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INTRODUCTION: Adherence, which is crucial to the success of antiretroviral therapy (HAART), is currently a major challenge in the care of children and adolescents living with HIV/AIDS. OBJECTIVE: To evaluate the prevalence of nonadherence to HAART using complementary instruments in a cohort of children and adolescents with HIV/AIDS followed in a reference service in Campinas, Brazil. METHODS: The level of adherence of 108 patients and caregivers was evaluated by an adapted standardized questionnaire and pharmacy dispensing records (PDR). Non-adherence was defined as a drug intake lower than 95% (on 24-hour or seven-day questionnaires), or as an interval of 38 days or more for pharmacy refills. The association between adherence and clinical, immunological, virological, and psychosocial characteristics was assessed by multivariate analysis. RESULTS: Non-adherence prevalence varied from 11.1% (non-adherent in three instruments), 15.8% (24-hour self-report), 27.8% (seven-day self-report), 45.4% (PDR), and 56.3% (at least one of the outcomes). 24-hour and seven-day self-reports, when compared to PDR, showed low sensitivity (29% and 43%, respectively) but high specificity (95% and 85%, respectively). In multivariate analysis, medication intolerance, difficulty of administration by caregiver, HAART intake by the patient, lower socioeconomical class, lack of virological control, missed appointments in the past six months, and lack of religious practice by caregiver were significantly associated with non-adherence. CONCLUSION: A high prevalence of HAART non-adherence was observed in the study population, and PDR was the most sensitive of the tested instruments. The instruments employed were complementary in the identification of non-adherence.

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BACKGROUND: Since healthcare-associated pneumonia (HCAP) is heterogeneous, clinical characteristics and outcomes are different from region to region. There can also be differences between HCAP patients hospitalized in secondary or tertiary hospitals. This study aimed to evaluate the clinical characteristics of HCAP patients admitted into secondary community hospitals. METHODS: This was a retrospective study conducted in patients with HCAP or community-acquired pneumonia (CAP) hospitalized in two secondary hospitals between March 2009 and January 2011. RESULTS: Of a total of 303 patients, 96 (31.7%) had HCAP. 42 patients (43.7%) resided in a nursing home or long-term care facility, 36 (37.5%) were hospitalized in an acute care hospital for > 2 days within 90 days, ten received outpatient intravenous therapy, and eight attended a hospital clinic or dialysis center. HCAP patients were older. The rates of patients with CURB65 scores of 3 or more (22.9% vs. 9.1%; p = 0.001) and PSI class IV or more (82.2% vs. 34.7%; p < 0.001) were higher in the HCAP group. Drug-resistant pathogens were more frequently detected in the HCAP group (23.9% vs. 0.4%; p < 0.001). However, Streptococcus pneumoniae was the most common pathogen in both groups. The rates of antibiotic change, use of inappropriate antibiotics, and failure of initial antibiotic therapy in the HCAP group were significantly higher. Although the overall survival rate of the HCAP group was significantly lower (82.3% vs. 96.8%; p < 0.001), multivariate analyses failed to show that HCAP itself was a prognostic factor for mortality (p = 0.826). Only PSI class IV or more was associated with increased mortality (p = 0.005). CONCLUSIONS: HCAP should be distinguished from CAP because of the different clinical features. However, the current definition of HCAP does not appear to be a prognostic for death. In addition, the use of broad-spectrum antibiotics for HCAP should be reassessed because S. pneumoniae was most frequently identified even in HCAP patients.

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Staphylococcus aureus (SA) remains a major cause of nosocomial and community-acquired infections worldwide. Nasal carriage of this bacterium among hospital personnel constitutes an important source for nosocomial infections. A cross-sectional study enrolling the whole medical student population (n = 387) of the School of Medicine at the Universidad de Cartagena, Colombia, was conducted to evaluate the carriage rates of both methicillin sensitive-and methicillin resistant-SA, the frequency of Panton-Valentine leukocidin genes in the isolates, and risk factors associated with carriage in this selected population. After signing an informed consent, participants completed a survey related to possible risk factors for colonization, and nasal swabs were collected from anterior nares. Staphylococcus aureus strains isolated from carriers were subjected to DNA extraction and PCR assays to determine the presence of MecA and Panton-Valentine leukocidin genes. Typing of the staphylococcal chromosomal cassette was performed for methicillin resistant strains. Molecular analysis was performed for only one strain per carrier. Prevalence of carriage for methicillin sensitiveand methicillin resistant-SA was 25% and 1.6% respectively. Most of the methicillin resistant isolates carried the staphylococcal chromosomal cassette type IV and the genes for Panton-Valentine leukocidin. To determine carrier types among medical students, each participant was subjected to four additional swabs, each taken two weeks apart. 9.8% persistent carriers, 53.1% intermittent carriers, and 37.1% non-carriers of SA were found. There was no association between risk factors analyzed and carriage of the bacterium. The study was conducted from April to September 2009 and found a persistent carriage of methicillin resistant-SA strains bearing the genes for Panton-Valentine leukocidin among medical students, evidencing the potential contribution of this portion of healthcare personnel either to the spread or introduction of these strains into the healthcare environment.

