Adauto Castelo

Risk factors for mortality in Staphylococcus aureus bacteremia.

OBJECTIVE To analyze risk factors for, and the role of methicillin resistance in, mortality in Staphylococcus aureus bacteremia. DESIGN Nested case-control study. SETTING General teaching hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains, in São Paulo, Brazil. PATIENTS 136 patients over 14 years old with documented S aureus bacteremia. Those who died were compared with those who survived at least 14 days. RESULTS Mortality within 14 days of bacteremia was 39% (53/136). Mean age was 47 years. Hospital-acquired bacteremia represented 86% (117/136) of episodes. In 26% (35/136), infection was related to an intravascular catheter and in 13% (17/136) to the respiratory tract. Septic shock occurred in 22% (30/136) of cases. MRSA was isolated in 66% (90/136). Multivariate analysis identified three variables that were significantly and independently associated with mortality: site of entry (lung, odds ratio [OR], 17.0; unknown, OR, 12.3; others, OR, 6.6); occurrence of shock (OR, 8.9), and resistance of S aureus to methicillin (OR, 4.2). CONCLUSION Our study shows that S aureus bacteremia has a high mortality, especially when the lung is the source of infection and when shock develops; resistance to methicillin may be another risk factor for poor outcome.

Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil

OBJECTIVE To identify medication use patterns among elderly people residing in areas with different socioeconomic status in the city of Fortaleza, Brazil. METHODS A total of 668 elderly (aged 60 years or older) residing in the city of Fortaleza, Ceará, Brazil, selected from a multistage random sampling stratified by socioeconomic status (higher, intermediate, and lower areas), were interviewed in a household survey. Descriptive statistics for dichotomous variables were presented as percent of the respective totals, and those for continuous variables as mean +/- SD. Multivariate analyses were performed to identify factors associated with the use of prescription, non-prescription and inappropriate) drugs. RESULTS Most (80.3% in the higher area) were on at least one non-prescription drug. More than one third (37.4%) were on at least one non- prescription drug and nearly 20% used at least one inappropriate in the lower area. PD use was associated with advanced age (OR=1.7, 95% CI=1.1-2.8); male sex (OR=0.5, 95% CI=0.3-0.7); health service visits (OR=2.5, 95% CI=1.9-3.1); chronic diseases (OR=4.0, 95% CI=2.5-6.2); and higher socioeconomic status (OR=2.0, 95% CI=1.5-2.6).Non- prescription drug use was associated with disability (OR=1.5, 95% CI=1.1-2.2), and higher socioeconomic status (OR=0.6; 95% CI=0.5-0.8). Inappropriate drugs use was mainly associated with male sex (OR=0.4, 95% CI=0.2-0.8); chronic diseases (OR=2.0, 95% CI=1.2-3.3); and higher socioeconomic status (OR=0.7, 95% CI=0.5-0.9). CONCLUSIONS The proportions of elderly using prescription, non-prescription and inappropriate drugs were remarkable and inequalities were seen particularly among those from different socioeconomic status. These results emphasize the need for strategies to optimize the access and rationalize the use of drugs for elderly people in Brazil.

Epidemiological profile of cocaine users on treatment in psychiatrics hospitals, Brazil

OBJECTIVE To describe the epidemiological profile and patterns of cocaine use among hospitalized drug users. METHODS A cross-sectional study was carried out among drug users, aged 18 years or more, hospitalized in one out six selected psychiatric hospitals in the metropolitan area of Greater S o Paulo, whose clinical conditions allowed them to reliably answer to a standardized questionnaire and who agreed to participate. Six psychiatric hospitals who attended spontaneously referred public and private patients from all Greater S o Paulo were selected. Data collection was conducted using structured interviews, individually applied by a trained psychologist. Statistical analysis was performed using Student t-test and Chi-square test at p<0.05. RESULTS There was a predominance of crack use (38.4%) over intravenous drug use (1.6%). Addicts who smoked cocaine had lower education, most were unemployed and had previously lived on the streets, and used higher amounts of drugs. These addicts also had been previously incarcerated more often than addicts who used other routes for drug administration. CONCLUSIONS Drug use is a serious public health problem in Greater S o Paulo, and this is shown by the great amount of hospital admissions due to drug addiction. Crack users have lower socioeconomic status and more often engage in violence and crimes.

