Macular dystrophy associated with Kjellin’s syndrome: a case report / Distrofia macular associada à síndrome de Kjellin: um relato de caso

Hereditary spastic paraplegia (HSP) is characterized by weakness and spasticity of the lower extremities. Kjellin’s syndrome is a rare syndrome associated with HSP. The syndrome is characterized by the presence of bilateral retinal flecks, similar to the findings in Stargardt disease and fundus flavimaculatus. We report the case of a 34-year-old male who presented with complete features of Kjellin’s syndrome, with typical retinal findings observed on multimodal imaging (spectral domain optical coherence tomography [SD-OCT], near-infrared reflectance and autofluorescence imaging). The ophthalmological changes at early stages of the disease may not impair visual acuity. Therefore, the detection of central retinal degeneration requires thorough fundus examination.

A paralisia espástica hereditária (HSP) é caracterizada por fraqueza e espasticidade das extremidades inferiores. A síndrome de Kjellin é uma rara associação de HSP com a presença de flecks retinianos similares aos encontrados em pacientes com doença de Stargardt ou fundus flavimaculatus. Descrevemos os achados em imagens multimodais da retina (tomografia de coerência óptica de domínio espectral [SD-OCT], reflectância próxima ao infravermelho e autofluorescência) em um paciente de 34 anos que apresenta conjunto completo de sinais e sintomas da síndrome de Kjellin. As alterações retinianas em estágios iniciais da doença podem aparecer, mesmo sem redução da acuidade visual, e por isso, para detecção da degeneração central da retina, é necessário exame minucioso do fundo de olho.

Impacto económico de la resistencia a la meticilina en pacientes con bacteriemia por Staphylococcus aureus en hospitales de Bogotá / Economic burden of methicillin-resistant Staphylococcus aureus bacteremia in critical care patients in hospitals in Bogotá

Introducción. Las infecciones por microorganismos resistentes, especialmente las que involucran el torrente sanguíneo, se asocian a un mayor uso de recursos. Sus estimaciones son variables y dependen de la metodología utilizada. Staphylococcus aureus es el agente de sangre aislado con mayor frecuencia en nuestro medio. No existe información sobre el costo asociado con la atención de bacteriemias por S. aureus resistente a meticilina en nuestro país. Objetivo. Presentar una aproximación del costo de atención de las bacteriemias por S. aureus resistente a la meticilina en nueve hospitales de Bogotá. Materiales y métodos. Se incluyeron 204 pacientes en un estudio de cohortes multicéntrico en una razón de 1:1 según la resistencia. Se aproximaron los costos médicos directos con base en las facturas del período de hospitalización; en cuanto al período de la bacteriemia, los costos detallados se calcularon aplicando las tarifas estandarizadas. Resultados. No se encontraron diferencias significativas en las características clínicas y demográficas de los grupos, salvo en los antecedentes de la bacteriemia. El 53 % de los sujetos falleció durante la hospitalización. La estancia y el valor total facturado por la hospitalización fueron significativamente mayores en el grupo con bacteriemia por S. aureus resistente a la meticilina, así como los costos de la estancia en cuidados intensivos, de los antibióticos, los líquidos parenterales, los exámenes de laboratorio y la terapia respiratoria. El incremento crudo del costo de la atención asociado con la resistencia a meticilina fue de 31 % y, el ajustado, de 70 %. Conclusión. Este estudio constituye un respaldo a los tomadores de decisiones para la búsqueda y la financiación de programas de prevención de infecciones causadas por microorganismos resistentes.

Introduction: Resistant infections, especially those involving the bloodstream, are associated with a greater use of resources. Their estimates are variable and depend on the methodology used. Staphylococcus aureus is the main pathogen isolated in blood in our hospitals. There is no consolidated data about economic implications of methicillin-resistant S. aureus infection. Objective: To describe the cost of care of methicillin-resistant S. aureus bacteremia in a reference population from nine hospitals in Bogotá. Materials y methods: A multicenter cohort study included 204 patients in a 1:1 ratio according to resistance. Direct medical costs were calculated from hospitalization bills, while the bacteremia period was calculated by applying microcosting based on standard fares. Results: We found no significant differences between groups in demographic and clinical characteristics, except for resistance risk factors. Fifty-three percent of patients died during hospitalization. Hospital stay and total invoiced value during hospitalization were significantly higher in the group with methicillin-resistant S. aureus bacteremia. For this group, higher costs in ICU stay, antibiotics use, intravenous fluids, laboratory tests and respiratory support were recorded. A crude increase of 31% and an adjusted increase of 70% in care costs associated with methicillin resistance were registered. Conclusion: Our study supports decision makers in finding and funding infection prevention programs, especially those infections caused by resistant organisms.

