Resumo em Inglês:

AIMS: To determine the appropriateness of the acute otitis media antibiotic treatment prescribed in the community in relation to the therapeutic guidelines. METHODS: Children aged 3 months-3 years diagnosed with simple uncomplicated acute otitis media in 6 community primary care clinics were enrolled. Data on the antibiotic treatment were collected using computerized medical files. RESULTS: 689 simple uncomplicated acute otitis media patients were enrolled; 597 (86.9%) were treated with antibiotics by 38 family medicine practitioners, 12 pediatricians and 7 general practitioners. 461 (77.2%) patients were <2 years of age. Amoxicillin was administered to 540 (90.5%) patients, with no differences between the various medical specialties. 127/540 (23.5%) patients did not receive the appropriate dosage; 140/413 (33.9%) patients treated with appropriate dosage did not receive the treatment for the appropriate duration of time. 258/357 (72.3%) evaluable patients <2 years of age received an antibiotic considered inappropriate to guidelines (38 not treated with amoxicillin, 94 received inappropriate dosage and 126 not treated for 10 days); 53/100 (53%) evaluable children >2 years of age received an inappropriate antibiotic treatment. CONCLUSIONS: The majority of primary care physicians treat simple uncomplicated acute otitis media with the recommended antibiotic drug. However, incorrect dosage and shorter than recommended duration of therapy may jeopardize the quality of care in children with simple uncomplicated acute otitis media.

Resumo em Inglês:

BACKGROUND: Local epidemiological data are always helpful when choosing the best antibiotic regimen, but it is more complex than it seems as it may require the analysis of multiple combinations. The aim of this study was to demonstrate a simplified mathematical calculation to determine the most appropriate antibiotic combination in a scenario where monotherapy is doomed to failure. METHODS: The susceptibility pattern of 11 antibiotics from 216 positive blood cultures from January 2012 to January 2013 was analyzed based on local policy. The length of hospitalization before bacteremia and the unit (ward or intensive care unit) were the analyzed variables. Bacteremia was classified as early, intermediate or late. The antibiotics were combined according to the combination model presented herein. RESULTS: A total of 55 possible mathematical associations were found combining 2 by 2, 165 associations with 3 by 3 and 330 combinations with 4 by 4. In the intensive care unit, monotherapy never reached 80% of susceptibility. In the ward, only carbapenems covered more than 90% of early bacteremia. Only three drugs combined reached a susceptibility rate higher than 90% anywhere in the hospital. Several regimens using four drugs combined reached 100% of susceptibility. CONCLUSIONS: Association of three drugs is necessary for adequate coverage of empirical treatment of bacteremia in both the intensive care unit and the ward.

Resumo em Inglês:

This study describes the characteristics of 31 children with congenital toxoplasmosis children admitted to the University Hospital of Londrina, Southern Brazil, from 2000 to 2010. In total, 23 (85.2%) of the mothers received prenatal care but only four (13.0%) were treated for toxoplasmosis. Birth weight was <2500 g in 37.9% of the infants. During the first month of life, physical examination was normal in 34.5%, and for those with clinical signs and symptoms, the main manifestations were hepatomegaly and/or splenomegaly (62.1%), jaundice (13.8%), and microcephaly (6.9%). During ophthalmic examination, 74.2% of the children exhibited injuries, 58.1% chorioretinitis, 32.3% strabismus, 19.4% microphthalmia, and 16.2% vitreitis. Anti-Toxoplasma gondii IgM antibodies were detected in 48.3% of the children. Imaging brain evaluation was normal in 44.8%; brain calcifications, hydrocephaly, or both conditions were observed in 27.6%, 10.3%, and 17.2%, respectively, of the patients. Patients with cerebrospinal fluid protein > 200 mg/dL presented more brain calcifications (p = 0.0325). Other sequelae were visual impairment (55.2% of the cases), developmental delay (31.0%), motor deficit (13.8%), convulsion (27.5%), and attention deficit (10.3%). All patients were treated with sulfadiazine, pyrimethamine, and folinic acid, and 55.2% of them exhibited adverse effects. The results demonstrate the significance of the early diagnosis and treatment of toxoplasmosis during pregnancy to reduce congenital toxoplasmosis and its consequences.

