Scielo RSS <![CDATA[Brazilian Journal of Infectious Diseases]]> http://www.scielo.br/rss.php?pid=1413-867020150003&lang=es vol. 19 num. 3 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[Salmonella Alachua: causative agent of a foodborne disease outbreak]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300233&lng=es&nrm=iso&tlng=es Objectives: The aim of this study is to report the occurrence of the first outbreak of food poisoning caused by Salmonella Alachua in Brazil, as well as the antimicrobial susceptibility and the genetic relatedness of Salmonella Alachua strains isolated from clinical and food samples. Material and methods: To elucidate the outbreak, an epidemiological investigation was carried out, and two samples of common food were tested - mayonnaise salad and galinhada (a traditional Brazilian dish of chicken and rice) - according to the Compendium of methods for the microbiological examination of foods. Five stool samples were tested employing classic methods for the isolation and identification of enterobacteria. Strains of Salmonella were characterized for antibiotic susceptibility according to the Clinical and Laboratory Stan- dards Institute guidelines (2013), and submitted to pulsed-field gel electrophoresis analysis, performed according to the Centers for Disease Control and Prevention PulseNet protocol. Results: A total of 94 people were interviewed after ingesting the food, 66 of whom had become ill. A 60-year old female patient who was hospitalized in a serious condition, developed septic shock and died two days after consuming the food. The presence of Salmonella Alachua was confirmed in all the analyzed stool samples, and in the two types of food. The five strains showed higher than minimum inhibitory concentration values of nalidixic acid (≥256 µg/mL) and reduced ciprofloxacin susceptibility (minimum inhibitory concentration = 0.5 µg/mL). The pulsed-field gel electrophoresis analysis revealed indistinguishable patterns in Salmonella Alachua strains isolated from clinical and food samples. Conclusion: The data presented herein confirm the foodborne disease outbreak. They also allowed for the identification of the source of infection, and suggest that products from poultry are potential reservoirs for this serotype, reinforcing the importance of warning consumers about the danger of possible contamination. <![CDATA[Enterobacteriaceae resistant to third generation cephalosporins upon hospital admission: risk factors and clinical outcomes]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300239&lng=es&nrm=iso&tlng=es Objectives: Evaluate risk factors and clinical outcomes of infections caused by Enterobacteriaceae resistant to third-generation cephalosporins present in samples collected upon hospital admission. Methods: Risk factors were evaluated using a 1:2 ratio case-control study. Influence of resistance on the appropriateness of antibiotic therapy, length of stay, and hospital mortality were prospectively evaluated. Characteristics independently associated with the presence of resistant enterobacteria were assessed by logistic regression. Results: Enterobacteria resistant to third-generation cephalosporins were quite common (26.0%). Male gender (OR: 2.66; 95% CI, 1.17-5.06; p = 0.019), invasive prosthesis (OR: 3.79; 95% CI, 1.29-11.08; p = 0.015), previous use of cephalosporins (OR: 2.77; 95% CI, 1.10-6.97; p = 0.029) and hospitalization in the last 6 months (OR: 5.33; 95% CI, 2.29-12.44; p &lt; 0.001) were independently associated with the presence of these microorganisms. These bacteria were associated with higher frequency of inappropriate antimicrobial therapy, worse clinical response, and longer length of stay. Finally, older age, admission to the ICU, and site of infection other than urinary tract were independently associated to higher hospital mortality. Conclusions: Risk factors identified in this study may help in the choice of empirical antibiotic therapy for infected patients suspected of harboring these bacteria and in the early implementation of measures to avoid the spread of these bacteria in the hospital environment. <![CDATA[Effects of a bundled Antimicrobial Stewardship Program on mortality: a cohort study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300246&lng=es&nrm=iso&tlng=es Objectives: To assess a bundled Antimicrobial Stewardship Program and its effect on mortality. Data: Eight months of clinical electronic medical records and Antimicrobial Stewardship Program registries were used as source of data. Method: This is a historical cohort study conducted in a Brazilian University Hospital. Eligible patients were admitted to general wards or intensive care units and had an antimicrobial therapy