An outbreak of handscrubbing-related surgical site infections in vascular surgical procedures.

OBJECTIVE: To investigate an outbreak of surgical site infections (SSI) in a vascular surgery unit. SETTING: A 60-bed unit of vascular surgery, where surgeons performed an average of 30 operations per month at the Hospital do Servidor Público Estadual, a 1,000-bed tertiary care hospital in São Paulo, Brazil. DESIGN: We included in the case group nine patients who had limb amputations or arterial reconstructions, October 16 through 23, 1992. We included in the control group patients whose operations were performed within 30 days of the outbreak period. Control patients were matched for sex and type of operation. RESULTS: Six of 9 case patients experienced SSI, as compared with 3 of 18 control patients (P = .026) and 28 of 244 patients in the pre-epidemic period (P = .0002). Risk factors were identical for case and control groups. Factors assessed were American Society of Anesthesiology (ASA) status, duration of surgery, wound class, emergency status, remote site infections, preoperative length of stay, use of prophylactic antibiotics, and underlying diseases. Possible common sources also were analyzed. No differences were observed concerning hair removal, preoperative shower, wound dressing, and surgical team present in the operating room. During the outbreak period, the operating room was not provided with povidone-iodine, used in our hospital for skin cleansing and handscrubbing. Surgeons from all departments, including vascular surgery, used 2% iodine with 70% alcohol for skin cleansing. Surgeons from other departments used this iodine solution for handscrubbing, but the vascular surgeons used plain soap for handscrubbing. No increases in SSI rates were reported in other services. Comparison of case and control groups for handscrubbing was statistically significant (P < .00001). After reinstitution of povidone-iodine, only one SSI was diagnosed in 13 vascular procedures. CONCLUSIONS: Although we could not demonstrate definitely that scrubbing with plain soap was related to SSI, we found a strong suggestion of this association.

Microbiological studies of abscesses complicating Bothrops snakebite in humans: a prospective study.

Forty patients with abscesses at the site of Bothrops bite were evaluated. Ten brought the snake responsible for the bite, Bothrops jararaca in all cases. On admission a sample was collected from each case for aerobic and anaerobic culture, and no abscesses drained spontaneously. None of the patients had received antibacterial therapy at this time. The bacteria most frequently isolated were Morganella morganii (23 patients), Providencia rettgeri (7) Enterobacter sp. (4), Escherichia coli (3), group D streptococcus (11) and Bacteroides sp. (6). All enterobacteria tested were sensitive to chloramphenicol, aminoglycosides and cefotaxime. Group D streptococci were sensitive to chloramphenicol, ampicillin and penicillin G, whereas anaerobic bacteria were sensitive to chloramphenicol and tetracycline. These results suggest that in cases of abscess formation secondary to Bothrops bite, chloramphenicol alone is a good choice, being both safe and cheap.

Relationship between the prevalence of antibodies to arbovirus and hepatitis B virus in the Vale do Ribeira region, Brazil.

280 students, between 6 and 14 years old, residents in the Iguape county, southern coast of the State of São Paulo, were studied in order to identify the existence of a possible association between the prevalence of specific antibodies to the hepatitis B virus and the exposure to haematophagous mosquitoes, evaluated indirectly through the prevalence of antibodies to 17 arboviruses isolated in Brazil. The children were from 4 areas with different topographical characteristics: 89 of the children were from the urban zone of the town of Iguape, 89 were from the peri-urban zone, 30 were from the rural area with extensive banana plantations, and 72 were from the jungle zone. Previous studies had shown significantly higher prevalence of antibodies to different arboviruses in the cultivated zone and the jungle zone, when compared to the urban and peri-urban zones of Iguape. The detection of antibodies to the HBV surface antigen (HBs Ag) was done through the radioimmunoassay (Ausab, Abbott Laboratory). The cases considered positive were confirmed through the presence of anti-core HBV antibodies (anti-HBc-EIA Roche). A significantly higher prevalence of anti-HBV antibodies was observed in children from the jungle zone (26/72 = 36.1%) when compared to those from the urban zone (5/89 = 5.6%), peri-urban (6/89 = 6.7%) or from the cultivated zone (0/30 = 0%). The result suggest the existence of a common factor in the dissemination of the arboviruses and the hepatitis B virus, supporting the hypothesis that mosquitoes may play an important role in the HBV transmission in tropical forested region.

Measles vaccination: influence of age on its efficacy.

The authors compare the serologic efficacy and the clinical protection afforded by three different measles vaccination schemes in adequately nourished children in São Paulo city, Brazil. Two hundred forty two children were divided into three groups. Group A, comprising 117 children who had received the vaccine before 12 months of age and a second dose at 12 months of age or more. Group B, comprising 46 children who had received only one dose, before 12 months of age. Group C, comprising 79 children who had received only one dose, at 12 months of age or more. The geometric mean titer of antibodies in Group A was 790.1; in Group B, 251.1; and in Group C, 550.3. There was no statistically significant difference between Groups A and C. The exposure to the measles virus was probably similar in all groups, and the children in Group A and C had similar chances of acquiring the disease after vaccination whereas in Group B the chances were higher when compared to the other two groups. The results obtained in this study favor the use, in developing countries, of a vaccination program against measles that includes an early first dose at eight months of age and revaccination after 12 months of age.

