Landscape of Invasive Fusariosis in Pediatric Cancer Patients: Results of a Multicenter Observational Study From Latin America.

Invasive fusariosis (IF) is a life-threatening opportunistic infection that affects vulnerable hosts. We conducted a multicenter and multinational retrospective study to characterize the natural history and clinical management of IF in pediatric cancer patients. We selected patients <18 years old who were sequentially hospitalized in 10 Latin American medical centers with a diagnosis of IF between 2002 and 2021. Data were collected using an electronic case report form complemented by a dictionary of terms. We assessed mortality rates at 30, 60, and 90 days. We collected data from 60 episodes of IF (median age, 9.8 years) that were mostly documented in patients with hematologic cancer (70%). Other risk conditions found were lymphopenia (80%), neutropenia (76.7%), and corticosteroid exposure (63.3%). IF was disseminated in 55.6% of patients. Skin lesions was present in 58.3% of our patients, followed by pulmonary involvement in 55%, sinusitis in 21.7%, bone/joint involvement in 6.7% and 1 case each of endocarditis and brain abscess. Positive blood and skin biopsy cultures were detected in 60% and 48.3% of cases, respectively. Fusarium solani complex was the most commonly identified agent (66.6%). The majority of patients received monotherapy within the first 72 hours (71.6%), either with voriconazole or amphotericin B formulation. The mortality rates at 30, 60, and 90 days were 35%, 41.6%, and 45%, respectively. An important factor affecting mortality rates appears to be disseminated disease. The high percentage of patients with fungal involvement in multiple organs and systems highlights the need for extensive workup for additional sites of infection in severely immunocompromised children.

Epidemiological Assessment and Risk Factors for Mortality of Bloodstream Infections by Candida sp. and the Impact of the COVID-19 Pandemic Era.

Candidemia is one of the healthcare-associated infections that has high mortality. The risk factors that predispose a patient to develop this infection are mostly found in patients of greater severity and COVID-19 contributes to the risk of death. The aim of this study is to evaluate epidemiological characteristics and risk factors for mortality in patients with candidemia before and during the COVID-19 pandemic era. This is a retrospective study conducted at Instituto Central from 2016 to 2020 of patients with candidemia that were evaluated for demographic data, medical history, risk factors, microbiological data, therapeutic measures, complementary exams, device management, and outcome defined by 30-day mortality. A total of 170 episodes were included (58.2% males; mean age of 56 years). The overall incidence density of candidemia per 1000 admissions and per 1000 patient-days was 1.17 and 0.17, respectively, with an increase of 38% in the year 2020. The use of a central venous catheter was the most prevalent (93.5%) condition, followed by the previous use of antibiotics (91.1%). Corticosteroid use ranked seventh (56.4%). C. albicans was responsible for 71 (41.7%) of the isolates, followed by C. tropicalis and C. glabrata, with 34 (20%) isolates each. Echinocandin was prescribed in 60.1% of cases and fluconazole in 37%. Echocardiography resulted in six (5.08%) cases of endocarditis and fundoscopy resulting in two (2.4%) endophthalmitis. The 30-day mortality was 93/170 (54.7%). The risk factors associated with mortality were age (OR 1.03, CI 95% 1.01-1.06), heart disease (OR 7.51, CI 95% 1.48-37.9), hemodialysis (OR 3.68, CI 95% 1.28-10.57), and use of corticosteroids (OR 2.83, CI 95% 1.01-7.92). The COVID-19 pandemic had an impact on the increase incidence of candidemia. The persistently high mortality highlights the need for better management strategies, control of risk factors, and guarantee of adequate treatment.

Guideline Adherence and Outcomes of Patients with Candidemia in Brazil.

