Diagnosis of congenital infections in premature, low-birthweight newborns with intrauterine growth restriction caused by cytomegalovirus (CMV), herpes simplex virus (HSV), Parvo-B 19, and Zika virus: a systematic review.

OBJECTIVES: To identify the prevalence of viral congenital infections in newborns classified as premature, low-birthweight, small for gestational age or intrauterine growth restriction. METHODS: The definition considered for selecting papers were: P as newborns younger than 28 days; V as low-birthweight, prematurity and intrauterine growth restriction; O as frequency of congenital infections with Cytomegalovirus, Parvovirus B19, Herpes Simplex, and Zika virus. The research was performed using EMBASE, LILACS, SCOPUS and MEDLINE databases, with no limitations on date and language. RESULTS: Eight studies were included. Manuscripts including Herpes Simplex, Zika virus or Parvovirus B19 did not fulfill the defined criteria. A wide variation in the frequency of CMV congenital infection (0-4.8%) was found, which might be attributed to regional and methodological differences between investigations. CONCLUSIONS: Newborn characteristics associated with CMV congenital infections may direct investigations towards these patients with a higher probability of infection. However, as data are controversial, studies concerning screening of infection are important to define recommendations of diagnosis.

Donor-Derived Tuberculosis: A Case Report and the Role of Communication Gaps in Transplantation Safety.

Donor-derived tuberculosis (DD-TB) accounts for less than 5% of TB cases and is considered a rare event. In the transplant setting, the frequency of active TB is estimated to be 20 to 74 times higher than that in the general population, and it is associated with high mortality. In this context, the main strategy to minimize the risk of DD transmission is to identify high-risk donors. Despite screening recommendations, failures may result in a breakdown of safety that ends in the transmission of potentially fatal diseases. This report describes a case of DD-TB and emphasizes communication gaps that may occur between organ procurement organizations and transplant centers. Failure in reporting results, lack of exchanging information regarding recipients from the same donor, and inefficient communication between organ procurement organizations and transplant centers are lacks that may be prevented by a more efficient approach towards screening protocols and communication.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review / Fatores de risco para infecção associada a cateteres venosos centrais em população neonatal - revisão sistemática

Abstract Objective: This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population. Data source: The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified. Data synthesis: A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs. Conclusion: Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Resumo Objetivo: Revisão sistemática sobre a densidade de incidência e de fatores de risco para infecção associada a cateter venoso central em população neonatal. Fontes dos dados: Usaram-se os bancos de dados Medline, Embase, Cochrane, Bdenf, Scielo e Lilacs, sem restrição de data ou de idioma. Identificaram-se os estudos que analisaram fatores de risco para infecção da corrente sanguínea em recém-nascidos. Síntese dos dados: Foram encontrados 134 artigos conforme os critérios de elegibilidade. Desses, foram selecionados 14 que abordaram fatores de risco para infecção associada a cateter venoso central em neonatos. A infecção da corrente sanguínea associada a cateter continua a mostrar-se como uma importante complicação, conforme demonstram as taxas de incidência relatadas nos estudos incluídos nesta revisão. Os fatores de risco observados apontam que baixo peso ao nascer, prematuridade e maior tempo de permanência do cateter estão relacionados a maior incidência de infecção da corrente sanguínea. Observou-se que taxas de infecção associada a cateter em valores baixos, próximos a zero, já são uma realidade em instituições de saúde de países desenvolvidos, uma vez que usam programas de vigilância e controle de infecção. Conclusão: A infecção da corrente sanguínea associada a cateter ainda apresenta altas taxas de densidade de incidência em países em desenvolvimento. Destaca-se a necessidade de mais estudos longitudinais e a necessidade de melhores estratégias de prevenção dos fatores de risco para a redução de infecção associada a cateter.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review.

