Current situation of endemic mycosis in the Americas and the Caribbean: Proceedings of the first international meeting on endemic mycoses of the Americas (IMEMA).

BACKGROUND: The Americas are home to biologically and clinically diverse endemic fungi, including Blastomyces, Coccidioides, Emergomyces, Histoplasma, Paracoccidioides and Sporothrix. In endemic areas with high risk of infection, these fungal pathogens represent an important public health problem. OBJECTIVES: This report aims to summarise the main findings of the regional analysis carried out on the status of the endemic mycoses of the Americas, done at the first International Meeting on Endemic Mycoses of the Americas (IMEMA). METHODS: A regional analysis for the Americas was done, the 27 territories were grouped into nine regions. A SWOT analysis was done. RESULTS: All territories reported availability of microscopy. Seventy percent of territories reported antibody testing, 67% of territories reported availability of Histoplasma antigen testing. None of the territories reported the use of (1-3)-ß-d-glucan. Fifty two percent of territories reported the availability of PCR testing in reference centres (mostly for histoplasmosis). Most of the territories reported access to medications such as trimethoprim-sulfamethoxazole, itraconazole, voriconazole and amphotericin B (AMB) deoxycholate. Many countries had limited access to liposomal formulation of AMB and newer azoles, such as posaconazole and isavuconazole. Surveillance of these fungal diseases was minimal. CONCLUSIONS: A consensus emerged among meeting participants, this group concluded that endemic mycoses are neglected diseases, and due to their severity and lack of resources, the improvement of diagnosis, treatment and surveillance is needed.

Methicillin-Resistant Staphylococcus aureus Bloodstream Infections in Hospitalized Patients in Peru.

There is a knowledge gap in the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) causing bloodstream infections (BSIs) in Peru. Through a surveillance study in 13 hospitals of 10 Peruvian regions (2017-2019), we assessed the proportion of MRSA among S. aureus BSIs as well as the molecular typing of the isolates. A total of 166 S. aureus isolates were collected, and 36.1% of them were MRSA. Of note, MRSA isolates with phenotypic and genetic characteristics of the hospital-associated Chilean-Cordobes clone (multidrug-resistant SCCmec I, non-Panton-Valentine leukocidin [PVL] producers) were most commonly found (70%), five isolates with genetic characteristics of community-associated MRSA (CA-MRSA)-SCCmec IV, PVL-producer-(8.3%) were seen in three separate regions. These results demonstrate that hospital-associated MRSA is the most frequent MRSA found in patients with BSIs in Peru. They also show the emergence of S. aureus with genetic characteristics of CA-MRSA. Further studies are needed to evaluate the extension of CA-MRSA dissemination in Peru.

Prevalence of Antimicrobial Resistance in Gram-Negative Bacteria Bloodstream Infections in Peru and Associated Outcomes: VIRAPERU Study.

Surveillance of antimicrobial resistance among gram-negative bacteria (GNB) is of critical importance, but data for Peru are not available. To fill this gap, a non-interventional hospital-based surveillance study was conducted in 15 hospitals across Peru from July 2017 to October 2019. Consecutive unique blood culture isolates of key GNB (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter spp.) recovered from hospitalized patients were collected for centralized antimicrobial susceptibility testing, along with linked epidemiological and clinical data. A total of 449 isolates were included in the analysis. Resistance to third-generation cephalosporins (3GCs) was present in 266 (59.2%) GNB isolates. Among E. coli (n = 199), 68.3% showed 3GC resistance (i.e., above the median ratio for low- and middle-income countries in 2020 for this sustainable development goal indicator). Carbapenem resistance was present in 74 (16.5%) GNB isolates, with wide variation among species (0% in E. coli, 11.0% in K. pneumoniae, 37.0% in P. aeruginosa, and 60.8% in Acinetobacter spp. isolates). Co-resistance to carbapenems and colistin was found in seven (1.6%) GNB isolates. Empiric treatment covered the causative GNB in 63.3% of 215 cases. The in-hospital case fatality ratio was 33.3% (92/276). Pseudomonas aeruginosa species and carbapenem resistance were associated with higher risk of in-hospital death. In conclusion, an important proportion of bloodstream infections in Peru are caused by highly resistant GNB and are associated with high in-hospital mortality.

