Ana Cristina Cisne Frota

Healthcare-associated infections among neonates in Brazil

OBJECTIVE To describe the epidemiology of healthcare-associated infections (HAIs) among neonates. DESIGN Prospective surveillance of HAIs was conducted during 2 years. Infections beginning within 48 hours of birth were defined as HAIs of maternal origin. Death occurring during an active episode of HAI was considered related to HAI. SETTING Seven neonatal units located in three Brazilian cities. PATIENTS All admitted neonates were included and observed until discharge. RESULTS Twenty-two percent of 4,878 neonates had at least one HAI. The overall incidence density was 24.9 per 1,000 patient-days, and 28.1% of all HAIs were maternally acquired. HAI rates ranged from 12.3% in the group with a birth weight (BW) of more than 2,500 g to 51.9% in the group with a BW of 1,000 g or less. The main HAIs were bloodstream infection (BSI) and pneumonia. Coagulase-negative staphylococci, Enterobacter species, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens. Forty percent of all deaths were related to HAI. Central venous catheter (CVC)-associated BSIs per 1,000 CVC-days ranged from 17.3 (BW, 1,501 to 2,500 g; device utilization [DU], 0.11) to 34.9 (BW, < or = 1,000 g; DU, 34.92). Ventilator-associated pneumonia per 1,000 ventilator-days ranged from 7.0 (BW, < or = 1,000 g; DU, 0.34) to 9.2 (BW, 1,001 to 1,500 g; DU, 0.14). CONCLUSIONS The high proportion of HAIs of maternal origin highlights perinatal care issues in Brazil and the need to improve the diagnosis of neonatal HAIs. The very low BW group and device-associated infections should be priorities for prevention strategies in this population.

Immunogenicity and safety of meningococcal C conjugate vaccine in children and adolescents infected and uninfected with HIV in Rio de Janeiro, Brazil.

Background: We aimed to evaluate the Meningococcal (Neisseria meningitidis) C conjugated (MCC) vaccine seroconversion and adverse events (AEs) in HIV-infected and HIV-uninfected children and adolescents in Rio de Janeiro, Brazil. Methods: HIV-infected or HIV-uninfected subjects, 2–18 years old, with CD4+ T-lymphocyte cell (CD4) percentage >15%, without active infection or antibiotic use, were enrolled. All patients were evaluated before and 1–2 months after immunization for seroconversion (defined as ≥4-fold titer increase in human serum bactericidal activity) and at 20 minutes, 3 and 7 days after immunization for AEs. Factors associated with seroconversion among HIV-infected group were studied. Results: Two hundred four subjects were enrolled: 154 HIV-infected and 50 HIV-uninfected. Median age was 12 years, and 53% were female. Among the HIV-infected group, 82 (53%) had a history of at least 1 C clinical category of Centers for Diseases Control and Prevention event, and 134 (87%) were using combination antiretroviral therapy. The median nadir CD4 percentage was 13% (0–47%). Seventy-six (37.3%) experienced mild AEs. Seroconversion occurred in 46 of 154 (30%) in the HIV-infected group and in 38 of 50 (76%) in the uninfected group (P < 0.01). Factors associated with seroconversion in the HIV-infected group were as follows: never had a C clinical category event [odds ratio (OR) = 2.1, 95% confidence interval (CI): 1.0–4.4]; undetectable viral load at immunization (OR: 2.4, 95% CI: 1.1–5.2) and higher CD4 nadir/100 cells (OR: 1.1, 95% CI: 1.0–1.2). Conclusion: MCC vaccine should be administered to HIV-infected children and adolescents after maximum immunologic and virologic benefits have been achieved with combination antiretroviral therapy. Our data suggest that a single dose of MCC vaccine is insufficient for HIV-infected individuals 2–18 years of age.

Use of peripherally inserted central catheters to prevent catheter-associated bloodstream infection in children.

Infection in Children • Author(s): E. Goes‐Silva, RN, MSc; T. F. Abreu, MD, PhD; A. C. C. Frota, MD, MSc; C. L. Pessoa‐ Silva, MD, PhD; A. J. L. A. Cunha, MD, PhD; C. B. Hofer, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 10 (October 2009), pp. 10241026 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/606040 . Accessed: 16/05/2014 11:37

Prevalence of lipodystrophy and risk factors for dyslipidemia in HIV-infected children in Brazil

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 Fishers exact test followed by logistic regression analysis. Presence of dyslipidemia (fasting cholesterol >200mg/dl or triglycerides >130mg/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.

CD4+ T-cell activation impairs serogroup C Neisseria meningitis vaccine response in HIV-infected children.

