Procalcitonin-guided protocol is not useful to manage antibiotic therapy in febrile neutropenia: a randomized controlled trial.

Febrile neutropenia (FN) requires immediate use of antibiotics (ATB), and procalcitonin (PCT) is proven to be useful in guiding antibiotic therapy in different settings. This study investigated the use of PCT as a guide for the duration of ATB in FN. A randomized controlled trial was carried out from January-December 2010. A total of 62 hematological adult patients with FN were randomized, in 1:1 ratio, into two groups: (1) PCT group: length of ATB guided by institutional protocol plus PCT dynamics, and (2) control group: duration of ATB in accordance with institutional protocol. There was no difference between groups regarding the use of ATB for the first episode of fever (HR 1.14, 95 % CI 0.66-1.95, p = 0.641), with equivalent median duration of ATB therapy (PCT group 9.0 days and control group 8.0 days, p = 0.67), and median number of days without ATB (0 days, IQR 0-2 days for both groups, p = 0.96). We observed no difference in clinical cure rate (p = 0.68), infection relapse (p = 1.0), superinfection (p = 0.85), length of hospitalization (p = 0.64), and mortality at 28 days (p = 0.39) and at 90 days (p = 0.72). Considering the cut-off of 0.5 ng/ml, PCT was correlated with bacteremia (sensitivity of 51.9 % and specificity of 76.5 %). In this randomized controlled trial, adding a PCT-guided protocol to the standard recommendations did not reduce the use of antibiotics in febrile neutropenia, although no apparent harm was caused. PCT proved to be a marker of bacteremia in this setting.

Phenotypic and genotypic diversity of multidrug-resistant Pseudomonas aeruginosa Isolates from bloodstream infections recovered in the Hospitals of Belo Horizonte, Brazil.

BACKGROUND: Pseudomonas aeruginosa commonly causes nosocomial bloodstream infections and the emergence of a variety of ß-lactamases (BLs) is worrying. In 5 hospitals in Belo Horizonte, Brazil, the presence of phenotypes encoding BL genes was established and the genetic diversity of the P. aeruginosa strains recovered from bloodstream infections was analyzed. MATERIALS AND METHODS: The isolates were investigated using a disk diffusion (DD) method and the Etest, for encoding metallo-ß-lactamases (MBLs), oxacillinases and cephalosporinases. Genes and genetic diversity were evaluated by random amplified polymorphic DNA (RAPD) genotyping and enterobacterial repetitive intergenic consensus (ERIC)-PCR. RESULTS: Twelve strains (30%) were positive for MBLs by Etest and DD, 15 were cephalosporinase-positive and 87.5% were positive for blaSPM-1 and blaVIM-1. Twenty-three strains (57.5%) were grouped into profile A, 32.5% into profile B and 10% into profile C by RAPD genotyping. ERIC-PCR revealed a varying degree of similarity between strains, ranging from 45 to 100%. CONCLUSIONS: The results suggest distinct clonal populations in the 5 hospitals studied, indicating a potentially problematic epidemiological situation in Belo Horizonte, Brazil.

Differentially regulated proteins in Prevotella intermedia after oxidative stress analyzed by 2D electrophoresis and mass spectrometry.

Prevotella intermedia is a rod-shaped, Gram-negative anaerobic bacterium found in human indigenous microbiota that plays an important role in opportunistic infections. The successful colonization depends on the ability of anaerobes to respond to oxidative stress (OS) in oxygenated tissues as well as to resist oxidative events from the host immune system until anaerobic conditions are present at the infection site. As knowledge of the mechanisms of protection against OS in Prevotella is limited, studies are needed to clarify aspects of molecular biology, physiology and ecology of this bacterium. The aim of this study was to access the proteins differentially regulated in P. intermedia after exposure to molecular oxygen by using two-dimensional gel electrophoresis (2DE) associated with the approach of MALDI-TOF/TOF Tandem Mass Spectrometry. The identity of the protein was evaluated by database search for homologous genomic sequences of P. intermedia strain 17 (TIGR). Twenty five out of 72 proteins found were identified as up-regulated (17) or down-regulated (9). These proteins were related to a variety of metabolic process, some of which could be associated to antioxidant and redox regulatory roles. Our data indicate that OS may stimulate an adaptive response in P. intermedia whose effect on its biology may be evidenced by the increase in aerotolerance and changes in protein abundance in the oxygen adapted cells.