[Current status of progressive disseminated histoplasmosis in HIV infected patients in a third level hospital in Peru]. / Estado actual de la histoplasmosis diseminada progresiva en pacientes con infección por el VIH en un hospital de tercer nivel en Perú.

BACKGROUND: Progressive disseminated histoplasmosis (PDH) is an endemic disease in most of Latin America, especially among patients with HIV. There are few reports about this disease in Peru. AIMS: To describe the clinical, epidemiological and mycological features of patients with PDH and HIV evaluated in a tertiary hospital. METHODS: A retrospective study to find out the data of patients diagnosed with PDH and HIV in the period 2000-2019 was carried out. For the statistical analysis of quantitative variables, measures of central tendency and dispersion were used; for the qualitative variables, absolute and relative frequencies were used. RESULTS: Forty-three male patients with PDH were diagnosed in the study period, with a median age of 33 years (IQR: 29-38 years) and a median CD4 lymphocytes count of 39cells/mm3 (IQR: 20-83 cells/mm3). Eighty six percent of the patients were born or had travelled to the jungle, 58.1% were alcohol users and 16.1% had a history of pulmonary tuberculosis. When compared to histopathology, the culture had a better sensitivity to achieve a diagnosis (p<0.05). CONCLUSIONS: Peruvian patients with PDH and HIV infection were mainly young male adults that were born or had travelled to the jungle, with a CD4 count below 100cells/mm3. In patients with the described characteristics it would be advisable to check for PDH. Implementing rapid diagnostic tests is also necessary.

Disseminated histoplasmosis in Peruvian non-HIV patients: an underrecognized endemic disease.

BACKGROUND: Histoplasmosis is a worldwide mycosis with endemic areas throughout Latin America. Disseminated histoplasmosis (DH) has been described in Peru, but there are few reports about its clinical presentation in non-HIV patients. METHODS: Case series was done with review of clinical and laboratory charts from Hospital Cayetano Heredia and Instituto de Medicina Tropical Alexander von Humboldt. Eight patients meet the case definition: HIV negative test and definitive diagnosis of DH (isolation of H. capsulatum in culture and/or presence of yeasts on the histopathology), between 2000-2019. RESULTS: Six were men with median age of 53 years [IQR 35-63,5], most of them were farmers or merchants and with a history of being born in or traveled to the jungle. The median time of illness until diagnosis was 390 days [IQR 60-730] and in 7 out 8 cases the diagnosis was made by isolation of fungi in culture. Isolates required 11 days [IQR 10-18] to become detectable in culture. Six cases had another concomitant disease that probably caused an immunosuppression. CONCLUSION: DH form occurs rarely in apparently healthy people. In this series, men in their fifties, working in farming or merchant, with history of being born in or traveled to the jungle were the most frequent epidemiological characteristics. Culture and histopathology were used for the diagnosis but obtaining the results required several days. It is necessary the use of other faster techniques and to strengthen the clinical awareness about this disease.

[Parasite intestinal infection and factors associated with coccidian infection in adults at public hospital in Lima, Peru]. / Infecciones parasitarias intestinales y factores asociados a la infección por coccidias en pacientes adultos de un hospital público de Lima, Perú.