OBJECTIVE: This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population. DATA SOURCE: The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified. DATA SYNTHESIS: A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs. CONCLUSION: Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Clinical and microbiological characteristics of OXA-23- and OXA-143-producing Acinetobacter baumannii in ICU patients at a teaching hospital, Brazil

ABSTRACT Background: Carbapenem-resistant Acinetobacter baumannii (CRAb) is an important cause of nosocomial infections especially in intensive care units. This study aimed to assess clinical aspects and the genetic background of CRAb among ICU patients at a Brazilian teaching hospital. Methods: 56 critically ill patients colonized or infected by CRAb, during ICU stay, were prospectively assessed. Based on imipenem MIC ≥ 4 µg/mL, 28 CRAB strains were screened for the presence of genes encoding metallo-β-lactamases and OXA-type β-lactamases. The blaOXA-type genes were characterized by PCR using primers targeting ISAba-1 or -3. Genetic diversity of blaOXA-positive strains was determined by ERIC-PCR analysis. Results: Patient's mean age (±SD) was 61 (±15.1), and 58.9% were male. Eighty-percent of the patients presented risk factors for CRAb colonization, mainly invasive devices (87.5%) and previous antibiotic therapy (77.6%). Thirty-three patients died during hospital stay (59.0%). Resistance to carbapenems was associated with a high prevalence of blaOXA-23 (51.2%) and/or blaOXA-143 (18.6%) genes. ERIC-PCR genotyping identified 10 clusters among OXA-producing CRAb. Three CRAb strains exhibited additional resistance to polymyxin B (MIC ≥ 4 µg/mL), whereas 10 CRAb strains showed tigecycline MICs > 2 µg/mL. Conclusions: In this study, clonally unrelated OXA-123- and OXA-143-producing A. baumannii strains in ICU patients were strongly correlated to colonization with infected patients being associated with a poor outcome.

Clinical and microbiological characteristics of OXA-23- and OXA-143-producing Acinetobacter baumannii in ICU patients at a teaching hospital, Brazil.

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAb) is an important cause of nosocomial infections especially in intensive care units. This study aimed to assess clinical aspects and the genetic background of CRAb among ICU patients at a Brazilian teaching hospital. METHODS: 56 critically ill patients colonized or infected by CRAb, during ICU stay, were prospectively assessed. Based on imipenem MIC≥4µg/mL, 28 CRAB strains were screened for the presence of genes encoding metallo-ß-lactamases and OXA-type ß-lactamases. The blaOXA-type genes were characterized by PCR using primers targeting ISAba-1 or -3. Genetic diversity of blaOXA-positive strains was determined by ERIC-PCR analysis. RESULTS: Patient's mean age (±SD) was 61 (±15.1), and 58.9% were male. Eighty-percent of the patients presented risk factors for CRAb colonization, mainly invasive devices (87.5%) and previous antibiotic therapy (77.6%). Thirty-three patients died during hospital stay (59.0%). Resistance to carbapenems was associated with a high prevalence of blaOXA-23 (51.2%) and/or blaOXA-143 (18.6%) genes. ERIC-PCR genotyping identified 10 clusters among OXA-producing CRAb. Three CRAb strains exhibited additional resistance to polymyxin B (MIC≥4µg/mL), whereas 10 CRAb strains showed tigecycline MICs>2µg/mL. CONCLUSIONS: In this study, clonally unrelated OXA-123- and OXA-143-producing A. baumannii strains in ICU patients were strongly correlated to colonization with infected patients being associated with a poor outcome.

Evaluation of national health-care related infection criteria for epidemiological surveillance in neonatology / Avaliação dos critérios nacionais de infecção relacionada à assistência à saúde para a vigilância epidemiológica em neonatologia

OBJECTIVE: to assess the use of the Brazilian criteria for reporting of hospital-acquired infections (HAIs) in the neonatal unit and compare them with the criteria proposed by the National Healthcare Safety Network (NHSN). METHODS: this was a cross-sectional study conducted from 2009 to 2011. It included neonates with HAI reporting by at least one of the criteria. Statistical analysis included calculation of incidence density of HAIs, distribution by weight, and by reporting criterion. Analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the national criteria was performed considering the NHSN as the gold standard, with agreement assessed by kappa. RESULTS: a total of 882 newborns were followed, and 330 had at least one infection notified by at least one of the criteria. A total of 522 HAIs were reported, regardless of the criteria. An incidence density of 27.28 infections per 1,000 patient-days was observed, and the main topographies were sepsis (58.3%), candidiasis (15.1%), and conjunctivitis (6.5%). A total of 489 (93.7%) were notified by both criteria, eight infections were notified only by the national criteria (six cases of necrotizing enterocolitis and two cases of conjunctivitis), and 25 cases of clinical sepsis were reported by NHSN criteria only. The sensitivity, specificity, PPV, and NPV were 95.1%, 98.6%, 98.4%, and 95.7%, respectively, for all topographies, and were 91.8%, 100%, 100%, and 96.3% for the analysis of sepsis. Kappa analysis showed an agreement of 96.9%. CONCLUSION: there was a high rate of agreement between the criteria. The use of the national criteria facilitates the reporting of sepsis in newborns, and can help to improve the specificity and PPV. .