A System for Structuring, Storage and Georeferenciation of Dengue Vector Surveillance Data.

Dengue is a main public health issue around the world and is an epidemic in Brazil. As part of the Brazilian national program to fight the disease, every municipality has a Zoonosis Control Center responsible for health and case surveillance, among other actions. The fieldwork includes routine visiting of houses and strategic sites (e.g. industries and vacant lands), water sampling, container elimination, and larvicide administration. However, the field data are gathered and summarized by hand. In this work, our goal is to ease the collection and visualization of field data to support decision-making. We have developed a mobile system to collect and georeference field data which could then be used to build geospatial and geo-temporal visualizations of indices such as House, Container, and Breteau1 indices. This solution could enhance entomological surveillance and leverage action planning and evaluation.

[Identification of bacterial contamination in liquid soap for hospital use]. / Identificação de contaminação bacteriana no sabão líquido de uso hospitalar.

This study performed a bacteriological analysis of the liquid soap in dispensers that health professionals use for hand washing. This exploratory, cross-sectional study was developed at the hospitalization units of a medium-sized hospital in Fortaleza, Ceará, Brazil. Data were collected between May and July 2007. Fifty-nine liquid soap dispensers were analyzed, of which 33 contained the following microorganisms: Burkholderia cepacia (14), Pseudomonas putidas (9), Pseudomonas aeruginosa (3), Klebsiella pneumoniae (3), Enterobacter clocae (2), and Pseudomonas luteola (2). The units with the largest number of contaminated samples were the surgical (n=7) and the dermatological clinics (n=4). Contamination was also found in an original flask of the same lot of liquid soap used to fill up the dispensers. In conclusion, there is a need to regulate and control the quality of these products in the production lines as well as during use in hospital services, mainly because they are used to prevent hospital infection.

Phenotypic and genotypic characterization of drug-resistant Mycobacterium tuberculosis strains.

Of 142 pulmonary tuberculosis patients, 76 were considered high risk for the development of resistance, and 24 were confirmed as resistant strain carriers. Resistant isoniazid strains presented a high frequency of katG and ahpC mutations (90%) correlated with an MIC >4 microg/mL (94%). inhA mutations were not seen. rpoB mutations were identified in 78.6% of rifampicin-resistant strains, usually in codon 531 (72.7%), and 75% had an MIC >16 microg/mL. katG and rpoB mutations recognized 88.2% of multidrug-resistant strains and proved more efficient than the katG and rpoB mutations alone. Seventy percent of resistant pyrazinamide strains had pncA mutations between genes 136 and 188, 62.5% of them with an MIC >900 microg/mL. Pyrazinamidase inactivity was not an efficient resistance marker because 60% of pncA-mutated strains maintained enzymatic activity despite displaying good correlation with high resistance levels. Resistant ethambutol strains had embB mutations in codon 306, with MIC >16 microg/mL.

Increased prevalence of human T cell lymphotropic virus type 1 in patients attending a Brazilian dermatology clinic.

Brazil may have the highest absolute number of individuals infected by human T cell lymphotropic virus type 1 (HTLV-1). It has been suggested that the prevalence of HTLV-1 is increased in patients with skin diseases. This study shows a higher prevalence of this infection in 1,229 patients attending a Brazilian dermatology clinic (0.7%) when compared to blood donors (0.22%). Of note, one additional patient tested positive for HTLV-2. The main skin diseases described in HTLV-1 seropositives were vitiligo (2 cases), dermatophytosis (2 cases), and leprosy (2 cases). A 23-year-old woman received a diagnosis of infectious dermatitis.

Human leptospirosis: occurrence of serovars of Leptospira spp. in the state of Minas Gerais, Brazil, from 2008 to 2012.

