Abstract in English:

This study describes vancomycin prescribing patterns in an average complexity hospital and compare the guidelines proposed by the Hospital Infection Control Practices Advisory Committee (HICPAC). The study was conducted in a 256-bed secondary-care hospital. Data were collected of all patients given vancomycin from March 2003 to February 2004, using a standardized chart-extraction form designed. Appropriate and inappropriate use was reviewed according to the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines on prudent vancomycin use. Out of 118 prescriptions, 95 (80.5%) were considered appropriate. Out of these 95 orders, 77 (81.1%) were administered for empiric treatment of suspected Gram-positive infections, 17 (17.9%) were administered for treatment of proven Gram-positive infections (76.5% identified as Staphyloccocus aureus-like agents) and 1 (1.0%) for beta-lactam allergy. The majority of the patients (96.6%) had recently used an antimicrobial medication (3 months). The mean pre-treatment hospitalization period was 11±10 days. Out of the 118 treatments, 67 (56.8%) were for nosocomial infections. The more frequent indications for vancomycin use were pneumonia (48.3%) and primary sepsis (18.6%), accounting for more than 66% of all treatments. No restriction policy was suggested because vancomycin use was considered adequate in the majority of the treatment cases. The broad empiric use of this antimicrobial was greater than expected in the institution and its use should be revised.

Abstract in English:

One hundred and fifty-one methicillin-resistant z (MRSA) strains have been isolated from patients admitted in tertiary care hospitals in two metropolitan areas (Campinas City and Ribeirão Preto City) in the southeast region of Brazil and analyzed through PCR-based techniques [(PCR amplification of spa, coa, and housekeeping genes (arcC, aroE, gmk, pta, tpi, yqiL)] and further restriction fragment typing of coa and of housekeeping genes. The heterogeneity of spa gene was determined directly by agarose gel electrophoresis migration. The results obtained indicate the existence of three (A, B, C) main clusters. Since the strain distribution in these three clusters is much characteristic, it denotes the existence of three main clones. All strains isolated in Campinas were grouped in clusters A and B, while most of the strains isolated in Ribeirão Preto were grouped in cluster C. This distribution denotes the existence of different founder strains that undergo independent genetic variability. The strains considered representative of the Brazilian Epidemic Clone (BEC) were categorized as cluster A. These results indicate a possible higher variability among Brazilian MRSA strains than currently described and indicate that the techniques herein used can be used as an alternative to Pulsed Field Gel Electrophoresis (PFGE).

Abstract in English:

This study determined the prevalence of metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa in two hospitals located in the Southern part of Brazil and compare the performance of two different phenotypic tests. Thirty-one non-repetitive Pseudomonas aeruginosa isolates from various clinical samples from patients admitted to two hospitals located in Rio Grande do Sul, Brazil (twenty-three from a hospital in Porto Alegre City and eight isolates from a hospital in Vale dos Sinos Region). All strains suggestive of possessing MBLs by phenotypic methods were included in this study. Phenotypic detection of MBLs was carried out simultaneously by using both the MBL Etest® and disk approximation test using 2-mercaptopropionic acid close to a ceftazidime disk. Strains positive were further confirmed using molecular techniques for blaVIM, blaIMP and blaSPM-1. The prevalence of MBLs from samplesof inpatients from the hospital located in Porto Alegre was 30.4% and that of inpatients from Vale dos Sinos hospital was only 3.1%. Only MBL type SPM-1 was detected in these samples by molecular analysis and all were detected by the Etest® MBL strips. The prevalence of P. aeruginosa that produce MBLs can be markedly different in distinct geographical areas, even among different hospitals in the same area. In our study, the EDTA-based method was the only method able to detect all strains harboring the SPM-1 enzyme.

