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Assis DB, Madalosso G, Padoveze MC, Lobo RD, Oliveira MS, Boszczowski Í, Singer JM, Levin AS. Implementation of tailored interventions in a statewide programme to reduce central line-associated bloodstream infections. J Hosp Infect 2018; 100:e163-e168. [PMID: 29730142 DOI: 10.1016/j.jhin.2018.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There have been few studies exploring implementation strategies to central line-associated bloodstream infections (CLABSIs) in low- or middle-income countries. AIM To implement tailored interventions to reduce CLABSI rates in adult intensive care units. METHODS The implementation strategy of the State Health Department was performed in São Paulo State, Brazil, over two cycles. Cycle 1 (56 hospitals) was exploratory and cycle 2 (77 hospitals) was designed to confirm the hypothesis generated by the first cycle, with three phases each (pre-intervention, intervention, post-intervention). Cycles included: evaluation of healthcare workers' knowledge, observation of practices, and CLABSI rates monthly report. In cycle 1, a log-normal mixed model was used to select variables significantly associated with the reduction of CLABSI. In cycle 2, CLABSI rates were evaluated. FINDINGS Healthcare workers' practices improved after intervention. In cycle 1, reduction of CLABSI rates was more pronounced in hospitals with initial CLABSI rates >7.4 per 1000 catheter-days (P < 0.001) and those that introduced the use of peripherally inserted central catheters (P = 0.01). For hospitals with high CLABSI initial rates, simulation demonstrated that the rates were expected to decrease by 36% (95% CI: 9-63), no matter the type of intervention. In cycle 2, there was an overall decrease in CLABSI rates during the intervention period; whereas the mean rate fell further post-intervention, rates at the 90th percentile increased. CONCLUSION The implementation strategy may have had an effect on infection rates independently of the specific interventions implemented; however, the sustainability of reduction in the post-intervention period remains a challenge.
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Affiliation(s)
- D B Assis
- Division of Nosocomial Infections, Center for Epidemiologic Surveillance 'Prof. Alexandre Vranjac', Center of Disease Control, São Paulo State Health Department, São Paulo, Brazil.
| | - G Madalosso
- Division of Nosocomial Infections, Center for Epidemiologic Surveillance 'Prof. Alexandre Vranjac', Center of Disease Control, São Paulo State Health Department, São Paulo, Brazil
| | - M C Padoveze
- Department of Collective Health Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil
| | - R D Lobo
- Department of Infection Control, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - M S Oliveira
- Department of Infection Control, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Í Boszczowski
- Department of Infection Control, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - J M Singer
- Department of Statistics, University of São Paulo, São Paulo, Brazil
| | - A S Levin
- Department of Collective Health Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil; Department of Infectious Diseases and LIM54, University of São Paulo, São Paulo, Brazil; Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
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2
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Salomão MC, Guimarães T, Duailibi DF, Perondi MBM, Letaif LSH, Montal AC, Rossi F, Cury AP, Duarte AJS, Levin AS, Boszczowski I. Carbapenem-resistant Enterobacteriaceae in patients admitted to the emergency department: prevalence, risk factors, and acquisition rate. J Hosp Infect 2017; 97:241-246. [PMID: 28826688 DOI: 10.1016/j.jhin.2017.08.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/14/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) have been reported worldwide and are associated with high mortality rates. Intestinal colonization acts as a reservoir and fosters exchange of resistance mechanisms. AIM To investigate the prevalence of patients harbouring CRE on hospital admission, risk factors associated, and the acquisition rate within the emergency department (ED). METHODS This was a cross-sectional survey with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain reaction (PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE. FINDINGS Forty-six patients were colonized; all positive PCR were Klebsiella pneumoniae carbapenemase. The acquisition rate was 18%. Previous exposure to healthcare in the last year, liver disease, and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community. CONCLUSION Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.
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Affiliation(s)
- M C Salomão
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, Brazil; Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil.
| | - T Guimarães
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - D F Duailibi
- Department of Infectious Diseases, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - M B M Perondi
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - L S H Letaif
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A C Montal
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - F Rossi
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A P Cury
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A J S Duarte
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A S Levin
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, Brazil; Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil; LIM54, Faculdade de Medicina, Universidade de São Paulo, Brazil
| | - I Boszczowski
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
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3
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Faria NR, Quick J, Claro IM, Thézé J, de Jesus JG, Giovanetti M, Kraemer MUG, Hill SC, Black A, da Costa AC, Franco LC, Silva SP, Wu CH, Raghwani J, Cauchemez S, du Plessis L, Verotti MP, de Oliveira WK, Carmo EH, Coelho GE, Santelli ACFS, Vinhal LC, Henriques CM, Simpson JT, Loose M, Andersen KG, Grubaugh ND, Somasekar S, Chiu CY, Muñoz-Medina JE, Gonzalez-Bonilla CR, Arias CF, Lewis-Ximenez LL, Baylis SA, Chieppe AO, Aguiar SF, Fernandes CA, Lemos PS, Nascimento BLS, Monteiro HAO, Siqueira IC, de Queiroz MG, de Souza TR, Bezerra JF, Lemos MR, Pereira GF, Loudal D, Moura LC, Dhalia R, França RF, Magalhães T, Marques ET, Jaenisch T, Wallau GL, de Lima MC, Nascimento V, de Cerqueira EM, de Lima MM, Mascarenhas DL, Neto JPM, Levin AS, Tozetto-Mendoza TR, Fonseca SN, Mendes-Correa MC, Milagres FP, Segurado A, Holmes EC, Rambaut A, Bedford T, Nunes MRT, Sabino EC, Alcantara LCJ, Loman NJ, Pybus OG. Establishment and cryptic transmission of Zika virus in Brazil and the Americas. Nature 2017; 546:406-410. [PMID: 28538727 DOI: 10.1038/nature22401] [Citation(s) in RCA: 377] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022]
Abstract
Transmission of Zika virus (ZIKV) in the Americas was first confirmed in May 2015 in northeast Brazil. Brazil has had the highest number of reported ZIKV cases worldwide (more than 200,000 by 24 December 2016) and the most cases associated with microcephaly and other birth defects (2,366 confirmed by 31 December 2016). Since the initial detection of ZIKV in Brazil, more than 45 countries in the Americas have reported local ZIKV transmission, with 24 of these reporting severe ZIKV-associated disease. However, the origin and epidemic history of ZIKV in Brazil and the Americas remain poorly understood, despite the value of this information for interpreting observed trends in reported microcephaly. Here we address this issue by generating 54 complete or partial ZIKV genomes, mostly from Brazil, and reporting data generated by a mobile genomics laboratory that travelled across northeast Brazil in 2016. One sequence represents the earliest confirmed ZIKV infection in Brazil. Analyses of viral genomes with ecological and epidemiological data yield an estimate that ZIKV was present in northeast Brazil by February 2014 and is likely to have disseminated from there, nationally and internationally, before the first detection of ZIKV in the Americas. Estimated dates for the international spread of ZIKV from Brazil indicate the duration of pre-detection cryptic transmission in recipient regions. The role of northeast Brazil in the establishment of ZIKV in the Americas is further supported by geographic analysis of ZIKV transmission potential and by estimates of the basic reproduction number of the virus.
