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OBJECTIVE: To identify lipodystrophy in prepubertal HIV-infected children using anthropometric parameters and body composition assessment. METHODS: Cross-sectional study including 40 prepubertal HIV-infected children of both genders seen at the Care Center of the Division of Pediatric Infectious Diseases - Universidade Federal de São Paulo, São Paulo city, Brazil, was carried out from August to December 2008. Age, clinical and immunological status, prophylaxis, transmission and highly active antiretroviral therapy were recorded. Body mass index z-score and height-for-age z-score were calculated to characterize the nutritional status. Circumferences were measured with flexible tape and skinfolds were assessed by an adipometry. Fat mass and lean mass were determined by dual-energy X-ray absorptiometry. Presence of clinical signs of lipodystrophy was assessed by a trained clinician. Data were analyzed using SPSS 12.0 software. RESULTS: The mean age and standard deviation were 9.8 (1.2) years, 50% were girls and 82.5% children from B and C categories. Clinical lipodystrophy and dislypidemia were present in 27.5% and 70%, respectively. The trunk to arm ratio and the limb to trunk ratio had positive association with lipodystrophy. Patients with lipodystrophy had short stature, higher triglycerides values and lower HDL-cholesterol. CONCLUSION: The ratios obtained by skinfolds and dual-energy X-ray absorptiometry measurements can be considered as indicators of preclinical lipodystrophy. The cutoff points have not been determined yet; however, continuous assessment may be useful to identify early body composition changes.

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BACKGROUND AND AIMS: Vibrio vulnificus causes an infectious disease that has extremely poor convalescence and leads to necrotic fasciitis. In this study, we sought to define the characteristic epidemiology of V. vulnificus infection and clarify its diagnosis at the global level. METHODS: Over a period of 10 years, we investigated the appearance of symptoms, underlying conditions, treatment, and mortality in 12 patients (eight men, four women; >50 years old; average age, 66 years,) infected with V. vulnificus. RESULTS: The development of symptoms occurred primarily between June and September, a period during which seawater temperature rises and the prevalence of V. vulnificus increases. All patients had underlying diseases, and seven patients reported a history of consuming fresh fish and uncooked shellfish. The patients developed sepsis and fever with sharp pain in the limbs. Limb abnormalities were observed on visual examination. All patients underwent debridement; however, in the survival group, the involved limb was amputated early in 80% patients. The mortality rate was 58.3%. CONCLUSION: Recognition of the characteristic epidemiology and clinical features of this disease is important, and positive debridement should be performed on suspicion. When the illness reaches an advanced stage, however, amputation should be the immediate treatment of choice.

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The Tigecycline Evaluation and Surveillance Trial is a global surveillance study monitoring the efficacy of tigecycline and comparators against clinically important pathogens. Between 2004 and 2010, 3126 isolates of Staphylococcus aureus were collected from 66 centers in 13 countries in Latin America; of these, 1467 (46.9%) were resistant to methicillin. The main contributors of S. aureus isolates were Mexico (n = 846), Argentina (n = 740), and Colombia (n = 445). The methicillin-resistant S. aureus rate was greater than 50% in five countries, the highest reported in Puerto Rico (73.9%). Methicillin-resistant S. aureus rates across Latin America ranged from 40.1% to 50.6% over the study period. All S. aureus isolates were susceptible to linezolid and vancomycin, while 100% of methicillin-susceptible S. aureus isolates and 99.8% of methicillin-resistant S. aureus isolates were susceptible to tigecycline. Both methicillin-susceptible S. aureus and methicillin-resistant S. aureus were highly susceptible to minocycline (99.2% and 97.0%, respectively). Latin American methicillinsusceptible S. aureus were highly susceptible to levofloxacin (94.6%) while only 16.2% of methicillin-resistant S. aureus were levofloxacin-susceptible. This study shows that linezolid, vancomycin, and tigecycline are all highly active against S. aureus from Latin America, regardless of methicillin resistance.