OBJETIVO: avaliar a aplicação dos critérios nacionais para notificação de infecções relacionadas à assistência à saúde (IRAS) em Unidade Neonatal e comparar com os critérios propostos pelo National Healthcare Safety Network (NHSN). MÉTODOS: estudo transversal realizado de 2009 a 2011. Forma incluídos os neonatos que apresentaram notificação de IRAS por pelo menos um dos critérios. Análise estatística incluiu cálculo de densidade de incidência de IRAS e distribuição por peso e por critério de notificação. Foi realizada análise da sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) para os critérios nacionais, considerando o NHSN como padrão-ouro e a concordância avaliada pelo Kappa. RESULTADOS: foram acompanhados 882 neonatos, e 330 apresentaram pelo menos uma infecção notificada por, no mínimo, um dos critérios. Foram notificadas 522 IRAS, independentemente do critério. Observou-se densidade de incidência de 27,28 infecções por 1.000 pacientes-dia, e as principais topografias foram sepse (58,3%), monilíase (15,1%) e conjuntivite (6,5%). Um total de 489 (93,7%) notificações foram por ambos os critérios; oito infecções foram notificadas apenas pelo critério nacional (duas conjuntivites e seis enterocolites necrosantes); e 25 casos de sepse clínica foram notificadas apenas pelo NHSN. A sensibilidade, especificidade, VPP e VPN foram de 95,1%, 98,6%, 98,4%, 95,7%, respectivamente, para todas as topografias, e para análise de sepse foram 91,8%, 100%, 100% e 96,3%. O Kappa revelou concordância de 96,9%. CONCLUSÃO: verificou-se uma elevada concordância entre os critérios. A utilização dos critérios nacionais facilita a n...

Evaluation of national health-care related infection criteria for epidemiological surveillance in neonatology.

OBJECTIVE: to assess the use of the Brazilian criteria for reporting of hospital-acquired infections (HAIs) in the neonatal unit and compare them with the criteria proposed by the National Healthcare Safety Network (NHSN). METHODS: this was a cross-sectional study conducted from 2009 to 2011. It included neonates with HAI reporting by at least one of the criteria. Statistical analysis included calculation of incidence density of HAIs, distribution by weight, and by reporting criterion. Analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the national criteria was performed considering the NHSN as the gold standard, with agreement assessed by kappa. RESULTS: a total of 882 newborns were followed, and 330 had at least one infection notified by at least one of the criteria. A total of 522 HAIs were reported, regardless of the criteria. An incidence density of 27.28 infections per 1,000 patient-days was observed, and the main topographies were sepsis (58.3%), candidiasis (15.1%), and conjunctivitis (6.5%). A total of 489 (93.7%) were notified by both criteria, eight infections were notified only by the national criteria (six cases of necrotizing enterocolitis and two cases of conjunctivitis), and 25 cases of clinical sepsis were reported by NHSN criteria only. The sensitivity, specificity, PPV, and NPV were 95.1%, 98.6%, 98.4%, and 95.7%, respectively, for all topographies, and were 91.8%, 100%, 100%, and 96.3% for the analysis of sepsis. Kappa analysis showed an agreement of 96.9%. CONCLUSION: there was a high rate of agreement between the criteria. The use of the national criteria facilitates the reporting of sepsis in newborns, and can help to improve the specificity and PPV.

Risk factors and lethality of laboratory-confirmed bloodstream infection caused by non-skin contaminant pathogens in neonates.