Abstract in English:

Oropharyngeal carriage of Pseudomonas aeruginosa is associated with increased risk of infection and may provide a source for spread of drug-resistant strains. In order to assess the incidence and risk factors of oropharyngeal carriage, we conducted a retrospective cohort study based on results of surveillance cultures (oropharyngeal swabs) from a medical-surgical intensive care unit, collected from March 2005 through May 2006. Variables investigated included demographic characteristics, comorbid conditions, invasive procedures, use of devices and use of antimicrobials. Thirty case patients with P. aeruginosa carriage were identified. Other 84 patients with surveillance cultures negative to P. aeruginosa were enrolled as control subjects. Case patients were more likely to have a solid malignancy (Odds Ratio [OR] = 12.04, 95% Confidence Interval [CI] = 1.93-75.09, p=0.008), Acquired Immunodeficiency Syndrome (AIDS, OR = 7.09, 95% CI= 1.11-45.39, p = 0.04), central nervous system disease (OR = 4.51, 95% CI = 1.52-13.39, p = 0.007), or to have a central venous catheter placed (OR = 7.76, 95% CI = 1.68-35.79, p=0.009). The use of quinolones was a protective factor (OR = 0.13, 95% CI = 0.03-0.47, p = 0.002). The predominance of comorbidities as risk factors points out a group of patients to whom preventive measures should be directed.

Abstract in English:

Staphylococcus aureus and coagulase-negative staphylococci are the main cause of sepsis in Neonatal Intensive Care Unit (NICU). Central venous catheters (CVCs) are an important part of critical neonates' treatment and are associated with sepsis. The aim of this study was to investigate two outbreaks caused by Staphylococcus aureus and Staphylococcus epidermidis associated with CVC inserted by phlebotomy in critical neonates. The surveillance was performed from January 2001 to December 2005 at the Brazilian NICU. The genotypic analysis of oxacillin susceptible S. aureus (OSSA) and oxacillin resistant S. epidermidis (ORSE) was performed based on pulsed-field gel electrophoresis (PFGE). Staphylococcus was the most frequent pathogen (65.8%) with highest incidence of CoNS (59.9%) followed by S. aureus (40.1%). During the five years of surveillance, there were two outbreaks detected, occurred in January-February/02 and August/02 and confirmed by PFGE analysis. The predisposing factors for infection corresponding to both outbreaks were: age <7 days, hospitalization > 7 days, and use of polyethylene CVC through dissection of vein (phlebotomy). This is the first relate of staphylococcal outbreaks associated with CVC inserted by phlebotomy in NICU. PFGE showed polyclonal spread of OSSA during both epidemic and endemic period, and two monoclonal outbreaks of ORSE in the same epidemic period of OSSA.

Abstract in English:

Lack of information on antiretroviral drugs or the misunderstanding of available information can facilitate incorrect use of such drugs. This can result in non-adherence to the prescribed regimen, leading to a great possibility of a therapeutic failure. The aim of this study was to know which information HIV/AIDS patients, who receive their medicines at the pharmacy of a reference hospital in the northeast Brazil, have on the drugs they use, the source of this information and whether there is a need for additional information. A total of 195 HIV/AIDS patients, who were using either zidovudina + lamivudina 300+150mg (AZT+3TC), efavirenz 600mg (EFZ) or lopinavir/ritonavir 133.33/33mg (LPV/r), were interviewed. The mean age was 41 years (SD = 9.55) and 70.8% were males. Of the total, 55.4% didn't know the effect of the drug in the organism; 35.9% were unaware of the necessity of taking antiretroviral drugs for the rest of their lives; only 14.4% knew how to proceed when a dosage was missed; 22.1% said they could die and the same number of individuals believed in aggravation of the disease in case of treatment interruption. The majority, 68.2%, considered it very necessary to receive drug information. The results show that there is an apparent lack of general information among users of antiretroviral drugs, and at the same time a need for it. It is necessary that all professionals involved in the health care of the patients agree that an efficient supply of information on prescribed drugs is an ethical component of the treatment that favors and fosters its adherence.

Abstract in English:

The treatment of chronic hepatitis C (CHC) with peginterferon alpha-2b/ribavirin (PegIFN + Rib) produced larger sustained viral response (SVR) compared to the conventional (non-pegylated) interferon/ribavirin (IFN + Rib), but its cost-effectiveness was not assessed in Brazil. We developed a Markov model to mirror the natural disease history and cohorts of patients with hepatitis C virus (HCV), that received PegIFN + Rib or IFN + Rib treatment for 48 or 24 weeks, according to viral genotype and liver histology. The SVRs for the treatments PegIFN + Rib and IFN + Rib were respectively 48% and 34% (genotype 1), and 88% and 80% (genotype non-1). Three Delphi panels were conducted with hepatologists and intensivists, and another one with oncologists. The costs are expressed in 2006 Brazilian Reais (R$) and the benefits were discounted at 3%. In genotype 1 HCV patients, PegIFN + Rib increases the life expectancy (LE) in 0.51 year, and the quality-adjusted life years (QALY) in 0.78, as compared to IFN + Rib. In genotype non-1 HCV patients, PegIFN + Rib increases the LE in 0.29 years and the QALY in 0.44 years, as compared to IFN + Rib. The incremental cost-effectiveness rate, considering all the genotypes, was of R$19,848.34 per QALY. Peginterferon alpha-2b with ribavirin is a cost-effective therapy for the treatment of naïve CHC adult patients compared to the interferon alpha-2b and ribavirin regime, irrespective of the viral genotype.

