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Nucci M, Nouér SA. Practical issues related to non-Aspergillus invasive mold infections. Mol Aspects Med 2023; 94:101230. [PMID: 38011770 DOI: 10.1016/j.mam.2023.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/04/2023] [Revised: 11/04/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
Infection by non-Aspergillus molds has been increasingly reported. The management of such infections is challenging both for diagnosis and treatment, including the need of well-trained mycologists to properly identify rare fungi, difficulties in distinguishing between contamination, colonization and infection, the lack of randomized studies comparing different drugs or regimens, poor activity of available antifungal agents, lack of correlation between in vitro antifungal susceptibility tests and clinical outcome, and poor prognosis. Mucormycosis and fusariosis are the most frequent non-Aspergillus mold infections. Mucormycosis occurs more frequently in four major groups of patients: solid organ transplant recipients, patients with hematologic malignancies receiving chemotherapy or hematopoietic cell transplantation, diabetic patients, and immunocompetent individuals who suffer various types of skin and soft tissue trauma. Invasive fusariosis occurs almost exclusively in patients with hematologic malignancies. In this review we discuss practical issues related to the management of these and other non-Aspergillus mold infections.
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Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Grupo Oncoclínicas, Rio de Janeiro, Brazil.
| | - Simone A Nouér
- Department of Infectious Diseases, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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Ramos JF, Pereira AD, Seiwald MCN, Gandolpho LS, Molla VC, Guaraná M, Nouér SA, Nucci M, Rodrigues CA. Low utilization of vancomycin in febrile neutropenia: real-world evidence from 4 Brazilian centers. Support Care Cancer 2023; 31:687. [PMID: 37947888 DOI: 10.1007/s00520-023-08152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/09/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE The prompt initiation of a betalactam antibiotic in febrile neutropenic patients is considered standard of care, while the empiric use of vancomycin is recommended by guidelines in specific situations, with a low level of evidence. The objective of this study was to assess the utilization of vancomycin in the management of febrile neutropenia within four Brazilian medical centers that implemented more stringent criteria for its administration. METHODS A comprehensive retrospective analysis was performed encompassing all instances of febrile neutropenia observed during the period from 2013 to 2019. The primary focus was to identify the reasons for initiating vancomycin therapy. RESULTS A total of 536 consecutive episodes of febrile neutropenia were documented, involving 384 patients with a median age of 52 years (range 18-86). Chemotherapy preceded febrile neutropenia in 59.7% of cases, while 40.3% occurred after hematopoietic stem cell transplantation. The most prevalent underlying diseases were acute myeloid leukemia (26.5%) and non-Hodgkin's lymphoma (22%). According to international guidelines, vancomycin should have been initiated at the onset of fever in 145 episodes (27%); however, it was administered in only 27 cases (5.0%). Three episodes were associated with Staphylococcus aureus bacteremia, two of which were methicillin resistant. The 15-day and 30-day mortality rates were 5.0% and 9.9%, respectively. CONCLUSIONS The results of this study underscore the notably low utilization rate of vancomycin in cases of febrile neutropenia, despite clear indications outlined in established guidelines. These findings emphasize the importance of carefully implementing guideline recommendations, considering local epidemiological factors, especially when the strength of recommendation is weak.
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Affiliation(s)
| | - André Domingues Pereira
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Instituto de Cardiologia Do Distrito Federal, Brasília, Brazil
| | | | - Larissa Simão Gandolpho
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
| | - Vinicius Campos Molla
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
| | - Mariana Guaraná
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Nucci
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil.
- , Grupo Oncoclínicas, Brazil.
| | - Celso Arrais Rodrigues
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
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Hlaing KM, Monday LM, Nucci M, Nouér SA, Revankar SG. Invasive Fungal Infections Associated with COVID-19. J Fungi (Basel) 2023; 9:667. [PMID: 37367603 DOI: 10.3390/jof9060667] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/22/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The COVID-19 pandemic caused >6 million deaths worldwide, often from respiratory failure. Complications frequently occurred in hospitalized patients, particularly in the intensive care unit. Among these, fungal infections were a cause of high morbidity and mortality. Invasive aspergillosis, candidiasis and mucormycosis were the most serious of these infections. Risk factors included alterations in immune defense mechanisms by COVID-19 itself, as well as immunosuppression due to various therapies utilized in severely ill patients. Diagnosis was often challenging due to lack of sensitivity of current testing. Outcomes were generally poor, due to significant co-morbidities and delayed diagnosis, with mortality rates >50% in some studies. High index of clinical suspicion is needed to facilitate early diagnosis and initiation of appropriate antifungal therapy.
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Affiliation(s)
- Kyaw M Hlaing
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Lea M Monday
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Marcio Nucci
- University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro 21941-853, Brazil
| | - Simone A Nouér
- University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro 21941-853, Brazil
| | - Sanjay G Revankar
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Gamarra F, Nucci M, Nouér SA. Evaluation of a stewardship program of antifungal use at a Brazilian tertiary care hospital. Braz J Infect Dis 2022; 26:102333. [PMID: 35180447 PMCID: PMC9387455 DOI: 10.1016/j.bjid.2022.102333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/31/2021] [Accepted: 01/23/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Stewardship programs have been developed to optimize the use of antibiotics, but programs focusing on antifungal agents are less frequent. Objective To evaluate the quality of antifungal prescriptions in a tertiary care hospital, and to test if a simple educational activity could improve the quality of prescriptions. Methods The study comprised three phases: 1) Retrospective audit of all antifungal prescriptions in a 6-month period, applying a score based on six parameters: indication, drug, dosage, route of administration, microbiologic adequacy after results of cultures, switching to an oral agent, and duration of treatment; 2) Creation of text boxes in the electronic medical records with information about antifungal agents, shown during prescription; 3) Retrospective audit of all antifungal prescriptions in a 6-month period, applying the same 6-parameters score, and comparison between the two periods. Results Among 333 prescriptions, fluconazole was the most frequently (80.5%) prescribed agent. Hematology (26.7%), Infectious Diseases Department (22.8%), Internal Medicine (15.9%) and Intensive Care Unit (14.4%) were the units with most antifungal prescriptions. The median score for the 333 prescriptions was 8.0 (range 0 – 10), and 72.7% of prescriptions were considered inappropriate. The median and mean scores in the first and second audit were 8.0 and 6.9, and 8.0 and 7.9, respectively (p<0.001). All items that comprised the score improved from the first to the second audit. Likewise, there was a reduction of inappropriate prescriptions (80.2% in the first audit vs. 64.6% in the second audit, p=0.001). Conclusions A large proportion of inappropriate prescriptions was observed, which improved with the implementation of simple educational activities.