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BACKGROUND: Sepsis is a systemic inflammation associated with infection caused by pathogenic micro-organisms with high mortality rates. OBJECTIVE: In this study, we investigated the protective effect of Propionibacterium acnes-killed against polymicrobial sepsis induced by cecal ligation and puncture. METHODS: The mice were treated by intramuscular route in 1, 3, 5, and 7 days before the cecal ligation and puncture induction. The control group animals received vehicle (saline solution 0.9%) and the animals of the treated group received the P. acnes-killed (0.4 mg/animal). After anesthesia, midline laparotomy was performed with exposure of cecum followed by ligature and one transverse perforation of the same, with a 18 G needle, for induction of lethal sepsis. After surgery, the cecum of the animals was replaced into the peritoneal cavity, and it was closed with a 4.0 nylon suture. The survival of animals subjected to lethal sepsis was evaluated after cecal ligation and puncture induction. Six hours after the induction of sepsis, neutrophil migration, the number of bacteria, TNF-α, MCP-1, IL-6, and IL-10 were performed in the peritoneal lavage. RESULTS: Prophylactic treatment with P. acnes-killed increased the survival of the animals, followed by a significant decrease in the TNF-α, IL-10, and MCP-1 levels, 6 h after cecal ligation and puncture. Furthermore, P. acnes-killed administration reduced the number of bacteria in the peritoneal cavity with increased migration of leukocytes, especially neutrophils. CONCLUSION: P. acnes-killed promoted increased survival rate of animals with sepsis, in part attributed to its immunomodulatory properties against pathogenic microorganisms, as well as better control of infection by reducing bacterial counts.

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Over the past several years, the epidemiological profile of dengue has been changing progressively and is currently characterized by an increase in the number of cases in children under 15 years of age. This study was aimed at comparing the clinical and laboratory features between adults and children with dengue; therefore, we performed a cross-sectional analysis of 5686 individuals with laboratory-confirmed dengue who sought treatment at a healthcare facility in Rio de Janeiro, Brazil from 2010 to 2011. A multivariate analysis indicated that myalgia (OR = 2.58; CI 95% = 2.08-3.18), retro-orbital pain (OR = 1.36; CI 95% = 1.15-1.62), nausea (OR = 1.92; CI 95% = 1.60-2.30), and arthralgia (OR = 3.64; CI 95% = 2.72-4.89) were the most frequent clinical symptoms in adults, whereas vomiting (OR = 0.52; CI 95% = 0.43-0.61) and skin rash (OR = 0.46; CI 95% = 0.25-0.85) were the most prevalent symptoms in children. Adults exhibited a higher hemoconcentration (OR = 3.04; CI 95% = 2.53-3.65), thrombocytopenia (OR = 2.17; CI 95% = 1.80-2.60), increased erythrocyte sedimentation rate (OR = 1.81; CI 95% = 1.53-2.14), and increased ALT (OR = 3.13; CI 95% = 2.44-4.02) than did children. In addition, adults exhibited a higher frequency of the severe forms of the disease (OR = 1.74; CI 95% = 1.12-2.72) and hospitalization (OR = 2.21; CI 95% = 1.59-3.06) relative to children. Based on these results, this study demonstrated significant differences in the clinical and laboratory presentations and disease severity between adults and children affected by dengue.

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In this study, Entamoeba histolytica had high prevalence and unusual presentation by affecting high proportion of infants under 1 year; severe clinical manifestations, and laboratory findings that were known to be usually encountered in invasive amebiasis as significant leukocytosis for age, neutrophilic leukocytosis for age, and positive C-reactive protein were found among more than 50% of admitted Saudi infants and children with E. histolytica infection in our locality. E. histolytica can be a re-emerging serious infection when it finds favorable environmental conditions and host factors which are mainly attributed to inadequate breastfeeding in this study. This may occur in any other area of the world with the same risk factors, so we must be ready to tackle it with effective and more powerful preventive measures.

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OBJECTIVES: To assess the virologic and immunological response of darunavir/ritonavir plus optimized background therapy in highly antiretroviral-experienced HIV-infected patients in Brazil. METHODS: Prospective cohort study carried out in a tertiary center in Sao Paulo, Brazil. Three-class antiretroviral-experienced patients with confirmed virologic failure began darunavir/ritonavir plus optimized background therapy (nucleoside/tide reverse transcriptase inhibitors ± raltegravir ± enfuvirtide ± maraviroc) after performing a genotypic resistance assay. Clinical evaluation and laboratory tests were collected at baseline and at weeks 12, 24, and 48. Multivariate analysis was performed to identify predictors of virologic response at 48 weeks. RESULTS: Ninety-two patients were included. The median of darunavir resistant mutation was 1 (range 0-6). The median genotypic sensitivity score in the optimized background therapy was 2 (interquartile range 1-2). At week 48, 83% (95% CI: 75-90%) had an HIV RNA level <50 copies/mL and the median CD4 cell count was 301 (interquartile range 224-445) cells/mm³. Baseline HIV RNA >100 000 copies/mL was inversely associated with virologic success at week 48 (HR: 0.22, 95% CI: 0.06-0.85, p = 0.028). CONCLUSIONS: Darunavir/ritonavir plus optimized background therapy was a highly effective salvage regimen under clinical routine conditions in a referral center in Brazil, which is similar to the reported in high-income countries.

