Caroline Deutschendorf

Cutaneous Cryptococccosis Due to Cryptococcus gattii in Immunocompetent Hosts: Case Report and Review

Cutaneous cryptococcosis caused by C. gattii, in immunocompent patients is a rare manifestation of disease, and may be one of the first manifestations of disseminated cryptococcosis. We report a case of disseminated cryptococcosis caused by Cryptococcus gattii presenting as cutaneous lesions in an immunocompetent patient. Previously to our report, only five cases of cutaneous involvement by Cryptococcus gattii in immunocompetent patients have been reported in the literature. Risk factors for C. gattii infection included exposure to the eucalypt reservoirs in tropical and subtropical areas. Skin involvement corresponded to the disseminated form of cryptococcosis in the majority of patients, and commonly affected the face and neck with different morphologies including papules, pustules, plaques, ulcers, subcutaneous masses, cellulitis or acneiform lesions. Due to the severity of this infection and the life threatening condition that it represents, clinicians must be aware that cutaneous involvement may be one of the first manifestations of disseminated cryptococcosis caused by C. gattii especially in patients living and coming from endemic areas.

Antimicrobial stewardship through telemedicine in a community hospital in Southern Brazil.

We developed an antimicrobial stewardship programme, based on telemedicine, for a remote community hospital in southern Brazil. Expertise in infectious diseases was provided from a 250-bed tertiary hospital for cardiology patients located 575 km away. At the community hospital, antimicrobial prescriptions were completed via a secure web site. A written reply was sent back to the prescriber by email and SMS text message. During a 4-month study period there were 81 prescriptions for 76 patients. Most antimicrobial prescriptions (67%) were for respiratory infections. Ampicillin was prescribed in 44% of cases (n = 56), gentamicin in 18% of cases (n = 23) and azithromycin in 18% of cases (n = 23). Two infectious diseases specialists independently reviewed each antimicrobial prescription. A total of 41 prescriptions (55%) were considered inappropriate. The median time to obtain a second opinion via the web site was 22 min (interquartile range 12–55). Overall compliance with the recommendations of the infectious diseases specialist was 100% (81 out of 81 requests). Telemedicine appears to have a useful potential role in antimicrobial stewardship programmes.

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation

BACKGROUND Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital. METHODS In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period. RESULTS During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year. CONCLUSION One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staffs workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Definindo pneumonia associada à ventilação mecânica: um conceito em (des)construção

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) setting. It has variable prevalence rates, ranging from 6 to 50 cases per 100 admissions to the ICU.(1,2) Such variability comes mainly from two aspects: the presence of case-mix differences among the different units evaluated in the literature and the lack of accurate diagnostic criteria that allow for an accurate functional diagnosis, making subjectivity an important aspect of definitive diagnosis and treatment decisions.(3) Several studies show that the incidence of this infection increases with the length of time on mechanical ventilation and show a rate of infection of approximately 3% per day during the first five days of mechanical ventilation.(2,4) The development of nosocomial pneumonia in an intensive care setting, especially of VAP, has significant morbidity, prolonging the duration of mechanical ventilation as well as the length of stay in the ICU with all the costs associated with that extended stay.(4-6) Bedside VAP diagnosis takes into consideration a combination of clinical, radiological and laboratory findings. Microbiological data are used as an attempt to refine diagnostic accuracy given the low specificity of clinical criteria alone. These criteria include the following: presence of a new or progressive, persistent infiltrate OR consolidation OR cavitation; AND at least two of these criteria: fever (axillary temperature above 38°C), without any other etiology OR leukopenia (<4,000 cells/mm3) or leukocytosis (>12,000 cells/mm3) OR emergence of purulent secretions OR change in secretion characteristics OR increased secretions. Additional factors to consider include the presence of functional impairment, hypoxemia with worsening PO2/FiO2 (relative partial pressure of oxygen/ fraction of inspired oxygen), increased biomarkers, altered mental status or the appearance of severe sepsis/septic shock. Ventilator-associated pneumonia is considered to have microbiological confirmation if at least one of the following laboratory criteria is present: positive blood culture without any other apparent source of infection OR positive pleural fluid culture OR bronchoalveolar lavage culture ≥104 UFC/ mL or tracheal aspirate culture ≥106 UFC/mL OR histopathology exam with evidence of lung infection OR urinary antigen or culture for Legionella spp. OR other positive laboratory tests for respiratory pathogens (serology, direct visualization and culture). In the absence of any of these microbiological criteria, VAP is diagnosed clinically. Camila Hubner Dalmora1, Caroline Deutschendorf1, Fabiano Nagel2, Rodrigo Pires dos Santos1,Thiago Lisboa2,3Such variability comes mainly from two aspects: the presence of case-mix differences among the different units evaluated in the literature and the lack of accurate diagnostic criteria that allow for an accurate functional diagnosis, making subjectivity an important aspect of definitive diagnosis and treatment decisions.

Previous use of quinolones: a surrogate marker for first line anti-tuberculosis drugs resistance in HIV-infected patients?

