Healthcare-associated infections on the intensive care unit in 21 Brazilian hospitals during the early months of the coronavirus disease 2019 (COVID-19) pandemic: An ecological study.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has caused a global health crisis and may have affected healthcare-associated infection (HAI) prevention strategies. We evaluated the impact of the COVID-19 pandemic on HAI incidence in Brazilian intensive care units (ICUs). METHODS: In this ecological study, we compared adult patients admitted to the ICU from April through June 2020 (pandemic period) with the same period in 2019 (prepandemic period) in 21 Brazilian hospitals. We used the Wilcoxon signed rank-sum test in a pairwise analysis to compare the following differences between the pandemic and the prepandemic periods: microbiologically confirmed central-line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP) incidence density (cases per 1,000 central line and ventilator days, respectively), the proportion of organisms that caused HAI, and antibiotic consumption (DDD). RESULTS: We detected a significant increase in median CLABSI incidence during the pandemic: 1.60 (IQR, 0.44-4.20) vs 2.81 (IQR, 1.35-6.89) (P = .002). We did not detect a significant difference in VAP incidence between the 2 periods. In addition, we detected a significant increase in the proportion of CLABSI caused by Enterococcus faecalis and Candida spp during the pandemic, although only the latter retained statistical significance after correction for multiple comparisons. We did not detect a significant change in ceftriaxone, piperacillin-tazobactam, meropenem, or vancomycin consumption between the studied periods. CONCLUSIONS: There was an increase in CLABSI incidence in Brazilian ICUs during the first months of COVID-19 pandemic. Additionally, we detected an increase in the proportion of CLABSI caused by E. faecalis and Candida spp during this period. CLABSI prevention strategies must be reinforced in ICUs during the COVID-19 pandemic.

Hydroxychloroquine plus azithromycin early treatment of mild COVID-19 in an outpatient setting: a randomized, double-blinded, placebo-controlled clinical trial evaluating viral clearance.

BACKGROUND: Hydroxychloroquine has shown potential to block viral replication of SARS-CoV-2 in some in vitro studies. This randomised, double-blinded, placebo controlled clinical trial evaluated the efficacy of hydroxychloroquine plus azithromycin (HCQ/AZT) in reducing viral loads in patients with early and mild SARS-CoV-2 infection. METHODS: A single-centre randomised placebo-controlled clinical trial was conducted with outpatients with early and mild SARS-CoV-2 infection. Inclusion criteria were: patients aged 18-65 years with symptoms suggestive of COVID-19 for < 5 days, no significant comorbidities, and positive nasopharyngeal/oropharyngeal swab screening tests (POCT-PCR). Randomised patients received either hydroxychloroquine for 7 days plus azithromycin for 5 days or placebo. The primary endpoint was viral clearance within a 9-day period. Secondary endpoints included viral load reduction, clinical evolution, hospitalization rates, chest computed tomography evolution, and adverse effects. RESULTS: From 107 potential trial participants, 84 were enrolled following predetermined criteria. Statistical analyses were performed on an intention-to-treat (N = 84) and per-protocol (PP) basis (N = 70). On the PP analysis, the treatment (N = 36) and placebo (N = 34) groups displayed similar demographic characteristics. At 95% CI, no statistically significant between-group differences were found in viral clearance rates within 9 days following enrolment (P = 0.26). CONCLUSIONS: This randomised, double-blinded, placebo-controlled clinical trial evaluating outpatients with early and mild COVID-19 showed that viral clearance rates within a 9-day period from enrolment did not change with HCQ/AZT treatment compared with placebo, although no major cardiovascular events were observed in participants without comorbidities. Secondary outcomes were also not significantly improved with HCQ/AZT treatment compared with placebo. These findings do not support use of HCQ/AZT in this setting.

The effect of a rapid molecular blood test on the use of antibiotics for nosocomial sepsis: a randomized clinical trial.