Objective:To investigate the influence of CD4+ T-cell activation and regulatory populations in HIV-infected children antibody response to vaccination with a conjugate C polysaccharide vaccine. Design:CD4+ T-cell activation was evaluated by expression of CD38, HLA-DR and CCR5 molecules. Regulatory CD4+ T cells (TReg) were characterized as FoxP3+CD127−CD25+ and inducer T cells (TInd) as CD4+FoxP3−CD25−CD39+. Methods:All patients (n = 36) were HIV-vertically infected, aged 2–17 years-old and were vaccinated with one vaccine injection. Blood samples were obtained before and after immunization to determine bactericidal antibody titers (SBA), CD4+ T-cell activation and frequency of TReg and TInd subsets (multiparametric flow cytometry). Results:Children not-responding (n = 18) to MenC vaccine expressed higher frequency of activated CD4+ T cells (HLA-DR+CD38+CCR5+) than responders (n = 18), both before and after vaccination (P < 0.05). A significant higher frequency of TReg was detected in responders compared with nonresponders (P = 0.0001). We also detected an inverse correlation between CD4+DR+CD38+CCR5+ (P = 0.01) or CD4+DR+CD38+ (P = 0.02) T cells and TReg cell frequency after vaccination. CD4+ T-cell activation negatively correlated (P = 0.006) with postvaccination SBA titers but a positive correlation (P = 0.0001) was detected between TReg cells and SBA. TReg and TInd subsets were inversely correlated (P = 0.04). Conclusion:Our findings suggest that higher CD4+ T-cell activation leads to poor vaccine response in children living with HIV, which may be associated with a TReg/TInd disequilibrium.

Quality of Hand Hygiene in a Pediatric Hospital in Rio de Janeiro, Brazil

We assessed the quality of hand hygiene among healthcare workers at a pediatrics hospital in Rio de Janeiro, Brazil. Hand hygiene was performed in 491 (34%) of 1,455 opportunities. Of these hand hygiene events, correct performance was observed in only 173 (35%). Multivariate analysis revealed that correct performance of hand hygiene was associated with the use of an alcohol-based product and a lack of jewelry (for all events) and employment in an infirmary with a comparatively higher ratio of nurses to patients (for events involving nurses).

In Utero Exposure to Antiretroviral Drugs: Effect on Birth Weight and Growth Among HIV-exposed Uninfected Children in Brazil.

Background: There are concerns about the effects of in utero exposure to antiretroviral drugs (ARVs) on the development of HIV-exposed but uninfected (HEU) children. The aim of this study was to evaluate whether in utero exposure to ARVs is associated with lower birth weight/height and reduced growth during the first 2 years of life. Methods: This cohort study was conducted among HEU infants born between 1996 and 2010 in Tertiary children’s hospital in Rio de Janeiro, Brazil. Weight was measured by mechanical scale, and height was measured by measuring board. Z-scores for weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length were calculated. We modeled trajectories by mixed-effects models and adjusted for mother’s age, CD4 cell count, viral load, year of birth and family income. Results: A total of 588 HEU infants were included of whom 155 (26%) were not exposed to ARVs, 114 (19%) were exposed early (first trimester) and 319 (54%) later. WAZ were lower among infants exposed early compared with infants exposed later: adjusted differences were −0.52 (95% confidence interval [CI]: −0.99 to −0.04, P = 0.02) at birth and −0.22 (95% CI: −0.47 to 0.04, P = 0.10) during follow-up. LAZ were lower during follow-up: −0.35 (95% CI: −0.63 to −0.08, P = 0.01). There were no differences in weight-for-length scores. Z-scores of infants exposed late during pregnancy were similar to unexposed infants. Conclusions: In HEU children, early exposure to ARVs was associated with lower WAZ at birth and lower LAZ up to 2 years of life. Growth of HEU children needs to be monitored closely.

Progressive multifocal leukoencephalopathy in a child with acquired immunodeficiency syndrome (AIDS)

Progressive multifocal leukoencephalopathy is a rare viral-induced demyelinating disease associated to immunodeficiency. A 10-year-old boy with AIDS is reported, who developed subacute cerebellar signs and symptoms with multiple cranial nerve involvement and dementia. A computed tomography scan revealed a focal nonenhancing area of low attenuation in the cerebellum. On magnetic resonance imaging high signal lesions in T2 weighted sequences were shown. The biopsy of one of those lesions showed the typical histological findings of progressive multifocal leukoencephalopathy. It seems important to consider this diagnosis in children with AIDS who present with progressive neurological features.

Nosocomial Infection Among Children With Symptomatic Human Immunodeficiency Virus Infection

A prospective cohort study was conducted during a 15-month period to compare nosocomial infections (NIs) among pediatric patients without (n = 989 and with (n = 50) symptomatic human immunodeficiency virus (HIV) infection. Patients with symptomatic HIV infection presented higher overall NI incidence density rates (relative risk, 1.65; P= .0001), and may represent a population at high risk for the acquisition of NI.

A cross-reacting material CRM197 conjugate vaccine induces diphtheria toxin neutralizing antibody response in children and adolescents infected or not with HIV

Anti-diphtheria antibody levels decrease with aging, and frequent booster vaccinations are required to maintain herd immunity. We analyzed the diphtheria toxin neutralizing antibody (DT-Nab) response induced by a conjugate vaccine (meningococcal C polysaccharide-CRM197) in HIV-vertically infected (HI) children and adolescents and healthy controls (HC) with matched age. We report the association of DT-Nab with the bactericidal antibodies to serogroup C meningococcus (MenC). Before vaccination, 21 HI patients (50%) had no protection against diphtheria (≤0.01IU/ml of antibody) and only 8 (19%) showed complete protection (≥0.1IU/ml). About half of the HC (56%) had complete protection before immunization and 6 subjects (12%) had no protection against diphtheria. After one and two vaccine injections, 96% of HC and 64% of HI vaccinees, respectively, showed full protection against diphtheria. These data indicate that CRM197 was able to induce primary and/or booster response in both groups of individuals.