Resumo em Inglês:

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) infection remains an important cause of new HIV infections worldwide, especially in low and middle-resource limited countries. Safety data from studies involving pregnant women and prenatal antiretroviral (ARV) exposure are still needed once these studies are often small and with a limited duration to assess adverse drug reactions (ADR). The aim of this study was to estimate the incidence of ADR related to the use of antiretroviral therapy (ART) in pregnant women in two referral centers in Rio de Janeiro State. A prospective study was carried out from February 2005 to May 2006. Women were classified according to their ART status during pregnancy diagnosis: ARV-experienced (ARTexp) or ARV-naïve (ARTn). Two hundred fourteen HIV-infected pregnant women were included: 36 ARTexp and 178 ARTn. ARTexp women have not experienced ADR. Among ARTn, 20.2% presented ADR. Incidence rate of ADR was 70.8 per 1000 person-months and the most common ADRs observed were: gastrointestinal (belly or abdominal cramps, diarrhea, nausea and vomit) in 16.3%, cutaneous (pruritus and rash) in 6.2%, anemia (2.2%) and hepatitis (1.7%). The frequency of obstetrical complications, pre-term delivery, low birth weight and birth abnormalities was low in this population. ADRs ranged from mild to moderate intensity, none of them being potentially fatal. Only in a few cases it was necessary to discontinue ART. In conclusion, the high effectiveness of ARV for HIV prevention of MTCT (PMTCT) overcomes the risk of ADR.

Resumo em Inglês:

OBJECTIVES: To analyze the behavior of meningococcal disease in the Federal District, Brazil, from 2005 to 2011, and to assess the direct impact of the meningococcal serogroup C conjugate vaccine. METHODS: A descriptive study of cases of meningococcal disease among residents of the Federal District. We included in the study confirmed cases of meningococcal disease reported to the local surveillance. To reduce underreporting we compared data to the Brazilian Mortality Database and the Public Health Laboratory Database. We studied sociodemographic, clinical, and pathogen-related variables. For the assessment of the impact of meningococcal serogroup C conjugate vaccine, which was introduced in 2010 for children under two years of age, we compared the incidence of meningococcal disease before and after vaccine introduction in the recommended age groups for vaccination. RESULTS: We identified 309 cases of meningococcal disease, of which 52.1% were males. The average case fatality rate was 20.7%, the median age was three years and there was a predominance of serogroup C (70.2%) and C:23:P1.14-6 phenotype throughout the study period. In 2005-2009, 2010 and 2011, the incidence rates of meningococcal disease were 2.0, 1.8 and 0.8/100,000 inhabitants/year, while mortality rates were 0.4, 0.4 and 0.2/100,000 inhabitants/year, respectively. In the first and last periods, the incidence in poorer and more affluent areas were, respectively, 2.0 and 0.8, and 0.9 and 0.0/100,000 inhabitants/year. Comparing 2009 (the year prior to the introduction of meningococcal serogroup C conjugate vaccine) and 2011, there was 85% reduction in the incidence of serogroup C meningococcal disease in children under four years of age, from 9.0 to 1.3/100,000 (p < 0.01). CONCLUSIONS: The meningococcal serogroup C conjugate vaccine strategy implemented in Brazil proved highly effective and had a strong direct impact on the target population. However, case fatality rates of meningococcal disease remain high with a wide gap in the risk of disease between poor and affluent areas, pointing to the need to reexamine the current strategy on a regular base.