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Nucci M, Barreiros G, Akiti T, Anaissie E, Nouér SA. Invasive Fusariosis in Patients with Hematologic Diseases. J Fungi (Basel) 2021; 7:jof7100815. [PMID: 34682236 PMCID: PMC8537065 DOI: 10.3390/jof7100815] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
Fusarium species are filamentous fungi widely encountered in nature, and may cause invasive disease in patients with hematologic conditions. Patients at higher risk are those with acute leukemia receiving induction remission chemotherapy or allogeneic hematopoietic cell transplant recipients. In these hosts, invasive fusariosis presents typically with disseminated disease, fever, metastatic skin lesions, pneumonia, and positive blood cultures. The prognosis is poor and the outcome is largely dependent on the immune status of the host, with virtually a 100% death rate in persistently neutropenic patients, despite monotherapy or combination antifungal therapy. In this paper, we will review the epidemiology, clinical manifestations, diagnosis, and management of invasive fusariosis affecting patients with hematologic diseases.
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Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
- Correspondence:
| | - Gloria Barreiros
- Mycology Laboratory, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil; (G.B.); (T.A.)
| | - Tiyomi Akiti
- Mycology Laboratory, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil; (G.B.); (T.A.)
| | - Elias Anaissie
- CTI Clinical Trial & Consulting Services, Cincinnati, OH 41011, USA;
| | - Simone A. Nouér
- Department of Infectious Diseases, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil;
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Guarana M, Nouér SA, Nucci M. EQUAL Fusariosis score 2021: An European Confederation of Medical Mycology score derived from current guidelines to measure QUALity of the clinical management of invasive fusariosis. Mycoses 2021; 64:1542-1545. [PMID: 34013538 DOI: 10.1111/myc.13321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Invasive fusariosis is a serious infection affecting mostly patients with haematologic malignancies and hematopoietic cell transplant recipients. OBJECTIVES To develop a scoring tool that evaluates guideline adherence in the management of invasive fusariosis. METHODS We reviewed two guidelines, provided by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM), and selected the strongest recommendations for management quality as the bases for the scoring tool. RESULTS We reviewed the recommendations regarding primary and secondary prophylaxis, diagnostics procedures (images, blood cultures, biopsy of skin lesions with direct examination, culture and histopathology, species identification, antifungal susceptibility tests and antigen detection), treatment choices and follow-up procedures. The tool comprises 18 items, with a maximum of 24 points. CONCLUSIONS The EQUAL score Fusariosis is a tool that may help clinicians to measure guidelines adherence.
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Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Guarana M, Nucci M, Barreiros G, Valeri J, Almeida C, Nouér SA. Early versus Late Fluconazole Prophylaxis in Autologous Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:681.e1-681.e5. [PMID: 33964515 DOI: 10.1016/j.jtct.2021.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/17/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 11/27/2022]
Abstract
Candidemia is a major complication in hematopoietic cell transplantation (HCT), and antifungal prophylaxis with fluconazole decreases the incidence of this complication. We compared 2 strategies for fluconazole prophylaxis in patients with hematologic malignancy undergoing autologous HCT between 1997 and 2017. From 1997 to 2003, fluconazole prophylaxis (400 mg/d) was given to all HCTs, started with the conditioning regimen (early prophylaxis), and given until neutrophil engraftment or the need of non-prophylactic antifungal therapy. From 2004 on, fluconazole (400mg daily) was started only if (and when) the patient developed oral mucositis (late prophylaxis). Among 571 HCT, 270 received early prophylaxis, 112 received late prophylaxis, and 189 did not receive fluconazole because they did not develop oral mucositis. The incidence of candidemia was 1.8% in the early prophylaxis group, 0% in the late prophylaxis group, and 1.1% in the no prophylaxis group (P = .31). Among patients receiving fluconazole, the median duration of prophylaxis was 17 days (range, 6-36 days) in the early prophylaxis group and 6 days (range, 2-16 days) in the late prophylaxis group (P < .001). The initiation of fluconazole prophylaxis guided by the occurrence of oral mucositis (late prophylaxis) was as good as early fluconazole prophylaxis.
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Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Gloria Barreiros
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Julio Valeri
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cecilia Almeida
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Nucci M, Barreiros G, Guimarães LF, Deriquehem VAS, Castiñeiras AC, Nouér SA. Increased incidence of candidemia in a tertiary care hospital with the COVID-19 pandemic. Mycoses 2020; 64:152-156. [PMID: 33275821 PMCID: PMC7753494 DOI: 10.1111/myc.13225] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 01/08/2023]
Abstract
Background The incidence of candidemia in our hospital has been stable over an 18‐year period (1.3 episodes per 1000 admissions). Since March 2020, we have observed an increase in cases of candidemia. Methods In March 2020, the hospital was prepared to receive patients with COVID‐19, with cancellation of elective procedures, discharge of less sick patients and the activation of beds for COVID‐19. We compared the incidence of candidemia in 2 periods: from January 2019 to February 2020 (period 1) and from March to September 2020 (period 2). Results We diagnosed 41 episodes of candidemia, 16 in period 1 and 25 in period 2 (9 COVID‐19 patients). Compared with non‐COVID‐19 patients, COVID‐19 patients with candidemia were more likely to be under mechanical ventilation (100% vs. 34.4%, P < .001). The median number of monthly admissions in period 1 and 2 was 723 (interquartile range 655‐836) and 523 (interquartile range 389‐574), respectively. The incidence of candidemia (per 1000 admissions) was 1.54 in period 1 and 7.44 in period 2 (P < .001). In period 2, the incidence of candidemia (per 1000 admissions) was 4.76 if we consider only cases of candidemia in non‐COVID‐19 patients, 2.68 if we consider only cases of candidemia in COVID‐19 patients and 14.80 considering only admissions of patients with COVID‐19. Conclusions The increase in the incidence of candidemia in our hospital may be attributed to 2 factors: a reduction in the number of admissions (denominator) and the occurrence of candidemia in COVID‐19 patients.
