Progressive chronic calvarial osteomyelitis in rhino-orbital mucormycosis associated with COVID-19.

We describe two cases of extensive indolent calvarial osteomyelitis after rhino-orbital-mucormycosis in diabetic patients previously diagnosed with COVID-19. Both patients presented with acute rhino-orbital symptoms about one month after being diagnosed with COVID-19. Treatment with intravenous liposomal Amphotericin B and prompt radical surgical debridement was instituted, but calvarial osteomyelitis ensued and persisted chronically despite maintenance of antifungal therapy and partial debridement of necrotic calvarial bone. The patients were discharged to continue antifungal therapy on a day-hospital regime. After more than 8 months of treatment, they remain with radiological signs of osteomyelitis but with no symptoms or intracranial extension of the infection. Calvarial indolent osteomyelitis secondary to mucormycosis is extremely rare, and little is known regarding its treatment. We believe it can be controlled with medical treatment and partial bony debridement although more studies are necessary to better define therapy.

Bacteremia by Leuconostoc mesenteroides in an immunocompetent patient with chronic Chagas disease: a case report.

BACKGROUND: The Leuconostoc mesenteroides are members of the Streptococcae family and currently has been recognized as potential pathogens. This case describes a bacteremia caused by L. mesenteroides in an immunocompetent patient affected by Chagas disease. CASE PRESENTATION: A 67-year-old female patient with chagasic megaesophagus and megacolon was submitted to a Heller myotomy for achalasia in 2000 and endoscopic dilatation in 2015. Patient was admitted to the Nutrology Ward in May 2016 with protein-calorie malnutrition associated with achalasia and receiving enteral nutrition. In July 2016, the patient underwent a Serra-Doria surgery. In the third postoperative day she presented an important abdominal distension. She was submitted to a new surgical intervention, and then a terminal ileum perforation was detected, leading the surgeon to perform an enterectomy with side-to-side anastomosis. The next day after the surgery (4th postoperative day) the patient presented a decreased level of consciousness (Glasgow coma scale = 8), hypotension and hypoxemia. In two samples of blood cultures there was growth of Leuconostoc mesenteroides. Susceptibility pattern was evaluated by the diffusion disk method. The microorganism was susceptible to penicillin, ampicillin, chloramphenicol, erythromycin, and fluoroquinolones, but resistant to rifampin, tetracycline, vancomycin and teicoplanin. CONCLUSION: We concluded that infections caused by L. mesenteroides is serious and should be considered not only in settings of immunosuppression and prolonged antimicrobial use, but also in immunocompetent patients undergoing surgeries involving the gastrointestinal tract.

Expansion and evolution of a virulent, extensively drug-resistant (polymyxin B-resistant), QnrS1-, CTX-M-2-, and KPC-2-producing Klebsiella pneumoniae ST11 international high-risk clone.

In this study, we report the early expansion, evolution, and characterization of a multiresistant Klebsiella pneumoniae clone that was isolated with increasing frequency from inpatients in a tertiary-care university hospital in Brazil. Seven carbapenem- and quinolone-resistant and polymyxin B-susceptible or -resistant K. pneumoniae isolates isolated between December 2012 and February 2013 were investigated. Beta-lactamase- and plasmid-mediated quinolone resistance (PMQR)-encoding genes and the genetic environment were investigated using PCR, sequencing, and restriction fragment length polymorphism (RFLP). Clonal relatedness was established using XbaI-pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and phylogenetic group characterization. Plasmid analyses included PCR-based replicon typing (PBRT) and hybridization of the S1-PFGE product, plasmid MLST, and conjugation experiments. Virulence potential was assessed by PCR by searching for 10 virulence factor-encoding genes (ureA, fimH, kfuBC, uge, wabG, magA, mrkD, allS, rmpA, and cf29a) and by phenotypic tests to analyze the hypermucoviscous phenotype. The genetic context of a multidrug-resistant and extensively drug-resistant K. pneumoniae ST11-KpI clone harboring IncFIIk-Tn4401a-blaKPC-2, qnrS1, and blaCTX-M-2 was found. Moreover, three isolates displayed high resistance to polymyxin B (MICs = 32, 32, and 128 mg/liter) as well as mucous and hypermucoviscous phenotypes. These bacteria also harbored ureA, fimH, uge, wabG, and mrkD, which code for virulence factors associated with binding, biofilm formation, and the ability to colonize and escape from phagocytosis. Our study describes the association of important coresistance and virulence factors in the K. pneumoniae ST11 international high-risk clone, which makes this pathogen successful at infections and points to the quick expansion and evolution of this multiresistant and virulent clone, leading to a pandrug-resistant phenotype and persistent bacteria in a Brazilian hospital.