Resumo em Inglês:

OBJECTIVE: To investigate the pathogenesis of bloodstream infection by Staphylococcus epidermidis, using the molecular epidemiology, in high-risk neonates. METHODS: We conducted a prospective study of a cohort of neonates with bloodstream infection using central venous catheters for more than 24 h. "National Healthcare Safety Network" surveillance was conducted. Genotyping was performed by DNA fingerprinting and mecA genes and icaAD were detected by multiplex-PCR. RESULTS: From April 2006 to April 2008, the incidence of bloodstream infection and central venous catheter-associated bloodstream infection was 15.1 and 13.0/1000 catheter days, respectively, with S. epidermidis accounting for 42.9% of episodes. Molecular analysis was used to document the similarity among six isolates of bloodstream infection by S. epidermidis from cases with positive blood and central venous catheter tip cultures. Fifty percent of neonates had bloodstream infection not identified as definite or probable central venous catheter-related bloodstream infection. Only one case was considered as definite central venous catheter-related bloodstream infection and was extraluminally acquired; the remaining were considered probable central venous catheter-related bloodstream infections, with one probable extraluminally and another probable intraluminally acquired bloodstream infection. Additionally, among mecA+ and icaAD+ samples, one clone (A) was predominant (80%). A polyclonal profile was found among sensitive samples that were not carriers of the icaAD gene. CONCLUSIONS: The majority of infections caused by S. epidermidis in neonates had an unknown origin, although 33.3% appeared to have been acquired intraluminally and extraluminally. We observed a polyclonal profile between sensitive samples and a prevalent clone (A) between resistant samples.

Resumo em Inglês:

The aim of present study was to describe the frequency of lipodystrophy syndrome associated with HIV (LSHIV) and factors associated with dyslipidemia in Brazilian HIV infected children. HIV infected children on antiretroviral treatment were evaluated (nutritional assessment, physical examination, and laboratory tests) in this cross-sectional study. Univariate analysis was performed using Mann-Whitney test or Fisher's exact test followed by logistic regression analysis. Presence of dyslipidemia (fasting cholesterol >200 mg/dl or triglycerides >130 mg/dl) was the dependent variable. 90 children were enrolled. The mean age was 10.6 years (3-16 years), and 52 (58%) were female. LSHIV was detected in 46 children (51%). Factors independently associated with dyslipidemia were: low intake of vegetables/fruits (OR = 3.47, 95%CI = 1.04-11.55), current use of lopinavir/ritonavir (OR = 2.91, 95%CI = 1.11-7.67). In conclusion, LSHIV was frequently observed; inadequate dietary intake of sugars and fats, as well as current use of lopinavir/ritonavir was associated with dyslipidemia.

Resumo em Inglês:

BACKGROUND: Healthcare Associated Infections constitute an important problem in Neonatal Units and invasive devices are frequently involved. However, studies on risk factors of newborns who undergo surgical procedures are scarce. OBJECTIVE: To identify risk factors for laboratory-confirmed bloodstream infection in neonates undergoing surgical procedures. METHODS: This case-control study was conducted from January 2008 to May 2011, in a referral center. Cases were of 21 newborns who underwent surgery and presented the first episode of laboratory-confirmed bloodstream infection. Control was 42 newborns who underwent surgical procedures without notification of laboratory-confirmed bloodstream infection in the study period. Information was obtained from the database of the Hospital Infection Control Committee Notification of infections and related clinical data of patients that routinely collected by trained professionals and follow the recommendations of Agência Nacional de Vigilância Sanitária and analyzed with Statistical Package for Social Sciences. RESULTS: During the study period, 1141 patients were admitted to Neonatal Unit and 582 Healthcare Associated Infections were reported (incidence-density of 25.75 Healthcare Associated Infections/patient-days). In the comparative analysis, a higher proportion of laboratory-confirmed bloodstream infection was observed in preterm infants undergoing surgery (p = 0.03) and use of non-invasive ventilation was a protective factor (p = 0.048). Statistically significant difference was also observed for mechanical ventilation duration (p = 0.004), duration of non-invasive ventilation (p = 0.04), and parenteral nutrition duration (p = 0.003). In multivariate analysis duration of parenteral nutrition remained significantly associated with laboratory-confirmed bloodstream infection (p = 0.041). CONCLUSIONS: Shortening time on parenteral nutrition whenever possible and preference for non-invasive ventilation in neonates undergoing surgery should be considered in the assistance of these patients, with the goal of reducing Healthcare Associated Infections, especially laboratory-confirmed bloodstream infection.

