Maria Luiza Moretti

Consenso em paracoccidioidomicose

1.Departamento de Molestias Infecciosas e Parasitarias da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP. 2. Departamento de Saude Comunitaria da Universidade Federal do Parana, Curitiba, PR. 3. Departamento de Doencas Tropicais e Diagnostico por Imagem da Faculdade de Medicina Botucatu da Universidade Estadual de Sao Paulo, Sao Paulo, SP. 4. Departamento de Medicina da Escola Paulista de Medicina, Sao Paulo, SP. 5. Departamento de Clinica Medica da Faculdade Ciencias Medicas da Universidade Estadual de Campinas, Campinas, SP. *Consultores do Consenso em Paracoccidioidomicose: Adriana Kono, Antonia Terezinha Tresoldi, Bodo Wanke, Carlos Roberto Carvalho, Gil Benard, Luiz Carlos Severo, Marcelo Simao Ferreira, Mario Leon Silva Vergara, Roberto Martinez, Rogerio Jesus Pedro, Silvio Alencar Marques, Zarifa Khoury. Patrocinio sem conflito de interesse com entidades privadas: Sociedade Brasileira de Medicina Tropical, Sociedade Brasileira de Infectologia e Sociedade Paulista de Infectologia. Endereco para correspondencia: Dra. Maria Aparecida Shikanai-Yasuda. Laboratorio de Imunologia. Av. Eneias de Carvalho Aguiar 500, Terreo, Sala 4, 05403-000 Sao Paulo, Brasil. Tel: 11 3066-7048, Fax:11 3069-7507 e-mail: lim48imuno@yahoo.com.br Recebido para publicacao em 20/5/2006 Aceito em 2/6/2006 1. INTRODUCAOUniversidade de Sao Paulo Faculdade de Medicina Departamento de Molestias Infecciosas e Parasitarias

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical.

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Postexposure prophylaxis after sexual assaults: a prospective cohort study.

Objective: The objective of this study was to evaluate HIV postexposure prophylaxis (PEP) protocol in rape victims. Study: The victims were assigned to 1 of 3 categories, according to the severity of exposure (I—low, II—moderate, III—high). HIV PEP was provided to victims in groups II (Zdv + 3TC) and III (Zdv + 3TC + PI) until 72 hours after exposure. The follow-up was 6 months. Results: From May 1997 to October 2001, 347 victims were attended. PEP was offered to 278 victims (141 in group II and 137 in group III). Side effects were more common in group III (P <0.01). No seroconversion was diagnosed in the 180 victims that completed the follow-up. Univariate analysis showed that the schooling level, knowledge of the aggressors HIV status, and the use of PEP were associated with compliance. Conclusions: Triple therapy was associated with side effects, which suggested that drug regimes should be reviewed. The variables related to a high risk of HIV transmission were also significant for compliance.

Is the incidence of candidemia caused by Candida glabrata increasing in Brazil? Five-year surveillance of Candida bloodstream infection in a university reference hospital in southeast Brazil

From 2006 to 2010, a retrospective study was conducted in a university referral tertiary care hospital to study the frequency and distribution of Candida species in different medical specialties. The use of mechanical ventilation, central venous catheter, and urinary catheter were recorded per 1,000 patient-days and the use of antifungals was calculated using defined daily dose (DDD). A total of 313 episodes were identified and the overall incidence was 0.54 (0.41-0.71) episodes per 1,000 patient-days. Candida albicans caused 44% of the overall episodes, followed by C. tropicalis (21.7%), C. parapsilosis (14.4%), C. glabrata (11.2%), and C. krusei (3.5%). The incidence of C. glabrata significantly increased from 2006-2010 (range: 4.8-23.5%) (P = 0.024). Candida glabrata was associated with malignancies (P = 0.004) and C. krusei with hematologic malignancies (P < 0.0001). The use of antifungals was higher in the hematology/bone marrow transplant units and represented 40% of all fluconazole prescription in the hospital. There was no correlation with the use of fluconazole and the increasing ratio of C. glabrata (r = 0.60). The use of invasive devices was significantly higher in the intensive care units (ICUs) than the medical and surgical emergencies units (P < 0.001). In contrast, the emergencies had higher incidence of candidemia (2-2.1 episodes/1,000 patient-days) than the ICUs (1.6 episodes 1,000 patient-days). Candida glabrata candidemia showed a significant increase in contrast to the current national literature where C. parapsilosis remained the most important non-C. albicans Candida species in Brazilian hospitals. Our findings suggested that the increasing incidence of C. glabrata was not associated with use of fluconazole and other risk factors might play an important role.