Candidemia is a significant cause of mortality among hospitalized patients, both worldwide and in Brazil. Prompt and appropriate treatment are essential to mitigate mortality, and clinical practice guidelines aim to optimize patient care based on the best scientific evidence. This study aims to examine the management of candidemia, assessing adherence to the guidelines of the Brazilian Society of Infectious Diseases in a single center located at São Paulo, Brazil. All adult patients hospitalized from 2016 to 2018 who presented one positive blood culture for Candida spp. were included. Electronic medical records were retrospectively reviewed to collect information relevant to the treatment for candidemia, in order to assess the adherence to the Brazilian guideline for the management of candidemia in relation to nine defined outcomes, and we correlated those findings with 30-day mortality by using uni- and multivariate analyses. A total of 115 patients were included; 68 patients (59.1%) were male, with a mean age of 55 years. C. albicans, C. tropicalis and C. glabrata were the most prevalent species. In total, 80 patients (69.5%) received antifungal treatment. The adherence to Brazilian guideline recommendations was determined as described in the following: initial treatment with echinocandin in 48 (60%); step-down to fluconazole in 21 (26.2%); collection of first control blood culture in 43 (58.9%); collection of second control blood culture, if the first one had been positive, in 14 (73.6%); treatment for 14 days after the first negative blood culture in 53 (65.4%); central venous catheter (CVC) removal in 66 (82.5%); CVC removal if the first control blood culture had been positive in 17 (89.4%); performance of a transthoracic echocardiogram in 51 (63.7%) and performance of a fundoscopy in 59 (73.7%). Univariate analysis showed that CVC removal and initial echinocandin therapy were more prevalent in the surviving group, but with no statistically significant difference. On the other hand, step-down to fluconazole demonstrated higher survival rate in the multivariate analysis OR 0.15 (95% CI 0.03-0.8); p = 0.02. The analysis of these nine recommendations demonstrates that it is necessary to improve adherence to specific recommendations and also disseminate strategies of the initial use of echinocandin as the drug of choice and addressing length of treatment and follow-up and complementary exams. Our study provides reassurance that the step-down to fluconazole is safe and may be recommended, if the preexisting conditions are present.

The yeast genus Tardiomyces gen. nov. with one new species and two new combinations.

PURPOSE: Rare yeasts species are increasingly reported as causative agents of invasive human infection. Proper identification and antifungal therapy are essential to manage these infections. Candida blankii is one of these emerging pathogens and is known for its reduced susceptibility to multiple antifungals. METHODS: To obtain more insight into the characteristics of this species, 26 isolates reported as C. blankii were investigated using genetic and phenotypical approaches. RESULTS: Among the 26 isolates, seven recovered either from blood, sputum, urine, or the oral cavity, displayed substantial genetic and some phenotypical differences compared to the other isolates, which were confirmed as C. blankii. We consider these seven strains to represent a novel species, Tardiomyces depauwii. Phylogenomics assigned C. blankii, C. digboiensis, and the novel species in a distinct branch within the order Dipodascales, for which the novel genus Tardiomyces is erected. The new combinations Tardiomyces blankii and Tardiomyces digboiensis are introduced. Differences with related, strictly environmental genera Sugiyamaella, Crinitomyces, and Diddensiella are enumerated. All three Tardiomyces species share the rare ability to grow up to 42 °C, display slower growth in nutrient-poor media, and show a reduced susceptibility to azoles and echinocandins. Characteristics of T. depauwii include high MIC values with voriconazole and a unique protein pattern. CONCLUSION: We propose the novel yeast species Tardiomyces depauwii and the transfer of C. blankii and C. digboiensis to the novel Tardiomyces genus.

Emergence of cryptic species and clades of Meyerozyma guilliermondii species complex exhibiting limited in vitro susceptibility to antifungals in patients with candidemia.

Members of the Meyerozyma guilliermondii species complex are able to cause superficial and life-threatening systemic infections with low susceptibility to azoles and echinocandins. We tested 130 bloodstream M. guilliermondii complex isolates collected from eight Latin American medical centers over 18 years (period 1 = 2000-2008 and period 2 = 2009-2018) to investigate trends in species distribution and antifungal resistance. The isolates were identified by rDNA ITS region sequencing, and antifungal susceptibility tests were performed against fluconazole, voriconazole, anidulafungin, and amphotericin B using the CLSI microbroth method. M. guilliermondii sensu stricto (s.s.; n = 116) was the most prevalent species, followed by Meyerozyma caribbica (n = 12) and Meyerozyma carpophila (n = 2). Based on rDNA ITS identification, three clades within M. guilliermondii sensu stricto were characterized (clade 1 n = 94; clade 2 n = 19; and clade 3 n = 3). In the second period of study, we found a substantial increment in the isolation of M. caribbica (3.4% versus 13.8%; P = 0.06) and clade 2 M. guilliermondii s.s. exhibiting lower susceptibility to one or more triazoles. IMPORTANCE Yeast-invasive infections play a relevant role in human health, and there is a concern with the emergence of non-Candida pathogens causing disease worldwide. There is a lack of studies addressing the prevalence and antifungal susceptibility of different species within the M. guilliermondii complex that cause invasive infections. We evaluated 130 episodes of M. guilliermondii species complex candidemia documented in eight medical centers over 18 years. We detected the emergence of less common species within the Meyerozyma complex causing candidemia and described a new clade of M. guilliermondii with limited susceptibility to triazoles. These results support the relevance of continued global surveillance efforts to early detect, characterize, and report emergent fungal pathogens exhibiting limited susceptibility to antifungals.

