Use of antibacterial agents in an intensive care unit in a hospital in Brazil.

It is essential to monitor the utilisation of antibacterial drugs in order to establish appropriate measures for their control. The pattern of usage of antibacterial drugs, and its association with indicators of hospital infection, has been investigated in a non-specialized adult intensive care unit (ICU) located in Santa Luzia Hospital (Brasília, DF, Brazil). The study was conducted between January 2001 and June 2004. Data concerning the utilisation of systemic antibacterial drugs, classified according to the Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system, and indicators of hospital infection, defined according to the National Nosocomial Infections Surveillance (NNIS) system, were obtained from appropriate hospital archives. During the study period, the average utilisation of antibacterial drugs was 1918.5 DDD units per 1000 patient-day (DDD(1000)). The three most used drugs were penicillins/beta-lactamase inhibitors (535.3 DDD(1000)), third generation cephalosporins (239.1 DDD(1000)) and quinolones (212.5 DDD(1000)). The total utilisation of antibacterial drugs was correlated significantly with the incidence of hospital infection (R = 0.62; p < 0.01) and the index of invasive procedures (R = 0.41; p < 0.01). Furthermore, the latter two indicators were significantly and positively correlated with the use of recently commercialized, broad spectrum antibacterial drugs (except for carbapenems). It is concluded that improved infection control procedures, together with more rigorous criteria regarding the use of invasive procedures, should be implemented by the ICU studied in order to diminish the utilisation of antibacterial drugs.

Use of antibacterial agents in an intensive care unit in a hospital in Brazil

It is essential to monitor the utilisation of antibacterial drugs in order to establish appropriate measures for their control. The pattern of usage of antibacterial drugs, and its association with indicators of hospital infection, has been investigated in a non-specialized adult intensive care unit (ICU) located in Santa Luzia Hospital (Brasília, DF, Brazil). The study was conducted between January 2001 and June 2004. Data concerning the utilisation of systemic antibacterial drugs, classified according to the Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system, and indicators of hospital infection, defined according to the National Nosocomial Infections Surveillance (NNIS) system, were obtained from appropriate hospital archives. During the study period, the average utilisation of antibacterial drugs was 1918.5 DDD units per 1000 patient-day (DDD1000). The three most used drugs were penicillins/beta-lactamase inhibitors (535.3 DDD1000), third generation cephalosporins (239.1 DDD1000) and quinolones (212.5 DDD1000). The total utilisation of antibacterial drugs was correlated significantly with the incidence of hospital infection (R = 0.62; p < 0.01) and the index of invasive procedures (R = 0.41; p < 0.01). Furthermore, the latter two indicators were significantly and positively correlated with the use of recently commercialised, broad spectrum antibacterial drugs (except for carbapenems). It is concluded that improved infection control procedures, together with more rigorous criteria regarding the use of invasive procedures, should be implemented by the ICU studied in order to diminish the utilisation of antibacterial drugs.

Emerging Chagas disease: trophic network and cycle of transmission of Trypanosoma cruzi from palm trees in the Amazon.

A trophic network involving molds, invertebrates, and vertebrates, ancestrally adapted to the palm tree (Attalaea phalerata) microhabitat, maintains enzootic Trypanosoma cruzi infections in the Amazonian county Paço do Lumiar, state of Maranhão, Brazil. We assessed seropositivity for T. cruzi infections in the human population of the county, searched in palm trees for the triatomines that harbor these infections, and gathered demographic, environmental, and socioeconomic data. Rhodnius pictipes and R. neglectus in palm-tree frond clefts or in houses were infected with T. cruzi (57% and 41%, respectively). Human blood was found in 6.8% of R. pictipes in houses, and 9 of 10 wild Didelphis marsupialis had virulent T. cruzi infections. Increasing human population density, rain forest deforestation, and human predation of local fauna are risk factors for human T. cruzi infections.

Persistent infections in chronic Chagas' disease patients treated with anti-Trypanosoma cruzi nitroderivatives.

