Paracoccidioidomycosis: Current Status and Future Trends.

Paracoccidioidomycosis (PCM), initially reported in 1908 in the city of São Paulo, Brazil, by Adolpho Lutz, is primarily a systemic and neglected tropical mycosis that may affect individuals with certain risk factors around Latin America, especially Brazil. Paracoccidioides brasiliensis sensu stricto, a classical thermodimorphic fungus associated with PCM, was long considered to represent a monotypic taxon. However, advances in molecular taxonomy revealed several cryptic species, including Paracoccidioides americana, P. restrepiensis, P. venezuelensis, and P. lutzii, that show a preference for skin and mucous membranes, lymph nodes, and respiratory organs but can also affect many other organs. The classical diagnosis of PCM benefits from direct microscopy culture-based, biochemical, and immunological assays in a general microbiology laboratory practice providing a generic identification of the agents. However, molecular assays should be employed to identify Paracoccidioides isolates to the species level, data that would be complemented by epidemiological investigations. From a clinical perspective, all probable and confirmed cases should be treated. The choice of treatment and its duration must be considered, along with the affected organs, process severity, history of previous treatment failure, possibility of administering oral medication, associated diseases, pregnancy, and patient compliance with the proposed treatment regimen. Nevertheless, even after appropriate treatment, there may be relapses, which generally occur 5 years after the apparent cure following treatment, and also, the mycosis may be confused with other diseases. This review provides a comprehensive and critical overview of the immunopathology, laboratory diagnosis, clinical aspects, and current treatment of PCM, highlighting current issues in the identification, treatment, and patient follow-up in light of recent Paracoccidioides species taxonomic developments.

Molecular epidemiology and clinical-laboratory aspects of chromoblastomycosis in Mato Grosso, Brazil.

INTRODUCTION: Chromoblastomycosis is a disease caused by melanized fungi, primarily belonging to the genera Fonsecaea and Cladophialophora, mainly affecting individuals who are occupationally exposed to soil and plant products. This research aimed to determine the clinical, epidemiological and laboratory characteristics of chromoblastomycosis in the state of Mato Grosso, Brazil. MATERIALS AND METHODS: Patients diagnosed with chromoblastomycosis treated at the Júlio Müller University Hospital, Cuiabá, Brazil, from January 2015 to December 2020, whose isolates were preserved in the Research Laboratory of the Faculty of Medicine of the Federal University of Mato Grosso. Isolates were identified by partly sequencing the Internal Transcribed Spacer (ITS) and ß-tubulin (BT2) loci. AFLP fingerprinting was used to explore the genetic diversity. Susceptibility to itraconazole, voriconazole, 5-fluorocytosine, terbinafine and amphotericin B was determined by the broth microdilution technique. RESULTS: Ten patients were included, nine were male (mean age = 64.1 years). Mean disease duration was 8.6 years. Lesions were mainly observed in the lower limbs. Predominant clinical forms were verrucous and scarring. Systemic arterial hypertension and type II diabetes mellitus were the predominant comorbidities. Leprosy was the main concomitant infectious disease. Fonsecaea pedrosoi was the unique aetiological agent identified with moderate genetic diversity (H = 0.3934-0.4527; PIC = 0.3160-0.3502). Antifungal agents with the highest activity were terbinafine, voriconazole and itraconazole. CONCLUSION: Chromoblastomycosis is affecting the poor population in rural and urban areas, mainly related to agricultural activities, with F. pedrosoi being the dominant aetiologic agent. All isolates had low MICs for itraconazole, voriconazole and terbinafine, confirming their importance as therapeutic alternatives for chromoblastomycosis.

Chromoblastomycosis-Leprosy Co-Infection in Central West Brazil. Presentation of Three Cases and Literature Review.

Chromoblastomycosis and leprosy are chronic diseases with high prevalence in tropical and subtropical regions. Brazil is one of the countries with the highest incidence and prevalence for both diseases, however, reports of co-infections are scarce. The aim of this study was to describe three cases of chromoblastomycosis-leprosy co-infection in patients from Mato Grosso state, Brazil. A review of chromoblastomycosis-leprosy co-infection was performed of English, Portuguese and Spanish publications in LILACS, SciELO, PubMed and Web of Science databases using the descriptors (chromoblastomycosis OR cromoblastomicose OR cromoblastomicosis) AND (leprosy OR hanseníase OR lepra), without time period delimitation. Nineteen cases were included, 16 cases were published in 11 articles, plus the three cases reported in the current study. Most reported coninfection cases came from Brazil. Majority of the patients were male with a mean age of 52.2 years. Farmer was the main occupational activity reported. In 12 patients, the clinical signs and symptoms of leprosy started first. No contacts with patients affected by leprosy, armadillos or history of injuries at the anatomical site of chromoblastomycosis lesions were reported. Five leprosy patients who received steroid treatment for leprosy reactions or neuropathies, were diagnosed with chromoblastomycosis during immunosuppressive therapy. Four cases (21.1%) were reported among the elderly patients. Co-infections in patients with chromoblastomycosis or leprosy are uncommon, but the possibility should always be considered, especially if the patient is undergoing immunosuppressive treatment or is elder.

Chromoblastomycosis in Latin America and the Caribbean: Epidemiology over the past 50 years.