Determinants of fluconazole resistance and the efficacy of fluconazole and milbemycin oxim combination against Candida parapsilosis clinical isolates from Brazil and Turkey.

Fluconazole-resistant Candida parapsilosis (FLZR-CP) outbreaks are a growing public health concern and have been reported in numerous countries. Patients infected with FLZR-CP isolates show fluconazole therapeutic failure and have a significantly increased mortality rate. Because fluconazole is the most widely used antifungal agent in most regions with outbreaks, it is paramount to restore its antifungal activity. Milbemycin oxim (MOX), a well-known canine endectocide, is a potent efflux pump inhibitor that significantly potentiates the activity of fluconazole against FLZR C. glabrata and C. albicans. However, the FLZ-MOX combination has not been tested against FLZR-CP isolates, nor is it known whether MOX may also potentiate the activity of echinocandins, a different class of antifungal drugs. Furthermore, the extent of involvement of efflux pumps CDR1 and MDR1 and ergosterol biosynthesis enzyme ERG11 and their link with gain-of-function (GOF) mutations in their transcription regulators (TAC1, MRR1, and UPC2) are poorly characterized among FLZR-CP isolates. We analyzed 25 C. parapsilosis isolates collected from outbreaks in Turkey and Brazil by determining the expression levels of CDR1, MDR1, and ERG11, examining the presence of potential GOF mutations in their transcriptional regulators, and assessing the antifungal activity of FLZ-MOX and micafungin-MOX against FLZR and multidrug-resistant (MDR) C. parapsilosis isolates. ERG11 was found to be universally induced by fluconazole in all isolates, while expression of MDR1 was unchanged. Whereas mutations in MRR1 and UPC2 were not detected, CDR1 was overexpressed in three Brazilian FLZR-CP isolates, which also carried a novel TAC1L518F mutation. Of these three isolates, one showed increased basal expression of CDR1, while the other two overexpressed CDR1 only in the presence of fluconazole. Interestingly, MOX showed promising antifungal activity against FLZR isolates, reducing the FLZ MIC 8- to 32-fold. However, the MOX and micafungin combination did not exert activity against an MDR C. parapsilosis isolate. Collectively, our study documents that the mechanisms underpinning FLZR are region specific, where ERG11 mutations were the sole mechanism of FLZR in Turkish FLZR-CP isolates, while simultaneous overexpression of CDR1 was observed in some Brazilian counterparts. Moreover, MOX and fluconazole showed potent synergistic activity, while the MOX-micafungin combination showed no synergy.

Surveillance of post-cataract endophthalmitis at a tertiary referral center: a 10-year critical evaluation.

