 14.3%. The median length of ICU stay was 5 days and the median length of hospital stay was 11 days. In-hospital mortality was 6.8%. Conclusion: Surgical treatment in patients with CHD and DS usually does not require highly complex surgical procedures, but are affected by infectious complications, resulting in a longer ICU and hospital length of stay with considerable mortality.

Should arboviruses be the only diagnosis hypothesis in pregnant women in endemic areas presenting with a rash?

Abstract Listeria is an unusual pathogen that causes neonatal infection with high morbidity and mortality. We present the case of a premature newborn whose mother had a rash during pregnancy; the newborn had severe early sepsis because of Listeria monocytogenes and histopathologically suggestive findings of the placenta. Obstetricians and neonatologists should suspect listeriosis in cases with compatible epidemiological history, clinical features, and examination findings of the placenta.

Assessment of clinical and epidemiological characteristics of patients with and without sepsis in intensive care units of a tertiary hospital / Avaliação das características clínicas e epidemiológicas de pacientes com e sem sepse nas unidades de terapia intensiva de um hospital terciário

ABSTRACT Objective To describe the clinical and epidemiological features of patients with and without sepsis at critical care units of a public hospital. Methods A cross-sectional study was carried out from May 2012 to April 2013. Clinical and laboratory data of patients with and without sepsis in the intensive care units were reviewed of medical records. Results We evaluated 466 patients, 58% were men, median age was 40 years, and 146 (31%) of them were diagnosed with sepsis. The overall mortality was 20% being significantly higher for patients with sepsis (39%). The factors associated with intensive care unit mortality were the presence of sepsis (OR: 6.1, 95%CI: 3.7-10.5), age (OR: 3.6, 95%CI: 1.4-7.2), and length of hospital stay (OR: 0.96, 95%CI: 0.94-0.98). Pulmonary (49%) and intra-abdominal (20%) infections were most commonly identified sites, and coagulase-negative staphylococci and enteric Gram negative bacilli the most frequent (66%) pathogens isolated. Conclusion Although the impact of sepsis on mortality is related to patients' clinical and epidemiological characteristics, a critical evaluation of these data is important since they will allow the direct implementation of local policies for managing this serious public health problem.

RESUMO Objetivo Descrever as características clínicas e epidemiológicas de pacientes com sepse e sem sepse em unidades de cuidados intensivos de um hospital público. Métodos Estudo transversal realizado de maio de 2012 a abril de 2013. Os dados clínicos e laboratoriais de pacientes com sepse e sem sepse das unidades de terapia intensiva foram revisados a partir dos prontuários médicos. Resultados Avaliamos 466 pacientes, 58% homens, mediana de idade 40 anos; sendo 146 (31%) diagnosticados com sepse. A mortalidade global foi 20%, e significativamente maior para pacientes com sepse (39%). Os fatores associados à mortalidade em unidade de terapia intensiva foram a presença de sepse (OR: 6,1, IC95%: 3,7-10,5), idade (OR: 3,6, IC95%: 1,4-7,2) e tempo de internação (OR: 0,96, IC95%: 0,94-0,98). As infecções pulmonares (49%) e intra-abdominais (20%) foram os focos mais comumente identificados, e os estafilococos coagulase-negativa e bacilos entéricos Gram-negativos foram os patógenos isolados mais frequentes (66%). Conclusão Embora o impacto da sepse sobre a mortalidade esteja relacionado às características clínicas e epidemiológicas dos pacientes, uma avaliação crítica desses dados é importante, pois permitirá a implementação direta de políticas locais para gerenciar este grave problema de saúde pública.

Calcificación heterotópica miocárdica y pericarditis constrictiva en contexto de sepsis por a propósito de un caso / Case Report: Myocardial heterotopic calcification and constrictive pericarditis in the context of sepsis due to

We report the case of a 21 years old woman without history of cardiovascular disease, who after her first euthocic delivery, did complain of genital infection of white parts complicated by pneumonia and pyothorax, isolating Streptococcus pyogenes, requiring intensive care, inotropic and vasoactive medication. Transesophageal echocardiography showed constrictive pericarditis and myocardial heterotopic calcification in the context of sepsis. Subsequently, the pericardial constriction and clinical symptoms improved, with persistent calcifications. The echocardiogram prior to delivery was completely normal.