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Affiliation(s)
- N R Faria
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK.,Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - J Quick
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - I M Claro
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - J Thézé
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK
| | - J G de Jesus
- Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Bahia, Brazil
| | - M Giovanetti
- Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Bahia, Brazil.,University of Rome Tor Vergata, Rome, Italy
| | - M U G Kraemer
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK.,Harvard Medical School, Boston, Massachusetts, USA.,Boston Children's Hospital, Boston, Massachusetts, USA
| | - S C Hill
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK
| | - A Black
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - A C da Costa
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - L C Franco
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - S P Silva
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - C-H Wu
- Department of Statistics, University of Oxford, Oxford OX1 3LB, UK
| | - J Raghwani
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK
| | - S Cauchemez
- Mathematical Modelling of Infectious Diseases and Center of Bioinformatics, Biostatistics and Integrative Biology, Institut Pasteur, Paris, France.,Centre National de la Recherche Scientifique, URA3012, Paris, France
| | - L du Plessis
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK
| | - M P Verotti
- Coordenação dos Laboratórios de Saúde (CGLAB/DEVIT/SVS), Ministry of Health, Brasília, Brazil
| | - W K de Oliveira
- Coordenação Geral de Vigilância e Resposta às Emergências em Saúde Pública (CGVR/DEVIT), Ministry of Health, Brasília, Brazil.,Center of Data and Knowledge Integration for Health (CIDACS), Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
| | - E H Carmo
- Departamento de Vigilância das Doenças Transmissíveis, Ministry of Health, Brasilia, Brazil
| | - G E Coelho
- Coordenação Geral dos Programas de Controle e Prevenção da Malária e das Doenças Transmitidas pelo Aedes, Ministry of Health, Brasília, Brazil.,Pan American Health Organization (PAHO), Buenos Aires, Argentina
| | - A C F S Santelli
- Coordenação Geral dos Programas de Controle e Prevenção da Malária e das Doenças Transmitidas pelo Aedes, Ministry of Health, Brasília, Brazil.,Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - L C Vinhal
- Coordenação Geral dos Programas de Controle e Prevenção da Malária e das Doenças Transmitidas pelo Aedes, Ministry of Health, Brasília, Brazil
| | - C M Henriques
- Departamento de Vigilância das Doenças Transmissíveis, Ministry of Health, Brasilia, Brazil
| | - J T Simpson
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - M Loose
- University of Nottingham, Nottingham, UK
| | - K G Andersen
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, California 92037, USA
| | - N D Grubaugh
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, California 92037, USA
| | - S Somasekar
- Departments of Laboratory Medicine and Medicine &Infectious Diseases, University of California, San Francisco, California, USA
| | - C Y Chiu
- Departments of Laboratory Medicine and Medicine &Infectious Diseases, University of California, San Francisco, California, USA
| | - J E Muñoz-Medina
- División de Laboratorios de Vigilancia e Investigación Epidemiológica, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - C R Gonzalez-Bonilla
- División de Laboratorios de Vigilancia e Investigación Epidemiológica, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - C F Arias
- Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Mexico
| | | | | | - A O Chieppe
- Laboratório Central de Saúde Pública Noel Nutels, Rio de Janeiro, Brazil
| | - S F Aguiar
- Laboratório Central de Saúde Pública Noel Nutels, Rio de Janeiro, Brazil
| | - C A Fernandes
- Laboratório Central de Saúde Pública Noel Nutels, Rio de Janeiro, Brazil
| | - P S Lemos
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - B L S Nascimento
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - H A O Monteiro
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil
| | - I C Siqueira
- Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Bahia, Brazil
| | - M G de Queiroz
- Laboratório Central de Saúde Pública do Estado do Rio Grande do Norte, Natal, Brazil
| | - T R de Souza
- Laboratório Central de Saúde Pública do Estado do Rio Grande do Norte, Natal, Brazil.,Universidade Potiguar do Rio Grande do Norte, Natal, Brazil
| | - J F Bezerra
- Laboratório Central de Saúde Pública do Estado do Rio Grande do Norte, Natal, Brazil.,Faculdade Natalense de Ensino e Cultura, Rio Grande do Norte, Natal, Brazil
| | - M R Lemos
- Laboratório Central de Saúde Pública do Estado da Paraíba, João Pessoa, Brazil
| | - G F Pereira
- Laboratório Central de Saúde Pública do Estado da Paraíba, João Pessoa, Brazil
| | - D Loudal
- Laboratório Central de Saúde Pública do Estado da Paraíba, João Pessoa, Brazil
| | - L C Moura
- Laboratório Central de Saúde Pública do Estado da Paraíba, João Pessoa, Brazil
| | - R Dhalia
- Fundação Oswaldo Cruz (FIOCRUZ), Recife, Pernambuco, Brazil
| | - R F França
- Fundação Oswaldo Cruz (FIOCRUZ), Recife, Pernambuco, Brazil
| | - T Magalhães
- Fundação Oswaldo Cruz (FIOCRUZ), Recife, Pernambuco, Brazil.,Department of Microbiology, Immunology &Pathology, Colorado State University, Fort Collins, Colorado 80523, USA
| | - E T Marques
- Fundação Oswaldo Cruz (FIOCRUZ), Recife, Pernambuco, Brazil
| | - T Jaenisch
- Section Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - G L Wallau
- Fundação Oswaldo Cruz (FIOCRUZ), Recife, Pernambuco, Brazil
| | - M C de Lima
- Laboratório Central de Saúde Pública do Estado de Alagoas, Maceió, Brazil
| | - V Nascimento
- Laboratório Central de Saúde Pública do Estado de Alagoas, Maceió, Brazil
| | - E M de Cerqueira
- Laboratório Central de Saúde Pública do Estado de Alagoas, Maceió, Brazil
| | - M M de Lima
- Universidade Estadual de Feira de Santana, Feira de Santana, Bahia, Brazil
| | - D L Mascarenhas
- Secretaria de Saúde de Feira de Santana, Feira de Santana, Bahia, Brazil
| | | | - A S Levin
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - T R Tozetto-Mendoza
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - S N Fonseca
- Hospital São Francisco, Ribeirão Preto, Brazil
| | - M C Mendes-Correa
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - F P Milagres
- Universidade Federal do Tocantins, Palmas, Brazil
| | - A Segurado
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A Rambaut
- Institute of Evolutionary Biology, University of Edinburgh, Edinburgh EH9 3FL, UK.,Fogarty International Center, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - T Bedford
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - M R T Nunes
- Evandro Chagas Institute, Ministry of Health, Ananindeua, Brazil.,Department of Pathology, University of Texas Medical Branch, Galveston, Texas 77555, USA
| | - E C Sabino
- Department of Infectious Disease, School of Medicine &Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | | | - N J Loman
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - O G Pybus
- Department of Zoology, University of Oxford, Oxford OX1 3SY, UK.,Metabiota, San Francisco, California 94104, USA
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4
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Freire MP, de Oliveira Garcia D, Garcia CP, Campagnari Bueno MF, Camargo CH, Kono Magri ASG, Francisco GR, Reghini R, Vieira MF, Ibrahim KY, Rossi F, Hajjar L, Levin AS, Hoff PM, Pierrotti LC, Abdala E. Bloodstream infection caused by extensively drug-resistant Acinetobacter baumannii in cancer patients: high mortality associated with delayed treatment rather than with the degree of neutropenia. Clin Microbiol Infect 2015; 22:352-358. [PMID: 26711434 DOI: 10.1016/j.cmi.2015.12.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 11/30/2022]
Abstract
This study aimed to describe severe infections with extensively drug-resistant Acinetobacter baumannii-calcoaceticus complex (XDR-ABC), as well as to investigate risk factors for mortality, in cancer patients. It was a retrospective study including all patients diagnosed with XDR-ABC bacteraemia during hospitalization in the intensive care unit of a cancer hospital between July 2009 and July 2013. Surveillance cultures were collected weekly during the study period, and clonality was analysed using pulsed field gel electrophoresis (PFGE). We analysed underlying diseases, oncology therapy, neutrophil counts, infection site and management of infection, in terms of their correlation with 30-day mortality. During the study period, 92 patients with XDR-ABC bacteraemia were identified, of whom 35 (38.0%) were patients with haematological malignancy. We identified XDR-ABC strains with four different profile patterns, 91.3% of patients harbouring the predominant PFGE type. Of the 92 patients with XDR-ABC bacteraemia, 66 (71.7%) had central line-associated bloodstream infections; infection occurred during neutropenia in 22 (23.9%); and 58 (63.0%) died before receiving the appropriate therapy. All patients were treated with polymyxin, which was used in combination therapy in 30 of them (32.4%). The 30-day mortality rate was 83.7%. Multivariate analysis revealed that septic shock at diagnosis of XDR-ABC infection was a risk factor for 30-day mortality; protective factors were receiving appropriate therapy and invasive device removal within the first 48 h. Among cancer patients, ineffective management of such infection increases the risk of death, more so than do features such as neutropenia and infection at the tumour site.
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Affiliation(s)
- M P Freire
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | | | - C P Garcia
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - C H Camargo
- Bacteriology Centre, Adolfo Lutz Institute, São Paulo, Brazil
| | - A S G Kono Magri
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - G R Francisco
- Bacteriology Centre, Adolfo Lutz Institute, São Paulo, Brazil
| | - R Reghini
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - M F Vieira
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - K Y Ibrahim
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - F Rossi
- Microbiology Section, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - L Hajjar
- Intensive Care Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - A S Levin
- Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P M Hoff
- Department of Oncology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - L C Pierrotti
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil
| | - E Abdala
- Hospital Infection Control and Infectious Diseases Unit, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil
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5
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de Oliveira MS, de Assis DB, Freire MP, Boas do Prado GV, Machado AS, Abdala E, Pierrotti LC, Mangini C, Campos L, Caiaffa Filho HH, Levin AS. Treatment of KPC-producing Enterobacteriaceae: suboptimal efficacy of polymyxins. Clin Microbiol Infect 2014; 21:179.e1-7. [PMID: 25599940 DOI: 10.1016/j.cmi.2014.07.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/16/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
Abstract
Treatment of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae infections (KPC-EI) remains a challenge. Combined therapy has been proposed as the best choice, but there are no clear data showing which combination therapy is superior. Our aim was to evaluate the effectiveness of antimicrobial regimens for treating KPC-EI. This was a retrospective cohort study of KPC-EI nosocomial infections (based on CDC criteria) between October 2009 and June 2013 at three tertiary Brazilian hospitals. The primary outcomes were the 30-day mortality for all infections and the 30-day mortality for patients with bacteraemia. Risk factors for mortality were evaluated by comparing clinical variables of survivors and nonsurvivors. In this study, 118 patients were included, of whom 78 had bacteraemia. Catheter-related bloodstream infections were the most frequent (43%), followed by urinary tract infections (n = 27, 23%). Monotherapy was used in 57 patients and combined treatment in 61 patients. The most common therapeutic combination was polymyxin plus carbapenem 20 (33%). Multivariate analysis for all infections (n = 118) and for bacteremic infections (n = 78) revealed that renal failure at the end of treatment, use of polymyxin and older age were prognostic factors for mortality. In conclusion, polymyxins showed suboptimal efficacy and combination therapy was not superior to monotherapy.