OBJECTIVE: To evaluate the frequency of intestinal parasites and risk factors associated with coccidian infection in patients cared for at a public hospital in Lima-Peru. METHODS: A descriptive, cross-sectional study was conducted using reports of the parasitology laboratory. Patients included were >18 years, who gave at least one faecal sample for parasitologic evaluation. Logistic regression was used to calculate Odd Ratios (OR) and 95%) confidence intervals. RESULTS: 2.056 patients were included in the analysis, 55.2% of them were males and 334 (16.3%) were HIV positive. Overall, Blastocystis hominis was the most frequent parasite (35.4%). The multivariate model adjusted for sex shows that HIV infection (OR = 4.53; 95% CI: 3.03-6.77), being hospitalized (OR = 2.42; 95% CI: 1.06-5.52), and age > or = 40 years (OR = 0.57; 95% IC: 0.37-0.86) were associated with coccidian infection. CONCLUSIONS: Blastocystis hominis was the most frequent parasite in HIV positive and negative patients. Being hospitalized and HIV infection were risk factors for coccidian infection, but age > or = 40 years was a protective factor.

Estado actual de la histoplasmosis diseminada progresiva en pacientes con infección por el VIH en un hospital de tercer nivel en Perú / Current status of progressive disseminated histoplasmosis in HIV infected patients in a third level hospital in Peru

Antecedentes:La histoplasmosis diseminada progresiva (HDP) es una enfermedad endémica en gran parte de Latinoamérica, en especial en pacientes con VIH. Existen pocos reportes sobre esta enfermedad en Perú.Objetivos:Describir los hallazgos clínicos, epidemiológicos y micológicos de pacientes con HDP y VIH atendidos en un hospital de tercer nivel.Métodos:Se llevó a cabo un estudio retrospectivo para analizar los datos de pacientes con diagnóstico definitivo de infección por VIH y HDP atendidos en el periodo 2000-2019. Para el análisis estadístico de variables cuantitativas se usaron medidas de tendencia central y de dispersión; para las variables cualitativas se usaron frecuencias absolutas y relativas.Resultados:Se contabilizaron 43 pacientes de sexo masculino con diagnóstico definitivo de HDP y una mediana de edad de 33 años (RIC: 29-38 años); la mediana de los valores de concentración de linfocitos CD4 fue de 39 células/mm3 (RIC: 20-83 células/mm3). El 86% de los pacientes había nacido en la selva o viajado a ella, el 58,1% consumía alcohol y el 16,1% tenía antecedente de tuberculosis pulmonar. El cultivo tuvo una mejor sensibilidad en el diagnóstico comparado con la histopatología (p<0,05).Conclusiones:En este estudio los pacientes con infección por VIH y HDP eran adultos jóvenes, de sexo masculino, que habían nacido o viajado a la selva y cuyo valor en sangre de células CD4 era inferior a 100 células/mm3. Es necesario realizar tamizaje para HDP en pacientes con las características descritas e implementar pruebas diagnósticas rápidas. (AU)

Background:Progressive disseminated histoplasmosis (PDH) is an endemic disease in most of Latin America, especially among patients with HIV. There are few reports about this disease in Peru.Aims:To describe the clinical, epidemiological and mycological features of patients with PDH and HIV evaluated in a tertiary hospital.Methods:A retrospective study to find out the data of patients diagnosed with PDH and HIV in the period 2000–2019 was carried out. For the statistical analysis of quantitative variables, measures of central tendency and dispersion were used; for the qualitative variables, absolute and relative frequencies were used.Results:Forty-three male patients with PDH were diagnosed in the study period, with a median age of 33 years (IQR: 29–38 years) and a median CD4 lymphocytes count of 39cells/mm3 (IQR: 20–83 cells/mm3). Eighty six percent of the patients were born or had travelled to the jungle, 58.1% were alcohol users and 16.1% had a history of pulmonary tuberculosis. When compared to histopathology, the culture had a better sensitivity to achieve a diagnosis (p<0.05).Conclusions:Peruvian patients with PDH and HIV infection were mainly young male adults that were born or had travelled to the jungle, with a CD4 count below 100cells/mm3. In patients with the described characteristics it would be advisable to check for PDH. Implementing rapid diagnostic tests is also necessary. (AU)

[Gastrointestinal tuberculosis as a cause of massive gastrointestinal bleeding in a patient with HIV infection]. / Tuberculosis gastrointestinal como causa de hemorragia digestiva masiva en un paciente con infección por VIH.