Presentamos el caso de una mujer de 21 años sin antecedentes cardiovasculares quien posterior a primer parto eutócico simple presenta infección genital de partes blancas complicada con neumonía y piotórax, aislándose Streptococcus pyogenes, ameritando cuidados intensivos, inotrópicos y vasoactivos. El ecocardiograma transesofágico evidenció pericarditis constrictiva y calcificación heterotópica miocárdica en contexto de sepsis. Posteriormente mejoró el cuadro de constricción pericárdica y la clínica, persistiendo las calcificaciones. El ecocardiograma previo al parto se encontraba completamente normal.

Emergence of bla NDM-1 associated with the aac(6')-Ib-cr, acrB, cps, and mrkD genes in a clinical isolate of multi-drug resistant Klebsiella pneumoniae from Recife-PE, Brazil

Abstract INTRODUCTION: The emergence of New Delhi metallo-β-lactamase (NDM) is concernig because it reduces the antibiotic therapy options for bacterial infections. METHODS: Resistant and virulent genes from an isolate of Klebsiella pneumoniae derived from a patient with sepsis in a hospital in Recife-PE, Brazil, were investigated using PCR and DNA sequencing. RESULTS: bla NDM-1, aac(6')-Ib-cr and acrB resistance genes, and cps and mrkD virulence genes were detected. CONCLUSIONS To our knowledge, this is the first report on bla NDM-1 in Recife-PE. This detection alerts researchers to the need to control the spread of bla NDM-1 resistance gene by this bacterium in Brazil.

Etiología aerobia de apendicitis aguda en adultos: Estudio multicéntrico de la sepsis abdominal en Argentina / Aerobic etiology of acute appendicitis in adults. Multicenter study of abdominal sepsis in Argentina

El tratamiento antibiótico de las apendicitis agudas se decide empíricamente basándose en la información epidemiológica. Las resistencias son variables entre regiones y los datos de Argentina son escasos. En el contexto de un estudio multicéntrico, observacional, de infecciones abdominales, se efectuó el análisis de los pacientes adultos con diagnóstico de apendicitis, incorporados al estudio entre enero 2014 y junio 2015, en 16 centros de 5 provincias argentinas. El objetivo fue analizar los gérmenes aeróbicos prevalentes, su resistencia a antibióticos y el patrón de prescripción antimicrobiana. Se estudiaron 131 apendicitis. Se aislaron 184 bacterias aerobias (1.4 bacterias/episodio): Escherichia coli 106 (57.6%), Klebsiella spp 16 (8.7%), Pseudomonas aeruginosa 19 (10.3%), Enterobacter spp. 2 (1%), otros bacilos Gram negativos 5 (2.7%). Enterococcus spp. 16 (8.7%) y otros cocos Gram positivos 20 (10.9%). La resistencia de E. coli y enterobacterias a ampicilina/sulbactam fue mayor a 34% y a ciprofloxacina mayor a 31%. En cambio, la resistencia de enterobacterias a piperacilina/tazobactam fue 4.8%, a ceftriaxona 9.5% y no se halló resistencia a carbapenemes. Respecto a amikacina fue 3.6% y a gentamicina 8.2%. En función de los resultados, el uso de quinolonas o de ampicilina/sulbactam para el tratamiento de las apendicitis debiera ser desaconsejado. Los esquemas basados en aminoglucósidos debieran ser jerarquizados en función de la sensibilidad hallada y su bajo impacto en la inducción de resistencias.

Antibiotic treatment for acute appendicitis is empirically chosen, based on epidemiological information. Resistance rates are different between regions and there are limited data on the situation in Argentina. As a part of a multicenter, observational study of abdominal infections, we performed the analysis of adult patients diagnosed with appendicitis, enrolled in 16 centers of 5 provinces, between Jan/01/2014 and Jun/30/2015. The aim was to analyze the prevalent aerobic pathogens, their resistance rates and the antimicrobial prescription pattern. On a total of 131 appendicitis cases analyzed, we found 184 aerobic pathogens (1.4 bacteria/episode): Escherichia coli 106 (57.6%), Klebsiella spp 16 (8.7%), Pseudomonas aeruginosa 19 (10.3%), Enterobacter spp. 2 (1%), other Gram negative bacilli 5 (2.7%); Enterococcus spp. 16 (8.7%) and other Gram positive cocci 20 (10.9%). The resistance rate of E. coli and enterobacteria to ampicillin/sulbactam was greater than 34% and greater than 31% to ciprofloxacin. However, the resistance of enterobacteria to piperacillin/tazobactam was 4.8%, to ceftriaxone 9.5%, to amikacin 3.6% and 8.2% to gentamicin. No resistance to carbapenems was found. The choice of quinolones or ampicillin/sulbactam for the treatment of appendicitis should be discouraged in our context, due to the high rates of resistance found in this prevalent etiology. Aminoglycoside-based treatments should be considered, given the findings of high antibiotic susceptibility and their low impact on the induction of resistance.

