Active surveillance of carbapenem-resistant Gram-negative healthcare-associated infections in a low-middle-income country city

ABSTRACT Background: Carbapenem-resistance in healthcare-associated infections (HCAIs) is of great concern, and it is urgent to improve surveillance. We aimed to describe and analyze HCAIs trends on Gram-negative antimicrobial susceptibility in a city from a developing country, following the implementation of an active surveillance program. Methods: This is an aggregated study describing data from 24 hospitals with intensive care units, including a trend analysis by Joinpoint regression between January 2012 and December 2017. Results: There were 23,578 pathogens in 39,832 HCAIs, from which 16,225 were Gram-negatives (68.8%). Carbapenem susceptibility was lowest in A. baumannii (15.4-25.9%), K. pneumoniae (51.0-55.9%), and P. aeruginosa (64.9-84.1%) and highest in E. coli (96.5-99.2%). Only K. pneumoniae showed a significant Joinpoint at 95% confidence interval: −10.71% (−18.02; −2.75) from 2012 to 2014, p = 0.02, and 6.54% (−2.00; 15.83) from 2015 to 2017, p = 0.12, which was most influenced by urinary tract infections: −9.98% (−16.02; −3.48) from 2012 to 2014, p = 0.01, and 9.66% (−1.75; 22.39) from 2015 to 2017, p = 0.09. Conclusion: Although we found a significant change toward an improvement in carbapenem susceptibility in K. pneumoniae, resistance is high for most pathogens. These data should encourage health institutions to improve their prevention and control strategies.

Risk factors for candidemia mortality in hospitalized children / Fatores de risco de mortalidade por candidemia em crianças internadas

Abstract Objective: To evaluate risk factors associated with death due to bloodstream infection caused by Candida spp. in pediatric patients and evaluate the resistance to the main anti-fungal used in clinical practice. Methods: This is a cross-sectional, observational, analytical study with retrospective collection that included 65 hospitalized pediatric patients with bloodstream infection by Candida spp. A univariate analysis was performed to estimate the association between the characteristics of the candidemia patients and death. Results: The incidence of candidemia was 0.23 cases per 1000 patients/day, with a mortality rate of 32% (n = 21). Clinical outcomes such as sepsis and septic shock (p = 0.001), comorbidities such as acute renal insufficiency (p = 0.01), and risks such as mechanical ventilation (p = 0.02) and dialysis (p = 0.03) are associated with increased mortality in pediatric patients. The resistance and dose-dependent susceptibility rates against fluconazole were 4.2% and 2.1%, respectively. No resistance to amphotericin B and echinocandin was identified. Conclusion: Data from this study suggest that sepsis and septic shock, acute renal insufficiency, and risks like mechanical ventilation and dialysis are associated with increased mortality in pediatric patients. The mortality among patients with candidemia is high, and there is no species difference in mortality rates. Regarding the resistance rates, it is important to emphasize the presence of low resistance in this series.

Resumo Objetivo: Avaliar os fatores de risco associados ao óbito por infecção da corrente sanguínea causada pela Candida spp em pacientes pediátricos e avaliar a resistência ao principal antifúngico usado na prática clínica. Métodos: Este é um estudo transversal, observacional e analítico com coleta retrospectiva que incluiu 65 pacientes pediátricos internados com infecção da corrente sanguínea por Candida spp. Foi feita uma análise univariada para estimar a associação entre as características dos pacientes com candidemia e o óbito. Resultados: A incidência de candidemia foi de 0,23 casos em cada 1.000 pacientes/dia, com taxa de mortalidade de 32% (n = 21). O resultado clínico como sepse e choque séptico (p = 0,001), comorbidades como insuficiência renal aguda (p = 0,01) e riscos como ventilação mecânica (p = 0,02) e diálise (p = 0,03) estão associados ao aumento da mortalidade em pacientes pediátricos. As taxas de resistência e susceptibilidade dose-dependente contra o fluconazol foram de 4,2% e 2,1%, respectivamente. Não foi identificada resistência à anfotericina B e equinocandina. Conclusão: Os dados de nosso estudo sugerem que a sepse e o choque séptico, a insuficiência renal aguda e riscos como ventilação mecânica e diálise estão associados ao aumento da mortalidade em pacientes pediátricos. A mortalidade entre pacientes com candidemia é alta e não há diferença nas taxas de mortalidade entre as espécies. Sobre a resistência, é importante enfatizar a presença de baixa resistência nesta série.