Chromoblastomycosis is a chronic disease caused by melanized fungi that mainly affect individuals performing soil-related labor. The objective of this study was to analyze the epidemiological and clinical characteristics of chromoblastomycosis in Latin America and the Caribbean by an extensive literature review. An integrative review was performed of English, French, Portuguese, and Spanish publications in LILACS, SciELO, PubMed, SCOPUS and Web of Science databases covering the period 1969-2019. A total of 1211 articles were identified, of which 132 were included in the review, covering 2081 patients, 80.3% were males, the mean age was 56.1 years. The mean duration of the disease was 10.8 years. The lesions were mainly described in the lower limbs (60%). The most frequent clinical forms were verrucous (46.4%) and tumorous (21.7%). Major disease symptoms and signs consisted of itching and pain. Bacterial infection and functional limitation were important complications. Immunosuppression post-kidney transplantation was the most frequent comorbidity while leprosy was the main concomitant infectious disease. Fonsecaea pedrosoi and Cladophialophora carrionii were the predominant etiological agents. Majority of the cured cases were treated with itraconazole as monotherapy or in combination with other antifungals, surgery or cryosurgery. Chromoblastomycosis affects hundreds of rural workers in Latin America and the Caribbean, causing disability and personal, family and economic losses. It is important to prioritize epidemiological surveillance and early diagnosis of this disease in order to reveal its real prevalence and direct resources to preventive actions, diagnosis and early treatment. LAY SUMMARY: Chromoblastomycosis is a slowly progressing chronic disease caused by melanized fungi. We collected data from South America and the Caribbean covering 1969-2019, the 132 articles included 2081 patients, mean disease duration was 10.8 years. Fonsecaea pedrosoi and Cladophialophora carrionii predominated.

Knowledge about healthcare-associated infections in medical, bioanalysis and nursing students from a Venezuelan university / Conocimiento sobre infecciones asociadas a la atención de la salud en estudiantes de Medicina, Licenciatura en Bioanálisis y Licenciatura en Enfermería de una universidad venezolana

Abstract Introduction: Knowledge about healthcare-associated infections (HAIs) among health professionals is fundamental to reduce morbidity and mortality rates attributable to these infections. Objective: To assess the level of knowledge on HAIs in final-year students enrolled in the School of Health Sciences of Universidad de Oriente, Venezuela. Materials and methods: A descriptive study was conducted in a stratified random sample (n=98). A survey was administered to all participants in order to determine their knowledge about 3 specific areas: basics of HAIs, universal precautions and hand hygiene. Students who obtained an average score of 17.5 were considered as having an adequate level of knowledge about HAIs. Results: Participants' average age was 24.9 years, and 74.9% were female. The average scores of nursing, medical and bioanalysis students were 18, 18.04 and 17.25, respectively; the total average score was 17.87. 59.2% of the respondents obtained a passing score. In terms of the 3 areas of knowledge assessed in the survey, most of the students obtained a failing score in basics of HAIs (n=78) and the Hand hygiene (n=76) components, while the majority (n=91) had a passing score in the Universal precautions area. Conclusions: In general, all respondents have adequate knowledge about HAIs and their prevention. However, regardless of the academic program they were enrolled in, students showed a lack of knowledge regarding specific aspects of HAIs, such as the source of the microorganisms that cause these infections or the proper use of gloves, thus it is necessary that more attention is paid to these issues in their curricula.

Resumen Introducción. El conocimiento acerca de las infecciones asociadas a la atención de la salud (IAAS) en profesionales en salud es fundamental para disminuir las tasas de morbimortalidad causadas por estas infecciones. Objetivo. Evaluar el nivel de conocimiento sobre las IAAS en estudiantes del último año de la Escuela de Ciencias de la Salud de la Universidad de Oriente, Venezuela. Materiales y métodos. Estudio descriptivo realizado en una muestra aleatoria estratificada (n=98). Se aplicó una encuesta para determinar los conocimientos de los participantes sobre 3 áreas específicas: generalidades sobre IAAS, precauciones universales e higiene de las manos. Se consideró que los estudiantes tenían un conocimiento adecuado si obtenían un puntaje promedio de 17.5. Resultados. La edad promedio de los encuestados fue 24.9 años y el 74.9% fueron mujeres. En promedio, los estudiantes de Licenciatura en Enfermería, los de Medicina y los de Licenciatura en Bioanálisis obtuvieron 18, 18.04 y 17.25 puntos, respectivamente; el 59.2% de los respondientes aprobó la encuesta y el puntaje promedio total fue 17.87 puntos. En cuanto a las tres áreas de conocimiento evaluadas, la mayoría de estudiantes reprobó Generalidades sobre IAAS (n=78) e Higiene de las manos (n=76), mientras que la mayoría (n=91) aprobó Precauciones universales. Conclusiones. En general, los estudiantes encuestados tienen un conocimiento adecuado de las IAAS y su prevención; sin embargo, independiente del programa académico, se evidenciaron deficiencias en aspectos puntuales del tema, tales como la fuente de los microorganismos causantes de las IAAS y el uso adecuado de guantes, por lo que es necesario que los currículos de estos programas profundicen más al respecto.