BACKGROUND: Leptospirosis is an infectious and acute disease caused by Leptospira spp. that have high epidemic potential. This study verified the main Leptospira spp. serovars detected by MAT from serum of patients with suspicion of leptospirosis from 2008 to 2012 in Minas Gerais State. METHODS: The laboratory received sera from 4654 patients. All serum were screened by IgM-ELISA according to the manufacturer's instructions. Each sample reactive or indeterminate were tested against twenty-four serovars of Leptospira by MAT. RESULTS: In this study, 597 patients were classified as reactive on MAT. Only 301 patients were confirmed by laboratory test. It was not possible confirmation by laboratory diagnosis of 296 patients. Among the samples classified as reactive on MAT, 273 patients exhibited titers bigger than 800 for one or more serovars; seroconversion was detected in 28 cases. Percentage of 85.1% of the samples reactive on MAT corresponded to males, 39.4% corresponded to patients aged between 20 and 39 years old. The most common serovars found were Icterohaemorrhagiae, Andamana, Patoc, Tarassovi, Copenhageni, Hardjo and Australis. Concerning the samples that exhibited titers bigger than 800, serovar Icterohaemorrhagiae was also the most common, followed by Copenhageni, Andamana, Patoc, Tarassovi, Grippotyphosa and Canicola. In this study, 40% of the cases occurred to the metropolitan area, state capital and 34 neighboring towns. CONCLUSION: Our results show the possibly spreading serovars in Minas Gerais State and contribute to knowledge of human leptospirosis, aiming at improving the prevention, control of the disease, as well as the treatment of infected patients.

Proposed panel of diagnostic tools for accurate temporal classification of symptomatic T. gondii infection.

Serological tests available for the diagnosis of acute Toxoplasma gondii infection have limitations in establishing the temporal diagnosis of acute toxoplasmosis. The present analytical-descriptive investigation comprises of a prospective longitudinal cohort study to search for accurate biomarkers to distinguish acute, early and late convalescent T. gondii infection. Classic methods (immunofluorescence-IFA along with Enzyme-linked immunosorbent-ELISA and fluorescent-ELFA assays) for IgM, IgA, IgG and IgG avidity were employed in parallel with flow cytometry-based anti-fixed T. gondii tachyzoites serology (FC-AFTA-IgM, IgG, IgG avidity and IgG subclasses). The results reemphasized the limitations of IgM & IgG IFA, IgG ELFA, IgG & IgG subclasses FC as well as IgA ELISA biomarkers for the temporal diagnosis of acute toxoplasmosis. Receiver Operating-characteristics features (ROC-curves) were employed to adjust conventional cut-offs aiming at establishing a novel protocol to discriminate more accurately the different phases of toxoplasmosis. Conversely, IgM presented high diagnostic co-positivity for acute toxoplasmosis (97% for ELISA, 96% for ELFA and 95% for FC-AFTA) along with moderate co-negativity for detection of late convalescent toxoplasmosis (82%, 76% and 79%, respectively). IgG avidity (ELFA and FC-AFTA) outstand with the highest performance indices with 91% and 96% co-negativity for assessing acute toxoplasmosis and 91% and 98% co-positivity for late convalescent toxoplasmosis, respectively. Multivariate analysis generated a three-step algorithm comprising IgM ELFA screening followed by ELFA and FC-AFTA IgG avidity with high accuracy in discriminating acute from late convalescent infection. Together, these findings demonstrate the applicability of the proposed panel of diagnostic tools for accurate temporal classification of T. gondii infection.

Dermatological findings in 3 generations of a family with a high prevalence of human T cell lymphotropic virus type 1 infection in Brazil.

