Candida parapsilosis Infection after Lumbosacral Arthrodesis with a PEEK TLIF Interbody Fusion Device: Case Report.

Spondylodiscitis is an uncommon but serious complication after spine surgeries, and its main etiologic agent is Staphylococcus aureus . Fungal infections are rare and mostly caused by Candida albicans . We report the clinical case of a 69-year-old male patient who underwent a L2-S1 arthrodesis for degenerative scoliosis correction. He presented an infection 2.5 months after the procedure, a spondylodiscitis at L5-S1 levels, caused by Candida parapsilosis . The treatment consisted of surgical material removal, tricortical iliac graft placement in an anterior approach (L5-S1), lumbopelvic fixation (from T10 to the pelvis) in a posterior approach, and drug treatment with anidulafungin and fluconazole. This last medication was administered for 12 months, with good clinical outcomes.

Clinical culture surveillance of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species in a teaching hospital in Sao Paulo, Brazil: a 7-year study.

Carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species are worrisome nosocomial pathogens. After introduction of a preventive program involving clinical surveillance culture to reduce the spread of those pathogens, we observed an 80% decrease in the percentage of cultures that yielded carbapenem-resistant Acinetobacter isolates. The percentage of cultures that yielded carbapenem-resistant P. aeruginosa remained relatively stable during the intervention.

Risk factors for vancomycin-resistant Enterococcus faecalis bacteremia in hospitalized patients: an analysis of two case-control studies.

BACKGROUND: Vancomycin-resistant enterococci (VRE) is an important pathogen in the hospital environment, and a progressive increase in its incidence is a cause of nosocomial infections. Bacteremia is one of the major infections caused by this pathogen. Risk factors for VRE bacteremia were assessed at a university-affiliated hospital. METHODS: Two case-control studies with different control groups were used. In study 1, patients with VRE bacteremia were compared with control patients matched by sex, admission unit, age (+/-10 years), and time of admission (+/-1 year). In study 2, the case group (VRE patients) was compared with vancomycin-susceptible enterococci (VSE) patients. RESULTS: A total of 34 patients with VRE bacteremia and 102 control patients were included in study 1, and 34 patients with VRE bacteremia and 55 patients with VSE bacteremia were included in study 2. In study 1, vancomycin use (OR, 10.19; CI 95%, 3.63-28.57) was associated with VRE bacteremia. In study 2, vancomycin use (OR, 17.58; CI 95%, 5.24-58.96) was also associated with VRE bacteremia. CONCLUSION: Because vancomycin use was the only variable associated with VRE bacteremia in the two studies, we confirmed that vancomycin exposure is the major risk factor for VRE bacteremia.

Candida parapsilosis Infection after Lumbosacral Arthrodesis with a PEEK TLIF Interbody Fusion Device: Case Report / Infecção por Candida parapsilosis em pós-operatório de artrodese lombossacra com dispositivo de fusão intersomático TLIF em PEEK: Relato de caso

Abstract Spondylodiscitis is an uncommon but serious complication after spine surgeries, and its main etiologic agent is Staphylococcus aureus. Fungal infections are rare and mostly caused by Candida albicans. We report the clinical case of a 69-year-old male patient who underwent a L2-S1 arthrodesis for degenerative scoliosis correction. He presented an infection 2.5 months after the procedure, a spondylodiscitis at L5-S1 levels, caused by Candida parapsilosis. The treatment consisted of surgical material removal, tricortical iliac graft placement in an anterior approach (L5-S1), lumbopelvic fixation (from T10 to the pelvis) in a posterior approach, and drug treatment with anidulafungin and fluconazole. This last medication was administered for 12 months, with good clinical outcomes.

Resumo As espondilodiscites são complicações infrequentes, porém graves em pós-operatórios de cirurgias da coluna vertebral, tendo como principal agente etiológico o Staphylococcus aureus. As infecções fúngicas são raras, sendo a Candida albicans a principal representante desse grupo. Relatamos o caso clínico de um paciente do sexo masculino, 69 anos, operado com artrodese de L2 a S1 para correção de escoliose degenerativa. O paciente apresentou quadro clínico infeccioso 2 meses e meio após o procedimento, relacionado à espondilodiscite L5-S1, causada por Candida parapsilosis. O tratamento consistiu na remoção do material cirúrgico, colocação de enxerto tricortical de ilíaco pela via anterior (L5-S1) e fixação lombopélvica (de T10 à pelve) pela via posterior, além de iniciar o tratamento medicamentoso com anidulafungina e fluconazol, mantendo essa última medicação por 12 meses, com boa evolução clínica.

