Chemical Composition and In Vitro Antimicrobial Activity of the Essential Oil Obtained from Eugenia pyriformis Cambess. (Myrtaceae)

Abstract Our study aimed to evaluate the chemical composition of the essential oil from the leaves of Eugenia pyriformis Cambess., belonging to the Myrtaceae family and native to the Brazilian Atlantic forest. The volatile compounds in the essential oil were extracted by hydrodistillation and analyzed using GC-MS; 36 compounds accounted for 78.80% of the total oil content. The major compounds were β-caryophyllene, bicyclogermacrene, globulol, and (δ-cadinene. We evaluated their antimicrobial potential of the essential oil and toxicity to Artemia salina. The antimicrobial activity of the essential oil was evaluated against 12 microorganisms using the broth microdilution method. Our results showed moderate inhibition of Staphylococcus aureus and methicillin-resistant S. aureus (MIC, 250 and 125 μg.mL-1, respectively) and toxicity to A. salina (LC50, 125.64 μg.mL-1). Our results establish the biological activity of the essential oil obtained from E. pyriformis.

Diagnostic characteristics of Xpert MTB/RIF assay for the diagnosis of tuberculous meningitis and rifampicin resistance in Southern Brazil / Características diagnósticas do Xpert MTB/RIF para o diagnóstico de meningite tuberculosa e resistência à rifampicina no Sul do Brasil

ABSTRACT Background: The timely diagnosis of tuberculous meningitis (TBM) is challenging. Molecular diagnostic tools are necessary for TBM, particularly in low- and middle-income countries. Objectives: We aimed to calculate the diagnostics characteristics of Xpert MTB/RIF for the detection of Mycobacterium tuberculosis in the cerebrospinal fluid (CSF) and the frequency of rifampicin (RIF)-resistance in the CSF samples. Methods: A total of 313 consecutive CSF samples were studied and categorized into TBM definite, probable, possible, or not TBM cases based on the clinical, laboratory, and imaging data. Results: For the definite TBM cases (n=7), the sensitivity, specificity, efficiency, and positive likelihood ratio were 100, 97, 97, and 38%, respectively. However, for the TBM definite associated with the probable cases (n=24), the sensitivity decreased to 46%. All CSF samples that were Xpert MTB/RIF-positive were RIF susceptible. Conclusion: Xpert MTB/RIF showed high discriminating value among the microbiology-proven TBM cases, although the values for the probable and possible TBM cases were reduced. Xpert MTB/RIF contributes significantly to the diagnosis of TBM, mainly when coupled with the conventional microbiological tests and clinical algorithms.

RESUMO Introdução: O diagnóstico da meningite tuberculosa (TBM) é desafiador. Ferramentas de diagnóstico molecular são necessárias para esse diagnóstico, particularmente em países de baixa e média renda. Objetivos: Calcular as características diagnósticas do Xpert MTB/RIF para a detecção de Mycobacterium tuberculosis no líquido cefalorraquidiano (LCR) e a frequência de resistência à rifampicina (RIF) nas amostras do LCR. Métodos: Um total de 313 amostras consecutivas de LCR foram estudadas e categorizadas em casos de TBM definida, provável, possível ou não TBM, com base nos dados clínicos, laboratoriais e de imagem. Resultados: Para os casos definidos de TBM (n=7), sensibilidade, especificidade, eficiência e razão de verossimilhança positiva foram de 100, 97, 97 e 38%, respectivamente. No entanto, para os casos de TBM definidos associados aos prováveis (n=24), a sensibilidade diminuiu para 46%. Todas as amostras de LCR que foram positivas para Xpert MTB/RIF foram suscetíveis a RIF. Conclusão: O Xpert MTB/RIF mostrou alto valor discriminante entre os casos TBM comprovados por microbiologia, porém o valor nos casos prováveis e possíveis de TBM foram reduzidos. O Xpert MTB/RIF contribui significativamente para o diagnóstico de TBM, principalmente quando associado aos testes microbiológicos convencionais e algoritmos clínicos.