BACKGROUND: Dermatologic manifestations are quite common in patients with adult T cell leukemia and lymphoma and patients with myelopathy and/or tropical spastic paraparesis associated with human T cell lymphotropic virus type 1 (HTLV-1). The aim of this study was to investigate dermatological findings presented by 30 members of a Brazilian family, half of whom are infected with HTLV-1 (as confirmed by enzyme-linked immunosorbent assay and Western blot). METHODS: The subjects underwent dermatologic examination and laboratory assessment, which included the search for the HTLV-1 genome in peripheral blood mononuclear cells (PBMCs) by qualitative and semiquantitative polymerase chain reaction (PCR) and in skin samples by nested qualitative PCR and immunofluorescence assay. RESULTS: We found that cases of xerotic dermatological alterations, including 3 cases of acquired ichthyosis, were more frequent among the infected patients (7 cases vs. none among the uninfected individuals; P=.0063). Other lesions observed in this group included impetigo, scabies, epidermal nevus, herpes zoster scar, rosacea, and juvenile acne. One HTLV-1-infected individual presented with concurrently acquired ichthyosis, impetigo, scabies, dermatophytosis, and seborrheic dermatitis. The PCR performed on PBMCs and skin samples from 24 patients confirmed the serological results in all cases. Additionally, the HTLV-1 proviral load was higher in patients with >1 skin lesion. Finally, HTLV-1 could be identified in the skin by immunofluorescence assay, which, by use of PCR as the gold standard, showed a sensitivity and specificity of 61.5% and 100%, respectively. CONCLUSIONS: Altogether, these clinical and laboratory findings point to an HTLV-1 tropism toward the skin, even in HTLV-1 carriers without adult T cell leukemia/lymphoma or HTLV-1-associated myelopathy and/or tropical spastic paraparesis.

Diagnosing human asymptomatic visceral leishmaniasis in an urban area of the State of Minas Gerais, using serological and molecular biology techniques.

A population-based cross-sectional study was set up in Sabará country, Southeastern Brazil, to identify asymptomatic human visceral leishmaniasis in an urban area of low disease prevalence. Blood was collected on filter paper (n=1,604 inhabitants) and examined by indirect immunofluorescent test, enzyme-linked immunosorbent assay and immunochromatographic strip test. The prevalence rates of infection ranged from 2.4 to 5.6% depending on the test used. One year later, venous blood was collected in a subset of 226 participants (102 seropositive and 124 seronegative). The tests performed were IFAT, ELISA, rk39-ELISA, polymerase chain reaction and hybridization with Leishmania donovani complex probe. No clinical signs or symptoms of leishmaniasis were observed. Using hybridization as a reference test, the sensitivity and specificity of serology were respectively: 24.8 and 71% (ELISA); 26.3 and 76.3% (rk-39); 30.1 and 63.4% (IFAT). Due to disagreements, different criteria were tested to define the infection and hybridization should be considered in epidemiological studies.

Risk factors for Leishmania chagasi infection in an urban area of Minas Gerais State.

In order to understand the determinants of human infection by Leishmania chagasi in an urban area, a cross-sectional population based study was conducted using molecular and serologic methods to identify infection. Participants were interviewed using a pre-coded questionnaire. Two criteria were tested to identify risk factors: Model 1--including all participants positive in hybridization by Leishmania donovani complex probe; Model 2--including all participants positive for hybridization and at least one serologic test. In Model 1, the variables associated with infection were: ownership of birds, time spent outside house between 6:00-10:00 PM and garbage not collected. In Model 2, the variables associated with infection were: family with knowledge of the vector, garbage not collected, garbage not removed or buried, ownership of birds and eroded areas in the neighborhood. The risk factors identified were associated with household conditions, presence of animals and the likelihood of contact with phlebotomine sandflies.

[Dermatologic lesions in patients infected with the human T-cell lymphotropic virus type 1 (HTLV-1)]. / Lesões dermatológicas em pacientes infectados pelo vírus linfotrópico humano de células T do tipo 1 (HTLV-1).

Human T-cell Lymphotropic virus type I (HTLV-1) was the first human retrovirus described. Some time after its discovery a group of diseases were related to this virus, such as, adult T-cell leukemia lymphoma (ATLL), HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) and HTLV-1 associated uveitis (HAU). In the nineties, HTLV-1 was associated to a severe eczema of children, called infective dermatitis (ID). Since then, several other skin manifestations have been observed in HTLV-1-infected individuals, particularly in patients with ATLL or HAM/TSP. However, according to some reports, dermatologic lesions are also common in asymptomatic HTLV-1 carriers. Besides ID, all other skin lesions reported are nonspecific. The aim of this review is to outline the dermatologic manifestations reported in HTLV-1 infected patients, emphasizing the clinical and epidemiological value of these findings.

