NDM-producing Enterobacterales prevalence associated to COVID-19 in a tertiary hospital.

Colonizations/Infections caused by carbapenem-resistant Enterobacterales are of great clinical and epidemiological importance due to their rapid dissemination and high mortality rates. In this scenario, the use of antibiotics intensified by the COVID-19 pandemic has brought about a great warning on the real impact that this pandemic could have on antimicrobial management programs and long-term antimicrobial resistance rates. The objective of this study was to evaluate the increase of New Delhi Metallo ß-Lactamase (NDM)-producing Enterobacterales cases in COVID-19 units of a complex Brazilian tertiary hospital. This retrospective observational study included all patients admitted to the hospital identified as colonized or infected by NDM-producing Gram negative bacilli (GNB), from January 2017 to April 2021. Forty-two NDM-producing Enterobacterales were identified in 39 patients. The rate of NDM cases per total surveillance cultures increased progressively between 2017 and 2021 (chi-2 for trend, p < 0.0001) and was associated with a higher occurrence specifically in COVID units (Fisher exact, p < 0.0001). The molecular investigation of the NDM-producing Klebsiella pneumoniae strains revealed the emergence of diverse clones during the COVID-19 period, also with possible evidence of horizontal transmission among patients within COVID units. NDM-producing Enterobacterales with multiple and different clonalities in the COVID-19 units also raised questions about the importance of other factors besides horizontal clonal transfer, including the increase of antimicrobial consumption by these patients.

NDM-producing enterobacterales prevalence associated to COVID-19 in a tertiary hospital

Colonizations/Infections caused by carbapenem-resistant Enterobacterales are of great clinical and epidemiological importance due to their rapid dissemination and high mortality rates. In this scenario, the use of antibiotics intensified by the COVID-19 pandemic has brought about a great warning on the real impact that this pandemic could have on antimicrobial management programs and long-term antimicrobial resistance rates. The objective of this study was to evaluate the increase of New Delhi Metallo b-Lactamase (NDM)-producing Enterobacterales cases in COVID-19 units of a complex Brazilian tertiary hospital. This retrospective observational study included all patients admitted to the hospital identified as colonized or infected by NDM-producing Gram negative bacilli (GNB), from January 2017 to April 2021. Forty-two NDM-producing Enterobacterales were identified in 39 patients. The rate of NDM cases per total surveillance cultures increased progressively between 2017 and 2021 (chi-2 for trend, p < 0.0001) and was associated with a higher occurrence specifically in COVID units (Fisher exact, p < 0.0001). The molecular investigation of the NDM-producing Klebsiella pneumoniae strains revealed the emergence of diverse clones during the COVID-19 period, also with possible evidence of horizontal transmission among patients within COVID units. NDM-producing Enterobacterales with multiple and different clonalities in the COVID-19 units also raised questions about the importance of other factors besides horizontal clonal transfer, including the increase of antimicrobial consumption by these patients.

NDM-producing Enterobacterales prevalence associated to COVID-19 in a tertiary hospital

Abstract Colonizations/Infections caused by carbapenem-resistant Enterobacterales are of great clinical and epidemiological importance due to their rapid dissemination and high mortality rates. In this scenario, the use of antibiotics intensified by the COVID-19 pandemic has brought about a great warning on the real impact that this pandemic could have on antimicrobial management programs and long-term antimicrobial resistance rates. The objective of this study was to evaluate the increase of New Delhi Metallo β-Lactamase (NDM)-producing Enterobacterales cases in COVID-19 units of a complex Brazilian tertiary hospital. This retrospective observational study included all patients admitted to the hospital identified as colonized or infected by NDM-producing Gram negative bacilli (GNB), from January 2017 to April 2021. Forty-two NDM-producing Enterobacterales were identified in 39 patients. The rate of NDM cases per total surveillance cultures increased progressively between 2017 and 2021 (chi-2 for trend, p < 0.0001) and was associated with a higher occurrence specifically in COVID units (Fisher exact, p < 0.0001). The molecular investigation of the NDM-producing Klebsiella pneumoniae strains revealed the emergence of diverse clones during the COVID-19 period, also with possible evidence of horizontal transmission among patients within COVID units. NDM-producing Enterobacterales with multiple and different clonalities in the COVID-19 units also raised questions about the importance of other factors besides horizontal clonal transfer, including the increase of antimicrobial consumption by these patients.

Abscesso cerebral em escolar com cardiopatia congênita cianogênica complexa: quando pensar em neurotuberculose? / Brain abscess in a schoolchild with complex cyanotic congenital heart disease: when to think about neurotuberculosis?