Erros inatos de imunidade: tempo de diagnóstico e episódios infecciosos em pacientes ambulatoriais / Inborn errors of immunity: time to diagnosis and infections in outpatients

Introdução: Os erros inatos de imunidade (EII) são distúrbios que ocasionam danos no desenvolvimento e/ou função do sistema imunológico. O diagnóstico muitas vezes não é realizado de imediato devido ao pouco conhecimento sobre as doenças, que leva a complicações graves e diminui a sobrevida e qualidade de vida desses pacientes. O objetivo desse estudo foi avaliar o tempo para o diagnóstico e as ocorrências infecciosas que acometeram pacientes com EII no decorrer de sua vida até o momento do diagnóstico. Método: Foi realizado um estudo transversal, retrospectivo, em pacientes atendidos pelo serviço de Alergia, Imunologia e Pneumologia do Complexo Hospital de Clínicas da Universidade Federal do Paraná (CHC-UFPR), no período de junho de 1993 a março de 2019. Foram excluídos pacientes sem história prévia ao diagnóstico e com diagnóstico não confirmado de EII ou indefinido. Resultados: Dos 57 pacientes incluídos no estudo, a maioria (n = 34) era do sexo masculino. A idade ao diagnóstico variou de 2 até 38 anos, sendo a média 9 anos. Dentre as imunodeficiências, 43 (75,4%) tinham deficiência de anticorpos, 10 (17,5%) deficiência combinada, 3 (5,3%) deficiência de fagócitos e 1 (1,8%) deficiência de complemento. Em relação às infecções, os pacientes apresentaram mais de um episódio infeccioso, e também sofreram acometimento em mais de um sítio anatômico. As infecções mais frequentes foram as do trato respiratório inferior (80,7%), seguido das infecções do trato respiratório superior (50,9%). Foi encontrado um atraso médio de diagnóstico de 66,1 meses, sendo que 10,5% dos pacientes foram a óbito. Conclusão: Apesar de já serem bem caracterizados, os EII ainda possuem diagnóstico tardio, levando os pacientes a complicações graves, e até à morte.

Introduction: Inborn errors of immunity (IEIs) cause damage in the development and/or function of the immune system. The diagnosis is often not done immediately because of lack of knowledge about the disorders, leading to serious complications and decreasing the survival and quality of life of these patients. The aim of this study was to evaluate time to diagnosis and occurrence of infections that affected patients with IEI throughout their life-span until the diagnosis. Methods: A retrospective crosssectional study was performed in patients treated at the Division of Allergy, Immunology and Pulmonology of the Complexo Hospital de Clínicas at Universidade Federal do Paraná, from June 1993 to March 2019. Patients with no history prior to diagnosis and those with unconfirmed diagnosis of IIE or undefined diagnosis were excluded from the study. Results: Of the 57 patients included in the study, most were male (n = 34). The mean age at the time of diagnosis was 9 years, ranging from 2 to 38 years. Among the immunodeficiencies, 43 (75.4%) patients had antibody deficiency disorder, 10 (17.5%) had combined immunodeficiency, 3 (5.3%) had phagocyte deficiency and 1 (1.8%) had complement disorder. Regarding infections, patients had more than one infectious episode and were affected in more than one anatomical site. The most frequent infections were those of the lower respiratory tract (80.7%), followed by upper respiratory tract infections (50.9%). A mean diagnosis delay of 66.1 months was found, and 10% of the patients died. Conclusion: Despite being well characterized, IEIs still have late diagnosis, leading patients to serious complications and even death.

Ralstonia mannitolilytica bacteremia in a neonatal intensive care unit

Abstract Ralstonia mannitolilytica, a Gram-negative bacterium, is rarely isolated in clinical laboratories. It has been associated with outbreaks due to its ability to survive in liquid media and hospital devices. We describe three cases of bacteremia caused by R. mannitolilytica in a neonatal intensive care unit in Curitiba, Southern Brazil. All isolates presented the same PFGE profile. The common source of infection was undetected in surveillance cultures for the outbreak survey. All patients received antimicrobial treatment and were discharged from the maternity. Due to the characteristics of the microorganism, clinicians and microbiologists should pay attention to the emergence of Ralstonia spp. infections.

Is it possible to perform bacterial identification and antimicrobial susceptibility testing with a positive blood culture bottle for quick diagnosis of bloodstream infections?