Descalonamento, adequação antimicrobiana e positividade de culturas em pacientes sépticos: estudo observacional / De-escalation, adequacy of antibiotic therapy and culture positivity in septic patients: an observational study

RESUMO Objetivo: Avaliar a prevalência de descalonamento antibiótico em pacientes com diagnóstico de sepse grave ou choque séptico em hospital acadêmico, público e terciário, além da adequação antibiótica e da positividade de culturas. Métodos: Foram analisadas prevalência de descalonamento, adequação antibiótica e positividade de culturas entre portadores de sepse grave e choque séptico, entre abril e dezembro de 2013, em uma unidade de terapia intensiva de um hospital universitário terciário. Resultados: Entre os 224 pacientes incluídos, o descalonamento era possível em 29,4% dos casos (66 pacientes), mas foi implementado em 19,6% deles (44 pacientes). Entre os pacientes que receberam descalonamento, metade foi por estreitamento de espectro antimicrobiano. A mortalidade foi de 56,3%, não havendo diferença entre pacientes com ou sem descalonamento (56,8% versus 56,1%; p = 0,999), assim como no tempo de internação. Terapia antimicrobiana empírica foi adequada em 89% dos casos. Houve isolamento de germe em 30% de todas as culturas e em 26,3% das hemoculturas. Conclusão: A taxa de adequação antibiótica empírica foi alta, refletindo ativa política institucional de monitorização do perfil epidemiológico e protocolos institucionais de uso de antimicrobianos. No entanto, o descalonamento antimicrobiano poderia ter sido maior do que o registrado. O descalonamento não impactou mortalidade.

ABSTRACT Objective: To evaluate the prevalence of antibiotic de-escalation in patients diagnosed with severe sepsis or septic shock at a public academic tertiary hospital and to evaluate antibiotic adequacy and culture positivity. Methods: The prevalence of antibiotic de-escalation, the adequacy of antibiotic treatment and the rates of culture positivity were analyzed in patients with severe sepsis and septic shock between April and December 2013 at an intensive care unit in a tertiary university hospital. Results: Among the 224 patients included in the study, de-escalation was appropriate in 66 patients (29.4%) but was implemented in 44 patients (19.6%). Among the patients who underwent de-escalation, half experienced narrowing of the antimicrobial spectrum. The mortality rate was 56.3%, with no differences between the patients with or without de-escalation (56.8% versus 56.1%; p = 0.999) nor in the length of hospital stay. Empirical antibiotic therapy was appropriate in 89% of cases. Microorganisms were isolated from total cultures in 30% of cases and from blood cultures in 26.3% of cases. Conclusion: The adequacy rate of empirical antibiotic therapy was high, reflecting an active institutional policy of monitoring epidemiological profiles and institutional protocols on antimicrobial use. However, antibiotic de-escalation could have been implemented in a greater number of patients. De-escalation did not affect mortality rates.

Thyroid abnormalities in term infants with fungal sepsis / Alterações tireoidianas no recém-nascido de termo com sepse fúngica

Summary Objective: To describe thyroid alterations in term newborns (TNB) with fungal sepsis during NICU hospitalization. Method: The study included six TNB that during the clinical and laboratory manifestations of sepsis with positive cultures for fungus showed changes in thyroid hormones, called low T3 syndrome and low T3-T4 syndrome. TNB that could present hormonal changes caused by disease as those born to mothers with thyroid disease, or who had perinatal asphyxia and major surgeries were excluded. Results: Of six TNB with fungal sepsis, five had positive culture for Candida albicans and one had positive culture for Candida tropicalis. Low T3 syndrome was observed in two TNB (50%), while T3-T4 syndrome was observed in other two (100%). The four children progressed to septic shock. Conclusion: Fungal sepsis is becoming more common among newborns admitted to NICU. Thyroid insufficiency could be a marker of disease severity with possible need for hormone supplementation.