Prevalence and factors associated with rectal vancomycin-resistant enterococci colonization in two intensive care units in São Paulo, Brazil.

Vancomycin-resistant enterococci (VRE) are important pathogens causing nosocomial infections, and there is reason for concern about their resistance and great ability to spread in hospital environments, especially intensive-care units (ICU). To determine the prevalence of rectal colonization by VRE, and the risk factors associated with their presence, rectal surveillance swabs were taken from patients under treatment in two intensive-care units (one medical and another both medical and surgical) at São Paulo Hospital, over a two-year period. Thirty-three percent of the 147 patients evaluated had VRE. The only significant variable in the logistic regression was the length of stay in the ICU.

[Incidence of vancomycin-resistant Enterococcus at a university hospital in Brazil]. / Incidência de Enterococcus resistente à vancomicina em hospital universitário no Brasil.

OBJECTIVE: Vancomycin-resistant Enterococcus (VRE) is today one of the principal microorganisms implicated in nosocomial infections. Thus, a study was carried out with the objective of evaluating its epidemiology at a tertiary-level teaching hospital. METHODS: This was a three-year retrospective epidemiological study conducted from 2000 to 2002. Samples of VRE-positive clinical cultures at a 660-bed university hospital were analyzed. The incidence of VRE and the main anatomical sites and hospital units from which it was isolated were defined. Differences between the variables over the three years of the study were verified, and these were considered significant when p<0.05. RESULTS: There was a progressive increase in the vancomycin resistance in the clinical cultures that were positive for Enterococcus spp., over the three years of the study. In 2000, 9.5% of the samples were vancomycin-resistant, and this increased to 14.7% in 2001 and 15.8% in 2002. The hospital units with the largest numbers of isolates were, respectively, the emergency ward (19.5%) and the general intensive care unit (15%). The anatomical sites with the highest amounts of isolates included: urine (36%) and blood (20%). CONCLUSIONS: With the progressive increase in the incidence of vancomycin resistance and the VRE rate, it is concluded that more effective control measures are needed for deterring the dissemination of VRE.

Healthcare-associated infections among neonates in Brazil.

OBJECTIVE: To describe the epidemiology of healthcare-associated infections (HAIs) among neonates. DESIGN: Prospective surveillance of HAIs was conducted during 2 years. Infections beginning within 48 hours of birth were defined as HAIs of maternal origin. Death occurring during an active episode of HAI was considered related to HAI. SETTING: Seven neonatal units located in three Brazilian cities. PATIENTS: All admitted neonates were included and observed until discharge. RESULTS: Twenty-two percent of 4,878 neonates had at least one HAI. The overall incidence density was 24.9 per 1,000 patient-days, and 28.1% of all HAIs were maternally acquired. HAI rates ranged from 12.3% in the group with a birth weight (BW) of more than 2,500 g to 51.9% in the group with a BW of 1,000 g or less. The main HAIs were bloodstream infection (BSI) and pneumonia. Coagulase-negative staphylococci, Enterobacter species, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens. Forty percent of all deaths were related to HAI. Central venous catheter (CVC)-associated BSIs per 1,000 CVC-days ranged from 17.3 (BW, 1,501 to 2,500 g; device utilization [DU], 0.11) to 34.9 (BW, < or = 1,000 g; DU, 34.92). Ventilator-associated pneumonia per 1,000 ventilator-days ranged from 7.0 (BW, < or = 1,000 g; DU, 0.34) to 9.2 (BW, 1,001 to 1,500 g; DU, 0.14). CONCLUSIONS: The high proportion of HAIs of maternal origin highlights perinatal care issues in Brazil and the need to improve the diagnosis of neonatal HAIs. The very low BW group and device-associated infections should be priorities for prevention strategies in this population.

Risk factors for mediastinitis after cardiac surgery.