Abstract INTRODUCTION: Bloodstream infections can be fatal, and timely identification of the etiologic agent is important for treatment. METHODOLOGY: An alternative method, consisting of direct identification and susceptibility testing of blood culture bottles using the automated VITEK 2® system, was assessed. RESULTS: All 37 of the Gram-negative bacilli (GNB) identifications and 57.1% of the 28 Gram-positive cocci (GPC) identifications matched those obtained with standard methods. In susceptibility testing, the agreement was greater than 90%. CONCLUSIONS: This alternative methodology may assist in the early identification and susceptibility testing of GNB. Further research is necessary to develop appropriate methods for GPC.

The detection of Bence Jones protein in urine by the heat test helps in diagnosis of multiple myeloma? / A detecção de proteína Bence Jones na urina pelo teste de calor auxilia no diagnóstico de mieloma múltiplo?

ABSTRACT Introduction: Multiple myeloma (MM) is a hematologic malignancy caused by the intense indiscriminate proliferation of plasma cells in the bone marrow. In view of clinical suspicion of MM, clinic laboratory tests and imaging tests should be used, among others. Objectives: Evaluate the laboratory test for protein detection heat method Bence Jones (BJ) used to complementary diagnosis pathology and to characterize the epidemiological profile of patients diagnosed with MM. Material and methods: A retrospective study was conducted from January 2010 to July 2015 of the patients treated at Hospital de Clínicas of Universidade Federal do Paraná (HC/UFPR) in Curitiba, Paraná, Brazil. Results: In the patients analyzed, the average age at diagnosis of MM was 65.6 years, with a minimum percentage of difference between genders [males 52.6% (n = 10) and females 47.4% (n = 9)], predominantly in the white race [84.2% (n = 16)]. Among the patients analyzed, 85.2% (n = 104) had negative BJ exam and 14.8 (n = 18), positive exam; 84.4% (n = 103) had no diagnosis of MM, and 15.6% (n = 19) were diagnosed with the disease. Conclusion: The evaluation results of BJ protein detection by the heat method showed sensitivity of 47.4%, specificity of 91.3%, with positive and negative predictive values of 50% and 90.4%, respectively.

RESUMO Introdução: O mieloma múltiplo (MM) é uma neoplasia maligna hematológica causada pela intensa proliferação indiscriminada de plasmócitos na medula óssea. Diante da suspeita clínica de MM devem ser realizados exames laboratoriais e exames de imagem, entre outros. Objetivos: Avaliar o teste laboratorial de calor para detecção de proteína Bence Jones (BJ), utilizado como diagnóstico complementar da patologia, e caracterizar o perfil epidemiológico dos pacientes diagnosticados com MM. Material e métodos: Foi realizado um estudo retrospectivo de janeiro de 2010 a julho de 2015 dos pacientes atendidos no laboratório do Hospital de Clínicas da Universidade Federal do Paraná (UFPR), Curitiba, Paraná, Brasil. Resultados: Dos pacientes avaliados, a média de idade no momento do diagnóstico de MM foi de 65,6 anos, com um percentual de diferença mínima entre os gêneros masculino [52,6% (n = 10)] e feminino [47,4% (n = 9)] e predomínio na raça branca [84,2% (n = 16)]. Entre os pacientes analisados, 85,2% (n = 104) apresentaram exame de BJ negativo e 14,8 (n = 18), positivo; 84,4% (n = 103) não apresentaram diagnóstico de MM e 15,6% (n = 19) foram diagnosticados com a patologia. Conclusão: Os resultados da avaliação do método de calor de detecção de proteína BJ mostraram sensibilidade de 47,4% e especificidade de 91,3%, com valores preditivos positivo e negativo de 50% e 90,4%, respectivamente.

Microbiological quality of Brazilian artisanal cheese and fermented sausages / Qualidade microbiológica de queijos e salames artesanais brasileiros

Cheeses and sausages are ready-to-eat foods, and the products prepared by artisanal processare susceptible to microbial contamination. Few studies on the quality of foods from different Brazilian regions have been done. In this context, this study aimed at evaluating the microbiological quality of 32 cheese and 13 sausages samples purchased from artisanal food stores or producers markets located in the metropolitan areas of 10 capital cities of Brazilian states. Microbiological analyses were performed to determine the counts of microbial contamination indicators, including Escherichia coli and coagulase-positive staphylococci, as well as for evaluating the presence of Listeria monocytogenes and Salmonella spp. using bacteriological methods.E. coli was detected in 50.0 % of samples, coagulase-positive staphylococci in 34.4 %, and Salmonella spp. in 6.3 % of cheese samples. In fermented sausage samples, coagulase-positive staphylococci were isolated from 23.1 % samples and Salmonella spp. from 7.7 %. According tothe Brazilian Sanitary Legislation, 63.0 % of cheese samples and 23.0 % of artisanal fermentedsausage samples from the metropolitan areas of 10 Brazilian capital cities were unsuitable for consumption, indicating the importance of conducting the close monitoring of these foodsand the application of the effective measures for preventing food-borne outbreaks.

