Pre-operative Colonization by Staphylococcus aureus and Cephalosporin Non-susceptible Bacteria in Patients with Proximal Femoral Fractures / Colonização pré-operatória por Staphylococcus aureus e as bactérias não suscetíveis à cefalosporina, em pacientes com fratura proximal do fêmur

Abstract Objective To estimate the frequency of Staphylococcus aureus and cephalosporin nonsusceptible bacteria colonization in patients with proximal femoral fracture during preoperative hospitalization. Methods Prevalence and incidence assessment in 63 hospitalized patients over 1 year. The median time of pretreatment hospitalization was 12 days. Samples were collected from the nostrils, groin skin and anal mucosa during the pretreatment hospitalization and were tested by the disc-diffusion technique. Results The hospital colonization incidence and the prevalence of positive results were 14.3 and 44.4% for S. aureus; 3.2 and 6.4% for meticillin-resistant S. aureus; 28.6 and 85.7% for meticillin-resistant coagulase-negative Staphylococcus; 28.6 and 61.9% for cefazolin nonsusceptible Enterobacteriaceae (KFNSE); and 20.6 and 28.6% for cefuroxime nonsusceptible Enterobacteriaceae (CXNSE). In addition, factors such as to the duration of the pretreatment hospitalization period, being non-walker before fracture, antimicrobial use, American Society of Anesthesiologists (ASA) 4 surgical risk, and previous hospitalization, were related to an increase in the incidence of hospital acquisition and prevalence of colonization by the evaluated strains. The prevalence of colonization by KFNSE was three times higher than by CXNSE on admission, and twice as high at the time of fracture treatment. Conclusion There was a high incidence of hospital colonization and prevalence of colonization by all strains studied, which may guide the indication of prophylactic measures for infection.

Resumo Objetivo Estimar a frequência da colonização por Staphylococcus aureus e as bactérias não suscetíveis à cefalosporina, em pacientes com fratura proximal do fêmur durante a internação pré-operatória. Métodos Avaliação da prevalência e incidência em 63 pacientes hospitalizados ao longo de um ano. O tempo médio de internação pré-tratamento foi de 12 dias. As amostras foram coletadas das narinas, pele da virilha e mucosa anal, durante a internação prévia ao tratamento e testadas pela técnica de disco-difusão. Resultados A incidência da colonização hospitalar e a prevalência de resultados positivos foram de 14,3% e 44,4% para Staphylococcus aureus; 3,2% e 6,4% para S. aureus resistente à meticilina; 28,6% e 85,7% para Staphylococcus coagulase-negativo resistente à meticilina; 28,6% e 61,9% para Enterobacteriaceae não suscetível à cefazolina (KFNSE); e 20,6% e 28,6% para Enterobacteriaceae não suscetível à cefuroxima (CXNSE). Além da duração do período de internação pré-tratamento, os pacientes não deambularam previamente à ocorrência da fratura e nem fizeram uso de antimicrobiano. Além disso, a duração do período de internação pré-tratamento cirúrgico, ser não-deambulador antes da fratura, uso de antimicrobianos, risco cirúrgico IV pela American Society of Anesthesiologists (ASA) e internação anterior, estiveram relacionados a um aumento na incidência de aquisição hospitalar e prevalência de colonização pelas cepas avaliadas. A prevalência de colonização pela KFNSE foi três vezes maior do que pela CXNSE na admissão e duas vezes maior no momento do tratamento da fratura. Conclusão Observou-se uma alta incidência da colonização hospitalar e prevalência da colonização por todas as cepas estudadas, o que pode orientar a indicação de medidas profiláticas contra a infecção.

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study

Abstract INTRODUCTION: Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil. METHODS This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome. RESULTS: Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%. CONCLUSIONS: In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

High-resolution computed tomography findings in young infants with cystic fibrosis detected by newborn screening

OBJECTIVE: High-resolution computed tomography (HRCT) allows the early detection of pathological changes in the lung structure, and reproducible scoring systems can be used to quantify chest computed tomography (CT) findings in patients with cystic fibrosis (CF). The aim of the study was to describe early HRCT findings according to a validated scoring system in infants with CF diagnosed by newborn screening (NBS). METHODS: This cross-sectional study included infants with CF diagnosed by NBS who were born between January 2013 and January 2017 and who underwent HRCT scanning within the first year after diagnosis when they were clinically stable. The CT scans were evaluated using the modified Bhalla score. RESULTS: Thirty-two subjects underwent HRCT scanning. The mean total-modified Bhalla score was 3.6±2.1, and 93.8% of the scans were abnormal. Pseudomonas aeruginosa airway colonization was associated with increased modified Bhalla score values. Bronchial wall thickening was the most common feature (90.6%), followed by bronchial collapse/consolidation (59.4%), mosaic attenuation/perfusion (50%), bronchiectasis (37.5%) and mucus plugging (15.6%). Bronchial wall thickening was diffuse in most of the patients. CONCLUSION: A substantial proportion of infants diagnosed with CF after detection by NBS already showed evidence of lung disease. P. aeruginosa colonization was associated with increased Bhalla scores, highlighting the importance of this CF pathogen in early structural lung disease. The presence of bronchial wall thickening at such a young age may reflect the presence of airway inflammatory processes. The detection and quantification of structural abnormalities with the modified Bhalla score may aid in the identification of lung disease before it is clinically apparent.