We used a molecular method and demonstrated that treatment of the chronic human Trypanosoma cruzi infections with nitroderivatives did not lead to parasitological cure. Seventeen treated and 17 untreated chronic Chagas' disease patients, with at least two out of three positive serologic assays for the infection, and 17 control subjects formed the study groups. PCR assays with nested sets of T. cruzi DNA primers monitored the efficacy of treatment. The amplification products were hybridized to their complementary internal sequences. Untreated and treated Chagas' disease patients yielded PCR amplification products with T. cruzi nuclear DNA primers. Competitive PCR was conducted to determine the quantity of parasites in the blood and revealed < 1 to 75 T. cruzi/ml in untreated (means 25.83+/-26.32) and < 1 to 36 T. cruzi/ml in treated (means 6.45+/-9.28) Chagas' disease patients. The difference between the means was not statistically significant. These findings reveal a need for precise definition of the role of treatment of chronic Chagas' disease patients with nitrofuran and nitroimidazole compounds.

Progressive chronic Chagas heart disease ten years after treatment with anti-Trypanosoma cruzi nitroderivatives.

A randomized ten-year follow-up study involving 91 Chagas patients and 41 uninfected controls was undertaken to determine the effectiveness of nitroderivative therapy. Anti-Trypanosoma cruzi antibodies were consistently lower one year after treatment than 10 years thereafter (P < 0.001). The blood of all treated and 93.7% of untreated Chagas patients yielded polymerase chain reaction (PCR) product from probes annealing to T. cruzi nuclear DNA, indicating active infection. Competitive PCR showed means +/- standard deviations of 20.1+/-22.6 T. cruzi/ml of blood from untreated and 13.8+/-14.9 from treated Chagas patients, but the differences between means were not statistically significant (P > 0.05). Electrocardiograms recorded a gamut of alterations several-fold more frequent in Chagas patients, regardless of treatment, than in uninfected controls (P < 0.001). These results show that nitroderivative therapy for T. cruzi infections is unsatisfactory and cannot be recommended since it fails to eradicate the parasite or change the progression of heart disease in chronic Chagas patients.

Superinfections with genetically characterized Trypanosoma cruzi clones did not aggravate morbidity and mortality in BALB/c mice.

To determine the role of Trypanosoma cruzi superinfections on the outcome of Chagas' disease, groups of BALB/c mice were prime-infected with low virulence clones h1 and h2 and challenged with high virulence clones m3 and m4. All mice injected with the m3 and m4 clones succumbed before or at 16 days postinfection. In contrast, all mice injected with the h1 and h2 clones survived the prime infection and were superinfected with the m3 and m4 clones. Low-level parasitemias were observed in mice after challenge with the virulent clones. The mortality ratios in the superinfected mice were not statistically different from those seen in the mice that received a single T. cruzi injection. The histopathological lesions recorded during the course of the infections showed features in the superinfected mice similar to those seen in the animals receiving a single infection. These data argue that morbidity and mortality in BALB/c mice, infected with T. cruzi clonal lines, are not associated with the frequency of receiving the parasite burden.

Protective effect of exposure to non-virulent Trypanosoma cruzi clones on the course of subsequent infections with highly virulent clones in mice.

The protective effect of primary infection with non-virulent Trypanosoma cruzi clones against subsequent infection with highly virulent clones was determined in groups of BALB/c mice. All mice inoculated with the highly virulent m3 and m4 clones succumbed in < or = 16 days. Mice inoculated with the non-virulent h1 and h2 clones survived and were superinfected with the m3 and m4 clones. Low degrees of parasitaemia were observed in mice challenged with the highly virulent clones. The survival ratios of the superinfected mice were not statistically different from those seen in mice that received a single injection of non-virulent T. cruzi. Mice given a non-virulent infection and subsequently challenged with a virulent clone differed from those given only a non-virulent infection in showing more frequently an inflammatory infiltrate in the heart, skeletal muscle and intestines.

