Effects of bulk tank milk, waste milk, and pasteurized waste milk on the nutrient utilization, gastrointestinal tract development, and antimicrobial resistance to Escherichia coli in preweaning dairy calves.

This study aimed to assess the effect of bulk tank milk (BTM), waste milk (WM), and pasteurized waste milk (PWM) on nutrient digestibility, ruminal and cecal fermentation, gastrointestinal tract (GIT) development, and antimicrobial resistance of fecal Escherichia coli from dairy calves at 2 periods (30 and 60 d of age). Calves were grouped according to BW, serum protein levels, and breed composition. Three treatments were included: BTM (n = 21), WM from cows under antibiotic treatment (n = 21), and PWM (WM submitted to HTST pasteurization; n = 21). A total of 63 calves were used, of which 18 animals (n = 6 per treatment) were evaluated in the period of 4 to 30 d, and 45 (n = 15 per treatment) from 4 to 60 d. During the experimental period, a daily intake of 6 L of milk was divided into 2 equal meals, with ad libitum access to water and starter. Milk and feed intakes were recorded daily. Apparent total-tract digestibility and nitrogen balance were conducted from 25 to 29 d of age (n = 6) and from 53 to 57 d of age (n = 15). Animals were slaughtered at 30 ± 1 and 60 ± 1 d of age for the assessment of ruminal and cecal fermentation and GIT development. Antimicrobial susceptibility testing was conducted at 1, 30, and 60 d of age (n = 15/treatment). Statistical analysis used a linear mixed-effects model for continuous outcomes and generalized linear models for single measurements (R software). Treatments WM and PWM had lower rumen pH, higher ruminal acetate concentration, larger reticulorumen and liver, and a higher prevalence of fecal-resistant E. coli compared with BTM at both 30 and 60 d. Up to 60 d, both BTM and WM treatments exhibited higher digestibility of ether extract and gross energy compared with the PWM, whereas WM and PWM treatments showed increased nitrogen intake and retention compared with the BTM treatment. These findings suggest that pasteurization of WM negatively affects nutrient digestibility and calf performance, while also affecting rumen development. Additionally, the use of milk containing antibiotic residue leads to the selection of resistant E. coli in the GIT over time.

Identification of bacteriophages in the vagina of pregnant women: a descriptive study.

OBJECTIVE: To determine the presence and identity of extracellular bacteriophage (phage) families, genera and species in the vagina of pregnant women. DESIGN: Descriptive, observational cohort study. SETTING: São Paulo, Brazil. POPULATION: Pregnant women at 21-24 weeks' gestation. METHODS: Vaginal samples from 107 women whose vaginal microbiome and pregnancy outcomes were previously determined were analysed for phages by metagenomic sequencing. MAIN OUTCOME MEASURES: Identification of phage families, genera and species. RESULTS: Phages were detected in 96 (89.7%) of the samples. Six different phage families were identified: Siphoviridae in 69.2%, Myoviridae in 49.5%, Microviridae in 37.4%, Podoviridae in 20.6%, Herelleviridae in 10.3% and Inviridae in 1.9% of the women. Four different phage families were present in 14 women (13.1%), three families in 20 women (18.7%), two families in 31 women (29.1%) and one family in 31 women (29.1%). The most common phage species detected were Bacillus phages in 48 (43.6%), Escherichia phages in 45 (40.9%), Staphylococcus phages in 40 (36.4%), Gokushovirus in 33 (30.0%) and Lactobacillus phages in 29 (26.4%) women. In a preliminary exploratory analysis, there were no associations between a particular phage family, the number of phage families present in the vagina or any particular phage species and either gestational age at delivery or the bacterial community state type present in the vagina. CONCLUSIONS: Multiple phages are present in the vagina of most mid-trimester pregnant women. TWEETABLE ABSTRACT: Bacteriophages are present in the vagina of most pregnant women.

The effects of increasing amounts of milk replacer powder added to whole milk on passage rate, nutrient digestibility, ruminal development, and body composition in dairy calves.