prescribed and assessed by different strategies: Bundled Antimicrobial Stewardship Program (bundled intervention consisted of clinical pharmacist chart review, discussion with microbiologist and infectious disease physicians, local education and continuous follow-up) or Conventional Antimicrobial Stewardship Program (clinical pharmacist chart review and discussion with infectious disease physician). Primary outcome from this study was 30-day mortality, which was compared between groups, by using Kaplan-Meier survival curve and log-rank test. Other outcomes included Defined Daily Doses per 1000 patient-days and occurrence of resistant bacteria. Results: From 533 patients, 491 were eligible for the study, of which 191 patients were included to Antimicrobial Stewardship Program and 300 to Conventional strategy. In general, they were likely to be male and age was similar in groups (58.9 vs 55.5 years, p = 0.38). Likewise, Charlson Comorbidity Index was not statistically different between groups (2.6 vs 2.7, p = 0.2). Bloodstream site infections were frequently diagnosed in both groups (30.89% vs 26%, p = 0.24). Other less common sites of infections were central nervous system and lungs. The ASP group had higher survival rates (p &lt; 0.01) and the risk difference was 10.8% (95% CI: 2.41-19.14). There were less Defined Daily Doses per 1000 patient-days (417 vs 557.2, p &lt; 0.05) and higher rates of resistant bacteria identified in the ASP group (83% vs 17%). Conclusion: Bundled ASP was the most effective strategy, with reduced mortality and Defined Daily Doses per 1000 patient-days. <![CDATA[Evaluation of late presentation for HIV treatment in a reference center in Belo Horizonte, Southeastern Brazil, from 2008 to 2010]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300253&lng=es&nrm=iso&tlng=es Introduction: Since 1996 Brazil has provided universal access to free antiretroviral therapy, and as a consequence, HIV/AIDS patients' survival rate has improved dramatically. However, according to scientific reports, a significant number of patients are still late presenting for HIV treatment, which leads to consequences both for the individual and society. Clinical and immunological characteristics of HIV patients newly diagnosed were accessed and factors associated with late presentation for treatment were evaluated. Methods: A cross-sectional study was carried out in an HIV/AIDS reference center in Belo Horizonte, Minas Gerais, in Southeastern Brazil from 2008 to 2010. Operationally, patients with late presentation (LP) for treatment were those whose first CD4 cell count was less than 350 cells/mm3 or presented an AIDS defining opportunistic infection. Patients with late presentation with advanced disease (LPAD) were those whose first CD4 cell count was less than 200 cells/mm3 or presented an AIDS defining opportunistic infection. LP and LPAD associated risk factors were evaluated using logistic regression methods. Results: Five hundred and twenty patients were included in the analysis. The median CD4 cell count was 336 cells/mm3 (IQR: 130-531). Two hundred and seventy-nine patients (53.7%) were classified as LP and 193 (37.1%) as LPAD. On average, 75% of the patients presented with a viral load (VL) &gt;10,000 copies/ml. In multivariate logistic regression analysis the factors associated with LP and LPAD were age, being symptomatic at first visit and VL. Race was a factor associated with LP but not with LPAD. Conclusion: The proportion of patients who were late attending a clinic for HIV treatment is still high, and effective strategies to improve early HIV detection with a special focus on the vulnerable population are urgently needed. <![CDATA[Relationship between viral load and behavioral measures of adherence to antiretroviral therapy in children living with human immunodeficiency virus in Latin America]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300263&lng=es&nrm=iso&tlng=es Few studies have examined antiretroviral therapy adherence in Latin American children. Standardized behavioral measures were applied to a large cohort of human immunodeficiency virus-infected children in Brazil, Mexico, and Peru to assess adherence to prescribed antiretroviral therapy doses during the three days prior to study visits, assess timing of last missed dose, and evaluate the ability of the adherence measures to predict viral suppression. Time trends in adherence were modeled using a generalized estimating equations approach to account for possible correlations in outcomes measured repeatedly in the same participants. Associations of adherence with human immunodeficiency virus viral load were examined using linear regression. Mean enrollment age of the 380 participants