Resumo Objetivo: descrever as alterações tireoidianas em recém-nascidos de termo (RNT) que apresentaram sepse fúngica durante internação na UTI neonatal. Método: foram incluídos seis RNT que, durante as manifestações clínicas e laboratoriais de sepse, com culturas positivas para fungo, apresentaram alterações dos hormônios tireoidianos, denominadas síndrome do T3 baixo e síndrome do T3 e T4 baixo. Foram excluídos RNT que apresentaram alteração hormonal por doença, como RNT filhos de mães com doença tireoidiana, asfixia perinatal e cirurgias de grande porte. Resultados: dos seis RNT com sepse fúngica, cinco apresentavam cultura positiva para Candida albicans e um para C. tropicalis. A síndrome do T3 baixo foi observada em duas crianças (50%) e a do T3 e T4 baixo em dois RN (100%). As quatro crianças evoluíram com choque séptico. Conclusão: a sepse fúngica é cada vez mais frequente nos recém-nascidos internados em UTI neonatal. A insuficiência tireoidiana pode vir a ser marcadora de gravidade da doença, e a suplementação hormonal pode ser necessária.

Endocarditis micótica en un recién nacido de extremadamente bajo peso al nacer: A propósito de un caso / Fungal endocarditis in an extremely low birth weight infant: Case report

Las tasas de supervivencia de los recién nacidos prematuros se han incrementado gracias a los avances tecnológicos y los conocimientos en constante evolución, aunque la sepsis de aparición tardía es más frecuente debido a los períodos prolongados de hospitalización de estos niños. Presentamos el caso de un recién nacido prematuro de extremadamente bajo peso al nacer hospitalizado con síndrome de dificultad respiratoria, enterocolitis necrosante y sepsis fúngica con endocarditis por Candida albicans. Se le administró tratamiento antimicótico hasta que se resolvió la vegetación fúngica. La sepsis y la endocarditis de origen micótico podrían ser una causa de morbilidad significativa en los recién nacidos prematuros. En este artículo revisamos las publicaciones científicas recientes acerca de los factores de riesgo, el diagnóstico, el tratamiento y la prevención de la sepsis fúngica en estos neonatos de alto riesgo.

Survival rates of premature infants have increased with developing technology and evolving knowledge but late-onset sepsis is more frequent due to prolonged hospitalization periods of these infants. We report the case of an extremely low birth weight premature infant who was admitted with respiratory distress syndrome, developed necrotizing enterocolitis and fungal sepsis with endocarditis by Candida albicans. He was treated with antifungal therapy until fungal vegetation resolved. Fungal sepsis and endocarditis may be an important morbidity in preterm infants; we review the recent literature about the risk factors, diagnosis, treatment and prevention of fungal sepsis in these high risk infants.

Tiempo de crecimiento bacteriano en hemocultivos en neonatos / Time bacterial growth in blood cultures in neonates Abstract

Introducción: La sepsis es causa importante de morbimortalidad neonatal. Objetivos: Detectar el tiempo en que la curva de crecimiento bacteriano es evidenciada en la muestra de sangre inoculada en los hemocultivos y comparar estos tiempos de crecimiento bacteriano entre bacterias gramnegativas y grampositivas, entre los tipos de sepsis neonatal y determinar las bacterias más frecuentemente aisladas entre neonatos prematuros y de término. Pacientes y método: Estudio descriptivo de recién nacidos en riesgo de sepsis o con sospecha de sepsis por manifestaciones clínicas o de laboratorio, en que se evaluaron 114 hemocultivos positivos entre 1.932 hemocultivos tomados entre mayo de 2010 y mayo de 2014. Los datos se analizaron con Stata® 11.0. Resultados: El 5,9% de los hemocultivos tuvieron crecimiento bacteriano. La mediana y rango intercuartílico de tiempos de crecimiento bacteriano para gramnegativos fue 11 h (10-13 h), para grampositivos diferentes a Staphylococcus coagulasa negativo (SCoN) 12 h (12-18 h) y para SCoN 42h (36-44h). El 95,8% de las bacterias grampositivas y el 96% de las gramnegativas tuvieron tiempos de crecimiento bacteriano ≤ 24 h de incubación, mientras que en los SCoN el 100% de los hemocultivos fue positivo en ≤ 62 h de incubación. Conclusión: El 100% de sepsis por bacterias gramnegativas, grampositivas no SCoN y 90% de las ocasionadas por SCoN, son identificadas en los hemocultivos en las primeras 48 h, por lo cual podemos concluir que para descartar una sepsis, un período de incubación en hemocultivos de 48 h es suficiente.

