Características de las fungemias en un centro de referencia del Perú: retrospectiva de cinco años / Characteristics of fungemia in a peruvian referral center: 5-year retrospective analysis

RESUMEN Con el objetivo de conocer las características de las fungemias en 285 pacientes oncológicos hospitalizados del 2012 al 2016 en el Instituto Nacional de Enfermedades Neoplásicas se realizó un estudio descriptivo retrospectivo. Se evaluó información demográfica, clínica y microbiológica. Las fungemias por C. albicans predominaron en pacientes con tumores sólidos y sin neutropenia, mientras las causadas por C. tropicalis predominaron en pacientes con neoplasias hematológicas y neutropenia. C. tropicalis fue el agente más aislado (47,0%). Las fungemias aumentaron con el tiempo en los pacientes sin neutropenia. Las fungemias causadas por C. albicans aumentan con la edad en pacientes con tumores sólidos sin neutropenia. Se concluye que las fungemias son mayormente causadas por C. tropicalis en pacientes con neoplasias hematológicas con neutropenia y por C. albicans en pacientes con tumores sólidos sin neutropenia. Además, las fungemias en pacientes sin neutropenia aumentan en el tiempo y las causadas por C. albicans, en tumores sólidos sin neutropenia, aumentan con la edad.

ABSTRACT Retrospective descriptive study carried out to determine the characteristics of fungemia in 285 cancer patients hospitalized from 2012 to 2016 at the Instituto Nacional de Enfermedades Neoplásicas (INEN). Demographic, clinical and microbiological information was evaluated. Fungemia by C. albicans predominated in patients with solid tumors and without neutropenia, while those caused by C. tropicalis predominated in patients with hematological neoplasia and neutropenia. C. tropicalis was the agent isolated in most cases (47.0%). Fungemia increased over time in patients without neutropenia. Fungemia caused by C. albicans increases with age in patients with solid tumors without neutropenia. It is concluded that fungemia are mainly caused by C. tropicalis in patients with hematological neoplasia with neutropenia and by C. albicans in patients with solid tumors without neutropenia. In addition, fungemia in patients without neutropenia increases over time; and those caused by C. albicans increase with age in patients with solid tumors without neutropenia.

Brote de fungemias por Sarocladium kiliense en ocho hospitales públicos por contaminación intrínseca de ondansetrón intravenoso / Outbreak of fungemias by Sarocladium kiliense in eight public hospitals per intrinsic contamination of ondansetron intravenous

Resumen Introducción: Sarocladium kiliense es un hongo saprófito que puede generar infecciones oportunistas asociadas a procedimientos invasores. Se informa un brote multicéntrico nosocomial de fungemias de fuente común por este agente. Luego del reporte de cinco casos en pacientes en tres hospitales al Programa de Control de Infecciones del Ministerio de Salud de Chile en julio de 2013, se estudiaron a nivel nacional todos los pacientes con hemocultivo positivo para este agente. Se trató de cuadros clínicos leves a moderados, sin muertes atribuibles. El estudio identificó 65 casos en 8 hospitales, en su mayoría pacientes pediátricos en quimioterapia. Estudios iniciales de 94 muestras de cuatro fármacos y dispositivos usados en todos los casos resultaron negativas hasta que, en un segundo análisis de lotes seleccionados por criterios epidemiológicos y su matriz farmacéutica, se identificó la contaminación intrínseca de ampollas de ondansetrón de un productor específico, que se usó en todos los casos. Se realizó un retiro nacional de las ampollas de los tres lotes contaminados del fármaco, después de lo cual se contuvo el brote. La vigilancia de infecciones en los hospitales y el programa nacional coordinado con los laboratorios de microbiología fueron claves para identificar un brote multicéntrico de fuente común por contaminación de un fármaco por un hongo inusual.

Sarocladium kiliense is a saprophyte fungus that can cause opportunistic infections associated to invasive procedures. We report a multi-hospital nosocomial outbreak of fungemias due to this agent. Patients with positive blood culture to this agent were studied after six bloodstream infections identified in three Chilean hospitals in July 2013 were reported to Ministry of Health National Infection and Prevention Control Program. In general, there were mild clinical manifestations, without deaths attributable to the infection. Epidemiological and micro-biological study identified 65 cases in 8 hospitals, mostly pediatric patients in chemotherapy. Initial studies of 94 different drugs and medical devices had negative results, until a second analysis of specific blisters and their pharmaceutical matrix selected by epidemiological criteria identified an intrinsic contamination of ondansetron blisters from a specific producer used in all the patients. A recall of contaminated ondansetron blisters was performed in all the country, after which the outbreak was contained. Surveillance and response of local and national infection prevention and control programs and laboratory support were key to control of a national multi-hospital common source outbreak due to contamination of a drug by an unusual fungus.

