Reappraisal of Pseudomonas aeruginosa hospital-acquired pneumonia mortality in the era of metallo-beta-lactamase-mediated multidrug resistance: a prospective observational study.

INTRODUCTION: Hospital-acquired pneumonia (HAP) due to Pseudomonas aeruginosa is associated with high mortality rates. The metallo-beta-lactamases (MBLs) are emerging enzymes that hydrolyze virtually all beta-lactams. We aimed to assess P. aeruginosa HAP mortality in a setting of high-rate MBL production METHODS: A prospective cohort study was performed at two tertiary-care teaching hospitals. A logistic regression model was constructed to identify risk factors for 30-day mortality. RESULTS: One-hundred and fifty patients with P. aeruginosa HAP were evaluated. The 30-day mortality was 37.3% (56 of 150): 57.1% (24 of 42) and 29.6% (32 of 108) for patients with HAP by MBL-producing P. aeruginosa and by non-MBL-producing P. aeruginosa, respectively (relative risk, 1.93; 95% confidence interval (CI), 1.30-2.85). The logistic regression model identified a higher Charlson comorbidity score (odds ratio, 1.21; 95% CI, 1.04-1.41), presentation with severe sepsis or septic shock (odds ratio, 3.17; 95% CI, 1.30-7.72), ventilator-associated pneumonia (odds ratio, 2.92; 95% CI, 1.18-7.21), and appropriate therapy (odds ratio, 0.24; 95% CI, 0.10-0.61) as independent factors for 30-day mortality. MBL production was not statistically significant in the final model. CONCLUSION: MBL-producing P. aeruginosa HAP resulted in higher mortality rates, particularly in patients with ventilator-associated pneumonia, most probably related to the less frequent institution of appropriate antimicrobial therapy. Therapeutic approaches should be reviewed at institutions with a high prevalence of MBL.

Immune reconstitution inflammatory syndrome in treatment-experienced HIV-infected patients

We described two cases of treatment-experienced HIV-infected patients who presented with cytomegalovirus uveitis and Cryptococcus neoformans adenitis as a manifestation of immune reconstitution inflammatory syndrome (IRIS) during salvage treatment. Little is known about IRIS in highly experienced patients, and this report suggests that IRIS should be considered in this setting if there is a favorable response to salvage therapy

Risk factors for nosocomial infections due to Pseudomonas aeruginosa producing metallo-beta-lactamase in two tertiary-care teaching hospitals.

OBJECTIVES: To assess risk factors for nosocomial infections due to Pseudomonas aeruginosa producing metallo-beta-lactamase (MBL-PA) in two teaching hospitals where horizontal dissemination has been demonstrated. METHODS: A case-control study was performed in both hospitals (assigned as hospital 1 and 2). Cases were patients with MBL-PA infections and controls were those with non-MBL-PA infections. Multivariate analysis was performed to identify independent risk factors. RESULTS: A total of 86 cases and 212 controls were included in the study. A logistic regression model showed that exposure to beta-lactams [odds ratio (OR) 3.21; 95% confidence interval (CI) 1.74-5.93] or fluoroquinolones (OR 3.50; 95% CI 1.46-8.37) was associated with MBL-PA infections. Other independent risk factors were neurological disease (OR 3.00; 95% CI 1.61-5.58), urinary tract infection (OR 2.48; 95% CI 1.21-5.09) and renal failure (OR 2.29; 95% CI 1.13-4.65). Admission to hospital 1 (OR 5.97; 95% CI 3.45-14.09) and intensive care unit stay (OR 2.07; 95% CI 1.46-3.96) were also associated with increased risk for MBL-PA infections. CONCLUSIONS: beta-Lactam exposure is an important risk factor for MBL-PA infections even in a setting where patient-to-patient transmission plays a major role in the spread of the isolates. Other risk factors deserve further investigation, particularly exposure to fluoroquinolones.

The influence of metallo-beta-lactamase production on mortality in nosocomial Pseudomonas aeruginosa infections.

OBJECTIVES: To assess the effect of metallo-beta-lactamase (MBL) production on Pseudomonas aeruginosa nosocomial infection mortality and to identify the determinants of such effect. METHODS: A cohort study of patients with P. aeruginosa nosocomial infections was conducted at two teaching hospitals. MBL was detected by ceftazidime/2-mercaptopropionic disc approximation test and selected isolates were submitted to PCR using bla(SPM-1) primer. Molecular typing was performed by DNA macrorestriction. To evaluate the influence of MBL on mortality a Cox proportional hazards model was performed using a hierarchized framework of the variables. RESULTS: A total of 298 patients with P. aeruginosa infections were included. Infections by MBL-carrying Pseudomonas aeruginosa (MBL-PA) resulted in higher in-hospital mortality than those by non-MBL-PA (51.2% versus 32.1%, respectively; relative risk 1.60, 95% CI 1.20-2.12) and higher mortality rates [17.3 per 1000 versus 11.8 per 1000 patient-days, respectively; hazard ratio (HR) 1.55, 95% CI 1.06-2.27]. In the final multivariate model, severe sepsis or septic shock [adjusted HR (AHR) 3.62, 95% CI 2.41-5.43], age (AHR 1.02, 95% CI 1.01-1.03) and use of appropriate therapy

Investigação de sopro em pacientes pediátricos / Inquiry of blow in pediatrics patients

Sopro cardíaco pediátrico é um diagnóstico de grande freqüência nos ambulatórios. O pediatra deve estar apto a distinguir um sopro inocente de um sopro patológico baseado em uma anamnese e exame físico sistematizados sem a necessidade de exames complementares. Também deve estar ciente dos sinais de alerta que indicam cardiopatias e encaminhar estes pacientes ao especialista.

Manifestações cutâneas no paciente HIV positivo / Cutaneous manifestations in the positive HIV patient

Os autores fazem uma revisão bibliográfica sobre as manifestações cutâneas mais prevalentes em pacientes HIV positivos, seus aspectos clínicos e epidemiologia.