BACKGROUND: Appropriate use of antimicrobials is essential to improve outcomes in sepsis. The aim of this study was to determine whether the use of a rapid molecular blood test-SeptiFast (SF) reduces the antibiotic consumption through early de-escalation in patients with nosocomial sepsis compared with conventional blood cultures (BCs). METHODS: This was a prospective, randomized, superiority, controlled trial conducted at Sao Paulo Heart Institute in the period October 2012-May 2016. Adult patients admitted to the hospital for at least 48 h with a diagnosis of nosocomial sepsis underwent microorganism identification by both SF test and BCs. Patients randomized into the intervention group received antibiotic therapy adjustment according to the results of SF. Patients randomized into the control group received standard antibiotic adjustment according to the results of BCs. The primary endpoint was antimicrobial consumption during the first 14 days after randomization. RESULTS: A total of 200 patients were included (100 in each group). The intention to treat analysis found no significant differences in median antibiotic consumption. In the subgroup of patients with positive SF and blood cultures (19 and 25 respectively), we found a statistically significant reduction in the median antimicrobial consumption which was 1429 (1071-2000) days of therapy (DOT)/1000 patients-day in the intervention group and 1889 (1357-2563) DOT/1000 patients-day in the control group (p = 0.017), in the median time of antimicrobial de-escalation (8 versus 54 h-p < 0.001), in the duration of antimicrobial therapy (p = 0.039) and in anti-gram-positive antimicrobial costs (p = 0.002). Microorganism identification was possible in 24.5% of patients (45/184) by SF and 21.2% (39/184) by BC (p = 0.45). CONCLUSION: This randomized clinical trial showed that the use of a rapid molecular-based pathogen identification test does not reduce the median antibiotic consumption in nosocomial sepsis. However, in patients with positive microbiological tests, the use of SeptiFast reduced antimicrobial consumption through early de-escalation compared to conventional blood cultures. These results were driven by a reduction in the consumption of antimicrobials used for Gram-positive bacteria. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT01450358) on 12th October 2011.

Bacteroides fragilis endocarditis: a case report and review of literature.

Endocarditis due to Bacteroides fragilis is a rare disorder. This article describes a case of Bacteroides fragilis endocarditis associated with portal and superior mesenteric venous thrombosis in a patient without preexisting valvular heart disease and review the cases of endocarditis due to this anaerobic bacterium in medical literature since 1980.

Bacteroides fragilis endocarditis: a case report and review of literature

Endocarditis due to Bacteroides fragilis is a rare disorder. This article describes a case of Bacteroides fragilis endocarditis associated with portal and superior mesenteric venous thrombosis in a patient without preexisting valvular heart disease and review the cases of endocarditis due to this anaerobic bacterium in medical literature since 1980.

Infective endocarditis due to Bartonella spp. and Coxiella burnetii: experience at a cardiology hospital in Sao Paulo, Brazil.

Bartonella spp. and Coxiella burnetii are recognized as causative agents of blood culture-negative endocarditis (BCNE) in humans and there are no studies of their occurrences in Brazil. The purpose of this study is to investigate Bartonella spp. and C. burnetii as a causative agent of culture-negative endocarditis patients at a cardiology hospital in São Paulo, Brazil. From January 2004 to December 2004 patients with a diagnosis of endocarditis at our Institute were identified and recorded prospectively. They were considered to have possible or definite endocarditis according to the modified Duke criteria. Those with blood culture-negative were tested serologically using the indirect immunofluorescent assay (IFA) for Bartonella henselae, B. quintana, and C. burnetii. IFA-IgG titers >800 for Bartonella spp. and C. burnetii were considered positive. A total of 61 patients with endocarditis diagnosis were evaluated, 17 (27%) were culture-negative. Two have had IgG titer greater than 800 (>/=3,200) against Bartonella spp. and one against C. burnetii (phase I and II>/=6,400). Those with Bartonella-induced endocarditis had a fatal disease. Necropsy showed calcifications and extensive destruction of the valve tissue, which is diffusely infiltrated with mononuclear inflammatory cells predominantly by foamy macrophages. The patient with C. burnetii endocarditis received specific antibiotic therapy. Reports of infective endocartitis due to Bartonella spp. and C. burnetii in Brazil reveal the importance of investigating the infectious agents in culture-negative endocarditis.

Clustering of Enterococcus faecalis infections in a cardiology hospital neonatal intensive care unit.

Early identification of an outbreak is one of the main advantages of routine epidemiological surveillance. Enterococcus spp. used to be regarded as microorganisms of low pathogenicity, because they are part of the normal microbial flora of the gastrointestinal and genitourinary tract. Recently, they have emerged as important pathogenic agents, sometimes causing infections with high mortality rates. We studied a clustering of primary bloodstream infections caused by Enterococcus faecalis in a cardiology hospital neonatal intensive care unit (NICU). Four cases of primary bloodstream infection by E. faecalis were detected from April 15 to May 13, 2004, during active infection surveillance. The isolates were sensitive to glycopeptides. Some aspects of the management of these patients, including the date of insertion and placement of a central venous catheter, prescription of a specific medication, contiguity of beds, personnel attending the patients, and occurrence of diarrhea were analyzed to look for factors that might affect the spread of the microorganisms. Measures taken to hamper the spread included contact precautions throughout the unit, cleansing and disinfection of equipment and surfaces, bathing children with 2% chlorhexidine-gluconate-containing soap, professional reeducation, and reinforcement of all measures to prevent infections. We suggest that there is a need to re-evaluate preventive infection measures and to review the strategies aimed at decreasing the nosocomial infection rate in the NICU.

