Treatment of KPC-producing Enterobacteriaceae: suboptimal efficacy of polymyxins.

Treatment of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae infections (KPC-EI) remains a challenge. Combined therapy has been proposed as the best choice, but there are no clear data showing which combination therapy is superior. Our aim was to evaluate the effectiveness of antimicrobial regimens for treating KPC-EI. This was a retrospective cohort study of KPC-EI nosocomial infections (based on CDC criteria) between October 2009 and June 2013 at three tertiary Brazilian hospitals. The primary outcomes were the 30-day mortality for all infections and the 30-day mortality for patients with bacteraemia. Risk factors for mortality were evaluated by comparing clinical variables of survivors and nonsurvivors. In this study, 118 patients were included, of whom 78 had bacteraemia. Catheter-related bloodstream infections were the most frequent (43%), followed by urinary tract infections (n = 27, 23%). Monotherapy was used in 57 patients and combined treatment in 61 patients. The most common therapeutic combination was polymyxin plus carbapenem 20 (33%). Multivariate analysis for all infections (n = 118) and for bacteremic infections (n = 78) revealed that renal failure at the end of treatment, use of polymyxin and older age were prognostic factors for mortality. In conclusion, polymyxins showed suboptimal efficacy and combination therapy was not superior to monotherapy.

Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae in cancer patients.

Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) is an emergent pathogen in healthcare-associated infections (HAIs). The aim of this study was to describe HAIs due to KPC-Kp, as well as identify mortality risk factors in cancer patients. In patients diagnosed with HAIs due to KPC-Kp between January 2009 and July 2013, we evaluated only the first infection episode of each patient, analyzing mortality separately for patients treated for ≥48 h with at least one antimicrobial agent proven to display in vitro activity against KPC-Kp. We evaluated variables related to the malignancy, the severity and characteristics of the HAI, and the antimicrobial therapy. We identified 83 HAIs due to KPC-Kp. The 30-day mortality was 57.8 % for all infections and 72.7 % for bacteremic infections. Of the 83 patients, 60 patients received ≥48 h of appropriate treatment and 44 (53 %) developed bacteremia. Ten patients (12 %) were neutropenic at HAI diagnosis and 33 (39.8 %) had infection at the tumor site. The most common HAI was urinary tract infection, seen in 26 patients (31.3 %), followed by primary bloodstream infection, seen in 24 patients (28.9 %). Forty-four patients (73.3 %) received combination antimicrobial therapy, most often including polymyxin (68.3 %). Risk factors for 30-day mortality are high sequential organ failure assessment (SOFA) score, need for intensive care stay at diagnosis of infection, and acute kidney injury; the removal of invasive devices related to infection and treatment with effective antibiotics for KPC-Kp are protective factors. In cancer patients, high mortality is associated with HAI due to KPC-Kp and mortality risk factors are more often related to acute infection than to the underlying disease.

Oral manifestation of cytomegalovirus associated with herpes simplex virus in renal transplant recipient.

We report a case of a renal transplant recipient who presented with oral lesions associated with cytomegalovirus (CMV) and herpes simplex virus (HSV). This female patient, who underwent a living donor renal transplant 26 months prior, presented with a painful buccal lesion after an episode of leukopenia. The search for CMV antigen was negative. A biopsy incision was made in the mucous membrane and the material collected by scarification was sent for polymerase chain reaction PCR, anatomic, pathological, and cytological exams. The lab results showed infections with CMV, HSV, and Candida albicans. Thus, the treatment involved the use of acyclovir (1 g a day for 10 days), topical Nystatin gargles (six times a day), and an aqueous solution of chlorexidine (0.12%), as well as laser therapy. After the adoption of these therapeutic modalities, there was complete remission of the buccal lesions. The odontological routine follow-up and early treatment of oral complications deriving from the immunosuppressive therapy contributed to a significant outcome.

Detection of methicillin resistance in Staphylococcus aureus isolated from pediatric patients: is the cefoxitin disk diffusion test accurate enough?

We evaluated the performance of several methods for the detection of methicillin resistance in Staphylococcus aureus using 101 clinical S. aureus isolates from pediatric patients in a tertiary hospital in Brazil; 50 isolates were mecA-positive and 51 were mecA-negative. The Etest and oxacillin agar screening plates were 100% sensitive and specific for mecA presence. Oxacillin and cefoxitin disks gave sensitivities of 96 and 92%, respectively, and 98% specificity. Alterations of CLSI cefoxitin breakpoints increased sensitivity to 98%, without decreasing specificity. Our results highlight the importance of a continuing evaluation of the recommended microbiological methods by different laboratories and in different settings. If necessary, laboratories should use a second test before reporting a strain as susceptible, especially when testing strains isolated from invasive or serious infections. With the new (2007) CLSI breakpoints, the cefoxitin-disk test appears to be a good option for the detection of methicillin resistance in S. aureus.