Conocimiento sobre infecciones asociadas a la atención de la salud en estudiantes de bioanálisis / Knowledge about healthcare associated infections in bioanalysis students

Se realizó un estudio descriptivo, de corte transversal, para evaluar el conocimiento sobre infecciones asociadas a la atención de la salud (IAAS) y la progresión de su adquisición, en estudiantes de Licenciatura en Bioanálisis de la Escuela de Ciencias de la Salud de la Universidad de Oriente, Venezuela. Se aplicó una encuesta para investigar conocimientos en tres áreas específicas: generalidades sobre IAAS, precauciones universales e higiene de manos. Se consideró que los estudiantes tenían un conocimiento adecuado si obtenían un puntaje promedio de 17,5. Se encuestaron 367 estudiantes, 77,9% del género femenino. La edad promedio fue 21,9 años. Se obtuvo un puntaje promedio de 16,5. Los estudiantes del VIII semestre alcanzaron el puntaje más elevado (18 puntos) seguidos por los cursantes de los semestres V y VII con puntaje promedio de 17,7. Los estudiantes de los restantes semestres no aprobaron la encuesta. Los estudiantes aprobaron el área de precauciones universales, pero no en generalidades de IAAS e higiene de manos; sin embargo, se pudo observar una tendencia positiva en la adquisición de conocimientos a medida que los estudiantes avanzaban en sus estudios. Los estudiantes no poseían conocimientos adecuados sobre IAAS, pero se observó un aumento progresivo en la adquisición del conocimiento.

A descriptive, cross-sectional study was conducted to evaluate the knowledge about healthcare-associated infections (HCAI) and progression of their acquisition, in students of the Bachelor in Bioanalysis of the School of Health Sciences of the Universidad de Oriente, Venezuela. A survey was carried out to investigate their knowledge in three specific areas: generalities about HCAI, universal precautions and hand hygiene. Students were considered to have adequate knowledge if they obtained an average score of 17.5. A total of 367 students were interviewed, 77.9% of the female gender. The average age was 21.9 years. An average score of 16.5 wasobtained. The students of the eighth semester obtained the highest score (18 points), followed by the students of the fifth and seventhsemesters with an average score of 17.7. The students of the remaining semesters did not passthe survey. The students passed the area of universal precautions, but not generalities of HCAI and hand hygiene, however, a positive tendency could be observed in the acquisition of knowledge while the students advanced in their studies. The students did not have adequate knowledge about HCAI, however a progressive increase in the acquisition of knowledge was observed.

Um estudo descritivo, de corte transversal foi feito para avaliar o conhecimento sobre infecções relacionadas à assistência à saúde (IRAS) e à progressão de sua aquisição nos estudantes de Licenciatura em Bioanálise da Escola de Ciências da Saúde da Universidade de Oriente, Venezuela. Um questionário foi aplicado para pesquisar os conhecimentos em três áreas específicas: conhecimento geral das IRAS, precauções universais e higiene das mãos. Considerou-se que os estudantes tinham conhecimento adequado se obtinham uma nota média de 17,5 pontos. Foram entrevistados 367 estudantes, 77,9% do gênero feminino. A média de idade foi de 21,9 anos. A nota média obtida no questionário foi de 16,5 pontos. Os estudantes do VIII semestre atingiram a maior nota (18 pontos) seguidos pelos estudantes dos semestres V e VII com nota média de 17,7 pontos. Os estudantes dos demais semestres não aprovaram o questionário. Os estudantes aprovaram na área das precauções universais, mas não em conhecimentos gerais das IRAS nem higiene das mãos, embora tenha se observado uma tendência positiva na aquisição de conhecimentos na medida em que os estudantes avançaram em seus estudos. Os estudantes não têm conhecimentos adequados sobre IRAS, no entanto se observou um aumento progressivo na aquisição do conhecimento.

Conocimiento sobre infecciones asociadas a la atención de la salud en residentes de postgrado de una Universidad Venezolana / Knowledge about healthcare associated infections in postgraduate residents from a Venezuelan University

Se realizó un estudio descriptivo, de corte transversal con diseño de campo para evaluar el conocimiento sobre las infecciones asociadas a la atención de la salud (IAAS) y su prevención en médicos residentes de los postgrados de la Escuela de Ciencias de la Salud "Dr. Francisco Battistini Casalta" de la Universidad de Oriente, Venezuela. La muestra estuvo constituida por 51 médicos residentes de diferentes postgrados a quienes se les aplicó una encuesta para investigar conocimientos en tres áreas específicas: generalidades sobre IAAS, precauciones universales e higiene de las manos. Se consideró que tenían un conocimiento adecuado si obtenían un puntaje promedio de 17,5 puntos o más. El 58,8% de los encuestados fue de sexo femenino con edad promedio de 31 años (DS ±4,32; rango: 25-47). El puntaje promedio en la encuesta fue de 17,9 puntos (DS ±1,87; rango: 12-22). El 56,87% aprobó la encuesta. Al evaluar el conocimiento sobre las áreas estudiadas, se encontró que la mayoría maneja conceptos básicos sobre precauciones universales (86,27%) pero no sobre generalidades de IAAS (37,25%) ni de higiene de las manos (19,6%). En conclusión, los residentes de postgrado poseen conocimientos adecuados sobre las IAAS y su prevención, pero presentan deficiencias en aspectos puntuales del tema.