Resumo em Inglês:

Sexual behavior is a key factor for susceptibility to sexually transmitted diseases. An evaluation of the sexual behavior of women at reproductive age was conducted in 1999. A replication of this study aims to evaluate the current situation and identify changes in sexual behavior, 13 years later. This is a population-based cross-sectional study, conducted with 1071 women in Pelotas, Brazil. Compared to the 1999 study, a 14% increase in early sexual debut and an 8% decrease in the non-use of condoms were observed in 2012. The proportion of women who reported anal sex doubled between these periods. There was no trend of increase or decrease in the prevalence of behaviors with distinct patterns being observed for each of them. Reduction of non-use of condoms may be an indicator of the effectiveness of campaigns to promote safe sex. However, the increased prevalence of early sexual debut and anal sex indicates the need for campaigns to continue and to expand their focus, especially among vulnerable groups.

Resumo em Inglês:

To review the epidemiology of nosocomial extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America, a systematic search of the biomedical literature (PubMed) was performed for articles published since 2005. Rates of nosocomial infections caused by extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America have increased since 2005. Up to 32% of Escherichia coli and up to 58% of Klebsiella pneumoniae isolates are extended spectrum β-lactamase-positive, rates that are higher than in other world regions. From a region-wide perspective, 11-25% of E. coli isolates and 45-53% of K. pneumoniae isolates were nonsusceptible to third-generation cephalosporins. At the country level, there was a wide range in Enterobacteriaceae resistance rates to third-generation cephalosporins, with especially high rates of resistance to E. coli in Guatemala, Honduras, and Mexico, and high resistance rates to Klebsiella spp. in Argentina, Brazil, Chile, Guatemala, Honduras, and Paraguay. Susceptibility of extended spectrum β-lactamase-producing Enterobacteriaceae to cefepime, fluoroquinolones, ampicillin/sulbactam, aminoglycosides, and piperacillin/tazobactam has also been compromised, leaving the carbapenems, tigecycline, and colistin as the only antibiotics with >90% susceptibility rates. There is a steady increase in the prevalence and types of extended spectrum β-lactamases produced by Enterobacteriaceae isolates in Latin American hospitals (particularly CTX-Ms), suggesting endemic conditions overlaid by clonal outbreaks. Appropriate treatment decisions and infection control strategies informed by surveillance of regional and local susceptibilities and mechanisms of resistance are required to mitigate this major public health concern.

Resumo em Inglês:

Leishmaniasis is an infectious disease caused by protozoa of the genus Leishmania transmitted by insects of the genus Lutzomyia sp. or Phlebotomus sp. The main syndromes are cutaneous leishmaniasis, mucocutaneous leishmaniasis, visceral leishmaniasis (kala-azar) and post-kala-azar dermal leishmaniasis. This article reviews kidney involvement in cutaneous and visceral leishmaniasis, highlighting the aspects of their pathophysiology, clinical manifestations, histopathological findings, outcome and treatment.

Resumo em Inglês:

The aim of this study was to evaluate the use of RNA interference to inhibit herpes simplex virus type-1 replication in vitro. For herpes simplex virus type-1 gene silencing, three different small interfering RNAs (siRNAs) targeting the herpes simplex virus type-1 UL39 gene (sequence si-UL 39-1, si-UL 39-2, and si-UL 39-3) were used, which encode the large subunit of ribonucleotide reductase, an essential enzyme for DNA synthesis. Herpes simplex virus type-1 was isolated from saliva samples and mucocutaneous lesions from infected patients. All mucocutaneous lesions' samples were positive for herpes simplex virus type-1 by real-time PCR and by virus isolation; all herpes simplex virus type-1 from saliva samples were positive by real-time PCR and 50% were positive by virus isolation. The levels of herpes simplex virus type-1 DNA remaining after siRNA treatment were assessed by real-time PCR, whose results demonstrated that the effect of siRNAs on gene expression depends on siRNA concentration. The three siRNA sequences used were able to inhibit viral replication, assessed by real-time PCR and plaque assays and among them, the sequence si-UL 39-1 was the most effective. This sequence inhibited 99% of herpes simplex virus type-1 replication. The results demonstrate that silencing herpes simplex virus type-1 UL39 expression by siRNAs effectively inhibits herpes simplex virus type-1 replication, suggesting that siRNA based antiviral strategy may be a potential therapeutic alternative.