BACKGROUND: Postoperative mediastinitis is one of the most feared complications in patients who undergo cardiac surgery because in addition to a high mortality rate (10% to 47%), there are increases in the length of hospital stay and in hospital costs. The purpose of the present study is to assess the risk factors for mediastinitis after cardiac surgery, the mediastinitis rate, and the mortality rate in our institution. METHODS: To determine the risk factors, a matched case-control study was carried out, with 39 cases and 78 controls, among the patients who underwent cardiac surgery at the Dante Pazzanese Cardiology Institute, São Paulo, Brazil. RESULTS: In the period of the study, 9,136 cardiac surgeries were performed and the mediastinitis rate was 0.5%. In the multivariate analysis, the independent risk factors found were obesity (odds ratio, 6.49; 95% confidence interval, 2.24 to 18.78), smoking (odds ratio, 3.27; 95% confidence interval, 1.04 to 10.20), intensive care unit stay more than 2 days (odds ratio, 4.50; 95% confidence interval, 1.57 to 12.90), and infection at another site (odds ratio, 8.86; 95% confidence interval, 1.86 to 42.27). The mortality rate was 23% among the patients with mediastinitis. CONCLUSIONS: We observed two independent risk factors related to patients' antecedents (obesity and smoking) and two risk factors related to problems in the postoperative period (length of intensive care unit stay and infection at another site). Efforts should be concentrated so that patients lose weight and stop smoking before elective surgeries. There should also be a prevention program against hospital infection directed to, and intensified for, at-risk patients.

Staphylococcus aureus bacteremia: comparison of two periods and a predictive model of mortality.

Staphylococcus aureus is an important pathogen causing bacteremia, primarily affecting hospitalized patients. We studied the epidemiology of S. aureus bacteremia, comparing two periods (early and mid 1990s) and developed a predictive model of mortality. A nested case-control was done. All 251 patients over 14 years old with positive blood cultures for S. aureus were selected. MRSA (methicillin resistant S. aureus) was isolated in 63% of the cases. When comparing the two periods MRSA community-acquired bacteremia increased from 4% to 16% (p=0.01). There was no significant difference in the mortality rate between the two periods (39% and 33%, p=0.40). Intravascular catheters provoked 24% of the cases of bacteremia and were associated with the lowest rate of mortality. In a logistic regression analysis, three variables were associated with death: septic shock, source of bacteraemia and resistance to methicillin. The probability of dying among patients with MRSA and those with methicillin sensitive S. aureus bacteraemia ranged from 10% to 90% and from 4% to 76%, respectively, depending on the source of the bacteraemia and the occurrence of septic shock. The MRSA found in Brazil may be a particularly virulent strain.

Impact of an education program on the incidence of central line-associated bloodstream infection in 2 medical-surgical intensive care units in Brazil.

An intervention study was undertaken to evaluate the impact of an education program on the incidence of central line-associated bloodstream infection (CLABSI) in 2 intensive care units. There was a nonsignificant reduction in the incidence of CLABSI (odds ratio, 0.46 [95% confidence interval, 0.21-1.02]; P=.04) despite a significant increase in knowledge of CLABSI prevention by the staff of both intensive care units after the education program.

Application of control measures for infections caused by multi-resistant gram-negative bacteria in intensive care unit patients.

Multi-resistant gram-negative rods are important pathogens in intensive care units (ICU), cause high rates of mortality, and need infection control measures to avoid spread to another patients. This study was undertaken prospectively with all of the patients hospitalized at ICU, Anesthesiology of the Hospital São Paulo, using the ICU component of the National Nosocomial Infection Surveillance System (NNIS) methodology, between March 1, 1997 and June 30, 1998. Hospital infections occurring during the first three months after the establishment of prevention and control measures (3/1/97 to 5/31/97) were compared to those of the last three months (3/1/98 to 5/31/98). In this period, 933 NNIS patients were studied, with 139 during the first period and 211 in the second period. The overall rates of infection by multi-resistant microorganisms in the first and second periods were, respectively, urinary tract infection: 3.28/1000 patients/day; 2.5/1000 patients/day; pneumonia: 2.10/1000 patients/day; 5.0/1000 patients/day; bloodstream infection: 1.09/1000 patients/day; 2.5/1000 patients/day. A comparison between overall infection rates of both periods (Wilcoxon test) showed no statistical significance (p = 0.067). The use of intervention measures effectively decreased the hospital bloodstream infection rate (p < 0.001), which shows that control measures in ICU can contribute to preventing hospital infections.