Infección del torrente sanguíneo en pacientes receptores de trasplante de precursores hematopoyéticos. Siete años de experiencia con adultos y niños / Bloodstream infection in patients receiving hematopoietic stem cell transplant. Seven years of experience with adults and children

Resumen Introducción: La infección del torrente sanguíneo es una complicación usual, que puede comprometer la vida de los pacientes que recibieron trasplante de precursores hematopoyéticos. Objetivo: Analizar las características de las infecciones del torrente sanguíneo en receptores de trasplante de precursores hematopoyéticos. Materiales y Métodos: Estudio observacional, retrospectivo. Se revisaron los registros de 451 pacientes (trasplantes autólogos y alogénicos), desde enero de 2009 a octubre de 2015. Resultados: Hubo 99 hemocultivos positivos en 73 pacientes con infección del torrente sanguíneo (16%). Mortalidad atribuible a causas infecciosas: 17%. De las 99 infecciones sanguíneas, 63% fueron provocados por bacilos gramnegativos (Escherichia coli 45%, Klebsiella spp 23%, Pseudomonas spp 11%, Acinetobacter spp 6% y otros bacilos gramnegativos 15%), 33% por cocáceas grampositivas, 3% por hongos y 1% por bacilos grampositivos. Se observó resistencia a ciprofloxacina (81%), piperacilina/tazobactam (48%), Enterobacteriaceae productoras de β-lactamasa de espectro extendido (BLEE) (40%), cefepime (39%) y ausencia de resistencia a amikacina. Discusión: Existe mayor frecuencia de infección por bacilos gramnegativos, con un importante porcentaje de aislados multi-resistentes, y consecuente, alta resistencia al tratamiento antimicrobiano empírico.

Background: Bloodstream infection is a common complication, which can be life-threatening for hematopoietic stem cells transplant recipients. Objective: To analyze the characteristics of bloodstream infections in hematopoietic stem cell transplant recipients. Materials and Methods: Observational, retrospective study. We reviewed the records of 451 patients (autologous and allogeneic transplants) from January 2009 to October 2015. Results: 99 positive blood cultures in 73 patients with bloodstream infection (16%) were found. Mortality attributable to infectious causes was 17%. From the 99 bloodstream infection, 63% were caused by gram-negative bacilli (Escherichia coli 45%, Klebsiella spp 23%, Pseudomonas spp 11% Acinetobacter spp % and other bacilli 15%), 33% by gram-positive cocci, 3% by fungi and 1% by gram-positive bacilli. The gram-negative bacilli were ciprofloxacin resistant (81%), piperacillin/tazobactam resistant (48%), extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae (40%), cefepime resistant (39%) and there was no resistance noted to amikacin. Discussion: There is a higher frequency of gram-negative bacilli infection, with a high percentage of multiresistant microorganisms and high resistance to empirical antibiotic treatment.

Prevalence of fungemia in a tertiary hospital: Analysis of the last decade / Prevalência de fungemia em um hospital terciário: análise da última década

Summary Introduction: The prevalence of nosocomial fungemia has increased worldwide, and mortality caused by this disease is high. Objective: To assess progress in the last decade, and the prevalence and profile of fungal agents isolated in blood cultures performed in a tertiary university hospital. Method: All the results of blood cultures processed at Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG), in the time intervals 2001-2003 and 2011-2013 were analyzed retrospectively. For each three-year period, the number of collected blood cultures, the overall positivity rate and the percentage of fungemia were recorded. In addition, all identified fungal species were cataloged. All blood samples were incubated in the BacT/ALERT® (bioMérieux) automation system. Results: In 2001-2003, 34,822 samples were evaluated, with 5,510 (15.8%) positive results. In 2011-2013, the number of blood cultures processed increased to 55,052 samples, with 4,873 (8.9%) positive results. There was an increase in the number of positive cultures for fungi in the analyzed period (2001-2003: 4.16%; 2011-2013: 5.95%; p<0.001). Among the agents, candidemias were predominant, especially those caused by non-albicans Candida species (2001-2003: 57.64%; 2011-2013: 65.17%; p<0.05). There was also an increase in fungemia caused by other genera (2001-2003: 2.62%; 2011-2013: 4.48%; p<0.01). Conclusion: There was an increase in the prevalence of fungemia in the last decade at HC-UFMG. Although candidemias have been responsible for most of the cases, there has been an increase in fungemias caused by other species.

Resumo Introdução: a prevalência de fungemia hospitalar tem aumentado em todo o mundo e a mortalidade por essa afecção é elevada. Objetivo: avaliar a evolução, na última década, da prevalência e do perfil dos agentes fúngicos isolados em hemoculturas realizadas em um hospital universitário terciário. Método: foram analisados retrospectivamente todos os resultados de hemocultura processados no Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG), entre os períodos de 2001-2003 e de 2011-2013. Para cada triênio foram registrados o número de hemoculturas coletadas, o percentual de positividade geral e o percentual de fungemia. Também foram catalogadas todas as espécies fúngicas identificadas. Todas as amostras sanguíneas foram incubadas no sistema de automação BacT/ALERT® (bioMérieux). Resultados: entre 2001-2003, foram avaliadas 34.822 amostras, sendo 5.510 (15,8%) positivas. Entre 2011-2013, o número de hemoculturas processadas aumentou para 55.052 amostras, sendo 4.873 (8,9%) positivas. Observou-se um aumento do número de culturas positivas para fungos no período analisado (2001-2003: 4,16%; 2011-2013: 5,95%; p<0,001). Dentre os agentes, as candidemias foram predominantes, principalmente por espécies de Candida não albicans (2001-2003: 57,64%; 2011-2013: 65,17%; p<0,05). Houve também aumento da fungemia por outros gêneros (2001-2003: 2,62%; 2011-2013: 4,48%; p<0,01). Conclusão: houve aumento da prevalência de fungemia na última década no HC-UFMG. Embora as candidemias tenham sido responsáveis pela maioria dos casos, houve aumento de fungemias causadas por outras espécies.