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This was a cross-sectional study aimed to determine the prevalence of and to identify risk factors for Chlamydia trachomatis (CT) among human immunodeficiency virus (HIV)-infected women attending the acquired immunodeficiency syndrome (AIDS) clinic in the city of Manaus, Brazil, in 2009-2010. Participants answered a questionnaire containing demographic, epidemiological, and clinical data. A genital specimen was collected during examination to detect CT-DNA by hybrid capture, and blood samples were taken to determine CD4+T and HIV viral load. There were 329 women included in the study. Median age was 32 years (IQR = 27-38) and median schooling was nine years (IQR = 4-11). The prevalence of CT was 4.3% (95%CI: 2.1-6.5). Logistic regression analysis showed that age between 18-29 years [OR = 4.1(95%CI: 1.2-13.4)] and complaint of pelvic pain [OR = 3.7 (95%CI: 1.2-12.8)] were independently associated with CT. The use of condom was inversely associated with CT [OR = 0.39 (95%CI: 0.1-0.9)]. The results showed that younger women who did not use condoms are at a higher risk for CT. Screening for sexually transmitted infections must be done routinely and safe sexual practices should be promoted among this population.

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OBJECTIVES: The objective of this cross-sectional study was to determine seroprevalence of hepatitis B surface antigen and related risk factors among new recruits in a military unit in Turkey. METHODS: Eight thousand five hundred eighty-nine newly-recruited soldiers were enrolled in the study. Blood samples were drawn from them between January 2006 and December 2006 and ELISA technique was applied to the samples. In addition, questions on the risk factors of hepatitis B exposure were asked to the participants in the survey. RESULTS: The results demonstrated that HBsAg seroprevalence was 2.8%. Further survey results indicated that seropositivity increased depending on certain risk factors. In multiple regression analysis, significant correlations were determined between HBsAg positivity and certain risk factors such as living in the Southeast Anatolia region (p < 0.01), having a history of living with a hepatitis B carrier (p < 0.001), and presence of a hepatitis B carrier in the neighborhood or at work (p < 0.05). CONCLUSIONS: The HBsAg seropositivity found in this study supports the fact that Turkey remains in the medium endemicity zone, and that horizontal transmission is predominant.

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Hematopoietic progenitor cells from peripheral blood (HPCPB) are commonly used for autologous and allogenic transplants in patients with most various onco-hematological diseases, and despite the utilization of sterile techniques during collection and processing of these products, bacterial contamination can occur. This study aimed to investigate the microbial contamination of HPCPB products. Microbial cultures of 837 HPCPB products between the year 2000 and 2009 were retrospectively analyzed to determine the incidence of culture positivity and identify the main organisms that cause contamination. The microbiological studies were performed with an automated system (BacT/Alert® bioMérieux Corporate). Thirty-six (4.3%) of 837 microbial cultures were contaminated. Coagulase-negative Staphylococcus was the most frequent bacteria isolated from HPCPB products (20 [56%] of the 36 positive microbial cultures). Considering the 36 contaminated samples, 22 HPCPB products were infused and 14 discarded. Pre-and post-infusion antibiotic therapy of the patients transfused with contaminated products was established based on the isolated microorganism and its antibiogram. Microbial contamination rate of HPCPB products was low. Clinically significant outcomes after infusion of contaminated HPCPB products were not observed.

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INTRODUCTION: The aim of this study was to determine risk factors for acquiring carbapenemresistant Pseudomonas aeruginosa bacteremia (CR-PA) and factors associated with in-hospital mortality. METHODS: Seventy-seven cases of bacteremia caused by P. aeruginosa were evaluated in a hospital with high incidence of CR-PA. Clinical and laboratorial factors, and previous use of antibiotics were also evaluated. In one analysis, CR-PA and carbapenem-susceptible P. aeruginosa (CS-PA) bacteremia were compared. A second analysis compared patients who died with survivors. RESULTS: Among 77 P. aeruginosa bacteremia, 29 were caused by CR-PA. Admission to the intensive care unit, higher number of total leukocytes, and previous use of carbapenem were statistically associated with CR-PA. In the multivariate analysis, only previous use of carbapenem (including ertapenem) turned out to be a risk factor for CR-PA (p = 0.014). The 30-day mortality of patients with P. aeruginosa bloodstream infection was 44.8% for CS-PA and 54.2% for patients with CR-PA (p = 0.288). Chronic renal failure, admission to the intensive care unit, mechanical ventilation, and central venous catheter were risk factors for mortality. Incorrect treatment increased mortality of patients with bacteremia caused by CS-PA, but not for CR-SA. The odd ratio of mortality associated with incorrect therapy in patients with CS-PA was 3.30 (1.01-10.82; p = 0.043). The mortality of patients with bacteremia caused by CR-PA was unexpectedly similar regardless of antimicrobial treatment adequacy. CONCLUSION: Appropriate treatment for CS-PA bacteremia initiated within the first 24 hours was associated with lower mortality, but this cannot be extrapolated for CR-PA.