A descriptive, cross-sectional study was carried out with field design to evaluate the knowledge about the healthcare associated infections (HCAI) and its prevention in postgraduate residents of the School of Health Sciences "Dr. Francisco Battistini Casalta" of the Universidad de Oriente, Venezuela. The sample consisted of 51 residents' physicians from different postgraduate programs. A survey was applied to investigate knowledge on three specific areas: generalities about HCAI, standard precautions and hand hygiene. They were considered to have adequate knowledge if they obtained an average score of 17.5 points or more. 58.8% of the respondents were female with an average age of 31 years (SD ±4.32, Range: 25-47). The average score in the survey was 17.9 points (SD ±1.87, Range: 12-22). The 56.87% approved the survey. When evaluating the knowledge about the studied areas, it was found that the majority have basic concepts about standard precautions (86.27%) but not about generalities of IAAS (37.25%) or hand hygiene (19.6%). In conclusion, the postgraduate residents have adequate knowledge about the HCAI and its prevention but present deficiencies in specific aspects.

Reporte de dos casos de inusual infección no letal por Chromobacterium violaceum. Revisión literaria / Report two cases non lethal infectious diseases for Chromobacterium violaceum. Review of the literature

Chromobacterium violaceum es una bacteria gramnegativa anaeróbica facultativa, que habita en el suelo y el agua de las áreas tropicales y subtropicales. La infección en seres humanos es rara. A continuación se presentan dos casos; una lactante mayor, indígena, quien posterior a baño de inmersión en aguas estancadas comienza a presentar fiebre con aumento de volumen y limitación funcional y gonalgia izquierda, se realiza lavado articular, se toma muestra para cultivo con crecimiento para Chromobacterium violaceum. Un escolar masculino de 7 años de edad con antecedente de Leucemia Linfoblastica Aguda con recaída en sistema nervioso central, cumpliendo esquema de altas dosis de metotrexate; quien comienza a presentar fiebre y signos de flogosis en sitio de colocación de cáteter de vía central, el cual es retirado y cultivado con crecimiento para Chromobacterium violaceum. Esta infección en humanos es una enfermedad grave y sistémica con una alta tasa de mortalidad.

Chromobacterium violaceum is a Gram-negative facultative anaerobic bacterium, which lives in the soil and water of subtropical and tropical areas. Infection in humans is rare. Here we present two cases. One was in one indigenous newborn, who after one immersion in stagnant waters presented fever and increase in the volume of testicle and limitation in movility of the left limb. After arthrocentesis of left knee and culture of the sinovial liquid, growth of Cromabacterium violaceum was reported. Another case was a male school of 7 years old with a history of acute lymphoblastic leukemia relapse in the central nervous system, that completed his high dose methotexate scheme. Some days after he presented fever and edema at the site of central venous catheterization. The catheter was retired and it was obtained growth of Chromobacterium violaceum. Human infection with Chromobacterium violaceum is a severe and systemic disease with a high mortality rate.

Vaginosis citolítica en pacientes con diagnóstico clínico de vulvovaginitis candidiásica / Cytolytic vaginosis in patients with clinical diagnosis of vulvovaginal candidiasis

La microbiota vaginal en la edad fértil está dominada por Lactobacillus spp. Su sobrecrecimiento provoca el aumento en la producción de ácido láctico, disminución del pH vaginal y lisis de células del epitelio vaginal, causando vaginosis citolítica, la cual se confunde con vulvovaginitis candidiásica (VVC) por la aparición de signos y síntomas similares. Se determinó la prevalencia de vaginosis citolítica, así como sus características clínicas y epidemiológicas en pacientes que consultaron con clínica sugestiva de VVC durante el período agosto-septiembre del año 2015. Se encontraron 12 pacientes con clínica compatible de VVC. En 11 (91,7%) se realizó el diagnóstico de vaginosis citolítica y en 1 (8,3%) de vulvovaginitis candidiásica. El 63,7% de las pacientes (7) tenían diagnóstico previo de VVC recurrente. Los síntomas más frecuentes fueron prurito vaginal o vulvar y secreción vaginal blanquecina de aspecto grumoso como leche cortada. La clínica iniciaba entre los 4-6 días posteriores a la menstruación, y desaparecía días antes o justo con el inicio de una nueva fase menstrual. En conclusión, se encontró que en las pacientes examinadas la sintomatología de ambas patologías resultó indistinguible, por tanto el diagnóstico clínico no es suficiente y debe recurrirse al diagnóstico de laboratorio para distinguir entre vaginosis citolítica y vulvovaginitis candidiásica.

The vaginal microbiota in fertile age is dominated by Lactobacillus spp. Its overgrowth causes increased production of lactic acid, decreased vaginal pH and lysis of cells of the vaginal epithelium, causing cytolytic vaginosis, which can be confused with vulvovaginal candidiasis (VVC) due to the similar signs and symptoms. The prevalence of cytolytic vaginosis, as well as its clinical and epidemiological characteristics was determined in patients who consulted with suggestive signs and symptoms of VVC during the period August to September of the year 2015. Twelve patients with signs and symptoms compatible with VVC were considered. Of those, 11 (91.7%) were diagnosed as cytolytic vaginosis and 1 (8.3%) corresponded to vulvovaginal candidiasis. From the 12 patients included, 7 (63.7%) had previous diagnosis of recurrent VVC. The most frequent symptoms recorded were vaginal or vulvar pruritus and whitish, cheesy or curd-like vaginal discharge. Signs and symptoms started between 4 to 6 days after menstruation, and disappeared days before or just with the onset of a new menstrual cycle. In conclusion, it was found that in the patients examined, signs and symptoms of both pathologies were indistinguishable. Therefore, the clinical diagnosis is not enough and laboratory studies should be used to distinguish between cytolytic vaginosis and vulvovaginal candidiasis.

