Frine Samalvides

Sexual behavior of international travelers visiting Peru

Background Sexual behavior of travelers to Latin America and the sexual behavior of US travelers in general are poorly characterized. Goal The goal of the study was to evaluate sexual risk factors of travelers to Peru. Study Design Anonymous written questionnaires were administered to 442/507 (87%) of the individuals approached in the international departures area of the Lima airport. Results Of the 442 respondents, 54 (12.2%) had new sex partners during their stay. Sex with a local partner (35/52; 67.3%) was more frequent than sex with other travelers (18/52; 34.6%) or with sex workers (4/52; 7.7%). Risk factors for a new sex partner included male sex (relative risk, 1.94), single marital status (relative risk, 2.59), duration of stay longer than 30 days (relative risk, 5.05), traveling alone or with friends (relative risk, 2.88), and bisexual orientation (relative risk, 4.94). Frequency of sexual activity among US travelers was greater than that among travelers from other countries (15.2% [22/145] versus 10.6% [30/282]; NS). Condoms were consistently used by 12/50 (24%) and sometimes used by 10/50 (20%), including 8/20 United States travelers and 13/29 travelers from other countries. Conclusion Behaviors and risk factors are similar to those described for travelers to Africa, Asia, and Eastern Europe. Behavior of US travelers did not differ from that of other travelers.

Parasitosis intestinal en poblaciones urbana y rural en Sandia, Departamento de Puno, Perú

* Instituto de Medicina Tropical Alexander von Humboldt (IMTAvH). Av. Honorio Delgado 430, Urb. Ingieneria,San Marin de Porres. A.P. 4314 - Lima 100, Peru. E-mail: egh@upch.edu.pe** Laboratorio de Parasitologia. Universidad Peruana Cayetano Heredia (UPCH), Lima, Peru.LUIS MARCOS*, VICENTE MACO*, ANGELICA TERASHIMA*, FRINE SAMALVIDES**,ELBA MIRANDA** y EDUARDO GOTUZZO*.

Fascioliasis in relatives of patients with Fasciola hepatica infection in Peru

High prevalence rates of human fascioliasis have been described in several regions of Peru. We surveyed 20 families in an endemic area of Peru in order to determine the proportion of infection with F. hepatica in relatives of diagnosed subjects and in order to identify associated risk factors. The study included feces and blood samples of 93 subjects. Ages ranged from one to 53 (mean = 18.6; SD = 14.2). The overall prevalence of fascioliasis by fecal examinations was 33.3% (n = 83) and by serology, 51.9% (n = 86). The prevalence in age group I (< or = 19 years old) by coprological and serological tests was 61.4% and 75.9%, respectively; in group II (> 19 years old) 15.4% and 37.5%. The main associated risk factor with fascioliasis was eating salads (OR = 3.29, CI = 1.2 - 9.0, p = 0.02). In conclusion, human fascioliasis is highly prevalent in the relatives of index cases and the most significant risk factor of acquiring fascioliasis in the family is eating salads in endemic areas.

