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

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

Lack of association of the KIR and HLA class I ligands with ZIKV infection in south and southeast of Brazil

BACKGROUND Zika virus (ZIKV) is an emerging arbovirus associated with foetal malformations and neurological complications. The infection is usually associated with mild symptoms. The comparison between the allelic frequency of polymorphic genes in symptomatic infected individuals in the population can clarify the pathogenic mechanisms of ZIKV. During ZIKV infection, cytokines are produced and natural killer (NK) cells are recruited, whose activation depends on signaling pathways activated by specific receptors, such as killer cell immunoglobulin-like receptors (KIR). These molecules interact with human leukocyte antigen (HLA) class I ligands and are encoded by polymorphic genes. OBJECTIVES This study aimed to evaluate the frequency of allelic variants of the genes encoding the KIR receptors and their HLA class I ligands in 139 symptomatic ZIKV-patients and 170 controls negative for the virus, and to evaluate the role of these variants for ZIKV susceptibility. METHODS KIR and HLA class I genes were genotyped using the polymerase chain reaction-sequence specific oligonucleotide (PCR-SSO) technique. FINDINGS No significant differences in the frequency distribution of KIRs and KIR-HLA in patients compared to controls were observed. MAIN CONCLUSIONS KIR and its HLA ligands might play a minor role in ZIKV infection in the south and southeast Brazilian individuals.

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

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

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

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

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

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital / Sucesso no controle da transmissão hospitalar de Enterococos resistentes a vancomicina em um hospital universitário público brasileiro

INTRODUCTION: Vancomycin-resistant enterococci (VRE) can colonize or cause infections in high-risk patients and contaminate the environment. Our objective was to describe theepidemiological investigation of an outbreak of VRE, the interventions made, and their impact on its control. METHODS: We conducted a retrospective, descriptive, non-comparative study by reviewing the charts of patients with a VRE-positive culture in the University Hospital of Campinas State University, comprising 380 beds, 40 of which were in intensive care units (ICUs), who were admitted from February 2008-January 2009. Interventions were divided into educational activity, reviewing the workflow processes, engineering measures, and administrative procedures. RESULTS: There were 150 patients, 139 (92.7%) colonized and 11 (7.3%) infected. Seventy-three percent were cared for in non-ICUs (p = 0.028). Infection was more frequent in patients with a central-line (p = 0.043), mechanical ventilation (p = 0.013), urinary catheter (p = 0.049), or surgical drain (p = 0.049). Vancomycin, metronidazole, ciprofloxacin, and third-generation cephalosporin were previously used by 47 (31.3%), 31 (20.7%), 24 (16%), and 24 (16%) patients, respectively. Death was more frequent in infected (73%) than in colonized (17%) patients (p < 0.001). After the interventions, the attack rate fell from 1.49 to 0.33 (p < 0.001). CONCLUSIONS: Classical risk factors for VRE colonization or infection, e.g., being cared for in an ICU and previous use of vancomycin, were not found in this study. The conjunction of an educational program, strict adhesion to contact precautions, and reinforcement of environmental cleaning were able to prevent the dissemination of VRE.

INTRODUÇÃO: Enterococos resistentes a vancomicina (ERV) podem colonizar e causar infecção em pacientes de alto risco, bem como contaminar o ambiente. Nosso objetivo foi descrever a investigação epidemiológica de um surto de ERV, as intervenções realizadas e o impacto no controle do surto. MÉTODOS: Estudo retrospectivo, descritivo, por revisão de prontuários de pacientes com cultura positiva para ERV em um hospital geral, público, universitário, admitidos entre fevereiro de 2008 e janeiro de 2009. As intervenções foram divididas em ações educacionais, revisão de processos de trabalho, medidas administrativas e de engenharia. RESULTADOS: Foram avaliados 150 pacientes, 139 (92,7%) colonizados e 11 (7,3%) infectados por ERV. Setenta e três por cento estavam internados em unidades de cuidados não intensivos (p=0,028). Infecção por ERV foi mais frequente em pacientes usando cateter venoso central (p=0,043), ventilação mecânica (p=0,013), cateter urinário (p=0,049) ou drenos cirúrgicos (p=0,049). Vancomicina, metronidazol, ciprofloxacina ou cefalosporina de terceira geração foram utilizados previamente por 47 (31,3%), 31 (20,7%), 24 (16%) e 24 (16%) pacientes, respectivamente. Óbito foi mais frequente em pacientes infectados por ERV (73%) em relação aos colonizados (17%) (p<0,001). Após as intervenções, a taxa de ataque diminuiu de 1,49 para 0,33 (p<0,001). CONCLUSÕES: Fatores de risco clássicos para colonização ou infecção por ERV, como internação em unidade de terapia intensiva e uso prévio de vancomicina, não foram identificados neste estudo. Um conjunto de intervenções, tais como programa educacional, maior adesão às precauções de contato e reforço da limpeza ambiental apresentou impacto no controle da disseminação hospitalar do ERV.