Introduction: Sepsis is a major cause of neonatal morbidity and mortality. Objectives: To detect the time when the bacterial growth curve is evidenced in the blood sample inoculated blood cultures and comparing the times of bacterial growth between Gram negative and Gram positive bacteria, among the types of neonatal sepsis and identifying microorganisms more often isolated from preterm and term. Patients and method: A descriptive study. 114 positive blood cultures from 1,932 blood cultures taken from 01-May-2010 and 31-May-2014 were evaluated. Data were analyzed with Stata® 11.0. Results: 5.9% of blood cultures had bacterial growth. The median and interquartile range of Gram negative times of bacterial growth was 11 h (10-13 h), for Gram positive coagulase-negative Staphylococcus different (CoNS) 12h (12-18h) and CoNS 42h (36-44h). 95.8% of Gram positive and 96% of Gram negative, were the times of bacterial growth ≤ 24 h incubation, whereas the 100% CoNS was positive ≤ 62 h of incubation. Conclusion: 100% of sepsis by Gram negative and Gram positive no CoNS and 90% of those caused by CoNS are identified in blood cultures in 48 h, so we can conclude that to rule out sepsis, an incubation period of 48 h in blood cultures is sufficient.

Etiologia e fatores prognósticos da sepse em crianças e adolescentes admitidos em terapia intensiva / Etiology and prognostic factors of sepsis among children and adolescents admitted to the intensive care unit

RESUMOObjetivo:Determinar a etiologia e as variáveis clínicas e evolutivas da sepse associadas ao prognóstico nos pacientes internados em unidade de terapia intensiva pediátrica.Métodos:Série de casos prospectiva e retrospectiva. Coleta de dados nos prontuários de pacientes com diagnóstico de sepse internados na unidade de terapia intensiva pediátrica de hospital geral, de janeiro de 2011 a dezembro de 2013. Foram identificadas bactérias em culturas de sangue e líquidos biológicos. As variáveis idade, sexo, esquema vacinal, comorbidades, uso prévio de antibióticos, dados clínicos à admissão e complicações na evolução foram comparadas nos grupos sobrevida e óbito (nível de significância de 5%).Resultados:Foram incluídos 115 pacientes, com média de idade de 30,5 meses. Etiologia bacteriana foi identificada em 40 pacientes. Perfusão periférica alterada à admissão e diagnóstico de sepse grave mostraram-se fatores associados às complicações. Houve maior número de complicações no grupo com idade maior de 36 meses (p = 0,003; odds ratio = 4,94). A presença de complicações durante a internação foi fator associado ao óbito (odds ratio = 27,7). As principais etiologias foram: bactérias Gram-negativas (15/40), Staphylococcus aureus (11/40) e Neisseria meningitidis (5/40).Conclusão:Bactérias Gram-negativas e Staphylococcus aureuspredominaram na etiologia da sepse em crianças e adolescentes admitidos em terapia intensiva. A gravidade da sepse e a perfusão periférica alterada à admissão estiveram associadas às complicações. A presença de complicações foi fator associado ao óbito.

ABSTRACTObjective:To determine the etiology and clinical disease progression variables of sepsis associated with the prognosis of patients admitted to a pediatric intensive care unit.Methods:Prospective and retrospective case series. Data were collected from the medical records of patients diagnosed with sepsis who were admitted to the pediatric intensive care unit of a general hospital from January 2011 to December 2013. Bacteria were identified in blood and fluid cultures. Age, sex, vaccination schedule, comorbidities, prior antibiotic use, clinical data on admission, and complications during disease progression were compared in the survival and death groups at a 5% significance level.Results:A total of 115 patients, with a mean age of 30.5 months, were included in the study. Bacterial etiology was identified in 40 patients. Altered peripheral perfusion on admission and diagnosis of severe sepsis were associated with complications. A greater number of complications occurred in the group of patients older than 36 months (p = 0.003; odds ratio = 4.94). The presence of complications during hospitalization was associated with death (odds ratio = 27.7). The main etiological agents were Gram-negative bacteria (15/40), Staphylococcus aureus (11/40) and Neisseria meningitidis (5/40).Conclusion:Gram-negative bacteria and Staphylococcus aureus predominated in the etiology of sepsis among children and adolescents admitted to an intensive care unit. The severity of sepsis and the presence of altered peripheral perfusion on admission were associated with complications. Moreover, the presence of complications was a factor associated with death.