Significant Increase in Cytomegalovirus (CMV) Infection in Solid Organ Transplants Associated With Increased Use of Thymoglobulin as Induction Therapy?

BACKGROUND: Cytomegalovirus (CMV) infection remains one of the most common viral pathogens affecting solid organ transplants (SOT). In 10 years of following the outcome of transplants, we noticed an increased incidence of CMV infection, along with increased use of rabbit anti-thymocyte globulin (rATG). The study aims to assess the incidence of active CMV infection and disease, response to treatment, and recurrence in a cohort of SOT. Furthermore, we look for correlating the CMV incidence with the type of induction therapy: r-ATG or interleukin 2 receptor-blocking antibody (basiliximab). METHODS: This was a single-center, retrospective 10-year study in patients submitted to kidney, kidney-liver, and kidney-pancreas transplants who used a preemptive therapy protocol for CMV. RESULTS: Among the 476 enrolled transplant recipients, 306 (64.2 %) had at least one episode of CMV infection (replication), and 71/306 patients (23.2 %) presented CMV-related disease. The most frequent clinical conditions associated with CMV disease were gastrointestinal. Among the 476 transplant patients, 333 received immunosuppressive induction with rATG (69.9 %); 140 (29.4 %) received induction with interleukin 2 receptor-blocking antibody (basiliximab). The initial maintenance immunosuppressive therapy in the patients who presented CMV infection was primarily performed with prednisone, tacrolimus, and sodium mycophenolate (91.7 %). The induction with rATG increased from 35.2%-94.6% in 10 years. The incidence of CMV infection was 20.7 % in the first year of observation and gradually increased to 87.3 % in the last year. CONCLUSIONS: The data suggest that the increase in the use of rATG in recent years could be responsible for the very expressive increase in the incidence of CMV infection/disease.

Chylothorax and chylous ascites due to juvenile paracoccidioidomycosis: a case report.

Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by Paracoccidioides species. Chylothorax is a rare complication of PCM. A 16-year-old adolescent presented daily fever, lymphadenomegaly, sweating, weight loss, ventilatory-dependent pain, and dysphagia, which confirmed PCM. During treatment, the patient developed chylothorax and chylous ascites. Chronic inflammatory and fibrotic lymphadenopathy may obstruct lymphatic vessels, resulting in the extravasation of lymph into the abdomen or pleural cavities. Chylothorax is one of several complications of PCM and can lead to respiratory insufficiency, even in patients undergoing antifungal therapy.

Sanitary measures to contain COVID-19 spread decreased pediatric hospitalizations due to other respiratory infections in São Paulo, Brazil.

OBJECTIVE: After the Covid-19 pandemics hit Brazil and sanitary measures were adopted to contain its dissemination, pediatric hospital admissions were apparently fewer than usual. The authors aimed to describe the time trends of public hospital admissions of children and adolescents due to respiratory infections (RIs) in São Paulo State, Brazil, before and after the adoption of sanitary measures to contain the dissemination of Covid-19. METHODS: Ecological, time-series study on the monthly average number of admissions per day of children and adolescents (< 16 years) admitted to public hospitals of São Paulo due to acute RIs between January 2008 and March 2021. Data from 2008 to 2019 were used to adjust the statistical model, while data from 2020 and 2021 were compared to the values predicted by the model. RESULTS: In 2020 and 2021, the number of hospital admissions was significantly lower than predicted by the time series. However, lethality was three times higher in these years, compared to the previous, and six times higher in patients with Covid-19, compared to those without the disease. Hospitalization costs in 2020 and 2021 were lower than in previous years. CONCLUSIONS: These findings suggest that the sanitary measures adopted to contain the dissemination of Covid-19 also effectively reduce the transmission of other respiratory viruses. Policymakers and administrators can use this knowledge as a guide to planning preventative interventions that could decrease the number and severity of RIs and related hospital admissions in children and adolescents, decreasing the burden on the public health system.