was 5 years; 57.6% had undetectable' viral load (&lt;400 copies/mL). At enrollment, 90.8% of participants were perfectly (100%) adherent, compared to 87.6% at the 6-month and 92.0% at the 12-month visit; the proportion with perfect adherence did not differ over time (p = 0.1). Perfect adherence was associated with a higher probability of undetectable viral load at the 12-month visit (odds ratio = 4.1, 95% confidence interval: 1.8-9.1; p &lt; 0.001), but not at enrollment or the 6-month visit (p &gt; 0.3). Last time missed any antiretroviral therapy dose was reported as "never" for 52.0% at enrollment, increasing to 60.7% and 65.9% at the 6- and 12-month visits, respectively (p &lt; 0.001 for test of trend). The proportion with undetectable viral load was higher among those who never missed a dose at enrollment and the 12-month visit (p ≤ 0.005), but not at the 6-month visit (p = 0.2). While antiretroviral therapy adherence measures utilized in this study showed some association with viral load for these Latin American children, they may not be adequate for reliably identifying non-adherence and consequently children at risk for viral resistance. Other strategies are needed to improve the evaluation of adherence in this population. <![CDATA[Quality of antenatal care as a risk factor for early onset neonatal infections in Rio de Janeiro, Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300272&lng=es&nrm=iso&tlng=es Background: Neonatal infection is a serious public health problem. The aim of this study was to assess the influence of the antenatal care on the risk of early-onset neonatal healthcare associated infection in two Brazilian maternities. Methods: Cohort study - Newborns admitted at two public neonatal intensive care units from 2008 to 2009 were included in the study. Data on antenatal and perinatal variables were collected from maternal prenatal cards and medical charts. Newborns were actively surveyed for early-onset neonatal healthcare associated infection, defined as a neonatal infection diagnosed within 48 h after birth. Multiple logistic regression was used to assess variables independently associated with early-onset neonatal healthcare associated infection. Results: 561 neonate-mother pairs were included in the study. Early-onset neonatal health-care associated infection was diagnosed in 283 neonates (51%), an incidence rate of 43.5/1000 live births. Neonates whose mothers had less then six antenatal visits were under risk significantly higher for early-onset neonatal healthcare associated infection (OR = 1.69, 95% CI = 1.11-2.57), after adjusting for birth weight, membranes ruptured for &gt;18 h, maternal complications during delivery, maternal infection at admission, and hospital where patients received care. Conclusions: The risk of neonatal early-onset neonatal healthcare associated infection was significantly associated with insufficient number of antenatal care visits. Further studies assessing the quality of antenatal care and targeting its improvement are warranted. <![CDATA[Detection of E. coli O157:H7 and Shigella dysenteriae toxins in clinical samples by PCR-ELISA]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300278&lng=es&nrm=iso&tlng=es Shiga toxin producing bacteria are potential causes of serious human disease such as hemorrhagic colitis, severe inflammations of ileocolonic regions of gastrointestinal tract, thrombocytopenia, septicemia, malignant disorders in urinary ducts, hemolytic uremic syndrome (HUS) Shiga toxin 1 (stx1), shiga toxin 2 (stx2), or a combination of both are responsible for most clinical symptoms of these diseases. A lot of methods have been developed so far to detect shiga toxins such as cell culture, ELISA, and RFPLA, but due to high costs and labor time in addition to low sensitivity, they have not received much attention. In this study, PCR-ELISA method was used to detect genes encoding shiga toxins 1 and 2 (stx1 and stx2). To detect stx1 and stx2 genes, two primer pairs were designed for Multiplex-PCR then PCR-ELISA. PCR products (490 and 275, respectively) were subsequently verified by sequencing. Sensitivity and specificity of PCR-ELISA method were determined by using genome serial dilution and Enterobacteria strains. PCR-ELISA method used in this study proved to be a rapid and precise approach to detect different types of shiga toxins and can be used to detect bacterial genes encoding shiga toxins. <![CDATA[Prevalence of hepatitis B and C virus infections among military personnel]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300285&lng=es&nrm=iso&tlng=es Background: Data regarding Hepatitis B and C viruses (HBV and HCV) prevalence among military personnel in Brazil are lacking, but