OBJECTIVE: To evaluate risk factors and lethality of late onset laboratory-confirmed bloodstream infection (LCBI) in a Brazilian neonatal unit for progressive care (NUPC). METHODS: This was a case-control study, performed from 2008 to 2012. Cases were defined as all newborns with late onset LCBI, excluding patients with isolated common skin contaminants. Controls were newborns who showed no evidence of late onset LCBI, matched by weight and time of permanence in the NUPC. Variables were obtained in the Hospital Infection Control Committee (HICC) database. Analysis was performed using the Statistical Package for the Social Sciences (SPSS). The chi-squared test was used, and statistical significance was defined as p < 0.05, followed by multivariate analysis. RESULTS: 50 patients with late onset LCBI were matched with 100 patients without late onset LCBI. In the group of patients with late onset LCBI, a significant higher proportion of patients who underwent surgical procedures (p = 0.001) and who used central venous catheter (CVC) (p = 0.012) and mechanical ventilation (p = 0.001) was identified. In multivariate analysis, previous surgery and the use of CVC remained significantly associated with infection (p = 0.006 and p = 0.047; OR: 4.47 and 8.99, respectively). Enterobacteriacea was identified in 14 cases, with three (21.4%) deaths, and Staphylococcus aureus was identified in 20 cases, with three (15%) deaths. CONCLUSIONS: Surgical procedures and CVC usage were significant risk factors for LCBI. Therefore, prevention practices for safe surgery and CVC insertion and manipulation are essential to reduce these infections, in addition to training and continuing education to surgical and assistance teams.

Fatores de risco e letalidade de infecção da corrente sanguínea laboratorialmente confirmada, causada por patógenos não contaminantes da pele em recém-nascidos / Risk factors and lethality of laboratory-confirmed bloodstream infection caused by non-skin contaminant pathogens in neonates

OBJECTIVE: To evaluate risk factors and lethality of late onset laboratory-confirmed bloodstream infection (ICSLC) in a Brazilian neonatal unit for progressive care (NUPC). Methods: This was a case-control study, performed from 2008 to 2012. Cases were defined as all newborns with late onset ICSLC, excluding patients with isolated common skin contaminants. Controls were newborns who showed no evidence of late onset ICSLC, matched by weight and time of permanence in the NUPC. Variables were obtained in the Hospital Infection Control Committee (HICC) database. Analysis was performed using the Statistical Package for the Social Sciences (SPSS). The chi-squared test was used, and statistical significance was defined as p < 0.05, followed by multivariate analysis. RESULTS: 50 patients with late onset ICSLC were matched with 100 patients without late onset ICSLC. In the group of patients with late onset ICSLC, a a significant higher proportion of patients who underwent surgical procedures (p = 0.001) and who used central venous catheter (CVC) (p = 0.012) and mechanical ventilation (p = 0.001) was identified. In multivariate analysis, previous surgery and the use of CVC remained significantly associated with infection (p = 0.006 and p = 0.047; OR: 4.47 and 8.99, respectively). Enterobacteriacea was identified in 14 cases, with three (21.4%) deaths, and Staphylococcus aureus was identified in 20 cases, with three (15%) deaths. CONCLUSIONS: Surgical procedures and CVC usage were significant risk factors for ICSLC. Therefore, prevention practices for safe surgery and CVC insertion and manipulation are essential to reduce these infections, in addition to training and continuing education to surgical and assistance teams.