BACKGROUND: Acute post-cataract endophthalmitis (APE) is a rare complication potentially causing irreversible visual loss. A 10-year study of APE was conducted to determine its incidence, microbiological spectra and antibiotic resistance profile of APE-related pathogens at a major tertiary referral center in Brazil. METHODS: APE cases reported between January 2010 and December 2019 were included. Phacoemulsification and extracapsular cataract techniques were eligible; combined procedures, traumatic and congenital cataract were excluded. Vitreous samples were cultured and antimicrobial resistance was compared for the periods of 2010-2014 and 2015-2019. The results were analyzed with Fisher's exact test. RESULTS: Our sample consisted of 40,491 cataract surgeries and 51 (0.126%) APE cases. Culture was positive in 35 cases (71.4%), of which 31 (88.6%) Gram-positive, 3 (8.6%) Gram-negative, and 1 (2.9%) fungal. The most frequently isolated organism was Staphylococcus epidermidis (n = 17/35, 48.6%), followed by Staphylococcus aureus (n = 4/35, 11.4%). From 2010-2014 to 2015-2019, antimicrobial resistance increased against moxifloxacin (11.1-54.5%, p = 0.07), ciprofloxacin (54.5-72.7%, p = 0.659) and oxacillin (66.7-93.3%, p = 0.13). CONCLUSIONS: The observed incidence and microbial spectra were compatible with previous studies. A trend towards growing moxifloxacin and ciprofloxacin resistance was observed. Surveillance remains crucial to prevent treatment failure from antimicrobial resistance.

Increasing Prevalence of Multidrug-Resistant Candida haemulonii Species Complex among All Yeast Cultures Collected by a Reference Laboratory over the Past 11 Years.

There is worldwide concern with the increasing rates of infections due to multiresistant Candida isolates reported in tertiary medical centers. We checked for historical trends in terms of prevalence rates and antifungal susceptibility of the Candida haemulonii species complex in our yeast stock culture collected during the last 11 years. The isolates were identified by sequencing the rDNA internal transcribed spacer (ITS) region, and antifungal susceptibility tests for amphotericin B, voriconazole, fluconazole, anidulafungin, and 5-fluorocytosine were performed by the Clinical and Laboratory Standards Institute (CLSI) microbroth method. A total of 49 isolates were identified as Candida haemulonii sensu stricto (n = 21), followed by C. haemulonii var. vulnera (n = 15) and C. duobushaemulonii (n = 13), including 38 isolates cultured from patients with deep-seated Candida infections. The prevalence of the C. haemulonii species complex increased from 0.9% (18 isolates among 1931) in the first period (December 2008 to June 2013) to 1.7% (31 isolates among 1868) in the second period (July 2014 to December 2019) of analysis (p = 0.047). All isolates tested exhibited high minimum inhibition concentrations for amphotericin B and fluconazole, but they remained susceptible to 5-fluorocytosine and anidulafungin. We were able to demonstrate the increased isolation of the multiresistant Candida haemulonii species complex in our culture collection, where most isolates were cultured from patients with deep-seated infections.

Lack of efficacy of echinocandins against high metabolic activity biofilms of Candida parapsilosis clinical isolates.

Candida parapsilosis produces biofilm, which colonizes catheters and other invasive medical devices that are manipulated by health care workers. In previous studies, C. parapsilosis in vitro biofilms have exhibited high resistance rates against conventional antifungals, but susceptibility to both echinocandins and lipid formulations of amphotericin B (lipid complex and liposomal). However, a recent study showed good activity of amphotericin B deoxycholate on the biomass of C. parapsilosis biofilms. Although moderate activity of echinocandins has been demonstrated against low metabolic activity biofilms of C. parapsilosis, few studies have analyzed the action of these drugs on high metabolic activity biofilms. Moreover, high biofilm-forming isolates have been associated with central venous catheter-related fungemia outbreaks and higher mortality rates. Therefore, it is relevant to verify the activity of the main antifungal drugs against high metabolic activity biofilms of C. parapsilosis. Our study aimed to evaluate the in vitro activity of amphotericin B deoxycholate, anidulafungin, caspofungin, and micafungin against high biofilm-forming and high metabolic activity clinical isolates of C. parapsilosis. Our results showed good activity of amphotericin B against C. parapsilosis biofilms, but none of the echinocandin drugs was effective. This suggests that amphotericin B deoxycholate may be a better choice than echinocandins for the treatment of biofilm-associated infections by C. parapsilosis, mainly in countries with insufficient health care resources to purchase lipid formulations of amphotericin B. These results warn of the possibility of persistent catheter-related candidemia caused by high biofilm-forming C. parapsilosis strains when treated with echinocandin drugs.

Diagnostic value of pediatric blood culture bottles for acute postoperative endophthalmitis.