Gastrointestinal tuberculosis is a rare and fatal complication in patients with HIV infection. It occurs in 3%-16% of extra pulmonary forms. The main location in 90% of cases is the ileocecal valve and colon. The most unusual presentation of gastrointestinal tuberculosis is massive bleeding with the presence of one or multiple ulcers in the colon. The diagnosis can be confirmed by biopsy and by culture of intestinal tissue. Surgical resection is the treatment of choice. We report a case of a HIV-infected patient, who did not receive antiretrovirals, and who developed disseminated tuberculosis with intestinal perforation, presenting a fatal massive intestinal bleeding.

[Nosocomial infections associated to invasive devices in the intensive care units of a national hospital of Lima, Peru]. / Infecciones intrahospitalarias asociadas a dispositivos invasivos en unidades de cuidados intensivos de un hospital nacional de Lima, Perú

In order to describe the incidence of nosocomial infections associated to invasive devices in intensive care units (UCI) of the National Hospital Cayetano Heredia, a retrospective observational study was conducted using the data from the Office of Epidemiology and Environmental Health from 2010 to 2012. A total number of 222 nosocomial infections were reported; the general medicine UCI reported the highest incidence of pneumonia cases associated to a mechanical ventilator in 1000 days of use of the device (28.6); infection of the blood stream associated to central venous catheter (11.9), and infection of the urinary tract associated to a catheter (8,1). The main infectious agents isolated were Pseudomona sp. (32.3%) in the emergency UCI, negative Staphylococcus coagulasa (36%) in the general medicine UCI and Candida sp (69.2%) in the Surgery UCI. The rates of infections associated to invasive devices were high as in other national hospitals with limited resources and infrastructure.

Tuberculosis gastrointestinal como causa de hemorragia digestiva masiva en un paciente con infección por VIH / Gastrointestinal tuberculosis as a cause of massive gastrointestinal bleeding in a patient with HIV infection

Resumen La tuberculosis (TBC) gastrointestinal es una complicación infrecuente y fatal en pacientes con infección por VIH. Se presenta en 3-16% de las formas extrapulmonares y su principal localización es la válvula ileocecal y colon. La hemorragia digestiva baja con presencia de una o múltiples úlceras en colon es una presentación muy inusual de TBC intestinal. El diagnóstico se confirma por biopsia y cultivo del tejido intestinal. La cirugía en caso de perforación intestinal sigue siendo el tratamiento de elección. Se presenta el caso de un paciente con infección por VIH, sin tratamiento anti-retroviral, quien desarrolló una TBC diseminada con perforación intestinal y hemorragia digestiva masiva de curso fatal.

Gastrointestinal tuberculosis is a rare and fatal complication in patients with HIV infection. It occurs in 3%-16% of extra pulmonary forms. The main location in 90% of cases is the ileocecal valve and colon. The most unusual presentation of gastrointestinal tuberculosis is massive bleeding with the presence of one or multiple ulcers in the colon. The diagnosis can be confirmed by biopsy and by culture of intestinal tissue. Surgical resection is the treatment of choice. We report a case of a HIV-infected patient, who did not receive antiretrovirals, and who developed disseminated tuberculosis with intestinal perforation, presenting a fatal massive intestinal bleeding.

High frequency of diarrheagenic Escherichia coli in human immunodeficiency virus (HIV) patients with and without diarrhea in Lima, Peru.