O impacto do programa mãe curitibana sobre a transmissão vertical do HIV no município de Curitiba entre 2000 e 2009 / The impact of the "mãe curitibana" program on the mother-to-child transmission of HIV in Curitiba between 2000 and 2009

Introdução: grande parte dos diagnósticos da infecção pelo HIV em mulheres ocorre durante a gestação e a transmissão vertical é a principal forma de aquisição do HIV em crianças. Assim, a assistência pré-natal representa excelente oportunidade para ações profiláticas, visto que sem medidas de intervenção durante a gestação, a taxa de transmissão do HIV atinge 30%. Objetivo: o presente estudo descreve as ações do Programa Mãe Curitibana em relação às gestantes HIV-positivo e a transmissão vertical. Métodos: análise retrospectiva no período de 2000 a 2009 dos dados de notificação e assistência de gestantes HIV-positivo residentes em Curitiba. Resultados: na ausência de intervenções, calcula-se que dentre as 1.169 gestantes HIV-positivo notificadas de 2000-2009 poderiam ocorrer 350 infecções verticais. Neste contexto, o total de 44 recém-nascidos infectados nestes 10 anos evidencia que as intervenções realizadas para evitar a transmissão contribuíram para evitar um total de 306 crianças infectadas verticalmente pelo HIV em Curitiba. Medidas como atestagem HIV descentralizada de gestantes, parturientes e parceiros, o referenciamento para acompanhamento especializado, a medicação antirretroviral na gestação, no parto e para o RN, cesariana eletiva quando indicada, inibição da lactação e acompanhamento de puerpério e puericultura mostraram-se eficazes para esta redução da transmissão. Com esforços, a taxa de transmissão que em 1999 se encontrava em 5,1% passou para 2,5% em 2009. Conclusão: acaptação precoce da gestante, o diagnóstico laboratorial, a organização dos fluxos, medidas rápidas de intervenção, adesão ao tratamento, acompanhamento da criança e da mulher são ações do Programa Mãe Curitibana que têm auxiliado na diminuição da transmissão vertical do HIV.

Introduction: the majority of diagnoses of HIV infection in women occur during pregnancy and the mother-to-child transmission is the main form of HIV infection in children. Therefore, prenatal care represents an excellent opportunity for prophylaxis, because with out intervention measures during pregnancy,the rate of HIV transmission reaches 30%. Objective: this study describes the actions of the "Mãe Curitibana" Program in relation to HIV positive pregnant women and the mother-to-child HIV transmission. Methods: retrospective analysis of 2000 to 2009 assistance and reporting data of HIV positive pregnant women living in Curitiba. Results: it is estimated that among the 1,169 HIV positive pregnant women reported in this period could occur 350 vertical infections. In this context, a total of 44 infected infants in these 10 years show that interventions to prevent transmission contributed to avoid a total of 306 vertically HIV infected children in Curitiba. Measures such as decentralized HIV testing of pregnant women, parturient and partners, referrals to specialized treatment, so as antiretroviral medication during pregnancy, childbirth and the newborn, the inhibition of lactation and postpartum and childcare follow-uphave been effective for this reducing transmission. With effort, the transmission rate in 1999 was at 5.1% and reduces to 2.5% in 2009. Conclusion: the early capture of pregnant womens, the organization of flowcharts, rapid intervention measures, treatment adherence, monitoring of children and women areactions of the "Mãe Curitibana" Program that has helped in reducing mother-to-child transmission of HIV.

Neurological profile and neurodevelopment of 88 children infected with HIV and 84 seroreverter children followed from 1995 to 2002

This study evaluated the degree of neurological compromise in HIV-infected children accompanied by the outpatient clinic of infectious diseases and pediatric neurology of the Clinical Hospital of the Federal University of Paraná (UFPR) starting in 1995. Long-term progressive prospective and cross sectional study of 88 children infected by HIV and 84 seroreverter children, using data from general neurological examinations, neuroimaging procedures (brain CT scan) and neurodevelopmental tests (CAT/CLAMS and DENVER I and II). Neurological and neurodevelopmental alterations were found in 82 percent of the HIV-infected patients and in 36 percent of the HIV-seroreverter group (P <0.01). In the CAT/CLAMS test, the development quotient (DQ) of the HIV-infected group was significantly lower than that of the HIV-seroreverter group. CAT/CLAMS scores lower than 70 (mental deficiency) were found in 31 percent of the HIV-infected patients during the first year of life and in only 1 percent of the patients of the HIV-seroreverter group, demonstrating the validity of this screening test for precocious detection of alterations in the neurodevelopment of infected patients. The same occurred with the Denver I and II tests, as the HIV-infected group failed more frequently than the HIV-seroreverter group. Nine HIV-infected children presented altered brain CT scans; calcification of basal ganglia was the main finding (five cases). Encephalopathy due to HIV causes early arrest of neurodevelopment, which can be detected with screening tests during the first year of life.