OBJETIVO: Avaliar os fatores de risco e a letalidade da infecção da corrente sanguínea laboratorialmente confirmada (ICSLC) de início tardio em uma Unidade Neonatal de Cuidados Progressivos (UNCP) brasileira. MÉTODOS: Trata-se de um estudo caso-controle realizado de 2008 a 2012. Os casos foram definidos como todos os recém-nascidos com ICSLC de início tardio, excluindo pacientes isolados com contaminantes da pele comuns. Os controles foram recém-nascidos que não mostraram qualquer evidência de ICSLC de início tardio, sendo separados por peso e tempo de permanência na UNCP. As variáveis foram obtidas na base de dados da Comissão de Controle de Infecção Hospitalar (CCIH). A análise foi realizada utilizando o Pacote Estatístico para Ciências Sociais. O teste χ² foi utilizado e a relevância estatística foi definida como p < 0,05, seguida pela análise multivariada. RESULTADOS: No estudo, 50 pacientes com ICSLC de início tardio foram combinados com 100 pacientes sem ICSLC de início tardio. No grupo de pacientes com ICSLC de início tardio, identificamos uma proporção significativamente maior de pacientes que foram submetidos a procedimentos cirúrgicos (p = 0,001) e que usaram cateter venoso central (CVC) (p = 0,012) e ventilação mecânica (p = 0,001). Na análise multivariada, cirurgia prévia e uso de CVC permaneceram significativamente associados à infecção (p = 0,006 e p = 0,047; OU: 4,47 e 8,99, respectivamente). A Enterobacteriacea foi identificada em 14 casos, com três (21,4%) óbitos, e Staphylococcus aureus foi identificado em 20 casos, com três (15%) óbitos. CONCLUSÕES: Procedimentos cirúrgicos e uso de CVC constituíram fatores de risco significativos para ICSLC. Portanto, práticas de prevenção para cirurgia segura, inserção e manipulação de CVC são essenciais para reduzir essas infecções, além de treinamento e educação contínua às equipes cirúrgicas e de assistência.

Infectious complications associated with the use of central venous catheters in patients undergoing hematopoietic stem cell transplantation.

In this prospective, observational study, we sought to investigate the incidence, risk factors, and outcomes of central venous catheter-associated infection in 56 patients admitted for hematopoietic stem cell transplantation. In multivariate analysis, we found a 7-fold higher risk of central line-associated bloodstream infection with central venous catheter insertion in the internal jugular vein as compared with the subclavian access. Patients with central line-associated bloodstream infection had a higher incidence of acute renal failure.

Risk factors and preventive measures for catheter-related bloodstream infections.

OBJECTIVE: To review the risk factors of central venous catheter-related bloodstream infection and the recommendations for its prevention. SOURCES: PubMed, Cochrane Collaboration and Bireme were reviewed using the following inclusion criteria: studies published between 2000 and 2010, study design, hospitalized pediatric population with central venous catheters and studies about central venous catheter-related bloodstream infection. In addition, reference documents were retrieved from the Centers for Disease Control and Prevention and the Brazilian Health Surveillance Agency. SUMMARY OF THE FINDINGS: Associated risk factors were: duration of central venous catheter use; length of hospitalization time; long-term indwelling central venous catheter; insertion of central venous catheter in intensive care unit; nonoperative cardiovascular disease; parenteral nutrition; and administration of blood products. The preventive measures recommended by studies in the literature are: development of records and multidisciplinary guidelines of care for central venous catheter insertion and maintenance; correct use of central venous catheter insertion technique; use of chlorhexidine-impregnated dressings; early catheter removal; and adoption of continued education programs for the healthcare team. CONCLUSION: The control of risk factors may lead to a reduction of 40% or greater in the incidence of catheter-related bloodstream infection. Insertion surveillance and special attention to central venous catheter in pediatric populations should guide the standardization of healthcare routines to achieve standards for comparisons within and between institutions.

Risk factors and preventive measures for catheter-related bloodstream infections / Fatores de risco e medidas preventivas das infecções associadas a cateteres venosos centrais

OBJETIVO: Rever os fatores de risco para infecção associada a cateteres venosos centrais e as recomendações para a sua prevenção. FONTES DOS DADOS: Foram revisados artigos publicados sobre o tema no PubMed, Cochrane Collaboration e Bireme. Os seguintes critérios de inclusão foram levados em consideração: trabalhos publicados entre 2000 e 2010, delineamento do estudo, população pediátrica hospitalizada com utilização de cateteres venosos centrais e artigos sobre infecção associada a cateteres venosos centrais. Além disso, foram utilizados documentos de referência dos Centers for Disease Control and Prevention e da Agência Nacional de Vigilância Sanitária. SÍNTESE DOS DADOS: Os fatores de risco associados foram: tempo de utilização de acesso central, duração da internação e uso de cateter central de longa permanência, colocação de cateter venoso central em Unidade de Terapia Intensiva, doença cardiovascular não cirúrgica, recebimento de nutrição parenteral e de transfusão de hemoderivados. Entre as medidas preventivas, a literatura recomenda a implementação de protocolos e diretrizes multidisciplinares de cuidados na inserção e manutenção dos cateteres centrais, cuidados com a técnica de inserção dos cateteres venosos centrais, utilização de curativos impregnados com clorexidina, retirada precoce do cateter e adoção de programas de educação continuada para a equipe assistencial. CONCLUSÃO: O controle dos fatores de risco pode levar a uma redução igual ou superior a 40% na incidência dessas infecções. A vigilância do processo de inserção e cuidados com os cateteres vasculares centrais na população pediátrica orienta a padronização de rotinas dos serviços de saúde para a obtenção de taxas de referência para comparação intra e interinstitucionais.