Antimicrobial Drug Resistance in Peru

To the Editor: In Latin American countries, rates of antimicrobial drug resistance among bacterial pathogens are high. Data on these rates in Peru are incomplete (1), and no institution in Peru has participated in multinational surveillance studies (2–4). To document the antimicrobial drug resistance profile of key pathogens, we organized a surveillance network of clinical laboratories from 9 hospitals (public, general, tertiary care, and quaternary care) in Lima, the capital of Peru. Over a 12-month period (April 2008–March 2009), we consecutively collected positive bacterial blood culture isolates (other than coagulase-negative staphylococci) from each of the 9 hospitals. Only the first isolate per patient was included. Patients’ age and hospital ward were recorded. Identification and susceptibility testing were performed at the Institute of Tropical Medicine Alexander von Humboldt (Lima, Peru). Staphylococcus aureus was identified by conventional methods, and susceptibility testing was conducted by oxacillin salt agar screening and disk diffusion (5). For gram-negative bacilli, including extended-spectrum β-lactamases (ESBL), identification and susceptibility testing were performed by conventional techniques and by MicroScan NC50 panels (Dade-Behring, West Sacramento, CA, USA) (5). American Type Culture Collection strains were used as controls. During the study period, we collected 1,681 unique isolates. We report the first 934 isolates tested from the more common species collected (375 Staphylococcus aureus, 321 Klebsiella pneumoniae, 125 Escherichia coli, and 113 Pseudomonas aeruginosa). Overall, S. aureus was the most frequently recovered species, accounting for 22.0% of organisms. Of 375 S. aureus isolates tested, 244 (65.0%) were methicillin resistant (MRSA) and 131 were methicillin susceptible. MRSA frequency was highest among isolates from intensive care units (ICUs) (61 [68.5%] of 89 isolates), but it was also high among isolates from emergency wards (55 [57.3%] of 96 isolates); this difference did not reach statistical significance. Among the 244 MRSA isolates, 170 (69.6%) were also co-resistant to the combination of ciprofloxacin, gentamicin, and clindamycin; rates of co-resistance did not differ significantly among MRSA isolates from patients in the emergency ward (32/55, 58.2%) and those from patients in ICUs and hospital wards (133/184, 72.3%, p = 0.67). Among the 131 methicillin-susceptible isolates, resistance rates were as follows: ciprofloxacin (5.3%), gentamicin (10.7%), clindamycin (14.5%), and erythromycin (14.5%). All S. aureus isolates were susceptible to linezolid, teicoplanin, and vancomycin; clindamycin-inducible resistance was found in 10 (38.5%) of 26 isolates resistant to erythromycin and apparently susceptible to clindamycin. K. pneumoniae was the second most frequently recovered organism, accounting for 19.1% of organisms collected. Among 321 K. pneumoniae isolates tested, 241 (75.1%) produced ESBL, 207 (64.5%) showed resistance to ciprofloxacin, and 233 (72.6%) were resistant to trimethoprim-sulfamethoxazole; proportions did not differ among age groups, wards, or hospitals. Of the 241 ESBL-producing isolates, 136 (56.4%) showed co-resistance to ciprofloxacin and gentamicin and 66 (27.4%) were also resistant to amikacin. Of the 80 non–ESBL-producing isolates, 37 (46.3%) were resistant to ciprofloxacin. All K. pneumoniae isolates retained susceptibility to imipenem and meropenem. A large proportion of K. pneumoniae infections were suspected to have been hospital acquired because most (280/321, 87.2%) were recovered from patients already hospitalized, including one third (96/321, 29.9%) of those from the neonatal ward. Although K. pneumoniae occasionally caused microepidemics in neonatal wards, most isolates were recovered randomly over time and from different hospitals. Among 125 E. coli isolates tested, 96 (76.8%) produced ESBL, 107 (85.6%) were resistant to ciprofloxacin, and 108 (86.4%) were resistant to trimethoprim-sulfamethoxazole. The resistance rate to ciprofloxacin was higher among adults than children (90.5% vs. 60.0%, p = 0.002). Of 96 ESBL-positive isolates, 59 (61.5%) were co-resistant to gentamicin and ciprofloxacin but only 9 (9.4%) were resistant to amikacin. Among 29 non–ESBL-producing E. coli isolates, 19 (65.5%) were resistant to ciprofloxacin. All isolates were susceptible to imipenem and meropenem. We hypothesized that the high level of E. coli resistance to ciprofloxacin may be related to community overuse of fluorquinolones for common infections, such as acute diarrhea. Among 113 P. aeruginosa isolates tested, 62 (54.8%) came from patients in ICUs and 73 (64.0%) were isolated from adults. Multidrug-resistance (defined as resistance to at least 3 of the following: ciprofloxacin, imipenem, amikacin, ceftazidime) was found for 67 (59.3%) of the 133 isolates, more among adults (65.7%) than among children (43.2%, p = 0.024). Overall, 34.5% were resistant to piperacilin-tazobactam. Our main study limitation was not having complete clinical and epidemiologic information to define which isolates were acquired in the hospital and which were acquired in the community. Overall, rates of antimicrobial drug resistance among common pathogens in hospitals of Lima, Peru, were high.