INTRODUÇÃO E/OU FUNDAMENTOS: Crianças portadoras de cardiopatias congênitas cianogênicas podem evoluir com diversas complicações secundárias à hipoxemia crônica. A policetemia e hiperviscosidade sanguínea podem levar à formação de trombos e microtrombos na microcirculação de vários órgãos e sistemas, incluindo o sistema nervoso central, sendo um fator de risco para a formação e desenvolvimento de abcessos cerebrais. RELATO DO CASO: Menino, 8 anos, 16.4 kg, com diagnóstico cardiológico de inversão ventricular, atresia pulmonar, CIV ampla não relacionada e PCA. Aos 4 meses, submetido à ligadura e secção do canal arterial e interposição de tubo VD-TP (PTFE 8 mm) com bandagem. Aos 3 anos, realizada angioplastia do tubo e, aos 5, oclusão de colaterais sistêmico-pulmonares, ambas por via percutânea. Durante toda a evolução, manteve SO2 basal de 75-80%. Aos 7 anos, admitido via pronto-socorro por febre hár 14 dias, cefaleia, confusão mental e hipoxemia grave (SO2 50%). Realizada extensa investigação infecciosa. Ecocardiograma: ausência de vegetações. TC crânio: lesão hipodensa encapsulada em região occipital. Hemograma: policitemia. Hemocultura: Stenotrophomonas maltophilia multissensível. Líquor cefalorraquidiano: celularidade aumentada (polimorfonucleares), proteinorraquia aumentada, glicorraquia e ADA normais e culturas negativas. Iniciada terapia antibiótica e antifúngica de amplo espectro, sem regressão da febre após 1 mês. Revisão detalhada do caso constatou história materna de tratamento incompleto para tuberculose pulmonar, sem profilaxia familiar. Na ocasião, com 1 ano de idade, paciente apresentara febre e tosse por 2 meses, sem investigação adequada. Aos 3 anos, apresentou PPD fortemente reagente. Por questões sociais, houve má adesão ao serviço ao longo de todo seguimento. Diante da falha terapêutica inicial, da somatória de fatores de riscos (cianose e desnutrição crônicas, epidemiologia positiva e risco social) e da imagem tomográfica sugestiva, foi instituído tratamento empírico para neurotuberculose (rifampicina, isoniazida e pirazinamida), obtendo-se resposta clínica inicial satisfatória e regressão do abscesso cerebral, permitindo alta hospitalar. CONCLUSÕES: A neurotuberculose é um importante diagnóstico diferencial na investigação de abscessos cerebrais em pacientes cianóticos crônicos. Apesar dos agentes mais comuns nesse contexto serem espécies de estafilococos e estreptococos, a alta incidência da Mycobacterium tuberculosis a alta incidência da Mycobacterium tuberculosis, sobretuda na falha terapêutica.

Pharmacodynamic and immunomodulatory effects of polymyxin B in combination with fosfomycin against KPC-2-producing klebsiella pneumoniae

Abstract Determining the role of the immune response in preventing antimicrobial resistance and optimizing antibiotic regimens against carbapenemase-producing Klebsiella pneumoniae (KPC) is a research gap that exists and needs to be further explored. The objective of this study was to determine the pharmacodynamics and immunomodulatory effects of fosfomycin alone and in combination with polymyxin B against KPC-2-producing K. pneumoniae clinical isolates. Six K. pneumoniae isolates were selected (polymyxin B_MIC: 0.5-64 mg/L; Fosfomycin MIC: 16-128 mg/L) to evaluate the pharmacodynamics of mono- and combination therapies in static time-kill studies. A mechanism based model was used to characterize the joint activity of polymyxin B and fosfomycin. A549 human airway epithelial cells were infected with four isolates to evaluate the immunomodulatory effects of treatment. Our mechanism-based model indicated greater bacterial killing efficacy of fosfomycin with polymyxin B compared to monotherapy. In combination, polymyxin B was assumed to exert an outer membrane effect which resulted in an increase in fosfomycin's ability to reach its target site. The mechanism based model described the data well across all six strains with R2 values ranging from 0.705 to 0.935. The combination reduced K. pneumoniae-induced IL-6 and IL-8 but not TNF-α expression. The reduction in cytokine expression was greater with polymyxin B than fosfomycin alone, and combinations showed significantly greater reductions compared to monotherapies. Our findings suggest that further research is needed to understand immune-mediated killing to identify a strategy which harnesses the power of the immune response against these hard to treat bacteria in an in vivo system.

