Surveillance of Candida spp bloodstream infections: epidemiological trends and risk factors of death in two Mexican tertiary care hospitals.

INTRODUCTION: Larger populations at risk, broader use of antibiotics and longer hospital stays have impacted on the incidence of Candida sp. bloodstream infections (CBSI). OBJECTIVE: To determine clinical and epidemiologic characteristics of patients with CBSI in two tertiary care reference medical institutions in Mexico City. DESIGN: Prospective and observational laboratory-based surveillance study conducted from 07/2008 to 06/2010. METHODS: All patients with CBSI were included. Identification and antifungal susceptibility were performed using CLSI M27-A3 standard procedures. Frequencies, Mann-Whitney U test or T test were used as needed. Risk factors were determined with multivariable analysis and binary logistic regression analysis. RESULTS: CBSI represented 3.8% of nosocomial bloodstream infections. Cumulative incidence was 2.8 per 1000 discharges (incidence rate: 0.38 per 1000 patient-days). C. albicans was the predominant species (46%), followed by C. tropicalis (26%). C. glabrata was isolated from patients with diabetes (50%), and elderly patients. Sixty-four patients (86%) received antifungals. Amphotericin-B deoxycholate (AmBD) was the most commonly used agent (66%). Overall mortality rate reached 46%, and risk factors for death were APACHE II score ≥ 16 (OR = 6.94, CI95% = 2.34-20.58, p<0.0001), and liver disease (OR = 186.11, CI95% = 7.61-4550.20, p = 0.001). Full susceptibility to fluconazole, AmBD and echinocandins among C. albicans, C. tropicalis, and C. parapsilosis was observed. CONCLUSIONS: The cumulative incidence rate in these centers was higher than other reports from tertiary care hospitals from Latin America. Knowledge of local epidemiologic patterns permits the design of more specific strategies for prevention and preemptive therapy of CBSI.

Active surveillance of candidemia in children from Latin America: a key requirement for improving disease outcome.

BACKGROUND: Active surveillance is necessary for improving the management and outcomes of patients with candidemia. The aim of this study was to describe the epidemiologic and clinical features of candidemia in pediatric patients in Latin America. METHOD: Prospective, multicenter, surveillance study of candidemia in a pediatric population from 23 hospitals in 8 Latin America countries between November 2008 and October 2010. RESULTS: Three hundred and two cases of candidemia were reported with a median incidence of 0.81/1000 admissions. Eighty nine (29%) were neonates. The main risk factors were prematurity, intensive care unit (ICU) admission, parenteral nutrition, respiratory disease and mechanical ventilation in neonates and malignancy, neutropenia, neurological disease and previous use of corticosteroids in children. The main species isolated in neonates and children were Candida albicans (43.8% and 35.7%), Candida parapsilosis (27.0% and 26.3%) and Candida tropicalis (14.6% and 14.6%), respectively. The most frequent antifungal therapy used in neonates and children was deoxycholate-amphotericin-B (43.8% and 29.1%) and fluconazole (28.1% and 53.1%). Seventeen neonates (19.1%) and 20 children (9.4%) did not receive antifungal therapy. The 30-day survival rate was 60% in neonates and 72% in children (P = 0.02). Survival was significantly higher in treated than in nontreated neonates (72% vs. 24%; P < 0.001). A multivariate analysis showed that independent predictors for 30-day mortality in children were renal disease (odds ratio: 4.38, 95% confidence interval: 1.92-10.1, P < 0.001) and receipt of corticosteroids (odds ratio: 2.08, 95% confidence interval: 1.04-4.17, P = 0.04). CONCLUSIONS: To our knowledge, this is the first prospective, multicenter surveillance study of candidemia in children in Latin America. This epidemiologic information may provide us with methods to improve preventive, diagnostic and therapeutic strategies in our continent.

Epidemiology of candidemia in Latin America: a laboratory-based survey.