The aim of this study was to evaluate the effects on feed intake, calf performance, feed efficiency, fecal score, passage rate, apparent nutrient digestibility, development of rumen and other organs, and body composition of increasing the total solids content of liquid feed (whole milk) by adding increasing amounts of milk replacer powder during the preweaning period. Crossbred Holstein-Gyr calves (n=32) were assigned to 1 of 4 treatments (n=8 per group), which consisted of different total solids concentrations: 12.5, 15.0, 17.5, and 20.0% of liquid feed. Calves received 6 L of liquid per day, divided into 2 equal meals (0800 and 1600 h) and provided in buckets, from 5 to 55d of age. Starter and water were provided ad libitum during the entire experiment. At 56d of age, animals were killed. Laboratory analysis determined that the actual total solids contents of the liquid feed were 13.5, 16.1, 18.2, and 20.4%, for the proposed 12.5, 15.0, 17.5, and 20.0% total solids treatments, respectively. The osmolality of liquid feed treatments was 265 to 533 mOsm/L. Fecal score was similar among treatments, except for wk 2 and 7. Intake of liquid feed was similar among treatments from 6wk of age. During wk 4, 5, and 6, we detected a linear decrease in starter intake. After wk 7, we observed greater starter intake for calves fed approximately 16.1% total solids. Water intake, feed efficiency, and withers height were similar among treatments. Increasing concentrations of total solids in liquid feed quadratically affected average daily gain, final body weight, and empty body weight. We observed a greater average daily gain for calves fed approximately 20.4% total solids. Passage rate, nutrient digestibility, development of pre-stomachs and intestine, and body composition were similar among treatments. Increasing the concentration of total solids in liquid feed up to 20.4% reduced starter intake between 4 and 6wk of life, but increased average daily gain. It did not affect passage rate, nutrient digestibility, ruminal and organ development, or body composition in calves during the preweaning period, indicating that this strategy may be a viable alternative for feeding without increasing the total volume of liquid feed provided to dairy calves.

Susceptibility of multiresistant gram-negative bacteria to fosfomycin and performance of different susceptibility testing methods.

Fosfomycin may be a treatment option for multiresistant Gram-negative bacteria. This study compared susceptibility methods using 94 multiresistant clinical isolates. With agar dilution (AD), susceptibilities were 81%, 7%, 96%, and 100% (CLSI) and 0%, 0%, 96%, and 30% (EUCAST), respectively, for Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter spp. Categorical agreement between Etest and AD for Enterobacteriaceae and A. baumannii was ≥80%. Disk diffusion was adequate only for Enterobacter. CLSI criteria for urine may be adequate for systemic infections.

Risk factor for death in hematopoietic stem cell transplantation: are biomarkers useful to foresee the prognosis in this population of patients?

BACKGROUND: The morbidity and mortality in hematopoietic stem cell transplantation (HSCT) occur due to infectious complications and constitute the major clinical problems in HSCT recipients. The role of the use of biomarkers in post-HSCT patients is still controversial. OBJECTIVES: To assess the serum values of biomarkers interleukin 6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) and risk factors for post-HSCT death. PATIENTS AND METHODS: Prospective study conducted in patients submitted to HSCT at a university hospital. Biomarkers (IL-6, PCT and CRP) were assessed on the day afebrile neutropenia was detected, in the febrile event, 24 and 72 h after fever onset and 48 h or 5 days if fever persisted. Patients were compared as to the death outcome within 30 days from the HSCT. Variables with p < 0.15 were included in the multivariate analysis model (MVA) that were performed for all patients included in the study and separated for autologous and allogeneic HSCT patients. RESULTS: 296 patients with ages ranging between 15 and 70 years, neutropenic, submitted to HSCT, being 216 (73%) autologous and 80 (20%) allogeneic were assessed. One hundred and ninety (64.2%) patients presented fever after the transplantation and infection microbiologically controlled in 78 (26.4%). Twenty-three cases (7.8%) evolved to death. The risk factors associated with death in the bivariate analysis were age, allogeneic transplantation, unrelated transplantation, GVHD, bloodstream infection by Gram-negative, IL-6 >140 pg/mL and CRP ≥ 120 mg/L and the protective ones were lymphoma and hospital outpatient support. The independent variables in the MVA associated with death were allogeneic and unrelated transplantation, blood stream infection (BSI) by Gram-negative, LDH ≥ 390 UI/L, urea ≥ 25 mg/dL and CRP ≥ 120 mg/L for HSCT transplanted patients and BSI due to Gram-negative and CRP ≥ 120 mg/L for allogeneic HSCT, however, CRP ≥ 120 mg/L did not remain in the model when urea ≥ 25 mg/L was included. No independent risk factor was found for autologous patients. CONCLUSIONS: Out of the biomarkers assessed, only CRP ≥ 120 mg/L was independently associated with death. Other risk factors found were: type of transplantation (allogeneic and unrelated), bloodstream infection by Gram-negative, LDH ≥ 390 UI/L and urea ≥ 25 mg/dL. For allogeneic patients only CRP ≥ 120 mg/L and BSI due to Gram-negative were risk factors for death; however, CRP did not remain in the model when urea ≥ 25 mg/L was included.