Comparing surgeons' skin tolerance and acceptability to alcohol-based surgical hand preparation vs traditional surgical scrub: A matched quasi-experimental study.

BACKGROUND: We aimed to compare the tolerance and acceptability of alcohol-based surgical hand preparation versus handscrubbing with antimicrobial soap and water by surgeons. METHODS: Matched quasi-experimental trial in an academic quaternary care hospital in Ribeirão Preto, Brazil, from April 1 to October, 31, 2017. Participants were cardiac and orthopedics surgeons from the study facility. In the first study phase, they performed handscrubbing with either 2% chlorhexidine (CHG) or 10% iodopovidone (PVP-I) and, in the second phase, they performed handrubbing with alcohol-based handrub (ABHR). Surgeons' skin tolerance and acceptability were evaluated using WHO-validated tools. Data were analyzed using the MacNemar's test within STATA. RESULTS: A total of 33 surgeons participated to the "per protocol" population; the majority were male (94%); mean age of 35 years (SD, 8.5). On product tolerance, there was a minimal variation in redness, scaliness, fissures, and visual evaluation of the skin when handrubbing with ABHR was compared to handscrubbing with either PVP-I or CHX. Regarding acceptability, participants rated better handrubbing with ABHR than handscrubbing with PVP-I when assessing product smell (66.6% vs 0%, p=0.002), color (73.3% vs 0%, p=0.001), product texture (60% vs 0%, p=0.004), skin dryness (60% vs 0%, p=0.004), ease of application (66.6% vs 0%, p=0.002) and overall satisfaction (66.6% vs 6.7% p=0.011). Participants rated similarly handrubbing with ABHR and handscrubbing with CHX, except for product texture, where handrubbing rated better (71,4% vs. 0%, p=0.002). Handrubbing with ABHR was preferred by 73.3%. CONCLUSION: Although handrubbing and handscrubbing were equally well tolerated by surgeons, alcohol-based surgical hand preparation fell into the personal preference for most of them. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (ReBEC), RBR-8ym9yj.

E-Learning versus Face-to-Face Methodology for Learning Antimicrobial Resistance and Prescription Practice in a Tertiary Hospital of a Middle-Income Country.

Background: Antimicrobial resistance is a growing health problem worldwide. One strategy to face this problem in a reasonable way is training health personnel for the rational use of antimicrobials. There are some difficulties associated with medical staff to receiving training with E-learning education, but there is a lack of studies and insufficient evidence of the effectiveness of this method compared to face-to-face learning. Methods: An educational intervention on antimicrobial resistance (AMR) and antimicrobial prescription practice (APP) was designed and implemented using two approaches: face-to-face and E-learning among physicians of the intensive care unit (ICU) and internal medicine ward (IMW) at Eugenio Espejo Hospital in Quito. Modalities of interventions were compared to propose a strategy of continuous professional development (CPD) for all hospital staff. An interventional study was proposed using a quasi-experimental approach that included 91 physicians, of which 49 belong to the IMW and 42 to the ICU. All of them received training on AMR­half in a face-to-face mode and the other half in an asynchronous E-learning mode. They then all participated on APP training but with switched groups; those who previously participated in the face-to-face experience participated in an E-learning module and vice-versa. We evaluated self-perception about basic knowledge, attitudes and referred practices towards AMR and APP before and after the intervention. A review of medical records was conducted before and after training by checking antimicrobial prescriptions for all patients in the ICU and IMW with bacteremia, urinary tract infection (UTI), pneumonia, and skin and soft tissue infection. The study received IRB clearance, and we used SPSS for statistical analysis. Results: No statistically significant difference was observed between the E-learning and the face-to-face methodology for AMR and APP. Both methodologies improved knowledge, attitudes and referred practices. In the case of E-learning, there was a self-perception of improved attitudes (p < 0.05) and practices (p < 0.001) for both AMR and APP. In face-to-face, there was a perception of improvement only in attitudes (p < 0.001) for APP. In clinical practice, the use of antimicrobials significantly improved in all domains after training, including empirical and targeted treatment of bacteremia and pneumonia (p < 0.001) and targeted treatment of UTI (p < 0.05). For the empirical treatment of pneumonia, the mean number of antibiotics was reduced from 1.87 before to 1.05 after the intervention (p = 0.003), whereas in the targeted management of bacteremia, the number of antibiotics was reduced from 2.19 to 1.53 (p = 0.010). Conclusions: There was no statistically significant difference between the effect of E-learning and face-to-face strategy in terms of teaching AMR and APP. Adequate self-reported attitudes and practices in E-learning exceed those of the face-to-face approach. The empiric and targeted use of antimicrobials improved in all reviewed cases, and we observed an overall decrease in antibiotic use. Satisfaction with training was high for both methods, and participants valued the flexibility and accessibility of E-learning.

