Nanci Silva

Evaluation of blood stream infections by Candida in three tertiary hospitals in Salvador, Brazil: a case-control study

Invasive infections caused by Candida spp. are an important problem in immunocompromised patients. There is scarce data on the epidemiology of blood stream candidiasis in Salvador, Brazil. This study evaluates the risk factors associated with candidemia, among patients admitted to three tertiary, private hospitals, in Salvador, Brazil. We conducted a case-control, retrospective study to compare patients with diagnosis of candidemia in three different tertiary hospitals in Salvador, Brazil. Patients were matched for nosocomial, acquired infections, according to the causal agent: cases were defined by positive blood cultures for Candida species. Controls were those patients who had a diagnosis of systemic bacterial infection, with a positive blood culture to any bacteria, within the same time period (+/- 30 days) of case identification. The groups were compared for the main known risk factors for candidemia and for mortality rates. A hundred thirty-eight patients were identified. Among the 69 cases, only 14 were diagnosed as infected by Candida albicans. Candida species were defined in only eight cultures: C. tropicalis (4 cases), C. glabrata, C. parapsilosis, C. guillermondi, C. formata (1 case each). The main risk factors, identified in a univariate analysis, were: presence of a central venous catheter (CVC), use of parenteral nutrition support (PNS), previous exposure to antibiotics, and chronic renal failure (CRF). No association was detected with surgical procedures, diabetes mellitus, neutropenia or malignancies. Patients were more likely to die during the hospitalization period, but the rates of death caused by the infections were similar for cases and controls. The length of hospitalization was similar for both groups, as well as the time for a positive blood culture. Blood stream infection by Candida spp. is associated with CVC, PNS, previous use of antibiotics, and CRF. The higher mortality rate for cases probably better reflects the severity of the underlying diseases, than as a direct consequence of Candidemia.

Trypanosoma cruzi meningoencephalitis in HIV-infected patients

Five cases of Trypanosoma cruzi meningoencephalitis in HIV-infected patients are reported. All patients presented with mass lesions on head computed tomographic scan, trypanosomes in the cerebrospinal fluid and failure to respond to antitoxoplasmosis therapy. Benznidazole therapy was associated with clinical improvement in 1 patient. Another 4 patients had T cruzi identified in a peripheral smear. T cruzi needs to be considered in the differential diagnosis of HIV-infected patients with central nervous system mass lesions if they have a history of appropriate exposure.

Risk Factors for Infection by Extended-Spectrum Beta-Lactamase Producing Klebsiella pneumoniae in a Tertiary Hospital in Salvador, Brazil

UNLABELLED Nosocomial infection caused by extended-spectrum beta-lactamase producing Klebsiella pneumoniae (ESBL-Kp) have been frequently reported worldwide. We have no information on such problems in Bahia, Brazil. OBJECTIVES Evaluate the risk factors for nosocomial infections caused by ESBL-Kp, in a tertiary hospital, in Bahia, Brazil. MATERIAL AND METHODS We evaluated all reported cases of nosocomial infections caused by ESBL-Kp in a private, tertiary hospital, in Salvador, Brazil, from 2000 through 2004. We compared patients with a diagnosis of ESBL-Kp (cases) and patients infected by non-ESBL producing K. pneumoniae (controls). Mean age, underlying disease, and frequency of invasive procedures were compared between the two groups. History of previous use of antibiotics was also analyzed. RESULTS Based on multivariate analysis, previous use of antibiotics, diagnosis of malignant diseases, and diabetes mellitus were independent risk factors for acquisition of ESBL-Kp infection. No correlation was found for age, use of corticosteroids, diagnosis of chronic renal failure or AIDS, and infection by ESBL-Kp. CONCLUSION Our findings suggest that the use of antibiotics or underlying disease that increases the chance of antibiotic are the main risk factors for ESBL-Kp infections. Programs focusing on rational use of antibiotics are mandatory for prevention and control of such infections.