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Affiliation(s)
- Marcio Nucci
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gloria Barreiros
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luiz Felipe Guimarães
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vitor A S Deriquehem
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Anna Carla Castiñeiras
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- Hospital Universitário Clementino Fraga Filho, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Souza L, Nouér SA, Morales H, Simões B, Solza C, Queiroz-Telles F, Nucci M. Epidemiology of invasive fungal disease in haematologic patients. Mycoses 2020; 64:252-256. [PMID: 33141969 DOI: 10.1111/myc.13205] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 10/06/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/15/2022]
Abstract
Invasive fungal disease (IFD) is frequent in patients with haematologic malignancies and in recipients of haematopoietic cell transplantation (HCT). An epidemiologic study conducted in Brazil reported a high incidence of IFD in haematologic patients, and invasive fusariosis was the leading IFD. A limitation of that study was that galactomannan was not available for at least half of the study period. In order to characterise the epidemiology and burden of IFD in three cohorts, HCT, acute myeloid leukaemia (AML) or myelodysplasia (MDS), and acute lymphoid leukaemia (ALL), we conducted a prospective multicentre cohort study in four haematologic Brazilian centres. From August 2015 to July 2016, all patients receiving induction chemotherapy for newly diagnosed or relapsed AML, MDS or ALL, and all HCT recipients receiving conditioning regimen were followed during the period of neutropenia following chemotherapy or the conditioning regimen. During a 1-year period, 192 patients were enrolled: 122 HCT recipients (71 allogeneic, 51 autologous), 46 with AML, and 24 with ALL. The global incidence of IFD was 13.0% (25 cases, 11 proven and 14 probable). Invasive aspergillosis (14 cases) was the leading IFD, followed by candidemia (6 cases) and fusariosis (3 cases). The incidence of IFD was 26.1% in AML/MDS, 16.7% in ALL, 11.3% in allogeneic HCT, and 2.0% in autologous HCT. The burden of IFD in haematologic patients in Brazil is high, with a higher frequency in AML and ALL. Invasive aspergillosis is the leading IFD, followed by invasive candidiasis and fusariosis.
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Affiliation(s)
- Luciana Souza
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Hugo Morales
- Hospital das Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
| | - Belinda Simões
- Hospital das Clínicas, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Cristiana Solza
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Marcio Nucci
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Nucci M, Shoham S, Abdala E, Hamerschlak N, Rico JC, Forghieri F, Nouér SA, Cappellano P, Solza C, Gonzaga Y, Nadali G, Nucci F, Colombo AL, Albuquerque AM, Queiroz-Telles Filho F, Lima CBL, Arrais-Rodrigues C, Rocha V, Marty FM. Outcomes of patients with invasive fusariosis who undergo further immunosuppressive treatments, is there a role for secondary prophylaxis? Mycoses 2019; 62:413-417. [PMID: 30720902 DOI: 10.1111/myc.12901] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 10/19/2018] [Accepted: 01/31/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients treated for invasive aspergillosis may relapse during subsequent periods of immunosuppression and should receive secondary prophylaxis. Little is known about the frequency of relapse and practices of secondary prophylaxis for invasive fusariosis (IF). OBJECTIVES Evaluate practices of secondary prophylaxis and the frequency of relapse in patients who survived IF and were exposed to subsequent periods of immunosuppression. METHODS Multicentre retrospective study of patients with haematological malignancies who developed IF, survived the initial fungal disease period, and were exposed to subsequent periods of immunosuppression. RESULTS Among 40 patients, 35 received additional chemotherapy and developed neutropenia (median, 24 days; range, 4-104), and five received glucocorticoids for the treatment of graft-vs-host disease. Overall, 32 patients received secondary prophylaxis (voriconazole in 24) for a median of 112 days (range, 12-468). IF relapsed in five patients (12.5%): 2/8 (25%) not on prophylaxis and 3/32 (9.4%) receiving prophylaxis. Among 28 patients with disseminated IF, relapse occurred in 2/2 (100%) not on prophylaxis and in 3/26 (11.5%) on prophylaxis (P = 0.03). All patients who relapsed IF died. CONCLUSIONS Patients with IF who survive the initial disease may relapse if exposed to subsequent episodes of immunosuppressive therapies. Secondary prophylaxis should be considered, especially if IF was disseminated.