Fungemia in a university hospital: an epidemiological approach / Fungemia em hospital universitário: uma abordagem epidemiológica

INTRODUCTION: Fungemia corresponds to the isolation of fungi in the bloodstream and occurs mostly in immunosuppressed patients. The early diagnosis and treatment of these infections are relevant given the serious threat to the affected patients and possible spread to other organs, often becoming fatal. The growing number of fungemia associated with poor prognosis resulted in this research aiming to diagnose and assess the epidemiological aspects of hematogenous infections by fungi. METHODS: The study included 58 blood samples collected within a 1-year period, from patients at the Hospital das Clinicas, Federal University of Pernambuco, by venipuncture in vacuum tubes. Blood samples were processed for direct examination and culture and identification, conducted by observing the macroscopic and microscopic characteristics, as well as physiological characteristics when necessary. RESULTS: Eight (13.8 percent) episodes of fungemia were identified, accounting for the total sample, and these pathogens were Candida, Histoplasma, Trichosporon, Cryptococcus, and a dematiaceous fungus. C. albicans was the prevalent species, accounting for 37.5 percent of the cases. Most affected patients were adult males. There was no predominance for any activity, and the risk of acquired immunodeficiency syndrome was the underlying pathology most often cited. CONCLUSIONS: The isolation of fungi considered as emergent species, such as C. membranifaciens and dematiaceous species, highlights the importance of epidemiological monitoring of cases of fungemia in immunocompromised patients, as the therapy of choice depends on the knowledge of the aethiological agent.

INTRODUÇÃO: Fungemia corresponde ao isolamento de fungos na corrente sanguínea e ocorre, sobretudo, em pacientes imunossuprimidos. O diagnóstico e tratamento precoce destas infecções são relevantes diante da grave ameaça aos pacientes acometidos e possível disseminação via hematogênica para outros órgãos, tornando-se muitas vezes fatal. O crescente número de casos de fungemia associados ao mau prognóstico resultou na realização desta pesquisa que teve por objetivo diagnosticar e avaliar aspectos epidemiológicos das infecções hematogênicas por fungos. MÉTODOS: O estudo incluiu 58 amostras de sangue coletadas, durante um ano, de pacientes internados no Hospital das Clínicas da Universidade Federal de Pernambuco, através da punção venosa em tubos a vácuo. As amostras de sangue foram processadas para exame direto e cultura e a identificação, conduzida através da observação das características macroscópicas, microscópicas e quando necessárias fisiológicas. RESULTADOS: Oito (13,8 por cento) episódios de fungemia foram identificados, correspondendo ao total das amostras e os agentes etiológicos envolvidos foram Candida, Histoplasma, Trichosporon, Cryptococcus e um fungo demáceo. C. albicans foi a espécie prevalente com 37,5 por cento dos casos. A maior parte dos pacientes acometidos pertencia ao sexo masculino, na idade adulta. Não houve predominância para nenhuma atividade de risco e a síndrome da imunodeficiência adquirida foi a patologia de base mais citada. CONCLUSÕES: O isolamento de fungos considerados emergentes como C. membranifaciens e espécies demáceas ressaltam a importância do acompanhamento epidemiológico dos casos de fungemia em imunocomprometidos, uma vez que a escolha terapêutica depende do conhecimento do agente etiológico.

The epidemiology of fungaemia at the University Hospital of the West Indies, Kingston, Jamaica / Epidemiología de la fungemia en la Hospital Universitario de West Indies, Kingston, Jamaica

OBJECTIVES: To determine the epidemiology of fungaemia at the University Hospital of the West Indies (UHWI) as well as the incidence of fungaemia at the UHWI over a four-year period. METHODS: A cross-sectional survey was conducted over a one-year period (2002). The RapID Yeast Plus Panel Identification kit was used to identify the yeasts found in blood while morphology and dimorphism were used to identify the single mold isolated, Histoplasma capsulatum. In addition, a retrospective review of the number of cases of fungaemia at the UHWI over a four-year period from 1998 was done using the laboratory and clinical records in order to determine the incidence over this period. RESULTS: The study showed that Yeast not C albicans (YNCA) accounted for 47% of the isolates while Candida albicans accounted for 29%. Of the YNCA species, Candida tropicalis was the most common (75%), followed by C pseudotropicalis (12.5%) and C glabrata (12.5%). Cryptococcus sp accounted for 18% of all fungal isolates and there was one isolate (6%) of Histoplasma capsulatum. The medical wards had the most isolates (47%), followed by surgery (29%) and the Intensive Care Unit (ICU) [24%]. While the rate at which fungi were isolated from the blood remained constant over 1998, 1999 and 2001, this doubled in 2002 from 0.26% to 0.5%. CONCLUSION: Although the incidence of fungaemia at the UHWI has remained relatively low, there was a marked increase in the last year of the study (2002) with a doubling of the number of positive fungal cultures. Candida species account for most cases of fungaemia at the UHWI. However, non-albicans Candida spp were more commonly isolated than C albicans, a trend that needs to be monitored because of its implications for therapy.