Assessment of preauthorization and 24-hour expert consultation as a restrictive antimicrobial stewardship bundle in a Brazilian tertiary-care hospital: an interrupted time series analysis.

BACKGROUND: Worldwide, healthcare facilities face high and often inappropriate consumption of antimicrobials. However, there are limited antimicrobial stewardship (ASP) studies from low- and middle-income countries that include restrictive measures and their impacts on antimicrobial consumption. AIM: This study aims to assess the impact of a restrictive bundle (preauthorization requirements and offering consultation with an infectious diseases physician 24 hours a day) on antimicrobial consumption, in a tertiary hospital in Brazil. METHODS: We conducted an interrupted time series analysis (ITS) with pharmacy-based data from January 2010 to December 2018 to evaluate changes of level and slope in antimicrobial consumption (expressed in DDD/1,000 patient-days) after the implementation of the restrictive bundle in September 2014. Fourteen restricted antimicrobials (amphotericin B deoxycholate, liposomal amphotericin B, micafungin, voriconazole, ganciclovir, amikacin, ampicillin/sulbactam, daptomycin, ertapenem, levofloxacin, linezolid, piperacillin/tazobactam, polymyxin B, and tigecycline) and eight unrestricted were analysed. FINDINGS: Among the 14 restricted antimicrobials, four presented a significant negative level change: micafungin (-2,14, p=.027), voriconazole (-14.72, p<.001), ertapenem (-1.89, p=.007) and amikacin (-13.98, p<.001). The only negative slope change was observed for the liposomal amphotericin B, -0.532 (p=.009). The restricted antibiotics group presented an increased consumption trend (1.068, p=.002) compared to the pre-intervention period, a similar change was observed for the unrestricted antibiotics group (1.360, p<.001). CONCLUSION: Preauthorization and 24 hour expert consultation were partially effective as a restrictive antimicrobial stewardship bundle in a Brazilian tertiary-care hospital. Increased consumption of unrestricted antimicrobials was observed as a side effect of the intervention.

Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: A quasi-experimental study.

BACKGROUND: We aimed to evaluate the impact of providing dental care to critically ill patients on their risk of death and ventilator-associated pneumonia (VAP). METHODS: A quasi-experimental study was conducted in 2 intensive care units (ICU) from 2016 to 2019. The intervention consisted of implementing routine dental care, focusing on oral hygiene and periodontal treatment, at least 3 times a week, for patients admitted to the study units. In the pre-intervention period, routine oral hygiene was provided by the ICU nursing staff. The primary and secondary study outcomes were mortality, evaluated at the end of the ICU stay, and VAP incidence density, respectively. Data were analyzed using the ARIMA (autoregressive integrated moving average) time series model in R software. RESULTS: During the intervention period, 5,147 dental procedures were performed among 355 patients. The time series showed that ICU mortality was 36.11%, 32.71%, and 32.30% within the 3 years before the intervention, and 28.71% during the intervention period (P = .015). VAP incidence density did not significantly change during the study period (P = .716). CONCLUSION: A dental care intervention focused on oral hygiene and periodontal treatment regularly provided by dentists to critically ill patients may decrease their risk of dying in the ICU. Randomized clinical trials should be performed to confirm these findings. TRIAL REGISTRATION: WHO-affiliated Brazilian Clinical Trials Registry. RBR-4jmz36. Registered 7 October 2018, before first patient enrollment.

Pre- and post-COVID-19 evaluation of antimicrobial susceptibility for healthcare-associated infections in the intensive care unit of a tertiary hospital.