Consenso em criptococose: 2008

Divisao de Clinica de Molestias Infecciosas Hospital das Clinicas Universidade de Sao Paulo, Sao Paulo, SP

Epidemiology and predictors of a poor outcome in elderly patients with candidemia

BACKGROUND Candidemia affects patient populations from neonates to the elderly. Despite this, little information is available about the epidemiology of candidemia in elderly patients. METHODS We performed a retrospective analysis of 987 episodes of candidemia in adults (>14 years of age) from the databases of three laboratory-based surveys of candidemia performed at 14 tertiary care hospitals. Patients aged ≥60 years were considered elderly (group 1, n=455, 46%) and were compared to younger patients (group 2, n=532, 54%) regarding demographics, underlying diseases, comorbidities, exposure to medical procedures, species, treatment, and outcome. RESULTS The median APACHE II score was significantly higher in the elderly patients (19 vs. 15, p=0.03). Variables that were observed significantly more frequently in elderly patients included admission to an intensive care unit, diabetes mellitus, renal failure, cardiac disease, lung disease, receipt of antibiotics or H2 blockers, insertion of a central venous catheter, mechanical ventilation, and candidemia due to Candida tropicalis. The 30-day mortality of elderly patients was significantly higher than that of younger patients (70% vs. 45%, p<0.001). Factors associated with higher mortality by multivariate analysis included APACHE II score and being in group 1 (elderly). Factors associated with mortality in elderly patients were lung disease and the receipt of mechanical ventilation. CONCLUSIONS Elderly patients account for a substantial proportion of patients with candidemia and have a higher mortality compared to younger patients.

Antifungal Drug Susceptibility Profile of Pichia anomala Isolates from Patients Presenting with Nosocomial Fungemia

ABSTRACT In vitro susceptibility of 58 isolates of Pichia anomala to five antifungal drugs using two broth microdilution methods (CLSI and EUCAST) was analyzed. Low susceptibility to itraconazole was observed. Fluconazole, voriconazole, amphotericin B, and caspofungin showed good antifungal activity, although relatively high drug concentrations were necessary to inhibit the isolates.

Human cryptococcosis: relationship of environmental and clinical strains of Cryptococcus neoformans var. neoformans from urban and rural areas.

Forty-five clinical and 55 environmental strains of Cryptococcus neoformans var. neoformans from São Paulo, Brazil, were tested for their susceptibilities to amphotericin B, fluconazole, itraconazole, and flucytosine by the broth microdilution method according to the National Committee of Clinical Laboratory Standards guidelines. Electrophoretic karyotypes analysis by counter-clamped homogeneous electrophoresis was used to compare their genetic relatedness. Molecular typing revealed three clinical profiles very similar to two environmental profiles and an identical environmental and clinical profile. The results showed that human cryptococcosis can be acquired from environmental strains, which had similar minimum inhibitory concentration values to clinical strains, for antifungal agents.

Staphylococcus aureus nasal colonization in HIV outpatients: Persistent or transient?

BACKGROUND Staphylococcus aureus nasal carriage in HIV patients remains incompletely characterized. The aim of the present study was to describe epidemiologic and molecular features of S. aureus nasal colonization in HIV outpatients. METHODS HIV outpatients with no history of hospitalization within the previous 2 years were screened for S aureus nasal colonization. Three samples were collected from each patient, and the risk factors for colonization were assessed. Nasal carriage was classified as persistent colonization, transient colonization, or no colonization. Persistent colonization was subdivided into simple (same DNA profile) or multiple (different DNA profiles) using pulsed-field gel electrophoresis (PFGE) for genotyping the strains of S. aureus. RESULTS A total of 111 patients were evaluated, of which 70 (63.1%) had at least 1 positive culture for S aureus. Patients in clinical stages of AIDS were more likely to be colonized than non-AIDS patients (P = .02). Among the patients with S aureus nasal carriage, 25.2% were transient carriers and 39.4% were persistent carriers. PFGE analysis showed that the persistent colonization was simple in 24 patients and multiple in 17 patients. CONCLUSION The HIV patients had a high rate of S. aureus nasal colonization. The most common characteristic of colonization was simple persistent colonization showing the same genomic profile.

Development of cycling probe-based real-time PCR system to detect Fusarium species and Fusarium solani species complex (FSSC)

In the present study, we developed a new real-time PCR system based on the cycling probe technology (CPT), which is composed of two single tube real-time PCR assays: the Fusarium genus-specific assay and the Fusarium solani species complex (FSSC)-specific assay with primers targeting the 28s ribosomal RNA gene. The Fusarium genus-specific assay was shown to be highly specific, detecting all reference Fusarium strains with no cross-reaction with other reference fungal strains, such as Aspergillus spp. and human DNA. The FSSC-specific assay also reacted very specifically with FSSC, except for a cross-reaction with Fusarium lunatum. To validate the real-time PCR system, we tested 87 clinical isolates of Fusarium spp. Identification results from the real-time PCR system were found to be 100% concordant with those from DNA sequencing of EF-1α gene. The sensitivity testing also demonstrated high sensitivity, enabling detection of one copy of standard DNA with good reproducibility. Furthermore, both assays were shown to be extremely sensitive even when fungal cells were mixed with human cells, detecting 3 germinated conidia spiked in 3mL of human blood. To apply our new real-time PCR system to the molecular diagnosis of fusariosis, we evaluated its efficacy using a mouse model of invasive F. solani infection. Plasma and whole blood samples of infected mice were tested using the real-time PCR system. The sensitivity of the real-time PCR system was found to be 100% (n=4) in plasma samples. In contrast, no amplification signal was detected in whole blood samples. This system could provide a rapid and precise diagnostic tool for early diagnosis, which is necessary for appropriate treatment and improvement of prognosis of disseminated fusariosis.