Impacto de una técnica automatizada rápida en la identificación de SAMR/ERV en pacientes trasladados desde otros centros hospitalarios / Impact of an automated rapid MRSA/VRE identification technique in the surveillance of patients transferred from other medical centers

Introduction: Identification of patients with methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococci (VRE) is essential to limit the spread of these agents, through the use of isolation and contact precautions. Traditional microbiology has a long turn around time (3-5 days) extending the time of isolation, increasing complexity and cost of these patients. Objectives: To implement a new real time polymerase chain reaction (PCR) GeneXpert R for SAMR and VRE detection. To compare costs and turn around time of PCR versus traditional cultures. Methods: Two periods were compared, in the first, traditional microbiology (standard group) was used, and in the second, only PCR was used (PCR group). Results: MRSA or VRE were identified in 29.9% of patients in the PCR group and in 9.6% in the standard group. Turn around time was 15 ± 9 hours in PCR group and 53 ± 23 hours in standard group. PCR group had a net cost of USD 245 per patient and standard group USD 530 per patient. Discussion: PCR technique GeneXpert R for MRSA and VRE had a positive impact in the management of these patients and justifies its inclusion.

Introducción: La identificación de pacientes con Staphylococcus aureus resistente a meticilina (SARM) y Enterococcus resistente a vancomicina (ERV), permite limitar su diseminación usando aislamiento en cohorte y precauciones de contacto. Los resultados de los cultivos microbiológicos demoran 3 a 5 días, lo que retrasa el retiro de las precauciones y agrega costos económicos. Objetivos: Implementar técnica de reacción de polimerasa en cadena en tiempo real (RPC), GeneXpert R, para SARM y ERV y comparar tiempos de respuesta y costos en relación al uso de microbiología convencional. Material y Métodos: Se compararon dos períodos, uno en que se usó solo RPC (grupo RPC) y otro histórico, en el que se usó microbiología tradicional (grupo estándar) Resultados: Se confirmó SARM y/o ERV en 29,9% de los pacientes del grupo RPC, y en 9,6% del grupo estándar. Los tiempos de respuesta fueron 15 ± 9 h (grupo RCP) y 53 ± 23 h (grupo estándar). Los costos directos por paciente fueron de USD 245 en el grupo RPC y de USD 530 en el grupo estándar. Discusión: La RPC en tiempo real, GeneXpert, para SAMR y ERV tuvo un alto impacto alto clínico que justifica su incorporación.

Healthcare-associated Staphylococcus aureus bloodstream infection: length of stay, attributable mortality, and additional direct costs

This study aimed to determine the excess length of stay, extra expenditures, and attributable mortality to healthcare-associated S. aureus bloodstream infection (BSI) at a teaching hospital in central Brazil. The study design was a matched (1:1) case-control. Cases were defined as patients > 13 years old, with a healthcare-associated S. aureus BSI. Controls included patients without an S. aureus BSI, who were matched to cases by gender, age (± 7 years), morbidity, and underlying disease. Data were collected from medical records and from the Brazilian National Hospital Information System (Sistema de Informações Hospitalares do Sistema Único de Saúde - SIH/SUS). A Wilcoxon rank sum test was performed to compare length of stay and costs between cases and controls. Differences in mortality between cases and controls were compared using McNemar's tests. The Mantel-Haenzel stratified analysis was performed to compare invasive device utilization. Data analyses were conducted using Epi Info 6.0 and Statistical Package for Social Sciences (SPSS 13.0). 84 case-control pairs matched by gender, age, admission period, morbidity, and underlying disease were analyzed. The mean lengths of hospital stay were 48.3 and 16.2 days for cases and controls, respectively (p < 0.01), yielding an excess hospital stay among cases of 32.1 days. the excess mortality among cases compared to controls that was attributable to s. aureus bloodstream infection was 45.2%. Cases had a higher risk of dying compared to controls (OR 7.3, 95% CI 3.1-21.1). Overall costs of hospitalization (SIH/SUS) reached US$ 123,065 for cases versus US$ 40,247 for controls (p < 0.01). the cost of antimicrobial therapy was 6.7 fold higher for cases compared to controls. healthcare-associated s. aureus BSI was associated with statistically significant increases in length of hospitalization, attributable mortality, and economic burden. Implementation of measures to minimize the risk of healthcare-associated bacterial infections is essential.