Vaginosis citolítica: presentación de un caso clínico / Cytolytic vaginosis: presentation of a clinical case

La vaginosis citolítica, descrita hace 30 años como citólisis de Döderlein, es frecuente en mujeres en la edad reproductiva y, por las características de flujo vaginal blanquecino y síntomas clínicos, es indistinguible de la vulvovaginitis micótica. Se presenta el caso de una paciente, con diagnóstico clínico presuntivo de vulvovaginitis por Candida spp. a repetición, tratada empíricamente con antifúngicos por año y medio sin ninguna mejoría. Luego de estudios microbiológicos, la coloración de Gram, demostró la presencia de 50 bacilos grampositivos por campo y abundantes núcleos celulares desnudos. El cultivo resultó puro para Lactobacillus spp., lo que permitió confirmar el diagnóstico de vaginosis citolítica. La paciente fue tratada con ampicilina-sulbactam y no ha vuelto a presentar recidivas. En conclusión, es fundamental determinar el pH vaginal de las pacientes en la consulta, así como practicar una coloración de Gram de la secreción vaginal para poner en evidencia los cambios celulares por el exceso de ácido en la vagina y así evitar tratamientos antifúngicos innecesarios que acrecentarán los trastornos de la microbiota vaginal.

Cytolytic vaginosis, described 30 years ago as Döderlein cytolysis, is common in women of reproductive age and, due to the characteristics of whitish vaginal discharge and clinical symptoms, is indistinguishable from mycotic vulvovaginitis. We describe the case of a patient with presumptive clinical diagnosis of recurrent vulvovaginitis by Candida spp. treated empirically with antifungal agents for one and a half years without improvement. After microbiological studies, Gram staining demonstrated the presence of 50 Gram-positive bacilli per field and abundant nude cell nuclei. The culture recovered pure Lactobacillus spp. which permitted the diagnosis of cytolytic vaginosis. The patient was treated with ampicillin-sulbactam and since, has not had recurrences. In conclusion, it is essential to examine the pH of the patient vaginal discharge, as well as to practice a Gram staining of the vaginal secretion to demonstrate the cellular changes produced by the excess of acid in the vagina and therefore avoid unnecessary antifungal treatments that will produce undue changes of the vaginal microbiota.

Persistencia clonal de Pseudomonas aeruginosa productora de metalo-β-lactamasas en un hospital de Ciudad Bolívar, Venezuela / Clonal persistence of Pseudomonas aeruginosa producing metallo-β-lactamases in a hospital in Ciudad Bolivar, Venezuela

Pseudomonas aeruginosa es una de las especies aisladas con mayor frecuencia en las infecciones asociadas a la atención en salud, con un importante rol como patógeno. Se determinó la relación clonal de P. aeruginosa productora de metalo-β-lactamasas (MBLs), aisladas de pacientes recluidos en el Complejo Hospitalario Universitario “Ruiz y Páez”, Ciudad Bolívar, Venezuela, durante los años 2008 al 2014. Se evaluó una colección de 10 aislados de P. aeruginosa productoras de MBLs. La susceptibilidad a los antimicrobianos se realizó mediante difusión con discos. La producción de MBLs se detectó fenotípicamente a través del método de discos de carbapenemos combinados con ácido etilendiaminotetraacético-mercaptoacético de sodio, y mediante la reacción en cadena de la polimerasa se investigó la presencia de los genes que codifican para las MBLs de las familias IMP, VIM y SPM. Se determinó la relación clonal mediante la Amplificación Aleatoria de ADN Polimórfico (RAPD). Todas las cepas fueron multirresistentes y se comprobó la presencia de MBLs de tipo VIM. Mediante RAPD se logró clasificar las cepas en tres grupos clonales distintos, pero altamente relacionados entre sí, demostrándose su diseminación y persistencia clonal.

Pseudomonas aeruginosa is one of the species most frequently isolated in associated health care infections with an important role as pathogen. The clonal relation of P. aeruginosa producing metallo-β-lactamases (MBLs) isolated from patients hospitalized at the Hospital Universitario “Ruiz y Páez” Complex of Ciudad Bolivar, Venezuela, for the years 2008 to 2014, was determined. A set of 10 isolates of P. aeruginosa producing MBLs were evaluated. The antimicrobial susceptibility was performed by the disk diffusion test. MBLs production was determined by the method of carbapenem disks combined with ethylene-diamine-tetra-acetic acid-sodium mercapto-acetic. By means of the polymerase chain reaction test the presence of the genes encoding for MBLs of the families: IMP, VIM and SPM were investigated. Clonal spread by Random Amplified Polymorphic DNA (RAPD) was investigated. All strains were multiresistant and the presence of VIM type MBLs was demonstrated. By the RAPD the different strains were classified into three distinct clonal groups, highly related. In conclusion, all strains of P. aeruginosa were multiresistant, producing VIM type MBL and the clonal dissemination and persistence were demonstrated.