Methicillin-resistant Staphylococcus aureus DNA electrophoretic pattern: temporal changes in an endemic hospital environment / Patrón electroforético del ADN de Staphylococcus aureus resistente a la meticilina: cambios temporales en unmedio hospitalario endémico

Objective. To describe the analysis of geographical and temporal distribution of DNA profiles determined by pulsed-field gel electrophoresis (PFGE) of methicillin-resistant Staphylococcusaureus (MRSA) strains isolated from hospitalized patients in a tertiary care university hospital in Brazil. Methods. Ninety-nine samples of MRSA obtained from 89 patients in the period 1999–2004 were studied. MRSA strains were isolated from central venous catheters (33 isolates) and bloodstream infections (66 strains). PFGE with 20 units of SmaI restriction endonucleasewas used for genomic typing. Results. Analysis of DNA PFGE of 99 strains of MRSA revealed 26 profiles and theirrespective related profiles. The mean time interval for detecting MRSA infection was 26 days from hospital admission. Forty-nine patients (57.6%) had a recent hospitalization. The DNAPFGE MRSA profiles were distributed in three clonal groups—I, II, and III—according to the period of time when the MRSA strains were isolated. DNA PFGE MRSA profiles were spreadhomogeneously through all hospital wards. Conclusions. Changes in the distribution of DNA PFGE MRSA profiles were largely temporal, with clonal groups being replaced over time, without predominance in any hospitalward or any specific area of the hospital.

Objetivo. Analizar la distribución geográfica y temporal de los perfiles de ADN determinados mediante electroforesis en gel de campo pulsado (PFGE) de cepas de Staphylococcus aureus resistente a la meticilina (SARM) aisladas de pacientes internados en un hospital universitario de atención terciaria en el Brasil. Métodos. Se estudiaron 99 muestras de SARM obtenidas 89 de pacientes en el período1999–2004. Las cepas de SARM se aislaron de infecciones de catéteres venosos centrales (33 aislados) y del torrente sanguíneo (66 cepas). Para la tipificación genómica se empleó PFGE con 20 unidades de endonucleasa de restricción SmaI. Resultados. El análisis del ADN de 99 cepas de SARM mediante PFGE reveló 26 perfiles, con sus respectivos perfiles relacionados. El intervalo medio de detección de la infección por SARM fue de 26 días desde el ingreso al hospital. En 49 pacientes (57,6%) había habido una hospitalización previa reciente. Los perfiles de ADN de SARM determinados mediante PFGE se distribuyeron en tres grupos clonales —I, II y III— según el período en el que se aislaron las cepas de SARM. Estos perfiles de ADN se encontraban distribuidos de manera homogénea en todos los servicios del hospital. Conclusiones. Los cambios en la distribución de los perfiles de ADN de SARM determinados mediante PFGE fueron en gran medida temporales, con reemplazo de los grupos clonales con el transcurso del tiempo, y sin predominio en ningún servicio ni área específica del hospital.