OBJETIVOS: Determinar la epidemiología de la fungemia en el Hospital Universitario de West Indies (UHWI) así como la incidencia de la fungemia en UHWI durante un período de cuatro años. MÉTODOS: Se llevó a cabo un estudio transversal por espacio de un año (2002). Se utilizó un kit de paneles para la identificación rápida de levaduras (Rapid Yeast Plus Panel), con el propósito de identificar las levaduras halladas en la sangre, en tanto que la morfología y el dimorfismo fueron usados a fin de identificar los aislados del moho individual, Histoplasma capsulatum. Además, se realizó un examen retrospectivo del número de casos de fungemia en el UHWI por espacio de cuatro años desde 1998, usando las historias clínicas e informes de laboratorio, a fin de determinar la incidencia en este período. RESULTADOS: El estudio mostró que las levaduras no C albicans (LNCA) representaban el 47% de los aislados, mientras que la Candida albicans representaba el 29%. De las especie LNCA, Candida tropicalis fue la más común (75%), seguida de C pseudotropicalis (12.5%) y C glabrata (12.5%). Cryptococcus sp representaba el 18% de todos los aislados fúngicos, y hubo un aislado (6%) de Histoplasma capsulatum. Las salas de hospitales fueron las que más aislados presentaron (47%), seguidas por las Unidades de cirugía (29%) y las de Cuidados Intensivos (UCI) (24%). Si bien el ritmo al cual los hongos fueron aislados de la sangre permaneció constante durante 1998, 1999, y 2001, el mismo se duplicó en el año 2002 pasando de 0.26% a 0.5%. CONCLUSIÓN: Aunque la incidencia de la fungemia en el UHWI ha permanecido relativamente baja, se produjo un marcado aumento en el último año de estudio (2002), en el que se duplicó el número de cultivos fúngicos positivos. Las especies de Candida son responsables de la mayor parte de los casos de fungemia en el UHWI. Sin embargo, las especies Candida no albicans fueron más comúnmente aisladas que las C albicans - una tendencia que necesita ser monitoreada debido a sus implicaciones para la terapia.

Invasive candidiasis in pediatric intensive care units.

Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.

Fatores de risco associados à colonização por Candida spp em neonatos internados em uma Unidade de Terapia Intensiva Neonatal brasileira / Risk factors associated with colonization by Candida spp in neonates hospitalized in a Neonatal Intensive Care Unit in Brazil

Os objetivos desse estudo foram investigar a participação de Candida albicans e não-albicans como agente de colonização e sepse, bem como os fatores de risco associados aos neonatos internados na Unidade de Terapia Intensiva Neonatal do Hospital de Clínicas da Universidade Federal de Uberlândia. Foi realizada vigilância epidemiológica pelo sistema National Healthcare Safety Network no período entre agosto de 2007 e abril de 2008. A taxa de incidência de sepse com critério microbiológico foi de 6,7/1.000 paciente/dia, constatando-se apenas um caso de candidemia. Aproximadamente, 19 por cento dos neonatos estavam colonizados por Candida, identificadas como Candida albicans (50 por cento) e Candida não-albicans (50 por cento). Os fatores de risco significantes para colonização por Candida spp foram a idade gestacional entre 26 e 30 semanas, o uso prévio de antibiótico e o cateter vascular central umbilical. A mortalidade total foi de 11,8 por cento nos neonatos internados durante o período de estudo com sepse, porém o recém-nascido com candidemia não evoluiu para óbito.

The objectives of this study were to investigate the participation of Candida albicans and non-albicans as colonization and sepsis agents, along with the risk factors associated with the neonates in the neonatal intensive care unit of the clinical hospital of the Federal University of Uberlândia. Epidemiological surveillance was implemented through the National Healthcare Safety Network between August 2007 and April 2008. The incidence rate for sepsis with microbiological criteria was 6.7/1,000 patients/day, which was shown as only one case of candidemia. Approximately 19 percent of the neonates were colonized by Candida, which was identified as Candida albicans (50 percent) and Candida not-albicans (50 percent). The significant risk factors for Candida spp colonization were gestational age of between 26 and 30 weeks, previous antibiotic use and umbilical central vascular catheter. The overall mortality among the neonates hospitalized with sepsis over the study period was 11.8 percent. However, the neonate with candidemia did not die.

Diagnóstico molecular de histoplasmosis humana en muestras de sangre entera / Molecular diagnosis of human histoplasmosis in whole blood samples

Se evaluó el uso de sangre entera para el diagnóstico molecular de histoplasmosis utilizando un método artesanal de extracción de ADN fúngico y una PCR anidada que amplifica una porción del gen HcP100 específica de Histoplasma capsulatum. La sangre entera se trató con liticasa, enzima lisante de Trichoderma harzianum y proteinasa K, seguido de una extracción fenólica. Este tratamiento permitió una lisis completa de las células, mostró buen rendimiento en la obtención de ADN y posibilitó la detección de la banda de 210 pb específica de H. capsulatum en la PCR anidada. El límite de detección fue de 0,25-1 levaduras/ml de sangre. El método se evaluó en 31 muestras de sangre de 19 pacientes con diagnóstico microbiológico de histoplasmosis, en 21 muestras de pacientes con otras micosis o infecciones por micobacterias y en 30 controles sanos. La PCR fue positiva en sangre para 17/19 pacientes con histoplasmosis (14/15 inmunocomprometidos y 3/4 sin inmunocompromiso aparente). Las muestras de sangre de los 30 controles sanos y de 20 pacientes con otras patologías fueron negativas, sólo hubo un falso positivo correspondiente a un paciente con infección por Mycobacterium avium-intracellulare. El método presentó 89% de sensibilidad y 96% de especificidad para el diagnóstico de histoplasmosis en sangre entera.

