Active case-finding of pulmonary TB in an urban emergency department.

BACKGROUND: The WHO recommends systematic screening of TB in high TB prevalence settings. We evaluated an active case-finding strategy using sputum screening regardless of symptoms in a high TB prevalence Emergency Department (ED) in Peru.METHODS: This was a cross-sectional study conducted at the Hospital Nacional Dos de Mayo ED, which serves low-income populations in downtown Lima, Peru. Adults presenting to the ED for any reason and able to provide sputum were enrolled. Participants provided one sputum specimen for acid-fast bacilli smear and culture. A second sputum specimen for Xpert® MTB/RIF testing was collected if the patient was admitted to an ED observation unit.RESULTS: Between September 2017 and March 2018, 5,171 individuals who presented to the ED were approached. Of 2,119 individuals able to provide sputum, 78 (3.7%) participants had a positive culture and/or Xpert result and were newly diagnosed with TB, whereas traditional screening using >2-week cough identified 41 (1.9%) cases (3.7% vs. 1.9%; P < 0.001). Twelve TB cases (15.4%) reported no TB symptoms of any duration.CONCLUSION: ED-based active case-finding of pulmonary TB using symptom-neutral sputum screening increased TB identification compared to traditional symptom-based screening. Our results align with current WHO recommendation of systematic screening in high TB prevalence areas, which may include ED settings.

Building a network for multicenter, prospective research of central nervous system infections in South America: Process and lessons learned.

Multicenter collaborative networks are essential for advancing research and improving clinical care for a variety of conditions. Research networks are particularly important for central nervous system infections, which remain difficult to study due to their sporadic occurrence and requirement for collection and testing of cerebrospinal fluid. Establishment of long-term research networks in resource-limited areas also facilitates diagnostic capacity building, surveillance for emerging pathogens, and provision of appropriate treatment where needed. We review our experience developing a research network for encephalitis among twelve hospitals in five Peruvian cities since 2009. We provide practical suggestions to aid other groups interested in advancing research on central nervous system infections in resource-limited areas.

Herpes simplex virus encephalitis in Peru: a multicentre prospective study.

Herpes simplex virus (HSV) is one of the most commonly identified infectious aetiologies of encephalitis in North America and Europe. The epidemiology of encephalitis beyond these regions, however, is poorly defined. During 2009-2012 we enrolled 313 patients in a multicentre prospective study of encephalitis in Peru, 45 (14·4%) of whom had confirmed HSV infection. Of 38 patients with known HSV type, 84% had HSV-1 and 16% had HSV-2. Patients with HSV infection were significantly more likely to present in the summer months (44·4% vs. 20·0%, P = 0·003) and have nausea (60·0% vs. 39·8%, P = 0·01) and rash (15·6% vs. 5·3%, P = 0·01) compared to patients without HSV infection. These findings highlight differences in the epidemiology and clinical presentation of HSV encephalitis outside of the Northern Hemisphere that warrant further investigation. Furthermore, there is an urgent need for improved HSV diagnostic capacity and availability of intravenous acyclovir in Peru.

Impacto de un programa de capacitación para la prevención de infecciones intrahospitalarias en un hospital general / Impact of a training program for the prevention of infections in a general hospital nosocomial

Objetivo: Incrementar la adherencia del personal de salud a tres prácticas de control de infecciones a través de una intervención educativa. Material y metodología: Durante 11 meses, 440 trabajadores de salud recibieron capacitación en control de infecciones. Se aplicó la capacitación de instrucción suplementaria basada en vídeos (VSI), incidiendo en el lavado de manos, uso de respirador N95 y prevención de cortes y punciones con instrumental. Se realizó una evaluación a los tres y a los seis meses post-intervención. Resultados: Se obtuvo en el personal de salud un incremento en la adecuada técnica del lavado de manos del 7% al 78% (p<0,05), en el uso adecuado del respirador N95 del 0% al 81,5% (p<0,01) y se observó una disminución en la proporción de cortes y punciones entre los internos de medicina del 0,20 al 0,44% (p<0,006). No se encontró diferencia en otros grupos poblacionales. Conclusión: La metodología VSI tiene efectos positivos en la adopción de prácticas de control de infecciones en personal de salud (AU)

Objective: To increase the adherence of health care workers to three infections control practices through an educational intervention. Methods: 440 health care workers were trained in infection control during the period of 11 months. The methodology training Video-based Supplemental Instruction (VSI) affecting three infection control practices: Wash hands, N95 respirator use and prevention of needle stick accidents. They were evaluated 3 and 6 months post-intervention. Results: Obtained health care workers increased from 7% to 78% (p<0.05) in the proper hand washing technique, from 0% to 81.5% in the proper use of N95 respirator and was observed decrease in the proportion of sharp accidents in medical interns trained 0.20 vs. 0.44 (p<0.006). No difference was found in other populations intervened. Conclusion: The methodology VSI has positive effects on the adoption of infection control practices in health care workers (AU)

Tuberculosis transmission risk and infection control in a hospital emergency department in Lima, Peru.