Polymyxin use as a risk factor for colonization or infection with polymyxin-resistant Acinetobacter baumannii after liver transplantation.

INTRODUCTION: Acinetobacter baumannii is a leading agent of healthcare-associated infection. The objective of this study was to evaluate cases of colonization or infection with polymyxin-resistant A. baumannii (PRAB) in liver transplant recipients and to identify the risk factors for the acquisition of PRAB. METHODS: We evaluated all patients undergoing liver transplantation (LT) between January and November of 2011. The exclusion criterion was death within the first 72 h after transplant. Patients were screened for PRAB through weekly rectal and inguinal swabs during their stay in the intensive care unit (ICU) and at ICU discharge. Patients who came from other hospitals or had been treated in the emergency room for >72 h were screened at ICU admission. The minimum inhibitory concentrations (MICs) for polymyxins were determined by broth microdilution, and clonality was determined by pulsed-field gel electrophoresis. The stepwise logistic regression was used to identify risk factors related to acquisition of PRAB, and Cox forward regression used to identify risk factors for 60-day mortality. RESULTS: We evaluated 65 patients submitted to LT, among whom PRAB was isolated in 7, 4 of whom developed infection. The MICs for polymyxin E ranged from 16 to 128 mg/mL. All patients with PRAB required dialysis. The median time of polymyxin use before PRAB isolation was 21 days. These 4 included 1 case of primary bloodstream infection (BSI), which was treated with the carbapenem-polymyxin combination; 1 case of surgical site infection, which was treated with gentamicin, polymyxin, ampicillin-sulbactam, and tigecycline; and 2 cases of pneumonia, treated with the combination of carbapenem-polymyxin. In the case of BSI and in 1 of the cases of pneumonia, the treatment was considered successful. Mortality was 71% among the cases, compared with 33% among the non-cases. CONCLUSION: In the final model of the survival analysis, PRAB colonization or infection after LT was independently associated with mortality. One predominant clone was identified. The only risk factor identified in the multivariate analysis was polymyxin use. PRAB was an agent with high mortality, and the most important risk factor associated with colonization or infection for such bacterium was polymyxin use.

An outbreak of respiratory syncytial virus infection in hematopoietic stem cell transplantation outpatients: good outcome without specific antiviral treatment.

BACKGROUND: Respiratory syncytial virus (RSV) is a common cause of seasonal respiratory viral infection in hematopoietic stem cell transplantations (HSCT) patients. The efficacy of treatment, however, remains controversial. We describe an outbreak of 31 cases of RSV that occurred in an HSCT outpatient care unit in the fall season from March through May 2010, with a good outcome without any specific antiviral treatment. METHODS: During these 3 months, 222 nasal wash samples were tested and, of these, 31 outpatients were positive for RSV. In 2009, 99 samples had been tested and only 10 outpatients were positive for RSV in the same period. RESULTS: Seven (22.5%) patients had severe neutropenia (<500 cells/µL); severe lymphopenia (<200 cells/µL) was present in 13 (41.9%) patients, and 14 (45%) had received intravenous broad-spectrum antibiotics. Hospitalization was necessary only for 8 patients (25.8%); 20 had lower respiratory tract infection (64.5%). Only 1 patient died as a result of proven invasive aspergillosis. CONCLUSION: This report suggests that HSCT outpatients with no risk factors may not always require specific treatment for RSV.

Infection rate and risk factors associated with infections related to external ventricular drain.