Detection of methicillin resistance in Staphylococcus aureus isolated from pediatric patients: is the cefoxitin disk diffusion test accurate enough?

We evaluated the performance of several methods for the detection of methicillin resistance in Staphylococcus aureus using 101 clinical S. aureus isolates from pediatric patients in a tertiary hospital in Brazil; 50 isolates were mecA-positive and 51 were mecA-negative. The Etest and oxacillin agar screening plates were 100 percent sensitive and specific for mecA presence. Oxacillin and cefoxitin disks gave sensitivities of 96 and 92 percent, respectively, and 98 percent specificity. Alterations of CLSI cefoxitin breakpoints increased sensitivity to 98 percent, without decreasing specificity. Our results highlight the importance of a continuing evaluation of the recommended microbiological methods by different laboratories and in different settings. If necessary, laboratories should use a second test before reporting a strain as susceptible, especially when testing strains isolated from invasive or serious infections. With the new (2007) CLSI breakpoints, the cefoxitin-disk test appears to be a good option for the detection of methicillin resistance in S. aureus.

Freqüência de parasitas intestinais em felinos mantidos em zoológicos / Frequency of intestinal parasites in felines kept in zoos

The endoparasites occurrence in felines confined in two Zoos, between December 1999 and April 2000, was studied. Fecal samples of 18 felines (Panthera tigris, Panthera leo, Felis serval, Panthera onca, Puma concolor, Leopardus tigrinus and Leopardus wiedii) were collected and the methods of Faust, modified Baermann and Hoffmann, were used for fecal analyses. Three genera were identified in the feces: Trichuris spp., Toxocara spp. and Giardia spp. In the zoo of Pomerode, six animals (46 percent) were infected by Trichuris spp. and/or Giardia spp. and all samples from the zoo of Brusque were infected by Trichuris spp., Toxocara spp. and Giardia spp.

Molecular characterization of van genes found in vancomycin-resistant Enterococcus spp. isolated from the Hospital das Clínicas, FMUSP, São Paulo, Brazil.

Vancomycin-resistant enterococci strains (VRE) is an important pathogen related with hospital infections in many countries, presenting limited or no therapeutic options for treating serious infections. VRE has presented some different genotypes been VanA and VanB considered to be the most important in hospital environments. In the present study the authors investigated the prevalence of van genes (A, B an C) among clinical isolates of VRE in a five month period at a large tertiary hospital in Sao Paulo, Brazil. The results showed the presence of vanA, but not vanB or vanC in all 43 strains of E. faecalis and five E. faecium studied. The results bring an important issue, due to the possibility of resistance spread of vanA genes, to be monitored and solved by the hospital infection control team and the microbiology and molecular biology laboratories at tertiary Hospitals.

Molecular characterization of van genes found in vancomycin-resistant Enterococcus spp. isolated from Hospital das Clínicas, FMUSP, Säo Paulo, Brazil

Vancomycin-resistant enterococci strains (VRE) is an important pathogen related with hospital infections in many countries, presenting limited or no therapeutic options for treating serious infections. VRE has presented some different genotypes been VanA and VanB considered to be the most important in hospital environments. In the present study the authors investigated the prevalence of van genes (A, B an C) among clinical isolates of VRE in a five month period at a large tertiary hospital in Sao Paulo, Brazil. The results showed the presence of vanA, but not vanB or vanC in all 43 strains of E. faecalis and five E. faecium studied. The results bring an important issue, due to the possibility of resistance spread of vanA genes, to be monitored and solved by the hospital infection control team and the microbiology and molecular biology laboratories at tertiary Hospitals

Simultaneous occurrence of lymphoepithelial cysts, cytomegalovirus and mycobacterial infections in the intraparotid lymph nodes of a patient with AIDS.

We report the unusual simultaneous occurrence of lymphoepithelial cysts, cytomegalovirus (CMV) and mycobacterial infections in the intraparotid lymph nodes of a 52-year-old AIDS patient who died of disseminated mycobacteriosis. Although cytomegalovirosis is a common finding in the salivary glands of HIV patients, the association of CMV inclusions with lymphoepithelial cyst (LC) has not been previously reported. Parotid mycobacterial infection is an uncommon finding, despite its usual disseminated presentation in HIV patients. These data emphasize that in immunosuppressed patients, simultaneous diseases of the parotid gland may occur and should be considered for diagnosis and treatment.

Epidemiologic investigation of an outbreak of coagulase-negative Staphylococcus primary bacteremia in a newborn intensive care unit.