Resumo em Inglês:

The aim of the present study was to investigate the association between polymorphism in the interleukin-10 gene promoter at position -1082 in human immunodeficiency virus-infected patients who had presented allergic reaction due to efavirenz. The study included 63 patients treated at the Hospital São José de Doenças Infecciosas, Fortaleza, Ceará, Brazil. Twenty-one patients who had presented allergic reaction to efavirenz were compared to 42 patients with no allergic reaction following exposure to this drug. Blood samples were collected for DNA extraction and submitted to the restriction fragment length polymorphism - polymerase chain reaction technique. The -1082AA genotype was significantly more frequent in allergic patients as compared to non-allergic patients (p = 0.019; χ 2 = 5.534; OR = 3.625; 95% CI = 1.210-10.860). Likewise the allele IL-10 -1082A was identified significantly more often among efavirenz allergic patients than in the non-allergic group (p = 0.009; χ 2 = 6.787; OR = 3.029; 95% CI = 1.290-7.111). These findings suggest that the polymorphism in the interleukin-10 gene promoter -1082G/A can be related to the development of allergic reactions to efavirenz.

Resumo em Inglês:

The aims of this study were to compare the automated AxSYM avidity assay index with the BED capture enzyme immunoassay test and to calculate the HIV-1 incidence using the BED capture enzyme immunoassay and AxSYM avidity assay index algorithms within a population seeking the Voluntary Counselling and Testing Centres in two municipalities in the Metropolitan Region of Recife, Northeast of Brazil. An analysis was conducted in 365 samples that tested positive for HIV infection from frozen serum collected during the period 2006-2009. There was a similar proportion of males and females; most patients were heterosexual (86%) with a median age of 29 years. Of the 365 samples, 102 (28%) and 66 (18.1%) were identified as recent infections by BED capture enzyme immunoassay and AxSYM avidity assay index, respectively. The HIV-1 total incidence in the BED capture enzyme immunoassay and AxSYM avidity assay index algorithms were: 0.79 (95% CI: 0.60-0.98) and 0.34 (95% CI: -0.04 to 0.72), respectively. Incidence was higher among men. There was good agreement between the tests, with a kappa of 0.654 and a specificity of 95.8%. AxSYM avidity assay index may be helpful in improving the quality of the estimates of recent HIV infection and incidence, particularly when used in a combined algorithm with BED capture enzyme immunoassay.

Resumo em Inglês:

Approximately 170 million people are infected with hepatitis C, and the sustained virological response rate to treatment with pegylated interferon and ribavirin is 30-50%. In an attempt to improve the chances of cure, boceprevir is being added to therapy, but it is associated with an increased incidence of adverse events. We herein report a case of acute pancreatitis developed during treatment with pegylated interferon, ribavirin and boceprevir. Boceprevir was the most likely cause of drug-associated pancreatitis after the most common causes were ruled out, since this adverse event had not occurred when the patient had previously been exposed to pegylated interferon and ribavirin and there was no recurrence of the episode of pancreatitis when these two drugs were reintroduced. Acute pancreatitis is a rare adverse event associated with boceprevir therapy, but a potentially fatal event. Sequential determination of pancreatic enzymes should be considered during hepatitis C treatment with boceprevir.

Resumo em Inglês:

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunecompetent woman, which was complicated with septic pulmonary emboli within 24 h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.