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Affiliation(s)
- M S de Oliveira
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - D B de Assis
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - M P Freire
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Infection Control Service, Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - G V Boas do Prado
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - A S Machado
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - E Abdala
- Infection Control Service, Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - L C Pierrotti
- Infection Control Service, Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - C Mangini
- Infection Control Service, Hospital Municipal Jose de Carvalho Florence, São José dos Campos, São Paulo, Brazil
| | - L Campos
- Infection Control Service, Hospital Municipal Jose de Carvalho Florence, São José dos Campos, São Paulo, Brazil
| | - H H Caiaffa Filho
- Laboratório de Investigação Médica LIM 03, Divisão de Laboratório Central, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - A S Levin
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Infectious Diseases, Laboratório de Investigação Médica - LIM 54 and Instituto de Medicina Tropical, University of São Paulo, Brazil
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6
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Massaro KSR, Macedo R, de Castro BS, Dulley F, Oliveira MS, Yasuda MAS, Levin AS, Costa SF. Risk factor for death in hematopoietic stem cell transplantation: are biomarkers useful to foresee the prognosis in this population of patients? Infection 2014; 42:1023-32. [PMID: 25263811 DOI: 10.1007/s15010-014-0685-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 09/12/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The morbidity and mortality in hematopoietic stem cell transplantation (HSCT) occur due to infectious complications and constitute the major clinical problems in HSCT recipients. The role of the use of biomarkers in post-HSCT patients is still controversial. OBJECTIVES To assess the serum values of biomarkers interleukin 6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) and risk factors for post-HSCT death. PATIENTS AND METHODS Prospective study conducted in patients submitted to HSCT at a university hospital. Biomarkers (IL-6, PCT and CRP) were assessed on the day afebrile neutropenia was detected, in the febrile event, 24 and 72 h after fever onset and 48 h or 5 days if fever persisted. Patients were compared as to the death outcome within 30 days from the HSCT. Variables with p < 0.15 were included in the multivariate analysis model (MVA) that were performed for all patients included in the study and separated for autologous and allogeneic HSCT patients. RESULTS 296 patients with ages ranging between 15 and 70 years, neutropenic, submitted to HSCT, being 216 (73%) autologous and 80 (20%) allogeneic were assessed. One hundred and ninety (64.2%) patients presented fever after the transplantation and infection microbiologically controlled in 78 (26.4%). Twenty-three cases (7.8%) evolved to death. The risk factors associated with death in the bivariate analysis were age, allogeneic transplantation, unrelated transplantation, GVHD, bloodstream infection by Gram-negative, IL-6 >140 pg/mL and CRP ≥ 120 mg/L and the protective ones were lymphoma and hospital outpatient support. The independent variables in the MVA associated with death were allogeneic and unrelated transplantation, blood stream infection (BSI) by Gram-negative, LDH ≥ 390 UI/L, urea ≥ 25 mg/dL and CRP ≥ 120 mg/L for HSCT transplanted patients and BSI due to Gram-negative and CRP ≥ 120 mg/L for allogeneic HSCT, however, CRP ≥ 120 mg/L did not remain in the model when urea ≥ 25 mg/L was included. No independent risk factor was found for autologous patients. CONCLUSIONS Out of the biomarkers assessed, only CRP ≥ 120 mg/L was independently associated with death. Other risk factors found were: type of transplantation (allogeneic and unrelated), bloodstream infection by Gram-negative, LDH ≥ 390 UI/L and urea ≥ 25 mg/dL. For allogeneic patients only CRP ≥ 120 mg/L and BSI due to Gram-negative were risk factors for death; however, CRP did not remain in the model when urea ≥ 25 mg/L was included.
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Affiliation(s)
- K S R Massaro
- Infectious and Parasitary Diseases Department, School of Medicine, Universidade de São Paulo, Lim54, São Paulo, Brazil
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7
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Mendes ET, Ramos J, Peixoto D, Dulley F, Alves T, Vilas Boas LS, Batista MV, da Silva DP, Levin AS, Shikanai-Yasuda MA, Costa SF. An outbreak of respiratory syncytial virus infection in hematopoietic stem cell transplantation outpatients: good outcome without specific antiviral treatment. Transpl Infect Dis 2012; 15:42-8. [PMID: 22783905 DOI: 10.1111/j.1399-3062.2012.00764.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/06/2012] [Accepted: 05/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is a common cause of seasonal respiratory viral infection in hematopoietic stem cell transplantations (HSCT) patients. The efficacy of treatment, however, remains controversial. We describe an outbreak of 31 cases of RSV that occurred in an HSCT outpatient care unit in the fall season from March through May 2010, with a good outcome without any specific antiviral treatment. METHODS During these 3 months, 222 nasal wash samples were tested and, of these, 31 outpatients were positive for RSV. In 2009, 99 samples had been tested and only 10 outpatients were positive for RSV in the same period. RESULTS Seven (22.5%) patients had severe neutropenia (<500 cells/μL); severe lymphopenia (<200 cells/μL) was present in 13 (41.9%) patients, and 14 (45%) had received intravenous broad-spectrum antibiotics. Hospitalization was necessary only for 8 patients (25.8%); 20 had lower respiratory tract infection (64.5%). Only 1 patient died as a result of proven invasive aspergillosis. CONCLUSION This report suggests that HSCT outpatients with no risk factors may not always require specific treatment for RSV.
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Affiliation(s)
- E T Mendes
- Departamento de Molestias Infecciosas, Hospital das Clínicas-Faculdade de Medicina Universidade de São Paulo, São Paulo, Brasil
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8
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Boszczowski I, Nóbrega de Almeida Júnior J, Peixoto de Miranda EJ, Pinheiro Freire M, Guimarães T, Chaves CE, Cais DP, Strabelli TMV, Risek CF, Soares RE, Rossi F, Costa SF, Levin AS. Nosocomial outbreak of Pantoea agglomerans bacteraemia associated with contaminated anticoagulant citrate dextrose solution: new name, old bug? J Hosp Infect 2012; 80:255-8. [PMID: 22245117 DOI: 10.1016/j.jhin.2011.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 12/15/2011] [Indexed: 11/17/2022]
Abstract
We describe an outbreak investigation of Pantoea agglomerans bacteraemia associated with anticoagulant citrate-dextrose 46% (ACD) solution prepared in-house. A healthy man presented with septic shock during plasmapheresis for granulocyte donation. The solution used for priming and blood samples were sent for culture. Identification of the isolate to species level was performed by gyrB sequencing. Typing was performed by pulsed-field gel electrophoresis (PFGE). In total, eight cases were identified during a three-week period. P. agglomerans was also cultured from six ACD solution bags. Isolates from patients and ACD bags were identical by PFGE. All isolates were susceptible to ampicillin, cephazolin, gentamicin, ciprofloxacin, cefepime and imipenem.
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Affiliation(s)
- I Boszczowski
- Infection Control Department, Hospital das Clínicas, University of São Paulo, Brazil.
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9
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Abstract
Although prophylaxis is current practice, there are no randomized controlled studies evaluating preoperative antimicrobial prophylaxis in dental procedures in patients immunocompromised by chemotherapy or organ transplants. To evaluate prophylaxis in dental-invasive procedures in patients with cancer or solid organ transplants, 414 patients were randomized to receive one oral 500-mg dose 2 hours before the procedure (1-dose group) or a 500-mg dose 2 hours before the procedure and an additional dose 8 hours later (2-dose group). Procedures were exodontia or periodontal scaling/root planing. Follow-up was 4 weeks. No deaths or surgical site infections occurred. Six patients (1.4%) presented with use of pain medication > 3 days or hospitalization during follow-up: 4 of 207 (2%) in the 1-dose group and 2 of 207 (1%) in the 2-dose group (relative risk, 2.02; 95% confidence interval, 0.37-11.15). In conclusion, no statistically significant difference occurred in outcome using 1 or 2 doses of prophylactic amoxicillin for invasive dental procedures in immunocompromised patients.