Epidemiología de las infecciones intrahospitalarias por el uso de catéteres venosos centrales / Epidemiology of intrahospital infections due to the use of central venous catheters

Las infecciones intrahospitalarias por el uso de catéteres venosos centrales son causa importante de morbi-mortalidad en países desarrollados y en vías de desarrollo, siendo la más frecuente la bacteriemia nosocomial. Objetivo: Determinar la frecuencia de las infecciones intrahospitalarias relacionadas al uso de catéteres venosos centrales en pacientes del Complejo Hospitalario Universitario “Ruíz y Páez” de Ciudad Bolívar. Venezuela. Metodología: Se estudiaron 31 pacientes portadores de catéteres venosos centrales en los servicios de Cirugía, Medicina, Emergencia de Adultos, Unidad de Cuidados Intensivos y Unidad de Diálisis; durante el período Mayo-Septiembre de 2008. Resultados: Se observó que 13 (41,90%) pacientes presentaron algún tipo de infección intrahospitalaria, siendo las bacteriemias nosocomiales las de mayor frecuencia en 6 (46,15%) pacientes, seguida de la infección del punto de entrada o conexión del CVC con 4 (30,80%) de los pacientes. Los microorganismos más frecuentes son bacterias Gram positivas, predominando Staphylococcus aureus y Estafilococos coagulasa negativo. El servicio con mayor incidencia de casos fue Unidad de Cuidados Intensivos con 30,80%. Los factores de riesgo más importantes fueron el tiempo de permanencia del catéter ³4 días, severidad de enfermedad de base, entre otros. Conclusiones: Las infecciones intrahospitalarias por el uso de catéteres venosos centrales son frecuentes en el complejo hospitalario, debiendo ser diagnosticadas por clínica y resultados microbiológicos. Además deben evidenciarse el uso de las técnicas adecuadas de colocación y manejo de los catéteres por el personal médico y enfermería.

Nosocomial infections due to the use of central venous catheters are a major cause of morbidity and mortality in developed and developing countries; the most frequent is nosocomial bacteremia. Objective: To determine the frequency of nosocomial infections related to use of central venous catheters in patients at the University Hospital Complex “Ruiz y Páez” in Ciudad Bolivar, State of Bolivar, Venezuela. Methods: Thirty-one patients with central venous catheters treated in the services for Surgery, Medicine, Adult Emergency, and the Intensive Care and Dialysis Units were studied during the period May to September, 2008. Results: It was observed that 13 (41.90%) patients had some type of nosocomial infection; nosocomial bacteremia was the most frequent in 6 patients (46.15%), followed by infection of the entry point or connection of the central venous catheters (4 patients; 30.80%). The most common microorganisms were gram-positive bacteria, predominantly Staphylococcus aureus and coagulase negative staphylococci. The hospital service with the highest incidence of cases was the Intensive Care Unit with 30.80%. The most important risk factors were prolonged catheterization ³4days and the severity of the underlying disease, among others. Conclusions: Nosocomial infections occasioned by the use of central venous catheters are common and must be diagnosed by clinical and microbiological results. The placement techniques and management of catheters by medical and nursing staff must be monitored.

Caracterización molecular de Pseudomonas aeruginosa resistentes a carbapenémicos provenientes de cuatro hospitales de Venezuela / Molecular characterization of carbapenem-resistant Pseudomonas aeruginosa from four hospitals of Venezuela

We analyzed 17 strains of Pseudomonas aeruginosa resistant to carbapenems isolated in four hospitals in eastern and southern Venezuela collected between 2007 and 2010. Combined disk method showed production of metallo־β־lactamases (MBLs) in all strains. PCR and sequencing of genes encoding IMP, VIM and SPM metallo־β־lactamase families confirmed the presence of VIM-2 MMBL in all strains. Pulsed field gel electrophoresis classified the strains into three similarity groups. The largest group, group A included 13 strains with over 83% similarity between them and was found in four hospitals. Two strains of Cumana hospital formed the group B and other two the Group C with similitary of 73% and 65% respectively with Group A. These results confirmed that hospitals in eastern and southern Venezuela, circulating strains of P. aeruginosa producing VIM-2 type MBLs with a common clonal origin. On the other hand, carbapenem-resistant P. aeruginosa circulating in Cumana city hospital had polyclonal origin.

Se analizaron 17 cepas de Pseudomonas aeruginosa resistentes a carbapenémicos aisladas en cuatro hospitales del oriente y sur de Venezuela colectadas entre los años 2007 y 2010. En todas las cepas se demostró la producción de metalo-β-lactamasas (MBLs) por el método de discos combinados. Mediante la amplificación por la reacción de polimerasa en cadena (RPC) de los genes que codifican para las metalo-β-lactamasas de las familias IMP, VIM y SPM, y su posterior secuenciación, se confirmó la presencia de MBLs de tipo VIM-2 en todas las cepas. Mediante la electroforesis de campos pulsantes (ECP), las cepas se clasificaron en tres grupos de similaridad. El grupo dominante (A) estuvo constituido por 13 cepas provenientes de los cuatro hospitales, con similaridad superior al 83% entre ellas. Dos cepas del hospital de Cumaná conformaron el Grupo B y otras dos el Grupo C con similaridad de 73 y 65%, respectivamente, con el Grupo A. Estos resultados confirmaron que en los hospitales del oriente y sur de Venezuela, circulan cepas de P. aeruginosa productoras de MBLs de tipo VIM-2, con un origen clonal común. Asimismo, en el hospital de Cumaná circulan cepas de origen policlonal.