INTRODUCTION: Antimicrobial resistance has worsened since the onset of COVID-19. METHODS: This study involved patients admitted to the adult intensive care unit (ICU) of a tertiary hospital. Pre- and post-COVID-19 data were analyzed. The healthcare-related infections (HCRIs) reported between January 2018 and January 2020 and during the pandemic between February and July 2020 were compared. RESULTS: Antimicrobial resistance increased during the pandemic, especially for Klebsiella pneumoniae isolates, with a rate increase from 5% to 50% for Polymyxin B. CONCLUSIONS: The susceptibilities of the main pathogens associated with HCRIs in the ICU changed and should be considered in managing severe COVID-19.

Cryptococcosis by Cryptococcus neoformans/Cryptococcus gattii Species Complexes in non-HIV-Infected Patients in Southeastern Brazil.

INTRODUCTION: The clinical manifestations of cryptococcosis are usually associated with the infecting agents Cryptococcus neoformans (CN) and C. gattii (CG) species complexes and the host. In this study, non-HIV-infected patients, at a university hospital in southeastern Brazil, had epidemiological and clinical data associated with cryptococcal disease and isolated Cryptococcus species: CN - 24 patients and CG - 12 patients. METHODS: The comparison was comprised of demographic data, predisposing factors, clinical and laboratory manifestations, and outcomes of cryptococcosis patients treated between 2000 and 2016. Immunocompetent and immunosuppressed patients were also compared, irrespective of the infecting species. Cryptococcus spp. were genotyped by PCR-RFLP analysis of the URA5 gene. RESULTS: Infections by the CN species complex (100% VNI genotype) were associated with drug immunosuppression and fungemia, and patients infected with the CG species complex (83% VG II and 17% VGI genotypes) had more evident environmental exposure and higher humoral response. CN and CG affected patients with or without comorbidities. CONCLUSIONS: Diabetes mellitus, other chronic non-infectious diseases, and alcoholism were likely predisposing factors for infection by both CN and CG species. Immunocompetent patients, independent of the infecting Cryptococcus species complexes, showed a higher occurrence of meningitis and a trend toward less fungal dissemination and longer survival than immunosuppressed hosts.

Prevalence of virological and serological markers of SARS-CoV-2 infection in the population of Ribeirão Preto, Southeast Brazil: an epidemiological survey.

INTRODUCTION: This epidemiological household survey aimed to estimate the prevalence of the current and past SARS-CoV-2 infections in Ribeirão Preto, a municipality of southeast Brazil. METHODS: The survey was conducted in two phases using a clustered sampling scheme. The first phase spanned May 1-3 and involved 709 participants. The second phase spanned June 11-14, 2020, and involved 646 participants. RESULTS: During the first phase, RT-PCR performed on nasopharyngeal swabs was positive at 0.14%. The serological tests were positive in 1.27% of the patients during the first phase and 2.79% during the second phase. People living in households with more than five members had a prevalence of 10.83% (95%CI: 1.58-74.27) higher than those living alone or with someone other. Considering the proportion of the positive serological test results with sex and age adjustments, approximately 2.37% (95%CI: 1.32-3.42) of the population had been cumulatively infected by mid-June 2020, which is equivalent to 16,670 people (95%CI: 9,267-24,074). Considering that 68 deaths from the disease in the residents of the city had been confirmed as at the date of the second phase of the survey, the infection fatality rate was estimated to be 0.41% (95%CI: 0.28-0.73). Our results suggest that approximately 88% of the cases of SARS-CoV-2 infection at the time of the survey were not reported to the local epidemiological surveillance service. CONCLUSIONS: The findings of this study provide in-depth knowledge of the COVID-19 pandemic in Brazil and are helpful for the preventive and decision-making policies of public managers.

Minimum concentration of Amphotericin B in serum according to the formulation, dose, and daily or prolonged intermittent therapeutic regimen.