OBJECTIVE: To review the risk factors of central venous catheter-related bloodstream infection and the recommendations for its prevention. SOURCES: PubMed, Cochrane Collaboration and Bireme were reviewed using the following inclusion criteria: studies published between 2000 and 2010, study design, hospitalized pediatric population with central venous catheters and studies about central venous catheter-related bloodstream infection. In addition, reference documents were retrieved from the Centers for Disease Control and Prevention and the Brazilian Health Surveillance Agency. SUMMARY OF THE FINDINGS: Associated risk factors were: duration of central venous catheter use; length of hospitalization time; long-term indwelling central venous catheter; insertion of central venous catheter in intensive care unit; nonoperative cardiovascular disease; parenteral nutrition; and administration of blood products. The preventive measures recommended by studies in the literature are: development of records and multidisciplinary guidelines of care for central venous catheter insertion and maintenance; correct use of central venous catheter insertion technique; use of chlorhexidine-impregnated dressings; early catheter removal; and adoption of continued education programs for the healthcare team. CONCLUSION: The control of risk factors may lead to a reduction of 40% or greater in the incidence of catheter-related bloodstream infection. Insertion surveillance and special attention to central venous catheter in pediatric populations should guide the standardization of healthcare routines to achieve standards for comparisons within and between institutions.

IgG and IgM western blot assay for diagnosis of congenital toxoplasmosis.

The aim of this study was to evaluate the utility of western blot (WB) analysis as a diagnostic tool for congenital toxoplasmosis in 215 newborn infants. The children were submitted to clinical examinations to assess macular, neurological and hearing signals. The WB results obtained were compared to the persistence of IgG antibodies at the end of 12 months, which is regarded as the "gold standard" diagnosis of congenital toxoplasmosis. Association between the WB results and the clinical signs presented by the infants was also assessed. Of the 215 children, 177 had a confirmed congenital toxoplasmosis diagnosis and 38 were uninfected. IgG-WB showed a sensitivity of 73.5% and a specificity of 97.4%. IgM-WB showed a sensitivity of 54.8% and a specificity of 94.7%. The IgG-WB and IgM-WB combination increased the sensitivity to 86.5%. The IgM-WB-positive children had a 1.4-fold greater risk of presenting active macular lesions than did those that were IgM-WB-negative. This study showed that the WB assay is a useful tool to confirm a diagnosis of congenital toxoplasmosis and that the IgM-WB-positive results can indicate active macular lesions in newborn infants.

Toxoplasmose congênita em filho de mãe cronicamente infectada com reativação de retinocoroidite na gestação / Congenital toxoplasmosis from a chronically infected woman with reactivation of retinochoroiditis during pregnancy an underestimated event?

Objetivo: Apresentar um caso raro de toxoplasmose congênita de uma mãe imunocompetente com infecção crônica que teve reativação da doença ocular durante a gestação. Descrição: O recém-nascido estava assintomático no nascimento e foi identificado através de triagem neonatal (IgM anti-Toxoplasma gondii em sangue seco) entre outros 190 bebês com toxoplasmose congênita durante um período de 7 meses. Sua mãe tinha tido um episódio não tratado de reativação de retinocoroidite toxoplásmica durante a gestação, com títulos de IgG estáveis e resultados negativos para IgM. Os resultados de IgM e IgG no soro do recém-nascido e o teste de immunoblotting para IgG foram positivos, e detectou-se lesões retinocoroideanas ativas na periferia da retina. O recém-nascido foi tratado com sulfadiazina, pirimetamina e ácido folínico. Aos 14 meses de vida, a criança permanecia assintomática, com regressão das lesões retinocoroideanas e persistência de IgG. Comentários: É possível que a triagem neonatal sistemática em áreas com alta prevalência de infecção possa identificar esses casos.