Antimicrobial susceptibility of microorganisms recovered from intraabdominal infections at Belo Horizonte, Brazil.

We evaluated antimicrobial susceptibility patterns of microorganisms isolated from intraabdominal infection of Brazilian patients, by agar dilution, agar diffusion, and E test. Among the strictly anaerobes, 57.7% were resistant to penicillin, 28.2% to clindamycin, and 9.9% to metronidazole. The majority of Escherichia coli and Staphylococcus were sensitive and resistant to almost all drugs, respectively. Half of Candida samples were resistant to itraconazole. Our data reinforce the importance of this kind of study to support rational antimicrobial therapy.

Opportunistic infections in patients with AIDS admitted to an university hospital of the Southeast of Brazil.

Opportunistic diseases in HIV-infected patients have changed since the introduction of highly active anti-retroviral therapy (HAART). This study aims at evaluating the frequency of associated diseases in patients with AIDS admitted to an university hospital of Brazil, before and after HAART. The medical records of 342 HIV-infected patients were reviewed and divided into two groups: group 1 comprised 247 patients before HAART and, group 2, 95 patients after HAART. The male-to-female rate dropped from 5:1 to 2:1for HIV infection. There was an increase in the prevalence of tuberculosis and toxoplasmosis, with a decrease in Kaposi's sarcoma, histoplasmosis and cryptococcosis. A reduction of in-hospital mortality (42.0% vs. 16.9%; p = 0.00002) has also occurred. An agreement between the main clinical diagnoses and autopsy findings was observed in 10 out of 20 cases (50%). Two patients with disseminated schistosomiasis and 2 with paracoccidioidomycosis are reported. Overall, except for cerebral toxoplasmosis, it has been noticed a smaller proportion of opportunistic conditions related to severe immunosuppression in the post HAART group. There was also a significant reduction in the in-hospital mortality, possibly reflecting improvement in the treatment of the HIV infection.

[Schistosomal myeloradiculopathy]. / Mielorradiculopatia esquistossomótica.

Schistosomal myeloradiculopathy is the most severe and disabling ectopic form of schistosomiasis mansoni. Its prevalence in endemic areas has been underestimated. The diagnosis relies on the presence of low thoracic/upper lumbar neurological symptoms, demonstration of the Schistosoma mansoni infection by microscopic or serologic techniques, and exclusion of other causes of transverse myelitis. When treatment with antischistosomal drugs and corticosteroids is started early, the clinical response is surprisingly good and those left untreated do not improve and frequently die. There is no consensus about doses and duration of treatment, but a recent study suggests that when steroids are given for at least 6 months clinical improvement is enhanced. As the diagnosis of SMR is presumptive and treatment is essentially clinical, physicians should be aware of the disease and more research is needed to increase the accuracy of the diagnostic methods and, hence, to avoid routine laminectomy. With the advent of magnetic resonance imaging of the spinal cord the diagnosis of this ectopic form of the disease was facilitated. In accordance, the number of cases of schistosomal myelopathy reported is increasing rapidly.

Resistance markers and genetic diversity in Acinetobacter baumannii strains recovered from nosocomial bloodstream infections.