Clustering of Enterococcus faecalis infections in a cardiology hospital neonatal intensive care unit

Early identification of an outbreak is one of the main advantages of routine epidemiological surveillance. Enterococcus spp. used to be regarded as microorganisms of low pathogenicity, because they are part of the normal microbial flora of the gastrointestinal and genitourinary tract. Recently, they have emerged as important pathogenic agents, sometimes causing infections with high mortality rates. We studied a clustering of primary bloodstream infections caused by Enterococcus faecalis in a cardiology hospital neonatal intensive care unit (NICU). Four cases of primary bloodstream infection by E. faecalis were detected from April 15 to May 13, 2004, during active infection surveillance. The isolates were sensitive to glycopeptides. Some aspects of the management of these patients, including the date of insertion and placement of a central venous catheter, prescription of a specific medication, contiguity of beds, personnel attending the patients, and occurrence of diarrhea were analyzed to look for factors that might affect the spread of the microorganisms. Measures taken to hamper the spread included contact precautions throughout the unit, cleansing and disinfection of equipment and surfaces, bathing children with 2 percent chlorhexidine-gluconate-containing soap, professional reeducation, and reinforcement of all measures to prevent infections. We suggest that there is a need to re-evaluate preventive infection measures and to review the strategies aimed at decreasing the nosocomial infection rate in the NICU.

Identification of human T-lymphotropic virus type I (HTLV-I) subtypes using restricted fragment length polymorphism in a cohort of asymptomatic carriers and patients with HTLV-I-associated myelopathy/tropical spastic paraparesis from São Paulo, Brazil.

Although human T-lymphotropic virus type I (HTLV-I) exhibits high genetic stability, as compared to other RNA viruses and particularly to human immunodeficiency virus (HIV), genotypic subtypes of this human retrovirus have been characterized in isolates from diverse geographical areas. These are currently believed not to be associated with different pathogenetic outcomes of infection. The present study aimed at characterizing genotypic subtypes of viral isolates from 70 HTLV-I-infected individuals from São Paulo, Brazil, including 42 asymptomatic carriers and 28 patients with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), using restricted fragment length polymorphism (RFLP) analysis of long terminal repeat (LTR) HTLV-I proviral DNA sequences. Peripheral blood mononuclear cell lysates were amplified by nested polymerase chain reaction (PCR) and amplicons submitted to enzymatic digestion using a panel of endonucleases. Among HTLV-I asymptomatic carriers, viral cosmopolitan subtypes A, B, C and E were identified in 73.8%, 7.1%, 7.1% and 12% of tested samples, respectively, whereas among HAM/TSP patients, cosmopolitan A (89.3%), cosmopolitan C (7.1%) and cosmopolitan E (3.6%) subtypes were detected. HTLV-I subtypes were not statistically significant associated with patients' clinical status. We also conclude that RFLP analysis is a suitable tool for descriptive studies on the molecular epidemiology of HTLV-I infections in our environment.

Identification of Human T-lymphotropic Virus Type I (HTLV-I) Subtypes Using Restrited Fragment Length Polymorphism in a Cohort of Asymptomatic Carriers and Patients with HTLV-I-associated Myelopathy/tropical Spastic Paraparesis from Säo Paulo, Brazil

Although human T-lymphotropic virus type I (HTLV-I) exhibits high genetic stability, as compared to other RNA viruses and particularly to human immunodeficiency virus (HIV), genotypic subtypes of this human retrovirus have been characterized in isolates from diverse geographical areas. These are currently believed not to be associated with different pathogenetic outcomes of infection. The present study aimed at characterizing genotypic subtypes of viral isolates from 70 HTLV-I-infected individuals from Säo Paulo, Brazil, including 42 asymptomatic carriers and 28 patients with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), using restricted fragment length polymorphism (RFLP) analysis of long terminal repeat (LTR) HTLV-I proviral DNA sequences. Peripheral blood mononuclear cell lysates were amplified by nested polymerase chain reaction (PCR) and amplicons submitted to enzymatic digestion using a panel of endonucleases. Among HTLV-I asymptomatic carriers, viral cosmopolitan subtypes A, B, C and E were identified in 73.8 percent, 7.1 percent, 7.1 percent and 12 percent of tested samples, respectively, whereas among HAM/TSP patients, cosmopolitan A (89.3 percent), cosmopolitan C (7.1 percent) and cosmopolitan E (3.6 percent) subtypes were detected. HTLV-I subtypes were not statistically significant associated with patients' clinical status. We also conclude that RFLP analysis is a suitable tool for descriptive studies on the molecular epidemiology of HTLV-I infections in our environment