Diversity of Trypanosoma cruzi stocks and clones derived from Chagas disease patients: I--Behavioral characterization in vitro

In this study, we isolated Trypanosoma cruzi from chronic Chagas heart disease and from megaesophagus patients. The parasite stock hSLU239 (heart disease) yielded clones h1 and h2, whereas stock mSEU142 (megaesophagus) yielded clones m1, m2, m3 and m4. The parasite growth kinetics, doubling time and differentiation in axenic liquid medium showed broad behavioral diversity. It was shown that a particular pattern of behavior for a parental stock could not necessarily be assigned for subsequent clones. This study indicates that i) each Chagas disease patient is infected with several T. cruzi populations; ii) clonal lines derived from patient samples may have different biological characteristics from the original isolate; and that iii) additional behavioral and/or molecular markers are required for further characterization of Trypanosoma cruzi stocks and clones derived from Chagas disease patients in order to identify correlations with pathology.

Neste estudo, foram obtidos estoques de Trypanosoma cruzi de pacientes chagásicos com a doença cardíaca ou com megaesôfago. O estoque hSLU239 (doença cardíaca) forneceu os clones h1 e h2, enquanto o estoque mSLU142 (megaesôfago) forneceu os clones m1, m2, m3 e m4. A cinética de crescimento do parasito, tempo de duplicação e diferenciação em meio líquido axênico mostraram ampla diversidade comportamental. Observou-se que um padrão particular de comportamento de um estoque parental podia não ser necessariamente encontrado na linhagem subclonal subseqüente. Este estudo indica que i) cada paciente chagásico é infectado com várias subpopulações de T. cruzi; ii) linhagens clonais derivadas de cada estoque do parasito podem ter características biológicas diferentes do isolado original de paciente chagásico; e que iii) marcadores comportamentais e/ou moleculares adicionais são necessários para melhor caracterização de estoques de T. cruzi e seus clones derivados de pacientes com doença de Chagas, a fim de identificar as possíveis correlações com a patologia.

Diversity of Trypanosoma cruzi stocks and clones derived from Chagas disease patients: I--Behavioral characterization in vitro.

In this study, we isolated Trypanosoma cruzi from chronic Chagas heart disease and from megaesophagus patients. The parasite stock hSLU239 (heart disease) yielded clones h1 and h2, whereas stock mSEU142 (megaesophagus) yielded clones m1, m2, m3 and m4. The parasite growth kinetics, doubling time and differentiation in axenic liquid medium showed broad behavioral diversity. It was shown that a particular pattern of behavior for a parental stock could not necessarily be assigned for subsequent clones. This study indicates that i) each Chagas disease patient is infected with several T. cruzi populations; ii) clonal lines derived from patient samples may have different biological characteristics from the original isolate; and that iii) additional behavioral and/or molecular markers are required for further characterization of Trypanosoma cruzi stocks and clones derived from Chagas disease patients in order to identify correlations with pathology.

Virulence and pathogenicity associated with diversity of Trypanosoma cruzi stocks and clones derived from Chagas' disease patients.

The intraspecific variation that has been described in Trypanosoma cruzi was examined in recent isolates from Chagas' disease patients, using behavioral and molecular markers for characterization of the parasite stocks and derived clones. We used these parasite populations to determine virulence and pathogenicity in vivo. The T.cruzi stocks mSLU142 (megaesophagus) and hSLU239 (heart disease) and the clones h1 and h2 induced very low parasitemias in BALB/c mice, whereas high parasitemias were obtained with clones m1, m2, m3, and m4. Clones m1-m4 also produced heart lesions of higher intensity than those observed in mice infected with the h1 and h2 clones. Furthermore, the heart lesions produced by all of these clones were significantly more intense than those seen in mice infected with either of the T. cruzi parental stocks. In addition, neither the kinetics of growth, doubling time, differentiation in axenic culture, zymodemes, nor DNA restriction length polymorphisms showed correlations with parasitemias and pathogenicity in mice. This study suggests that multiple biochemical and physiological markers are required to enable an association of clinical and pathologic manifestations of the disease with intrinsic characters of the T. cruzi populations.