Epidemiología molecular de Klebsiella pneumoniae productora de ß-lactamasas de espectro extendido / Molecular epidemiology of extended spectrum ß-lactamases producing Klebsiella pneumoniae

La rápida emergencia de la resistencia antimicrobiana debida a las betalactamasas de espectro extendido (BLEE) tiene un impacto clínico significativo, lo cual se considera un problema de salud pública. El objetivo de este estudio fue determinar si existe diseminación clonal de K. pneumoniae productora de BLEE, en pacientes adultos hospitalizados en el Complejo Hospitalario “Ruiz y Páez” (CHRP), Ciudad Bolívar, Venezuela. Se evaluaron 13 cepas de K. pneumoniae aisladas de pacientes adultos con infección intrahospitalaria. La confirmación fenotípica de la producción de BLEE, fue realizada por los métodos de sinergia de doble disco y del disco combinado. Se realizó la tipificación molecular de los aislados mediante electroforesis de campo pulsante (ECP). Todas las cepas presentaron resistencia asociada a las fluoroquinolonas y 9 fueron resistentes a los aminoglucósidos. Se encontraron 12 fenotipos de susceptibilidad; el fenotipo I prevaleció en dos cepas. La ECP reveló que la mayoría de las cepas presentaron pulsotipos distintos, descartando una posible relación clonal entre ellas, a excepción de dos aislados que presentaron pulsotipos indistinguibles entre sí, ambos del mismo servicio de hospitalización. Se puede concluir que en el CHRP para el período marzo-junio de 2011, no hubo diseminación clonal de K. pneumoniae productoras de BLEE.

The rapid emergence of antimicrobial resistance to extended spectrum ß-lactamases (ESBL) has a significant clinical impact, and is considered a public health problem. The purpose of this study was to determine if there is clonal dissemination of ESBL producer K. pneumonia in adult patients hospitalized at the Complejo Hospitalario “Ruiz y Paez” (CHRP) of Ciudad Bolivar, Venezuela. Thirteen K. pneumoniae strains isolated from adult patients with intra-hospital infections were evaluated. The phenotypic confirmation of ESBL production was done with the double disk synergy and combined disk methods. The molecular typing of the isolates was done through pulse field electrophoresis (PFE). All the strains presented fluoroquinolone-associated resistance and 9 were aminoglucoside resistant. Twelve susceptibility phenotypes were found; phenotype I prevailed in 2 strains. PFE revealed that most of the strains presented different pulsetypes, discarding a possible clonal relationship among them, except for 2 isolates which presented undistinguishable pulsetypes, both from the same hospitalization service. It can be concluded that at the CHRP there was no clonal dissemination of ESBL producer K. pneumoniae during the March-June 2011 period.

[Enterobacteria producers of extended-spectrum beta-lactamase in a hospital from Venezuela]. / Enterobatteri produttori di beta-lattamasi a spettro esteso in un ospedale in Venezuela.

The emergence of antimicrobial resistance due to extended-spectrum beta-lactamase (ESBL) has significant clinical impact and is a public health problem. The aim of the present study was to determine the frequency of infections by ESBL-producing enterobacteria in patients hospitalized in the "Ruiz y Paez" Hospital (CHRP) from Cuidad Bolivar, Venezuela, from January to July 2011. We determined the ESBL production from all isolates of E. coli, K. pneumoniae, K. oxytoca and P. mirabilis, using a double disk synergy test and combined disk method. Of the Enterobacteriaceae isolated, 20.3% (53) were ESBL producers, the main ones being K. pneumoniae and E. coli with 56.6% and 43.3% respectively: 15.7% of all E. coli and 47.6% of all K. pneumoniae were ESBL producers, and were more frequent in the purulent samples (43.3%) and blood (30.1%). The service with the greatest number of isolated ESBL-producing enterobacteria was medicine (26.4%) followed by perinatology (24.5%). We concluded that the CHRP has a high rate of ESBL-producing enterobacteria, mainly K. pneumoniae.

[Molecular characterization of carbapenem-resistant Pseudomonas aeruginosa from four hospitals of Venezuela]. / Caracterización molecular de Pseudomonas aeruginosa resistentes a carbapenémicos provenientes de cuatro hospitales de Venezuela.

We analyzed 17 strains of Pseudomonas aeruginosa resistant to carbapenems isolated in four hospitals in eastern and southern Venezuela collected between 2007 and 2010. Combined disk method showed production of metalloÖ¾ßÖ¾lactamases (MBLs) in all strains. PCR and sequencing of genes encoding IMP, VIM and SPM metalloÖ¾ßÖ¾lactamase families confirmed the presence of VIM-2 MMBL in all strains. Pulsed field gel electrophoresis classified the strains into three similarity groups. The largest group, group A included 13 strains with over 83% similarity between them and was found in four hospitals. Two strains of Cumana hospital formed the group B and other two the Group C with similitary of 73% and 65% respectively with Group A. These results confirmed that hospitals in eastern and southern Venezuela, circulating strains of P. aeruginosa producing VIM-2 type MBLs with a common clonal origin. On the other hand, carbapenem-resistant P. aeruginosa circulating in Cumana city hospital had polyclonal origin.