Objectives: To report a rare case of congenital toxoplasmosis from an immunocompetent mother with chronic infection who had reactivation of ocular disease during pregnancy. Descriptions:The newborn was asymptomatic at birth and identified by neonatal screening (IgM anti-Toxoplasma gondii in dried blood) among other 190 infants with congenital toxoplasmosis during a 7-month period. His mother had had a non-treated episode of reactivation of toxoplasmic retinochoroiditis during pregnancy, with stable IgG titers and negative IgM results. Results of IgM and IgG in the newborn’s serum, as well as IgG immunoblotting were positive and active retinochoroidal lesions were detected in his peripheral retina. The neonate was treated with sulfadiazine, pyrimethamine and folinic acid. At 14 months of life, the child remained asymptomatic, with regression of retinochoroidal lesions and persistence of IgG. Comments: It is possible that systematic neonatal screening in areas with high prevalence of infection may identify these cases.

Congenital toxoplasmosis from a chronically infected woman with reactivation of retinochoroiditis during pregnancy.

OBJECTIVE: To report a rare case of congenital toxoplasmosis from an immunocompetent mother with chronic infection who had reactivation of ocular disease during pregnancy. DESCRIPTION: The newborn was asymptomatic at birth and identified by neonatal screening (IgM anti-Toxoplasma gondii in dried blood) among other 190 infants with congenital toxoplasmosis during a 7-month period. His mother had had a non-treated episode of reactivation of toxoplasmic retinochoroiditis during pregnancy, with stable IgG titers and negative IgM results. Results of IgM and IgG in the newborn's serum, as well as IgG immunoblotting were positive and active retinochoroidal lesions were detected in his peripheral retina. The neonate was treated with sulfadiazine, pyrimethamine and folinic acid. At 14 months of life, the child remained asymptomatic, with regression of retinochoroidal lesions and persistence of IgG. COMMENTS: It is possible that systematic neonatal screening in areas with high prevalence of infection may identify these cases.

Congenital toxoplasmosis in southeastern Brazil: results of early ophthalmologic examination of a large cohort of neonates.

OBJECTIVE: To report results of early ophthalmologic examinations in a large cohort of newborns with congenital toxoplasmosis (CT) after neonatal screening. DESIGN: Cross-sectional analysis of a cohort. PARTICIPANTS: A total of 178 newborns with confirmed CT from 146,307 screened babies (95% of live births) from Minas Gerais state, southeastern Brazil. METHODS: From November 2006 to May 2007, newborns underwent neonatal screening by immunoglobulin (Ig)M capture of dried blood samples. On all positive or suspected cases, confirmative serology was performed on babies and their mothers. Congenital toxoplasmosis was confirmed in newborns who had IgM and/or IgA and IgG, or IgG associated with suggestive ocular lesions (with IgM and IgG in the mother). Ophthalmologic evaluation consisted of indirect ophthalmoscopy with a lid speculum. Pediatric examination and radiologic studies of the central nervous system were also performed. In selected cases, biomicroscopy of the anterior segment, fundus photographs, or ultrasonography (B-scan) was performed. MAIN OUTCOME MEASURES: Prevalence of retinochoroidal lesions, either cicatricial or active, and their location and associated findings, such as vascular sheathing, hemorrhage, vitreous opacities, and retinal detachment, were evaluated. The occurrence of cataract, microphthalmia, microcephaly, intracranial calcification, and hydrocephalus was also recorded. RESULTS: Of 146,307 neonates screened, 190 had CT, yielding a prevalence of 1 in 770 live births, of whom 178 (93.7%) underwent standardized ophthalmologic examination at an average age of 55.6+/-16.6 days. Of these 178 infants, 142 (79.8%) had retinochoroidal lesions consistent with CT in at least 1 eye. Bilateral involvement was noted in 113 patients (63.5%). Macular involvement was seen in 165 eyes (46.3%) of 111 patients (62.4%). Active lesions were observed in 142 eyes (39.9%) of 85 patients (47.8%). These lesions were located in the macula of 75 eyes (21.1%) and were associated with retinal vascular sheathing in 44 eyes (12.4%). CONCLUSIONS: A high prevalence of CT was encountered (1/770) with high rates of early retinochoroidal involvement ( approximately 80%) and many active lesions (in approximately 50%), indicating a possibly more severe ocular involvement by CT in Brazil than in other parts of the world. The hypotheses of higher parasite virulence and increased individual susceptibility are being currently investigated.