the work-related risk of exposure can be high. The objective of this study was to estimate the seroprevalence of HBV and HCV and the risk factors associated to HBV exposure among Brazilian military personnel. Methods: A cross-sectional study was conducted and included 433 male military adults aged 18-25 years old working in Rio de Janeiro during October 2013. All individuals completed a questionnaire to assess their risk of exposure and provided a blood sample to HBV and HCV testing. Results: None of the participants presented HBsAg or anti-HBc IgM, 18 (4.1%) were positive for total anti-HBc, 247 (57.0%) were positive for anti-HBs, and 3 (0.7%) were anti-HCV reactive. The majority of military personnel with past HBV infection (anti-HBc reactive) and HBV immunity (anti-HBs reactive) had a history of prior dental procedures (88.9% and 77.3%), consumption of alcohol at least once a week (50% and 55.9%), and practiced oral sex (61.1% and 58.3%, respectively). In addition, anti-HBc positivity was common among individuals with a history of surgery (44.4%) and practice of anal sex (50%). At univariate analysis, age group was associated to anti-HBc and anti-HBs positivity. Conclusions: Low rates of HBV and HCV infection were observed among Brazilian military personnel in comparison to the general Brazilian population. HBV immunity rates were relatively low indicating the need for vaccination campaigns in this group. <![CDATA[Microarray-based genotyping and detection of drug-resistant HBV mutations from 620 Chinese patients with chronic HBV infection]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300291&lng=es&nrm=iso&tlng=es Background: Research has shown that hepatitis B virus (HBV) genotypes are closely linked to the clinical manifestations, treatment, and prognosis of the disease. Objective: To study the association between genotype and drug-resistant HBV mutations in 620 Chinese patients with chronic HBV infection. Methods: HBV DNA levels were determined using real-time quantitative PCR in plasma samples. Microarrays were performed for the simultaneous detection of HBV genotypes (HBV/B, C, and D) and drug-resistance-related hotspot mutations. A portion of the samples analyzed using microarrays was selected randomly and the data were confirmed using direct DNA sequencing. Results: Most samples were genotype C (471/620; 76.0%), followed by genotype B (149/620; 24.0%). Among the 620 patient samples, 17 (2.7%) had nucleotide analogs (NA) resistance-related mutations. Of these, nine and eight patients carried lamivudine (LAM)-/telbivudine (LdT)-resistance mutations (rtL180M, rtM204I/V) and adefovir (ADV)-resistance mutations (rtA181T/V, rtN236T), respectively. No patients had both lamivudine (LAM)- and either ade-fovir (ADV) or entecavir (ETV) resistance mutations. Additionally, out of the 620 patient samples, 64.0% (397/620) were also detected with the precore stop-codon mutation (G1896A) by microarray assay. Conclusion: The results of the current study revealed that the prevalence of nucleotide analogs (NA)-resistance in Chinese hospitalized HBV-positive patients was so low that intensive nucleotide analogs (NA)-resistance testing before nucleotide analog (NA) treatment might not be required. In addition, the present study suggests that chronic HBV patients with genotype C were infected with fitter viruses and had an increased prevalence of nucleotide analogs (NA)-resistance mutations compared to genotype B virus. <![CDATA[Tuberculosis contact tracing among children and adolescent referred to children's hospital in Rio de Janeiro, Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300296&lng=es&nrm=iso&tlng=es Objective: To describe the investigation of latent tuberculosis infection and indication for isoniazid preventive therapy in children and adolescents evaluated at the children's hospital. Methods: This retrospective study examines all latent tuberculosis infection subjects with indication for isoniazid preventive therapy attended during 2002-2009 at the pulmonology outpatient clinic from children's hospital in Rio de Janeiro, Brazil. The subjects were classified into three groups by origin: (G1) primary and secondary health units; (G2) children's hospital-pulmonology outpatient clinic; and (G3) children's hospital-specialty outpatient clinics. The association between the variables examined and G1 was analyzed using uni- variate analysis. Results: Of the 286 latent tuberculosis infection cases included 169 (59.1%) were from G1, 56 (19.6%) from G2, and 61 (21.3%) from G3. Latent tuberculosis infection diagnosis without isoniazid preventive therapy prescription was present in 142 (49.6%) cases before arrival at the pulmonology outpatient clinic: 135 (95.1%) from G1, three (2.1%) from G2, and four (2.8%) from G3. Variables associated with G1 were presence of isoniazid preventive therapy criteria before attending the pulmonology outpatient clinic (OR: 62.3; 26.6-146.2), negative HIV infection status (OR: 9.44; 1.16-76.3); contact with pulmonary tuberculosis (OR: 5.57; 1.99-15.5), and residing in Rio de Janeiro city (OR: 1.89; 1.04-3.44). Conclusion: Strategies that increase latent tuberculosis infection identification and isoniazid preventive therapy prescription in primary and secondary health units are urgently needed. <![CDATA[Field validation of a Leishmania (Leishmania) mexicana exo-antigens ELISA for diagnosing tegumentary leishmaniasis in regions of Leishmania (Viannia) predominance]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300302&lng=es&nrm=iso&tlng=es Background: Several tests are performed to obtain better accuracy when diagnosing American tegumentary leishmaniasis (ATL). It is believed that antigens released via secretion, excretion and metabolism are more specific than are antigens released by the lysis of Leishmania parasites. Such antigens are known as exo-antigens (exo-Ag) and are formed from products released by cultured parasites in a way that is similar to that in which they cause infections in hosts. Objective: We attempted to validate a Leishmania mexicana ELISA exo-Ag for ATL diagnosis in Midwestern Brazil. Methods: A total of 281 patients were included in the study. We analysed pre-treatment blood from 98 ATL patients; out of those, 85.7% and 14.3% had cutaneous and mucosal forms, respectively. Results: The exo-Ag accuracy was 83.99% (95% CI = 79.24-87.81) with a sensitivity value of 90.82% (95% CI = 83.46-95.09) and an overall specificity value of 80.33% (95% CI = 73.97-85.44). The positive predictive value and negative predictive value were 71.20% (95% CI = 62.72-78.41) and 94.23% (95% CI = 89.40-96.94), respectively. Among healthy controls, exo-Ag had a specificity of 91.25% (95% CI = 83.02-95.70); additionally, the test had specificity rates of 66.67% (95% CI = 46.71-82.03) in Chagas disease patients, 60.61% (95% CI = 43.68-75.32) in patients with rheumatic diseases, 76.92% (95% CI = 49.74-91.82) in pemphigus foliaceus patients, 87.50% (95% CI = 52.91-97.76) in leprosy patients, 87.50% (95% CI = 63.98-96.50) in VRDL-positive patients, and 77.78 (95% CI = 45.26-93.68) in deep mycosis patients. Conclusion: Based on the indicators of validity, we conclude that the results obtained in this study enable the recommendation of the exo-Ag ELISA for ATL diagnosis once it presented a reasonable accuracy compared to classical methods. Cost evaluations are necessary to completely define the role of this technique in large scale. <![CDATA[Ebola hemorrhagic fever outbreaks: strategies for effective epidemic management, containment and control]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300308&lng=es&nrm=iso&tlng=es Ebola hemorrhagic fever, caused by the highly virulent RNA virus of the filoviridae family, has become one of the world's most feared pathogens. The virus induces acute fever and death, often associated with hemorrhagic symptoms in up to 90% of infected patients. The known sub-types of the virus are Zaire, Sudan, Taï Forest, Bundibugyo and Reston Ebola viruses. In the past, outbreaks were limited to the East and Central African tropical belt with the exception of Ebola Reston outbreaks that occurred in animal facilities in the Philippines, USA and Italy. The on-going outbreak in West Africa that is causing numerous deaths and severe socio-economic challenges has resulted in widespread anxiety globally. This panic may be attributed to the intense media interest, the rapid spread of the virus to other countries like United States and Spain, and moreover, to the absence of an approved treatment or vaccine. Informed by this widespread fear and anxiety, we analyzed the commonly used strategies to manage and control Ebola outbreaks and proposed new approaches that could improve epidemic management and control during future outbreaks. We based our recommendations on epidemic management practices employed during recent outbreaks in East, Central and West Africa, and synthesis of peer-reviewed publications as well as published "field" information from individuals and organizations recently involved in the management of Ebola epidemics. The current epidemic management approaches are largely "reactive", with containment efforts aimed at halting spread of existing outbreaks. We recommend that for better outcomes, in addition to "reactive" interventions, "pre-emptive" strategies also need to be instituted. We conclude that emphasizing both "reactive" and "pre-emptive" strategies