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Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edson Abdala
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juan Carlos Rico
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Fabio Forghieri
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Simone A Nouér
- Department of Internal Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paola Cappellano
- Division of Infectious Diseases, Department of Medicine, Federal University of São Paulo, Sao Paulo, Brazil
| | - Cristiana Solza
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Yung Gonzaga
- Instituto Nacional de Cancer José de Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil
| | - Giampaolo Nadali
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Fabio Nucci
- Department Hematology, Fluminense Federal University, Niterói, Brazil
| | - Arnaldo L Colombo
- Division of Infectious Diseases, Department of Medicine, Federal University of São Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | - Francisco M Marty
- Division of Infectious Diseases, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Nucci M, Barreiros G, Reis H, Paixão M, Akiti T, Nouér SA. Performance of 1,3‐beta‐D‐glucan in the diagnosis and monitoring of invasive fusariosis. Mycoses 2019; 62:570-575. [DOI: 10.1111/myc.12918] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/17/2019] [Accepted: 04/19/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
- Mycology Laboratory University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
| | - Gloria Barreiros
- Mycology Laboratory University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
| | - Henrique Reis
- Mycology Laboratory University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
| | - Marilene Paixão
- Mycology Laboratory University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
| | - Tiyomi Akiti
- Mycology Laboratory University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
| | - Simone A. Nouér
- Department of Preventive Medicine University Hospital Universidade Federal do Rio de Janeiro Rio de Janeiro Brazil
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Nucci M, Braga PR, Nouér SA, Anaissie E. Time of catheter removal in candidemia and mortality. Braz J Infect Dis 2018; 22:455-461. [PMID: 30468708 PMCID: PMC9425687 DOI: 10.1016/j.bjid.2018.10.278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 11/29/2022] Open
Abstract
Background The impact of central venous catheter (CVC) removal on the outcome of patients with candidemia is controversial, with studies reporting discrepant results depending on the time of CVC removal (early or any time during the course of candidemia). Objective Evaluate the effect of time to CVC removal, early (within 48 h from the diagnosis of candidemia) vs. removal at any time during the course of candidemia, on the 30-day mortality. Methods Retrospective cohort study of 285 patients with candidemia analyzing CVC removal within 48 h (first analysis) or at any time (second analysis). Results A CVC was in place in 212 patients and was removed in 148 (69.8%), either early (88 patients, 41.5%) or late (60 patients, 28.3%). Overall, the median time to CVC removal was one day (range 1–28) but was six days (range 3–28) for those removed later. In the first analysis, APACHE II score (odds ratio [OR] 1.111, 95% confidence interval [95% CI] 1.066–1.158), removal at any time (OR 0.079, 95% CI 0.021–0.298) and Candida parapsilosis infection (OR 0.291, 95% CI 0.133–0.638) were predictors of 30-day mortality. Early removal was not significant. In the second analysis APACHE II score (OR 1.122, 95% CI 1.071–1.175) and C. parapsilosis infection (OR 0.247, 95% CI 0.103–0.590) retained significance. Conclusions The impact of CVC removal is dependent on whether the optimal analysis strategy is deployed and should be taken into consideration in future analyses.
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Affiliation(s)
- Marcio Nucci
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil.
| | - Paula Rocha Braga
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Simone A Nouér
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
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Braga PR, Cruz IL, Ortiz I, Barreiros G, Nouér SA, Nucci M. Secular trends of candidemia at a Brazilian tertiary care teaching hospital. Braz J Infect Dis 2018; 22:273-277. [PMID: 30118654 PMCID: PMC9427822 DOI: 10.1016/j.bjid.2018.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- Paula Rocha Braga
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Isabela L Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Isadora Ortiz
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Gloria Barreiros
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Simone A Nouér
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro, Hospital Universitário, Rio de Janeiro, RJ, Brazil.
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Morgado PGM, da Costa TM, Damasco AP, Ribeiro VN, Ferreira ALP, Nouér SA, Santos KRND. Vitek ®2 cannot identify vancomycin-intermediate isolates: missing the opportunity for Staphylococcus aureus therapy. J Hosp Infect 2017; 98:170-172. [PMID: 28734724 DOI: 10.1016/j.jhin.2017.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/16/2017] [Indexed: 10/19/2022]
Affiliation(s)
- P G M Morgado
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Brazil
| | - T M da Costa
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Brazil
| | - A P Damasco
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Brazil
| | - V N Ribeiro
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Brazil
| | - A L P Ferreira
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - S A Nouér
- Faculdade de Medicina and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - K R N Dos Santos
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Brazil.
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Nucci M, Nouér SA, Esteves P, Guimarães T, Breda G, de Miranda BG, Queiroz-Telles F, Colombo AL. Discontinuation of empirical antifungal therapy in ICU patients using 1,3-β-d-glucan. J Antimicrob Chemother 2016; 71:2628-33. [DOI: 10.1093/jac/dkw188] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/25/2016] [Indexed: 01/09/2023] Open
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Nicolato A, Nouér SA, Garnica M, Portugal R, Maiolino A, Nucci M. Invasive fungal diseases in patients with acute lymphoid leukemia. Leuk Lymphoma 2016; 57:2084-9. [DOI: 10.3109/10428194.2016.1154957] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Barreiros G, Akiti T, Magalhães ACG, Nouér SA, Nucci M. Effect of the implosion and demolition of a hospital building on the concentration of fungi in the air. Mycoses 2015; 58:707-13. [DOI: 10.1111/myc.12418] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/04/2015] [Accepted: 09/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gloria Barreiros
- Hospital Universitário Clementino Fraga Filho; Federal University of Rio de Janeiro; Rio de Janeiro Brazil
| | - Tiyomi Akiti
- Hospital Universitário Clementino Fraga Filho; Federal University of Rio de Janeiro; Rio de Janeiro Brazil
| | | | - Simone A. Nouér
- Hospital Universitário Clementino Fraga Filho; Federal University of Rio de Janeiro; Rio de Janeiro Brazil
| | - Marcio Nucci
- Hospital Universitário Clementino Fraga Filho; Federal University of Rio de Janeiro; Rio de Janeiro Brazil
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Abstract
Fusarium species are frequent agents of onychomycosis and fungal keratitis, and occasional agents of invasive disease. The clinical spectrum of fusariosis in the lungs includes allergic disease (allergic bronchopulmonary fusariosis), hypersensitivity pneumonitis, colonization of a preexisting cavity, and pneumonia. Fusarial pneumonia occurs almost exclusively in severely immunocompromised patients, especially acute leukemia patients and recipients of allogeneic cell transplantation. In such patients, invasive fusariosis is usually disseminated, and pneumonia occurs in almost 50% of cases. The radiologic picture is similar to invasive aspergillosis, with alveolar infiltrates, nodules with or without halo sign, ground-glass infiltrates, and pleural effusions. Different from aspergillosis is the frequent occurrence of disseminated nodular and papular skin lesions and positive blood cultures. The drug of choice for the treatment of invasive fusariosis is either voriconazole or liposomal amphotericin B. The outcome is usually poor, and largely dependent on the recovery of the immune status of the host, particularly neutropenia.