Evaluación del ácido etilendiaminotetraacético y del mercaptoacético de sodio en la detección de metalo β-lactamasas en Pseudomonas aeruginosa mediante la técnica del disco combinado / Evaluation of ethylenediaminetetraacetic acid and sodium mercaptoacetic acid in the detection of metallo β-lactamases in Pseudomonas aeruginosa by the combined disk technique

Pseudomonas aeruginosa es un bacilo gramnegativo capaz de adquirir genes que codifican para la producción de metalo β-lactamasas (MBLs), las cuales son activas contra carbapenemos e inhibidas por agentes quelantes, como el ácido etilendiaminotetraacético (EDTA). Se determinó la efectividad del EDTA y del ácido mercaptoacético de sodio (SMA) en la detección de MBLs en 25 cepas de P. aeruginosa procedentes de diferentes hospitales y centros de investigación, empleando el método de discos combinados. Se evaluó el efecto de los antibióticos solos y combinados con EDTA, SMA o ambos. Se encontró que, mediante el aumento del diámetro de los halos de inhibición de los carbapenemos combinados con la mezcla EDTA/SMA (0,5 M/300 mg/mL) o sólo con EDTA (0,5 M), se pudieron diferenciar de manera clara y confiable las cepas productoras de MBLs de las no productoras, estableciéndose como punto de corte una diferencia de 5 mm o más entre los halos de inhibición del antibiótico sólo y combinado con el o los agentes quelantes.

Pseudomanas aeruginosa is a gram negative bacillus capable of acquiring genes which code for metallo β-lactamase production (MBLs) which are active against carbapenems and inhibited by chelating agents such as ethylenediaminetetraacetic acid (EDTA). We determined the effectiveness of EDTA and sodium mercaptoacetic acid (SMA) in the detection of MBLs on 25 P. aeruginosa strains from different hospitals and research centers, using the combined disk technique. We evaluated the effect of the antibiotics alone and combined with EDTA, SMA, or both. We found that through the increase of the diameter of the inhibition halos of the carbapenems combined with an EDTA/SMA mixture (0.5 M/300 mg/mL) o with EDTA alone (0.5 M), we could differentiate in a clear and reliable way the MBLs producing from the non producing strains, establishing as cutoff point a difference of 5 mm or more between the antibiotic alone and the antibiotic combined with the chelating agent(s).

[blaVIM-2 gene detection in metallo-beta-lactamase-producing Pseudomonas aeruginosa strains isolated in an intensive care unit in Ciudad Bolívar, Venezuela]. / Detección del gen blaVIM-2 en cepas de Pseudomonas aeruginosa productoras de metalo beta-lactamasa aisladas en una unidad de cuidados intensivos en Ciudad Bolívar, Venezuela.

Ten Pseudomonas aeruginosa strains with resistance to broad-spectrum cephalosporin and carbapenems were studied to determine the presence of genes that mediate the production of metallo-beta-lactamases. These strains were isolated from patients with nosocomial infection at the Intensive Care Unit of the Complejo Hospitalario "Ruiz y Paéz" of Ciudad Bolívar, Bolívar State, Venezuela, from 2003 to 2006. In all isolates a metallo-enzyme activity was detected by using the double disk synergism test. PCR amplification of genes encoding the families IMP, VIM and SPM metallo-beta-lactamases showed the presence of a blaVIM gene in all strains studied. DNA sequencing revealed that all isolates showed the presence of blaVIM-2. These results suggest that it is necessary to keep these strains under epidemiologic surveillance, establish laboratory strategies for opportune detection and the implementation of new policies to ensure the appropriate use of antibiotics in this institution.

Detección del gen blaVIM-2 en cepas de Pseudomonas aeruginosa productoras de metalo ß-lactamasa aisladas en una unidad de cuidados intensivos en Ciudad Bolívar, Venezuela / blaVIM-2 gene detection in metallo-ß-lactamase-producing Pseudomonas aeruginosa strains isolated in an Intensive Care Unit in Ciudad Bolívar, Venezuela

Ten Pseudomonas aeruginosa strains with resistance to broad-spectrum cephalosporin and carbapenems were studied to determine the presence of genes that mediate the productionof metallo-p-lactamases. These strains were isolated from patients with nosocomial infection at the Intensive Care Unit of the Complejo Hospitalario "Ruiz y Paéz" of Ciudad Bolívar, Bolívar State, Venezuela, from 2003 to 2006. In all isolates a metallo-enzyme activity was detected by using the double disk synergism test. PCR amplification of genes encoding the families IMP, VIM and SPM metallo-ß-lactamases showed the presence of a blaVIM gene in all strains studied. DNA sequencing revealed that all isolates showed the presence of blaVIM-2These results suggest that it is necessary to keep these strains under epidemiologic surveillance, establish laboratory strategies for opportune detection and the imple-mentation of new policies to ensure the appropriate use of antibiotics in this institution.

Se estudiaron 10 cepas de Pseudomonas aeruginosa con resistencia a cefalosporinas y carbapenémicos con el objeto de determinar la presencia de genes que median la producción de metalo ß-lactamasas. Estas cepas se aislaron de pacientes con infección nosocomial hospitalizados en la Unidad de Cuidados Intensivos (UCI) del Complejo Hospitalario "Ruiz y Paéz" de Ciudad Bolívar, estado Bolívar, Venezuela, durante el período 2003 - 2006. En todas las cepas se detectó la actividad de una metalo-enzima, mediante la prueba del sinergismo del doble disco. La amplificación por la reacción de polimerasa en cadena de los genes que codifican para las metalo ß-lactamasas de las familias IMP, VIM y SPM, y su posterior secuenciación, permitió confirmar la presencia de metalo p-lactamasas de tipo VIM-2. Estos resultados sugieren que es necesario mantener bajo vigilancia epidemiológica a estas cepas, establecer estrategias de laboratorio para su detección oportuna e implementar nuevas políticas que aseguren el uso adecuado de los antibacterianos en esta institución.