Prevalence and factors associated with rectal vancomycin-resistant enterococci colonization in two intensive care units in São Paulo, Brazil

Vancomycin-resistant enterococci (VRE) are important pathogens causing nosocomial infections, and there is reason for concern about their resistance and great ability to spread in hospital environments, especially intensive-care units (ICU). To determine the prevalence of rectal colonization by VRE, and the risk factors associated with their presence, rectal surveillance swabs were taken from patients under treatment in two intensive-care units (one medical and another both medical and surgical) at São Paulo Hospital, over a two-year period. Thirty-three percent of the 147 patients evaluated had VRE. The only significant variable in the logistic regression was the length of stay in the ICU.

Incidência de Enterococcus resistente à vancomicina em hospital universitário no Brasil / Incidence of vancomycin-resistant Enterococcus at a university hospital in Brazil

OBJETIVO: O enterococo resistente à vancomicina é atualmente um dos principais microorganismos implicados em infecções nosocomiais. Assim, realizou-se estudo com o objetivo de avaliar sua epidemiologia em um hospital terciário de ensino. MÉTODOS: Trata-se de um estudo epidemiológico retrospectivo, realizado de 2000 a 2002, que analisou amostras de culturas clínicas positivas para enterococo resistente à vancomicina (VRE) em um hospital universitário com 660 leitos. Procurou-se definir sua incidência e os principais sítios e unidades de isolamento. Foi verificada a significância entre as variáveis nos três anos de estudo, sendo considerado como significante p<0,05. RESULTADOS: Houve aumento progressivo na resistência à vancomicina nas culturas clínicas positivas para Enterococcus spp. nos três anos de estudo. Em 2000, 9,5 por cento das amostras eram resistentes à vancomicina, com aumento para 14,7 por cento em 2001 e 15,8 por cento em 2002. As unidades com maior número de isolados foram respectivamente: pronto-socorro (19,5 por cento) e UTI geral (15 por cento); os sítios mais isolados foram: urina (36 por cento) e sangue (20 por cento). CONCLUSÕES: Com o aumento progressivo na incidência de resistência à vancomicina e da taxa de VRE, concluiu-se ser necessárias medidas de controle mais efetivas para deter a disseminação do VRE.

Staphylococcus aureus bacteremia: comparison of two periods and a predictive model of mortality

Staphylococcus aureus is an important pathogen causing bacteremia, primarily affecting hospitalized patients. We studied the epidemiology of S. aureus bacteremia, comparing two periods (early and mid 1990s) and developed a predictive model of mortality. A nested case-control was done. All 251 patients over 14 years old with positive blood cultures for S. aureus were selected. MRSA (methicillin resistant S. aureus) was isolated in 63 percent of the cases. When comparing the two periods MRSA community-acquired bacteremia increased from 4 percent to 16 percent (p=0.01). There was no significant difference in the mortality rate between the two periods (39 percent and 33 percent, p=0.40). Intravascular catheters provoked 24 percent of the cases of bacteremia and were associated with the lowest rate of mortality. In a logistic regression analysis, three variables were associated with death: septic shock, source of bacteraemia and resistance to methicillin. The probability of dying among patients with MRSA and those with methicillin sensitive S. aureus bacteraemia ranged from 10 percent to 90 percent and from 4 percent to 76 percent, respectively, depending on the source of the bacteraemia and the occurrence of septic shock. The MRSA found in Brazil may be a particularly virulent strain.

Cut and puncture accidents involving health care workers exposed to biological materials

The first repor of occupational acquisition of HIV appeared in 1984, and, by june,1997, the Centers for Disease Control and Prevention (CDC) had reported 52 document cases of sero-conversion following occupational exposure to HIV-1 by health care workers of those cases. 47(90.3 percent) were exposed to blood. The most frequent type of accident reported was percutaneous needlestick injury. Prospective studies have estimated that the risk of HIV transmission following percutaneous exposure to infected blood is 0,3 percent (Confidence Interval 95 percent=0,2 percent to 0,5 percent). Following a mucous membrane exposure, the risk is 0,09 percent (CI95 percent=0.006 percent to 0,5 percent). The risk of hepatitis B acquisition ranges from 6 percent to 30 percent, and hepatitis C acquisition, 3 percent to 10 percent. Since 1992, the São Paulo Hospital's Hospital Infectious Prevention and Control Service (SPCIH) has notified and treated all workers exposed to accidents involving biological materials. In the last six years, we have handled approximately 1,300 cases of reported accidents, of which 90 percent were percutaneous, most involving needlesticks. Such cases were frequently caused by the inadequate disposal and reccaping of needles. In these accidents, 20 percent of the source patients were HIV positive, 10 percent were hepatitis C positive, and 7,6 percent were hepatitis B positive. This review summarizes the guidelines for a standardized response When deadling with accidents involving health care workers. Transmission of hepatitis B and HIV can be reduced if adequate preventive measures are taken in advance. If proper prophyllaxis is not being done, it should be initiated immediately.

