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

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.

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.

Identification and Phylogenetic Characterization of Human Enteroviruses Isolated from Cases of Aseptic Meningitis in Brazil, 2013-2017.

Aseptic meningitis is a common viral infection associated with human enteroviruses. The aim of the present study was to identify and characterize the enteroviruses associated with outbreaks and sporadic cases of aseptic meningitis that occurred in different regions of Brazil between 2013 and 2017. Cerebrospinal fluids obtained from patients admitted to public health facilities were analyzed. A total of 303 patients were positive for Human Enteroviruses (EV) by cell culture isolation with a median isolation rate throughout the year of 12%. We were able to identify enterovirus serotypes in 295 clinical specimens. Nineteen different serotypes were identified; the large majority corresponded to HEV-B species. Echovirus 30 (E-30) and Echovirus 6 (E-6) were the most prevalent genotypes (66.8%). Sequence analysis suggested that circulating E-30 was closely related to E-30 from other American countries; while E-6 was derived from Europe. Most of the patients consisted of children ≤ 15 years old. The temporal distribution of all aseptic meningitis and EV-positive cases showed an obvious seasonal pattern during autumn. Our results have provided valuable information about the enteroviral etiology of the aseptic meningitis cases in Brazil pointing to the importance of enterovirus surveillance in neurological diseases.

Zika Virus Infection at Different Pregnancy Stages: Anatomopathological Findings, Target Cells and Viral Persistence in Placental Tissues.

Zika virus (ZIKV) infection in humans has been associated with congenital malformations and other neurological disorders, such as Guillain-Barré syndrome. The mechanism(s) of ZIKV intrauterine transmission, the cell types involved, the most vulnerable period of pregnancy for severe outcomes from infection and other physiopathological aspects are not completely elucidated. In this study, we analyzed placental samples obtained at the time of delivery from a group of 24 women diagnosed with ZIKV infection during the first, second or third trimesters of pregnancy. Villous immaturity was the main histological finding in the placental tissues, although placentas without alterations were also frequently observed. Significant enhancement of the number of syncytial sprouts was observed in the placentas of women infected during the third trimester, indicating the development of placental abnormalities after ZIKV infection. Hyperplasia of Hofbauer cells (HCs) was also observed in these third-trimester placental tissues, and remarkably, HCs were the only ZIKV-positive fetal cells found in the placentas studied that persisted until birth, as revealed by immunohistochemical (IHC) analysis. Thirty-three percent of women infected during pregnancy delivered infants with congenital abnormalities, although no pattern correlating the gestational stage at infection, the IHC positivity of HCs in placental tissues and the presence of congenital malformations at birth was observed. Placental tissue analysis enabled us to confirm maternal ZIKV infection in cases where serum from the acute infection phase was not available, which reinforces the importance of this technique in identifying possible causal factors of birth defects. The results we observed in the samples from naturally infected pregnant women may contribute to the understanding of some aspects of the pathophysiology of ZIKV.

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.

Risk factors for candidemia mortality in hospitalized children.

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 1000patients/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.

Risk Adjustment for Congenital Heart Surgery Score as a Risk Factor for Candidemia in Children Undergoing Congenital Heart Defect Surgery.

BACKGROUND: Candida species are the primary cause of invasive fungal infection in hospitalized children. There are few data on risk factors for postoperative candidemia in pediatric patients with congenital heart defects. This study aimed to identify risk factors for candidemia in patients with congenital heart defects who underwent cardiac surgery. METHODS: This was a case-control study conducted in patients admitted to a pediatric cardiology intensive care unit from January 2006 to December 2013. Candidemia cases were matched with control patients without candidemia. Multivariate analyses were conducted to determine predictive probabilities for the incidence of candidemia at a risk higher than 10%. RESULTS: Thirty patients diagnosed with candidemia (incidence: 0.7 cases/1000 patient days) were matched with 75 controls. Risk factors independently associated with candidemia included Risk Adjustment for Congenital Heart Surgery (RACHS-1) category ≥3 [odds ratio (OR) = 3.165, 95% confidence interval: 1.377-8.467], use of acid suppression therapy (OR = 1.9, 95% confidence interval: 0.949-3.979) and thrombocytopenia (OR = 2.2, 95% confidence interval: 1.2-4.2). Predictive probabilities ranged from 11% (only in RACHS-1 category ≥3) to 58% (combined RACHS-1 ≥3, thrombocytopenia and acid suppression therapy use). The case fatality rate within 30 days after candidemia was 50%. CONCLUSION: This is the first report using the RACHS-1 category as a risk factor for invasive candidiasis in patients with congenital heart defects in the pediatric intensive care unit. Further studies must be conducted to validate the risk factors for candidemia in this pediatric population.

