A Brazilian Inter-Hospital Candidemia Outbreak Caused by Fluconazole-Resistant Candida parapsilosis in the COVID-19 Era.

Horizontal transmission of fluconazole-resistant Candida parapsilosis (FRCP) through healthcare workers' hands has contributed to the occurrence of candidemia outbreaks worldwide. Since the first COVID-19 case in Brazil was detected in early 2020, hospitals have reinforced hand hygiene and disinfection practices to minimize SARS-CoV-2 contamination. However, a Brazilian cardiology center, which shares ICU patients with a cancer center under a FRCP outbreak since 2019, reported an increased FRCP candidemia incidence in May 2020. Therefore, the purpose of this study was to investigate an inter-hospital candidemia outbreak caused by FRCP isolates during the first year of the COVID-19 pandemic in Brazil. C. parapsilosis bloodstream isolates obtained from the cancer (n = 35) and cardiology (n = 30) centers in 2020 were submitted to microsatellite genotyping and fluconazole susceptibility testing. The ERG11 gene of all isolates from the cardiology center was sequenced and compared to the corresponding sequences of the FRCP genotype responsible for the cancer center outbreak in 2019. Unprecedentedly, most of the FRCP isolates from the cardiology center presented the same genetic profile and Erg11-Y132F mutation detected in the strain that has been causing the persistent outbreak in the cancer center, highlighting the uninterrupted horizontal transmission of clonal isolates in our hospitals during the COVID-19 pandemic.

Characteristics and Outcomes of Heart Transplant Recipients With Coronavirus-19 Disease in a High-volume Transplant Center.

BACKGROUND: Heart transplant (HT) recipients may be at higher risk of acquiring SARS-CoV-2 infection and developing critical illness. The aim of this study is to describe characteristics and outcomes of HT recipients infected by SARS-COV-2, from a high-volume transplant center. METHODS: We have described data of all adult HT recipients with confirmed coronavirus disease 2019 by RT-PCR in nasopharyngeal samples from April 5, 2020, to January 5, 2021. Outcomes and follow-up were recorded until February 5, 2021. RESULTS: Forty patients were included. Twenty-four patients (60%) were men; the median age was 53 (40-60) y old; median HT time was 34 mo; and median follow-up time 162 d. The majority needed hospitalization (83%). Immunosuppressive therapy was reduced/withdrawn in the majority of patients, except from steroids, which were maintained. Seventeen patients (42.5%) were classified as having severe disease according to the ordinal scale developed by the World Health Organization Committee. They tended to have lower absolute lymphocyte count (P < 0.001) during follow-up when compared with patients with mild disease. Thirty-day mortality was 12.5%. However, a longer follow-up revealed increased later mortality (27.5%), with median time to death around 35 d. Bacterial nosocomial infections were a leading cause of death. Cardiac allograft rejection (10%) and ventricular dysfunction (12.5%) were also not negligible. CONCLUSIONS: Major findings of this study corroborate other cohorts' results, but it also reports significant rate of later events, suggesting that a strict midterm surveillance is advisable to HT recipients with coronavirus disease 2019.

Usefulness of PCR for Trypanosoma cruzi DNA in blood and endomyocardial biopsies for detection of Chagas disease reactivation after heart transplantation: A comparative study.

BACKGROUND: Chagas disease reactivation (CDR) after heart transplantation is characterized by relapse of the infectious disease with proliferation and dissemination of Trypanosoma cruzi parasites. Serial blood PCR testing is consensually recommended for CDR monitoring, but there is uncertainty about the incremental value in performing the molecular tests in endomyocardial biopsies (EMB). METHODS: We compared qualitative and quantitative results of PCR for T cruzi DNA in 62 pairs of blood and EMB collected with a maximum time interval of 7 days, from 34 heart-transplanted, chagasic patients. RESULTS: Blood PCR resulted positive in 39/62 (62.9%) samples, with PL ranging from 0.14 to 1610.73 (median: 3.31). PCR resulted positive in 8/60 (13.3%) EMB, with PL ranging from 2.82 to 1670.55 (median: 65.63). All blood samples which tested negative presented a paired EMB which also tested negative. However, 31/39 (79.5%) blood samples which tested positive presented a paired EMB which tested negative. There was poor agreement between blood and EMB PCR (kappa = 0.153). CDR affecting the myocardium (myo-CDR) was diagnosed in three occasions. PCR resulted positive in both blood and EMB at the time of myo-CDR, with PL ranging from 0.61 to 1610.73 in blood and 13.8 to 1670.55 in EMB. CONCLUSIONS: Negative PCR for T cruzi in blood rules out myo-CDR, with no value of testing EMB. Positive PCR in blood with high PL is diagnostic for myo-CDR. If PCR in blood results positive with low PL, testing EMB is useful: negative PCR turns unlikely, and positive PCR reinforces greatly the possibility of myo-CDR.

Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review.

OBJECTIVES: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. DESIGN: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. SETTING: Surgical ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. INTERVENTIONS: Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27. CONCLUSIONS: Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

Cytomegalovirus colitis in immunocompetent critically ill patients.

OBJECTIVES: Cytomegalovirus (CMV) is a ubiquitous virus and its reactivation may lead to CMV end-organ disease (CMV EOD) in immunocompromised patients and also in immunocompetent patients when they are critically ill. We aimed to investigate the frequency and the clinical features of proven CMV EOD in previously non-immunosuppressed patients admitted to our institution. METHODS: From January 2000 to March 2013, the records of all patients with a histopathological diagnosis of CMV EOD at our teaching hospital were reviewed retrospectively. CMV EOD was diagnosed histologically by the identification of true cytomegalic viral inclusion involving endothelial, stromal, and/or epithelial cells on hematoxylin and eosin staining, and was subsequently confirmed by immunohistochemistry using specific antibody against CMV antigens. Immunocompromised patients were excluded. RESULTS: CMV EOD manifesting as colitis was diagnosed in 14 previously immunocompetent intensive care unit (ICU) patients. The mean age of the patients was 64 years. All had co-morbidities and developed shock before CMV EOD. The major manifestation was gastrointestinal bleeding. The in-hospital mortality rate was 71.4% despite specific treatment with ganciclovir. CONCLUSIONS: Despite being a rare condition, lower gastrointestinal bleeding in this profile of ICU patients could be the clinical manifestation of CMV colitis, and intensivists should be alert to this condition.

Infecções em 100 pacientes submetidos a transplante cardíaco / Infections in 100 heart transplantation patients

PURPOSE--A prospective study of infective agents in diagnosed infections and deaths by specific agents in cardiac transplant patients. METHODS--Infections occurring in a series of 100 consecutive cardiac transplant patients after transplantation with definite infectious diagnosis were studied; follow-up after transplantation was 3 to 90 (medium 25.38 +/- 25.97) months. Diagnostic criteria for defining infections were those used in the Epidemiology and Quality Control Division of the INCOR, that are the same published by the Centers for Disease Control. The following parameters were analysed: infections/patient/time, causes of infection and organs infected, clinical presentation and clinical aspects of infections, methods used for the infective diagnosis and relationship between rejection episodes and infection. Death caused by infections and survival rates per infection were also studied. RESULTS--Bacterial infections were more frequent (56.3 of all infections), followed by viral infections (19.6), fungal infections (18) and protozoal infections (6.1). Of all deaths after transplantation, 25 were caused by infections. CONCLUSION--Infections are an important cause of mortality and morbidity in this patient population; our data are in accordance to the other reported series.

Cytomegalovirus and other herpesviruses infections in heart and bone marrow transplant recipients

De janeiro de 1988 a janeiro de 1989 todos os pacients submetidos a transplante de coraçiao de medula óssea no Instituto do Coraçäo do Hospital das Clínicas da Faculdade de Medicina da Universidade de Siao Paulo foram estudados quanto à incidência e morbidade das infecçöes pós-transplante causadas por vírus do grupo herpes. Cinco recipientes de medula óssea e 5 transplantados cardíacos foram observados por um período médio de 4.2 meses após o transplante. Todos os pacientes tinham sorologia positiva para citomegalovírus (CMV) antes do transplantee 80% desenvolveram uma ou mais recorrências durante o período de observaçäo. Dos 12 episódios de infecçäo por CMV detectados neste estudo, 83% foram acompanhados por alteraçöes clínicas ou laboratoriais. Apenas um caso apresentou doença grave. A incidência de infecçöes causadas por vírus Herpes simplex (HSV) fossem reprsentadas por lesöes orais ou genitais, houve também umcaso de hepatite por HSV. Um dos 6 episódios de infecçäo, por HSV. Um dos 6 episódios de infecçäo, por HSV que foram tratados com aciclovir näo respondeu ao tratamento. Posteriormente, o paciente se beneficiou com o uso de ganciclovir. Todos os indivíduos apresentavam antes do transplante anticorpos anti-vírus da varicela zoster. Porém, näo houve nenhum caso de reativaçäo. Este estudo realça a importância do cocntrole diagnóstico ativo da infeccöes por herpes-vírus em pacientes transplantados. Tanto as infecçöes causadas por CMV como por HSV mostraram alta incidência e grande mortalidade indicando a necessidade de quimioprofilaxia