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INTRODUCTION: Variations in human T cell lymphotropic virus type 1 (HTLV-1) proviral load (PVL) in infected individuals over time are not well understood. Objective: To evaluate the evolution of proviral load in asymptomatic individuals and HAM/TSP patients in order to help determine periodicity for measuring proviral load. METHODS: A group of 104 HTLV-1 infected patients, followed at the HTLV reference center in Salvador, Brazil, were included in the study (70 asymptomatic and 34 HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) patients). HTLV-1 PVL was measured using real-time polymerase chain reaction (PCR) at baseline and again at another point, either < 12 months, between 12-24 months, or > 24 months. RESULTS: HAM/TSP patients had higher PVL (ranging from 11,041 to 317,009 copies/10(6) PBMC) when compared to asymptomatic individuals (ranging from 0 to 68,228 copies/10(6) PBMC). No statistically significant differences were observed in the medians of PVL in HAM/TSP patients or asymptomatic individuals over time. However, in asymptomatic individuals with a PVL below 50,000 copies/10(6) PBMC, a statistically significant two-fold increase was observed over time. CONCLUSION: HTLV-1-PVL remained stable in both asymptomatic individuals and HAM/TSP patients over time. Frequent monitoring of asymptomatic individuals with low PVLs is recommended and further studies should be conducted to assess the course of PVL in these patients over extended periods of time.

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BACKGROUND: Usual treatment regimens with vancomycin often fail to provide adequate serum levels in patients with severe infections. METHODS: Retrospective analysis of vancomycin trough serum measurements. The following parameters were calculated by Bayesian analysis: vancomycin clearance, distribution volume, and peak estimated concentrations. The area under the concentration curve (AUC) (total daily dose/24 h clearance of vancomycin) was used to determine the effectiveness of treatment through the ratio of AUC/minimum inhibitory concentration (MIC) above 400, using MIC = 1 µg/mL, based on isolates of Staphylococci in cultures. RESULTS: Sixty-one vancomycin trough measurements were analyzed in 31 patients. AUC/MIC > 400 was obtained in 34 out of 61 dosages (55.7%), but the mean vancomycin dose required to achieve these levels was 81 mg/kg/day. In cases where the usual doses were administered (40-60 mg/kg/day), AUC/MIC > 400 was obtained in nine out of 18 dosages (50%), in 13 patients. Trough serum concentrations above 15 mg/L presented a positive predictive value of 100% and a negative predictive value of 71% for AUC/MIC > 400. CONCLUSION: Higher than usual vancomycin doses may be required to treat staphylococcal infections in children with oncologic/hematologic diseases. Since the best known predictor of efficacy is the AUC/MIC ratio, serum trough concentrations must be analyzed in conjunction with MICs of prevalent Staphylococci and pharmacokinetic tools such as Bayesian analysis.

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The results of several new clinical trials that compared the effectiveness of entecavir (ETV) treatment with that of adefovir (ADV) treatment in patients with chronic hepatitis B (CHB) were published in recent years. However, the numbers of patients included in these clinical trials were too small to draw a clear conclusion as to whether ETV is more effective than ADV. Therefore, a new meta-analysis was needed to compare ETV with ADV for the treatment of CHB. A search of the Cochrane Central Register of Controlled Trials (CCTR), MEDLINE, the Science Citation Index, Embase, the China National Knowledge Infrastructure (CNKI), and the Wanfang Database for relevant studies published between 1966 and 2010 was performed. Trials comparing the use of ETV and ADV for the treatment of CHB were assessed. Of the 2,358 studies screened, 13 randomized controlled clinical trials comprising 1,230 patients (ETV therapy, 621; ADV therapy, 609) were analyzed. The serum hepatitis B virus (HBV) DNA clearance rate obtained in patients treated with ETV was significantly higher than that in patients treated with ADV at the 24th and 48th weeks of treatment (24 weeks: 59.6% vs. 31.8%, relative risk [RR], 1.82, 95% CI: 1.49-2.23; 48 weeks: 78.3% vs. 50.4%, RR, 1.61, 95% CI: 1.32-1.96). The serum HBeAg clearance rate, the HBeAg seroconversion rate, and the ALT normalization rate obtained for patients treated with ETV were also higher than the corresponding values for patients treated with ADV at the 48th week of treatment. The safety profiles were similar between patients treated with ETV and those treated with ADV. The evidence reviewed in this meta-analysis suggests that patients with hepatitis B have a greater likelihood of achieving a viral response and a biomedical response when treated with ETV than when treated with ADV.

