Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment.

Mycobacterium haemophilum is a slow-growing nontuberculous mycobacterium that can cause disease in both immunocompetent and immunocompromised patients. The most common clinical presentations of infection are the appearance of suppurative and ulcerated skin nodules. For the diagnosis, samples collected from suspected cases must be processed under the appropriate conditions, because M. haemophilum requires lower incubation temperatures and iron supplementation in order to grow in culture. In this case report, we describe the occurrence of skin lesions in a kidney transplant recipient, caused by M. haemophilum, associated with acupuncture treatment. The diagnosis was established by direct smear and culture of material aspirated from cutaneous lesions. Species identification was achieved by characterization of the growth requirements and by partial sequencing of the hsp65 gene. The patient was successfully treated with clarithromycin and ciprofloxacin for 12 months. Considering that the number of patients receiving acupuncture treatment is widely increasing, the implications of this potential complication should be recognized, particularly in immunosuppressed patients.

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.

Infecçäo causada por Mycobacterium tuberculosis com resistência primária a múltiplas drogas: relato de caso em paciente com AIDS / Infection caused by Mycobacterium tuberculosis with primary resistance to multiple drugs: a case report of a patient with AIDS

Mycobacterium tuberculosis, primariamente resistente a múltiplas drogas, é problema de crescente importância nos Estados Unidos. No Brasil, näo existem relatos, pelo menos em literatura formal, de infecçäo por este patógeno. Relato de caso. Os autores relatam caso de paciente do sexo masculino que teve diagnóstico de tuberculose ganglionar cervical por meio de baciloscopia. Adicionalmente, anti-HIV feito por método ELISA resultou positivo. O paciente iniciou esquema terapêutico com isoniazida, rifampicina e pirazinamida. Segundo o paciente e seus familiares, os medicamentos foram administrados corretamente, mas näo foi observada melhora clínica. Após 75 dias de tratamento, o paciente foi internado no Hospital do Servidor Público Estadual de Säo Paulo com piora clínica caracterizada por aumento de gânglio submandibular, insuficiência respiratória e dor abdominal, vindo a falecer seis dias após a admissäo. Cultura do aspirado ganglionar, colhida no dia da internaçäo, mostrou crescimento de M. tuberculosis sensível ao etambutol e resistente à isoniazida, rifampicina, pirazinamida, etionamida e estreptomicina. Discussäo. O isolamento de M. tuberculosis multirresistente, mesmo que em paciente com forma extra-pulmonar da doença, traz à tona discussäo da necessidade da prevalência do patógeno em nosso meio mediante realizaçäo de cultura e antibiograma, e ressalta problemas inerentes à MTB-MDR, como a alta letalidade em pacientes com infecçäo clinicamente manifesta e a transmissäo intra-hospitalar, já demonstrada em outros países. É discutida a necessidade de cumprimento rigoroso das medidas de isolamento

[Infection caused by Mycobacterium tuberculosis with primary resistance to multiple drugs: a case report of a patient with AIDS]. / Infecção causada por Mycobacterium tuberculosis com resistência primária a múltiplas drogas: relato de um caso em paciente com AIDS.

Primary multidrug-resistant Mycobacterium tuberculosis is an important problem in the United States. There is no report in formal literature of this pathogen in Brazilian patients. CASE REPORT--We report a case of ganglionar tuberculosis diagnosed by acid-fast smears in a male, HIV positive patient. Mode of acquisition of HIV was not determined. Treatment was started, and isoniazid, rifampicin and pyrazinamide were prescribed. The patient and his family reported strict adherence to therapy, but no improvement was observed. After 75 days, the patient was admitted in our hospital because of clinical worsening. Clinical features were the presence of large submandibular and axillar lymph nodes, respiratory insufficiency and complains of abdominal pain. He died six days after admission. Culture obtained from the ganglionar aspirate disclosed M. tuberculosis susceptible to ethambutol, but resistant to isoniazid, rifampicin, pyrazinamide, ethionamide and streptomycin. DISCUSSION--Although this was a case of extrapulmonary tuberculosis, there is a concern about multidrug-resistant tuberculosis, that has been poorly evaluated in Brazil. Since high lethality and intrahospital transmission have been reported, we discuss the need of performing culture and antibiogram in suspected cases, and the prevention of the spread of M. tuberculosis to patients and health-care workers through the strict adherence to the isolation practices.

An outbreak of handscrubbing-related surgical site infections in vascular surgical procedures.

OBJECTIVE: To investigate an outbreak of surgical site infections (SSI) in a vascular surgery unit. SETTING: A 60-bed unit of vascular surgery, where surgeons performed an average of 30 operations per month at the Hospital do Servidor Público Estadual, a 1,000-bed tertiary care hospital in São Paulo, Brazil. DESIGN: We included in the case group nine patients who had limb amputations or arterial reconstructions, October 16 through 23, 1992. We included in the control group patients whose operations were performed within 30 days of the outbreak period. Control patients were matched for sex and type of operation. RESULTS: Six of 9 case patients experienced SSI, as compared with 3 of 18 control patients (P = .026) and 28 of 244 patients in the pre-epidemic period (P = .0002). Risk factors were identical for case and control groups. Factors assessed were American Society of Anesthesiology (ASA) status, duration of surgery, wound class, emergency status, remote site infections, preoperative length of stay, use of prophylactic antibiotics, and underlying diseases. Possible common sources also were analyzed. No differences were observed concerning hair removal, preoperative shower, wound dressing, and surgical team present in the operating room. During the outbreak period, the operating room was not provided with povidone-iodine, used in our hospital for skin cleansing and handscrubbing. Surgeons from all departments, including vascular surgery, used 2% iodine with 70% alcohol for skin cleansing. Surgeons from other departments used this iodine solution for handscrubbing, but the vascular surgeons used plain soap for handscrubbing. No increases in SSI rates were reported in other services. Comparison of case and control groups for handscrubbing was statistically significant (P < .00001). After reinstitution of povidone-iodine, only one SSI was diagnosed in 13 vascular procedures. CONCLUSIONS: Although we could not demonstrate definitely that scrubbing with plain soap was related to SSI, we found a strong suggestion of this association.

An overview of nosocomial infection control in Brazil.

Brazil is the largest country in Latin America, with a population of 146 million people. The socioeconomic development and the distribution of population and health services varies widely within the country. There are approximately 1.2 million hospital admissions per month, 80% of them paid by a government healthcare program that follows the diagnosis-related groups (DRGs) model. The Ministry of Health has been trying to establish a nationwide nosocomial infection control program since 1983. Most Brazilian hospitals now have some kind of infection control activity, but only a few of them have complete programs. Infrastructural deficiencies, the scarcity of well-trained healthcare workers, and the widespread occurrence of multiresistant Staphylococcus aureus and gram-negative bacteria are some of the challenges faced by Brazilian hospitals in the control of nosocomial infection.