Abstract in English:

Human herpesvirus 8 (HHV-8), the etiological agent of Kaposi's sarcoma (KS), is endemic in parts of the sub-Saharan, and KS has increased concomitantly with the HIV/AIDS epidemic. In Mozambique (MZ), no data concerning HHV-8 infection was available, thus the main of this work was to investigate, for the first time, the presence of HHV-8 infection in Maputo, MZ. Latent and lytic HHV-8-specific antibodies were assessed in blood samples from 189 individuals from the Central Hospital of Maputo, MZ, using "in-house" immunofluorescence assays conducted in São Paulo, Brazil. The results obtained were analyzed according to socio-demographic and clinical variables using the Chi-square test and logistic regression. An HHV-8 seropositivity of 1.8% and 9.7% was detected among 57 medical students and 31 individuals from the staff, respectively, in contrast to 16.4% detected among 67 out-patients. Concerning 34 hospitalized patients from the Dermatology Unit, 47.1% were HHV-8-seropositive overall, while the rate was 85.7% among KS patients. The present survey, conducted in Maputo, MZ, demonstrates great variation in HHV-8 infection frequencies depending on the group analyzed and epidemiological variables. An association between HHV-8 seropositivity and male gender (OR 5.72), the central origin of patients (OR 5.33), blood transfusions (OR 3.25), and KS (OR 24.0) was detected among hospitalized patients, and primary school (OR 7.18) and HIV-1 infection (OR 8.76) among out-patients.

Abstract in English:

Cervical cancer is the most frequent malignant tumour of women in Latin America being human papillomavirus (HPV) the main cause. The aim of this study was to increase the knowledge about the cervical infections with oncogenic HPV types (HR-HPV) in Asuncion, Paraguay. Two hundred and seventy-two cervical samples were analyzed using hybrid capture II assay (HCA II) for HR-HPV. The frequency of HR-HPV in the study group was 44%. HR-HPV was detected in 25% of the women negative for squamous intraepithelial lesions (NSIL), 72% with atypical squamous cells of undetermined significance (ASCUS), 68% with low SIL and 78% with high SIL. A moderate concordance was observed between HCA II assay and cytology (kappa: 0.43 IC95% 0.3 - 0.5). It was detected a high frequency of HR-HPV in women from 11 to 30 years old and in those over 60 years old. The data obtained in this study showed a high frequency of HR-HPV in woman with NSIL and ASCUS, which corroborate that the use of cytology together with HCA II assay for HR-HPV could improve remarkably the efficiency of screening programs of cervical cancer in Paraguay. Furthermore, these findings point out the need for the periodical follow-up of HR-HPV infections in older women.

Abstract in English:

Despite the prevalence of syphilis worldwide, little is known about its manifestations when associated with other Sexually Transmitted Infections (STI), specifically the Human Papilloma Virus (HPV). Current epidemiological studies show that there is a high incidence of both diseases in ambulatory clinics all over Brazil. This study aims to estimate the incidence of syphilis - HPV co-infections, among patients from the STI ambulatory clinic at the Santa Casa da Misericórdia Hospital, Rio de Janeiro, Brazil. Two-hundred and seven patients were seen in the clinic between March and December 2005, of which 113 (54.6%) sought care for an HPV infection. Blood samples were taken from all patients to check syphilis serology using the flocculation and the non-treponemic test or VDRL (Venereal Disease Research Laboratory) and the TPHA (Treponema Pallidum Hemagglutination Assay) treponemic and confirmatory method. Of the 207 patients, 113 (54.6%) consulted referring to HPV as their primary complaint, and of these, 18 (15.9%) also presented with positive syphilis serology, demonstrating a high incidence of coinfection. The average age of the patients varied between 20 and 25 years, 203 (98.1%) were male and 4 (1.9%) were female. The predominance of the male sex in this sample confirms the profile usually treated in STI clinics across the country, and the age range is that of typically high sexually activity. Conclusion: The results demonstrated the need for a differentiated examination of all STD patients.