To assess the value of using whole blood samples for the molecular diagnosis of histoplasmosis, we applied an in-house DNA extraction method and a nested PCR targeting a 210 bp specific segment of the Histoplasma capsulatum HcP100 gene. A whole blood volume of 2.5-3 milliliters was centrifuged and the cellular pellet was treated with Trichoderma harzianum lyticase and proteinase K prior to applying a conventional phenol DNA extraction. This procedure allowed complete cell lysis, high DNA yield and specific amplification. The PCR detection limit was 0.25-1 yeast cells/ml of blood sample. The method was assessed on 31 blood samples from 19 patients with microbiological diagnosis of histoplasmosis, 30 healthy persons and 21 patients with other mycoses or mycobacterial diseases. Positive results were obtained in samples from 17/19 patients with histoplasmosis (14/15 immunocompromised and 3/4 without known immunological disorder). Blood samples from the 30 healthy controls and 20 patients with other conditions proved negative; the only false positive result was obtained from a patient with Mycobacterium avium-intracellulare infection. With 89% sensitivity and 98% specificity, this molecular method for detection of the agent in blood shows promising for the rapid diagnosis of human histoplasmosis.

An outbreak of Candida spp. bloodstream infection in a tertiary care center in Bogotá, Colombia

Several cases of Candida bloodstream infections were documented from June to October 2004 at a tertiary care center in Bogotá, Colombia. Since no cases of candidemia had occurred during the preceding four months, an outbreak was declared. As a result, a microbiological study, a revision of infection control practices and a case-control study were performed. In all, 18 cases of candidemia were ascertained. Parenteral nutrition (p=0.04), presence of a central line (p=0.03), and severity of illness (p=0.03) were associated with candidemia in bivariate analysis. Diverse Candida species were observed. Candida parapsilosis contamination was found in plastic containers used for transient intravenous (IV) medication storage at the bedside, plastic bags reused for the transportation of IV medicines and cotton used for disinfection of IV ports. Poor infection control practices were widely observed. The outbreak was controlled after elimination of plastic bags used for transportation, instauration of daily disinfection of IV medication containers, acquisition of sterile alcohol swabs for port disinfection and staff education. It was concluded that candidemia was associated with previously-described risk factors and that poor infection-control practices were likely responsible for the outbreak.

Molecular investigation of a fungemia outbreak due to Candida parapsilosis in an intensive care unit

We investigated a nosocomial cluster of four Candida parapsilosis fungemia episodes that occurred in a neurological intensive care unit over a two-week period. The four infected patients had received parenteral nutrition through central lines, and all four had catheter-related candidemia. All of the isolates were susceptible to all of the antifungals tested, including amphotericin B, fluconazole, voriconazole, and caspofungin. They had strictly related fingerprints, based on randomly amplified polymorphic DNA analysis. Additional DNA sequencing data revealed that they were same strain. Although no isolate of Candida parapsilosis was recovered from other clinical, surveillance, or environmental samples, nosocomial spread of this yeast ceased, following the reinforcement of infection-control measures. Candida parapsilosis may require an intravascular foreign body to cause fungemia, but this outbreak shows that it can be transmitted nosocomially and can cause epidemics.

Candida bloodstream infection: data from a teaching hospital in Mato Grosso do Sul, Brazil / Infecção na corrente sangüínea por Candida spp. dados de um hospital universitário em Mato Grosso do Sul, Brasil

The incidence of Candida bloodstream infection has increased over the past years. In the Center-West region of Brazil, data on candidemia are scarce. This paper reports a retrospective analysis of 96 cases of Candida bloodstream infection at a Brazilian tertiary-care teaching hospital in the state of Mato Grosso do Sul, from January 1998 to December 2006. Demographic, clinical and laboratory data were collected from medical records and from the hospital's laboratory database. Patients' ages ranged from three days to 92 years, with 53 (55.2 percent) adults and 43 (44.8 percent) children. Of the latter, 25 (58.1 percent) were newborns. The risk conditions most often found were: long period of hospitalization, utilization of venous central catheter, and previous use of antibiotics. Fifty-eight (60.4 percent) patients died during the hospitalization period and eight (13.7 percent) of them died 30 days after the diagnosis of candidemia. Candida albicans (45.8 percent) was the most prevalent species, followed by C. parapsilosis (34.4 percent), C. tropicalis (14.6 percent) and C. glabrata (5.2 percent). This is the first report of Candida bloodstream infection in the state of Mato Grosso do Sul and it highlights the importance of considering the possibility of invasive Candida infection in patients exposed to risk factors, particularly among neonates and the elderly.

A incidência de infecções na corrente sangüínea causada por Candida spp. tem aumentado nos últimos anos. Na região Centro-Oeste do Brasil, os dados sobre candidemia são escassos. Realizamos uma análise retrospectiva de casos de infecção na corrente sangüínea por Candida em um hospital terciário de ensino de Mato Grosso do Sul. Noventa e seis episódios diagnosticados de janeiro de 1998 a dezembro de 2006 foram incluídos no estudo. Os dados demográficos e clínicos foram obtidos de prontuários; os dados laboratoriais provieram de registros do laboratório hospitalar. Dos pacientes, 43 (44,8 por cento) eram crianças e 53 (55,2 por cento) adultos, com idades variando de três dias a 92 anos. Das crianças, 25 (58,1 por cento) eram recém-nascidas. As condições de risco mais encontradas foram: prolongado tempo de internação, uso de cateter venoso central e uso prévio de antibióticos. Cinqüenta e oito (60,4 por cento) pacientes foram a óbito durante a hospitalização e oito (13,7 por cento) deles foram a óbito 30 dias após o diagnóstico de candidemia. Candida albicans (45,8 por cento) foi a espécie mais prevalente seguida por C. parapsilosis (34,4 por cento), C. tropicalis (14,6 por cento) e C. glabrata (5,2 por cento). Esta é a primeira descrição de infecção na corrente sangüínea por espécies de Candida em Mato Grosso do Sul, confirmando a importância da suspeita clínica de infecções invasivas por tais microrganismos na evolução de pacientes expostos a fatores de risco, principalmente no caso de idosos e neonatos.