OBJECTIVE: To report our experience using conventional culture methods (CM) and pediatric blood culture bottles (PBCBs) for vitreous sample culture of acute postoperative endophthalmitis. METHODS: A retrospective study was conducted at the Department of Ophthalmology, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, BR, from January 2010 to December 2015, and it included 54 patients with clinically suspected acute postoperative endophthalmitis. Vitreous samples were obtained by vitreous tap or vitrectomy. Samples from January 2010 to December 2011 were cultivated in CM, whereas samples from January 2012 to December 2015 were inoculated in PBCBs. The measured outcome was the yield of positive cultures. RESULTS: Twenty cases were included in the CM group, and 34 cases were included in the PBCB group. The yield of positive cultures in PBCBs (64.7%) was significantly higher than that in conventional CM (35%, p=0.034). Staphylococcus epidermidis and Streptococcus viridans were the two most commonly found agents. CONCLUSION: PBCBs can be used successfully in clinically suspected endophthalmitis. The method showed a higher yield of positive cultures than the conventional method. This technique appears to have several advantages over the traditional method: it saves time, as only one medium needs to be inoculated; transportation to a laboratory is easier than in the traditional method, and there is no need to maintain a supply of fresh agar media. The use of PBCBs may be recommended as the primary method for microbiological diagnosis and is especially suitable for office settings and remote clinics.

Diagnostic value of pediatric blood culture bottles for acute postoperative endophthalmitis

OBJECTIVE: To report our experience using conventional culture methods (CM) and pediatric blood culture bottles (PBCBs) for vitreous sample culture of acute postoperative endophthalmitis. METHODS: A retrospective study was conducted at the Department of Ophthalmology, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, BR, from January 2010 to December 2015, and it included 54 patients with clinically suspected acute postoperative endophthalmitis. Vitreous samples were obtained by vitreous tap or vitrectomy. Samples from January 2010 to December 2011 were cultivated in CM, whereas samples from January 2012 to December 2015 were inoculated in PBCBs. The measured outcome was the yield of positive cultures. RESULTS: Twenty cases were included in the CM group, and 34 cases were included in the PBCB group. The yield of positive cultures in PBCBs (64.7%) was significantly higher than that in conventional CM (35%, p=0.034). Staphylococcus epidermidis and Streptococcus viridans were the two most commonly found agents. CONCLUSION: PBCBs can be used successfully in clinically suspected endophthalmitis. The method showed a higher yield of positive cultures than the conventional method. This technique appears to have several advantages over the traditional method: it saves time, as only one medium needs to be inoculated; transportation to a laboratory is easier than in the traditional method, and there is no need to maintain a supply of fresh agar media. The use of PBCBs may be recommended as the primary method for microbiological diagnosis and is especially suitable for office settings and remote clinics.

Bactec™ blood culture bottles allied to MALDI-TOF mass spectrometry: rapid etiologic diagnosis of bacterial endophthalmitis.

Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) has been used for direct identification of pathogens from blood-inoculated blood culture bottles (BCBs). We showed that MALDI-TOF MS is an useful technique for rapid identification of the causative agents of endophthalmitis from vitreous humor-inoculated BCBs with a simple protocol.

Streptococcus pyogenes strains in Sao Paulo, Brazil: molecular characterization as a basis for StreptInCor coverage capacity analysis.

BACKGROUND: Several human diseases are caused by Streptococcus pyogenes, ranging from common infections to autoimmunity. Characterization of the most prevalent strains worldwide is a useful tool for evaluating the coverage capacity of vaccines under development. In this study, a collection of S. pyogenes strains from Sao Paulo, Brazil, was analyzed to describe the diversity of strains and assess the vaccine coverage capacity of StreptInCor. METHODS: Molecular epidemiology of S. pyogenes strains was performed by emm-genotyping the 229 isolates from different clinical sites, and PCR was used for superantigen profile analysis. The emm-pattern and tissue tropism for these M types were also predicted and compared based on the emm-cluster classification. RESULTS: The strains were fit into 12 different emm-clusters, revealing a diverse phylogenetic origin and, consequently, different mechanisms of infection and escape of the host immune system. Forty-eight emm-types were distinguished in 229 samples, and the 10 most frequently observed types accounted for 69 % of all isolates, indicating a diverse profile of circulating strains comparable to other countries under development. A similar proportion of E and A-C emm-patterns were observed, whereas pattern D was less frequent, indicating that the strains of this collection primarily had a tissue tropism for the throat. In silico analysis of the coverage capacity of StreptInCor, an M protein-conserved regionally based vaccine candidate developed by our group, had a range of 94.5 % to 59.7 %, with a mean of 71.0 % identity between the vaccine antigen and the predicted amino acid sequence of the emm-types included here. CONCLUSIONS: This is the first report of S. pyogenes strain characterization in Sao Paulo, one of the largest cities in the world; thus, the strain panel described here is a representative sample for vaccine coverage capacity analysis. Our results enabled evaluation of StreptInCor candidate vaccine coverage capacity against diverse M-types, indicating that the vaccine candidate likely would induce protection against the diverse strains worldwide.

