Rodrigo Pires dos Santos

Hemoplasma infection in HIV-positive patient, Brazil.

Hemotrophic mycoplasmas infect a variety of mammals. Although infection in humans is rarely reported, an association with an immunocompromised state has been suggested. We report a case of a Mycoplasma haemofelis–like infection in an HIV-positive patient co-infected with Bartonella henselae.

Ehrlichiosis in Brazil.

Erliquiose e uma doenca causada por rickettsias pertencentes ao genero Ehrlichia. No Brasil, estudos sorologicos e moleculares tem avaliado a ocorrencia de especies de Ehrlichia em caes, gatos, animais selvagens e seres humanos. Ehrlichia canis e a principal especie em caes no Brasil, embora a infeccao por E. ewingii tenha, recentemente, despertado suspeita em cinco caes. O DNA de E. chaffeensis foi detectado e caracterizado em cervo-do-pantanal, enquanto que E. muris e E. ruminantium ainda nao foram identificadas no Brasil. A erliquiose monocitica canina causada pela E. canis parece ser altamente endemica em muitas regioes do Brasil, embora dados de prevalencia nao estejam disponiveis em muitas delas. O DNA de E. canis tambem foi detectado e caracterizado em tres gatos domesticos, enquanto anticorpos contra E. canis foram detectados em felideos neotropicais de vida livre. Evidencias sorologicas sugerem a ocorrencia de erliquiose humana no Brasil, entretanto, o agente etiologico ainda nao foi identificado. A melhoria do diagnostico molecular promovera a identificacao e caracterizacao de especies associadas a erliquiose humana no Brasil.Ehrlichiosis is a disease caused by rickettsial organisms belonging to the genus Ehrlichia. In Brazil, molecular and serological studies have evaluated the occurrence of Ehrlichia species in dogs, cats, wild animals and humans. Ehrlichia canis is the main species found in dogs in Brazil, although E. ewingii infection has been recently suspected in five dogs. Ehrlichia chaffeensis DNA has been detected and characterized in mash deer, whereas E. muris and E. ruminantium have not yet been identified in Brazil. Canine monocytic ehrlichiosis caused by E. canis appears to be highly endemic in several regions of Brazil, however prevalence data are not available for several regions. Ehrlichia canis DNA also has been detected and molecularly characterized in three domestic cats, and antibodies against E. canis were detected in free-ranging Neotropical felids. There is serological evidence suggesting the occurrence of human ehrlichiosis in Brazil but its etiologic agent has not yet been established. Improved molecular diagnostic resources for laboratory testing will allow better identification and characterization of ehrlichial organisms associated with human ehrlichiosis in Brazil.

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.

Hand hygiene, and not ertapenem use, contributed to reduction of carbapenem-resistant Pseudomonas aeruginosa rates.

OBJECTIVE To evaluate the impact of ertapenem use in Pseudomonas aeruginosa carbapenem resistance, taking into account the volume of antimicrobial consumption, the consumption by the entire hospital of alcohol-based antiseptic hand rub, and the density rate of invasive practices. DESIGN Before-and-after trial. SETTING A tertiary care university hospital in southern Brazil. METHODS Ertapenem was first added to the hospital formulary in June 2006, and it was excluded in February 2009. We evaluated Pseudomonas aeruginosa resistance rates through 3 study periods: period 1, before ertapenem use (17 months); period 2, during ertapenem use (33 months); and period 3, after exclusion of ertapenem (15 months). RESULTS After introduction of ertapenem, there was a significant decrease in median consumption of imipenem or meropenem, from 2.6 to 2.2 defined daily doses (DDDs) per 100 patient-days (level change from 0.04 to -1.08; P < .01), and an increase in the use of these medications after ertapenem exclusion, from 2.2 to 3.3 DDDs per 100 patient-days (level change from -0.14 to 0.91; P < .01), by segmented regression analysis. There was no difference in the incidence density of carbapenem-resistant P. aeruginosa infection related to ertapenem use throughout the study periods. However, by multiple regression analysis, the reduction in the rate of carbapenem-resistant P. aeruginosa infection correlated significantly with the increase in the volume of alcohol used as hand sanitizer, which was from 660.7 mL per 100 patient-days in period 1 to 2,955.1 mL per 100 patient-days in period 3 (P = .04). Ertapenem use did not impact the rate of carbapenem-resistant P. aeruginosa infection. CONCLUSIONS Use of alcohol-based hand gel, rather than ertapenem, was associated with a reduction in the rates of carbapenem-resistant P. aeruginosa infection. Measures to reduce resistance must include factors other than just antimicrobial stewardship programs alone.