Diarrhea is still a prevalent health issue in HIV patients. Our objective was to characterize the different diarrheagenic E. coli (DEC) groups in stools from adult HIV patients. Cross sectional study: We enrolled HIV-positive and -negative patients with and without diarrhea from a tertiary-care center of Lima, Peru. Clinical data was recorded and a stool sample per patient was cultured. Multiplex PCR was used to detect different DECs. One hundred eighty-four participants were enrolled. The frequency of having at least one DEC was more common in HIV-positive than HIV-negative patients with diarrhea (42% versus 20%, P < 0.05). The enterotoxigenic E. coli (ETEC) was the most common DEC in patients with diarrhea, 13% in HIV patients. The diffusely adherent E. coli (DAEC) was only present in HIV positive patients with diarrhea (10.1%). Different types of DEC are frequent in stools from HIV-positive patients.

Influenza-like illness sentinel surveillance in Peru.

BACKGROUND: Acute respiratory illnesses and influenza-like illnesses (ILI) are a significant source of morbidity and mortality worldwide. Despite the public health importance, little is known about the etiology of these acute respiratory illnesses in many regions of South America. In 2006, the Peruvian Ministry of Health (MoH) and the US Naval Medical Research Center Detachment (NMRCD) initiated a collaboration to characterize the viral agents associated with ILI and to describe the clinical and epidemiological presentation of the affected population. METHODOLOGY/PRINCIPAL FINDINGS: Patients with ILI (fever > or =38 degrees C and cough or sore throat) were evaluated in clinics and hospitals in 13 Peruvian cities representative of the four main regions of the country. Nasal and oropharyngeal swabs, as well as epidemiological and demographic data, were collected from each patient. During the two years of this study (June 2006 through May 2008), a total of 6,835 patients, with a median age of 13 years, were recruited from 31 clinics and hospitals; 6,308 were enrolled by regular passive surveillance and 527 were enrolled as part of outbreak investigations. At least one respiratory virus was isolated from the specimens of 2,688 (42.6%) patients, with etiologies varying by age and geographical region. Overall the most common viral agents isolated were influenza A virus (25.1%), influenza B virus (9.7%), parainfluenza viruses 1, 2, and 3, (HPIV-1,-2,-3; 3.2%), herpes simplex virus (HSV; 2.6%), and adenoviruses (1.8%). Genetic analyses of influenza virus isolates demonstrated that three lineages of influenza A H1N1, one lineage of influenza A H3N2, and two lineages of influenza B were circulating in Peru during the course of this study. CONCLUSIONS: To our knowledge this is the most comprehensive study to date of the etiologic agents associated with ILI in Peru. These results demonstrate that a wide range of respiratory pathogens are circulating in Peru and this fact needs to be considered by clinicians when treating patients reporting with ILI. Furthermore, these data have implications for influenza vaccine design and implementation in South America.

Enfermedad hidática diseminada con localización mediastinal como causa de síndrome de vena cava superior / Disseminated hydatidic illness with mediastinal location causing superior cave syndrome

Hydatidic illness is a frequent parasitic zoonosis in our country whose more frequent localization is the liver and the lungs. However other many sites have been described, depending their symptoms on the cyst's size, localization and effect on next structures, being sometimes its evolution fatal. This is a 52 year-oldfemale patient admitted at emergency room for dysfunction of sensory and neurological localization. She had a previous history of surgery many years ago by abdominal tumor. We found a collateal circulation on right hemithorax and facial arms edema at exam. The cerebral CT showed extensive left parietal parenchymal hemorrhage. Thoracoabdominal CT revealed multiple cystic masses of diverse sizes in the mediastinum, lungs, liver and other places. The patient's evolution was torpid, theneurological compromise didn't improve in spite of the treatment against the intracranial hypertension (EH), being also adde a nosocomial pneumonia. The patient died after several days. Necropsy revealed presence of cystic lesions in mediastinum, heart's great vessels, pericadium, lungs, liver, spleen and omentum, as well as intra and extraparenchymal hemorrhages of hipertensive cause in brain, not beig cystic lesions in central nervous system. We concluded that it was disseminated hydatidic illnes, cysts in themediastinum caused comprenssion of the heart's great vessels, causing a superior cave vin syndrome.