Incidence of diarrhea by Clostridium difficile in hematologic patients and hematopoietic stem cell transplantation patients: risk factors for severe forms and death.

We describe the rate of incidence of Clostridium difficile-associated diarrhea (CDAD) in hematologic and patients undergone stem cell transplant (HSCT) at HC-FMUSP, from January 2007 to June 2011, using two denominators 1,000 patient and 1,000 days of neutropenia and the risk factors associated with the severe form of the disease and death. The ELISA method (Ridascreen-Biopharm, Germany) for the detections of toxins A/B was used to identify C. difficile. A multivariate analysis was performed to evaluate potential factors associated with severe CDAD and death within 14 days after the diagnosis of CDAD, using multiple logistic regression. Sixty-six episodes were identified in 64 patients among 439 patients with diarrhea during the study period. CDA rate of incidence varied from 0.78 to 5.45 per 1,000 days of neutropenia and from 0.65 to 5.45 per 1,000 patient-days. The most common underlying disease was acute myeloid leukemia 30/64 (44%), 32/64 (46%) patients were neutropenic, 31/64 (45%) undergone allogeneic HSCT, 61/64 (88%) had previously used antibiotics and 9/64 (13%) have severe CDAD. Most of the patients (89%) received treatment with oral metronidazole and 19/64 (26%) died. The independent risk factors associated with death were the severe form of CDAD, and use of linezolid.

Padronização da espectrometria de massa MALDI-TOF para identificação de cepas de Trichosporon spp. de importância médica / Standardization of MALDI-TOF mass spectrometry for identification of Trichosporon spp of medical relevance

O gênero Trichosporon é composto por leveduras artrosporadas do Filo Basidiomycota e é conhecido agente de infecção fúngica invasiva (IFI) em pacientes imunodeprimidos ou com outros fatores de risco. Em pacientes onco-hematológicos é a principal levedura responsável por IFI depois do gênero Candida. Entre as espécies responsáveis por infecções no homem encontram-se: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. A tecnologia de identificação de fungos por espectrometria de massa (SM) MALDI-TOF ainda carece de padronização para identificação de fungos do gênero Trichosporon, mas a literatura mostra resultados encorajadores. O objetivo deste estudo é padronizar a técnica de espectrometria de massa MALDI-TOF para a identificação das espécies do gênero Trichosporon de importância médica. O estudo foi realizado em cooperação entre a Divisão de Laboratório Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (DLC, HC-FMUSP), Instituto de Medicina Tropical da USP (IMT-USP), Instituto Adolfo Lutz (IAL) e Laboratoire de Parasitologie-Mycologie do Hospital Saint Antoine de Paris, vinculado ao grupo de pesquisa INSERM/UPMC UMR S945 "Immunité et Infection" Faculté de Medecine et Université Pierre et Marie Curie de Paris. Noventa e três cepas/isolados foram analisado(a)s, sendo dezenove cepas de referência adquiridas junto à coleção holandesa Centraalbureau Schimmelcultures (CBS), 19 isolados do HC-FMUSP e IAL, e 55 isolados de diferentes hospitais franceses. A identificação molecular foi realizada através do sequenciamento da região IGS1 do rDNA e foi considerada como método de referência. O protocolo de extração de proteínas foi estabelecido através da comparação do desempenho de três metodologias (Bruker®, Cassagne et al., Sendid et al.). Os espectros de massa foram obtidos no...