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Affiliation(s)
- D R Lopes
- Department of Infectious Diseases and LIM-54, University of São Paulo, Brazil
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10
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Miranda LN, van der Heijden IM, Costa SF, Sousa API, Sienra RA, Gobara S, Santos CR, Lobo RD, Pessoa VP, Levin AS. Candida colonisation as a source for candidaemia. J Hosp Infect 2009; 72:9-16. [PMID: 19303662 DOI: 10.1016/j.jhin.2009.02.009] [Citation(s) in RCA: 175] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 02/06/2009] [Indexed: 11/16/2022]
Abstract
Candida spp. are important healthcare-associated pathogens. Identifying the source of infection is important for prevention and control strategies. The objective of this study was to evaluate candida colonisation sites as potential sources for candidaemia. Sixty-three consecutive patients with a positive blood culture for candida were included. Surveillance cultures were collected from urine, rectum, oropharynx, skin, intravascular catheter tip and skin around catheter. Molecular typing was performed when the same species of candida was isolated from blood and surveillance sites of a patient. C. albicans was associated with 42% of candidaemias, C. parapsilosis 33%, C. tropicalis 16% and C. guilliermondii, C. krusei, C. glabrata, C. holmii and C. metapsilosis were all 2% each. Six of 10 C. parapsilosis catheter tip isolates were indistinguishable from corresponding blood isolates (all in neonates). C. albicans isolates from blood were indistinguishable from corresponding gastrointestinal tract isolates in 13 of 26 patients and from catheter tip isolates in two patients. In conclusion, the results suggest that gastrointestinal colonisation is the probable source of C. albicans candidaemia and C. parapsilosis is exogenous.
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Affiliation(s)
- L N Miranda
- Department of Infectious Diseases and LIM 54, University of São Paulo, São Paulo, Brazil
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11
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Paez JIG, Tengan FM, Barone AA, Levin AS, Costa SF. Factors associated with mortality in patients with bloodstream infection and pneumonia due to Stenotrophomonas maltophilia. Eur J Clin Microbiol Infect Dis 2008; 27:901-6. [PMID: 18483755 DOI: 10.1007/s10096-008-0518-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Accepted: 03/25/2008] [Indexed: 01/25/2023]
Abstract
Severe infections caused by Stenotrophomonas maltophilia are associated with high mortality, and strategies to improve the clinical outcome for infected patients are needed. A retrospective cohort study of patients with bloodstream infection (BSIs) and pneumonia caused by S. maltophilia was conducted. Multivariate analysis was performed to access factors associated with 14-day mortality. A total of 60 infections were identified. Among these, eight (13%) were pneumonias and 52 were BSIs; 33.3% were primary, 13% were central venous catheter (CVC)-related and 40% were secondary BSIs. Fifty-seven (85%) patients had received previous antimicrobial therapy; 88% had CVC, 57% mechanical ventilation and 75% were in the intensive care unit at the onset of infection. Malignancy (45%) was the most frequent underlying disease. The mean of the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores was 17 and for the Sepsis-related Organ Failure Assessment (SOFA) score, it was 7 points. The overall and 14-day mortality were, respectively, 75% and 48%. Forty-seven (78%) patients were treated and, of these, 74% received trimethoprim-sulfamethoxazole. Independent risk factors associated with mortality were SOFA index >6 points (0.005) and septic shock (0.03). The Kaplan-Meier estimations curves showed that patients with APACHE II score >20 and SOFA score >10 had a survival chance of, respectively, less than 8% and less than 10% (P<or=0.001) at 21 days after the first positive S. maltophilia culture. Our results suggest that the independent factors associated with outcome in patients with infection caused by S. maltophilia are septic shock and higher SOFA index.
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Affiliation(s)
- J I Garcia Paez
- Department of Infectious Diseases, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.
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12
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Oliveira MS, Prado GVB, Costa SF, Grinbaum RS, Levin AS. Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp. J Antimicrob Chemother 2008; 61:1369-75. [DOI: 10.1093/jac/dkn128] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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13
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Binelli CA, Moretti ML, Assis RS, Sauaia N, Menezes PR, Ribeiro E, Geiger DCP, Mikami Y, Miyaji M, Oliveira MS, Barone AA, Levin AS. Investigation of the possible association between nosocomial candiduria and candidaemia. Clin Microbiol Infect 2006; 12:538-43. [PMID: 16700702 DOI: 10.1111/j.1469-0691.2006.01435.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study aimed to determine whether candiduria is associated with the occurrence of nosocomial candidaemia. In the case-control part of the study, 115 cases (nosocomial candidaemia) and 115 controls (nosocomial bacteraemia) were similar in age, severity of condition and time of hospitalisation. There was a significant association of candidaemia with candiduria (OR 9.79; 95% CI 2.14-44.76). In the microbiology part of the study, 23 pairs of Candida-positive urine and blood cultures were obtained from 23 patients. In ten (43%) cases, the urine and blood culture isolates belonged to different species, and molecular typing showed a difference in two of the 13 cases yielding the same species from both specimens. Overall, there was a significant association between candiduria and candidaemia, but the Candida isolates from urine and blood were different for 52% of the patients. Thus, the data indicated that the urinary tract was probably not a source for the candidaemia.
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Affiliation(s)
- C A Binelli
- Faculty of Medicine of the University of São Paulo, São Paulo, Brazil
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14
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Matsuoka DM, Costa SF, Mangini C, Almeida GMD, Bento CN, Van Der Heijden IM, Soares RE, Gobara S, Távora LGF, Levin AS. A nosocomial outbreak of Salmonella enteritidis associated with lyophilized enteral nutrition. J Hosp Infect 2004; 58:122-7. [PMID: 15474183 DOI: 10.1016/j.jhin.2004.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2003] [Accepted: 02/25/2004] [Indexed: 11/17/2022]
Abstract
Outbreaks of Salmonella spp. gastro-enteritis in hospitals are of concern because of the increased susceptibility of patients and associated high morbidity. This study is a report of a nosocomial outbreak of Salmonella enteritidis associated with enteral nutrition. In December 1999, one sample of enteral feed tested positive for S. enteritidis. During the subsequent 6 weeks, eight cases of nosocomial salmonellosis occurred. Patients involved in the outbreak were aged 19-79 years (median = 36.5), and salmonella was isolated from the blood of two patients. All patients were receiving enteral nutrition at the time and all had diarrhoea. Three patients died. All 13 employees of the Nutrition Department were asymptomatic and their stool samples were negative. Environmental and water samples were also negative. The diet, however, contained lyophilized egg albumin. Molecular typing showed that the isolates of seven patients were indistinguishable from the one obtained from the enteral diet. It was thought that the nosocomial salmonellosis probably occurred due to the use of a commercial lyophilized diet. Another method of processing diets may be necessary to ensure patient safety.
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Affiliation(s)
- D M Matsuoka
- Nosocomial Infection Control Group, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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15
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Moretti ML, Bratfich OJ, Stucchi RB, Levi C, Levin AS, Duboc GM, Vormittag E, Blum-Menezes D. Clonal dissemination of VanA-type glycopeptide-resistant Enterococcus faecalis between hospitals of two cities located 100 km apart. Braz J Med Biol Res 2004; 37:1339-43. [PMID: 15334199 DOI: 10.1590/s0100-879x2004000900008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nosocomial dissemination of glycopeptide-resistant enterococci represents a major problem in hospitals worldwide. In Brazil, the dissemination among hospitals in the city of São Paulo of polyclonal DNA profiles was previously described for vancomycin-resistant Enterococcus faecium. We describe here the dissemination of VanA phenotype E. faecalis between two hospitals located in different cities in the State of São Paulo. The index outbreak occurred in a tertiary care university hospital (HCUSP) in the city of São Paulo and three years later a cluster caused by the same strain was recognized in two patients hospitalized in a private tertiary care hospital (CMC) located 100 km away in the interior of the state. From May to July 1999, 10 strains of vancomycin-resistant E. faecalis were isolated from 10 patients hospitalized in the HCUSP. The DNA genotyping using pulsed-field gel electrophoresis (PFGE) showed that all isolates were originated from the same clone, suggesting nosocomial dissemination. From May to July 2002, three strains of vancomycin-resistant E. faecalis were isolated from two patients hospitalized in CMC and both patients were colonized by the vancomycin-resistant Enterococcus in skin lesions. All isolates from CMC and HCUSP were highly resistant to vancomycin and teicoplanin. The three strains from CMC had minimum inhibitory concentration >256 micro g/ml for vancomycin, and 64 (CMC 1 and CMC 2) and 96 micro g/ml (CMC 3) for teicoplanin, characterizing a profile of VanA resistance to glycopeptides. All strains had the presence of the transposon Tn1546 detected by PCR and were closely related when typed by PFGE. The dissemination of the E. faecalis VanA phenotype among hospitals located in different cities is of great concern because E. faecalis commonly colonizes the gastrointestinal tract of patients and healthy persons for periods varying from weeks to years, which, together with the persistence of vancomycin-resistant Enterococcus in hospital rooms after standard cleaning procedures, increases the risk of the dissemination and reservoir of the bacteria.