INTRODUCTION: The therapeutic efficacy of daily amphotericin B infusion is related to its maximum concentration in blood; however, trough levels may be useful in intermittent regimens of this antifungal drug. METHODS: : High performance liquid chromatography (HPLC) was used to determine the minimum concentration (Cmin) of amphotericin B in the serum of patients receiving deoxycholate (D-Amph) or liposomal amphotericin B (L-AmB) for the treatment of cryptococcal meningitis (n=28), histoplasmosis (n=8), paracoccidioidomycosis (n=1), and leishmaniasis (n=1). RESULTS: Daily use of D-Amph 30 to 50 mg or L-AmB 50 mg resulted in a similar Cmin, but a significant increase ocurred with L-AmB 100 mg/day. The geometric mean Cmin tended to decrease with a reduction in the dose and frequency of intermittent L-AmB infusions: 357 ng/mL (100 mg 4 to 5 times/week) > 263 ng/mL (50 mg 4 to 5 times/week) > 227 ng/mL (50 mg 1 to 3 times/week). The impact on Cmin was variable in patients whose dose or therapeutic scheme was changed, especially when administered the intermittent infusion of amphotericin B. The mean Cmin for each L-AmB schedule of intermittent therapy was equal or higher than the minimum inhibitory concentration of amphotericin B against Cryptococcus isolates from 10/12 patients. The Cmin of amphotericin B in patients with cryptococcal meningitis was comparable between those that survived or died. CONCLUSIONS: By evaluating the Cmin of amphotericin B, we demonstrated the therapeutic potential of its intermittent use including in the consolidation phase of neurocryptococcosis treatment, despite the great variability in serum levels among patients.

Paracoccidioidomycosis due to Paracoccidioides lutzii complicated with adrenal injury and pulmonary arterial hypertension.

Paracoccidioidomycosis caused by Paracoccidioides lutzii is endemic in the Midwest of Brazil and its clinical spectrum is still little known due to the recent identification of this fungal species. A patient resident in Southeast Brazil, but who had lived for many years in the Midwest region, presented with skin injuries, chronic cough and bilateral adrenal involvement. Paracoccidioides spp. was isolated in culture from a skin lesion biopsy. This isolate was later identified as P. lutzii using gene sequencing. A favorable initial response to treatment with itraconazole was observed, but a few weeks later, the patient developed respiratory failure and worsening of lung lesions. Evaluation by computed tomography and echocardiography were suggestive of pulmonary arterial hypertension, and a bronchoscopic biopsy showed peribronchial remodeling. The patient completed the antifungal treatment but maintained the respiratory dysfunction. The reported case shows that P. lutzii can be isolated from patients in a geographic area far from the place of infection acquisition and that, as P. brasiliensis , it can cause adrenal injury and cardio-respiratory complications as a consequence of excessive necrosis and fibrosis.

Microbial Community Profiling in Intensive Care Units Expose Limitations in Current Sanitary Standards.

Hospital-associated infections (HAIs) are a leading cause of morbidity and mortality in intensive care units (ICUs) and neonatal intensive care units (NICUs). Organisms causing these infections are often present on surfaces around the patient. Given that microbiota may vary across different ICUs, the HAI-related microbial signatures within these units remain underexplored. In this study, we use deep-sequencing analyses to explore and compare the structure of bacterial communities at inanimate surfaces of the ICU and NICU wards of The Medical School Clinics Hospital (Brazil). The data revealed that NICU presents higher biodiversity than ICU and surfaces closest to the patient showed a peculiar microbiota, distinguishing one unit from the other. Several facultative anaerobes or obligate anaerobes HAI-related genera were classified as biomarkers for the NICU, whereas Pseudomonas was the main biomarker for ICU. Correlation analyses revealed a distinct pattern of microbe-microbe interactions for each unit, including bacteria able to form multi-genera biofilms. Furthermore, we evaluated the effect of concurrent cleaning over the ICU bacterial community. The results showed that, although some bacterial populations decreased after cleaning, various HAI-related genera were quite stable following sanitization, suggesting being well-adapted to the ICU environment. Overall, these results enabled identification of discrete ICU and NICU reservoirs of potentially pathogenic bacteria and provided evidence for the presence of a set of biomarkers genera that distinguish these units. Moreover, the study exposed the inconsistencies of the routine cleaning to minimize HAI-related genera contamination.

Long-term prevention of catheter-associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study.