Trichosporon spp. are arthrospored yeasts from the Filum Basidiomycota that are known to produce invasive fungal infection (IFI) in patients with immunosupression or other risk factors. After Candida, Trichosporon is the second genus of yeasts responsible for IFI in patients with onco-hematological diseases. The most important species related to human infection are: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. The technology of mass spectrometry (MS) for identification of Trichosporon species has not yet been standardized. However, preliminary promising results can be found in the literature. The objective of this study is to analyse and validate MS MALDI-TOF for the identification of Trichosporon species of medical relevance. This was a multicentric study with collaboration from the Central Laboratory Section from Clinics Hospital of the Medical School from the University of São Paulo (DLC-HCFMUSP), Tropical Medicine Institute from the University of São Paulo (IMT-USP), Instituto Adolfo Lutz (IAL) and Laboratoire de Parasitologie-Mycologie from the Hospital Saint Antoine of Paris and INSERM/UPMC UMR S945 "Immunité et Infection", Faculté de Medecine et Université Pierre et Marie Curie of Paris. Ninety three strains/isolates belonging to sixteen Trichosporon species were analysed. Nineteen were purchased from Centraalbureau Schimmelcultures (CBS) yeast collection, 19 belonged to HC-FMUSP and IAL collections, 55 belonged to different French collections. The reference identification method was the IGS1 rDNA sequencing. A protein extraction protocol was first established after comparing the performance of three different methodologies (Bruker(TM),...

Diferença de tempo de positividade: método útil no diagnóstico de infecção de corrente sanguínea relacionada com cateter? / Differential time to positivity: a useful tool for the diagnosis of catheter-related infections?

INTRODUÇÃO: As infecções de corrente sanguínea relacionadas com cateter (ICSRCs) apresentam impacto significativo na morbidade e na mortalidade de pacientes internados, além de elevar custos hospitalares. A utilização de equipamentos automatizados no processamento de hemoculturas gerou uma alternativa para diagnóstico de ICSRC por meio da análise da diferença de tempo de positividade (DTP) entre hemoculturas pareadas (coletadas simultaneamente) de sangue periférico e sangue de cateter. Um diagnóstico acurado e rápido dessas infecções pode otimizar as condutas clínicas e terapêuticas, poupando a retirada precoce dos cateteres. OBJETIVOS: Avaliar na rotina a DTP como ferramenta auxiliar no diagnóstico de ICSRC e determinar os principais microrganismos isolados. MÉTODOS: Foram avaliadas retrospectivamente hemoculturas coletadas no complexo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP) de maio a agosto de 2008. Somente amostras que apresentaram DTP maior que 120 minutos foram consideradas possíveis ICSRCs pelo critério laboratorial. RESULTADOS: A seção processou 11.017 hemoculturas aeróbias durante o período de estudo; somente 5% foram coletadas de forma pareada. Destas, 148 (28%) foram positivas, sendo 9% com crescimento somente em sangue periférico, 41% somente em sangue de cateter e 50% em ambas as amostras com 88% de homologia de microrganismos identificados. A DTP apresentou valores acima de 120 minutos em 50% dos casos e os microrganismos mais isolados foram Staphylococcus aureus (22%), Candida spp. (18%), Klebsiella spp. (7%) e Enterobacter spp. (7%). CONCLUSÃO: A determinação da DTP como ferramenta auxiliar no diagnóstico de ICSRC é viável e fácil de ser executada em laboratórios de rotina com automação, porém o processo de coleta das amostras pareadas deve ser rigidamente padronizado.