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Affiliation(s)
- Fabio Nucci
- Hematology Service, University Hospital, Universidade Federal Fluminense, Niteroi, Brazil
| | - Simone A Nouér
- Department of Preventive Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Domenico Capone
- Department of Preventive Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Elias Anaissie
- Division of Hematology/Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Marcio Nucci
- Department of Internal Medicine, University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Nouér SA, Nucci M, Anaissie E. Tackling antibiotic resistance in febrile neutropenia: current challenges with and recommendations for managing infections with resistant Gram-negative organisms. Expert Rev Hematol 2015; 8:647-58. [DOI: 10.1586/17474086.2015.1060576] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nucci M, Nouér SA, Anaissie E. Distinguishing the Causes of Pulmonary Infiltrates in Patients With Acute Leukemia. Clinical Lymphoma Myeloma and Leukemia 2015; 15 Suppl:S98-103. [DOI: 10.1016/j.clml.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 12/16/2022]
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Colombo AL, Guimarães T, Sukienik T, Pasqualotto AC, Andreotti R, Queiroz-Telles F, Nouér SA, Nucci M. Erratum to: Prognostic factors and historical trends in the epidemiology of candidemia in critically ill patients: an analysis of five multicenter studies sequentially conducted over a 9-year period. Intensive Care Med 2014. [PMCID: PMC4643568 DOI: 10.1007/s00134-014-3527-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Colombo AL, Guimarães T, Sukienik T, Pasqualotto AC, Andreotti R, Queiroz-Telles F, Nouér SA, Nucci M. Prognostic factors and historical trends in the epidemiology of candidemia in critically ill patients: an analysis of five multicenter studies sequentially conducted over a 9-year period. Intensive Care Med 2014; 40:1489-98. [PMID: 25082359 PMCID: PMC4176831 DOI: 10.1007/s00134-014-3400-y] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/06/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe temporal trends in the epidemiology, clinical management and outcome of candidemia in intensive care unit (ICU) patients. METHODS This study was a retrospective analysis of 1,392 episodes of candidemia in 647 adult ICU patients from 22 Brazilian hospitals. The characteristics of candidemia in these ICU patients were compared in two periods (2003-2007, period 1; 2008-2012, period 2), and the predictors of 30-day mortality were assessed. RESULTS The proportion of patients who developed candidemia while in the ICU increased from 44 % in period 1 to 50.9 % in period 2 (p = 0.01). Prior exposure to fluconazole before candidemia (22.3 vs. 11.6 %, p < 0.001) and fungemia due to Candida glabrata (13.1 vs. 7.8 %, p = 0.03) were more frequent in period 2, as was the proportion of patients receiving an echinocandin as primary therapy (18.0 vs. 5.9 %, p < 0.001). The 30-day mortality rate decreased from 76.4 % in period 1 to 60.8 % in period 2 (p < 0.001). Predictors of 30-day mortality by multivariate analysis were older age, period 1, treatment with corticosteroids and higher APACHE II score, while treatment with an echinocandin were associated with a higher probability of survival. CONCLUSIONS We found a clear change in the epidemiology and clinical management of candidemia in ICU patients over the 9-year period of the study. The use of echinocandins as primary therapy for candidemia appears to be associated with better outcomes.
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Affiliation(s)
- Arnaldo L Colombo
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil,
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Nucci M, Nouér SA, Cappone D, Anaissie E. Early diagnosis of invasive pulmonary aspergillosis in hematologic patients: an opportunity to improve the outcome. Haematologica 2014; 98:1657-60. [PMID: 24186309 DOI: 10.3324/haematol.2013.094359] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Nucci M, Varon AG, Garnica M, Akiti T, Barreiros G, Trope BM, Nouér SA. Increased incidence of invasive fusariosis with cutaneous portal of entry, Brazil. Emerg Infect Dis 2014; 19:1567-72. [PMID: 24050318 PMCID: PMC3810727 DOI: 10.3201/eid1910.120847] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Most cases of infection with Fusarium spp. fungi involved primary skin lesions. Invasive fusariosis (IF) is an infection with Fusarium spp. fungi that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. A cutaneous portal of entry is occasionally reported. We reviewed all cases of IF in Brazil during 2000–2010, divided into 2 periods: 2000–2005 (period 1) and 2006–2010 (period 2). We calculated incidence rates of IF and of superficial infections with Fusarium spp. fungi identified in patients at a dermatology outpatient unit. IF incidence for periods 1 and 2 was 0.86 cases versus 10.23 cases per 1,000 admissions (p<0.001), respectively; superficial fusarial infection incidence was 7.23 versus 16.26 positive cultures per 1,000 superficial cultures (p<0.001), respectively. Of 21 cases of IF, 14 showed a primary cutaneous portal of entry. Further studies are needed to identify reservoirs of these fungi in the community and to implement preventive measures for patients at risk.
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Nucci M, Carlesse F, Cappellano P, Varon AG, Seber A, Garnica M, Nouér SA, Colombo AL. Earlier diagnosis of invasive fusariosis with Aspergillus serum galactomannan testing. PLoS One 2014; 9:e87784. [PMID: 24489964 PMCID: PMC3905034 DOI: 10.1371/journal.pone.0087784] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/30/2013] [Indexed: 11/21/2022] Open
Abstract
Cross-reactivity of Fusarium species with serum galactomannan antigen (GMI) test has been observed. We sought to evaluate if GMI could help to early diagnose invasive fusariosis and to monitor treatment response. We reviewed the records of all patients with invasive fusariosis between 2008 and 2012 in three Brazilian hospitals. We selected patients who had at least 1 GMI test within 2 days before or after the date of the first clinical manifestation of fusariosis, and analyzed the temporal relationship between the first positive GMI test and the date of the diagnosis of invasive fusariosis, and the kinetics of GMI in relation to patients' response to treatment. We also selected 18 controls to determine the sensitivity and specificity of the test. Among 18 patients, 15 (83%) had at least one positive GMI (median 4, range 1–15). The sensitivity and specificity of was 83% and 67%, respectively. GMI was positive before the diagnosis of invasive fusariosis in 11 of the 15 cases (73%), at a median of 10 days (range 3–39), and after the diagnosis in 4 cases. GMI became negative in 8 of the 15 patients; 3 of these 8 patients (37.5%) were alive 90 days after the diagnosis of fusariosis compared with 2 of 7 (29%) who did not normalize GMI (p = 1.0). GMI is frequently positive in invasive fusariosis, and becomes positive before diagnosis in most patients. These findings may have important implications for the choice of antifungal therapy in settings with high prevalence of invasive fusariosis.