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

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

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

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

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

Molecular epidemiology of Shigella spp strains isolated in two different metropolitam areas of southeast Brazil

Shigella spp., the human pathogen responsible for shigellosis, is highly infectious even at low levels. The incidence rate of shigellosis varies with geographical distribution, location human development index, and age groups, being higher among children aged under 5 years. In Brazil, a few works indicate that shigellosis cases are underestimated, with S. flexneri and S. sonnei strains being the major agents responsible for the shigellosis cases. The present study used pulsed field gel electrophoresis (PFGE) to investigate the molecular epidemiology of 119 strains of S. sonnei and S. flexneri isolated from shigellosis cases that occurred in the metropolitan areas of Ribeirão Preto and Campinas Cities, São Paulo Sate, southeast Brazil. The results indicated (i) the existence of just a few strain clusters for both species, but with genotype variability with either a high speed of genetic change or constant introduction of several genotypes, considering the intense migration to these two metropolitan areas, and (ii) the prevalence of specific genotypes in each geographical area, which suggests the successful adaptation of some genotypes to the local environmental conditions. Our results indicate the need of more efficacious sanitary barriers to prevent Shigella spp. outbreaks and epidemics.

Shigella spp., o patógeno humano responsável pela shiguelose, apresenta grande poder infeccioso, mesmo em pequenas doses. A incidência de shiguelose varia de acordo com a distribuição geográfica, o índice de desenvolvimento humano local e a faixa de idade, sendo alto entre crianças com menos de 5 anos de idade. No Brasil, alguns trabalhos indicam que os casos de shiguelose são subnotificados sendo, S. flexneri e S. sonnei os principais agentes responsáveis pelos casos ocorridos. O presente estudo usou a técnica de eletroforese em campo pulsado (PFGE) para investigar a epidemiologia molecular de 119 linhagens de S. flexneri e S. sonnei, isoladas de casos de shiguelose que ocorreram nas regiões metropolitanas das cidades de Ribeirão Preto e Campinas, estado de São Paulo, na região Sudeste do Brasil. Os resultados indicam (i) a existência de apenas alguns grupos clonais para ambas as espécies, mas com variabilidade de genótipos indicando ou um alto índice de variação genética, ou a constante introdução de vários genótipos, considerando o movimento migratório intenso de pessoas nestas duas áreas metropolitanas, e (ii) a prevalência de genótipos específicos em cada área geográfica, o que sugere a existência de genótipos com maior capacidade de adaptação às condições ambientais locais. Os resultados indicam a necessidade de barreiras sanitárias mais eficientes para prevenir surtos e epidemias de Shigella spp.

Determinação da freqüência de Candida spp na cavidade oral de pacientes graves internados no Hospital das Clínicas - Unicamp, através de testes fenotípicos / Detection and frequency of Candida spp in oral cavity from serious patients hospitalized in Teaching Hospital of Unicamp, by phenotypic tests

Os métodos fenotípicos tradicionais e os testes comerciais utilizados na identificação das espécies do gênero Candida são úteis na averiguação da colonização oral, especialmente se utilizados em conjunto. O presente estudo foi realizado no Hospital de Clínicas da Unicamp com o objetivo de averiguar a diversidade das espécies de Candida na cavidade oral de 225 pacientes gravemente enfermos, internados nas unidades de Moléstias Infecciosas, Cirurgia do Trauma, Emergência Clínica e Transplante de Medula Óssea. A coleta do material ocorreu quinzenalmente no período compreendido entre novembro de 2000 e dezembro de 2002. Foram utilizados cinco testes: temperatura de crescimento, assimilação da xilose, CHROMagar Candida®, Candida Check® e ID 32®. Dentre os 349 “swabs” orais colhidos, obtiveram-se 141/349 (40,4%) culturas positivas de 126/225 (56,0%) pacientes. Os resultados obtidos com o teste de CHROMagar Candida® deixaram dúvidas quanto à diferenciação entre as amostras de C. albicans e C. dubliniensis, mas os demais testes confirmaram a ausência dessa segunda espécie. A espécie predominante detectada no presente estudo foi C. albicans, com 91 (64,5%), seguida de C. tropicalis com 17 (12,0%), C. glabrata com 9 (6,4%), C. parapsilosis com 7 (5,0%), C. krusei com 6 (4,2%), C. lusitaniae 5 (3,5%) e C. humicola, C. norvegiensis e C. kefyr com 2 (1,4%) cada. Os dados obtidos indicam que o conjunto de testes utilizados foi útil e suficientemente discriminatório na determinação das espécies colonizadoras da cavidade oral dos pacientes em estudo.