Pan-American Guidelines for the Treatment of SARS-CoV-2/COVID-19: a joint evidence-based guideline of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API) [Pré-print]

Since the beginning of the COVID-19 pandemic, therapeutic options for treating COVID-19 have been investigated at different stages of clinical manifestations. Considering the particular impact of COVID-19 in the Americas, this document aims to present recommendations for the pharmacological treatment of COVID-19 specific to this population. Fifteen experts, members of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API) make up the panel responsible for developing this guideline. Questions were formulated regarding prophylaxis and treatment of COVID-19 in outpatient and inpatient settings. The outcomes considered in decision-making were mortality, hospitalisation, need for mechanical ventilation, symptomatic COVID-19 episodes, and adverse events. In addition, a systematic review of randomised controlled trials was conducted. The quality of evidence assessment and guideline development process followed the GRADE system. Nine technologies were evaluated, and ten recommendations were made, including the use of tixagevimab + cilgavimab in the prophylaxis of COVID-19, tixagevimab + cilgavimab, molnupiravir, nirmatrelvir + ritonavir, and remdesivir in the treatment of outpatients, and remdesivir, baricitinib, and tocilizumab in the treatment of hospitalised patients with severe COVID-19. The use of hydroxychloroquine or chloroquine and ivermectin was discouraged. This guideline provides recommendations for treating patients in the Americas following the principles of evidence-based medicine. The recommendations present a set of drugs that have proven effective in the prophylaxis and treatment of COVID-19, emphasising the strong recommendation for the use of nirmatrelvir/ritonavir in outpatients as the lack of benefit from the use of hydroxychloroquine and ivermectin

Hepatite E crônica - relato de um caso brasileiro / Chronic hepatitis E - a brazilian case report

Hepatite é a quinta forma conhecida de hepatites humanas virais. Apesar de ser muito incomum em nossa prática clínica, a incidência em países ocidentais vem aumentando. O vírus da Hepatite E (HVE) pode estar relacionado à doença aguda, falência hepática, hepatite crônica e cirrose. O HVE é um RNA vírus, com 5 genótipos descritos (1, 2, 3, 4 e 5), sendo que quatro deles podem afetar humanos. Além das manifestações hepáticas, o genótipo 3 pode também levar a manifestações extra-hepáticas, como alterações neurológicas, renais e reumatológicas. O diagnóstico pode ser difícil porque existem poucos testes validados e ainda com baixa sensibilidade e especificidade. A hepatite aguda não precisa ser tratada, já a hepatite E crônica deve ser tratada. Relatamos aqui um caso brasileiro de Hepatite E crônica em um paciente imunossuprimido.

Hepatitis E is the fifth known form of human viral hepatitis. Although not very common in our clinical practice, the incidence in Western countries is increasing. Hepatitis E virus (HEV) may be related to acute illness, liver failure, chronic hepatitis and cirrhosis. HEV is an RNA virus, with 5 described genotypes (1,2,3,4,5), 4 of them can affect humans. Besides liver manifestations, genotype 3 is also related to extra-hepatic manifestations, such as neurological, renal and rheumatological. The diagnosis may be difficult because of the low availability of tests and due to low sensibility and specificity. The acute illness does not have to be treated, but the chronic one does. We presente here a Brazilian case of chronic hepatitis E in an immunosuppressed patient.

Effects of a bundled Antimicrobial Stewardship Program on mortality: a cohort study