Evaluation of the performance of two liquid-phase culture media for the diagnosis of pulmonary tuberculosis in a national hospital in Lima, Peru

OBJECTIVE To evaluate the diagnostic performance of two liquid-phase culture media for the diagnosis of pulmonary tuberculosis. PATIENTS AND METHODS From May to July 2003, sputum samples for culture were obtained from patients with respiratory symptoms attending the Hospital Nacional Cayetano Heredia. These were cultured in Ogawa medium, mycobacteria growth indicator tube (MGIT), and modified Middlebrook 7H9. Results were compared against a composite reference standard. RESULTS One hundred sputum specimens from 100 patients were included. Of these, 33 had culture-proven tuberculosis. The sensitivity of MGIT was found to be 100%. The modified Middlebrook 7H9 medium was found to have a sensitivity of 72.73%, while the sensitivity of Ogawa medium was found to be 69.70%. The mean growing time for MGIT was 12.18 days (95% confidence interval 10.24 to 14.12; p<0.01 vs. Ogawa and modified Middlebrook 7H9); for modified Middlebrook 7H9 was 16.65 days (95% confidence interval 14.85 to 18.80; p<0.01 vs. Ogawa), and for the Ogawa medium 25.74 days (95% confidence interval 22.22 to 29.6). CONCLUSIONS The liquid culture medium MGIT was superior to the modified Middlebrook 7H9 and the Ogawa media, both in terms of sensitivity and shorter growing time of colonies of Mycobacterium tuberculosis. The modified Middlebrook 7H9 medium is significantly faster but comparable in diagnostic performance to Ogawa. Costs remain an issue for MGIT.

Antimicrobial resistance and molecular typing of Staphylococcus aureus bloodstream isolates from hospitals in Peru.

OBJECTIVES Methicillin-resistant Staphylococcus aureus (MRSA) infections are of worldwide concern. The present study describes the antimicrobial resistance and molecular typing of methicillin-resistant and methicillin-susceptible S. aureus (MSSA) bloodstream isolates in Peru. METHODS Consecutive non-duplicate S. aureus bloodstream isolates were collected over a 15-month period (2008-2009) from seven hospitals in Lima and Callao, two contiguous cities in Peru. Detection of mecA gene, spa typing and Staphylococcal Chromosomal Cassette (SCC)mec typing were performed. Antimicrobial resistance was assessed by disk diffusion. RESULTS Of 338 isolates, MRSA rate was 50.0%. Among MRSA isolates (n = 169), 81.7% were associated to MLST CC5, 68.8% had spa t149/SCCmec I, and more than 85% were co-resistant to ciprofloxacin, clindamycin, erythromycin and gentamicin; 8.9% (n = 15) were associated to MLST CC8, 14 of them had spa t148/SCCmec IV, and more than 70% were co-resistant to ciprofloxacin, clindamycin and erythromycin. Among MSSA isolates (n = 169), there was a higher diversity of spa types (n = 56) compared to MRSA isolates (n = 17), 27.2% were associated to MLST CC8, 23.7% were resistant to erythromycin and clindamycin resistance exceeded 20%. CONCLUSIONS MRSA rate among bloodstream isolates in Peru was 50%, with MLST CC5/t149/SCCmec I representing the most frequent clone.