OBJECTIVE: To describe incidence rates and risk factors associated with external ventricular drain (EVD)-related infections at a tertiary Brazilian teaching hospital. METHODS: The patient cohort consisted of all patients at a major teaching hospital in Brazil with an EVD during the period 1 April 2007 to 30 June 2008 (15 months). Patients were followed up for 30 days after catheter removal. According to the Center for Diseases Control and Prevention criteria for meningitis/ventriculitis, all of the central nervous system (CNS) infections that occurred during this period could be considered to be meningitis or ventriculitis related to EVD placement. Infection rates were calculated using different denominators, such as (1) per patient (incidence), (2) per procedure, and (3) per 1,000 catheter-days (drain-associated infection rate). Patient demographic data, medical history of underlying diseases, antibiotic prophylaxis usage, American Society of Anesthesiologists Score classification, duration of surgery and hospitalization, length of time the EVD was in place, and overall mortality were evaluated during the study period. A logistic regression model was developed to identify factors associated with infection. RESULTS: A total of 119 patients, 130 EVD procedures, and 839 catheter-days were evaluated. The incidence of infection was 18.3%, the infection rate was 16.9% per procedure, and the drain-associated infection rate was 22.4 per 1,000 catheter-days; 77% of the infections were caused by Gram-negative micro-organisms. Only 75% of patients received antibiotic prophylaxis. The infection rate increased with length of the hospital stay. The length of time the catheter was in place was the only independent risk factor associated with infection (p = 0.0369). CONCLUSION: The incidence of EVD-related infections is high in our hospital, Gram-negative micro-organisms were the most frequent causal agents identified and length of time that the catheter was in place contributed to the infection rate.

Impact of the reduction of environmental and equipment contamination on vancomycin-resistant enterococcus rates.

More than 1,500 perirectal swab cultures and 552 environmental and equipment cultures were collected during the study period. Enterococcus faecium was the most frequent species isolated, being responsible for 71% of the positive cultures. Fifty infections were documented, with bloodstream infections (18, 36%) being the most frequent, followed by urinary tract infection (15, 30%). An educational intervention was given to 136 healthcare workers (HCWs), and a questionnaire regarding vancomycin-resistant enterococcus (VRE) transmission was also performed pre- and post-intervention. Overall, 858 opportunities of patient care were evaluated. The compliance with contact precautions did not improve; however, in general, the proportion of correct answers regarding VRE increased significantly when comparing pre- and post-intervention periods (p < 0.05). On the other hand, the proportion of environmental and equipment contaminated by VRE decreased significantly from pre- (23.2%) to post-intervention (8.2%) (p < 0.001) and was associated with a significant decrease in VRE infection from 7.7 to 1.9 when comparing the pre- and post-intervention periods. The use of vancomycin (defined daily dose [DDD]) did not change significantly over the study period (p = 0.970), and the use of teicoplanin increased (p < 0.001). Seventy-six percent of E. faecium belong to type and subtype A by pulsed-field gel electrophoresis (PFGE). This predominant type was found in the environment and caused colonization and infection. In conclusion, the present study showed that reduction of the proportion of environmental and equipment contamination was associated with a decrease of colonization and infection due to VRE, and that the strategy to control VRE dissemination should be based on local problems.

Global point prevalence survey of antimicrobial consumption in Brazilian hospitals.

BACKGROUND: The inappropriate use of antimicrobials and increased rates of antimicrobial resistance is a challenge all over the world. Although antibiotic stewardship is recommended by the Brazilian government, data regarding antibiotic use in Brazilian hospitals are scarce. The aim of this study was to conduct a point prevalence survey of antimicrobial use in 18 Brazilian hospitals. METHODS: Eighteen Brazilian hospitals conducted the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) in 2017. The study enrolled inpatients on antimicrobials. Data collection included details on the antimicrobial prescriptions. A web-based programme was used for data-entry, validation and reporting. The Global-PPS was developed by the University of Antwerp and bioMérieux provided funding support. FINDINGS: A total of 1801 patients were evaluated, of which 941 (52.2%) were on antimicrobials. Four hundred (42.5%) patients were given at least two antimicrobials. Out of the 1317 antibacterials for systemic use, 514 (39%) were prescribed for community-acquired infections, 533 (40.5%) for healthcare-associated infections and 248 (18.8%) for prophylactic use. The most frequently used antimicrobials were ceftriaxone (12.8%), meropenem (12.3%) and vancomycin (10.3%). Pneumonia or lower respiratory tract infection was the most common site of infection (29.2%). In general, antimicrobials were given mainly parenterally (91%) and empirically (81.2%). CONCLUSIONS: A high prevalence of antibiotic use was observed in the 18 Brazilian hospitals. The antibiotics were prescribed mainly empirically. Intravenous broad-spectrum antibiotics were the most frequent antimicrobials used, showing that reinforcement of de-escalation strategy is needed. The Global-PPS data can be very useful for monitoring stewardship programmes and intervention.

Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp.

BACKGROUND: There has been an increase in worldwide infections caused by carbapenem-resistant Acinetobacter. This poses a therapeutic challenge as few treatment options are available. OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of polymyxins and ampicillin/sulbactam for treating infections caused by carbapenem-resistant Acinetobacter spp. and to evaluate prognostic factors. METHODS: This was a retrospective review of patients from two teaching hospitals who had nosocomial infections caused by carbapenem-resistant Acinetobacter spp. from 1996 to 2004. Diagnosis of infection was based on CDC criteria plus the isolation of Acinetobacter from a usually sterile site or from bronchoalveolar lavage. Urinary tract infections were not included. Data on demographic and clinical features and treatment were collected from medical records. Prognostic factors associated with two outcomes (mortality during treatment and in-hospital mortality) were evaluated. RESULTS: Eighty-two patients received polymyxins and 85 were treated with ampicillin/sulbactam. Multiple logistic regression analysis revealed that independent predictors of mortality during treatment were treatment with polymyxins, higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score, septic shock, delay in starting treatment and renal failure. On multivariate analysis, prognostic factors for in-hospital mortality were older age, septic shock and higher APACHE II score. CONCLUSIONS: This is the first study comparing current therapeutic options for infections due to carbapenem-resistant Acinetobacter. The most important finding of the present study is that ampicillin/sulbactam appears to be more efficacious than polymyxins, which was an independent factor associated with mortality during treatment.

Risk factors associated with mortality of infections caused by Stenotrophomonas maltophilia: a systematic review.

The objective of this review was to assess the quality of available literature regarding risk factors associated with mortality of infections caused by S. maltophilia. PubMed and OVID were searched from March 1985 to March 2008, and eligible studies were considered to be those that related S. maltophilia infection with risk factors associated with mortality; described the characteristics of patients in detail; and provided data regarding the outcome and mortality. Thirty-eight studies were found referring to S. maltophilia (four with multivariate analysis and 10 with univariate analysis). This review has several limitations, mainly due to the heterogeneity of patients, lack of appropriate statistical analysis and lack of definition of nosocomial and community infection studies. Data reviewed suggest that infections caused by S. maltophilia have high mortality and that the risk factors associated with mortality are related to the initial clinical condition and patient type. Underlying haematological disease in cancer patients and admission to the intensive care unit are independent risk factors associated with mortality. Shock, thrombocytopenia and Acute Physiological Assessment and Chronic Health Evaluation (APACHE) score >15 are independent risk factors associated with outcome in patients with bloodstream infection and pneumonia. Organ dysfunction is the only independent risk factor associated with death from infection caused by sulfamethoxazole-resistant S. maltophilia. The impact of adequate antimicrobial therapy and removal of central venous catheter on mortality require further clinical studies.

Investigation of an outbreak of Enterobacter cloacae in a neonatal unit and review of the literature.

Enterobacter cloacae has emerged as an important pathogen in neonatal units, with several outbreaks of infection being reported. The aim of this study was to investigate an outbreak of sepsis due to E. cloacae in a neonatal unit and to review the literature. A retrospective cohort study was conducted in which cases were compared with all newborns hospitalised for more than 48h in the neonatal intensive care unit (NICU). Cohorting of infected patients and work reorganisation were implemented. Pulsed-field gel electrophoresis was performed. The retrospective cohort included the six cases and 13 control patients that had been in the NICU during April 2006. Univariate analysis showed that the use of dobutamine was significantly associated with infection (P=0.036) and that enteral feeding was a protective factor (P=0.02). Multivariate analysis did not find any independent risk factor. Bed occupancy rate in March 2006 was 109.6%, indicating overcrowding. PFGE identified indistinguishable patterns among isolates from all six newborns. PubMed and OVID was search from 1 January 1983 to 15 January 2008 for papers including the terms 'E. cloacae', 'outbreaks', 'clusters' in combination with 'neonate', 'newborn', and 'infant'. We found 26 reports of outbreaks due to E. cloacae in neonate patients: sixteen (52%) were bloodstream infection outbreaks, of which two (12.5%) were related to multiple-dose medications. The source for our outbreak was not identified. Reinforcement of hygiene practices, restrictions on new admissions and the establishment of single-dose medications helped to control the outbreak.