[Bacterial flora of the oral cavity, fangs and venom of Bothrops jararaca: possible source of infection at the site of bite]. / Flora bacteriana da cavidade oral, presas e veneno de Bothrops jararaca: possível fonte de infecção no local da picada.

Culture of fang, fang sheath and venom of fifteen healthy freshly captured Bothrops jararaca were analyzed. The bacteria most frequently encountered were group D streptococci (12 snakes), Enterobacter sp. (6), Providencia rettgeri (6), Providencia sp. (4), Escherichia coli (4), Morganella morganii (3) and Clostridium sp. (5). The bacteria observed are similar to those found in the abscesses from Bothrops bitten patients. Since these snake mouth bacteria may be inoculated during the snake bite, bacterial multiplication and infection may occur under favorable conditions.

[Serological evaluation of immunization against measles with 2 doses administered at 6 and 11 months of age: a prospective study]. / Avaliação sorológica de imunização contra o sarampo com duas doses administradas aos 6 e 11 meses de idade: estudo prospectivo.

A prospective study was designed to evaluate the serologic efficacy of a two dose measles vaccination schedule, at 6 months and 11 months of age. Infants were given a further attenuated measles virus vaccine (BIKEN CAM 70, Fundação Oswaldo Cruz) and serum samples were tested for measles antibodies using the indirect immunofluorescence technique (IFA) and ELISA. Seroconversion rates 6 to 12 months (mean of 8.0 +/- 1.7 months) following the second dose of measles vaccine were 88.5% (85/96) by IFA and 96.8% (93/96) by ELISA. No measles cases were reported during the study period. In regions where a significant proportion of measles cases occurs before nine months of age, vaccination with a two doses schedule, at 6 and 11 months of age, may represent an alternative for measles control.

[The treatment of cryptosporidiosis in AIDS patients using paromomycin]. / Tratamento da criptosporidíase em pacientes com AIDS, por meio da paromomicina.

The authors treated with paromomycin 25 patients, with AIDS and cryptosporidiosis. The drug was given orally in a doses of 500 mg qid, for a period of 14 days. Tolerance was good, with just two cases of mild side-effects. Clinical improvement was obtained in 19 (76%) patients. Parasitological cure, however, occurred only in a low percentage (25%). In some cases where initial success was observed, recrudescence occurred after some weeks or few months, but with retreatment again clinical improvement was obtained. Even if it does not lead to frequent parasite eradication, the good clinical results and tolerance permit us to consider paromomycin one of the few drugs effective for the treatment of cryptosporidial diarrhea in AIDS patients. Studies with maintainance therapy are indicated.

[Treatment of american cutaneous leishmaniasis, with lesions in the mucosa, using pentamidine isethionate]. / Tratamento da leishmaniose tegumentar americana, com lesão em mucosa, por meio do isotionato de pentamidina.

Ten patients with mucosal lesions caused by American tegumental leishmaniasis were treated with pentamidine isethionate at the dose 4 mg/kg on alternate days by the intravenous route. The mean posology was 2,140 mg. Healing of the lesions occurred in 9 (90%) of the patients who completed treatment. There was no recurrence during a follow-up time of 1 to 24 months (mean, 7,7 months). One patient discontinued treatment before healing of the lesion because be developed diabetes mellitus. In 3 (30%) patients, blood exams showed increased urea and creatinine levels and leucopenia, which were corrected by increasing the interval between administrations of the drug. Pentamidine isethionate is efficient in bringing about cicatrization of the lesions but needs further evaluation in terms of its value in preventing recurrence.

[Infection caused by Mycobacterium tuberculosis with primary resistance to multiple drugs: a case report of a patient with AIDS]. / Infecção causada por Mycobacterium tuberculosis com resistência primária a múltiplas drogas: relato de um caso em paciente com AIDS.

Primary multidrug-resistant Mycobacterium tuberculosis is an important problem in the United States. There is no report in formal literature of this pathogen in Brazilian patients. CASE REPORT--We report a case of ganglionar tuberculosis diagnosed by acid-fast smears in a male, HIV positive patient. Mode of acquisition of HIV was not determined. Treatment was started, and isoniazid, rifampicin and pyrazinamide were prescribed. The patient and his family reported strict adherence to therapy, but no improvement was observed. After 75 days, the patient was admitted in our hospital because of clinical worsening. Clinical features were the presence of large submandibular and axillar lymph nodes, respiratory insufficiency and complains of abdominal pain. He died six days after admission. Culture obtained from the ganglionar aspirate disclosed M. tuberculosis susceptible to ethambutol, but resistant to isoniazid, rifampicin, pyrazinamide, ethionamide and streptomycin. DISCUSSION--Although this was a case of extrapulmonary tuberculosis, there is a concern about multidrug-resistant tuberculosis, that has been poorly evaluated in Brazil. Since high lethality and intrahospital transmission have been reported, we discuss the need of performing culture and antibiogram in suspected cases, and the prevention of the spread of M. tuberculosis to patients and health-care workers through the strict adherence to the isolation practices.