Comparative radiological features of disseminated disease due to Mycobacterium tuberculosis vs non- tuberculosis mycobacteria among AIDS patients in Brazil

BackgroundDisseminated mycobacterial disease is an important cause of morbidity and mortality in patients with HIV-infection. Nonspecific clinical presentation makes the diagnosis difficult and sometimes neglected.MethodsWe conducted a retrospective cohort study to compare the presentation of disseminated Mycobacterial tuberculosis (MTB) and non-tuberculous Mycobacterial (NTM) disease in HIV-positive patients from 1996 to 2006 in Brazil.ResultsTuberculosis (TB) was diagnosed in 65 patients (67.7%) and NTM in 31 (32.3%) patients. Patients with NTM had lower CD4 T cells counts (median 13.0 cells/mm3versus 42.0 cells/mm3, P = 0.002). Patients with tuberculosis had significantly more positive acid-fast smears (48.0% vs 13.6%, P = 0.01). On chest X-ray, miliary infiltrate was only seen in patients with MTB (28.1% vs. 0.0%, P = 0.01). Pleural effusion was more common in patients with MTB (45.6% vs. 13.0%, P = 0.01). Abdominal adenopathy (73.1% vs. 33.3%, P = 0.003) and splenic hypoechoic nodules (38.5% vs. 0.0%, P = 0.002) were more common in patients with TB.ConclusionMiliary pulmonary pattern on X-ray, pleural effusion, abdominal adenopathy, and splenic hypoechoic nodules were imaging findings associated with the diagnosis of tuberculosis in HIV-infected patients. Recognition of these imaging features will help to distinguish TB from NTM in AIDS patients with fever of unknown origin due to disseminated mycobacterial disease.

Evaluation of respiratory syncytial virus group A and B genotypes among nosocomial and community-acquired pediatric infections in southern Brazil

BackgroundRespiratory syncytial virus (RSV) is the main cause of lower respiratory tract illness in children worldwide. Molecular analyses show two distinct RSV groups (A and B) that comprise different genotypes. This variability contributes to the capacity of RSV to cause yearly outbreaks. These RSV genotypes circulate within the community and within hospital wards. RSV is currently the leading cause of nosocomial respiratory tract infections in pediatric populations. The aim of this study was to evaluate the G protein gene diversity of RSV amplicons.MethodsNasopharyngeal aspirate samples were collected from children with nosocomial or community-acquired infections. Sixty-three RSV samples (21 nosocomial and 42 community-acquired) were evaluated and classified as RSV-A or RSV-B by real-time PCR. Sequencing of the second variable region of the G protein gene was performed to establish RSV phylogenetics.ResultsWe observed co-circulation of RSV-A and RSV-B, with RSV-A as the predominant group. All nosocomial and community-acquired RSV-A samples were from the same phylogenetic group, comprising the NA1 genotype, and all RSV-B samples (nosocomial and community-acquired) were of the BA4 genotype. Therefore, in both RSV groups (nosocomial and community-acquired), the isolates belonged to only one genotype in circulation.ConclusionsThis is the first study to describe circulation of the NA1 RSV genotype in Brazil. Furthermore, this study showed that the BA4 genotype remains in circulation. Deciphering worldwide RSV genetic variability will aid vaccine design and development.

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.

Risk factors for multidrug-resistant bacteremia in hospitalized cancer patients with febrile neutropenia: A cohort study

We conducted a prospective cohort study in a single tertiary hospital with the aim of assessing predictors of multidrug-resistant bacteremia in 307 cases of febrile neutropenia in adult patients with cancer. On multivariate analysis using stepwise logistic regression, age (P = .009), duration of neutropenia (P = .022), and presence of an indwelling central venous catheter (P = .022) were associated with bloodstream infection by multidrug-resistant bacteria.

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.

Disseminated Histoplasma capsulatum and Cryptococcus neoformans Co-Infection in Patients with AIDS

Histoplasmosis and cryptococcosis are the most prevalent systemic mycoses in HIV-infected patients. The authors report a 20-year-old Brazilian HIV-positive woman with concomitant disseminated histoplasmosis and cryptococcosis. In addition, we review the reported cases described in the medical literature.