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OBJECTIVES: This study aimed to analyze the pattern of surgical chemoprophylaxis, surgical site infection rate, and to check rationality of surgical chemoprophylaxis based on Kunin's criteria. MATERIALS AND METHODS: A prospective, observational study was performed on patients undergoing surgery, in a tertiary care teaching hospital. Data were collected in a pro-forma which included the patients' details, prescriptions from date of admission to discharge or any other outcome and operative notes. Surgical site infection as defined by Centre for Disease Control criteria was recorded. Rationality was assessed based on Kunin's criteria. RESULTS: Total 220 patients were enrolled over a period of one year. Mean hospital stay was 8.67 ± 5.17 days. A total of 2294 drugs were prescribed out of which 840 (36.61%) were antimicrobials. Mean duration for pre-operative intravenous antimicrobial therapy was 0.75 ± 0.45 day and for post-operative intravenous antimicrobial therapy was 3.33 ± 2.24 days while post-operative oral antimicrobial therapy was 4.58 ± 3.34 days. Third generation cephalosporins were prescribed most frequently 64.74% and 64.40% pre-operatively and post-operatively respectively. Antimicrobial prescribing was inappropriate in 52.28%. Total of 19 patients developed surgical site infection. Surgical site infection rate was significantly higher (13.04%) in patients receiving inappropriate chemoprophylaxis (p < 0.01). Surgical site infection adds 9.98 days of hospital stay (p < 0.0001) and 3.57 extra drugs (p < 0.0001) compared to group without surgical site infection. CONCLUSION: Inappropriate use of antimicrobials is highly prevalent in surgical chemoprophylaxis leading to higher surgical site infection rate. Adoption of international standard and formulation of locally feasible guidelines can help overcome this situation.

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The zoonotic potential to cause human and/or animal infections among multidrug-resistant extraintestinal pathogenic Escherichia coli from avian origin was investigated. Twenty-seven extraintestinal pathogenic E. coli isolates containing the increased survival gene (iss) were obtained from the livers of healthy and diseased poultry carcasses at two slaughterhouses in Salvador, northeastern Brazil. The antimicrobial resistance-susceptibility profiles were conducted with antibiotics of avian and/or human use by the standardized disc-diffusion method. Antimicrobial resistance was higher for levofloxacin (51.8%), amoxicillin/clavulanic acid (70.4%), ampicillin (81.5%), cefalotin (88.8%), tetracycline (100%) and streptomycin (100%). The minimum inhibitory concentrations above the resistance breakpoints of doxycycline, neomycin, oxytetracycline and enrofloxacin reached, respectively, 88.0%, 100%, 75% and 91.7% of the isolates. Strains with high and low antimicrobial resistance were i.p. administered to Swiss mice, and histopathological examination was carried out seven days after infection. Resistance to goat and human serum complement was also evaluated. The results show that Swiss mice challenged with strain 2B (resistant to 11 antimicrobials) provoked a severe degeneration of hepatocytes besides lymphocytic infiltration in the liver, whereas the spleen showed areas of degeneration of the white and red pulp. Conversely, the spleen and liver of mice challenged with strain 4A (resistant to two antimicrobials) were morphologically preserved. In addition, complement resistance to goat and human serum was high for strain 2B and low for strain 4A. Our data show that multidrug resistance and pathogenesis can be correlated in extraintestinal pathogenic E. coli strains obtained from apparently healthy poultry carcasses, increasing the risk for human public healthy.