Angiossarcoma epitelioide em bioprótese mitral / Epithelioid angiosarcoma in mitral bioprosthesis

INTRODUÇÃO: Os angiossarcomas epitelioides são tumores malignos com origem no endotélio vascular. Devido à sua raridade, o conhecimento desses tumores permanece incompleto, pois em sua maioria são conhecidos por relatos de casos isolados ou em série de autópsias, com uma incidência estimada de 0,001-0,03%. As manifestações clínicas são caracterizadas por três mecanismos: obstrução, embolização ou arritmias. Apesar do tratamento ser predominantemente cirúrgico, os angiossarcomas tem um prognóstico sombrio com sobrevida média de 6 a 25 meses após o diagnóstico. OBJETIVO E MÉTODOS: Relatar o caso raro de um paciente de 67 anos diagnosticado com angiossarcoma epiteliode em prótese mitral biológica. As informações foram obtidas por meio de revisão do prontuário, entrevista com o paciente, sendo aplicado o Termo de Consentimento Esclarecido, registro fotográfico do método diagnóstico ao qual o paciente foi submetido e revisão da literatura. RELATO DE CASO: Homem de 67 anos, com antecedente de troca valvar mitral biológica associado a revascularização miocárdica cirúrgica em 2008, evoluiu com sintoma de dispneia progressiva em 2020. Ao exame ecocardiográfico observou-se uma disfunção da prótese devido à rotura de um dos folhetos associado à presença de massa ecogênica heterogênea aderida à base do outro folheto, o que suscitou o diagnóstico diferencial entre trombo e vegetação. Diante desses achados, o paciente foi submetido à retroca de valva mitral por prótese biológica e a valva retirada foi encaminhada para estudo anatomopatológico, onde foi evidenciado um angiossarcoma epitelioide. (Figura 1) O paciente apresentou boa evolução clínica no pós-operatório e na alta hospitalar foi encaminhado para acompanhamento oncológico. Discussão: O angiossarcoma é um tumor raro, com apresentação mais comum o acometimento do lado direito do coração, sendo 74% das vezes ocorrendo no átrio direito. Um dos principais sintomas observados é a dispneia, normalmente causada pela obstrução mecânica da massa sob a valva. A dificuldade de um diagnóstico precoce ainda permanece sendo um dos principais desafios, além do prognóstico ruim apesar da terapêutica aplicada. CONCLUSÃO: O angiossarcoma é uma patologia rara e muitas vezes observada como achado transoperatório. O diagnóstico é difícil principalmente devido às alterações ecocardiográficas serem confundidas com massas, trombos ou vegetações, além da necessidade de realização de estudo imunohistoquímico. O tratamento combina ressecção do tumor, quimioterapia e radioterapia, com uma sobrevida bastante reduzida.

Pharmacodynamic and immunomodulatory effects of polymyxin B in combination with fosfomycin against KPC-2-producing Klebsiella pneumoniae.

Determining the role of the immune response in preventing antimicrobial resistance and optimising antibiotic regimens against carbapenemase-producing Klebsiella pneumoniae is a research gap that exists and needs to be further explored. The objective of this study was to determine the pharmacodynamic and immunomodulatory effects of fosfomycin alone and in combination with polymyxin B against KPC-2-producing K. pneumoniae clinical isolates. Six K. pneumoniae isolates were selected (polymyxin B MIC, 0.5-64 mg/L; fosfomycin MIC, 16-128 mg/L) to evaluate the pharmacodynamics of monotherapy and combination therapies in static time-kill studies. A mechanism-based model was used to characterise the joint activity of polymyxin B and fosfomycin. A549 human airway epithelial cells were infected with four isolates to evaluate the immunomodulatory effects of treatment. Our mechanism-based model indicated greater bacterial killing efficacy of fosfomycin with polymyxin B compared with monotherapy. In combination, polymyxin B was assumed to exert an outer membrane effect that resulted in an increase in the ability of fosfomycin to reach its target site. The mechanism-based model described the data well across all six strains, with R2 values ranging from 0.705-0.935. Combination therapy reduced K. pneumoniae-induced IL-6 and IL-8 but not TNFα expression. The reduction in cytokine expression was greater with polymyxin B than fosfomycin alone; combination therapy showed significantly greater reduction compared to either monotherapy. Our findings suggest that further research is needed to better understand immune-mediated killing in order to identify a strategy which harnesses the power of the immune response against these hard-to-treat bacteria.