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Affiliation(s)
- M L Moretti
- Laboratório de Epidemiologia Molecular e Moléstias Infecciosas, Divisão de Moléstias Infecciosas, Faculdade de Ciências Médicas, Universidade Estadual de CampinasCampinas, SP, Brasil.
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16
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Abstract
Resistance of Streptococcus pneumoniae is a worldwide, growing problem. Studies of factors associated with resistance to penicillin have not been conducted in Brazil. The objective of the present study was to evaluate factors associated with infection by S. pneumoniae not susceptible to penicillin. A prevalence study was conducted including all patients with a positive culture for S. pneumoniae in a hospital from July 1991 to December 1992 and the year 1994. Of 165 patients identified, 139 were considered to have clinically relevant infections and 88% of them had invasive infections. All infections were community acquired and consisted of pneumonia (44%) and of central nervous system (19%), pelvic or abdominal (12%), upper airway or ocular (12%), primary bloodstream (9%) and skin and soft tissue (5%) infections. Mortality was 25%. Susceptibility to penicillin was present in 77.6% of the isolates; 21.8% were relatively resistant, and one isolate was resistant (minimal inhibitory concentration = 4 micro g/ml). Multivariate analysis showed that age below 4 years (odds ratio (OR): 3.53, 95% confidence interval (95%CI): 1.39-8.96) and renal failure (OR: 5.50, 95%CI: 1.07-28.36) were associated with lack of susceptibility to penicillin. Bacteremia occurred significantly less frequently in penicillin-nonsusceptible infections (OR: 0.34, 95%CI: 0.14-0.84), possibly suggesting that lack of penicillin susceptibility is associated with lower virulence in S. pneumoniae.
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Affiliation(s)
- A S Levin
- Departamento de Moléstias Infecciosas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
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17
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Távora LGF, Gambale W, Heins-Vaccari EM, Arriagada GLH, Lacaz CS, Santos CR, Levin AS. Comparative performance of two air samplers for monitoring airborne fungal propagules. Braz J Med Biol Res 2003; 36:613-6. [PMID: 12715080 DOI: 10.1590/s0100-879x2003000500008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Many studies have attempted to evaluate the importance of airborne fungi in the development of invasive fungal infection, especially for immunocompromised hosts. Several kinds of instruments are available to quantitate fungal propagule levels in air. We compared the performance of the most frequently used air sampler, the Andersen sampler with six stages, with a portable one, the Reuter centrifugal sampler (RCS). A total of 84 samples were analyzed, 42 with each sampler. Twenty-eight different fungal genera were identified in samples analyzed with the Andersen instrument. In samples obtained with the RCS only seven different fungal genera were identified. The three most frequently isolated genera in samples analyzed with both devices were Penicillium, Aspergillus and Cladophialophora. In areas supplied with a high efficiency particulate air filter, fungal spore levels were usually lower when compared to areas without these filters. There was a significant correlation between total fungal propagule measurements taken with both devices on each sampling occasion (Pearson coefficient = 0.50). However, the Andersen device recovered a broader spectrum of fungi. We conclude that the RCS can be used for quantitative estimates of airborne microbiological concentrations. For qualitative studies, however, this device cannot be recommended.
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Affiliation(s)
- L G F Távora
- Departamento de Moléstias Infecciosas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
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18
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Abstract
The objective of this study is to describe infections in a specialized burns intensive care unit from 1993 to 1999. The criteria for admission to the unit are: children with burns involving at least 10% or adults with burns involving at least 20% of total body surface; burns affecting face, perineum or feet; suspected or proven airway injury; electric or chemical burns; age less than one year or above 50; or pre-existing disease with any extent of burns. Surveillance of hospital-acquired infection was prospective. Hospital-acquired infection criteria used were those modified from the Centers for Disease Control and Prevention. Diagnosis of infection using skin biopsy was not done. Over the study period, 320 patients were admitted to our burns intensive care unit. One hundred and seventy-five (55%) developed 388 hospital-acquired infections. The rate for vascular catheter-associated bloodstream infections was 34 per 1,000 central line-days. The rate of ventilator associated pneumonia was 26 infections per 1,000 ventilator-days. Primary bloodstream was the most common infection with 189 episodes (49%); followed by 83 burn wound infections (21%) and 56 pneumonias (14%). In 76% of these infections and in 97% of the primary bloodstream infections, aetiological agents were identified. The micro-organisms causing infections were S taphylococcus aureus (24%), Pseudomonas aeruginosa (18%), Acinetobacter spp. (14%) and coagulase-negative staphylococci (12%). Candida spp. caused 8% of infections. Gram-positive and Gram-negative organisms exhibited resistance to most antimicrobial agents used for therapy. During the first three days of hospitalization in the burns intensive care unit there were eight infections caused by S. aureus and three of these were resistant to oxacillin. These data provide background information regarding extensive burn patients on which decisions for control and prevention of hospital-acquired infections can be made.
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Affiliation(s)
- S G Santucci
- Nosocomial Infection Control Department, Hospital das Clínicas, Brazil
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19
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Abstract
Recent studies have highlighted the emergence of infections involving multiresistant Acinetobacter clinical isolates. Sulbactam offers direct antimicrobial activity against Acinetobacter species. Accordingly, co-administration of sulbactam with ampicillin or cefoperazone offers the potential of effective empirical therapy against Acinetobacter and other bacteria such as Enterobacteriaceae in institutions in which they are susceptible. Many in vitro studies have indicated that Acinetobacter remains fully susceptible to ampicillin-sulbactam or cefoperazone-sulbactam. Furthermore, ampicillin-sulbactam has proven clinically effective and well tolerated in the treatment of severe acinetobacter infections, including bacteremia. Therefore, ampicillin-sulbactam is a sensible option for the treatment of life-threatening acinetobacter infections.
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Affiliation(s)
- A S Levin
- Division of Infectious Diseases, São Paulo University Hospital, Rua Harmonia, Brazil.
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Levin AS, Gobara S, Mendes CM, Cursino MR, Sinto S. Environmental contamination by multidrug-resistant Acinetobacter baumannii in an intensive care unit. Infect Control Hosp Epidemiol 2001; 22:717-20. [PMID: 11842994 DOI: 10.1086/501852] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Contamination in an intensive care unit caused by multidrug-resistant Acinetobacter baumannii complex (MRAB)-colonized patients was evaluated using environmental and patient cultures. MRAB occurred in 21% of patients' cultures, 2.1% of 513 areas surrounding MRAB-patients, and one of 372 common areas. No transmission to other patients occurred. Barrier precautions and ethanol disinfection may prevent dissemination.
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Affiliation(s)
- A S Levin
- Hospital Infection Control Department, Hospital das Clínicas, University of São Paulo, Brazil
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21
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Abstract
BACKGROUND Pichia anomala is a rare cause of fungemia. From February to April, 1998, eight cases of fungemia occurred in the intensive care and high risk units of the Nursery. There were four infants with P. anomala infection, one of whom also had Candida parapsilosis infection, two cases with C. parapsilosis infection and two with Candida albicans infection. OBJECTIVE To determine factors associated with fungemia in the intensive care and high risk units of the Nursery, especially P. anomala. METHODS A cohort study with 59 newborns. RESULTS Factors associated with fungemia were: central venous catheter (CVC) (P = 0.0006); total parenteral nutrition (TPN) (P = 0.0005); lipid emulsion (P = 0.002); previous antimicrobial use (P = 0.002); and other invasive procedures (P = 0.002). Factors associated with P. anomala fungemia were: CVC (P = 0.004); TPN (P = 0.018); previous antibiotic use (P = 0.037); and other invasive procedures (P = 0.037). Evaluation of the units demonstrated that there were several technical problems involving administration of TPN that was manipulated in the Nursery without precautions. Changes in TPN formulation and education as to adequate technique were implemented. During follow-up (1998 to 1999) only two fungemias occurred that were caused by C. albicans. Cultures of hands of personnel were negative for P. anomala. Electrophoretic karyotyping of P. anomala showed three profiles. CONCLUSIONS Factors associated with fungemia were catheter use, invasive procedures and total parenteral nutrition, suggesting that the acquisition of P. anomala was exogenous.
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Affiliation(s)
- P A Aragão
- Infection Control Department, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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22
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Costa SF, Newbaer M, Santos CR, Basso M, Soares I, Levin AS. Nosocomial pneumonia: importance of recognition of aetiological agents to define an appropriate initial empirical therapy. Int J Antimicrob Agents 2001; 17:147-50. [PMID: 11165120 DOI: 10.1016/s0924-8579(00)00316-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Of the 16,024 patients hospitalized from January 1995 to October 1997, 397 (2.4%) acquired nosocomial pneumonia and the aetiological agent was defined in 101 (25%). About 82% developed late onset pneumonia (>7 days of hospitalization). The site of isolation of microorganisms was bronchoalveolar lavage (BAL) (49%), blood culture (39%), pleural effusion (10%) and (2%) pulmonary tissue. Gram-negative bacteria were responsible for 54% of infections. Staphylococcus aureus (34%) was the most frequent microorganism isolated followed by Acinetobacter baumannii (29%) and Pseudomonas aeruginosa and Klebsiella pneumoniae, responsible for 7% of nosocomial pneumonia. Monotherapy gave good cover for early onset pneumonia, but not for late onset pneumonia. Based on our selection criteria, ciprofloxacin was the best monotherapy for early (50%) and late (31%) onset pneumonia. Vancomycin plus ciprofloxacin gave cover of 85% of early and 64% of late onset pneumonia. Monotherapy with ciprofloxacin and also combination therapy of ciprofloxacin plus vancomycin may be good options as initial empirical therapy for nosocomial pneumonia.