Queijos e salames são alimentos prontos para consumo e quando artesanalmente produzidos são suscetíveis à contaminação microbiana. A importância deste estudo em dez capitais brasileiras deve-se à carência de dados obtidos simultaneamente abrangendo-se diferentes regiões do Brasil. O objetivo do presente trabalho foi de avaliar a qualidade microbiológica de 32 amostras de queijos e 13 de salames artesanais, adquiridos em casas de produtos artesanais ou feiras de produtores nas regiões metropolitanas de dez capitais brasileiras. Análises microbiológicas com as respectivas contagens de indicadores de contaminação microbiana, Escherichia coli e Staphylococcus coagulase positiva, e a pesquisa de Listeria monocytogenes e Salmonella spp. foram realizadas por meio de métodos bacteriológicos. Nas amostras de queijos foram observadas E. coli em 50,0 %, Staphylococcus coagulase positiva em 34,4 % e Salmonella spp. em 6,3 %. Nas amostras de salames foram detectadas Staphylococcus coagulase positiva em 23,1 % e Salmonella spp. em 7,7 %. De acordo com a legislação sanitária brasileira, 63,0 % das amostras de queijos e 23,0 % das amostras de salames artesanais coletadas da Região Metropolitana de dez capitais brasileiras estavam impróprias para o consumo, o que demonstra a importância de realizar monitoramento próximo e efetivo para prevenir surtos de origem alimentar.

Microbiological quality of Brazilian artisanal cheese and fermented sausages / Qualidade microbiológica de queijos e salames artesanais brasileiros

Cheeses and sausages are ready-to-eat foods, and the products prepared by artisanal process are susceptible to microbial contamination. Few studies on the quality of foods from different Brazilian regions have been done. In this context, this study aimed at evaluating the microbiological quality of 32 cheese and 13 sausages samples purchased from artisanal food stores or producers markets located in the metropolitan areas of 10 capital cities of Brazilian states. Microbiological analyses were performed to determine the counts of microbial contamination indicators, including Escherichia coli and coagulase-positive staphylococci, as well as for evaluating the presence of Listeria monocytogenes and Salmonella spp. using bacteriological methods. E. coli was detected in 50.0 % of samples, coagulase-positive staphylococci in 34.4 %, and Salmonella spp. in 6.3 % of cheese samples. In fermented sausage samples, coagulase-positive staphylococci were isolated from 23.1 % samples and Salmonella spp. from 7.7 %. According to the Brazilian Sanitary Legislation, 63.0 % of cheese samples and 23.0 % of artisanal fermented sausage samples from the metropolitan areas of 10 Brazilian capital cities were unsuitable for consumption, indicating the importance of conducting the close monitoring of these foods and the application of the effective measures for preventing food-borne outbreaks.

Queijos e salames são alimentos prontos para consumo e quando artesanalmente produzidos são suscetíveis à contaminação microbiana. A importância deste estudo em dez capitais brasileiras deve-se à carência de dados obtidos simultaneamente abrangendo-se diferentes regiões do Brasil. O objetivo do presente trabalho foi de avaliar a qualidade microbiológica de 32 amostras de queijos e 13 de salames artesanais, adquiridos em casas de produtos artesanais ou feiras de produtores nas regiões metropolitanas de dez capitais brasileiras. Análises microbiológicas com as respectivas contagens de indicadores de contaminação microbiana, Escherichia coli e Staphylococcus coagulase positiva, e a pesquisa de Listeria monocytogenes e Salmonella spp. foram realizadas por meio de métodos bacteriológicos. Nas amostras de queijos foram observadas E. coli em 50,0 %, Staphylococcus coagulase positiva em 34,4 % e Salmonella spp. em 6,3 %. Nas amostras de salames foram detectadas Staphylococcus coagulase positiva em 23,1 % e Salmonella spp. em 7,7 %. De acordo com a legislação sanitária brasileira, 63,0 % das amostras de queijos e 23,0 % das amostras de salames artesanais coletadas da Região Metropolitana de dez capitais brasileiras estavam impróprias para o consumo, o que demonstra a importância de realizar monitoramento próximo e efetivo para prevenir surtos de origem alimentar.