Serological Testing for COVID-19, Immunological Surveillance, and Exploration of Protective Antibodies.

Serological testing is a powerful tool in epidemiological studies for understanding viral circulation and assessing the effectiveness of virus control measures, as is the case of SARS-CoV-2, the pathogenic agent of COVID-19. Immunoassays can quantitatively reveal the concentration of antiviral antibodies. The assessment of antiviral antibody titers may provide information on virus exposure, and changes in IgG levels are also indicative of a reduction in viral circulation. In this work, we describe a serological study for the evaluation of antiviral IgG and IgM antibodies and their correlation with antiviral activity. The serological assay for IgG detection used two SARS-CoV-2 proteins as antigens, the nucleocapsid N protein and the 3CL protease. Cross-reactivity tests in animals have shown high selectivity for detection of antiviral antibodies, using both the N and 3CL antigens. Using samples of human serum from individuals previously diagnosed by PCR for COVID-19, we observed high sensitivity of the ELISA assay. Serological results with human samples also suggest that the combination of higher titers of antiviral IgG antibodies to different antigen targets may be associated with greater neutralization activity, which can be enhanced in the presence of antiviral IgM antibodies.

Evaluation Strategies for Triple-Drug Combinations against Carbapenemase-Producing Klebsiella Pneumoniae in an In Vitro Hollow-Fiber Infection Model

Mounting antimicrobial resistance to carbapenemase-producing Klebsiella pneumoniae (CPKP) highlights the need to optimize currently available treatment options. The objective of this study was to explore alternative dosing strategies that limit the emergence of resistance to preserve the utility of last-line antibiotics by: (i) evaluating the pharmacodynamic (PD) killing activity of simulated humanized exposures to monotherapy and two-drug and three-drug combinations against CPKP bacterial isolates with different resistance mechanisms; and (ii) optimizing polymyxin B (PMB) exposure simulated in the three-drug combination regimens to maximize the killing activity. Two CPKP clinical isolates (BAA2146 (NDM-1) and BRKP76 (KPC-2)) were evaluated over 168 hours using a hollow-fiber infection model simulating clinically relevant PMB, fosfomycin, and meropenem dosing regimens. PMB-based three-drug combinations were further optimized by varying the initial exposure (0­24 hours) or maintenance dose received over the duration of treatment. The area under the bacterial load-versus-time curve (AUCFU) was used to determine PD activity. Overall reductions in PMB exposure ranged from 2 to 84%. BAA2146 and BRKP76 had median (range) AUCFUs of 11.0 (10.6­11.6) log10 CFU hour/mL and 7.08 (7.04­11.9) log10 CFU hour/mL, respectively. The PMB "front loaded" 2.5 mg/ kg/day + 0.5 mg/kg maintenance dose in combination with meropenem and fosfomycin was a promising regimen against BRKP76, with an overall reduction in PMB exposure of 56% while still eradicating the bacteria. Tailored triple combination therapy allows for the optimization of dose and treatment duration of last-line agents like PMB to achieve adequate drug exposure and appropriate PD activity while minimizing the emergence of resistance.

Evaluation Strategies for Triple-Drug Combinations against Carbapenemase-Producing Klebsiella Pneumoniae in an In Vitro Hollow-Fiber Infection Model.

Mounting antimicrobial resistance to carbapenemase-producing Klebsiella pneumoniae (CPKP) highlights the need to optimize currently available treatment options. The objective of this study was to explore alternative dosing strategies that limit the emergence of resistance to preserve the utility of last-line antibiotics by: (i) evaluating the pharmacodynamic (PD) killing activity of simulated humanized exposures to monotherapy and two-drug and three-drug combinations against CPKP bacterial isolates with different resistance mechanisms; and (ii) optimizing polymyxin B (PMB) exposure simulated in the three-drug combination regimens to maximize the killing activity. Two CPKP clinical isolates (BAA2146 (NDM-1) and BRKP76 (KPC-2)) were evaluated over 168 hours using a hollow-fiber infection model simulating clinically relevant PMB, fosfomycin, and meropenem dosing regimens. PMB-based three-drug combinations were further optimized by varying the initial exposure (0-24 hours) or maintenance dose received over the duration of treatment. The area under the bacterial load-versus-time curve (AUCFU) was used to determine PD activity. Overall reductions in PMB exposure ranged from 2 to 84%. BAA2146 and BRKP76 had median (range) AUCFUs of 11.0 (10.6-11.6) log10  CFU hour/mL and 7.08 (7.04-11.9) log10 CFU hour/mL, respectively. The PMB "front loaded" 2.5 mg/kg/day + 0.5 mg/kg maintenance dose in combination with meropenem and fosfomycin was a promising regimen against BRKP76, with an overall reduction in PMB exposure of 56% while still eradicating the bacteria. Tailored triple-combination therapy allows for the optimization of dose and treatment duration of last-line agents like PMB to achieve adequate drug exposure and appropriate PD activity while minimizing the emergence of resistance.