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Affiliation(s)
- S F Costa
- Nosocomial Infection Control Group, Hospital das Clínicas, University of São Paulo, HC-FMUSP, Avenida Dr Eneas Carvalho de Aguiar 255, SP, São Paulo, Brazil.
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23
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Abstract
Eighty-six consecutive patients with fungaemia were studied during a period of 2 years, 81% had two or more positive blood cultures. Gastrointestinal tract (28%) and haematological diseases (17%) were the most common underlying conditions. The majority of cases had received vancomycin and/or imipenem (87%) and a central venous catheter (78%). Candida albicans (50%) and Candida parapsilosis (17%) were the most frequent isolates. Overall mortality was 41%, and for patients with Candida tropicalis was 71%. There was not significant difference in survival with gender, age and days of treatment with antifungal drugs. Haematological diseases, neutropenia and a higher number of positive blood cultures were associated with poor outcome.
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Affiliation(s)
- S F Costa
- Nosocomial Infection Control Group of Hospital das Clinicas of University of São Paulo, Brazil
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24
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Costa SF, Woodcock J, Gill M, Wise R, Barone AA, Caiaffa H, Levin AS. Outer-membrane proteins pattern and detection of beta-lactamases in clinical isolates of imipenem-resistant Acinetobacter baumannii from Brazil. Int J Antimicrob Agents 2000; 13:175-82. [PMID: 10724021 DOI: 10.1016/s0924-8579(99)00123-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In order to compare imipenem-sensitive and -resistant Acinetobacter baumannii strains isolated from three patients, ribotyping, plasmid, beta-lactamase detection and outer-membrane analysis were performed. Ribotyping and the use of a beta-lactam during the period when the strains were isolated suggested that they had a common origin and that resistance occurred in vivo. Outer membrane analysis showed no difference between susceptible and resistant strains with the exception of an A2 imipenem-resistant strain that lost a protein band of 31-36 kDa. Beta-lactamases were detected using isoelectric focusing in all strains (pI of 7.4). In addition, two beta-lactamases (pI of 5.9 and 6.7) were found in imipenem-resistant isolates. The double-disc technique demonstrated the presence of a beta-lactamase capable of imipenem inactivation in resistant strains. Plasmid analysis showed that all susceptible strains had the same pattern, one resistant strain did not have any plasmid, one had the same plasmid pattern of its susceptible pair and only one had a different pattern when compared with its susceptible pair.
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Affiliation(s)
- S F Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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25
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Arruda EA, Marinho IS, Boulos M, Sinto SI, Caiaffa HH, Mendes CM, Oplustil CP, Sader H, Levy CE, Levin AS. Nosocomial infections caused by multiresistant Pseudomonas aeruginosa. Infect Control Hosp Epidemiol 1999; 20:620-3. [PMID: 10501262 DOI: 10.1086/501683] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A case-control study was done to evaluate factors associated with nosocomial infections by multiresistant Pseudomonas aeruginosa (MRPA). Results showed that MRPA was associated with the use of immunosuppressive and antimicrobial drugs. Five typing methods indicated that the MRPA infections were due to multiple strains rather than a single strain.
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Affiliation(s)
- E A Arruda
- Hospital Infection Control Department, Hospital das Clinicas, University of São Paulo, Brazil
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26
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Levin AS, Barone AA, Penço J, Santos MV, Marinho IS, Arruda EA, Manrique EI, Costa SF. Intravenous colistin as therapy for nosocomial infections caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. Clin Infect Dis 1999; 28:1008-11. [PMID: 10452626 DOI: 10.1086/514732] [Citation(s) in RCA: 421] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Sixty nosocomial infections caused by Pseudomonas aeruginosa and Acinetobacter baumannii resistant to aminoglycosides, cephalosporins, quinolones, penicillins, monobactams, and imipenem were treated with colistin (one patient had two infections that are included as two different cases). The infections were pneumonia (33% of patients), urinary tract infection (20%), primary bloodstream infection (15%), central nervous system infection (8%), peritonitis (7%), catheter-related infection (7%), and otitis media (2%). A good outcome occurred for 35 patients (58%), and three patients died within the first 48 hours of treatment. The poorest results were observed in cases of pneumonia: only five (25%) of 20 had a good outcome. A good outcome occurred for four of five patients with central nervous system infections, although no intrathecal treatment was given. The main adverse effect of treatment was renal failure; 27% of patients with initially normal renal function had renal failure, and renal function worsened in 58% of patients with abnormal baseline creatinine levels. Colistin may be a good therapeutic option for the treatment of severe infections caused by multidrug-resistant P. aeruginosa and A. baumannii.
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Affiliation(s)
- A S Levin
- Hospital Infection Control Department, Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, SP, Brazil.
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27
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Levin AS, Costa SF, Mussi NS, Basso M, Sinto SI, Machado C, Geiger DC, Villares MC, Schreiber AZ, Barone AA, Branchini ML. Candida parapsilosis fungemia associated with implantable and semi-implantable central venous catheters and the hands of healthcare workers. Diagn Microbiol Infect Dis 1998; 30:243-9. [PMID: 9582583 DOI: 10.1016/s0732-8893(98)00006-6] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A cluster of six cases of fungemia among hematology, bone marrow transplant, and oncology patients was investigated in a case-control study (18 controls). The use of implantable and semi-implantable central venous catheters was significantly associated with cases (p = 0.016). The hands of three healthcare workers (HCWs) were positive for Candida parapsilosis. Electrophoretic karyotyping showed two profiles among patients and HCWs, and five among six unrelated strains. The profiles of two HCWs matched the ones of the patients they had handled. The patients' strains were moderate or strong slime producers, whereas none of the HCWs' were strong producers. In conclusion, our results indicated the occurrence of an outbreak C. parapsilosis fungemia related to long-term central venous catheters in which the hands of HCWs were implicated. The amount of slime production might be associated with the pathogenicity of the strains.
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Affiliation(s)
- A S Levin
- Hospital das Clínicas, University of São Paulo, Brazil
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28
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Teixeira LM, Carvalho MG, Castineiras TM, Fracalanzza SA, Levin AS, Facklam RR. Serotyping distribution and antimicrobial resistance of Streptococcus pneumoniae isolated in Brazil (1992-1996). Adv Exp Med Biol 1997; 418:269-71. [PMID: 9331650 DOI: 10.1007/978-1-4899-1825-3_66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L M Teixeira
- Institute of Microbiology, University Hospital, Federal University of Rio de Janeiro, Brazil
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29
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Levin AS, Mendes CM, Sinto SI, Sader HS, Scarpitta CR, Rodrigues E, Sauaia N, Boulos M. An outbreak of multiresistant Acinetobacter baumanii in a university hospital in São Paulo, Brazil. Infect Control Hosp Epidemiol 1996; 17:366-8. [PMID: 8805068 DOI: 10.1086/647319] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A case-control (46 cases, 23 controls) study was done to determine risk factors for an outbreak of a multiresistant Acinetobacter baumanii (only susceptible to colistin) in a university hospital. The use of antecedent antibacterials and intubation were independent risk factors. No common source was found. With control measures, the outbreak resolved gradually.
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30
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Levin AS, Teixeira LM, Sessegolo JF, Barone AA. Resistance of streptococcus pneumoniae to antimicrobials in São Paulo, Brazil: clinical features and serotypes. Rev Inst Med Trop Sao Paulo 1996; 38:187-92. [PMID: 9163982 DOI: 10.1590/s0036-46651996000300004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
To study resistance to antimicrobials, serotypes and clinical features of S. pneumoniae in S. Paulo, Brazil, 50 patients with a positive culture were evaluated: 7 were considered carriers and 43 had pneumococcal infections. Pneumonia and meningitis were the most common infections. Mortality was 34% and underlying diseases were present in 70%. Relative resistance to penicillin occurred in 24% and complete resistance was not detected. Resistance to tetracycline was 32% and to sulfamethoxazole/trimethoprim 32%; one strain had intermediate susceptibility to erythromycin; no resistance was present for chloramphenicol, rifampin or vancomycin. Resistance to at least one of the drugs tested occurred in 62%. Results by the E-test for penicillin were similar to those by the agar dilution method. There were 24 different serotypes and 74% of the strains belonged to the 23-valent vaccine including all the penicillin-resistant strains. In this study S. pneumoniae caused severe infections and presented a high resistance rate to commonly used antimicrobials. Routine surveillance of resistance and the use of vaccination, as well as the restriction of inappropriate use of antimicrobials, are recommended in São Paulo, Brazil.