Research on antimicrobial residues activity in urine samples of hospitalized patients / Pesquisa da atividade de resíduos de antimicrobianos em amostras de urina de pacientes hospitalizados

Introduction: Urinary tract infection is quite frequent in a hospital environment, and the urine culture is the gold standard for diagnosis of this disease, because it allows bacterial identification and performing antimicrobial susceptibility testing. Culturenegative urine samples result of patients with strong suspicion of infection may occur due to the activity of antimicrobial residues, which can interfere with bacterial growth in vitro and produce false-negative results. Objective: Verify the occurrence of falsenegative urine cultures due to the presence of antimicrobial residues in samples of patients admitted to the Clinical Hospital of Paraná Federal University. Material and methods: A total of 188 urine samples from hospitalized patients were randomly selected, during the period from July to December 2012. All samples were evaluated on the result of the urine culture, bacteriuria, and research on residues of antimicrobial activity by manual and automated techniques. Results: 44 (23.4%) presented positive urine culture, 121 (64.4%) negative urine culture, and 23 (12.2%) presented growth of many species. In 14 samples, negative urine cultures associated with the presence of bacteria and were positive for the research on antimicrobial residues activity (RARA), were observed. Conclusion: Automated technique showed better performance when compared to manual technique, with sensitivity of 92.8% and 71.4%, respectively. The presence of antimicrobial residues may affect the recovery of bacteria in the urine, producing a false-negative result. .

Introdução: A infecção do trato urinário é bastante frequente em ambiente hospitalar, e a cultura de urina é padrão-ouro para o diagnóstico dessa doença, pois permite a identificação bacteriana e a realização do teste de suscetibilidade aos antimicrobianos. Amostras de urina de pacientes com forte suspeita de infecção que resultam em cultura negativa podem ocorrer devido à atividade de resíduos de antimicrobianos, os quais podem interferir no crescimento bacteriano in vitro e gerar resultados falso negativos. Objetivo: Verificar a ocorrência de culturas de urina falso negativas devido à presença de resíduos de antimicrobianos em amostras de pacientes internados no Hospital de Clínicas da Universidade Federal do Paraná. Material e métodos: Um total de 188 amostras de urina de pacientes internados foi selecionado aleatoriamente, durante o período de julho a dezembro de 2012. Todas as amostras foram avaliadas quanto ao resultado da cultura de urina, da bacteriúria e da pesquisa da atividade de resíduos de antimicrobianos por meio das técnicas manual e automatizada. Resultados: Quarenta e quatro (23,4%) apresentaram cultura de urina positiva, 121 (64,4%), cultura negativa e 23 (12,2%), crescimento de várias espécies. Em 14 amostras foi observada cultura negativa associada à presença de bactérias e pesquisa da atividade de resíduos de antimicrobianos (PRA) positiva. Conclusão: A técnica automatizada apresentou melhor desempenho quando comparada com a técnica manual, apresentando sensibilidade de 92,8% e 71,4%, respectivamente. A presença de resíduos de antimicrobianos pode comprometer a recuperação de bactérias na urina, gerando resultado falso negativo. .

Characterization of virulence genes cagA and vacA in Helicobacter Pylori and their prevalence in gastrointestinal disorders

Prevalence of H. pylori infection was determined using cultures of gastric biopsy samples of patients attended at the academic hospital of the Federal University of Paraná, Curitiba, Paraná, Brazil. Molecular methods were used to characterize the cagA and vacA genes from bacterial isolates associated with different diseases presented by patients. Out of a total of 81, forty-two gastric biopsy samples tested were positive for H. pylori, with a prevalence of 51.9 percent. No significant difference was found with regard to the gender (p=0.793) and age (p=0.183) of the patients. Genotype s1m1 vacA gene was found in 67 percent of the cases of peptic ulcer investigated (p=1.0), despite the limited number of patients with this disease (n=3). A correlation between the presence of less virulent strains (s2m2) and reflux esophagitis was found in the majority of the cases (45 percent), but without statistical significance. An association between the prevalence of cagA gene, found in 92 percent of isolates, and peptic ulcer was not observed (p=1.0), suggesting that this gene cannot be considered a specific marker of severity in our environment. The results reinforce the importance of conducting regional studies and the need to characterize H. pylori virulence genes associated with different diseases.