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There are scanty data on the epidemiology of influenza and other respiratory viruses in South America and Brazil. The aim of this study was to summarize the data from the Brazilian surveillance system of influenza and other respiratory viruses and discuss the patterns of viral circulation. The system is based on detecting cases of influenza-like illness in sentinel sites and weekly collection of five nasopharyngeal secretions samples, which are processed in state public health laboratories for respiratory viruses by indirect immunofluorescence assay. Data from 2000 to 2010 were described over time, by region, gender, and age group, and an analysis of Spearman correlation was performed between monthly influenza detection and rainfall and temperature data in two state capitals with the highest number of positive samples, one from the northeast region (Maceió) and other from the southern region (Curitiba). There were 3,291,946 visits for influenza-like illness; of these, 37,120 had samples collected and 6421 tested positive: 1690 (26%) influenza A, 567 (9%) influenza B, 277 (4%) parainfluenza 1, 571 (9%) parainfluenza 2, 589 (9%) parainfluenza 3, 742 (12%) adenovirus, and 1985 (31%) respiratory syncytial virus. Overall, increased activity of respiratory syncytial virus was observed from March to June, preceding the peak of influenza activity, from May to August, but with regional differences. In Maceió, there was a weak correlation between temperature and influenza detection (ρ = 0.05), but a moderate positive correlation between rainfall and influenza detection (ρ = 0.36). In Curitiba, a high correlation was observed between the decrease in temperature and rainfall and the increase in influenza detection (ρ = -0.83 and -0.78 respectively). These data are important to guide public health control measures as the best time for influenza vaccination and use of antivirals.

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OBJECTIVES: Intravenous therapy is a complex procedure usually requiring the preparation of the medication in the clinical area before administration to the patient. Breaches in aseptic technique may result in microbial contaminations of vials which is a potential cause of different avoidable infections. We aimed to investigate the prevalence and pattern of microbial contamination of single- and multiple-dose vials in the largest pulmonary teaching hospital in Iran. METHODS: In a period of 2 months, opened single- and multiple-dose vials from different wards were sampled by a pharmacist. The name of the medication, ward, labeling of the vials, the date of opening, and storing temperature were recorded for each vial. Remained contents of each vial were cultured using appropriate bacterial and fungal growth media. RESULTS: Microbial contamination was identified in 11 of 205 (5.36%) of vials. The highest contamination rate was 14.28% for vials used in interventional bronchoscopy unit. The most frequent contaminated medication was insulin. Gram-positive bacteria (81.82%) were more significantly involved than gram-negative ones (9.09%) and fungi (9.09%), with the highest frequency for Staphylococcus epidermidis . CONCLUSIONS: Our data demonstrate that repeated use of vials especially if basic sterility measures are disobeyed can cause microbial contamination of administered products to the patients. Infection preventionists are responsible to train health care workers regarding aseptic techniques and apply guidelines for aseptic handling of intravenous solutions.

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Tuberculosis infection is a serious human health threat and the early 21st century has seen a remarkable increase in global tuberculosis activity. The pathogen responsible for tuberculosis is Mycobacterium tuberculosis, which adopts diverse strategies in order to survive in a variety of host lesions. These survival mechanisms make the pathogen resistant to currently available drugs, a major contributing factor in the failure to control the spread of tuberculosis. Multiple drugs are available for clinical use and several potential compounds are being screened, synthesized, or evaluated in preclinical or clinical studies. Lasting and effective achievements in the development of anti-tuberculosis drugs will depend largely on the proper understanding of the complex interactions between the pathogen and its human host. Ample evidence exists to explain the characteristics of tuberculosis. In this study, we highlighted the challenges for the development of novel drugs with potent bacteriostatic or bactericidal activity, which reduce the minimum time required to cure tuberculosis infection.

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OBJECTIVES: Describing rates of seroconversion and its associated factors in a series of Brazilian infants following the final dose of the vaccine at 6 months of age. METHODS: Peripheral blood samples were collected after the third dose of the vaccine for the detection of anti-hepatitis B surface antibodies among infants of 7-12 months of age. We measured the association between seroconversion and birthweight, gestational age, time since administration of the vaccine in the maternity hospital and whether or not testing for hepatitis B surface antigen had been performed during pregnancy. RESULTS: We examined 40 infants. The mean birthweight was 2787 g (standard deviation = 853 g) and mean gestational age was 37.5 (standard deviation = 3.08) weeks. The proportion that seroconverted was non-significantly higher in infants who weighed >2000 g at birth (96.7%) than in those with birthweights <2000 g (80%, p = 0.149). There was no difference between the infants who were born at <37 weeks of gestational age and those born at >37 weeks (p < 0.178) neither between seroconversion and the time of application of the first dose of the vaccine after delivery (p = 0.202). CONCLUSION: The proportion of infants who seroconverted was similar to that found in other Brazilian studies. There were no differences in the proportion seroconverting by age at first immunization.