Diversity of Trypanosoma cruzi stocks and clones derived from Chagas disease patients. II. Isozyme and RFLP characterizations.

Isoenzyme and RFLP analyses were carried on freshly isolated Trypanosoma cruzi stocks and subsequent clones derived from patients with chronic Chagas disease. The isoenzymes separated the parasite stocks and clones in two groups: The stock hSLU239 (group I), isolated from a heart disease patient, showed the zymodeme 3 (Z3) profile (M. A. Miles et al., 1977, Transactions of the Royal Society of Tropical Medicine and Hygiene 71, 217-225). The stock mSLU142 (group II), isolated from a digestive disease (megaesophagus) patient, showed the Z2 profile. The parasite clones m1, m2, m3, and m4, derived from mSLU142, and clones h1 and h2, derived from hSLU239, showed isoenzyme profiles similar to those of Z2 and ZA (Miles et al. 1977; J. A. Romanha, 1982, Thesis, Universidade Federal de Minas Gerais). Furthermore, the T. cruzi clones derived from the cardiac disease patient differed from those derived from the megacolon patient in 3 of the 13 enzymes analyzed. RFLP analysis showed polymorphism at the EcoRI and PstI restriction fragments of the DNA sequences coding the glycolytic enzymes ALD, GPI, GAPDH, and PYK and separated the T. cruzi stocks and clones in three groups: I, comprising the stock hSLU239 and clone m4, which was classified as homozygous CC, BB, AA, and AA for the ALD, GPI, PYK, and GAPDH genes, respectively; II, formed by the parasite stock mSLU142 and clones h1 and h2 (derived from hSLU239), which was classified as homozygous AA, AA, CC, and BB for ALD, GPI, PYK, and GAPDH genes, respectively . These findings show that the infection of each Chagas disease patient may be produced by genetically diverse mixed parasite populations.

Polymorphisms in Trypanosoma cruzi: evidence of genetic recombination.

The ploidy of Trypanosoma cruzi is until now undetermined although analysis of isoenzymes, molecular karyotype and DNA content suggest diploidy in a very plastic genome. Also, there has been no convincing demonstration of genetic exchange and it has been proposed that reproduction is clonal. We have compared 18 T cruzi stocks and clones from the same area or host by means of isoenzyme analysis (12 loci) and restriction site polymorphisms in and around three glycolytic genes (glyceraldehyde-3-phosphate dehydrogenase, aldolase and glucosephosphate isomerase). The analysis demonstrated the presence of homozygotes and heterozygotes and is compatible with diploidy for these housekeeping genes. This strongly supports the hypothesis of genetic exchange in T cruzi and further elucidates the genetic diversity within natural T cruzi populations.

[The use of 4 immunological exams for the determination of Chagas disease prevalence in streetsweepers of the City Sanitation Service in the Federal District]. / Emprego de quatro exames imunológicos na determinação da prevalência da doença de Chagas nos garis do Serviço de Limpeza Urbana do Distrito Federal.

Seropositivity for Trypanosoma cruzi infection was studied in 368 street-sweepers of the SLU, Federal District, Brazil, with the aid of haemaglutination, immunofluorescence and, also, a delayed-type skin test to the parasite T12E antigen. It showed 32.1%, 42.1% and 38.6% positive results, respectively for each assay. Among these, however, only 47% were positive with each of three exams performed. In addition, 19.7% were positive with two out of three exams performed. The remaining 33.3% sera yielded one positive result out of three exams employed and were submitted to the immunoblot assay. This analysis confirmed 3 cases (37.5%) positive by hemmaglutination, 3 (11.5%) positive by skin test, and 1 (3.7%) positive by immunofluorescence. At the end of the analysis, it was shown that 129 (35%) individuals yielded at least two positive assays and, therefore, they should be considered as T. cruzi-infected individuals.