Management of Contacts of Patients With Severe Invasive Group A Streptococcal Infection.

BACKGROUND: Conflicting recommendations regarding antibiotic prophylaxis for contacts of patients with invasive group A streptococcal (GAS) infection exist. Close contacts of patients with such severe and rapidly progressive disease often strongly appeal to the treating clinicians for antimicrobial treatment to prevent additional cases. We aimed to use an approach based on pharyngeal culture testing of contacts and targeted antibiotic prophylaxis. METHODS: A large throat swab survey including 105 contacts was undertaken after a fulminant and fatal case of GAS necrotizing fasciitis. GAS strains were characterized by emm typing and antimicrobial susceptibility to 7 antibiotics. The presence of 30 virulence determinants was determined by polymerase chain reaction and sequencing. RESULTS: The GAS isolate recovered from the index patient was an M1T1 GAS clone susceptible to all antimicrobial agents tested. The same clone was present in the throat of 36% of close contacts who had exposure to the index patient (family households and classroom contacts) for >24 hours/week, whereas the strain was present in only 2% of the other contacts. CONCLUSIONS: Although the study does not allow firm conclusions to be drawn as to whether antibiotic prophylaxis is effective, we describe a practical approach, including an educational campaign and targeted antibiotic treatment to close contacts who have been exposed to an index patient for > 24 hours/week before the initial disease onset.

Echinocandin resistance in two Candida haemulonii isolates from pediatric patients.

We report 3 cases of patients with Candida haemulonii isolates that were obtained from hemocultures. In 2 of the 3 cases, isolates exhibited resistance to echinocandins and fluconazole. This is the first report of an echinocandin-resistant species of this fungus in pediatric patients.

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.

Molecular characterization of Mycobacterium tuberculosis isolated in the State of Parana in southern Brazil.

Sequence IS6110 has been successfully used throughout the world for characterizing the Mycobacterium tuberculosis lineages. The aim of this study was to obtain data about circulating strains of M. tuberculosis in patients from the State of Parana in southern Brazil. Sixty-two clinical specimens obtained from sputum, bronchial aspirate, biopsy and urine from 62 patients clinically diagnosed with tuberculosis and admitted to the SUS-Brazil - The Brazilian Centralized Health Service System - were genotyped by the mixed-linker PCR DNA fingerprinting technique. The analysis demonstrated that the number of copies of the IS6110 sequence per isolates varied from four to 13 bands, with an average number of 8.5. From this, 93% of the isolates presented multiple copies. Isolates with no copies of the IS6110 element were not observed. The genetic analysis by UPGMA grouped the 62 isolates by similarity into three different groups: the first group contained two strains, the second was composed of 23, and the third, a more heterogeneous group, contained 37 isolates. Only two isolates (3.2%) formed a cluster; in other words, they presented a pattern of polymorphism with similarity above 95%. Such findings suggest that in the State of Parana, illness predominantly develops through reactivation of the latent infection as opposed to exogenous transmission. The methodology used (mixed-linker PCR DNA fingerprinting) allowed for 93.5% differentiation of the isolates tested, and proved to be a powerful tool for differentiation in the molecular genotyping of M. tuberculosis.

Development of bioprocess for the production of purified protein derivative with Brazilian strains of Mycobacterium tuberculosis for diagnosis use.

Tuberculin, a purified protein derivative (PPD), when diluted in adequate concentration it is utilized for an early detection and to control tuberculosis. In Brazil, the PPD is imported and distributed by the Health System in all Brazilian regions. This, in addition to eventual delay in delivery caused by the legal import process, makes difficult the access of the product to poor communities from distant places as Brazil is a geographically a large country. Thus, indigenous production of PPD would be very beneficial for the society. This work was undertaken with a view to initiate studies towards the development of an indigenous technology for PPD production, using the strains of Mycobacterium tuberculosis isolated from patients during the course of disease from several regions of Brazil. The strain selection criteria for PPD production were the sequencing of three immunodominant proteins and the genetic differentiation by DNA fingerprinting and grouped by UPGMA program, the capacity of protein production in liquid medium, and finally the intradermal injection tests used on animal model. Compared to gold standard, the PPD showed similar indurations when tested individually, and better results were obtained when products were combined in pool. These strategies are discussed in detail in this research.

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.

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% of the HIV-infected patients and in 36% 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% of the HIV-infected patients during the first year of life and in only 1% 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.