Evaluation of methods and costs for detecting methicillin-resistant Staphylococcus aureus isolates from clinical specimens at regional hospitals in Trinidad and Tobago / Evaluación de métodos y costos para la detección de aislados de Staphylococcus aureus resistentes a la meticilina a partir de especímenes clínicos en los hospitales regionales de Trinidad y Tobago

OBJECTIVES: To evaluate and determine the most cost effective, rapid and specific method for detection of methicillin resistance in clinical isolates of S aureus in a setting with limited personnel and resources. METHODS: Standard laboratory methods were used to identify S aureus isolates. The conventional Methicillin Resistance Staphylococcus aureus (MRSA) detection methods used included, 1 µg oxacillin disk diffusion, oxacillin salt agar screen (CLSI), penicillin binding protein (PBP 2') latex agglutination test and E-tests oxacillin. Results of conventional tests were compared with a polymerase chain reaction (PCR) method for detecting MRSA isolates. Polymerase chain reaction detection of the mecA gene in S aureus was used as the " gold standard" for MRSA identification. RESULTS: All methods had 100% sensitivity except for oxacillin disk diffusion and oxacillin-salt agar screening with 98% and 99%, respectively. Specificity was also 100% for all methods except for oxacillin-disk diffusion (99%). Turn around time (TAT) for detection of MRSA was calculated to be within six hours for PCR. The fastest TAT of 1.25 hours was obtained for PBP 2' latex agglutination. Total cost for labour and materials to perform each method was highest for E-test, US$13.76/isolate. The cost for PCR when compared to that of latex agglutination was not statistically significant (US$3.74 vs US5.91, p = 0.4). CONCLUSIONS: All methods presented high sensitivity and specificity, but the latex agglutination test had the advantage of giving a reliable, rapid and most cost effective result that compares well to PCR in this environment.

OBJETIVOS: Evaluar y determinar el método más específico, rápido y costo-efectivo para la detección de la resistencia a la meticilina en aislados clínicos de S aureus en un lugar con personal y recursos limitados. MÉTODOS: A fin de identificar los aislados de S aureus, se utilizaron métodos estándar de laboratorio. Los métodos convencionales de detección de SARM usados incluyeron difusión por disco de oxacilina de 1 µg, prueba de tamizaje (" screening" ) de oxacilina en agar-sal (CLSI), test de aglutinación en látex para la detección de la proteína 2 fijadora de la penicilina (PBP 2'), y la prueba E-Test de oxacilina. Los resultados de las pruebas convencionales fueron comparados con un método de PCR para la detección de aislados SARM. La detección por PCR del gene mecA en S aureus fue usada como " estándar de oro" para la identificación de SARM. RESULTADOS: Todos los métodos tuvieron 100% de sensibilidad excepto la difusión por disco de oxacilina y el tamizaje de oxacilina en agar-sal, con 98% y 99% respectivamente. La especificad también fue de 100% para todos los métodos, con excepción de la difusión por disco de oxacilina (99%). El tiempo de respuesta (TAT, del inglés turn around time) para la detección de SARM se halla, según los cálculos, dentro de las seis horas para PCR. El TAT más rápido, 1.25 hrs, se obtuvo en la aglutinación en látex de PBP 2'. El costo total del trabajo y los materiales en la ejecución de cada método fue más alto en la prueba de E-Test, aislado/$13.76 USD. El costo de PCR en comparación con el de la aglutinación látex no fue estadísticamente significativo ($3.74 USD vs $5.91USD, p = 0.4). CONCLUSIONES: Todos los métodos presentaron alta sensibilidad y especificidad, pero el test de aglutinación en látex tuvo como ventaja el ofrecer un resultado confiable, rápido y altamente costo-efectivo, no muy diferente del PCR en este ambiente.

An outbreak of methicillin-resistant Staphylococcus aureus (M.R.S.A.) in a burn unit.

An outbreak of methicillin-resistant Staphyllococcus aureus (MRSA) in the burn unit of Siriraj Hospital from August 1990 to July 1991 was reported. Temporary decrease in the incidence of MRSA was observed during a period when no new cases were admitted. The incidence rose again after normal service resumed. Surveillance cultures in 29 patients from May to July 1991 grew MRSA in 19 patients (65.5 per cent). Infection by MRSA was found in 14 patients (48.3 per cent). Methicillin-resistant Staphylococcus aureus first appeared in these patients mainly during the first and second weeks of admission. Wound infections were the only manifestation in 14 patients. Four of the MRSA infected patients died of infection by organisms other than MRSA. Nasal carriage was found in 2 of 25 ward staff members. The cost of treatment for each episode of MRSA infection was as high as 19,322.90 baht. The epidemic of MRSA infections persisted despite all control measures resulting in temporary closure of the ward.