Common Mental Disorders in Public Transportation Drivers in Lima, Peru

Background Traffic related injuries are leading contributors to burden of disease worldwide. In developing countries a high proportion of them can be attributed to public transportation vehicles. Several mental disorders including alcohol and drug abuse, psychotic disorders, mental stress, productivity pressure, and low monetary income were found predictors of high rates of traffic related injuries in public transportation drivers. The goal of this study was to estimate the prevalence of common mental disorders in the population of public transportation drivers of buses and rickshaws in Lima, Peru. Methodology/Principal Findings Cross sectional study. A sample of bus and rickshaw drivers was systematically selected from formal public transportation companies using a snowball approach. Participants completed self-administered questionnaires for assessing major depressive episode, anxiety symptoms, alcohol abuse, and burnout syndrome. Socio demographic information was also collected. The analyses consisted of descriptive measurement of outcomes taking into account both between and within cluster standard deviation (BCSD and WCSD). A total of 278 bus and 227 rickshaw drivers out of 25 companies agreed to participate in the study. BCSD for major depressive episode, anxiety symptoms and burnout syndrome was not found significant (p>0.05). The estimated prevalence of each variable was 13.7% (IC95%: 10.7–16.6%), 24.1% (IC95%: 19.4–28.8%) and 14.1% (IC95%: 10.8–17.4%) respectively. The estimated prevalence of alcohol abuse was 75.4% (IC95%: 69–81.7%, BCSD = 12.2%, WCSD = 41.9%, intra class correlation (ICC): 7.8%). Conclusion Common mental disorders such as alcohol abuse, major depressive episode, anxiety symptoms and burnout syndrome presented higher rates in public transportation drivers than general population.

Efficacy and tolerability of two single-day regimens of triclabendazole for fascioliasis in Peruvian children.

INTRODUCTION The therapeutic scheme of triclabendazole (TCBZ), the recommended anthelmintic against Fasciola hepatica , involves 10mg/kg of body weight administered in a single dose; however, clinical trials in children are scarce. We evaluated the efficacy and tolerability of 2 schemes of TCBZ. METHODS Eighty-four Peruvian children with F. hepatica eggs in their stools were allocated into 2 groups: 44 received 2 dosages of 7.5mg/kg each with a 12-h interval (Group I), and 40 received a single 10-mg/kg dose (Group II). Evaluation of efficacy was based on the presence of eggs in stools, and tolerability was based on the presence of symptoms and signs post-treatment. RESULTS A parasitological cure was obtained in 100% of individuals from Group I and 95% of individuals from Group II. The most common adverse event was biliary colic. CONCLUSIONS The tested scheme was efficacious and tolerable, and it might be an optimal scheme in the region. To the best of our knowledge, this represents the largest series of children treated with TCBZ in a non-hospital setting.

Mortality caused by bacteremia Escherichia coli and Klebsiella spp. extended-spectrum beta-lactamase- producers: a retrospective cohort from a hospital in Lima, Peru