Abstract in English:

Intestinal barrier function and serum concentrations of rifampin, isoniazid and pyrazinamide were studied in healthy controls and patients with active pulmonary tuberculosis. A case-control study of 29 controls and 30 cases attending at the Health Center, July, 2004 to December, 2005 was conducted. The body mass index was significantly reduced in cases compared to controls (p < 0.001). The intestinal paracellular transport of lactulose was significantly (p = 0.019) reduced in cases compared to controls. The transcellular transport of mannitol and the lactulose:mannitol ratio were not significantly (p = 0.0698) reduced in cases compared to controls. Low serum concentrations of rifampin, isoniazid and pyrazinamide were observed in 81% (48/59), 92% (54/59) and 28% (12/59), respectively, in all individuals. The results demonstrated a marked decrease on intestinal paracellular transport in patients with active pulmonary tuberculosis and reduced serum concentrations of rifampin and isoniazid in both groups.

Abstract in English:

A study was conducted in São Paulo, Brazil, to compare azithromycin with thiamphenicol for the single-dose treatment of chancroid. In all, 54 men with chancroid were tested. The etiology was determined by clinical characterization and direct bacterioscopy with Gram staining. None of the patients had positive serology or dark-field examination indicating active infection with Treponema pallidum. Genital infections due to Neisseria gonorrhoeae and herpes simplex virus were excluded by polymerase chain reaction testing. For 54 patients with chancroid, cure rates with single-dose treatment were 73% with azithromycin and 89% with thiamphenicol. HIV seropositivity was found to be associated with treatment failure (p=0.001). The treatment failed in all HIV positive patients treated with azithromycin (p=0.002) and this drug should be avoided in these co-infected patients. In the view of the authors, thiamphenicol is the most indicated single-dose regimen for chancroid treatment.

Abstract in English:

This study defined the normal variation range for different subsets of T-lymphocyte cells count in two different Brazilian regions. We analysed the T-lymphocytes subpopulations (CD3+, CD4+, CD8+) in blood donors of two Brazilian cities, located in North (Belem, capital state of Para, indian background) and Northeast (Salvador, capital state od Bahia, African background) regions of Brazil. Results were compared according to gender, stress level (sleep time lower than 8 hours/day), smoking, and alcohol intake. Lymphocytes subpopulations were measured by flow cytometry. Five hundred twenty-six blood donors from two Brazilians cities participated in the study: 450 samples from Bahia and 76 samples from Pará. Most (60%) were men, 59% reported alcohol intake, 12% were smokers, and 80% slept at least 8 h/day. Donors from Bahia presented with significantly higher counts for all parameters, compared with Para. Women had higher lymphocytes levels, in both states, but only CD4+ cells count was significantly higher than men's values. Smokers had higher CD4+ counts, but sleep time had effect on lymphocytes levels only for Para's donors (higher CD3+ and CD4+ counts). That state had also, a higher proportion of donors reporting sleep time <8 h/day. The values for CD3, CD4 and CD8+ cells count were significantly higher in blood donors from Bahia than among those from Pará. Female gender, alcohol intake, stress level, and smoking were associated with higher lymphocyte counts. The use of a single reference range for normal lymphocytes count is not appropriate for a country with such diversity, like Brazil is.

Abstract in English:

Several pathogenic or opportunistic bacteria have the ability to either induce or inhibit host cell apoptosis. The capacity to modulate cell pathways that result in the induction or delay of host cell apoptosis is considered to be an important bacterial virulence mechanism. These processes could be mediated by different host cell signaling pathways that are subverted by the bacteria. Pathogens are able to activate apoptotic proteins, such as caspases, or inactivate anti-apoptotic proteins, such as NFkB and the MAPKKs, or even up-regulate the endogenous receptor/ligand system that induces apoptosis, generally when the bacteria are bound to the host cell surface. The bacteria-induced apoptotic or anti-apoptotic processes are often related with the fact that the bacteria acquire the ability to reach the host tissues. However, apoptosis is also considered to be a host defense mechanism against infectious agents. Thus, the apoptosis phenomenon plays a central role in host-pathogen interactions.