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Affiliation(s)
- Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | - Fabianne Carlesse
- Institute of Pediatric Oncology (GRAACC), Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Paola Cappellano
- University Hospital, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Andrea G. Varon
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adriana Seber
- Institute of Pediatric Oncology (GRAACC), Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcia Garnica
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A. Nouér
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arnaldo L. Colombo
- University Hospital, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Cavalcante FS, Schuenck RP, Ferreira DC, da Costa CR, Nouér SA, dos Santos KRN. Meticillin-resistant Staphylococcus aureus: spread of specific lineages among patients in different wards at a Brazilian teaching hospital. J Hosp Infect 2013; 86:151-4. [PMID: 24433925 DOI: 10.1016/j.jhin.2013.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 06/14/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Abstract
This study aimed to characterize meticillin-resistant Staphylococcus aureus (MRSA) lineages circulating in a Brazilian teaching hospital. MRSA isolates from nasal swabs were evaluated to assess antimicrobial susceptibility, staphylococcal cassette chromosome mec (SCCmec), Panton-Valentine leucocidin status, pulsed-field gel electrophoresis profile and multi-locus sequence type (MLST) analysis. Eighty-three MRSA isolates were analysed. SCCmec III (43.4%) and IV (49.4%) were predominant. ST1-IV (USA400) was more common in internal medicine (P = 0.002) whereas 'clone M' (SCCmec III) was more common in the medical and surgical intensive care unit (P = 0.004), and all isolates were ST5-IV (USA800) in dermatology (P < 0.001). These data improved the understanding of the MRSA epidemiology inside the hospital and helped to establish effective control measures.
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Affiliation(s)
- F S Cavalcante
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - R P Schuenck
- Departamento de Patologia, Universidade Federal do Espirito Santo, Espirito Santo, Brazil
| | - D C Ferreira
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - C R da Costa
- Hospital Universitário Clementino Fraga Filho e Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - S A Nouér
- Hospital Universitário Clementino Fraga Filho e Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - K R N dos Santos
- Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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Garnica M, Nouér SA, Pellegrino FLPC, Moreira BM, Maiolino A, Nucci M. Ciprofloxacin prophylaxis in high risk neutropenic patients: effects on outcomes, antimicrobial therapy and resistance. BMC Infect Dis 2013; 13:356. [PMID: 23899356 PMCID: PMC3729823 DOI: 10.1186/1471-2334-13-356] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 07/25/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of quinolone prophylaxis in high-risk neutropenic patients is considered standard of care but the development of resistance is a concern. Previous studies have focused mainly on quinolone resistance among patients receiving prophylaxis, with very few data reporting its impact on the hospital microbial epidemiology. METHODS We analyzed a cohort of 329 episodes of chemotherapy-induced neutropenia in adults, and compared two periods: 2005 (period 1, no prophylaxis, n=110) and 2006-2008 (period 2, ciprofloxacin prophylaxis, n=219). Outcomes analyzed were the frequency of febrile neutropenia, bacteremia, duration of antibiotic therapy and hospitalization, and antimicrobial resistance to ciprofloxacin and extended-spectrum beta-lactamase [ESBL] production. We analyzed resistance rates (by patients-day) in the cohort, as well as in other patients (neutropenic and non-neutropenic, 11,975 patients-day) admitted to the hematology unit in the same period, taking into consideration the general resistance patterns in the hospital. RESULTS Quinolone prophylaxis (period 2) resulted in fewer episodes of febrile neutropenia (159/219 [73%] vs. 102/110 [93%], Chi-square 18.09, p = 0.00002), and bacteremia (49/219 [22] vs. 36/110 [33%], Chi-square 4.10, p = 0.04), shorter duration of antibiotic therapy (p = 0.0002) and hospitalization (p = 0.002), but more frequent use of carbapenems (79/219 [36%] vs. 15/110 [14%], Chi-square 18.06, p = 0.0002). In addition, period 2 was associated with higher rates of quinolone resistance (6.77 vs. 3.02 per 1,000 patients-day, p = 0.03). The rate of ESBL-producing enterobacteria in the two periods was slightly higher in patients receiving quinolone prophylaxis (1.27 vs. 0.38 per 1,000 patients-day, p = 0.26) as well as in the hematology unit overall (1.59 vs. 0.53 per 1,000 patients-day, p = 0.08), but remained stable in the whole hospital (0.53 vs. 0.56 per 1,000 patients-day, p = 0.74). CONCLUSIONS Ciprofloxacin prophylaxis was beneficial in high risk neutropenic patients, but important modifications in the prescription of carbapenems and on antimicrobial resistance patterns of isolates were observed. The importance of hospital or ward ecology must be taken into account when deciding for quinolone prophylaxis in high-risk neutropenic patients.
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Affiliation(s)
- Marcia Garnica
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco 255, Cidade Universitária, Rio de Janeiro 21941-913, Brazil
| | - Simone A Nouér
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco 255, Cidade Universitária, Rio de Janeiro 21941-913, Brazil
| | - Flávia LPC Pellegrino
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco 255, Cidade Universitária, Rio de Janeiro 21941-913, Brazil
- Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Beatriz M Moreira
- Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Angelo Maiolino
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco 255, Cidade Universitária, Rio de Janeiro 21941-913, Brazil
| | - Marcio Nucci
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco 255, Cidade Universitária, Rio de Janeiro 21941-913, Brazil
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Pellegrino FLPC, Casali N, Dos Santos KRN, Nouér SA, Scheidegger EMD, Riley LW, Moreira BM. Pseudomonas aeruginosaEpidemic Strain CarryingblaSPMMetallo-Beta-Lactamase Detected in Rio de Janeiro, Brazil. J Chemother 2013; 18:151-6. [PMID: 16736883 DOI: 10.1179/joc.2006.18.2.151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The present study was designed to characterize beta-lactamase genes and evaluate polymerase chain reaction (PCR) typing for multidrug-resistant Pseudomonas aeruginosa pulsed-field gel electrophoresis (PFGE) genotype A isolates from Rio de Janeiro, Brazil, collected between April 1999 and March 2000 and one additional isolate collected in June 2002. As reported previously, all of the genotype A isolates produced non-characterized metallo-beta-lactamase. These isolates (22) were screened for the bla(SPM) gene by PCR and dot-blotting. Isolates were typed by PCR fingerprinting with primers RAPD-1, 272, 208, 1290, ERIC-1 and ERIC-2. The bla(SPM) gene was detected in 18 (82%) of the 22 isolates. PCR fingerprinting gave results that correlated with PFGE, except with primer 1290. In Rio de Janeiro and other Brazilian states, nearly all SPM-producing P. aeruginosa isolates belong to a single PFGE type accounting for a large proportion of drug-resistant P. aeruginosa hospital infections. RAPD PCR fingerprinting may be a useful technique to screen for an epidemic multidrug-resistant strain in Brazil.