OBJECTIVES To evaluate the factors associated to mortality caused by bacteremia due to Escherichia coli and Klebsiella spp. producers of extended-spectrum beta-lactamase (ESBL). MATERIALS AND METHODS We performed a retrospective cohort study, including 85 patients older than 16 and diagnosed with bacteremia by Escherichia coli or Klebsiella spp., hospitalized between 2006 and 2008 in Cayetano Heredia National Hospital. Cohorts were classified according to the ESBL production following blood culture results. Factors associated to gross and attributable mortality were evaluated using the Poisson regression in a multivariate model, through which adjusted relative risks (ARRs) were obtained. Mortality curves were also built. RESULTS 35.3% of bacteremia cases were caused by ESBL-producing strains. The analysis of gross mortality showed a higher mortality rate in the group with ESBL producing strains (63.3%), ARR being 1.5 (CI 95%: 1.02-2.3). In the case of the attributable mortality, the proportion was also higher (63.3%), ARR being 1.9 (CI 95%: 1.2-2.9). The use of a central venous catheter was another factor associated to both gross mortality (ARR= 2.4; CI 95%: 1.2-4.8) and attributable mortality (ARR= 3.8; CI 95%: 1.6-8.8). CONCLUSIONS The production of ESBL is an independent risk factor for bacteremia mortality caused by E. coli and Klebsiella spp. Its presence should be evaluated following diagnosis consideration and initial therapy elaboration, which could in turn decrease the mortality by this cause.Objetivos. Evaluar los factores asociados a la mortalidad causada por bacteriemias por Escherichia coli y Klebsiella spp. productoras de beta lactamasas de espectro extendido (BLEE). Materiales y Metodos. Se realizo un estudio de cohortes retrospectivo, que incluyo 85 pacientes mayores de 16 anos con diagnostico de bacteriemia por Escherichia coli o Klebsiella spp. hospitalizados entre 2006 y 2008 en el Hospital Nacional Cayetano Heredia. Las cohortes se clasificaron de acuerdo a la produccion de BLEE segun los resultados de los hemocultivos. Se evaluaron los factores asociados a la mortalidad cruda y atribuible empleando regresion de Poisson en un modelo multivariado, con lo que se obtuvo riesgos relativos ajustados (RRa). Ademas, se construyeron curvas de mortalidad. Resultados. Se encontro que el 35,3% de las bacteriemias fueron debidas a cepas productoras de BLEE. El analisis de la mortalidad cruda mostro una mayor mortalidad en el grupo de cepas productoras de BLEE (63,3%). El RRa fue de 1,5 (IC95%: 1,02-2,3). En el caso de mortalidad atribuible, la proporcion tambien fue mayor (63,3%), el RRa fue de 1,9 (IC95%: 1,2-2,9). El uso de cateter venoso central fue otro factor asociado tanto a la mortalidad cruda (RRa= 2,4; IC95%: 1,2- 4,8) como a la mortalidad atribuible (RRa= 3,8; IC95%: 1,6-8,8). Conclusiones. La produccion de BLEE es un factor de riesgo independiente para mortalidad por bacteriemia causada por E. coli y Klebsiella spp. Su presencia debe evaluarse tras la sospecha diagnostica y la elaboracion de la terapeutica inicial, lo que podria disminuir la mortalidad por esta causaObjetivos. Evaluar los factores asociados a la mortalidad causada por bacteriemias por Escherichia coli y Klebsiella spp. productoras de beta lactamasas de espectro extendido (BLEE). Materiales y Metodos. Se realizo un estudio de cohortes retrospectivo, que incluyo 85 pacientes mayores de 16 anos con diagnostico de bacteriemia por Escherichia coli o Klebsiella spp. hospitalizados entre 2006 y 2008 en el Hospital Nacional Cayetano Heredia. Las cohortes se clasificaron de acuerdo a la produccion de BLEE segun los resultados de los hemocultivos. Se evaluaron los factores asociados a la mortalidad cruda y atribuible empleando regresion de Poisson en un modelo multivariado, con lo que se obtuvo riesgos relativos ajustados (RRa). Ademas, se construyeron curvas de mortalidad. Resultados. Se encontro que el 35,3% de las bacteriemias fueron debidas a cepas productoras de BLEE. El analisis de la mortalidad cruda mostro una mayor mortalidad en el grupo de cepas productoras de BLEE (63,3%). El RRa fue de 1,5 (IC95%: 1,02-2,3). En el caso de mortalidad atribuible, la proporcion tambien fue mayor (63,3%), el RRa fue de 1,9 (IC95%: 1,2-2,9). El uso de cateter venoso central fue otro factor asociado tanto a la mortalidad cruda (RRa= 2,4; IC95%: 1,2- 4,8) como a la mortalidad atribuible (RRa= 3,8; IC95%: 1,6-8,8). Conclusiones. La produccion de BLEE es un factor de riesgo independiente para mortalidad por bacteriemia causada por E. coli y Klebsiella spp. Su presencia debe evaluarse tras la sospecha diagnostica y la elaboracion de la terapeutica inicial, lo que podria disminuir la mortalidad por esta causa

Espondilitis tuberculosa en adultos: revisión de una serie de casos en un hospital de tercer nivel, Lima-Perú

We describe the demographic and clinical characteristics of adult patients with tuberculous spondylitis as well as an exploratory analysis that seeked to establish patient characteristics that contributed to the development of this disorder at a reference hospital in Lima. This is a case-series descriptive study where data collection from 33 medical records of patients from 1999 to 2009 was done. Eighteen (55%) were male. Median age was 31 years (IQR 23 to 51 years). Median time of symptoms was 3 months (IQR 1 to 8 months). The most frequent symptom was back pain in 28 (85%). The most frequently affected areas were the thoracic spine involved in 28 (60%) cases and lumbar spine in 13 (28%). Pulmonary tuberculosis was present in fourteen (42%) cases. Twenty four (73%) patients received first line treatment. Treatment duration was 10.5 ± 4.2 months. Clinical and diagnostic characteristics were similar to previous Peruvian case reports and current literature.