Factors associated with mortality in patients with bloodstream infection and pneumonia due to Stenotrophomonas maltophilia.

Severe infections caused by Stenotrophomonas maltophilia are associated with high mortality, and strategies to improve the clinical outcome for infected patients are needed. A retrospective cohort study of patients with bloodstream infection (BSIs) and pneumonia caused by S. maltophilia was conducted. Multivariate analysis was performed to access factors associated with 14-day mortality. A total of 60 infections were identified. Among these, eight (13%) were pneumonias and 52 were BSIs; 33.3% were primary, 13% were central venous catheter (CVC)-related and 40% were secondary BSIs. Fifty-seven (85%) patients had received previous antimicrobial therapy; 88% had CVC, 57% mechanical ventilation and 75% were in the intensive care unit at the onset of infection. Malignancy (45%) was the most frequent underlying disease. The mean of the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores was 17 and for the Sepsis-related Organ Failure Assessment (SOFA) score, it was 7 points. The overall and 14-day mortality were, respectively, 75% and 48%. Forty-seven (78%) patients were treated and, of these, 74% received trimethoprim-sulfamethoxazole. Independent risk factors associated with mortality were SOFA index >6 points (0.005) and septic shock (0.03). The Kaplan-Meier estimations curves showed that patients with APACHE II score >20 and SOFA score >10 had a survival chance of, respectively, less than 8% and less than 10% (P

Epidemiology, risk factors and outcomes of multi-drug-resistant bloodstream infections in haematopoietic stem cell transplant recipients: importance of previous gut colonization.

BACKGROUND: Bloodstream infections (BSI) are a major complication in the early phase of a haematopoietic stem cell transplant (HSCT). AIM: To describe the incidence and risk factors for BSI occurring in the pre-engraftment phase of HSCT, and its impact on mortality. METHODS: Clinical variables of 232 HSCT patients were analysed retrospectively between 2014 and 2015. Univariate Cox regression analyses were performed to test the association between each covariate and the outcome. Covariates with P < 0.10 on univariate analysis were included in a multiple Cox regression analysis using a backward elimination method. FINDINGS: The cumulative incidence of BSI was 25.4%, mainly caused by Gram-negative bacteria (GNB) (55.2%). Approximately 40.5% of the patients had gut colonization by multi-drug-resistant (MDR) bacteria (vancomycin-resistant enterococcus and carbapenem-resistant GNB). Among patients colonized by MDR GNB, 20% developed an overt BSI due to MDR bacteria with the same pattern of sensitivity. Of the 13 deaths related to infection, 10 were patients with BSI caused by MDR GNB. The independent risk factors for BSI were gut colonization by MDR bacteria including GNB (P < 0.001) and duration of neutropenia >10 days (P = 0.005), and those associated with BSI caused by MDR bacteria were age >62 years (P = 0.03), use of total parenteral nutrition (TPN) (P < 0.001) and previous gut colonization by MDR GNB (P = 0.002). CONCLUSIONS: Previous gut colonization by MDR was an independent risk factor for BSI, together with TPN and age, and had an impact on outcome. These findings suggest that gut decolonization may be a potential strategy to prevent BSI.

Vancomycin-resistant enterococci isolates colonizing and infecting haematology patients: clonality, and virulence and resistance profile.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are an important agent of colonization and infection in haematology patients. However, the role of virulence on VRE colonization and infection is controversial. AIM: To characterize the lineage, virulence and resistance profile of VRE infection and colonization isolates; as well as their impact on outcome of haematology patients using a regression logistic model. METHODS: Eighty-six isolates (80 Enterococcus faecium and six E. faecalis) from 76 patients were evaluated. Polymerase chain reaction for resistance and virulence genes, and pulsed-field gel electrophoresis and whole genome sequencing of the major clusters, were performed. Bivariate and multivariate analyses were carried out to evaluate the role of virulence genes on outcome. FINDINGS: All isolates harboured the vanA gene. Regarding the virulence genes, 96.5% of isolates were positive for esp, 69.8% for gelE and asa1 genes. VRE infection isolates were more virulent than colonization isolates and harboured more often the gelE gene (P = 0.008). Infections caused by VRE carrying asa1 gene resulted more frequently in death (P = 0.004), but only the predominant clone remained as protector in the multivariate model. The E. faecium strains were assigned to seven STs (ST78, ST412, ST478, ST792, ST896, ST987, ST963) that belonged to CC17. The E. faecalis sequenced belonged to ST9 (CC9). CONCLUSION: E. faecium was predominant, and infection isolates were more virulent than colonization isolates and harboured more often the gene gelE. Infections caused by VRE carrying the asa1 gene appeared to be associated with a fatal outcome.