BACKGROUND: Removing an indwelling urinary catheter as soon as possible is the cornerstone of catheter-associated urinary tract infections (CAUTI) prevention. However, implementing this measure may be challenging in clinical settings. To evaluate the impact of implementing a healthcare workers (HCWs) educational program and a daily checklist for indwelling urinary catheter indications among critical patients on the incidence of CAUTI. METHODS: This was a quasi-experimental study performed in a general intensive care unit of a tertiary-care hospital over a 12 years period, from January 1, 2005 to December 31, 2016. Rates of urinary catheter use and incidence density of CAUTI were monthly evaluated following the Centers for Disease Control and Prevention (CDC) criteria throughout the study period. Phase I (2005-2006) was the pre-intervention period. In phase II (2007-2010), HCWs routine training on CAUTI prevention was performed twice-a-year. In phase III (2011-2014), we implemented a daily checklist for indwelling urinary catheter indications, in addition to the biannual training. In phase IV, (2015-2016) the biannual training was replaced by training only newly hired HCWs and the daily checklist was maintained. RESULTS: The mean rate of urinary catheter utilization decreased from phase I to phase IV (73.1%, 74.1%, 54.9%, and 45.6%, respectively). Similarly, the incidence density of CAUTI decreased from phase I to phase IV (14.9, 7.3, 3.8, and 1.1 per 1000 catheter-days, respectively). CONCLUSIONS: HCWs education and daily evaluation of indwelling urinary catheter indications were highly effective in reducing the rates of catheter utilization as well as the incidence density of CAUTI.

Human pulmonary dirofilariasis with secondary myocarditis.

Dirofilariasis is a little-known zoonosis, with dogs and cats as definitive hosts. It is caused by nematodes and transmitted by mosquito bites. We report the case of a 67-year-old man with a consumptive syndrome with two subpleural pulmonary opacities. A transthoracic lung biopsy revealed a Dirofilaria worm. Myocardial nuclear magnetic resonance (NMR) demonstrated dilated cardiomyopathy after myocarditis related to dirofilariasis. Human infection is rare and occurs accidentally. The most common radiological alteration is a mainly subpleural coin lesion. Dirofilariasis is a neglected emergent disease and knowledge about it is important for differential diagnoses from neoplastic pulmonary nodules.

Is it necessary to have a dentist within an intensive care unit team? Report of a randomised clinical trial.

OBJECTIVE: To evaluate the effectiveness of dental treatment in improving oral health in critical patients. METHODS: This randomised clinical trial was conducted in a general intensive care unit (ICU) at a tertiary care public facility from 1 January 2011 to 8 August 2013. Data from 254 adult patients staying in the ICU for 48 hours or more were analysed. The experimental group (n = 127) had access to dental treatment provided by a dentist four to five times a week, in addition to routine oral hygiene, whereas the control group (n = 127) had access only to routine oral hygiene, including topical application of chlorhexidine, provided by the ICU nursing staff. The baseline oral health status of the enrolled patients was poor and included edentulism, caries, gingivitis, periodontitis and residual roots. Dental treatment consisted of toothbrushing, tongue scraping, removal of calculus, scaling and root planing, caries restoration and tooth extraction. RESULTS: The Oral Hygiene Index Simplified (OHI-S) and Gingival Index (GI) scores decreased in the experimental group but did not change significantly in the control group during the ICU stay. Dental treatment prevented most of the episodes of respiratory tract infections, as previously reported. No severe adverse events from the dental treatment were observed. CONCLUSION: From an interprofessional perspective, our results support the idea of including dentists in the ICU team to improve oral health in critical patients and effectively prevent respiratory tract infections, in addition to the improvement achievable by applying chlorhexidine alone.

Chylothorax and chylous ascites due to juvenile paracoccidioidomycosis: a case report

ABSTRACT Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by Paracoccidioides species. Chylothorax is a rare complication of PCM. A 16-year-old adolescent presented daily fever, lymphadenomegaly, sweating, weight loss, ventilatory-dependent pain, and dysphagia, which confirmed PCM. During treatment, the patient developed chylothorax and chylous ascites. Chronic inflammatory and fibrotic lymphadenopathy may obstruct lymphatic vessels, resulting in the extravasation of lymph into the abdomen or pleural cavities. Chylothorax is one of several complications of PCM and can lead to respiratory insufficiency, even in patients undergoing antifungal therapy.