OBJECTIVES Drug resistant Mycobacterium tuberculosis causes much higher rates of treatment toxicity, failure or relapse, and mortality. We determined the drug resistant profile of Mycobacterium tuberculosis strains isolated from a population of HIV-infected patients in southern Brazil and studied the potential factors associated with resistance. METHODS We conducted a retrospective cohort study to determine the resistance profile of Mycobacterium tuberculosis isolated from HIV-infected patients and factors that could be associated with resistance from 2000 to 2005. RESULTS 236 patients were included in the study. Resistance to at least one drug was observed in 32 (14.6%) isolates, and multi-drug resistance was observed in 4 (1.82%) isolates. On multivariate analysis, previous use of tuberculostatics and quinolones were related to any first-line drug resistance. CONCLUSIONS In our study, previous quinolone use was significantly associated to first-line anti-TB drugs resistance. Multi-drug-resistant tuberculosis (MDR-TB) is a major problem worldwide, and we believe quinolones should be used with caution in settings where TB is endemic.

In-hospital mortality of disseminated tuberculosis in patients infected with the human immunodeficiency virus.

Background. Tuberculosis (TB) is a cause of significant morbidity and mortality in patients with AIDS. The goal of our study was to determine predictors of in-hospital mortality in patients with AIDS and disseminated tuberculosis in a middle-income country. Material and Methods. We conducted a retrospective cohort study in a tertiary care center, for patients with AIDS in southern Brazil. From 1996 to 2008, all patients with the diagnosis of disseminated TB were included. Results. Eighty patients were included. In-hospital mortality was 35%  (N = 28). On multivariate Cox regression analysis, low basal albumin (P < .01) was associated with death, and fever at admission was related to better survival (P < .01). Conclusion. Albumin levels or fever are independent predictors of survival in patients with HIV and disseminated TB. They can serve as indirect markers of immunodeficiency in patients with disseminated TB and AIDS.

Antimicrobial stewardship through telemedicine and its impact on multi-drug resistance:

Introduction Telemedicine technologies are increasingly being incorporated into infectious disease practice. We aimed to demonstrate the impact of antimicrobial stewardship through telemedicine on bacterial resistance rates. Methods We conducted a quasi-experimental study in a 220-bed hospital in southern Brazil. An antimicrobial stewardship program incorporating the use of telemedicine was implemented. Resistance and antimicrobial consumption rates were determined and analysed using a segmented regression model. Results After the intervention, the rate of appropriate antimicrobial prescription increased from 51.4% at baseline to 81.4%. Significant reductions in the consumption of fluoroquinolones (level change, β = −0.80; P < 0.01; trend change, β = −0.01; P = 0.98), first-generation cephalosporins (level change, β = −0.91; P < 0.01; trend change, β = +0.01; P = 0.96), vancomycin (level change, β = −0.47; P = 0.04; trend change, β = +0.17; P = 0.66) and polymyxins (level change, β = −0.15; P = 0.56; trend change, β = −1.75; P < 0.01) were identified. There was an increase in the consumption of amoxicillin + clavulanate (level change, β = +0.84; P < 0.01; trend change, β = +0.14; P = 0.41) and cefuroxime (level change, β = +0.21; P = 0.17; trend change, β = +0.66; P = 0.02). A significant decrease in the rate of carbapenem-resistant Acinetobacter spp. isolation (level change, β = +0.66; P = 0.01; trend change, β = −1.26; P < 0.01) was observed. Conclusions Telemedicine, which provides a tool for decision support and immediate access to experienced specialists, can promote better antibiotic selection and reductions in bacterial resistance.

Applicability of the surgical site infection risk index to patients undergoing cardiac, neurologic and orthopedic surgery

Introduction: The surgical site infection risk index (SSIRI) includes three risk factors for surgical site infection (SSI): potential for surgical contamination, duration of surgery, and patient’s ASA score. A patient having a preoperative American Society of Anesthesiologists (ASA) score of III, IV or IV; a surgery classified as either contaminated or dirty-infected; an operation with duration of surgery more than T hours, where T depends on the surgical procedure being performed are considered in risk of SSI. The SSIRI can be used as a method of postoperative surveillance. The aim of this study is to analyze the applicability of the SSIRI to patients undergoing cardiac, neurologic and orthopedic surgery. Methods: A retrospective cohort study including patients undergoing cardiac, neurological and orthopedic surgeries considered major, from January to December 2014, evaluated through review of medical charts of patients admitted to a university hospital in southern Brazil. Values of p <0.05 were considered significant. Results: A total of 761 patients were included in the study; of these, 122 (16%) developed SSI. The SSIRI did not demonstrate statistical significance to distinguish the patients most likely to develop SSI between the four levels of the ASA score. Black and brown patients, patients who underwent intraoperative blood transfusion, and patients who underwent surgical reintervention were more susceptible to SSI. Conclusions: The SSIRI could not be used as a method of postoperative surveillance for patients in the present study. The other risk factors found may serve as a guide to articulate SSI prevention strategies and, thus, minimize chances of development of serious infections. Keywords: Postoperative complications; infection; risk index