BACKGROUND: The epidemiology of candidemia varies depending on the geographic region. Little is known about the epidemiology of candidemia in Latin America. METHODS: We conducted a 24-month laboratory-based survey of candidemia in 20 centers of seven Latin American countries. Incidence rates were calculated and the epidemiology of candidemia was characterized. RESULTS: Among 672 episodes of candidemia, 297 (44.2%) occurred in children (23.7% younger than 1 year), 36.2% in adults between 19 and 60 years old and 19.6% in elderly patients. The overall incidence was 1.18 cases per 1,000 admissions, and varied across countries, with the highest incidence in Colombia and the lowest in Chile. Candida albicans (37.6%), C. parapsilosis (26.5%) and C. tropicalis (17.6%) were the leading agents, with great variability in species distribution in the different countries. Most isolates were highly susceptible to fluconazole, voriconazole, amphotericin B and anidulafungin. Fluconazole was the most frequent agent used as primary treatment (65.8%), and the overall 30-day survival was 59.3%. CONCLUSIONS: This first large epidemiologic study of candidemia in Latin America showed a high incidence of candidemia, high percentage of children, typical species distribution, with C. albicans, C. parapsilosis and C. tropicalis accounting for the majority of episodes, and low resistance rates.

High prevalence of sexually transmitted infections among young Peruvians who have sexual intercourse with foreign travelers in Cuzco.

BACKGROUND: Sexual networking in popular tourist destinations is a problem worldwide. In Peru, locals sexually interacting with travelers bridge high-risk groups, the general population, and travelers. METHODS: A cross-sectional study was conducted in Cuzco about sexual behavior among young Peruvians who admitted having sex with travelers. A subgroup of the participants had serologic testing for Chlamydia trachomatis, Herpes simplex virus (HSV) type 2, and Treponema pallidum. RESULTS: Eighty-eight subjects volunteered for blood sampling. Their mean age was 22.9 years (+/-4.1) and 53.4% were male. The majority were single (86.2%), but 12.6% had a stable relationship. The median number of sexual partners in the 3 months prior to the study was 2 [interquartile range (IQR): 1-4]. During that period, 43.1% reported foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported Peruvian partners, and the remaining 11.5% reported combinations of Peruvian, foreign, and sex workers partners. The median number of foreign partners in the 12-month period prior to the study was 4 (IQR: 2-8). Only 25.3% reported consistent condom use. Alcohol (69%) and drugs (36.8%) were commonly used before sexual activity. Seventy-eight percent tested positive for HSV type 2, 25% for C trachomatis, and 1.1% for T pallidum. CONCLUSIONS: The core group of young Peruvians we report on demonstrated a high-risk sexual behavior and a high prevalence of sexually transmitted infections. Our results underscore the need for education on safer sex practices among this group and among travelers.

Risk factors associated with diarrhea among international visitors to Cuzco, Peru.

The objective of this study was to determine the risk factors for travelers' diarrhea (TD) reported by visitors to Cuzco, Peru. In this cross-sectional study, self-administered questionnaires looking at perceived occurrence of health problems and pre-travel health advice were obtained from departing travelers at Cuzco's International Airport between August and November 2002. A total of 5,988 travelers participated in the study. The mean age was 35 years, and 51% were women. The prevalence of TD was 24%. Factors associated with TD in the multivariable analysis were use of antibiotic prophylaxis (OR: 3.20), vaccination against cholera (OR: 1.44), history of advice for safe food and water consumption (OR: 1.46), being younger than 35 years of age (OR: 1.37), being a resident of the United States (OR: 1.28), not staying in hotels in Cuzco (OR: 1.13), and number of unsafe food or beverages consumed (OR: 1.04). Remaining in Cuzco < 1 week was a protective factor (OR: 0.58). TD is common among travelers to Cuzco. This study suggests that conventional recommendations are not invariably effective at decreasing TD.

Pretravel health advice among international travelers visiting Cuzco, Peru.