Prevalencia de microorganismos causantes de bacteriemias y fungemias en pacientes oncológicos pediátricos: Patrones de sensibilidad a los antimicrobianos / Prevalence and antimicrobial susceptibility patterns of microorganisms causing bacteremia and fungemia in pediatric oncology patients

El objetivo del presente trabajo fue conocer la distribución y frecuencia de los microorganismos causantes de bacteriemias y fungemias en los pacientes oncológicos internados en el Hospital de Niños de Córdoba, así como describir sus patrones de sensibilidad a los antimicrobianos. Se estudiaron 59 episodios de bacteriemias y fungemias ocurridos entre enero de 2006 y abril de 2007 en 44 pacientes. Del total de los aislamientos recuperados, el 45,8% fueron bacilos gram-negativos, el 35,6% cocos gram-positivos y el 18,6% levaduras. La distribución global de los microorganismos más prevalentes fue: Klebsiella spp. 15,3%; Staphylococcus aureus 11,9%; Candida parapsilosis 11,9%; estafilococos coagulasa negativos 10,2%; Escherichia coli 8,5% y Pseudomonas aeruginosa 6,8%. El 41,2% de las enterobacterias aisladas presentó un fenotipo compatible con la presencia de alguna b-lactamasa de espectro extendido, y el 20,0% de los bacilos gram-negativos no fermentadores presentó multirresistencia a los antibióticos ensayados. En cuanto a los cocos gram-positivos, el 38,5% de los Staphylococcus spp. fue resistente a meticilina. Se puede concluir que los microorganismos más prevalentes en la población estudiada fueron los bacilos gram-negativos; dentro de este grupo las enterobacterias fueron las que presentaron mayor porcentaje de resistencia a los antibióticos ensayados.

The purpose of our research was to know the frequency of microorganisms causing bacteremia and/or fungemia in oncology patients from Hospital de Niños de Córdoba, as well as to describe the antimicrobial susceptibility patterns of bacteria isolated from January 2006 to April 2007. A total of 59 bacteremia and fungemia cases in 44 patients were studied. From the total number of isolations, 45.8% were gram-negative bacilli, 35.6% were gram-positive cocci, and 18.6% were yeasts. The global distribution of the most prevalent microorganisms was the following: Klebsiella spp. 15.3%; Staphylococcus aureus and Candida parapsilosis 11.9%; coagulase-negative staphylococci 10.2%; Escherichia coli 8.5%, and Pseudomonas aeruginosa 6.8%. More than 40% (41.2%) of enterobacteria showed an extended-spectrum b-lactamase phenotype, and 20.0% of non-fermenting gram-negative bacilli were multi-resistant to tested antibiotics, while 38.5% of Staphylococcus spp. were methicillin-resistant. In conclusion, the most prevalent microorganisms were gram-negative bacilli, and within this group, enterobacteria evidenced a higher percentage of resistance to tested antibiotics.

Factores de riesgo asociados a candidemias causadas por múltiples especies / Risk factors associated with multiple-species candidemia

Los episodios de candidemia han aumentado en la última década. Sin embargo, la publicación de casos de candidemias causadas por múltiples especies (CME) es infrecuente. De un total de 155 candidemias diagnosticadas entre 1998 y 2004 en el Hospital de Clínicas de la Universidad de Buenos Aires, se identificaron 7 casos de CME (6 adultos y 1 neonato), cuyos datos clínicos y evolutivos se compararon con 21 casos de candidemias producidas por una única especie de Candida (CUE) en pacientes de similar edad e igual sexo. No se hallaron mayores diferencias clínicas o evolutivas entre los pacientes con CME y CUE; sin embargo, la mediana del tiempo de internación y del tiempo promedio de permanencia de los catéteres venosos centrales con anterioridad a la candidemia (39 y 32 días para los pacientes con CME vs. 18 y 12 días para aquellos con CUE, respectivamente) resultaron ser factores predisponentes relevantes. La duración de la candidemia fue más prolongada en los pacientes con CME que en los afectados por CUE (5 días vs. 1 día). En conclusión, aunque los episodios de CME son menos frecuentes que los causados por una única especie de Candida, factores de riesgo potencialmente controlables como el tiempo de internación y el tiempo de utilización de catéteres venosos centrales tienen mayor importancia en el desarrollo de CME.

The incidence of fungemia has increased over the past decade. Multiple-species candidemia (MSC) has been infrequently reported. From 1998 to 2004, of 155 patients with diagnosis of candidemia at the Hospital de Clínicas (University of Buenos Aires), seven cases of MSC were identified (6 adults and 1 newborn) and compared with 21 cases of similar age and sex with monomicrobial candidemia. There were no differences in clinical data and outcome, except for the mediana duration of hospital stay (39 days for patients with MSC vs. 18 days for patients with monomicrobial candidemia, the mean time of central venous catheter permanence previous to candidemia (32 days for patients with MSC vs. 12 days for patients with monomicrobial candidemia and the duration of candidemia (5 days for MSC and 1 day for monomicrobial candidemia. In conclusion, although MSC episodes are less common than those caused by monomicrobial candidemia, modifiable risk factors such as duration of hospitalization and central venous catheter permanence account for the development of MSC.