Is it cost effective to use a 2% chlorhexidine wipes bath to reduce central-line associated blood stream infection? A quasi-experimental study.

BACKGROUND: Bathing with 2% chlorhexidine (CHG) wipes is an important measure regarding infection prevention in critically ill patients. The aim of this study was to evaluate the impact of CHG wipes bath to prevent central-line associated bloodstream infection (CLABSI) in critically ill patients and determine if such measure is cost-saving. METHODS: a quasi-experimental study, conducted from July 2017 to April 2019. Daily bath with 2% CHG was used in all patients at the unit in the intervention period. The following were evaluated: CLABSI incidence density in both periods, 30- day mortality, guided antimicrobials used to treat CLABSI and 2% CHG costs. RESULTS: CLABSI incidence density dropped from 8.69 to 1.83 per 1.000 central line-days (p = 0.001), mainly by Klebsiella pneumoniae Carbapenen Resistant (Kp-KPC) (p = 0.05). Costs with guided antimicrobials for the treatment in pre-intervention were US$ 46,114.36, and in the intervention period, US$ 4,177.50. The 2% CHG monthly cost was US$ 2,698.00, achieving 30% savings when comparing both periods. DISCUSSION: An expressive reduction of 79% in CLABSI incidence density was observed, mainly due to Kp-KPC infection and also a reduction in guided antimicrobial costs. CONCLUSIONS: Bathing with 2% CHG led to evident CLABSI reduction.

Is it cost effective to use a 2% chlorhexidine wipes bath to reduce central-line associated blood stream infection? A quasi-experimental study

BACKGROUND: Bathing with 2% chlorhexidine (CHG) wipes is an important measure regarding infection prevention in critically ill patients. The aim of this study was to evaluate the impact of CHG wipes bath to prevent central-line associated bloodstream infection (CLABSI) in critically ill patients and determine if such measure is cost-saving. METHODS: a quasi-experimental study, conducted from July 2017 to April 2019. Daily bath with 2% CHG was used in all patients at the unit in the intervention period. The following were evaluated: CLABSI incidence density in both periods, 30- day mortality, guided antimicrobials used to treat CLABSI and 2% CHG costs. RESULTS: CLABSI incidence density dropped from 8.69 to 1.83 per 1.000 central line-days (p = 0.001), mainly by Klebsiella pneumoniae Carbapenen Resistant (Kp-KPC) (p = 0.05). Costs with guided antimicrobials for the treatment in pre-intervention were US$ 46,114.36, and in the intervention period, US$ 4,177.50. The 2% CHG monthly cost was US$ 2,698.00, achieving 30% savings when comparing both periods. DISCUSSION: An expressive reduction of 79% in CLABSI incidence density was observed, mainly due to Kp-KPC infection and also a reduction in guided antimicrobial costs. CONCLUSIONS: Bathing with 2% CHG led to evident CLABSI reduction.

Coronary artery bypass surgery in patients with COVID-19: What have we learned ?

COVID-19 caused by the novel coronavirus SARS-CoV-2 led to the pandemic, causing unprecedented health and social crisis worldwide. Acute coronary syndromes patients, especially when coronary artery bypass graft (CABG) surgery is needed, may present with higher severity risk if affected by COVID-19. Extracorporeal circulation leads to activation of endothelium and microcirculatory network, which activates the coagulation, platelet aggregation and inflammation 1. COVID-19 may also course with severe inflammation, massive secretion of inflammatory cytokines, plaque rupture and a procoagulant state 2. Therefore, it is advisable to postpone surgeries interventions when possible. However, our institution is a public tertiary referral hospital for high-risk cardiovascular patients even in SARS-CoV-2 pandemic. We describe a series of thirteen high risk coronary artery disease patients submitted to CABG and who had COVID-19 infection during the same hospitalization, six patients had COVID-19 before surgery, three patients were operated with active infection and four patients were infected after surgery…

Serological Testing for COVID-19, Immunological Surveillance, and Exploration of Protective Antibodies