INTRODUCTION: Not only do catheter related bloodstream infections (CRBSIs) have considerable impact on morbidity and mortality in hospitalized patients, but they also raise hospital costs. The use of automated equipment in blood culture processing has allowed an alternative diagnosis of CRBSI by analyzing the differential time to positivity (DTP) of paired blood cultures (collected simultaneously) of peripheral blood and catheter blood. A rapid and accurate diagnosis of these infections may optimize clinical and therapeutic management, which prevents early catheter removal. OBJECTIVES: To assess DTP as an auxiliary tool for the diagnosis of CRBSI as well as to determine the main isolated microorganisms. METHODS: We evaluated blood cultures that had previously been collected in the complex Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP) from May to August 2008. According to the laboratory criteria, only DTP higher than 120 minutes was regarded as possible CRBSI. RESULTS: During the investigation period 11,017 aerobic blood cultures were processed, from which only 5% were paired samples. One hundred forty-eight (28%) samples were positive, from which 9% showed growth in peripheral blood, 41% only in catheter blood and 50% in both blood samples with 88% homology of identified microorganisms. DTP higher than 120 minutes occurred in 50% of the cases. The most common isolated microorganisms were: Staphylococcus aureus (22%), Candida spp. (18%), Klebsiella spp (7%). and Enterobacter spp (7%). CONCLUSION: The determination of the DTP as an auxiliary tool for the diagnosis of CRBSI is feasible and easily performed in clinical laboratories with automation, although the process of paired sample collection must be rigidly standardized.

Carbapenem stewardship: positive impact on hospital ecology

INTRODUCTION: Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE: We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS: Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemar's test) were determined. RESULTS: The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION: Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility.

Candidemia epidemiology and susceptibility profile in the largest Brazilian teaching hospital complex

INTRODUCTION: Although the spectrum of fungi causing bloodstream fungal infections continues to expand, Candida spp. remains responsible for the majority of these cases. OBJECTIVE: The purpose of this study was to characterize the candidemia epidemiology, species distribution and antifungal susceptibility patterns at a Brazilian tertiary teaching public hospital with 2,500 beds. METHODS: Records from the microbiology laboratory were used to identify patients with positive blood cultures during 2006. The in vitro activity of amphotericin B, caspofungin, itraconazole, fluconazole, voricanozole, and posaconazole were determined using the Etest method. RESULTS: One hundred and thirty-six cases of candidemia were identified and 100 strains were available for antifungal susceptibility testing. The overall incidence of candidemia was 1.87 cases/1.000 admissions and 0.27 cases/1.000 patient-days. Among the patients, 58.1 percent were male, and the median age was 40 years old. C. albicans was the most common species (52.2 percent), followed by C. parapsilosis (22.1 percent), C. tropicalis (14.8 percent), and C. glabrata (6.6 percent). All strains were susceptible to amphotericin B with a MIC90 of 0.5 µg/mL. Overall susceptibility for voriconozole, fluconazole, and caspofungin was > 97 percent with a MIC90 of 0.064, 4.0 and 1.0 µg/mL, respectively. For itraconazole the susceptibility rate was 81 percent with a MIC90 of 0.5 µg/mL. Posaconazole also demonstrated good in vitro activity with a MIC90 of 0.25 µg/mL. CONCLUSION: This is the first antifungal susceptibility report in our institution.

Candidemia epidemiology and susceptibility profile in the largest Brazilian teaching hospital complex.

INTRODUCTION: Although the spectrum of fungi causing bloodstream fungal infections continues to expand, Candida spp. remains responsible for the majority of these cases. OBJECTIVE: The purpose of this study was to characterize the candidemia epidemiology, species distribution and antifungal susceptibility patterns at a Brazilian tertiary teaching public hospital with 2,500 beds. METHODS: Records from the microbiology laboratory were used to identify patients with positive blood cultures during 2006. The in vitro activity of amphotericin B, caspofungin, itraconazole, fluconazole, voricanozole, and posaconazole were determined using the Etest method. RESULTS: One hundred and thirty-six cases of candidemia were identified and 100 strains were available for antifungal susceptibility testing. The overall incidence of candidemia was 1.87 cases/1.000 admissions and 0.27 cases/1.000 patient-days. Among the patients, 58.1% were male, and the median age was 40 years old. C. albicans was the most common species (52.2%), followed by C. parapsilosis (22.1%), C. tropicalis (14.8%), and C. glabrata (6.6%). All strains were susceptible to amphotericin B with a MIC90 of 0.5 µg/mL. Overall susceptibility for voriconozole, fluconazole, and caspofungin was > 97% with a MIC90 of 0.064, 4.0 and 1.0 µg/mL, respectively. For itraconazole the susceptibility rate was 81% with a MIC90 of 0.5 µg/mL. Posaconazole also demonstrated good in vitro activity with a MIC90 of 0.25 µg/mL. CONCLUSION: This is the first antifungal susceptibility report in our institution.