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Human immunodeficiency virus (HIV)-associated neurological complications continue to occur despite the development in antiretroviral treatment. New forms of old opportunistic infections and increased prevalence of neurocognitive disorders are the challenges that infectious diseases specialists face in daily clinic. How to screen and treat these disorders are subject of debate and new studies are underway to answer these questions. This review focuses on a brief discussion about opportunistic infections still present in late diagnosed HIV-infected patients and describes new forms of HIV-related neurological complications.

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Treatment for chronic hepatitis B in Brazil are funded by the Ministry of Health and by the state Departments of Health. Clinical protocol and therapeutic guidelines approve the use of adefovir, entecavir, interferon-a, lamivudine, and tenofovir for the treatment of chronic hepatitis B. The aim of this study was to establish the profile of users of these drugs in the state of Paraná. A cross-sectional study was conducted with patients under treatment in Paraná in August 2011. The following data were obtained: gender, hepatitis B used drug, International Classification of Diseases, and regional health unit. The monthly cost of these drugs for the public health system was also calculated. 1,093 patients registered were found, 70% male, and 2.6% co-infected with the delta agent. Tenofovir was the drug most commonly used (355 users). The highest prevalence was found in the regional health units of Pato Branco, Cascavel, Foz do Iguaçú, Francisco Beltrão, Toledo, Londrina, and Maringá. The annual cost for the public health system in Paraná was U$1,066,867. Through this study it was possible to investigate the distribution and profile of users of drugs for the treatment of chronic hepatitis B in Paraná in August 2011.

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OBJECTIVE: To study the human migration inhibitory factor (MIF) level in tuberculosis (TB) patients, and the relationship between MIF-794CATT microsatellite polymorphism and susceptibility of TB in Southwest China. METHODS: TB patients (n = 151) and healthy unrelated controls (n = 149) were recruited for this study. Genomic DNA was extracted, and then amplified by polymerase chain reaction (PCR). MIF-794CATT5-8 microsatellite polymorphism was genotyped by DNA sequencing. MIF level was detected by ELISA. RESULTS: In the TB group, the repeat number of 7/7 and 7/8 (17.89%) was significantly higher than that of the control group (8.05%), and the serum MIF level was also much higher than that of the healthy controls (705.21 ± 67.98 vs. 355.31 ± 57.29 pg/mL, p < 0.01). CONCLUSION: The appearance of MIF-794CATT 7/7 and 7/8 is associated with susceptibility to TB, and may play an important role in the occurrence and development of TB in Southwest China.

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At the beginning of a new millennium, syphilis incidence has been increasing worldwide, occurring primarily among men who have sex with men (MSM). The clinical features of primary syphilis among MSM is described, a case-note review of the primary syphilis (PS) patients who attended the Institute of Skin and Venereal Diseases. The diagnosis was assessed based upon the clinical features and positive syphilis serology tests. Among 25 patients with early syphilis referred during 2010, PS was diagnosed in a total of 13 cases. In all patients, unprotected oral sex was the only possible route of transmission, and two out of 13 patients had HIV co-infection. Overall, 77% of men presented with atypical penile manifestation. The VDRL test was positive with low titers. The numerous atypical clinical presentations of PS emphasize the importance of continuing education of non-experienced physicians, especially in countries with lower reported incidence of syphilis.

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Members of the genus Myroides are aerobic Gram-negative bacteria that are common in environmental sources, but are not components of the normal human microflora. Myroides organisms behave as low-grade opportunistic pathogens, causing infections in severely immunocompromised patients and rarely, in immunocompetent hosts. A case of Myroides odoratimimus cellulitis following a pig bite in an immunocompetent child is presented, and the medical literature on Myroides spp. soft tissue infections is reviewed.

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Fluoroquinolone (FQ)-associated tendinopathy and myopathy are uncommon but well recognized complications of the use of this class of antibacterial agents. The case of a 63-year-old previously asymptomatic female patient who developed severe left shoulder tendinopathy after surreptitiously doubling the prescribed dose of levofloxacin for the treatment of community-acquired pneumonia is reported here. Surgical stabilization with suture anchors and subacromial decompression were needed.