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Affiliation(s)
- F L P C Pellegrino
- Instituto de Microbiologia, Universidade Federal do Rio de Janeiro, Brazil
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Martins N, Martins IS, de Freitas WV, de Matos JA, Magalhães ACG, Girão VBC, Dias RCS, de Souza TC, Pellegrino FLPC, Costa LD, Boasquevisque CHR, Nouér SA, Riley LW, Santoro-Lopes G, Moreira BM. Severe infection in a lung transplant recipient caused by donor-transmitted carbapenem-resistant Acinetobacter baumannii. Transpl Infect Dis 2011; 14:316-20. [PMID: 22168176 DOI: 10.1111/j.1399-3062.2011.00701.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 07/22/2011] [Accepted: 09/25/2011] [Indexed: 01/12/2023]
Abstract
We describe a case of proven donor transmission of carbapenem-resistant Acinetobacter baumannii, which resulted in severe infectious complications after lung transplantation. A single bla(OXA-23) positive strain, belonging to a new multilocus sequence type (ST231), was isolated from donor and recipient, who died 65 days after transplantation. This report highlights the current challenges associated with the potential transmission of multidrug-resistant infections through organ transplantation.
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Affiliation(s)
- N Martins
- Instituto de Microbiologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Nouér SA, Nucci M, Kumar NS, Grazziutti M, Barlogie B, Anaissie E. Earlier response assessment in invasive aspergillosis based on the kinetics of serum Aspergillus galactomannan: proposal for a new definition. Clin Infect Dis 2011; 53:671-6. [PMID: 21846834 DOI: 10.1093/cid/cir441] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Current criteria for assessing treatment response of invasive aspergillosis (IA) rely on nonspecific subjective parameters. We hypothesized that an Aspergillus-specific response definition based on the kinetics of serum Aspergillus galactomannan index (GMI) would provide earlier and more objective response assessment. METHODS We compared the 6-week European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) response criteria with GMI-based response among 115 cancer patients with IA. Success according to GMI required survival with repeatedly negative GMI for ≥2 weeks. Time to response and agreement between the 2 definitions were the study endpoints. RESULTS Success according to EORTC/MSG and GMI criteria was observed in 73 patients (63%) and 83 patients (72%), respectively. The GMI-based response was determined at a median of 21 days after treatment initiation (range, 15-41 days), 3 weeks before the EORTC/MSG time point, in 72 (87%) of 83 responders. Agreement between definitions was shown in all 32 nonresponders and in 73 of the 83 responders (91% overall), with an excellent κ correlation coefficient of 0.819. Among 10 patients with discordant response (EORTC/MSG failure, GMI success), 1 is alive without IA 3 years after diagnosis; for the other, aspergillosis could not be detected at autopsy. The presence of other life-threatening complications in the remaining 8 patients indicates that IA had resolved. CONCLUSIONS The Aspergillus-specific GMI-based criteria compare favorably to current response definitions for IA and significantly shorten time to response assessment. These criteria rely on a simple, reproducible, objective, and Aspergillus-specific test and should serve as the primary endpoint in trials of IA.
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Affiliation(s)
- Simone A Nouér
- Department of Preventive Medicine and Myeloma Institute forResearch and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Pellegrino FL, Casali N, Nouér SA, Riley LW, Moreira BM. A carbapenem-susceptible Pseudomonas aeruginosa strain carrying the blaSPM gene. Diagn Microbiol Infect Dis 2008; 61:214-6. [DOI: 10.1016/j.diagmicrobio.2008.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 01/02/2008] [Accepted: 01/07/2008] [Indexed: 11/27/2022]
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Schuenck RP, Lourenco MCS, Iório NLP, Ferreira ALP, Nouér SA, Santos KRN. Improved and rapid detection of methicillin-resistant Staphylococcus aureus nasal carriage using selective broth and multiplex PCR. Res Microbiol 2006; 157:971-5. [PMID: 17005377 DOI: 10.1016/j.resmic.2006.08.004] [Citation(s) in RCA: 11] [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] [Received: 06/06/2006] [Revised: 08/16/2006] [Accepted: 08/17/2006] [Indexed: 11/29/2022]
Abstract
To improve efficiency in detecting nasal methicillin-resistant Staphylococcus aureus (MRSA), we evaluated a multiplex PCR using pre-enrichment of the specimen in selective broths, and compared it with detection performed by routine tests in hospital laboratories. Nasal swab specimens from 311 patients were inoculated onto mannitol-salt agar (MSA) at the hospital laboratories and in two Mueller-Hinton broths with 7% NaCl containing oxacillin at concentrations of 2 and 4 micro g/ml. Isolates on MSA were identified as MRSA by classical laboratory tests (coagulase and oxacillin disk diffusion tests). Oxacillin broth cultures were subcultured on blood agar and MRSA isolates were identified by coagulase and susceptibility tests, including agar dilution and the oxacillin-screening method (gold standard method). Simultaneously, multiplex-PCR was performed from the selective broths to detect S. aureus species-specific and mecA gene segments (OxMPCR method). Thirty-two S. aureus isolates were recovered: 29 (90.6%) were MRSA strains and 3 (9.4%) were oxacillin-susceptible isolates. Twenty-eight (96.5%) MRSA isolates were detected by OxMPCR, while 17 (58.6%) were identified by routine tests (P=0.002). This new method for detection of MRSA nasal carriers showed higher sensitivity and led to faster reporting--i.e., within 24 h--of results.