Sepsis neonatal temprana, incidencia y factores de riesgo asociados en un hospital público del occidente de México / Early neonatal sepsis, incidence and associated risk factors in a public hospital in western Mexico

Background: Early neonatal sepsis (EOS) is the second leading cause of death in the first week of life. Epidemiology differs in developed and developing countries. Aim: To describe the epidemiology of EOS among newborn patients in a public hospital in western Mexico. Methods: A prospective cohort study was performed in newborns of Nuevo Hospital Civil de Guadalajara "Dr. Juan I Menchaca". EOS was diagnosed with blood cultures or cultures of cerebrospinal fluid within the first 72 h of life. We analyzed risk factors (RF) by multivariate analysis with logistic regression. Results: We identified an EOS incidence of 4.7 events per 1,000 live births. Seventy two percent of the isolated bacteria were gram negative bacilli. Factors associated with EOS were maternal age ≤ 15 years (OR 3.50; 95% CI 1.56-7.85), rupture of membranes > 18 h (OR 2.65; 95% CI 1.18-5.92), maternal fever (OR 6.04; 95% CI 1.54-23.6), birth weight ≤ 2,500 g (OR 4.82; 95% CI 2.38-9.75) and gestational age < 37 weeks (OR 3.14; 95% CI 1.58-6.22). Conclusions: In addition to the RF known for EOS an independent association was observed with maternal age ≤ 15 years.

Introducción: La sepsis neonatal temprana (SNT) es la segunda causa de muerte en la primer semana de vida; la epidemiología difiere en países desarrollados y en vías de desarrollo. Objetivo: Describir la epidemiología de SNT en recién nacidos (RN) de un hospital público del occidente de México. Material y Métodos: Estudio de cohorte prospectivo en RN del Nuevo Hospital Civil de Guadalajara "Dr. Juan I Menchaca". Se diagnosticó SNT con cultivos de sangre o líquido cefalorraquídeo en las primeras 72 h de vida. Se indagaron factores de riesgo (FR) mediante análisis multivariado con regresión logística. Resultados: La incidencia de SNT fue de 4,7 eventos por 1.000 RN vivos. El 72% de las bacterias aisladas correspondió a bacilos gramnegativos. Los factores asociados a SNT fueron la edad materna ≤ 15 años (OR 3,50; IC 95% 1,56-7,85), ruptura de membranas > 18 h (OR 2,65; IC 95% 1,18-5,92), fiebre materna (OR 6,04; IC 95%1,54-23,6), peso al nacimiento ≤ 2.500 g (OR 4,82; IC 95% 2,38-9,75) y edad gestacional < 37 semanas (OR 3,14; IC 95% 1,58-6,22). Conclusiones: Además de los FR ya conocidos para SNT se observó asociación independiente con edad materna ≤ 15 años.

Clinico-microbiological study of neonatal sepsis.

Neonatal sepsis, a systemic infection manifesting in the first month of life is a leading cause of mortality in the newborn .Blood culture is the main stay in the diagnosis of neonatal sepsis. The present study focuses on the bacterial agents, the antibiogram and the clinical risk factors associated with neonatal sepsis. One hundred and ten neonates with clinical suspicion of neonatal sepsis were included in this study. Bacterial pathogens isolated in positive blood cultures were identified and the antibiotic susceptibility testing was performed. The risk factors were noted from the case records & statistical analysis was done using the Chi square test. Thirty six (32.72%) cultures were positive among 110 suspected cases of neonatal sepsis. 22(61.11%) cases presented with early onset sepsis and 14(38.89%) presented as late onset sepsis. The common bacteria isolated were Klebsiella spp., Escherichia coli & Staphylococcus aureus. Antibiotics effective against gram negative bacilli were cefaperazone/sulbactam and piperacillin/tazobactam. The rate of Methicillin resistant Staphylococcus aureus isolation was 57%. Gram negative bacilli predominate as agents of neonatal sepsis & antibiotic resistance among bacteria is on rise. Thus there is a need for continuous screening and surveillance for antibiotic resistance in NICU.