BACKGROUND: Overcrowded emergency departments (EDs) are used by undiagnosed tuberculosis (TB) patients. TB infection control measures are seldom prioritized, making EDs potential foci of unrecognised nosocomial transmission. OBJECTIVE: To quantify TB infection risk among health care workers in an ED in a high TB-burden setting, Lima, Peru, and to evaluate TB infection control measures. METHODS: Consenting ED staff were tested for TB infection at baseline and after 1 year using the QuantiFERON-TB Gold In-Tube (QFT-G). In parallel, sputum for TB culture was requested from patients spending >2 h in the ED, irrespective of presenting complaint. Infection control measures were documented and room ventilation measured. RESULTS: Over 1 year, there were 2246 TB patient-hours of exposure in the ED from 153 different patients. At baseline, 56% of the 70 staff recruited were QFT-G-positive; 27 of 31 baseline-negatives consented to follow-up after 1 year, and eight (30%, all clinical staff) tested positive. Annual incidence of infection was 1730 per 100,000 population. TB infection control measures were sub-optimal, with no patient screening, no isolation rooms, inadequate ventilation and sporadic respirator use. CONCLUSIONS: ED staff were exposed to an unexpectedly large TB burden in the workplace, resulting in a high rate of TB infection. TB infection control should be prioritized in EDs, especially in high-prevalence settings.

Treatment of cryptococcal meningitis in Peruvian AIDS patients using amphotericin B and fluconazole.

OBJECTIVES: To describe the mycologic and clinical outcomes and factors associated with failure in Peruvian patients with AIDS-associated cryptococcal meningitis (CM) treated with amphotericin B deoxycholate (Amph B) followed by fluconazole. METHODS: Patients were treated with intravenous Amph B 0.7 mg/kg/day for 2 or 3 weeks followed by oral fluconazole 400mg/day for 7 or 8 weeks. Clinical and laboratory evaluations including cerebrospinal fluid (CSF) studies were performed at baseline and at weeks 2 and 10. RESULTS: The CSF cultures were negative in 25% and 68% of 47 patients at weeks 2 and 10, respectively. In the univariate analysis, baseline low body mass index (BMI), hyponatremia, low serum albumin, positive blood culture and CSF antigen titers >or=1024 were associated with a positive CSF culture at week 2. Baseline positive urine culture, positive blood culture, any positive extraneural culture and CSF opening pressure at week 2 >or=300 mm H2O were associated with a positive CSF culture at week 10. In the multivariate analysis no association was found. CONCLUSIONS: Therapy with Amph B and fluconazole, combined with aggressive management of elevated intracranial pressure (ICP), results in low CSF sterilization rates at week 2 and acceptable CSF sterilization rates at week 10 when compared with other series.

A randomized, double blind, comparative trial of micafungin (FK463) vs. fluconazole for the treatment of oesophageal candidiasis.

AIM: To determine efficacy and safety of intravenous micafungin vs. intravenous fluconazole in the treatment of oesophageal candidiasis. METHODS: A total of 523 patients > or =16 years with documented oesophageal candidiasis were randomized (1:1) in this controlled, non-inferiority study to receive either micafungin (150 mg/day) or fluconazole (200 mg/day). Response was evaluated clinically and endoscopically. Post-treatment assessments were performed at 2 and 4 weeks after discontinuation of therapy. RESULTS: Median duration of therapy was 14 days. For the primary end-point of endoscopic cure, treatment difference was -0.3% (micafungin 87.7%, fluconazole 88.0%). Documented persistent invasive disease at the end of therapy was reported in 2.7% and 3.9% of patients, respectively. Both 84.8% of micafungin and 88.7% of fluconazole patients remained recurrence free at 4-weeks post-treatment. The overall therapeutic response rate was 87.3% for micafungin and 87.2% for fluconazole. The incidence of drug-related adverse events was 27.7% for micafungin and 21.3% for fluconazole. Six (2.3%) micafungin- and two (0.8%) fluconazole-treated patients discontinued therapy; rash was the most common event leading to discontinuation. CONCLUSION: Intravenous micafungin (150 mg daily) is well tolerated and as efficacious as intravenous fluconazole (200 mg daily) in the primary treatment of oesophageal candidiasis, achieving high rates of clinical and endoscopic cure.

Tuberculosis and nutrition: disease perceptions and health seeking behavior of household contacts in the Peruvian Amazon.

SETTING: Households of TB patients in the Peruvian Amazon. OBJECTIVE: To investigate how knowledge and beliefs of household contacts about TB affected health seeking behavior. DESIGN: Interviews with 73 patients finishing treatment and 79 of their adult household contacts. RESULTS: Contacts were knowledgeable about free screening and treatment, but contacts who noted weight loss, not cough, were more likely to be screened for TB (P = 0.03). Forty-two per cent reported that TB was prevented by nutrition, 28% by separating eating utensils, and only 19% by avoiding a coughing patient. Only one household contact reported being stigmatized. Stigma centered upon nutrition, and only 12% knew of the association between TB and HIV. Only 14% had a BMI < 20, yet 30% reported regularly going to sleep hungry. Free food packages were reported to be the most important reason for treatment adherence by 33% of patients. CONCLUSION: Contacts misperceived TB as a nutritional disease and did not fear airborne transmission, which should be corrected by public health education. Weight loss, and not cough, led to screening. Stigma appeared to be minimized because risk was perceived as personal, through malnutrition, rather than exposure-based. Nutritional incentives that utilize these beliefs may reduce diagnostic delay and enhance treatment adherence.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens.

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Double aortic arch in a dog (Canis familiaris): a case report.

We herein report a case of a double aortic arch in a 10-week-old male dog of no defined race, which presented episodes of regurgitation at the time of weaning. This vascular malformation was characterized by the persistence of two aortic arches, right and left, of varying dimensions. The right aortic arch was observed to be larger. During post mortem examination the vessels of the animal were injected with coloured latex bi-centrifuged CIS 1-4 polisopreno which revealed the patency of the two aortic arches. Concomitantly, dilation of the cranial oesophagus causing constriction was observed, indicating megaesophagus. Apart from the constriction, the oesophagus presented normal morphometric parameters in relation to its dimensions.