Nosocomial bloodstream infections caused by Klebsiella pneumoniae: impact of extended-spectrum β-lactamase (ESBL) production on clinical outcome in a hospital with high ESBL prevalence

BackgroundThe frequency of ESBL producing Klebsiella pneumoniae bloodstream infections (BSI) is high in Brazilian hospitals, however little is known regarding what role, if any, resistance plays in the expected outcome in hospitals with a high prevalence of these pathogens.MethodsFrom 1996 to 2001, hospital acquired K. pneumoniae BSI were evaluated retrospectively. Each patient was included only once at the time of BSI. ESBL producing strains were identified using the E-test method. The association of variables with the mortality related to bacteremia was included in a stepwise logistic regression model.ResultsOne hundred and eight hospital acquired K. pneumoniae BSI met criteria for inclusion. Fifty two percent were due to ESBL producing strains. The overall in-hospital mortality was 40.8%. Variables independently predicting death by multivariate analysis were the following: mechanical ventilation (p = 0.001), number of comorbidities (p = 0.003), antimicrobials prescribed before bacteremia (p = 0.01) and fatal underlying disease (p = 0.025).ConclusionBacteremia due to ESBL producing K. pneumoniae strains was not an independent predictor for death in patients with BSI. An increased mortality in hospital-acquired BSI by K. pneumoniae was related to the requirement for mechanical ventilation, more than two comorbidities, the previous use of two or more antibiotics, and the presence of a rapidly fatal disease.

High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection

Hepatitis C virus (HCV) causes infectious hepatitis worldwide. It is transmitted mainly by blood products and sharing of intravenous paraphernalia during illicit drug use. High prevalence rates have been described among specific groups considered to be at higher risk for HCV infection, including prison inmates. The objectives of this study were: to determine the HCV seroprevalence among inmates of Casa de Detenção de São Paulo; to identify risk factors for HCV infection; and to compare the seroprevalence of HCV to other blood borne or sexually transmitted diseases. From December, 1993, to January, 1994, a total of 779 inmates were interviewed to collect information on sociodemographic status, sexual behavior, and past experience with illicit drugs. Blood samples were obtained from 756 inmates for serological tests. 310 (41%) blood samples were positive for anti-HCV, 425 (56.2%) were negative, and 21 (2.8%) showed indeterminate results. In this population, we found a seroprevalence of 13.7% for HIV, 3.3% for syphilis (VDRL), and 68.1% for hepatitis B virus previous infection. Four variables were each identified as associated with a positive anti-HCV serologic test: a positive VDRL (OR = 2.63 IC 95% 1.08 to 6.36); a time of current imprisonment longer than 130 months (OR = 2.44 IC 95% 1.04 to 5.71); previous incarceration at Casa de Detenção de São Paulo (OR = 1.73 IC 95% 1.19 to 2.52) and; illicit drug use before admission to the Casa de Detenção de São Paulo (OR = 1.64 IC 95% 1.15 to 2.33). The seroprevalence of HCV antibodies among the study population was high (41%), indeed, one of the highest clusters of HCV infection recorded until now. Four variables were each shown to be associated with HCV infection. The simultaneous presence of these 4 variables is associated with an 82% probability of being anti-HCV positive. Although risk factor analysis indicates most HCV infections occur prior to inprisonment, initiation of control measures to prevent continued transmission after incarceration should be done.

Risk factors associated with hepatitis C virus (HCV) infection among prostitutes and their clients in the city of Santos, São Paulo State, Brazil

We studied the role of sexual transmission in the epidemiology of HCV by a cross‐sectional study comparing prostitutes and HCV seropositive and seronegative sexual clients recruited from the bordellos of the docks of Santos, São Paulo State. The average age in the prostitute group was 27.2 years. The median time spent in prostitution was 3 years. The average number of clients per week was 7. A total of 5.2% of the prostitutes admitted to having used injectable drugs. Nine percent patients said that they had received a blood transfusion and 36.3% claimed to have had a sexually transmissible disease in the past. The prevalence of HCV antibodies was 10.9%. There was a positive and independent relationship between HCV seropositivity and the following variables: use of injectable drugs (OR = 5.2; 95% Cl = 2.2 to 12.2), prior blood transfusion (OR = 2.3; 95% Cl = 1.08 to 4.9), time spent in prostitution (OR = 2.0; 95% Cl = 1.13 to 3.6), and a positive FTA‐ABS result (OR = 1.7; 95% Cl = 0.95 to 3.0). The risk factors indicating parenteral exposure (use of an injectable drug and prior blood transfusion) presented a stronger relationship with HCV seropositivity. The time spent in prostitution and FTA‐ABS positivity, risk factors indicating sexual exposure, also presented a positive relationship with HCV seropositivity, suggesting a significant role for sexual transmission in HCV epidemiology, particularly in groups involved in promiscuous sexual behavior. J. Med. Virol. 51:338–343, 1997.

Genetic diversity and HIV-1 incidence estimation among cocaine users in Sao Paulo Brazil.