Infections due to coagulase-negative Staphylococcus (CNS) are an ever-increasing nosocomial problem, particularly in the pediatric population. The authors describe a cluster of three primary bloodstream infections due to CNS in a newborn intensive care unit that occurred between November 23 and December 2, 1992. Two children died as a direct consequence of the bacteremia; at autopsy, one had a large bacteria-containing thrombus extending from the insertion site of a central catheter to the superior vena cava. The children were placed in isolation, and the nursing and medical staff were given topical nasal mupirocin. Plasmid analysis performed later disclosed three different blood isolates that also were different from any of the staff's nasal isolates. The authors concluded that molecular methods such as plasmid analysis are important tools in identifying true outbreaks and can prevent needless interventions, such as those during this cluster.

Avaliaçäo da sensibilidade a teicoplanina e vancomicina, em Staphylococcus aureus e estafilococos coagulase negativos / Evaluation of teicoplanin and vancomycin susceptibility in Staphylococcus aureus and coagulase-negative staphylococci

Membros do gênero staphylococcus säo os patógenos mais comuns encontrados no ambiente hospitalar e vêm adquirindo resistência múltipla aos antimicrobianos. OBJETIVO. Avaliar as atividades inibitórias in vitro da teicoplanina e da vancomicina frente a 195 amostras de estafilococos isolados de processos infecciosos significativos, provenientes de pacientes internados. MÉTODOS. foram estudadas 100 amostras de Staphylococcus aureus, sendo a metade representada por cepas resistentes à oxacilina, e 95 amostras de estafilococos coagulase negativos (ECN), sendo 44 cepas resistentes à oxacilina, que foram submetidas às provas de sensibilidade pela técnica da diluiçäo en ágar e da difusäo do disco em ágar. RESULTADOS. Todas as cepas (100 por cento) foram sensíveis à vancomicina; as amostras de S. aureus apresentaram MIC90 DE 0,5µg/mL, enquanto que os ECN mostraram MIC90 de 1,0µg/mL. Para a teicoplanina, 98,5 por cento das amsotras se mostraram sensíveis; o MIC90 foi de 0,5µg/mL para as cepas de S. aureus, de 2,0 µg/mL para as cepas de ECN (sensíveis à oxacilina) e de 8,0µg/mL para as cepas de ECN (resistentes à oxacilina). CONCLUSÄO. Do ponto de vista microbiológico, os resultados demonstraram o alto potencial de ambas as drogas como agentes terapêuticos para infecçöes causadas por estafilococos multiresistentes de origem hospitalar

[Teicoplanin and vancomycin susceptibility in Staphylococcus aureus and coagulase-negative staphylococci]. / Avaliação da sensibilidade à teicoplanina e vancomicina, em Staphylococcus aureus e estafilococos coagulase negativos.

Members of the genera Staphylococcus are the most common pathogens found in the hospital environment and they are acquiring resistance to multiple drugs. PURPOSE--To evaluate the in vitro activity of teicoplanin and vancomycin against 195 strains of staphylococci isolated from in-patients. METHODS--One hundred strains of Staphylococcus aureus (50% methicillin-resistant) and 95 strains of coagulase-negative staphylococci (46.3% strains methicillin-resistant) were tested by the agar dilution and the disk diffusion techniques. RESULTS--All strains (100%) were susceptible to vancomycin, S. aureus strains presented MIC90 of 0.5 microgram/mL whereas strains of coagulase-negative staphylococci showed MIC90 of 1.0 microgram/mL. For teicoplanin, 98.5% of the strains were susceptible. MIC90 values were 0.5 microgram/mL for S. aureus strains, 2.0 micrograms/mL for coagulase-negative methicillin-susceptible staphylococci strains and 8.0 micrograms/mL for coagulase-negative methicillin-resistant staphylococci strains. CONCLUSION--From the microbiological point of view, the results showed a high potential for both drugs as therapeutic agents in staphylococcal infections due to multiresistant strains of hospital origin.

An outbreak of nosocomial Legionnaires' disease in a renal transplant unit in São Paulo, Brazil. Legionellosis Study Team.

From June 1989 to March 1990 there were eight cases of Legionnaires' disease caused by Legionella pneumophila serogroup 1 in a renal transplant unit. There were seven cases of pneumonia and one case of pleural effusion. A study was conducted to identify the source of the outbreak. Legionella anisa was cultured from tap water. Twenty-seven staff members of the unit were serologically tested and antibody titres were positive in two. The probable source of infection was the potable water system. Control measures were hyperchlorination and heating of the water, after which there were no further cases during 5 months' follow up. We believe this is the first reported Legionnaires' disease outbreak in Latin America.