Candida parapsilosis fungemia associated with implantable and semi-implantable central venous catheters and the hands of healthcare workers.

A cluster of six cases of fungemia among hematology, bone marrow transplant, and oncology patients was investigated in a case-control study (18 controls). The use of implantable and semi-implantable central venous catheters was significantly associated with cases (p = 0.016). The hands of three healthcare workers (HCWs) were positive for Candida parapsilosis. Electrophoretic karyotyping showed two profiles among patients and HCWs, and five among six unrelated strains. The profiles of two HCWs matched the ones of the patients they had handled. The patients' strains were moderate or strong slime producers, whereas none of the HCWs' were strong producers. In conclusion, our results indicated the occurrence of an outbreak C. parapsilosis fungemia related to long-term central venous catheters in which the hands of HCWs were implicated. The amount of slime production might be associated with the pathogenicity of the strains.

Nosocomial pneumonia: importance of recognition of aetiological agents to define an appropriate initial empirical therapy.

Of the 16,024 patients hospitalized from January 1995 to October 1997, 397 (2.4%) acquired nosocomial pneumonia and the aetiological agent was defined in 101 (25%). About 82% developed late onset pneumonia (>7 days of hospitalization). The site of isolation of microorganisms was bronchoalveolar lavage (BAL) (49%), blood culture (39%), pleural effusion (10%) and (2%) pulmonary tissue. Gram-negative bacteria were responsible for 54% of infections. Staphylococcus aureus (34%) was the most frequent microorganism isolated followed by Acinetobacter baumannii (29%) and Pseudomonas aeruginosa and Klebsiella pneumoniae, responsible for 7% of nosocomial pneumonia. Monotherapy gave good cover for early onset pneumonia, but not for late onset pneumonia. Based on our selection criteria, ciprofloxacin was the best monotherapy for early (50%) and late (31%) onset pneumonia. Vancomycin plus ciprofloxacin gave cover of 85% of early and 64% of late onset pneumonia. Monotherapy with ciprofloxacin and also combination therapy of ciprofloxacin plus vancomycin may be good options as initial empirical therapy for nosocomial pneumonia.

Outer-membrane proteins pattern and detection of beta-lactamases in clinical isolates of imipenem-resistant Acinetobacter baumannii from Brazil.

In order to compare imipenem-sensitive and -resistant Acinetobacter baumannii strains isolated from three patients, ribotyping, plasmid, beta-lactamase detection and outer-membrane analysis were performed. Ribotyping and the use of a beta-lactam during the period when the strains were isolated suggested that they had a common origin and that resistance occurred in vivo. Outer membrane analysis showed no difference between susceptible and resistant strains with the exception of an A2 imipenem-resistant strain that lost a protein band of 31-36 kDa. Beta-lactamases were detected using isoelectric focusing in all strains (pI of 7.4). In addition, two beta-lactamases (pI of 5.9 and 6.7) were found in imipenem-resistant isolates. The double-disc technique demonstrated the presence of a beta-lactamase capable of imipenem inactivation in resistant strains. Plasmid analysis showed that all susceptible strains had the same pattern, one resistant strain did not have any plasmid, one had the same plasmid pattern of its susceptible pair and only one had a different pattern when compared with its susceptible pair.

Nosocomial fungaemia: a 2-year prospective study.

Eighty-six consecutive patients with fungaemia were studied during a period of 2 years, 81% had two or more positive blood cultures. Gastrointestinal tract (28%) and haematological diseases (17%) were the most common underlying conditions. The majority of cases had received vancomycin and/or imipenem (87%) and a central venous catheter (78%). Candida albicans (50%) and Candida parapsilosis (17%) were the most frequent isolates. Overall mortality was 41%, and for patients with Candida tropicalis was 71%. There was not significant difference in survival with gender, age and days of treatment with antifungal drugs. Haematological diseases, neutropenia and a higher number of positive blood cultures were associated with poor outcome.