Abstract in English:

The recognition of sessile form of bacteria with particular features, known as biofilm, has given new insights to the understanding of pathogenesis of several chronic diseases, including Chronic Rhinosinusitis (CRS). In this article we review the main characteristics of biofilms, describe the current methods used to demonstrate biofilms in chronic rhinosinusitis and discuss the future directions of research in the field.

Abstract in English:

A fatal case of primary amoebic encephalitis (PAM) in a 20 year old boy, a proven case of acute leukemic leukemia (ALL) type L2, in remission is described. No history of swimming could be elicited. The clinical presentation, the isolation of the amoeba from the cerebrospinal fluid (CSF), the poor response to amphotericin B, and the ultimately fatal outcome are all consistent with the diagnosis of PAM. On the basis of its ability to grow at temperature 42ºC and 45ºC, morphology of trophozoite, and the presence of flagellate forms in CSF, the amoeba was identified as Naegleria fowleri. Other drugs used in combination with amphotericin B are tetracycline, rifampicin, and miconazole. A possibility of PAM should always be considered in all cases of acute purulent meningoencephalitis in which no bacteria or fungus are found.

Abstract in English:

A patient with mantle cell non-Hodgkin's lymphoma presented herself with fever, nausea, right upper quadrant pain on the 7th day of R-CHOP chemotherapy. After hospitalization with the suspicion of acute cholecystitis, she received antibiotherapy with G-CSF because of emerging neutropenia at the 10th day of chemotherapy. Abdominal computed tomography revealed small infarcts in the spleen and kidneys. The echymotic lesion which developed on her right lateral malleolus, became bullous in the following days and treated as ecthyma gangrenosum. Altough the patient was afebrile with a normal neutrophil count on the third day of antibiotherapy, she developed acute renal failure and deteriorated rapidly. The patient underwent hemodialysis but expired on the 10th day of hospitalization. Post mortem autopsy findings showed ischemic infarction and necrosis of parenchyma due to mycotic thrombosis of arteries and veins of many organs (heart, lung, diaphgram, kidneys, spleen, gut mucosa) as well as invasion of vessel walls and parenchyma by mucor. We reviewed mucormycosis in the light of this case.

Abstract in English:

Clinical cases involving paracoccidioidomycosis in children, diagnosed in Mato Grosso State, in the central western region of Brazil, are rare despite the state being classified with a moderate to high incidence. We describe a clinical case of infant acute disseminated Paracoccidioidomycosis in Mato Grosso State, Brazil, highlighting the importance of early differential diagnosis from other severe pathologies, thus contributing to the survival of compromised patients. A 3 year-old male child, weighing 12.8 Kg, originating from Vila Rica, MT, Brazil. The patient presented intermittent 40ºC fever evolving over 40 days, dry cough and painless bilateral cervical adenomegaly, showing no signs of inflammation. This was associated with diarrhea, distension and important abdominal pain and weight loss. Diagnosis was achieved by visualization of Paracoccidioides brasiliensis yeasts in a direct mycological exam and posterior fungus isolation in culture medium. The patient evolved presenting good clinical response to antifungal treatment and progressive reduction of abdominal and cervical ganglions. To improve the prognosis of compromised patients it is essential that professionals realize a full clinical-laboratorial evaluation, including differential diagnoses for other severe pathologies, as early as possible. The degree and intensity of paracoccidioidomycosis compromise are determining factors for defining the most efficient treatment.

Abstract in English:

A 41 year old man presented to the outpatient department with a three month history of difficulty in walking. He also had a history of positive sensory symptoms in the form of pins and needle sensation mostly below the waist. His symptoms had been progressive and there was no significant family history. He demonstrated a spastic gait and could only walk with assistance and support. DTR were hypertonic and sensory deficit was observed below twelfth dorsal vertebra. Sphincter abnormalities were present. Plantars were extensor bilaterally. Cerebral and spinal MRI with contrast was unremarkable. Brucella antigen titers were significantly high. CSF report was consistent with neurobrucellosis. After detailed analysis of his history, clinical picture and investigations the diagnosis of neurobrucellosis was made. Combined antimicrobial therapy was started, his neurologic condition gradually improved and he was able to walk without help after three months of treatment. Hence this case showed that neurobrucellosis may present as acquired progressive spastic paraparesis and it should always be borne in mind in patients with spastic paraparesis.