Summary: We describe HIV‐1 incidence and the prevalence of genetic subtypes among cocaine users in São Paulo, Brazil. A cross‐sectional HIV‐1 survey was carried out among 839 current cocaine users attending seven drug treatment units in the São Paulo metropolitan area from 1997 to 1998. HIV‐1 subtyping was performed among 41 positive individuals using the heteroduplex mobility assay and DNA sequencing. Participants were mainly male (95.7%) with a history of previous imprisonment (54%), and the mean age was 26.9 years (SD = 7.2). The majority (64.4%) were current crack cocaine users, and 82.1% of the total participants were noninjectors. HIV‐1 seroprevalence was 4.9% (95% confidence interval [CI], 3.6%‐6.6%), and the incidence (estimated by the sensitive/less‐sensitive immunoassay testing strategy) was 0.71% per year (95% CI, 0.07‐3.03). HIV‐1 subtype B was predominant (90.3%), followed by subtype F. There was no statistically significant association between HIV‐1 subtype and specific route of drug administration. Our incidence data show evidence of recent HIV‐1 transmission among cocaine users, mainly among noninjectors. Detection of recently infected HIV‐1 cases linked to genetic diversity analysis may provide baseline information for public health interventions in this sentinel group.

Human Papillomavirus prevalence, viral load and cervical intraepithelial neoplasia in HIV-infected women

HIV-infected women from S o Paulo city were enrolled in a cross-sectional study on Human Papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN) prevalence and their association with laboratory markers of AIDS, namely HIV viral load and CD(4)(+) cell counts. A cervical specimen was collected and submitted to Hybrid Capture, a test for HPV viral load determination. HPV-DNA was detected in 173 of 265 women (64.5%). Twenty (7.5%) women were infected by one or more low-risk viruses, 89 (33%) by one or more high-risk viruses, and 64 (24%) harbored at least one HPV type from each risk group. Abnormal smears were observed in 19% of the patients, though there were no invasive carcinomas. Severely immunosuppressed patients (CD(4)/microL <100) were at the greatest risk of having a cytological abnormality and a high high-risk HPV viral load.

Tradução e validação de um questionário de avaliação de qualidade de vida em AIDS no Brasil

OBJECTIVES To translate the HIV/AIDS-Targeted Quality of Life Instrument (HAT-QoL) into Brazilian Portuguese, culturally adapt it, and evaluate its psychometric properties (validity and reliability) as a Brazilian version. METHODS This cross-sectional study was carried out at the laboratory of infectious diseases at Escola Paulista de Medicina (Universidade Federal de São Paulo). Data were collected on clinical and sociodemographic characteristics of 106 HIV-infected individuals who answered the HAT-QoL and the SF-36. Pearsons correlation coefficient was used to measure construct validity. Reliability was assessed using Cronbachs alpha and intraclass correlation coefficients. RESULTS The sample was 70.8% male. The mean age was 39.9 years, with 40.5% of the participants being homosexual or bisexual. Eleven (10.4%) patients had a CD4 cell count <or= 200 cells/mm(3). A substantial ceiling effect was observed in 7 of 9 HAT-QoL domains (overall function, life satisfaction, health worries, medication worries, HIV acceptance, provider trust, and sexual function). Sexual function was the domain with the highest ceiling effect (63.2%). A substantial floor effect (30.2%) was observed for financial worries. Statistically significant associations were observed between the HAT-QoL domains and clinical and sociodemographic characteristics, as well as with SF-36 domains. Internal consistency was satisfactory (Cronbachs alpha = 0.73-0.90). Inter- and intra-observer reproducibility was very high (0.87-0.98 and 0.82-0.97, respectively). CONCLUSION The Brazilian Portuguese version of the HAT-QoL is valid, reliable, and may contribute to evaluating the impact of HIV infection on the quality of life of patients in Brazil.

HIV-infected pregnant women have greater adherence with antiretroviral drugs than non-pregnant women

The objective of the study was to evaluate the influence of pregnancy on the level of adherence with antiretroviral (ARV) drugs, in a prospective cohort of 72 pregnant women and 79 non-pregnant women. Adherence was measured by pill counting and self-reporting. Women were deemed adherent if 95% or more of all ARV had been taken as prescribed, in two occasions. According to pill counting, 43.1 and 17.7% of pregnant and non-pregnant women, respectively, met the criteria of adherence (P = 0.001); in the postpartum, adherence declined to 20.6% (P = 0.002). In both groups, adherence rates by self-reporting were significantly higher as compared with pill counting (P = 0.001). In multivariate regression analysis, age >29 years (odds ratio [OR] 3.58, confidence interval [CI] 95% 0.10–0.75, P = 0.011), mean number of pills/day <6 (OR 2.53, CI 95% 1.07–6.01, P = 0.035), and being pregnant (OR 3.33, CI 95% 1.36–8.13, P = 0.008) were independently associated to greater adherence.