Methicillin-resistant Staphylococcus aureus in cystic fibrosis patients: do we need to care? A cohort study

ABSTRACT CONTEXT AND OBJECTIVE: The prevalence of a variety of potentially pathogenic microorganisms in cystic fibrosis patients, such as methicillin-resistant Staphylococcus aureus (MRSA), has increased over the past decade. Given the increasing prevalence of MRSA and the few data available in the literature, better understanding of the clinical repercussions of colonization by this bacterium in cystic fibrosis patients becomes essential. This study aimed to evaluate the repercussions of chronic colonization by MRSA in cystic fibrosis patients. DESIGN AND SETTING: Retrospective cohort study from January 2004 to December 2013 in a cystic fibrosis reference center. METHODS: Each patient with cystic fibrosis was evaluated for nutritional status (body mass index, BMI, and BMI percentile), pulmonary function and tomographic abnormalities (modified Bhalla scores) at the time of chronic colonization by MRSA or methicillin-susceptible Staphylococcus aureus (MSSA) and throughout the study period. RESULTS: Twenty pairs of patients were included. There were no significant differences between the groups regarding nutritional characteristics. Spirometric data showed a trend towards greater obstruction of the airways in patients with MRSA. Patients with MRSA presented greater structural damage to their lungs, demonstrated not only by the total Bhalla score but also by its parameters individually. CONCLUSIONS: Patients colonized by MRSA presented greater functional and structural respiratory impairment at the time of chronic colonization. Disease progression was also faster in patients chronically colonized by MRSA than in those with MSSA. This was shown through comparisons that avoided possible confounding variables.

Molecular characterization of methicillin-resistant Staphylococcus aureus isolated from blood in Rio de Janeiro displaying susceptibility profiles to non-ß-lactam antibiotics

Abstract The distinction between healthcare-associated MRSA (HA-MRSA) and community-associated MRSA (CA-MRSA) infections has become increasingly blurred. We assessed the molecular characterization and antimicrobial resistance profile for MRSA isolates from blood. Most of all (81.9%) isolates are related to known HA-MRSA and CA-MRSA epidemic lineages, such as, USA300, USA400, USA600, USA800 and USA1100. This is the first multicenter study in Rio de Janeiro.

Genomic information on multidrug-resistant livestock-associated methicillin-resistant Staphylococcus aureus ST398 isolated from a Brazilian patient with cystic fibrosis

Alarmingly, the isolation of methicillin-resistant Staphylococcus aureus (MRSA) has been increasing among patients with cystic fibrosis (CF). During a previous molecular characterisation of MRSA isolates obtained from patients with CF from Rio de Janeiro, Brazil, one isolate was identified as the ST398 clone, a livestock-associated (LA) MRSA. In this study, we report the draft genome sequence of an LA-MRSA ST398 clone isolated from a patient with CF.

Draft genome sequences of four Achromobacter ruhlandii strains isolated from cystic fibrosis patients

Achromobacter species are being increasingly isolated from the respiratory tract of cystic fibrosis patients. Recent reports indicate that Achromobacter ruhlandii is a potential human pathogen in cystic fibrosis-related infections. Here we report the draft genome of four A. ruhlandii strains isolated from cystic fibrosis patients in Brazil. This report describes A. ruhlandii as a potential opportunistic pathogen in cystic fibrosis and provides a framework to for additional enquires into potential virulence factors and resistance mechanisms within this species.

Draft genome sequence of Acinetobacter pittii ST643 shared by cystic fibrosis patients

Acinetobacter pittii has emerged as an important hospital pathogen that is associated with outbreaks and drug resistance. In cystic fibrosis (CF) patients, the detection of Acinetobacter spp. is rare; however, we isolated the A. pittii sequence type ST643 in several Brazilian CF patients treated in the same centre. The current study describes the draft genome of A. pittii ST643.