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Burkholderia cenocepacia may cause serious infections in patients with cystic fibrosis, and this microorganism can be highly transmissible. Pulsed-field gel electrophoresis is widely used to study the dynamics of strain spread in cystic fibrosis patients. The aim of this work was to perform pulsed-field gel electrophoresis-based molecular typing of B. cenocepacia isolates to evaluate the epidemiology of this species at our hospital. A total of 28 isolates from 23 cystic fibrosis patients were analyzed. Initially, we compared isolates obtained from the same patient at different periods of time. We then compared the pulsed-field gel electrophoresis profiles of 15 IIIA isolates, and in a third analysis, evaluated the genetic profile of 8 IIIB isolates from different patients. The pulsed-field gel electrophoresis profiles of isolates from the same patient indicated that they are genetically indistinguishable. Analysis of isolates from different patients revealed the presence of multiple clonal groups. These results do not indicate cross-transmission of a unique clone of B. cenocepacia among cystic fibrosis patients, although this has been observed in some patients. Our findings highlight the importance of adequate patient follow-up at cystic fibrosis centers and adherence to management and segregation measures in cystic fibrosis patients colonized with B. cenocepacia.

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Empyema is a severe complication of different diseases and traumas. Management of this complication is difficult and should comprise general and local procedures. The general procedure is mainly based on administering wide-spectrum antibiotics. Local management depends on patient general condition, but in all cases the essential procedure is to insert a drain into the pleural cavity and to evacuate the pus. Sometimes pus is very thick and its evacuation and following re-expansion of the lung is rather impossible. In these patients surgical intervention is needed. The use of intrapleural enzymes to support the drainage was first described in 1949 by Tillett and Sherry using a mixture of streptokinase and streptococcal deoxyribonuclease. Nowadays, purified streptokinase has come into widespread use, but recent studies reported no streptokinase effect on pus viscosity. On the other side, deoxyribonuclease reduces pus viscosity and may be more useful in treatment. We report two cases of intrapleural administration of Pulmozyme (alfa dornase - deoxyribonuclease (HOFFMANN-LA ROCHE AG) in dosage 2 × 2.5 mg with a significant improvement caused by changes in pus viscosity.

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Rabies is a fatal disease resulting from rabies virus infection, causing severe neurological symptoms and ultimately death by destroying the nervous system. In general, a patient tends to see a neurologist or an infectious diseases physician, with very common and typical discipline-related signs and symptoms, such as hydrophobia, aerophobia, and mental disorders. However, we reported a rabies patient who was first admitted to see a thoracic surgeon with spontaneous pneumomediastinum.

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Human parvovirus B19 is a well-known cause of severe conditions in patients with sickle cell disease, but the molecular mechanisms of the infection are insufficiently understood. The different clinical outcome of the acute parvovirus B19 infection in two pediatric patients with sickle cell disease has been examined. One of them developed life-threatening condition requiring emergency transfusions, while the other had asymptomatic infection, diagnosed occasionally. Both cases had high viral load and identical subgenotype, indicating that the viral molecular characteristics play a minimal role in the infection outcome.

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Posaconazole Histoplasmosis Salvage therapy African histoplasmosis is a granulomatous mycosis caused by Histoplasma capsulatum var. duboisii. Treatment is usually extrapolated from guidelines for classical histoplasmosis, and includes 2-4 weeks of amphotericin B followed by a step-down maintenance therapy with itraconazole. Pediatric usage of posaconazole, an oral second-generation azole, remains off-label, but recent surveys show that it is safe and well tolerated in children. We report a case of disseminated African histoplasmosis in a 12-year-old boy from Guinea-Bissau. Therapy with amphotericin B and itraconazole led to a progressive clinical deterioration. A dramatic and lasting improvement was observed using posaconazole. He completed 12 months of therapy. No relapse was noted during or 3 months after treatment. We report that posaconazole may be a safe and efficacious drug in the salvage management of disseminated AH, either in patients with disease refractory to conventional anti-fungal therapy, or in patients whose serious adverse effects of first-line drugs preclude its use.