Serological testing is a powerful tool in epidemiological studies for understanding viral circulation and assessing the effectiveness of virus control measures, as is the case of SARS-CoV-2, the pathogenic agent of COVID-19. Immunoassays can quantitatively reveal the concentration of antiviral antibodies. The assessment of antiviral antibody titers may provide information on virus exposure, and changes in IgG levels are also indicative of a reduction in viral circulation. In this work, we describe a serological study for the evaluation of antiviral IgG and IgM antibodies and their correlation with antiviral activity. The serological assay for IgG detection used two SARS-CoV-2 proteins as antigens, the nucleocapsid N protein and the 3CL protease. Cross-reactivity tests in animals have shown high selectivity for detection of antiviral antibodies, using both the N and 3CL antigens. Using samples of human serum from individuals previously diagnosed by PCR for COVID-19, we observed high sensitivity of the ELISA assay. Serological results with human samples also suggest that the combination of higher titers of antiviral IgG antibodies to different antigen targets may be associated with greater neutralization activity, which can be enhanced in the presence of antiviral IgM antibodies.

Adequação das práticas do laboratório de cateterismo durante a pandemia de COVID-19: o protocolo do Instituto Dante Pazzanese de Cardiologia / Adapted Catheterization Laboratory Practices during the COVID-19 Pandemic: The Instituto Dante Pazzanese de Cardiologia Protocol

Introdução A pandemia global da doença de coronavírus 2019 (COVID-19) causada pelo novo vírus de síndrome respiratória aguda grave coronavírus 2 (SARS-CoV-2) começou em Wuhan, China, em dezembro de 2019 e afetou mais de 4,4 milhões de pessoas em todo o mundo, com 302.169 mortes até o dia 16 de maio de 2020.1 Embora os sintomas respiratórios sejam a apresentação mais comum de COVID-19, o envolvimento cardíaco é uma característica proeminente dessa doença, ocorrendo em 20% a 30% dos pacientes hospitalizados e contribuindo para 40% dos óbitos.2-4 O envolvimento cardíaco relacionado à COVID-19 tem sido documentado por elevações em biomarcadores cardíacos e frequentemente apresenta alterações no segmento ST-T no eletrocardiograma (ECG) de 12 derivações, motivo pelo qual a equipe do laboratório de cateterismo é frequentemente ativada. Além disso, as atividades do laboratório de cateterismo devem continuar no atendimento a pacientes não COVID-19 que apresentam síndrome coronariana aguda (SCA) verdadeira, infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) e doença cardíaca isquêmica estável muito sintomática. Devido à escalada no número de casos de COVID-19 na cidade de São Paulo, epicentro da doença no Brasil, reformularam-se a logística e as práticas no laboratório de cateterismo cardíaco do Instituto Dante Pazzanese de Cardiologia, que entraram em vigor em abril de 2020 e continuarão durante o período da pandemia. Os objetivos são fornecer atendimento otimizado à população que necessita de procedimentos cardíacos invasivos durante a pandemia, com a proteção adequada aos profissionais de saúde (PS), pacientes e seus familiares. Os protocolos aqui descritos representam os esforços multidisciplinares e dinâmicos do Departamento de Cardiologia Invasiva do Instituto Dante Pazzanese de Cardiologia validados pelo Comitê de Controle de Infecção da instituição. Essas práticas estão sujeitas a alterações em função do estado epidemiológico local, a fase da epidemia e a disponibilidade de equipamento de proteção individual (EPI). Estes protocolos podem não se aplicar a outras localidades sem casos (ou casos esporádicos) de COVID-19 ou a serviços que atendem diferentes perfis populacionais com logísticas e disponibilidade de EPI diversas.

Severe Strongyloides stercoralis infection in kidney transplant recipients: A multicenter case-control study.

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/PRINCIPAL FINDINGS: This was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61). CONCLUSIONS/SIGNIFICANCE: Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

Severe Strongyloides stercoralis infection in kidney transplant recipients: a multicenter case-control study

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/Principal findings This was a retrospective, multicenter, case­control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5­965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05­18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2­7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001­1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46­2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83­35316.61). CONCLUSIONS/Significance Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment. (AU)

Late ascending aortic prosthesis infection by porphyromonas pogonae: An unexpected infectious complication

Late complications in ascending aortic surgeries are uncommon and may occur by infectious processes, usually caused by gram positive bacteria. We report a case of aortic prosthesis infection by Porphyromonas pogonae, an anaerobic gram-negative coccobacillus that can grow under microaerobic conditions, three years after ascending aortic reconstruction surgery. (AU)