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Affiliation(s)
- Ricardo P Schuenck
- Departamento de Microbiologia Médica, Instituto de Microbiologia Prof Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Colombo AL, Nucci M, Park BJ, Nouér SA, Arthington-Skaggs B, da Matta DA, Warnock D, Morgan J. Epidemiology of candidemia in Brazil: a nationwide sentinel surveillance of candidemia in eleven medical centers. J Clin Microbiol 2006; 44:2816-23. [PMID: 16891497 PMCID: PMC1594610 DOI: 10.1128/jcm.00773-06] [Citation(s) in RCA: 321] [Impact Index Per Article: 17.8] [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: 04/11/2006] [Revised: 05/27/2006] [Accepted: 06/08/2006] [Indexed: 11/20/2022] Open
Abstract
Candidemia studies have documented geographic differences in rates and epidemiology, underscoring the need for surveillance to monitor trends. We conducted prospective candidemia surveillance in Brazil to assess the incidence, species distribution, frequency of antifungal resistance, and risk factors for fluconazole-resistant Candida species. Prospective laboratory-based surveillance was conducted from March 2003 to December 2004 in 11 medical centers located in 9 major Brazilian cities. A case of candidemia was defined as the isolation of Candida spp. from a blood culture. Incidence rates were calculated per 1,000 admissions and 1,000 patient-days. Antifungal susceptibility tests were performed by using the broth microdilution assay, according to the Clinical and Laboratory Standards Institute guidelines. We detected 712 cases, for an overall incidence of 2.49 cases per 1,000 admissions and 0.37 cases per 1,000 patient-days. The 30-day crude mortality was 54%. C. albicans was the most common species (40.9%), followed by C. tropicalis (20.9%) and C. parapsilosis (20.5%). Overall, decreased susceptibility to fluconazole occurred in 33 (5%) of incident isolates, 6 (1%) of which were resistant. There was a linear correlation between fluconazole and voriconazole MICs (r = 0.54 and P < 0.001 [Spearman's rho]). This is the largest multicenter candidemia study conducted in Latin America and shows the substantial morbidity and mortality of candidemia in Brazil. Antifungal resistance was rare, but correlation between fluconazole and voriconazole MICs suggests cross-resistance may occur.
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Affiliation(s)
- Arnaldo L Colombo
- Division of Infectious Diseases, Universidade Federal de São Paulo, Rua Botucatu 740, 04023-062 São Paulo, Brazil.
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Nucci M, Nouér SA, Garnica M, de Oliveira ALM, Maiolino A. Prophylactic meropenem during neutropenia in allogeneic stem cell transplant recipients. Bone Marrow Transplant 2004; 33:973-4; author reply 975-6. [PMID: 15004545 DOI: 10.1038/sj.bmt.1704459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mamoni RL, Nouér SA, Oliveira SJ, Musatti CC, Rossi CL, Camargo ZP, Blotta MHSL. Enhanced production of specific IgG4, IgE, IgA and TGF-beta in sera from patients with the juvenile form of paracoccidioidomycosis. Med Mycol 2002; 40:153-9. [PMID: 12058728 DOI: 10.1080/mmy.40.2.153.159] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [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: 10/20/2022] Open
Abstract
Paracoccidioidomycosis (PCM) occurs in two distinct forms, the acute or juvenile form (JF), and the chronic or adult form (AF). To clarify the basis of this dichotomy, specific IgG subclasses, IgA and IgE anti-gp43 were measured by enzyme-linked immunosorbent assay, in patients with different forms of PCM. Serum levels of tumor necrosis factor-alpha, interleukin (IL)-6, IL-8, macrophage inflammatory protein (MIP)-1alpha and transforming growth factor (TGF)-beta were also quantified. We show here that JF patients have significantly higher titers of IgE antibodies against gp43, an immunodominant antigen specific for Paracoccidioides brasiliensis, than do patients with the unifocal adult form (UF-AF, isolated lesions). Patients with the multifocal adult form (MF-AF, lesions in more than one organ) also produced elevated levels of anti-P. brasiliensis IgE. Furthermore, specific IgE levels were correlated with IgG4, IgA and eosinophilia. Patients with JF showed eosinophilia and increased levels of TGF-beta, a switching factor for IgA. These results indicate a T helper (Th)-2 pattern of cytokine expression in both the JF and the MF-AF of PCM. On the other hand, patients with UF-AF had a significantly lower production of specific IgE, IgG4 and IgA than was seen in the other patient groups.
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Affiliation(s)
- R L Mamoni
- Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), SP, Brazil
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Blotta MH, Mamoni RL, Oliveira SJ, Nouér SA, Papaiordanou PM, Goveia A, Camargo ZP. Endemic regions of paracoccidioidomycosis in Brazil: a clinical and epidemiologic study of 584 cases in the southeast region. Am J Trop Med Hyg 1999; 61:390-4. [PMID: 10497977 DOI: 10.4269/ajtmh.1999.61.390] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.4] [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: 11/07/2022] Open
Abstract
This paper describes the clinical-seroepidemiologic characteristics of patients with paracoccidioidomycosis (PCM) who visited the University Hospital at the State University of Campinas (Campinas, Sao Paulo, Brazil). The study group consisted of 584 individuals (492 males and 92 females) with ages ranging from 5 to 87 years. The highest incidence of the disease occurred between the ages of 41 and 50 years for men and between 11 and 40 years for women. Rural activities were the principal occupation of 46% of the patients. The diagnosis was confirmed by histopathologic examination and demonstration of fungus in scrapings, secretions, or in the sputum. Serologic test results for PCM were positive in 80% of the 584 patients studied. The significant number of patients, including 33 children less than 14 years old, indicates the presence of the fungus in the area and that this region is an important endemic area for PCM.
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Affiliation(s)
- M H Blotta
- Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas, SP, Brazil
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