Comparison of the worldwide transmissible Pseudomonas aeruginosa with isolates from brazilian cystic fibrosis patients

Cross-infection with Pseudomonas aeruginosa among cystic fibrosis (CF) patients is a rare occurrence. However, the emergence of transmissible strains has been reported between unrelated individuals. We analyzed the genetic relationship among P. aeruginosa isolates from Brazilian CF patients and transmissible clones which are worldwide spread. The data does not indicate the presence of closely related variant clones.

O Sistema de reparo do DNA em Pseudomonas aeruginosa: caracterização molecular e ocorrência natural de mutantes / The DNA repair system in Pseudomonas aeruginosa: molecular characterization and naturally occurring mutant

A infecção pulmonar é uma das principais causas de morbidade e mortalidade em pacientes com Fibrose Cística (FC). O prognóstico destes pacientes é influenciado pelo número de exacerbações anuais e a carga microbiana nas secreções respiratórias. Pseudomonas aeruginosa é o principal patógeno, tanto em importância quanto em prevalência. Recentemente, foi demonstrada a ocorrência de cepas de P. aeruginosa altamente transmissíveis em centros de atendimento a pacientes com FC. A persistência de P. aeruginosa no pulmão de pacientes com FC está associada, em parte, à presença de cepas com hipermutabilidade (HPM), um fenômeno decorrente, principalmente, de defeitos em genes envolvidos no sistema de reparo do DNA. Tivemos como objetivo investigar a ocorrência de cepas HPM em P. aeruginosa, associadas às infecções pulmonares crônicas em pacientes com FC, bem como, avaliar a associação entre HPM, resistência a antimicrobianos e expressão de fatores de virulência. Das 179 amostras bacterianas estudadas, isoladas de 17 (85%) dos 20 pacientes incluídos no estudo, 43 (24%) apresentaram HPM seguindo os critérios estabelecidos por Maciá e colaboradores. Essas subpopulações apresentaram maiores taxas de resistência a antimicrobianos. As amostras estudadas apresentaram grande variabilidade genética (49 perfis definidos com a utilização da técnica de RADP), embora tenha sido observada, também, a incidência de clones compartilhados por diferentes pacientes. Não encontramos similaridade entre os clones estudados e as cepas epidêmicas circulantes em outros países. Das 43 amostras classificadas como HPM pelos critérios de Macia e colaboradores, apenas 3 delas apresenteram frequência de mutação que permitisse sua classificação como HPM. Com o sequenciamento do DNA encontramos mutações que levaram a mudança de aminoácidos nas proteínas codificadas pelos genes mutS, MutD e urvD. Não observamos mutações nos genes mutM, mutT e mutY que pudessem alterar os aminoácidos sintetizados...

Pulmonary infection is a major cause of morbidity and mortality in patients with Cystic Fibrosis (CF). The prognosis of these patients is influenced by the number of annual exacerbations of the infectious processes and the microbial load in their respiratory secretions. Pseudomonas aeruginosa is the mais CF pathogen, both in importance and predominance. Recently, highly transmissible P. aeruginosa strains were reported among CF patients from different CF Health Care centers. The persistance of P. aeruginosa in the lung of CF patients is associated, at leat in part, with the presence of strains with hipermutability (HPM), a phenomenon caused mainly by defects in genes involved in the DNA repair system. In this report, 43 (24%) out of 179 P. aeruginosa isolates recovered from 17 (85%) out of 20 CF patients included in the study were characterized as HPM, according to the criteria established by Maciá and collegues. The HPM subpopulations exhibited higher rates of antimicrobial resistance. By using the RAPD technique, bacteria included in our study were shown to exhibit high genetic variability and could be grouped in 49 different clones. However, a few clones were shared by different patients. No similarity was detected among these clones and epidemic strains from others countries. Of the 43 isolates classified as HPM by Maciá's criteria, only 3 exhibited mutation frequencies allowing their inclusion in the HPM group. By sequencing the DNA from these bacteria we found mutations in the genes mutS, mutD and urvD that resulted in changes in the aminoacids sequences. We did not observe mutations in the genes mutM, mutT and mutY that could have altered the aminoacid sequence from synthesized protein. Since there are only a few report in the literature on the influence of HPM on bacterial phenotypic alterations other than antimicrobial resistance, we also compared 81 bacterial isolates from the wild populations and HPM subpopulations in virulence properties...