Candidemia em um hospital terciário brasileiro: incidência, freqüência das diferentes espécies, fatores de risco e suscetibilidade aos antifúngicos / Candidemia in a Brazilian tertiary care hospital: incidence, frequency of different species, risk factors and antifungal susceptibility

São apresentados os resultados de estudo transversal e observacional sobre candidemia realizado no Hospital de Clínicas da Universidade Federal do Paraná. No período de janeiro de 2001 a dezembro de 2004, foram analisados 100 episódios de candidemia. A incidência foi de 1,27 por 1.000 internações, sendo Candida spp o oitavo agente mais isolado nas infecções da corrente sanguínea. A idade variou de 5 dias a 89 anos com uma média de 32 anos, 60 por cento dos casos ocorreram em adultos (66 por cento > 50 anos) e 40 por cento em crianças (52 por cento < 1 ano). Cinqüenta e nove pacientes estavam internados em enfermarias e 41 em unidade de terapia intensiva. Candida albicans foi a espécie mais (59 por cento) freqüente, seguida por Candida tropicalis (15 por cento), Candida parapsilosis (9 por cento). As condições associadas mais (97 por cento) freqüentes foram uso de antibióticos, cateter venoso central (77 por cento), bloqueador H2 (57 por cento), nutrição parenteral total (49 por cento) internamento em unidade de terapia intensiva (41 por cento). Dos 51 isolados testados, 3 de Candida glabrata apresentaram suscetibilidade dose-dependente ao fluconazol e eram resistentes ao itraconazol. Uma amostra de Candida krusei apresentou suscetibilidade dose-dependente ao fluconazol, e uma de Candida pelliculosa suscetibilidade dose-dependente ao itraconazol. Na população de estudo, 68 por cento receberam tratamento antifúngico, no entanto a mortalidade foi de 56 por cento.

Results from a cross-sectional observational study on candidemia conducted at Hospital de Clínicas, Federal University of Paraná, are presented. From January 2001 to December 2004, one hundred candidemia cases were evaluated. The incidence was 1.27 episodes per 1,000 hospitalizations and Candida was the eighth most frequently isolated agent from bloodstream infections. The patients’ ages ranged from five days to 89 years, with a mean of 32 years. Sixty percent of the cases occurred in adults (66 percent > 50 years old) and 40 percent in children (52 percent < one year old). Fifty-nine percent had been admitted to medical wards and 41 percent to the intensive care unit. Candida albicans was the most (59 percent) frequent species followed by Candida tropicalis (15 percent) and Candida parapsilosis (9 percent). The most (97 percent) prevalent coexisting conditions were the use of antibacterial drugs, central venous catheter (77 percent), H2 blockers (57 percent), total parenteral nutrition (49 percent) and admission to the intensive care unit (41 percent). Out of the 51 isolates tested, three of Candida glabrata presented dose-dependent susceptibility to fluconazole and resistance to itraconazole. One sample of Candida krusei presented dose-dependent susceptibility to fluconazole and one of Candida pelliculosa presented dose-dependent susceptibility to itraconazole. Among the study population, 68 percent received antifungal therapy, but the mortality was 56 percent.

Candida spp. other than Candida albicans: a major cause of fungaemia in a tertiary care centre.

This study was conducted to determine the frequency of different Candida spp. isolated from different parts of the hospital, associated risk factors and mortality rate. A total of 59 cases were selected for prospective analysis over a period of one and half years. Blood samples collected were processed by BACTEC (9240) method. Candidaemia was diagnosed by positive blood culture at least from two blood culture samples or from a clinically significant single blood culture sample. Candida spp. were identified by standard techniques. Most frequent isolates were C. tropicalis (35.6%), C. parapsilosis (28.8%), C. glabrata (11.9%) and C. pelliculosa (11.9%). Candida albicans was isolated only in 3.4% cases. Neonatology department accounted for highest number of isolates (27.1%), followed by gastrointestinal surgery (15.3%) and cardiac surgery (13.6%). Mortality was noted in 16.9%. Probable risk factors determined were intensive care unit stay (74.6%), antibiotic therapy (50.8%), central line (42.4%), urinary catheter (32.2%), ventilator (23.7%), malignancy (20.3%) and abdominal surgery (15.3%).

Microorganisms Isolated from Blood Cultures and Their Antimicrobial Susceptibility Patterns At a University Hospital During 1994-2003 / 대한진단검사의학회지

BACKGROUND: Blood culture is important for the determination of the etiologic agent of bacteremia. Analysis of blood culture results and antimicrobial susceptibility trend can provide clinicians with relevant information for the empirical treatment of patients. METHODS: The species and antimicrobial susceptibility of the isolates from blood cultures at the Severance Hospital during 1994-2003 were analysed. Blood specimens were cultured for 7 days using tryptic soy broth and thioglycollate medium. Identification of organism was based on conventional methods or commercial kit systems. Antimicrobial susceptibility was tested by a disk diffusion method. RESULTS: Of 536,916 blood specimens cultured, 24,877 (4.6%) from 13,102 patients were positive. Among the isolates, 93.1% were aerobic or facultative anaerobic bacteria, 3.3% anaerobes, and 3.6% fungi. Escherichia coli was isolated most frequently, followed by Staphylococcus aureus, -hemolytic Streptococcus, Enterococcus spp., and Klebsiella pneumoniae. The proportion of patients with Enterococcus faecium and K. pneumoniae gradually increased during this study. Enterococcus, S. aureus and alpha-hemolytic Streptococcus were frequently isolated from the age group of less than 2 yr. E. coli, Enterococcus spp., K. pneumoniae and S. aureus from the age group of over 50 yr. Oxacillin-resistant S. aureus decreased, whereas vancomycin-resistant E. faecium and imipenemresistant Pseudomonas aeruginosa and Acinetobacter baumannii increased. CONCLUSIONS: E. coli was the most common cause of bacteremia and S. aureus, -hemolytic Streptococcus, and K. pneumoniae were frequently isolated pathogens. The bacteremia due to Enterococcus, K. pneumoniae, fungi, vancomycin-resistant E. faecium, and imipenem-resistant P. aeruginosa and A. baumannii gradually increased during this period.