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Affiliation(s)
- A S Levin
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil
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31
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Levin AS, Gobara S, Scarpitta CM, Warschauer CL, Sinto SI, Rodrigues E, Mendes CM, Sabbaga E, Boulos M. Electric showers as a control measure for Legionella spp. in a renal transplant unit in São Paulo, Brazil. Legionellosis Study Team. J Hosp Infect 1995; 30:133-7. [PMID: 7673686 DOI: 10.1016/0195-6701(95)90153-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
After an outbreak of legionnaires' disease Legionella pneumophila serogroup 1 in a renal transplant unit in São Paulo, Brazil, periodic hyperchlorination and flushing of pipes were instituted as control measures. These were only partially effective as every two to five months water cultures turned positive or new cases of the disease occurred. In November 1993 the hot water was disconnected from the unit and small, plastic electric showers were installed in each bathroom. Over a period of 12 months water from showers and taps was cultured for Legionella spp. every two weeks. On only one occasion was a water culture positive for L. pneumophila from a sink tap. No water sample obtained from showers was positive during the study period. No cases of legionnaires' disease occurred. We considered the use of electric showers an inexpensive and effective method of controlling the problem of Legionella spp. in the water system of our renal transplant unit.
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Affiliation(s)
- A S Levin
- Hospital Infection Control Group, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
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32
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Mazieri NA, de Godoy CV, Alves SF, de Andrade DR, Levin AS, Hablitzel AC. Legionnaires' disease in the renal transplant unit of "Hospital das Clinicas, FMUSP". During a five year period (1988-1993). Rev Inst Med Trop Sao Paulo 1994; 36:231-6. [PMID: 7855487 DOI: 10.1590/s0036-46651994000300007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Several reports have related Legionella pneumophila with pneumonia in renal transplant patients, however this association has not been systematically documented in Brazil. Therefore this paper reports the incidence, by serological assays, of Legionella pneumophila serogroup 1 in these patients during a five year period. For this purpose sera from blood samples of 70 hospitalized patients with pneumonia from the Renal Transplant Unit of Hospital das Clinicas, FMUSP collected at the acute and convalescent phase of infection were submitted to indirect immunofluorescence assay (IFA) to demonstrate anti-Legionella pneumophila serogroup 1 antibodies. Of these 70 patients studied during the period of 1988 to 1993, 18 (25.71%) had significant rises in specific antibody titers for Legionella pneumophila serogroup 1. Incidence was interrupted following Hospital water decontamination procedures, with recurrence of infections after treatment interruption. In this study, the high susceptibility (25.71%) of immunodepressed renal transplant patients to Legionella pneumophila serogroup 1 nosocomial infections is documented. The importance of the implementation and maintenance of water decontamination measures for prophylaxis of the infection is also clearly evident.
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Affiliation(s)
- N A Mazieri
- Laboratório de Investigação Médica (LIM-54), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), Brazil
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33
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Byers VS, Levin AS, Malvino A, Waites L, Robins RA, Baldwin RW. A phase II study of effect of addition of trichosanthin to zidovudine in patients with HIV disease and failing antiretroviral agents. AIDS Res Hum Retroviruses 1994; 10:413-20. [PMID: 7915124 DOI: 10.1089/aid.1994.10.413] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Patients infected with HIV, including those with AIDS-related complex and AIDS, and failing treatment with antiretroviral agents such as zidovudine, have been evaluated following addition of trichosanthin to the antiretroviral agent regimen. This ribosomal inhibitory protein is specifically cytotoxic for HIV-infected macrophages and lymphocytes. Ninety-three patients were treated with trichosanthin, using a schedule of weekly, then monthly, intravenous injections of 1.2 mg of drug in combination with antiretroviral agents, usually zidovudine. Side effects included myalgias, fevers, mild elevation in liver function tests, and mild-moderate anaphylactic reactions, which respond well to therapy with steroids and/or benedryl. Reversible mental status changes were noted in two patients, both receiving concomitant therapy with ddI. Clinical responses to trichosanthin treatment were monitored primarily by changes in laboratory parameters, particularly levels of CD4+ T lymphocytes. In the total population evaluated for efficacy (85 patients) there was a significant increase in CD4+ cell levels after initiation of trichosanthin therapy. A second analysis performed on 72 patients measured the rate of change of CD4+ cells during therapy, using an "area under the curve" analysis. During therapy there was a median increase of 1.2 cells/mm3/month. In patients in the top 25th percentile, this increase was greater than 8.4 cells/mm3/month. In 59 of the 72 patients, responses could also be monitored by comparing the rate of loss of CD4+ cell levels on antiretroviral agents (zidovudine or ddI) alone, during the year prior to initiation of trichosanthin, to the rate of change when trichosanthin was added to the treatment regimen. During the period before trichosanthin treatment (311 +/- 11.7 days) the median loss of CD4+ cells was 6.91 cells/mm3/month. Addition of trichosanthin to the treatment regimen resulted in a median gain of 1.1 CD4+ cells/mm3/month.
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Affiliation(s)
- V S Byers
- Immunology, Inc., San Francisco, California 94108
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34
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Sessegolo JF, Levin AS, Levy CE, Asensi M, Facklam RR, Teixeira LM. Distribution of serotypes and antimicrobial resistance of Streptococcus pneumoniae strains isolated in Brazil from 1988 to 1992. J Clin Microbiol 1994; 32:906-11. [PMID: 8027342 PMCID: PMC263161 DOI: 10.1128/jcm.32.4.906-911.1994] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Forty-two serotypes were identified among 288 Streptococcus pneumoniae strains isolated from patients living in Brazil. Serotyping was determined by the capsular typing test (Quellung reaction). Types 14 (10.4%), 6B (9.8%), 23F (8.0%), 5 (7.3%), 19F (6.9%), 6A (6.0%), and 1 and 4 (4.6%) were the most commonly identified strains. Two hundred twenty (76.4%) of the strains were of serotypes that are included in the 23-valent pneumococcal polysaccharide vaccine. If vaccine-related serotypes are also considered, the proportions of coverage in the vaccine are 82.3% (if type 6B alone is added) and 85.7% (if all the vaccine-related types are considered to be cross-protecting). Decreased susceptibility to penicillin, which was identified by using the 1-microgram oxacillin disk method as a screening test, was detected in 70 (26.7%) strains. The MICs of nine antimicrobial agents were determined by using the procedures recommended by the National Committee for Clinical Laboratory Standards. Seventy (35.9%) of the strains were resistant to tetracycline, 57 (29.2%) were resistant to sulfamethoxazole-trimethoprim, 3 (1.5%) were resistant to rifampin, 2 (0.80%) were resistant to penicillin, and 1 (0.5%) was resistant to chloramphenicol. The two penicillin-resistant strains were also resistant to or had decreased susceptibilities to cephalosporins. Forty-seven (17.9%) of the strains were intermediately resistant to penicillin, 17 (8.7%) were intermediately resistant to tetracycline, 13 (6.7%) were intermediately resistant to chloramphenicol, 12 (6.1%) were intermediately resistant to erythromycin, and 6 (3.1%) were intermediately resistant to rifampin.
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Affiliation(s)
- J F Sessegolo
- Instituto de Microbiologia, Universidade Federal do Rio de Janeiro, Brazil
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35
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Garcia PA, Bredesen DE, Vinters HV, Graefin von Einsiedel R, Williams RL, Kahn JO, Byers VS, Levin AS, Waites LA, Messing RO. Neurological reactions in HIV-infected patients treated with trichosanthin. Neuropathol Appl Neurobiol 1993; 19:402-5. [PMID: 8278023 DOI: 10.1111/j.1365-2990.1993.tb00461.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Trichosanthin is a ribosome-inactivating protein that is being studied as a possible treatment for patients infected with human immunodeficiency virus (HIV). We report the clinical and pathological features in two patients who experienced neurological reactions to trichosanthin. Both patients were neurologically asymptomatic prior to treatment but developed coma and multifocal neurological deficits after treatment. Neuropathological examination revealed regions of severe, multifocal necrosis with histiocytic infiltrates. These reactions to trichosanthin may be mediated by soluble factors released by HIV-infected macrophages.