Anti-Helicobacter pylori activity of plant extracts traditionally used for the treatment of gastrointestinal disorders

The antibacterial activity of plant extracts obtained from Bixa orellana L., Chamomilla recutita L., Ilex paraguariensis A. St.-Hil., Malva sylvestris L., Plantago major L. and Rheum rhaponticum L. has been evaluated against two reference strains and eleven clinical isolates of Helicobacter pylori. All the plant species chosen are used in popular Brazilian cuisine and folk medicine in the treatment of gastrointestinal disorders. Initial screening was made by the disk diffusion test and then minimum inhibitory concentration was determined by the agar dilution method. The results presented in this work demonstrated that among the plant preparations analyzed, B. orellana L., C. recutita L., I. paraguariensis A. St.-Hil. and M. sylvestris L. were capable of inhibiting the in vitro growth of H. pylori.

Avaliação da qualidade microbiológica de águas minerais envasadas / Evaluation of bottled mineral water microbiological quality: population dynamics of Pseudomonas aeruginosa

Com o intuito de monitorar alterações no índice de contaminação durante o armazenamento, foram avaliadas quanto à contaminação por Pseudomonas aeruginosa setenta e cinco amostras, de cinco marcas distintas, de água mineral envasadas em copos ou garrafas plásticas de 500mL e 1500 mL. Os ensaios foram efetuados em dois períodos diferenciados, o primeiro um dia após aquisição das amostras completaram seis meses de armazenamento. Segundo os padrões determinados pela RDC n.275/05 do Ministério da Saúde, 53 por cento dos lotes foram rejeitados. O monitoramento da contaminação durante o armazenamento revelou que, independente da elevação ou redução nas contagens, P aeruginosa foi detectada mesmo após 180 dias de estocagem, confirmando que se trata de micro-organismo que se adapta em ambientes com baixo teor nutricional. O percentual de rejeição das amostras revelou a necessidade de práticas de higiene mais efetivas a serem adotadas durante o envase, garantindo a comercialização de produtos seguros e que atendam aos rigorosos padrões microbiológicos estabelecidos pela legislação brasileira.

Enrichment methodology to increase the positivity of cultures from body fluids

Isolation and identification of etiological agents found in body fluids can be of critical importance for the recovery of patients suffering from potentially-severe infections, which are often followed by serious sequels. Eighty-two samples of different body fluids were analyzed using two different methods: (1) the conventional culture method (agar plating) and (2) the enrichment culture technique, using the Bact/Alert® blood culture bottle. The number of positive cultures increased on average from 9.7 percent to 23.1 percent with the enrichment culture technique. Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus were the most frequently isolated bacteria. The enrichment method could provide a more accurate means the identifying etiological agents.

Occurrence of extended-spectrum beta-lactamases in Enterobacteriaceae isolated from hospitalized patients in Curitiba, southern Brazil

Production of extended-spectrum beta-lactamases (ESBL) by enterobacteria is an important resistance mechanism against antimicrobial beta-lactamics. We tested 498 bacterial strains isolated from two tertiary-care teaching hospitals for ESBL production, using screening breakpoints for aztreonam and third generation cephalosporins, according to CLSI recommendations. Among these isolates, 155 were positive for the ESBL screening test, and 121 (78 percent) were confirmed by the clavulanic acid combination disk method. We found a high frequency of ESBL (24 percent) among Enterobacteriaceae, with a frequency of 57.4 percent for Klebsiella pneumoniae, 21.4 percent for Klebsiella oxytoca, and 7.2 percent for E. coli. In other members of Enterobacteriaceae, non-Klebsiella and non-E. coli, the prevalence was 21.6 percent. Ceftriaxone and cefotaxime showed a higher sensitivity in the screening test (99.2 percent) when compared to ceftazidime, aztreonam and cefpodoxime. However, cefotaxime/cefotaxime plus clavulanic acid showed a higher sensitivity in the confirmatory test (96.7 percent).