Temporal evolution of the prevalence of methicillin-resistant Staphylococcus aureus in a tertiary hospital in Bahia, Brazil: a nine-year evaluation study

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) have become an increasing problem in Brazilian hospitals within the last years. In Bahia, there is scarce information on the epidemiological characteristics of MRSA infections and their determinants. The objective of this study was to evaluate the temporal evolution of MRSA infections in a private, tertiary hospital, in Salvador, the capital of the state of Bahia. We reviewed the microbiological records of bacterial isolates from the Hospital Espanhol, a 300 bed, general hospital, in Salvador. We analyzed the frequency of positive cultures for S. aureus during the last nine years, the prevalence of MRSA, and the spatial distribution of the isolates in the hospital. We also evaluated the temporal evolution of MRSA during the study period. Seven-hundred-ten cultures were positive for S. aureus from 1996 through 2004. The prevalence of MRSA was 28%. The intensive care unit (59%), the hemodyalisis unit (43%), and the infectious diseases unit (34%) presented with significantly higher prevalence of MRSA, when compared to the remaining clinics of the hospital. We detected a significant increase of MRSA isolation among patients with nosocomial infections, over time (P<0.0001). MRSA isolates were highly resistant to alternative drugs (clyndamicin, erythromycin, co-trimexazole, levofloxacin), reinforcing the likelihood of nosocomial acquisition of the pathogen. The overall prevalence of MRSA in the hospital has remained relatively stable within the last nine years, but there was a significant trend forincreasing nosocomial acquisition of MRSA over time, which is even higher for patients attended in intensive care units, HDU, or IDU.

Evaluation of Efficacy and Safety of Itraconazole Oral Solution for the Treatment of Oropharyngeal Candidiasis in AIDS Patients

This study was a non-comparative multicenter clinical trial to evaluate the efficacy and tolerability of itraconazole oral solution 200 mg/day (100 mg twice a day in the fasting state) for the treatment of oropharyngeal candidiasis in AIDS patients. We included 50 patients who were treated and followed for up to 3 weeks after ending therapy in the analysis. Mycological cures at the end of therapy occurred in 20/50 patients (40%), but colonization by Candida sp. was recorded in 42/50 (84%) by the end of follow-up. A high rate of clinical response was observed in 46/50 (92%), and the response was sustained for up to 21 days after stopping therapy in 24/46 patients (52%). Clinical relapses were documented among 22 patients, but all causative fungal organisms associated with a relapse were susceptible to itraconazole. There were many patients with persistence or recurrence of Candida, but without mucositis. Relapse of Candida mucositis was significantly related to low levels of CD(4) lymphocytes exhibited by symptomatic patients. The drug was well tolerated by all but 1 patient. We conclude that itraconazole oral solution (100 mg bid for 7-14 days) is a well tolerated and effective treatment for suppressing the symptoms of oropharyngeal candidiasis in AIDS patients. Patients with severe immunosuppression may relapse and require frequent cycles of treatment or longterm suppressive therapy.

The influence of CD4+ T cells, HIV disease stage and zidovudine on HIV isolation in Bahia, Brazil.

HIV-1 isolation was attempted on 72 individuals, including persons with known HIV infection and five without proven HIV infection but with indeterminate Western blot patterns, as well as on low-risk HIV seronegative persons. The ability to detect HIV-1 from culture supernatant by p24 antigen capture assay was evaluated by segregating patients by absolute CD4+ cell counts, clinical stage of disease, p24 antigenemia and zidovudine use. The likelihood of a p24 positive HIV culture was highest among patients with CD4+ T-cell counts below 200/ul and patients with advanced clinical disease. Use of zidovudine did not affect the rate of HIV positivity in cultures.

Identificação de isosporíase em pacientes com síndrome de imunodeficiência adquirida em Salvador, Bahia

In the US only .2% of AIDS patients are afflicted with Isospora belli infection in Brazil less than 1% of patients were diagnosed with isosporosis while in Haiti 15% present with this infection. 7 cases of AIDS with chronic diarrhea caused by this infection are presented. The diagnosis of isosporosis was established by the direct stool examination using the modified Ziehl-Neelsen coloration test. All patients were treated with 800 mg of sulfamethoxazole and 160 mg of trimetoprim orally 4 times/day for 10 days subsequently 2 times/day for 2 weeks and maintaining a daily dose 3 times/week for prophylaxis of recurrence. The patients had watery diarrhea without mucus or blood with 11 +or- 3 evacuations/day accompanied by diffuse abdominal pain. Treatment resolved the diarrhea within 3.5 +or- 1.7 days. Diarrhea is a common symptom in AIDS patients. 76 (69%) of 110 AIDS patients in Bahia had diarrhea and the identification of the etiologic agent occurred in only 28 (37%) of these. The above coloration method for the detection of the coccidia Isospora belli and Cryptosporidium sp. should be included in routine diagnostic investigation of patients with diarrhea and AIDS since this would facilitate the detection of a treatable infection whose incidence is probably underestimated by means of a simple and noninvasive method.