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Affiliation(s)
- P A Garcia
- Department of Neurology, University of California, San Francisco 94143
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36
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Levin AS, Mazieri NA, Carvalho NB, Meireles LP, de Andrade DR, Barone AA. Five cases of nosocomial and community-acquired Legionnaires' disease in São Paulo, Brazil. Rev Inst Med Trop Sao Paulo 1993; 35:103-6. [PMID: 8278738 DOI: 10.1590/s0036-46651993000100015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Legionella sp has been emerging over the last decade as an important cause of pneumonia both hospital and community-acquired. Following an outbreak in a Renal-Transplant Unit stocked serum was tested for antibodies against Legionella pneumophila serogroup 1, and 5 cases of Legionnaires' Disease were reviewed. Two of the cases were nosocomial and three cases were community-acquired. Clinical and laboratorial aspects were similar to those expected for other causes of pneumonia, however jaundice was encountered in two cases. This study suggests that the real incidence of pneumonia caused by Legionella sp is being underestimated and the authors emphasize the importance of considering Legionnaires' Disease when empirically treating community-acquired pneumonia.
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Affiliation(s)
- A S Levin
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil
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37
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Henry DH, Jemsek JG, Levin AS, Levine JD, Levine RL, Abels RI, Nelson RA, Thompson D, Rudnick SA. Recombinant human erythropoietin and the treatment of anemia in patients with AIDS or advanced ARC not receiving ZDV. J Acquir Immune Defic Syndr (1988) 1992; 5:847-8. [PMID: 1517970 DOI: 10.1097/00126334-199208000-00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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38
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Levin AS, Byers VS. Multiple chemical sensitivities: a practicing clinician's point of view. Clinical and immunologic research findings. Toxicol Ind Health 1992; 8:95-109. [PMID: 1412497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The multiple chemical sensitivities syndrome is a symptom complex characterized by emotional depression, short-term memory loss, acquired intolerance to environmental agents such as aerosolized petrochemicals and foods, and alteration in metabolic rate associated with increased body mass. This syndrome can be caused by multiple etiologic agents. With careful evaluation, it is rare that a causal agent can not be identified in this syndrome. Our treatment regimens include combinations of diet and environment control as well as antiviral, antifungal, and immune modulator therapy. We find that the majority of patients can, through time and appropriate treatment, be restored to a normal and productive lives.
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Affiliation(s)
- A S Levin
- Immunology, Inc., San Francisco, CA 94102-1114
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39
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Levin AS, Caiaffa Filho HH, Sinto SI, Sabbaga E, Barone AA, Mendes CM. An outbreak of nosocomial Legionnaires' disease in a renal transplant unit in São Paulo, Brazil. Legionellosis Study Team. J Hosp Infect 1991; 18:243-8. [PMID: 1680907 DOI: 10.1016/0195-6701(91)90149-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
From June 1989 to March 1990 there were eight cases of Legionnaires' disease caused by Legionella pneumophila serogroup 1 in a renal transplant unit. There were seven cases of pneumonia and one case of pleural effusion. A study was conducted to identify the source of the outbreak. Legionella anisa was cultured from tap water. Twenty-seven staff members of the unit were serologically tested and antibody titres were positive in two. The probable source of infection was the potable water system. Control measures were hyperchlorination and heating of the water, after which there were no further cases during 5 months' follow up. We believe this is the first reported Legionnaires' disease outbreak in Latin America.
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Affiliation(s)
- A S Levin
- Hospital das Clínicas da Faculdade de Medicina Universidade de São, Paulo, Brasil
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40
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Byers VS, Levin AS, Waites LA, Starrett BA, Mayer RA, Clegg JA, Price MR, Robins RA, Delaney M, Baldwin RW. A phase I/II study of trichosanthin treatment of HIV disease. AIDS 1990; 4:1189-96. [PMID: 2128454 DOI: 10.1097/00002030-199012000-00002] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Trichosanthin, a ribosomal inhibitor protein, blocks HIV replication in lymphocytes and macrophages. This agent was used to treat 51 patients with advanced HIV disease in a dose-escalation study in which three injections were administered over a 9-21-day period in a dose range of 10-30 micrograms/kg per injection. The maximum tolerated dose was estimated to be 30 micrograms/kg. Reversible but severe fatigue and myalgias were the major dose-limiting side-effects; mild leucocytosis and elevations in serum transaminases were noted and were reversible. Non-dose-related reversible mental status changes were seen in six patients and were considered to be associated with the drug. This was usually manifest as dementia, but progressed to coma in two patients. This reversed, but the sequelae resulted in death in one patient. Decreases in serum p24 antigen levels were noted 1 month after the first infusion in 10 of 18 patients who entered the study with elevated levels; one converted to negative. Values usually remained low to the end of the study period (2 months). In those patients with CD4+ cell levels greater than 50 x 10(6) cells/l significant decreases in sedimentation rate and increases in CD4+ cell numbers were also noted. These changes were found at all dose levels but only in patients receiving three infusions.
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41
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Abstract
24 cases of fulminant hepatitis (FH) hospitalized in the Clínica de Doenças Infecciosas e Parasitárias do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the period from January 1976 to December 1986 were reviewed from their clinical, epidemiological and laboratorial aspects. 88% of the patients died; 20 patients (83%) presented hemorrhages and, of these, 19 died. Bacterial infections occurred in 14 patients (58%) all of whom died. Ascitis was noted in 3 cases; cerebral edema was present in 16 cases. Maximal ALT levels for each patient during hospitalization ranged widely from 81 to 4,460 UI/l. Thirteen patients presented high creatinine levels (54%). Prothrombin time activity ranged from 2.1% to 67%. Fever was present in 20 cases (83%). Encephalopathy occurred within the first 2 weeks of illness in 72% of the cases. In 7 cases other illnesses were present. The etiology could not be determined in 13 cases. In 3 cases it was due to yellow fever and 6 cases were caused by viruses other than yellow fever. In one case the cause was drug usage and in another case, possibly alcohol. The authors believe that the clinical definition of FH requires further discussion before it is established. In this study FH is a young person's disease. The mortality found was similar to that by other authors. Factors that contributed to death were: hemorrhages and bacterial infection. Factors that worsened the prognosis of hepatitis were: associated illnesses and surgical procedure. The levels of ALT during hospitalization did not correlate well with the severity of the hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)
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42
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Pinto WP, Lopes MH, Levin AS, Strabelli TV, Shikanai-Yasuda MA, Amato Neto V. [Prolonged bacteremia caused by Salmonella typhimurium in patients with AIDS. A case report]. Rev Hosp Clin Fac Med Sao Paulo 1988; 43:216-9. [PMID: 3249893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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43
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Byers VS, Levin AS, Ozonoff DM, Baldwin RW. Association between clinical symptoms and lymphocyte abnormalities in a population with chronic domestic exposure to industrial solvent-contaminated domestic water supply and a high incidence of leukaemia. Cancer Immunol Immunother 1988; 27:77-81. [PMID: 3260823 PMCID: PMC11038768 DOI: 10.1007/bf00205762] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/1987] [Accepted: 01/26/1988] [Indexed: 01/04/2023]
Abstract
An unusually high incidence of leukaemia and recurrent infections was noted in children exposed in utero to domestic water supply contaminated with industrial solvents including trichloroethylene, perchloroethylene and 1,2-transdichloroethylene. Medical and laboratory investigations were carried out on 28 family members of the patients with leukaemia with particular emphasis on the immunological system to determine if they displayed symptoms associated with acute or chronic exposure to these chlorinated hydrocarbons. The principal organ systems affected were neurological, immunological and cardiological. Damage to these systems was found in all subjects by history, physical and laboratory parameters. Damage to the immunological system was manifest by altered ratios of T lymphocyte subpopulations, increased incidence of auto-antibodies, increased infections and recurrent rashes.
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Affiliation(s)
- V S Byers
- Cancer Research Campaign Laboratories, University of Nottingham, U.K
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Levin AS, Byers VS. Environmental illness: a disorder of immune regulation. Occup Med 1987; 2:669-81. [PMID: 3313763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Devido à importância do tétano nos países em desenvolvimento, foi feita uma revisão da literatura recente abordando aspectos históricos e bases fisio-patológicas do uso da soroterapia intratecal no tratamento do tétano. Discute-se principalmente a eficácia dessa terapêutica envolvendo o uso da antitoxina heteróloga e homóloga, associada ou não à antitoxina e a corticosteróides por via sistêmica. São abordadas também as complicações do uso da antitoxina por via intrarraquideana que são, em geral, leves e transitórias. As tentativas de introduzir definitivamente a administração intratecal da antitoxina tetânica, na terapêutica do tétano, são precoces, uma vez que estudos existentes até o momento tem resultados contraditórios e muitas variáveis envolvidas.
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Levin AS, Barone AA, Shiroma M. [Fulminant viral hepatitis--etiological and physiopathological aspects]. Rev Hosp Clin Fac Med Sao Paulo 1987; 42:179-84. [PMID: 3135569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Levin AS. "Toxic torts". Science 1987; 235:268. [PMID: 3798111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Binder RL, Callaway E, Levin AS, Stites DP. Relationship between creatine phosphokinase and immunoglobulins in unmedicated Caucasian schizophrenics. Biol Psychiatry 1983; 18:1493-6. [PMID: 6661476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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