Experiências referentes à contracepção por mulheres sabidamente infectadas pelo HIV que engravidam / Experiences related to contraception by HIV-Infected women that become pregnant

Introdução: um crescente número de mulheres infectadas pelo HIV tem sido identificado, principalmente em idade reprodutiva. Apesar de receberem todas as medidas para a prevenção da transmissão vertical, observam-se dificuldades na assistência pós-natal, incluindo a ocorrência de gestações não-planejadas. Objetivo: investigar percepções sobre a contracepção por mulheres sabidamente infectadas pelo HIV com experiência prévia da maternidade e que engravidaram após o diagnóstico. Métodos: este foi um estudo clínico-qualitativo, desenvolvido no ambulatório Carlos Chagas do Hospital das Clínicas da Universidade Federal de Minas Gerais, de Janeiro de 2004 a Dezembro de 2005. Foram incluídas mulheres infectadas pelo HIV, com filhos vivos prévios e novas gestações após o diagnóstico. O número de entrevistadas foi definido pelo critério da saturação. Entrevistas semi-estruturadas foram gravadas e transcritas na íntegra. A análise foi realizada pelo processo de categorização. Resultados: vinte mulheres foram entrevistadas, com mediana de idade de 29 anos. A mediana de gestações foi de 3,5, mas após o diagnóstico 1,04. Dezenove gestações não foram planejadas. As mulheres tinham informações sobre métodos contraceptivos disponíveis, mas relatavam dificuldade do uso do preservativo pelo parceiro, dificuldades de uso de anticoncepcional oral e de acesso à salpingotripsia. Conclusão: a ocorrência de gestações não planejadas não dependeu do conhecimento prévio da infecção pelo HIV. As expectativas e o desejo podem ser modificados pelo estigma da doença, mas não foram determinantes na utilização do método contraceptivo eficaz. Profissionais de saúde devem atuar de forma integral, focando a utilização de contracepção eficaz e permitindo com que elas exerçam seus direitos reprodutivos.

Effectiveness of dual and triple antiretroviral therapy in the treatment of HIV-infected children.

OBJECTIVE: The use of antiretroviral therapy in HIV-infected children has been a widely discussed issue. The aim of this study was to compare the effectiveness of dual nucleoside analogue reverse transcriptase inhibitor (NRTI) regimens and three-drug regimens [2NRTI+ non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI)] in a cohort of HIV-infected children. METHODS: The study was carried out in a referral center for the management of infected children, which is affiliated with the School of Medicine of Universidade Federal de Minas Gerais (UFMG). Those children whose antiretroviral therapy was implemented between January 1998 and December 2000 and who were followed until December 2001 were included in the study. Therapeutic failure or death was regarded as the endpoint in our analysis. RESULTS: A total of 101 patients were assessed, 58 (57.4%) on dual therapy and 43 (42.6%) on triple therapy. No statistically significant difference was observed between the groups in terms of gender, age, CD4+ count and baseline viral load. The average duration of dual therapy was 26.3 months (95%CI 21.3-31.3) and that of triple therapy was 34.3 months (95%CI 29.2-39.5%). There was therapeutic failure in 33 (56.9%) patients on dual therapy and in 11 (25.6%) patients on triple therapy (log rank = 5.03; p = 0.025). The relative risk of therapeutic failure of the dual therapy was 2.2 times higher (95%CI 1.3-3.9). The percentage of initial CD4+ T cells was a predictor of risk for therapeutic failure (p = 0.001). Patients on triple therapy showed a more remarkable reduction in their viral load (p = 0.001). CONCLUSION: Triple therapy was efficient for a longer time period and showed better virologic response than dual therapy in this cohort of HIV-infected children. Therefore, triple therapy should be the treatment of choice.