BACKGROUND: Cuzco, a Peruvian city of historical interest located 3,326 m above sea level, is a frequent destination for tourists. We conducted a descriptive study to assess the extent and sources of pretravel health advice received by international travelers before their arrival to Cuzco. METHODS: Data were collected as part of a health survey among travelers. Between August and November 2002, travelers between 15 and 65 years old were invited to fill out a questionnaire in the departing area of Cuzco's international airport. RESULTS: A total of 5,988 travelers participated. The mean age was 35.4 years (SD 11.4 yr); 50.6% were female and 50.8% were single. Tourism was the reason for traveling in 90.2% of the participants, and 89.3% of them were traveling with companions. Pretravel health information was received by 93.6%. The median number of information sources was two, with books (41.5%), travel medicine clinics (38.8%), the Internet (23.3%), and general practitioners (22.7%) as the main sources. Most frequently received recommendations were about safe food and water consumption (85%), use of insect repellents (66.0%), sunburn protection (64.4%), and condom use (22%). Only 16.5% took medication to prevent altitude sickness, and 14.2% took medication to prevent traveler's diarrhea. Variables independently associated with receiving pretravel health information from a health care professional were female gender, country of residence other than the United States, length of stay in Cuzco > 7 days, length of stay in other Peruvian cities > 7 days, tourism as the main reason for visiting Cuzco, traveling with companions, and consulting of more than one source of information. CONCLUSIONS: Most travelers arriving to Cuzco had received pretravel health information, and the majority obtained it from more than one source. Recommendations addressed for specific health risks, such as altitude sickness prophylaxis, were received by few travelers.

Sexual behavior in travelers visiting Cuzco.

BACKGROUND: In South America, little is known about sexual behavior and risk factors for acquiring sexually transmitted diseases (STDs) among travelers and among local people sexually interacting with travelers. There is evidence that, in Peru, significant sexual interaction between these groups exists. METHOD: An anonymous written questionnaire was administered to travelers in the airport and bus stations before they left Cuzco. RESULTS: Of the travelers,5.6% engaged in sexual activity with a new partner during their stay in Cuzco. Sexual intercourse with other travelers was most common (76/140, 54.3%), followed by sex with local partners (57/140, 40.7%), and with commercial sex workers (3/140, 2.15%). Consistent condom use was reported by 97/140 (69.3%). In the multivariate analysis, the following variables were independently associated with casual sex: male gender, single marital status, age between 15 and 35 years, non-United States travelers (NUSTs), traveling alone or with friends, length of stay more than 30 days, homosexual or bisexual orientation, and expectation of having sex before traveling. Homosexual and bisexual travelers had 3 or more new sexual partners more frequently than heterosexual travelers (4/8, 18/129, OR=6.17 (1.16

Sexual behavior of international travelers visiting Peru.

BACKGROUND: Sexual behavior of travelers to Latin America and the sexual behavior of US travelers in general are poorly characterized. GOAL: The goal of the study was to evaluate sexual risk factors of travelers to Peru. STUDY DESIGN: Anonymous written questionnaires were administered to 442/507 (87%) of the individuals approached in the international departures area of the Lima airport. RESULTS: Of the 442 respondents, 54 (12.2%) had new sex partners during their stay. Sex with a local partner (35/52; 67.3%) was more frequent than sex with other travelers (18/52; 34.6%) or with sex workers (4/52; 7.7%). Risk factors for a new sex partner included male sex (relative risk, 1.94), single marital status (relative risk, 2.59), duration of stay longer than 30 days (relative risk, 5.05), traveling alone or with friends (relative risk, 2.88), and bisexual orientation (relative risk, 4.94). Frequency of sexual activity among US travelers was greater than that among travelers from other countries (15.2% [22/145] versus 10.6% [30/282]; NS). Condoms were consistently used by 12/50 (24%) and sometimes used by 10/50 (20%), including 8/20 United States travelers and 13/29 travelers from other countries. CONCLUSION: Behaviors and risk factors are similar to those described for travelers to Africa, Asia, and Eastern Europe. Behavior of US travelers did not differ from that of other travelers.