In this study, phenotypic and genotypic methods were used to detect metallo-ß-lactamases, cephalosporinases and oxacillinases and to assess genetic diversity among 64 multiresistant Acinetobacter baumannii strains recovered from blood cultures in five different hospitals in Brazil from December 2008 to June 2009. High rates of resistance to imipenem (93.75%) and polymyxin B (39.06%) were observed using the disk diffusion (DD) method and by determining the minimum inhibitory concentration (MIC). Using the disk approximation method, thirty-nine strains (60.9%) were phenotypically positive for class D enzymes, and 51 strains (79.6%) were positive for cephalosporinase (AmpC). Using the E-test, 60 strains (93.75%) were positive for metallo-ß-lactamases (MßLs). All strains were positive for at least one of the 10 studied genes; 59 (92.1%) contained blaVIM-1, 79.6% contained blaAmpC, 93.7% contained blaOXA23 and 84.3% contained blaOXA51. Enterobacteria Repetitive Intergenic Consensus (ERIC)-PCR analysis revealed a predominance of certain clones that differed from each other. However, the same band pattern was observed in samples from the different hospitals studied, demonstrating correlation between the genotypic and phenotypic results. Thus, ERIC-PCR is an appropriate method for rapidly clustering genetically related isolates. These results suggest that defined clonal clusters are circulating within the studied hospitals. These results also show that the prevalence of MDR A. baumannii may vary among clones disseminated in specific hospitals, and they emphasize the importance of adhering to appropriate infection control measures.

Human leptospirosis: occurrence of serovars of Leptospira spp. in the state of Minas Gerais, Brazil, from 2008 to 2012

Abstract Background: Leptospirosis is an infectious and acute disease caused by Leptospira spp. that have high epidemic potential. This study verified the main Leptospira spp. serovars detected by MAT from serum of patients with suspicion of leptospirosis from 2008 to 2012 in Minas Gerais State. Methods: The laboratory received sera from 4654 patients. All serum were screened by IgM-ELISA according to the manufacturer's instructions. Each sample reactive or indeterminate were tested against twenty-four serovars of Leptospira by MAT. Results: In this study, 597 patients were classified as reactive on MAT. Only 301 patients were confirmed by laboratory test. It was not possible confirmation by laboratory diagnosis of 296 patients. Among the samples classified as reactive on MAT, 273 patients exhibited titers bigger than 800 for one or more serovars; seroconversion was detected in 28 cases. Percentage of 85.1% of the samples reactive on MAT corresponded to males, 39.4% corresponded to patients aged between 20 and 39 years old. The most common serovars found were Icterohaemorrhagiae, Andamana, Patoc, Tarassovi, Copenhageni, Hardjo and Australis. Concerning the samples that exhibited titers bigger than 800, serovar Icterohaemorrhagiae was also the most common, followed by Copenhageni, Andamana, Patoc, Tarassovi, Grippotyphosa and Canicola. In this study, 40% of the cases occurred to the metropolitan area, state capital and 34 neighboring towns. Conclusion: Our results show the possibly spreading serovars in Minas Gerais State and contribute to knowledge of human leptospirosis, aiming at improving the prevention, control of the disease, as well as the treatment of infected patients.

Flow cytometry-based algorithm to analyze the anti-fixed Toxoplasma gondii tachyzoites IgM and IgG reactivity and diagnose human acute toxoplasmosis.

In the present study we evaluated the performance of a flow cytometry-based algorithm as a new serological approach to detect antibodies to T. gondii and specific IgG avidity to diagnose acute toxoplasmosis. The results showed that using FC-AFTA-IgM assay, all serum samples from patients with acute toxoplasmosis demonstrated seropositivity, whereas 90% of patients with chronic infection and 100% of non-infected individuals presented negative results. Thus, only 10% of patients with chronic toxoplasmosis showed residual IgM, in contrast with other methodologies used to diagnosis acute toxoplasmosis. On the order hand, FC-AFTA-IgG assay as well as FC-AFTA-IgG subclasses is unlikely to discriminate acute from chronic toxoplasmosis. We have also evaluated the performance of FC-AFTA-IgG avidity as a tool to exclude chronic toxoplasmosis in patients with positive FC-AFTA-IgM. Our data showed an excellent performance of FC-AFTA-IgG avidity employing the cut-off of 60% for Avidity Index (AI) with sensitivity and specificity of 100%. All serum samples from patients presenting acute toxoplasmosis showed low avidity index (AI≤60%), whereas all chronic patients showed high avidity index (AI>60%). The outstanding performance indexes of this novel flow cytometry-based algorithm support its use as a non-conventional alternative serological approach to diagnose human acute toxoplasmosis.