is more likely to lead to better epidemic preparedness and response at individual, community, institutional, and government levels, resulting in timely containment of future Ebola outbreaks. <![CDATA[HAM/TSP and major depression: the role of age]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300314&lng=es&nrm=iso&tlng=es Objective: To investigate the role of demographic variables in the relationship between the presence of HAM/TSP and current major depression. Methods: It is a cross-sectional study of 108 HTLV-1 infected patients (47 with TSP/HAM) resident of Salvador, Brazil. The Mini International Neuropsychiatric Interview, Brazilian Version 5 was used to evaluate the presence of depression. Prevalence ratios were used to describe relationship between HAM/TSP and depression. The HAM/TSP classification was carried out according to the criteria proposed by Castro-Costa et al. Results: Prevalence of depression was 37.96%. No association was observed between presence of HAM/TSP and diagnosis of current major depression in the global analysis of patients (PR: 0.94; CI 95%: 0.57-1.55). In the stratified analysis, however, greater prevalence of depres- sion was observed amongst individuals with HAM/TSP in the 18-39 age group (PR: 2.59; CI 95%: 1.36-4.95). Conclusion: Our findings suggest that age is an effect modifier in the relationship between HAM/TSP and depression, and this aspect should be considered in future studies on the topic. <![CDATA[Bacterial sensitivity to fosfomycin in pregnant women with urinary infection]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300319&lng=es&nrm=iso&tlng=es The aim this study was to determine the in vitro susceptibility to fosfomycin of bacteria isolated from urine samples of pregnant women with urinary tract infection. Samples of urine culture with bacterial growth of pregnant women were collected from clinical laboratories in Tubarão, state of Santa Catarina, Brazil, between September 2012 and May 2013. In the experimental stage, the colonies were tested for sensitivity to fosfomycin by using the Kirby-Bauer method. The following information relating to the samples was also collected: patients' age, colony count, type(s) of identified bacterial(s) and result of the antimicrobial sensitivity test. Student's t-test was used for mean comparison. A total of 134 samples were selected for the study. The age of the subjects ranged from 15 to 40 years (mean 26.7). Escherichia coli (Gram-negative) and Staphylococcus aureus (Gram-positive) were the most commonly identified species. In 89% of cases, the microorganisms were sensitive to fosfomycin. E. coli and S. aureus were the main species of bacteria responsible for urinary tract infections in women in the study area. The most prevalent microorganisms in pregnant women with urinary tract infection were susceptible to fosfomycin. <![CDATA[KPC-producing Enterobacter aerogenes infection]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300324&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed. <![CDATA[Total abdominal aortic occlusion: a complication of brucellosis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300328&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed. <![CDATA[No blood culture examinations during off-hours?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300330&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed. <![CDATA[Factors associated with vaccination against hepatitis B in adolescents and young adults from an urban settlement]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300332&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed. <![CDATA[Changing the face of fever of unknown origin in Egypt: a single hospital study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300334&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed. <![CDATA[Pleuritis caused by Acremonium strictum in a patient with metastatic testicular teratocarcinoma]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-86702015000300336&lng=es&nrm=iso&tlng=es Background: Enterobacter is a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear. Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenes infections, detailing the site of infection, therapy, clinical and epidemiological data. Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05. Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p = 0.004) and Charlson score of comorbidities (p = 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age &gt;43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score &gt;3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy. Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceae infection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed.