A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance

Antibiotic resistance has become a critical health issue on a global scale, with much of the problem resulting from inappropriate use of antibiotics in primary care. To change this practice, the global respiratory infection partnership has formulated a pentagonal (five P) framework for the non-antibiotic management of upper respiratory tract infections (URTIs) - one of the most common conditions in primary care for which antibiotics are prescribed. The framework presents the rationale for focusing on URTIs to promote antibiotic stewardship in primary care and elaborates on five key areas to focus on to bring about change: policy, prevention, prescribers, pharmacy and patients. The ultimate aim is to adopt a patient-centred symptomatic management strategy using a flexible framework that can be adapted across countries to create a consistent global approach to change behaviour.

Assessing the diversity of the virulence potential of Escherichia coli isolated from bacteremia in São Paulo, Brazil

Most of the knowledge of the virulence determinants of extraintestinal pathogenic Escherichia coli (ExPEC) comes from studies with human strains causing urinary tract infections and neonatal meningitis and animal strains causing avian colibacillosis. In this research, we analyzed the phylogenetic background, the presence of 20 ExPEC virulence factors, and the intrinsic virulence potential of 74 E. coli strains isolated in São Paulo, Brazil, from 74 hospitalized patients (43 males and 31 females) with unknown-source bacteremia. Unlike other places in the world, the bacteremic strains originated equally from phylogroups B2 (35%) and D (30%). A great variability in the profiles of virulence factors was noted in this survey. Nevertheless, 61% of the strains were classified as ExPEC, meaning that they possessed intrinsic virulent potential. Accordingly, these strains presented high virulence factor scores (average of 8.7), and were positively associated with 12 of 17 virulence factors detected. On the contrary, the non-ExPEC strains, isolated from 39% of the patients, presented a generally low virulence capacity (medium virulence factor score of 3.1), and were positively associated with only the colicin cvaC gene. These results show the importance of discriminating E. coli isolates that possess characteristics of true pathogens from those that may be merely opportunistic in order to better understand the virulence mechanisms involved in extraintestinal E. coli infections. Such knowledge is essential for epidemiological purposes as well as for development of control measures aimed to minimize the incidence of these life-threatening and costly infections.

Cross-transmission of vancomycin-resistant Enterococcus in patients undergoing dialysis and kidney transplant

The objective of this study was to investigate the occurrence of vancomycin-resistant Enterococcus (VRE) cross-transmission between two patient groups (long-term dialysis and kidney transplant patients). Molecular typing, by automated ribotyping with the RiboPrinter Microbial Characterization System (Qualicon, USA), was used to analyze VRE isolates from 31 fecal samples of 320 dialysis patients and 38 fecal samples of 280 kidney transplant patients. Clonal spread of E. faecalis and E. casseliflavus was observed intragroup, but not between the two groups of patients. In turn, transmission of E. gallinarum and E. faecium between the groups was suggested by the finding of vancomycin-resistant isolates belonging to the same ribogroup in both dialysis and transplant patients. The fact that these patients were colonized by VRE from the same ribogroup in the same health care facility provides evidence for cross-transmission and supports the adoption of stringent infection control measures to prevent dissemination of these bacteria.

Bloodstream infections in late-stage acquired immunodeficiency syndrome patients evaluated by a lysis centrifugation system

Opportunistic infections, which affect acquired immunodeficiency syndrome (Aids) patients, are frequently disseminated and may cause bloodstream infections (BSI). The aim of this study was to evaluate the main causes of BSI in Aids patients with advanced stage of the disease, with special emphasis on the identification of fungemia. During a 21 months period, all patients with Aids (CD4 < 200) and febrile syndrome admitted to 3 university hospitals were systematically evaluated. For each patient presenting fever, a pair of blood cultures was collected and processed by using a commercial lysis-centrifugation system. One hundred and eleven patients (75 males) with a mean age of 36 years (median 33 years) and mean CD4 count of 64 cells/ml were included. Among the 111 patients evaluated we documented 54 episodes of BSI, including 46 patients with truly systemic infections and 8 episodes considered as contaminants. BSI were caused by gram-positive bacteria (43%), fungi (20%), gram-negative bacteria (15%), mycobacteria (15%), and mixed flora (7%). The crude mortality rate of our patients was 39%, being 50% for patients with BSI and 31% for the others. In conclusion, BSI are a common related to systemic infections on Aids patients with advanced stage of disease and is associated with a high rate of mortality.

Typing of Enterococcus faecium by polymerase chain reaction and pulsed field gel electrophoresis

Polymerase chain reaction (PCR) with JB1 or REP consensus oligonucleotides and pulsed field gel electrophoresis (PFGE) were used to study genomic DNA extracted from 31 strains of enterococci. Eleven ATCC strains, representative of 11 species of Enterococcus, were initially tested by JB1-PCR, revealing that Enterococcus malodoratus and Enterococcus hirae presented identical banding patterns. Eight Enterococcus faecium isolates from Stanford University and 12 from São Paulo Hospital were studied by JB1-PCR, REP-PCR (1/2)R and PFGE. Among the isolates from Stanford University, 5 genotypes were defined by JB1-PCR, 7 by REP-PCR (1/2)R and 4 by PFGE. Among the isolates from São Paulo Hospital, 9 genotypes were identified by JB1-PCR, 6 by REP-PCR and 5 by PFGE. The three methods identified identical genotypes, but there was not complete agreement among them.

Comparative study of agar diffusion test and the NCCLS macrobroth method for in vitro susceptibility testing of Candida spp

We performed a prospective double-blind study to evaluate the correlation between inhibition zones obtained by a disk-diffusion test, using Neo-sensitabs of fluconazole (Rosco Diagnostica), and the MICs generated by the NCCLS macrobroth dilution assay. Eighty clinical isolates, representing 5 of the clinically relevant species of Candida, were tested simultaneously by both methods. A clear inverse correlation was found between the results obtained by both tests (r = -0.69). In addition, there was high degree of agreement between methods in the identification of susceptible isolates. However, the resistance definition by disk-diffusion test had a positive predictive value of only 17%. Our data support the hypothesis that Rosco Fluconazole Neo-sensitabs have potential as a screening test for the identification of Candida isolates susceptible to fluconazole. Resistant isolates should be further investigated by standardized broth procedures.

Geographic distribution of penicillin resistance of Streptococcus pneumoniae in Brazil: genetic relatedness

From January 1993 through December 1996, 1,252 Streptococcus pneumoniae strains from different geographic regions of Brazil were studied for penicillin (Pen) susceptibility. All pneumococci were isolated from normally sterile fluids from patients, newborns to 88 years old. Pen resistance (R) had a mean rate of 15.1%, with 14.5% of strains showing intermediate level Pen-R and 0.6% showing high-level Pen-R. Similar Pen-R rates were observed in different regions of the country, in the range of 9.5% to 17.1%. A Pen-R increase was noted from 9.6% in 1993 to 20.6% in 1996. Pen-R was mostly associated to serotypes 6B, 14, 19A, and 23F (89%). Chromosomal DNA relatedness of Pen-R strains was determined by pulsed field gel electrophoresis (PFGE). High genetic diversity was identified, being represented by 27 patterns among the 92 strains. Two important features were observed: the predominance of relatively low-level Pen MIC (range 0.1-0.5 mg/L) in 86 of the 92 strains, and the presence of 60.8% as four major PFGE clusters unique to Brazil. Another feature was the geographic spread of these clusters over large distances in the country. The city of São Paulo seems to be a Pen-R focus (18.4%) in Brazil. Only two strains representing the international clone B widely spread in France, Portugal, and Spain, belonging to serotype 14, were found.

[Effect of nosocomial bacteremia caused by oxacillin-resistant Staphylococcus aureus on mortality and length of hospitalization]

OBJECTIVES

To identify the attributed mortality rate of bloodstream hospital infection by Staphylococcus aureus resistant to methicillin (MRSA) and its effect on length of hospital stay.

DESIGN

Case-control study.

SETTING

Hospital São Paulo da Universidade Federal de São Paulo, a 660-bed, tertiary-care teaching hospital in São Paulo, Brazil.

PATIENTS

Seventy one adults patients with hospital-acquired MRSA bacteremia diagnosed between January 1, 1991, and September 30, 1992, and 71 MRSA-free controls were matched by the following criteria: age, sex, underlying disease, surgical procedure, same risk time and admission date.

RESULTS

The incidence of patients with hospital sepsis by MRSA accounted for 73.22% of the patients with hospital bloodstream infection by Staphylococcus aureus. The mortality rate of the cases was 56.33 (40/71) and 11.26 (8/71) of the controls. The attributable mortality rate was 45.07% (OR = 17.0; IC 95% = 3.58-202.26; p = 0.000001). The length of hospital stay median time was of 32.55 days for the cases and 29.75 for the controls (p = 0.32).

CONCLUSION

A high level of sepsis by MRSA was observed in all the Staphylococcus aureus bacteremia. The bloodstream hospital infection by MRSA itself does provide a high level of mortality independently from the patients base disease, without however, increasing their hospital length of stay.

Staphylococcus aureus prophylaxis in hemodialysis patients using central venous catheter: effect of mupirocin ointment

Central venous catheterization is a common technique to establish rapid and temporary access for hemodialysis. However, it is a known risk factor for Staphylococcus aureus infection and bacteremia. Mupirocin is a topical antibiotic with high in vitro anti-staphylococcal activity. A randomized prospective trial was conducted to assess the effectiveness of mupirocin ointment in the prevention of Staphylococcus aureus skin and catheter colonization, and episodes of bacteremia in 136 end-stage renal disease patients. Of these, 67 received skin disinfection at the venous catheter insertion site with povidone iodine (control group), and 69 received the same treatment followed by application of 2% mupirocin ointment at the cannula site after catheter placement and at the end of each dialysis session. Patients were followed until catheter removal and were monitored for the development of Staphylococcus aureus skin/catheter colonization and episodes of bacteremia. Median duration of catheter use was greater in the mupirocin than in the control group (37 versus 20 d, P < 0.01). Patients in the mupirocin group had a significantly lower rate of Staphylococcus aureus isolation from the pericatheter skin (1.76 per 1000 versus 14.27 per 1000 patient-days, P < 0.001) and from the catheter surface (3.17 per 1000 versus 14.27 per 1000 patient-days, P < 0.001). The proportion of patients with Staphylococcus aureus skin infection at the insertion site was lower in the mupirocin group (4.3% versus 23.9%, P = 0.001). Staphylococcus aureus-associated bacteremia was observed in 17 patients (two in the mupirocin group [0.71 episodes per 1000 patient-days] and 15 in the control group [8.92 per 1000 patient-days], P < 0.001). The hazard ratio of developing Staphylococcus aureus bacteremia was 7.2 (95% confidence interval, 1.6 to 31.6) times greater in patients not receiving mupirocin. Mupirocin applied to the insertion site significantly reduces the risk of Staphylococcus aureus skin and catheter colonization, exit-site infection, and Staphylococcus aureus bacteremia in hemodialysis patients.

[Sensitivity pattern of 117 clinical isolates of Staphylococcus aureus from 12 hospitals]

OBJECTIVE

To evaluate the antimicrobial susceptibility pattern of oxacillin susceptible (OSSA) and resistant Staphylococcus aureus (ORSA) isolates to other antimicrobial agents that can be used for the treatment of staphylococcal infections.

MATERIAL AND METHOD

We evaluated 117 clinical S. aureus isolates from several São Paulo hospitals. Clinical isolates from Campinas, SP and from João Pessoa, PB, were also included. The in vitro susceptibility testing was performed by broth microdilution as described by the National Committee for Clinical Laboratory Standards (NCCLS). The minimum inhibitory concentration (MIC) was evaluated for 24 antimicrobial agents, including beta-lactams, fluoroquinolones, aminoglycosides, glycopeptides, macrolides, lincosamides and streptogramins. Both commercially available and experimental drugs were included in the study. Cross-resistance among fluoroquinolones was evaluated by susceptibility testing 24 isolates to 10 fluoroquinolones.

RESULTS

The antimicrobial agents that showed the highest in vitro activity were the glycopeptides, the streptogramin RP-59.500, and the mupirocin (100% susceptibility). Eighty-seven percent of the OSSA and only 38% of the ORSA isolates were susceptible to ciprofloxacin (MIC50 0.25 microgram/mL and > 4 micrograms/mL, respectively). Cross-resistance among fluoroquinolones were noted even for the experimental drugs. Two fluoroquinolones remained active against ciprofloxacin-resistant isolates, clinafloxacin and WIN-57.273. However, the ciprofloxacin-resistant isolates had MICs eight-to 64-fold higher than the ciprofloxacin-susceptible isolates, suggesting that the MICs may continue to increase when these fluoroquinolones become commercially available.

CONCLUSION

Our results showed a high rate of antimicrobial resistance among S. aureus from the Brazilian hospitals. Very few drugs can still be used for the treatment of staphylococcal infections.

[Evaluation of in vitro activity of new fluoroquinolones, cephalosporins and carbapenems against 569 gram-negative bacteria]

OBJECTIVE

Evaluation of the in vitro activity of new fluoroquinolones, cephalosporins and carbapenems against gram-negative bacteria.

MATERIAL AND METHOD

A total of 569 clinical isolates were obtained from inpatients at São Paulo Hospital--UNIFESP/EPM in June and July of 1992. The species distribution was as follows: Enterobacter sp. (62), Escherichia coli (308), Klebsiella pneumoniae (27), Klebsiella sp. (9), Proteus mirabilis (23), Pseudomonas aeruginosa (88), Pseudomonas sp. (4), Serratia sp. (30) and other gram-negatives (7). Susceptibility tests were performed by broth microdilution. The antimicrobials agents tested were: ciprofloxacin, ofloxacin, levofloxacin, grepafloxacin, DU 6859-alpha, ceftazidime, cefepime, FK 037, imipenem, meropenem and biapenem.

RESULTS

DU 6859-alpha showed the highest anti-microbial activity among the fluoroquinolones. It was two- to four-fold more active than ciprofloxacin against some species. The potency and antimicrobial spectrum were similar between the fourth-generation cephalosporins against Enterobacteriaceae, except for Enterobacter sp. strains which were more susceptible to cefepime than they were to cefetazidime or FK 037. When testing Pseudomonas aeruginosa, ceftazidime was slightly more active than the other cephalosporins. Against Enterobacteriaceae and Pseudomonas aeruginosa strains, meropenem was more active than imipenem or biapenem. In addition, the percentage of strains, susceptible to meropenem was higher than the percentage susceptible to the other cerbapenems against these species.

CONCLUSION

The new antimicrobial agents demonstrated in vitro activity higher than that of agents commercially available. However, more studies are necessary to further evaluate the in vivo activity and the clinical benefit of these compounds.

[Clinical significance, epidemiology and microbiology of coagulase-negative staphylococcal nosocomial bacteremia at a teaching hospital]

Coagulase-negative staphylococci (CNS) are an important cause of nosocomial bacteremia and they are frequently considered as contaminants of blood-cultures. From October 1990 to September 1992, 300 positive blood-cultures for CNS at the Hospital São Paulo were studied and 141 CNS bacteremias were characterized as nosocomial bacteremias. Clinical and microbiological criteria were defined to differentiate between true CNS bacteremia and contaminated cultures. Only 20.6% of the CNS nosocomial bacteremia were considered as true bacteremia. Most of the CNS true nosocomial bacteremia were detected among newborns admitted to the neonatal intensive care unit; the presence of intravascular catheter and parenteral nutrition were significant findings. We did not detect significant difference between true nosocomial bacteremia and contaminated cultures regarding to resistance to oxacillin and SLIME production. The clinical criteria and the positivity of the blood-cultures up to 48 hours after incubation, utilized in our definitions, were useful parameters to characterize the CNS true nosocomial bacteremia.

Use of macrorestriction analysis to demonstrate interhospital spread of multiresistant Acinetobacter baumannii in São Paulo, Brazil

We evaluated the spread of Acinetobacter baumannii strains among three hospitals located in São Paulo, Brazil. A total of 46 isolates, which were typed by chromosomal DNA analysis with use of pulsed field gel electrophoresis (PFGE), were tested for susceptibility to the fluoroquinolones, carbapenems, aminoglycosides (amikacin), cephalosporins, polymyxin B, and ampicillin/sulbactam by means of the broth microdilution method, disk diffusion, and the E-test. Isolates with an identical PFGE pattern (pattern B) that were susceptible only to carbapenems, polymyxin B, and ampicillin/ sulbactam were recovered in all three hospitals. In addition, isolates with PFGE pattern A that were susceptible only to polymyxin B and ampicillin/sulbactam were recovered in hospitals 1 and 2. The results of our study strongly suggest the interhospital transmission of multiresistant epidemic strains of A. baumannii in São Paulo. Once in the hospital, these strains can disseminate and cause outbreaks with devastating consequences.

[In vitro susceptibility testing of 446 clinical isolates of gram-positive bacteria to new quinolones, carbapenems and cephalosporins]

OBJECTIVE

To assess the in vitro susceptibility of gram-positive bacteria isolated in the São Paulo Hospital against five fluoroquinolones, three carbapenems and three cephalosporins.

MATERIALS AND METHOD

Susceptibility was tested in 77 isolates of streptococci, 38 enterococci, 25 S. aureus and 91 S. epidermidis. The strains were isolated in the São Paulo Hospital in June and July of 1992. The susceptibility testing was performed by broth microdilution according to the procedure described by the national committee for Clinical Laboratory Standards (NCCLS). The antimicrobial agents tested were: ciprofloxacin, ofloxacin, levofloxacin, grepafloxacin (formerly OPC 17116), DU-6859, imipenem, meropenem, biapenem, ceftazidime, cefepime and FK-037.

RESULTS

The best in vitro activity was demonstrated by the new fluoroquinolones, especially DU 6859. Among the commercially available compounds, the fluoroquinolones ciprofloxacin and ofloxacin (81% susceptibility) and the carbapenem imipenem (74% susceptible) were the most active compounds. The highest resistance rates were shown by enterococci and oxacillin-resistant staphylococci.

CONCLUSIONS

The results of the present study showed that the in vitro activities of the new carbapenems are similar to that of imipenem and the fourth generation cephalosporins are more active than ceftazidime against gram-positive bacteria. In addition, the newer fluoroquinolones were four to sixteen-fold more active than that showed by the commercially available compounds of this class, especially against enterococci and oxacillin-resistant staphylococci. These results indicate that these newer fluoroquinolones should be further evaluated in clinical trials.

[Study of the susceptibility of Staphylococcus sp. and Enterococcus sp. to teicoplanin and vancomycin]

PURPOSE

The study was performed in order to evaluate the susceptibility of Enterococcus and Staphylococcus to teicoplanin and vancomycin.

METHODS

150 Enterococcus strains and 450 Staphylococcus strains (298 Staphylococcus aureus and 152 negative coagulase strains) isolated in three Brazilian hospitals were studied. The MICs were determined using teicoplanin and vancomycin E Test strips. The range of the antimicrobial concentration in each strip went from 256 mcg/mL to 0.016 mcg/mL. Diffusion tests using disks impregnated with 10 mcg of teicoplanin and 30 mcg of vancomycin were also performed.

RESULTS

All the 298 Staphylococcus aureus strains were susceptible to the two antimicrobials. Three of the 152 negative coagulase strains presented intermediate susceptibility to teicoplanin (MICs between 8 and 16 mcg/mL). Four of the 150 Enterococcus strains presented intermediate susceptibility to vancomycin but were totally susceptible to teicoplanin.

CONCLUSION

According to these results teicoplanin and vancomycin are good therapeutical options in the treatment of staphylococcal and enterococcal infections.

Gastrointestinal translocation as a possible source of candidemia in an AIDS patient

Apart from cryptococcosis and histoplasmosis, which are mycoses contained by T cell-mediated mechanisms of host defense, fungemia is rarely found in AIDS patients. The frequency of fungemia due to Candida spp. has been reported to be as low as 1%. We report a non-neutropenic AIDS patient who presented a candidemia which probably arose from her gastrointestinal tract.

Analysis of the clonal diversity of Staphylococcus aureus methicillin-resistant strains isolated at João Pessoa, state of Paraíba. Brazil

To investigate the clonal diversity of Staphylococcus aureus strains isolated at João Pessoa, State of Paraíba, Brazil, digested genomic DNA were studied by pulsed-field gel electrophoresis (PFGE) in nine methicillin-resistant strains (MRSA) and three methicillin-sensitive strains (MSSA), selected among 67 isolates based on their antimicrobial susceptibility and epidemiology. The isolates were obtained between April and November 1992 from the Hospital of the Federal University of Paraíba, located in João Pessoa. Two MRAS isolates from the Oswaldo Cruz Hospital, São Paulo, Brazil, including an epidemic strain previously detected from different hospitals at the country were used as control. Five different patterns, were demonstrated by MRSA isolated in João Pessoa and these patterns were described in several epidemiologically unrelated hospitals in São Paulo. Our results suggest the interstate dissemination of a MRSA clone in João Pessoa which is similar to that described in other cities of Brazil.

Molecular typing of Candida albicans strains isolated from nosocomial candidemia

Yeasts of the genus Candida have been recognized as important microorganisms responsible for nosocomial fungemia. Six blood-stream and two intravenous central catheter C. albicans strains were isolated from eight patients and studied by electrophoretic karyotyping of chromosomal DNA by pulsed-field gel electrophoresis. Seven chromosomal DNA profiles were identified. Two patients showed isolates with the same profile, suggesting nosocomial transmission. Karyotyping of C. albicans revealed an excellent discriminatory power among the isolates and may therefore be useful in the study of nosocomial candidemia.

[Analysis of the program of control of the use of antimicrobials at the Hospital São Paulo--Escola Paulista de Medicina]

BACKGROUND AND OBJECTIVE

Antimicrobial agents represent a group of drugs that are frequently used in hospitals. Approximately, 50% of hospitalized patients receive at least one antimicrobial drug during the hospitalization period. However, half of these drugs are prescribed incorrectly. The objective of this paper was to analyse the antimicrobial control program that has been used at Escola Paulista de Medicina since 1989.

CASUISTIC & METHODS

The prescription of eleven controlled antibiotics should be done in a special form. Any requisition of a controlled antibiotic was evaluated, within 24 hours, by an infection diseases specialist who was hired exclusively for this function.

RESULTS

During 1989, 5,573 controlled antimicrobials were requested by the hospital staff, and 17.6% of them were considered inadequate and were refused. Such a percentage was high considering that our institution is a university hospital where the antibiotic usage should be more precise and adequate. We also should take into account that the indication of only 11 antimicrobial drugs were evaluated.

CONCLUSION

The results allow us to conclude that each hospital should have not only a policy on antimicrobial usage but also an effective program of control of these drugs.

E test: a novel technique for antimicrobial susceptibility testing

We describe the applicability of the E test (AB Biodisk Solna, Sweden), a new method for determining minimum inhibitory concentrations of antimicrobial agents against bacteria. This report is based on the literature review and on our own experience using the E test for susceptibility testing of the Xanthomonas maltophilia, Streptococcus pneumoniae and Streptococcus viridans group against eight different drugs.

Evaluation of interhospital spread of methicillin-resistant Staphylococcus aureus in Sao Paulo, Brazil, using pulsed-field gel electrophoresis of chromosomal DNA

To evaluate the interhospital spread of methicillin-resistant Staphylococcus aureus (MRSA) clone in Sao Paulo, we analyzed the restriction fragment length polymorphisms (RFLP) of chromosomal DNA from isolates from nine Sao Paulo hospitals. Restriction digestion of genomic DNA was performed with SmaI and the fragments were separated by pulsed-field gel electrophoresis. Only six different RFLP patterns were demonstrated among 30 MRSA isolates. Isolates possessing an identical RFLP pattern were demonstrated in eight of the nine Sao Paulo hospitals evaluated. Our results documented the widespread dissemination of a single clone of MRSA in several hospitals. Furthermore, the small clonal variability among multidrug-resistant MRSA coupled with the wide spread of this clone could make the intrahospital epidemiological evaluation of RMSA outbreaks very difficult.

Levofloxacin in vitro activity: results from an international comparative study with ofloxacin and ciprofloxacin

Levofloxacin, the S-(-)-isomer of ofloxacin, was compared to ofloxacin and ciprofloxacin against > 6000 recent clinical isolates of Gram-positive and Gram-negative bacteria from six different countries. This international multicenter study demonstrated a high level of antibacterial activity of levofloxacin against all the members of Enterobacteriaceae [minimum inhibitory concentration (MIC)50s, < or = 0.03 to 0.12 mg/L] except Providencia rettgeri (MIC50, 2 mg/L), and Providencia stuartii (MIC50, 1 mg/L). Oxacillin-susceptible staphylococci (MIC50s, 0.12 to 0.25 mg/L), enterococci (MIC50s, 0.5 to 2 mg/L), and streptococci (MIC50s, 0.5 mg/L) were also susceptible to levofloxacin, but most isolates of oxacillin-resistant staphylococci had MICs of > or = 4 mg/L. Levofloxacin was also active against non-enteric Gram-negative bacilli, including Acinetobacter species (MIC50s, < or = 0.03 to 1 mg/L), Pseudomonas species (MIC50s, 0.5 to 1 mg/L) and Xanthomonas maltophilia (MIC50, 0.5 mg/L). Overall, levofloxacin inhibited 50% and 90% of all the tested strains at the concentrations of 0.12 and 4 mg/L, respectively. The activity of levofloxacin was generally two-fold greater than ofloxacin and equal to or slightly less potent than ciprofloxacin.

Antimicrobial activity of FK-037, a new broad-spectrum cephalosporin. International in vitro comparison with cefepime and ceftazidime

The in vitro activity of FK-037, a new parenteral 7-aminothiazolyl-methoxyimino cephalosporin, was compared with cefepime and ceftazidime against 6094 aerobic isolates collected in six medical centers worldwide. FK-037 demonstrated potent activity against the Enterobacteriaceae family except for some Enterobacter spp., Providencia spp., and Serratia liquefaciens (MIC90s, > or = 16 micrograms/ml). Against nonenteric Gram-negative bacilli, all compounds tested showed similar, but more limited activity. The FK-037 MIC50s for Pseudomonas spp. and P. aeruginosa were 2 and 4 micrograms/ml, respectively. The least susceptible organisms were Xanthomonas maltophilia, enterococci, and Bacillus spp. (MIC50s, > 16 micrograms/ml), followed by Flavobacterium spp., other nonenterics, and oxacillin-resistant Staphylococcus aureus (MIC50s, 16 micrograms/ml). Good FK-037 activity was observed against oxacillin-susceptible staphylococci as well as against beta-hemolytic and viridans-group streptococci (MIC90 range, < or = 0.12 to 2 micrograms/ml). While FK-037 was slightly more active than cefepime against Gram-positive organisms, enteric bacilli were most susceptible to cefepime. Overall, the antibacterial spectrum of both FK-037 and cefepime was superior to ceftazidime.

In vitro activity of three carbapenem antibiotics. Comparative studies with biapenem (L-627), imipenem, and meropenem against aerobic pathogens isolated worldwide

The in vitro activity of biapenem (formerly L-627 or LJC10, 627), a new carbapenem, was compared with that of imipenem and meropenem against > 6000 clinically significant pathogens isolated in six countries worldwide. Biapenem was active against members of the family Enterobacteriaceae with a 90% minimum inhibitory concentration (MIC90) ranging from < or = 0.06 to 2 micrograms/ml. Only Serratia spp. and Providencia spp. were less susceptible (MIC90, 8 micrograms/ml). Pseudomonas aeruginosa and Xanthomonas maltophilia displayed an MIC90 of > or = 8 micrograms/ml biapenem/ml whereas Acinetobacter spp. were susceptible at < or = 1 micrograms/ml. Oxacillin-resistant staphylococci were resistant to biapenem at > 8 micrograms/ml whereas oxacillin-sensitive staphylococci were susceptible at < or = 1 micrograms/ml. Biapenem, imipenem, and meropenem displayed poor activity against Ent. faecium (MIC90, > or = 8 micrograms/ml), and only imipenem displayed slightly better activity against Ent. faecalis (MIC90, 4 micrograms/ml). The rank order of activity against groups of isolates was Enterobacteriaceae (meropenem > biapenem > or = imipenem), Ps. aeruginosa (biapenem = meropenem = imipenem), oxacillin-sensitive staphylococci (imipenem > or = biapenem = meropenem), oxacillin-resistant staphylococci (biapenem = meropenem = imipenem), and Enterococcus spp. (biapenem = meropenem = imipenem). These in vitro suggest that further developmental work on biapenem is warranted.

Nosocomial and community acquired bacteremia: variables associated with outcomes

Bacteremia is related to high morbidity and lethality. The present investigation was conducted to evaluate the variables associated with outcomes of bacteremia at a University Hospital in São Paulo, Brazil. Patients with bacteremia were identified through positive blood cultures performed at the microbiology laboratory between August 1985 and July 1986. Their charts were reviewed and the following variables were considered: age, sex, presence of underlying disease, where was the bacteremia acquired, source of infection, presence of shock and appropriateness of antimicrobial therapy. In the period of the study, there were 362 cases of bacteremia out of 16,636 admissions to the hospital. The lethality rate was 33.4%, six times higher than the mortality rate for non-bacteremic patients. Age greater than 40 years, presence of severe underlying disease, nosocomial acquisition, respiratory tract as the source of bacteremia, presence of shock and, being infected with Pseudomonas sp were significantly associated with fatal outcome. Appropriate antimicrobial therapy reduced the incidence of shock and improved survival of patients with bacteremia. This study provides information on outcome of patients with bacteremia at a University Hospital in Brazil and, settles the variables associated with poor outcome in these patients.

Epidemiologic typing of multiply drug-resistant Pseudomonas aeruginosa isolated from an outbreak in an intensive care unit

From June to August 1991, there was an outbreak of Pseudomonas aeruginosa infections in an intensive care unit in a general hospital in Sao Paulo, Brazil. We obtained 14 isolates from 14 patients, 11 from tracheal aspirate, and 3 from surgical wound exudates. These strains were typed by serotyping, pyocin typing, and pulsed-field electrophoresis (CHEF) of chromosomal DNA (chrDNA), and the different typing methods were analyzed. These three methods demonstrated seven identical strains. We also performed an extensive antibiogram (33 drugs) in all 14 isolates. The incidence of resistance to aminoglycosides, extended-spectrum beta-lactams, and quinolones was very high among the seven identical isolates; however, the antibiogram profile differed significantly among the isolates. Our results suggest that a unique strain caused several cross-transmitted infections during this period of time, and the emergence of antimicrobial resistance has been occurring before and after the establishment of the epidemic strain by selective drug use. The chrDNA fingerprinting proved to be versatile and precise for epidemiologic investigations of P. aeruginosa infections.

[Cryptococcal meningitis in pregnancy. Review of the literature. Report of 2 cases]

Two cases of neurocryptococcosis were diagnosed during pregnancy in São Paulo (Brazil). Amphotericin B was used in the second trimester in one patient. The other, received amphotericin B during the first trimester of pregnancy and 5-fluorocytosine was added in the second trimester. In both, the pregnancy was uneventful and the fetus suffered no damage. The therapy used to treat pregnant women with cryptococcal meningitis is commented. The newborn follow-up is discussed. A review of the literature concerning neurocryptococcosis during pregnancy is presented.

Oxacillin- and quinolone-resistant Staphylococcus aureus in Sao Paulo, Brazil: a multicenter molecular epidemiology study

OBJECTIVE

To investigate the possibility of interhospital spread of multiresistant Staphylococcus aureus in Sao Paulo, Brazil.

DESIGN

We evaluated 13 nosocomial S aureus strains selected because of resistance to oxacillin and ciprofloxacin.

SETTING

The strains were collected between March 1991 and September 1991 from four different hospitals in Sao Paulo. Two were teaching hospitals, and two were private hospitals.

PATIENTS

Each strain was isolated from a different patient. All patients were hospitalized when the strains were isolated.

INTERVENTIONS

The strains were typed by restriction endonuclease analyses of plasmid DNA (REAP) using EcoRI, HindIII, RsaI, and AluI and by extended antibiogram profile (34 drugs).

RESULTS

All strains had identical plasmid and antibiogram profile. They demonstrated the same plasmid pattern as previously described in one of the hospitals studied.

CONCLUSIONS

Our results suggest the dissemination of a unique oxacillin- and quinolone-resistant strain of S aureus in several hospitals of Sao Paulo, Brazil.

[Epidemiology of bacteremias at a university hospital]

The epidemiological aspects of bacteremias were determined in a university hospital, according to service, age, sex and place of acquisition (nosocomial or community-acquired). From August 1985 through July 1986 the incidence rate of bacteremias at the Sao Paulo Hospital was 21.7/1000 admissions. Such a high rate is probably related to the characteristics of the patients admitted to the hospital. The incidence was higher in the extremes of age and was similar in either sex. Approximately 60% of the bacteremias were nosocomial including 9.1% that were present at admission in patients transferred from other hospitals. The most frequent isolated pathogen was S. aureus. The most important source of bacteremia was the respiratory tract followed by the gastrointestinal and urinary tracts.

Restriction endonuclease analysis of Staphylococcus aureus plasmid DNA from three continents

Staphylococcus aureus isolates (n = 1201) from 20 centers in Europe, the USA and Brazil were evaluated for the presence of epidemiologic markers. Plasmid typing and restriction endonuclease analysis of plasmid DNA confirmed the presence of an apparently identical plasmid in 13% of clinical isolates. The plasmid was recovered from all 20 hospitals studied, with an overall frequency of greater than 10% on each of the three continents. Since relatively few staphylococcal plasmids may be shared by epidemiologically unrelated strains, there are inherent limitations to this otherwise useful technique. Additionally, these data demonstrate the importance of including unrelated strains of Staphylococcus aureus from the local region as controls when molecular typing methods are performed.

[Hepatic involvement in human brucellosis. Report of 2 clinical cases]

São relatados dois casos de brucelose humana apresentando comprometimento hepático, com especial referência ao diagnóstico diferencial das hepatites granulomatosas.