Candida colonization in preterm babies admitted to neonatal intensive care unit in the rural setting.

PURPOSE: Candida colonization in neonates results in significant morbidity and mortality. The purpose of this study was to determine colonization of Candida spp. in preterm babies and identify the risk factors. METHODS: Swabs from oral, rectum, groin and umblicus of 103 preterm and 100 term neonates were obtained within 24 hours of birth, day three, day five, day seven and thereafter every week till the neonate was admitted in the neonatal intensive care unit (NICU). Swabs were also collected from the mother's vagina prior to delivery. Twice every month, air of the NICU was sampled by settle plate and swabs were collected from the hands of health care workers and inanimate objects of NICU. Identification and speciation was done by standard methods. Antibiotic sensitivity was studied against amphotericin B, ketoconazole and fluconazole by disk diffusion method. RESULTS: Colonization with Candida was significantly higher in preterms. Earliest colonization was of oral mucosa and 77.1% of the preterms had colonised at various sites by the first week of life. Significant risk factors in colonized versus non-colonized preterms were male sex, longer duration of rupture of membranes (DROM), administration of steroids and antibiotics and vaginal colonization of mothers, whereas those in preterms versus terms were low birth weight and gestational age. C. albicans was the commonest species, both in the colonized preterms (45.9%) and vagina of mothers. Resistance was seen to fluconazole and ketoconazole only. No Candida spp. was isolated from health care personnel or environment. CONCLUSIONS: Colonization of preterms by Candida is a significant problem in NICU and the significant risk factors observed in colonized preterms were male sex, longer DROM, administration of steroids and antibiotics and vaginal colonization of mothers.

Evaluation of blood stream infections by Candida in three tertiary hospitals in Salvador, Brazil: a case-control study

Invasive infections caused by Candida spp. are an important problem in immunocompromised patients. There is scarce data on the epidemiology of blood stream candidiasis in Salvador, Brazil. This study evaluates the risk factors associated with candidemia, among patients admitted to three tertiary, private hospitals, in Salvador, Brazil. We conducted a case-control, retrospective study to compare patients with diagnosis of candidemia in three different tertiary hospitals in Salvador, Brazil. Patients were matched for nosocomial, acquired infections, according to the causal agent: cases were defined by positive blood cultures for Candida species. Controls were those patients who had a diagnosis of systemic bacterial infection, with a positive blood culture to any bacteria, within the same time period (± 30 days) of case identification. The groups were compared for the main known risk factors for candidemia and for mortality rates. A hundred thirty-eight patients were identified. Among the 69 cases, only 14 were diagnosed as infected by Candida albicans. Candida species were defined in only eight cultures: C. tropicalis (4 cases), C. glabrata, C. parapsilosis, C. guillermondi, C. formata (1 case each). The main risk factors, identified in a univariate analysis, were: presence of a central venous catheter (CVC), use of parenteral nutrition support (PNS), previous exposure to antibiotics, and chronic renal failure (CRF). No association was detected with surgical procedures, diabetes mellitus, neutropenia or malignancies. Patients were more likely to die during the hospitalization period, but the rates of death caused by the infections were similar for cases and controls. The length of hospitalization was similar for both groups, as well as the time for a positive blood culture. Blood stream infection by Candida spp. is associated with CVC, PNS, previous use of antibiotics, and CRF. The higher mortality rate for cases probably better reflects the severity of the underlying diseases, than as a direct consequence of Candidemia.

Candidemia in a Brazilian hospital: the importance of Candida parapsilosis

O presente estudo objetivou desenvolver uma análise retrospectiva de casos de candidemia em hospital brasileiro na cidade de Fortaleza, Ceará. Um total de 50 hemoculturas foram analisadas de 40 pacientes com quadros de candidemia. O diagnóstico micológico foi baseado na análise morfológica e bioquímica e os dados dos pacientes foram coletados das histórias clínicas. As espécies mais freqüentes foram Candida parapsilosis (n = 18), seguida por C. albicans (n = 14), C. tropicalis (n = 8), C. guillermondii (n = 6), C. glabrata (n = 2) e Candida spp. (n = 2). Um estudo descritivo foi realizado com apenas 21 pacientes os quais possuíam dados clínicos completos. Os episódios de candidemia aconteceram em oito pacientes do sexo masculino e 13 do feminino. Os fatores de risco implicados em candidemia foram antibioticoterapia prévia, uso de cateter venoso central, nutrição parenteral, sondagem gástrica e ventilação mecânica. A morte aconteceu em 13 dos 21 pacientes com candidemia. Este estudo demonstrou a emergência de candidemia causada por C. parapsilosis em um hospital brasileiro na cidade de Fortaleza, Ceará.