Infecção pulmonar por Pseudomonas aeruginosa na fibrose cística: diagnótico sorológico e conduta / Pseudomonas aeruginosa pulmonary infection in cystic fibrosis: serologic diagnosis and therapeutic / Infección pulmonar por Pseudomonas aeruginosa en la fibrosis cística: diagnóstico serológico y conducta

Objetivo: avaliar o diagnóstico da infecção e colonização pulmonar por Pseudomonas aeruginosa (Pa), através da detecção de anticorpos séricos específicos em pacientes fibrocísticos.Fontes pesquisadas: foi revisada a base de dados Medline, no período de 1986 a 2007, com os descritores fibrose cística e pseudomonas. Síntese dos dados: as alterações no transporte de íons nas células epiteliais levam à obstruçãocrônica das vias aéreas, com infecções secundárias. A Pa mucóide é o principal agente que aumenta a morbidade e a mortalidade nos pacientes fibrocísticos. A erradicação da bactéria é possível com antibioticoterapia precoce, queaumenta a sobrevida dos pacientes. A cultura de secreções respiratórias apresenta limitação como método diagnóstico, pela dificuldade decoleta da amostra. Parece promissora a detecção de anticorpos específicos no soro para Pa, que, em muitos casos, precede o isolamento bacterianoem cultura. O método mais utilizado é ode ELISA, com pesquisa de IgG ou IgG, IgM, e IgA. A positividade da sorologia não discrimina entre colonização e infecção pulmonar e, a condutaantibiótica não é uniforme nessa situação. Conclusões: a pesquisa sorológica de anticorpos para Pa pode ser útil no tratamento do pacientefibrocístico. Complementa a avaliação clínica, permite reavaliações não invasivas durante a evolução e possibilita a antibioticoterapia precoceem parte dos casos.

Objective: to evaluate the diagnosis of lung infection and colonization by Pseudomonas aeruginosa (Pa) through the detection of specific seric antibodies in fibrocystic patients. Data sources: the Medline database, was searched in the period 1986 to 2007, with the keywords cystic fibrosisand pseudomonas. Data synthesis: the epithelium cells disturb in ion transport cause a chronic airways obstruction, with secondary infections. Themucoid Pa is the main agent that increases morbidity and mortality in fibrocystic patients. The Objective: to evaluate the diagnosis of lung infectionand colonization by Pseudomonas aeruginosa (Pa) through the detection of specific seric antibodies in fibrocystic patients. Data sources: the Medline database, was searched in the period1986 to 2007, with the keywords cystic fibrosis and pseudomonas. Data synthesis: the epithelium cells disturb in ion transport cause a chronic airwaysobstruction, with secondary infections. The mucoid Pa is the main agent that increases morbidity and mortality in fibrocystic patients. The bacteria eradication is possible with early antibiotic therapy, which increases patients’ survival period. Respiratory secretions culture is limited as a diagnostic method, due to the difficulty incollecting samples. The detection of specific antibodies in serum for Pa, which in many cases precedesthe bacteria isolation in culture, seems to be promising. The most used method is the ELISA, with survey of IgG or IgG, IgM, and IgA. The serological positive result does not make a distinctionbetween lung colonization and infection, and the antibiotic procedure is not uniform in such situation. Conclusions: the serological antibodies survey for Pa can be useful in the treatment of fibrocystic patients. It completes the clinical evaluation, allowing non invasive reevaluations during the evolution as well as an early antibiotictherapy in some cases.

Objetivo: evaluar el diagnostico de la infección y colonización pulmonar por Pseudomonas aeruginosa (Pa) en pacientes con fibrosis cística, mediante la detección de anticuerpos sericosespecíficos. Fuente de los datos: fueron seleccionados los artículos en la base de datos Medline publicados entre 1986 y 2007, con las palabras clave fibrose cistica y pseudomonas. Síntesis delos datos: las alteraciones en el transporte de los iones de las células epiteliales llevan a la obstruccióncrónica de las vias aereas, con infecciones secundarias. La Pa mucoide es el principal agente que aumenta la morbidad y mortalidad de los pacientes fibrocisticos. La eliminación de labacteria es posible con antibióticoterapia precoz, qui determina mayor sobrevida de los pacientes.Lo cultivo de secreciones respiratorias presenta limitación como método diagnóstico, determinada por la dificultad de recolectar la muestra. Ladetección de anticuerpos específicos en el suero para Pa en muchos casos precede el islamiento bacteriano en cultura. Lo metodo más utilizadoes el de ELISA, con pesquisa de IgG, o IgG IgM y IgA. El resultado positivo non discrimina entre la ocurrencia de colonización o infección pulmonary, por lo tanto, a conducta non es uniforme en esta situación. Conclusiones: la pesquisa serologicade anticuerpos para Pa puede ser util en el tratamiento del paciente con fibrose cística. Complementa la evaluación clinica, permite reevaluaciones non invasivas, y posibilita la antibioticoterapia precoz en parte dos casos.