Objectives: To assess a bundled Antimicrobial Stewardship Program and its effect on mortality. Data: Eight months of clinical electronic medical records and Antimicrobial Stewardship Program registries were used as source of data. Method: This is a historical cohort study conducted in a Brazilian University Hospital. Eligible patients were admitted to general wards or intensive care units and had an antimicrobial therapy prescribed and assessed by different strategies: Bundled Antimicrobial Stewardship Program (bundled intervention consisted of clinical pharmacist chart review, discussion with microbiologist and infectious disease physicians, local education and continuous follow-up) or Conventional Antimicrobial Stewardship Program (clinical pharmacist chart review and discussion with infectious disease physician). Primary outcome from this study was 30-day mortality, which was compared between groups, by using Kaplan-Meier survival curve and log-rank test. Other outcomes included Defined Daily Doses per 1000 patient-days and occurrence of resistant bacteria. Results: From 533 patients, 491 were eligible for the study, of which 191 patients were included to Antimicrobial Stewardship Program and 300 to Conventional strategy. In general, they were likely to be male and age was similar in groups (58.9 vs 55.5 years, p = 0.38). Likewise, Charlson Comorbidity Index was not statistically different between groups (2.6 vs 2.7, p = 0.2). Bloodstream site infections were frequently diagnosed in both groups (30.89% vs 26%, p = 0.24). Other less common sites of infections were central nervous system and lungs. The ASP group had higher survival rates (p < 0.01) and the risk difference was 10.8% (95% CI: 2.41-19.14). There were less Defined Daily Doses per 1000 patient-days (417 vs 557.2, p < 0.05) and higher rates of resistant bacteria identified in the ASP group (83% vs 17%). Conclusion: Bundled ASP was the most effective strategy, with reduced ...

Effects of a bundled Antimicrobial Stewardship Program on mortality: a cohort study.

OBJECTIVES: To assess a bundled Antimicrobial Stewardship Program and its effect on mortality. DATA: Eight months of clinical electronic medical records and Antimicrobial Stewardship Program registries were used as source of data. METHOD: This is a historical cohort study conducted in a Brazilian University Hospital. Eligible patients were admitted to general wards or intensive care units and had an antimicrobial therapy prescribed and assessed by different strategies: Bundled Antimicrobial Stewardship Program (bundled intervention consisted of clinical pharmacist chart review, discussion with microbiologist and infectious disease physicians, local education and continuous follow-up) or Conventional Antimicrobial Stewardship Program (clinical pharmacist chart review and discussion with infectious disease physician). Primary outcome from this study was 30-day mortality, which was compared between groups, by using Kaplan-Meier survival curve and log-rank test. Other outcomes included Defined Daily Doses per 1000 patient-days and occurrence of resistant bacteria. RESULTS: From 533 patients, 491 were eligible for the study, of which 191 patients were included to Antimicrobial Stewardship Program and 300 to Conventional strategy. In general, they were likely to be male and age was similar in groups (58.9 vs 55.5 years, p=0.38). Likewise, Charlson Comorbidity Index was not statistically different between groups (2.6 vs 2.7, p=0.2). Bloodstream site infections were frequently diagnosed in both groups (30.89% vs 26%, p=0.24). Other less common sites of infections were central nervous system and lungs. The ASP group had higher survival rates (p<0.01) and the risk difference was 10.8% (95% CI: 2.41-19.14). There were less Defined Daily Doses per 1000 patient-days (417 vs 557.2, p<0.05) and higher rates of resistant bacteria identified in the ASP group (83% vs 17%). CONCLUSION: Bundled ASP was the most effective strategy, with reduced mortality and Defined Daily Doses per 1000 patient-days.

Use of assisted reproductive technology to separate sperm from human immunodeficiency virus infected men resulting in pregnancy among serodiscordant couples.

Due to HIV care improvement, discordant couples more frequently seek help in order to conceive their own biological child. Besides the advance of antiretroviral therapy, unprotected intercourse is not a complete safe option, carrying a low but still present risk of HIV transmission. We report 10 serodiscordant couples in whom the male partner is HIV positive, submitted to sperm washing and intrauterine insemination. The procedure resulted in four pregnancies and no HIV transmission to mother or child was observed. Techniques of assisted reproduction can help HIV discordant couples to conceive biological offspring and is a safer option than unprotected intercourse.