Profilaxia antimicrobiana em cirurgia do aparelho digestivo: uma proposta de adequação / Antibiotic prophylaxis in gastroenterologic surgery: a proposal of adjustment

A profilaxia antimicrobiana é uma das medidas de controle da infecção da ferida cirúrgica. Mesmo com os princípios básicos hoje bem estabelecidos, cerca de 40 por cento das indicações habituais de profilaxia são inadequadas e um dos erros mais comuns está relacionado à duração, em geral superior a 48 horas. Ajustes na profilaxia, além de favorecer sua eficácia na prevenção da infecção cirúrgica, provavelmente contribuiriam para reduzir a pressão seletiva sobre a emergência de bactérias resistentes e custos hospitalares. A simples instituição de uma rotina de antibiótico-profilaxia não garante a adesão dos cirurgiões para adequação do uso de antimicrobianos. No presente estudo, uma intervenção foi realizada na Disciplina de Gastroenterologia Cirúrgica da Universidade Federal de São Paulo - Escola Paulista de Medicina, com a implantação de uma rotina de profilaxia, com a supervisão direta de um infectologista. Os objetivos deste estudo foram avaliar a adequação do uso do antibiótico profilático e seu efeito sobre a infecção cirúrgica pós-operatória. Foi considerada adequada a profilaxia com duração menor ou igual a 24 horas. Dos 318 procedimentos cirúrgicos realizados nos períodos pré e pós-intervenção, em 67,9 por cento foi usado um antibiótico profilático. A intervenção reduziu o uso inadequado de antibiótico de 46,3 por cento para 20,4 por cento (X²= 15,59; p<0,05). Infecção do sítio cirúrgico ocorreu em 35,8 por cento dos procedimentos, não se observando modificação deste índice com a adequação da antibiótico-profilaxia. A participação do infectologista é importante na difícil tarefa de racionalizar o uso dos antimicrobianos em nível hospitalar

Application of control measures for infections caused by multi-resistant gram-negative bacteria in intensive care unit patients

Multi-resistant gram-negative rods are important pathogens in intensive care units (ICU), cause high rates of mortality, and need infection control measures to avoid spread to another patients. This study was undertaken prospectively with all of the patients hospitalized at ICU, Anesthesiology of the Hospital São Paulo, using the ICU component of the National Nosocomial Infection Surveillance System (NNIS) methodology, between March 1, 1997 and June 30, 1998. Hospital infections occurring during the first three months after the establishment of prevention and control measures (3/1/97 to 5/31/97) were compared to those of the last three months (3/1/98 to 5/31/98). In this period, 933 NNIS patients were studied, with 139 during the first period and 211 in the second period. The overall rates of infection by multi-resistant microorganisms in the first and second periods were, respectively, urinary tract infection: 3.28/1000 patients/day; 2.5/1000 patients/day; pneumonia: 2.10/1000 patients/day; 5.0/1000 patients/day; bloodstream infection: 1.09/1000 patients/day; 2.5/1000 patients/day. A comparison between overall infection rates of both periods (Wilcoxon test) showed no statistical significance (p = 0.067). The use of intervention measures effectively decreased the hospital bloodstream infection rate (p < 0.001), which shows that control measures in ICU can contribute to preventing hospital infections.

Risk factors for mediastinitis after cardiac surgery

Postoperative mediastinitis is one of the most feared complications in patients who undergo cardiac surgery because in addition to a high mortality rate (10% to 47%), there are increases in the length of hospital stay and in hospital costs. The purpose of the present study is to assess the risk factors for mediastinitis after cardiac surgery, the mediastinitis rate, and the mortality rate in our institution. METHODS: To determine the risk factors, a matched case-control study was carried out, with 39 cases and 78 controls, among the patients who underwent cardiac surgery at the Dante Pazzanese Cardiology Institute, Sao Paulo, Brazil...