Use of assisted reproductive technology to separate sperm from human immunodeficiency virus infected men resulting in pregnancy among serodiscordant couples

Due to HIV care improvement, discordant couples more frequently seek help in order to conceive their own biological child. Besides the advance of antiretroviral therapy, unprotected intercourse is not a complete safe option, carrying a low but still present risk of HIV transmission. We report 10 serodiscordant couples in whom the male partner is HIV positive, submitted to sperm washing and intrauterine insemination. The procedure resulted in four pregnancies and no HIV transmission to mother or child was observed. Techniques of assisted reproduction can help HIV discordant couples to conceive biological offspring and is a safer option than unprotected intercourse.

HIV subtype, epidemiological and mutational correlations in patients from Paraná, Brazil

OBJECTIVE: Analyze patients with HIV infection from Curitiba, Paraná, their epidemiological characteristics and HIV RAM. METHODS: Patients regularly followed in an ID Clinic had their medical data evaluated and cases of virological failure were analyzed with genotypic report. RESULTS: Patients with complete medical charts were selected (n = 191). Demographic and clinical characteristics were compared. One hundred thirty two patients presented with subtype B infection (69.1 percent), 41 subtype C (21.5 percent), 10 subtype F (5.2 percent), 7 BF (3.7 percent) and 1 CF (0.5 percent). Patients with subtype B infection had been diagnosed earlier than patients with subtype non-B. Also, subtype B infection was more frequent in men who have sex with men, while non-B subtypes occurred more frequently in heterosexuals and women. Patients with previous history of three classes of ARVs (n = 161) intake were selected to evaluate resistance. For RT inhibitors, 41L and 210W were more frequently observed in subtype B than in non-B strains. No differences between subtypes and mutations were observed to NNTRIs. Mutations at 10, 32 and 63 position of protease were more observed in subtype B viruses than non-B, while positions 20 and 36 of showed more amino acid substitutions in subtype non-B viruses. Patients with history of NFV intake were evaluated to resistance pathway. The 90M pathway was more frequent in subtypes B and non-B. Mutations previously reported as common in non-B viruses, such as 65R and 106M, were uncommon in our study. Mutations 63P and 36I, previously reported as common in HIV-1 subtypes B and C from Brazil, respectively, were common. CONCLUSION: There is a significant frequency of HIV-1 non-B infections in Paraná state, with isolates classified as subtypes C, F, BF and BC. Patients with subtype C infection were more frequently female, heterosexual and had a longer average time of HIV diagnosis.

HIV subtype, epidemiological and mutational correlations in patients from Paraná, Brazil.

OBJECTIVE: Analyze patients with HIV infection from Curitiba, Paraná, their epidemiological characteristics and HIV RAM. METHODS: Patients regularly followed in an ID Clinic had their medical data evaluated and cases of virological failure were analyzed with genotypic report. RESULTS: Patients with complete medical charts were selected (n = 191). Demographic and clinical characteristics were compared. One hundred thirty two patients presented with subtype B infection (69.1%), 41 subtype C (21.5%), 10 subtype F (5.2%), 7 BF (3.7%) and 1 CF (0.5%). Patients with subtype B infection had been diagnosed earlier than patients with subtype non-B. Also, subtype B infection was more frequent in men who have sex with men, while non-B subtypes occurred more frequently in heterosexuals and women. Patients with previous history of three classes of ARVs (n = 161) intake were selected to evaluate resistance. For RT inhibitors, 41L and 210W were more frequently observed in subtype B than in non-B strains. No differences between subtypes and mutations were observed to NNTRIs. Mutations at 10, 32 and 63 position of protease were more observed in subtype B viruses than non-B, while positions 20 and 36 of showed more amino acid substitutions in subtype non-B viruses. Patients with history of NFV intake were evaluated to resistance pathway. The 90M pathway was more frequent in subtypes B and non-B. Mutations previously reported as common in non-B viruses, such as 65R and 106M, were uncommon in our study. Mutations 63P and 36I, previously reported as common in HIV-1 subtypes B and C from Brazil, respectively, were common. CONCLUSION: There is a significant frequency of HIV-1 non-B infections in Paraná state, with isolates classified as subtypes C, F, BF and BC. Patients with subtype C infection were more frequently female, heterosexual and had a longer average time of HIV diagnosis.