Factors predictive of inappropriateness in requests for parenteral antimicrobials for therapeutic purposes: A study in a small teaching hospital in Brazil

Background: The identification of patterns of inappropriate antimicrobial prescriptions in hospitals contributes to the improvement of antimicrobial stewardship programs (ASP). Methods: We conducted a cross-sectional study to identify predictors of inappropriateness in requests for parenteral antimicrobials (RPAs) in a teaching hospital with 285 beds. We reviewed 25% of RPAs for therapeutic purposes from y 2005. Appropriateness was evaluated according to current guidelines for antimicrobial therapy. We assessed predictors of inappropriateness through univariate and multivariate models. RPAs classified as 'appropriate' or 'probably appropriate' were selected as controls. Case groups comprised inappropriate RPAs, either in general or for specific errors. Results: Nine hundred and sixty-three RPAs were evaluated, 34.6% of which were considered inappropriate. In the multivariate analysis, general predictors of inappropriateness were: prescription on week-ends/holidays (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.20-2.28, p = 0.002), patient in the intensive care unit (OR 1.57, 95% CI 1.11-2.23, p = 0.01), peritoneal infection (OR 2.15, 95% CI 1.27-3.65, p = 0.004), urinary tract infection (OR 1.89, 95% CI 1.25 -2.87, p = 0.01), combination therapy with 2 or more antimicrobials (OR 1.72, 95% CI 1.15-2.57, p = 0.008) and prescriptions including penicillins (OR 2.12, 95% CI 1.39-3.25, p = 0.001) or 1(st) generation cephalosporins (OR 1.74, 95% CI 1.01-3.00, p = 0.048). Previous consultation with an infectious diseases (ID) specialist had a protective effect against inappropriate prescription (OR 0.34, 95% CI 0.24-0.50, p < 0.001). Factors independently associated with specific prescription errors varied. However, consultation with an ID specialist was protective against both unnecessary antimicrobial use (OR 0.04, 95% CI 0.01-0.26, p = 0.001) and requests for agents with an insufficient antimicrobial spectrum (OR 0.14, 95% CI 0.03-0.30, p = 0.01). Conclusions: Our results demonstrate the importance of previous consultation with an ID specialist in assuring the quality of prescriptions. Also, they highlight prescription patterns that should be approached by ASP policies.

Cervical Lactobacillus and leukocyte infiltration in preterm premature rupture of membranes

Objectives: To evaluate the possible association between microorganisms present in the cervical secretions and amniotic fluid of pregnant women with preterm premature rupture of membranes (PPROM), and histologic chorioamnionitis. Methods: Thirty-seven pregnant women with PPROM and 21 healthy pregnant women were studied. Secretions from the cervical canal and amniotic fluid were collected to isolate microorganisms present in the genital tract. Cervical smears were Gram stained and evaluated microscopically. At delivery, chorioamniotic membranes were collected for histopathologic analysis. Results: Microscopic examination of the cervical secretion smears obtained from the PPROM group showed a low rate of Lactobacillus species, large numbers of leukocytes, and a wide diversity of microorganisms compared with the control group. The PPROM group presented an 80% rate of chorioamnionitis. Staphylococcus aureus isolation in cervical secretion was associated with intense inflammatory infiltrate in the membranes and might play a role in the pathogenesis of PPROM. Conclusions: the low colonization of cervical flora by Lactobacillus species associated with an intense leukocyte infiltrate detected in Gram-stained cervical smears can be considered a rapid method of detecting chorioamnionitis in pregnant women with PPROM. (C) 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier B.V. Ireland Ltd. All rights reserved.

Correlation of Atopobium vaginae Amount With Bacterial Vaginosis Markers

Objective. The purpose of this study was to test the correlation of the amount of Atopobium vaginae with the most commonly used markers for bacterial vaginosis (BV).Materials and Methods. We enrolled 103 nonpregnant and premenopausal women that were positive for BV by Amsel criteria and with a Nugent score higher than 3. All women were negative for yeast, Chlamydia trachomatis, Trichomonas vaginalis, and Neisseria gonorrhoeae. A. vaginae concentration was determined by quantitative polymerase chain reaction from samples of vaginal rinsings with 2 mL of sterile saline.Results. There was no difference in the median values of A. vaginae concentration when comparing samples with presence or absence of each individual Amsel criterion. In the case of a higher pH cutoff value of 4.9, greater amounts of this microorganism (p = .02) were found. In addition, correlation tests showed that A. vaginae concentration is positively correlated with pH (p < .001) and with Nugent scores (p = .003).Conclusions. The quantification of A. vaginae is useful for identification of the most severe cases of BV.

Fatores associados à recorrência da infecção do trato urinário em crianças

OBJETIVOS: verificar a freqüência de infecção urinária recorrente (ITU) e avaliar os fatores associados à recorrência da ITU em crianças. MÉTODOS: estudo retrospectivo de 95 pacientes com seguimento de um ano (68 meninas e 27 meninos, mediana de idade três anos). As variáveis estudadas foram: sexo, idade, febre, constipação, tipo de bactéria, refluxo vésico-ureteral (RVU), anormalidades na cintilografia renal com ácido dimercaptosuccínico (DMSA). RESULTADOS: infecção urinária recorrente ocorreu em 49,5% crianças (19 com trato urinário normal, 19 com RVU e 9 com estenose da junção pielocalicial). Comparando o grupo com ITU recorrente com o grupo sem ITU recorrente não se encontrou diferença significativa entre sexos, presença de febre, constipação e anormalidades na cintilografia renal com DMSA. A ITU recorrente foi significativamente maior nas crianças com um ano ou menos, naquelas menores de dois anos com RVU, nas com bactéria diferente da Escherichia coli e sem profilaxia antibacteriana. Os fatores de risco significativos para a recorrência ITU foram idade < 2 anos (OR = 3,83) e refluxo vésico-ureteral (OR = 4,95). CONCLUSÕES: por causa da elevada freqüência de ITU recorrente é importante o seguimento regular de grupo de crianças com fatores de risco para ITU recorrente.

Cicatrizes renais em crianças com refluxo vesicoureteral primário

OBJETIVO: verificar a incidência de cicatrizes renais em crianças com refluxo vesicoureteral primário, comparando com sexo, idade no diagnóstico, infecção febril, grau do refluxo e tipo de bactéria. MÉTODOS: estudo retrospectivo de 58 crianças, com idade entre dois meses a 11 anos, apresentando refluxo vesicoureteral primário, detectado pela uretrocistografia miccional, após episódio documentado de infecção urinária. Diagnóstico de cicatriz renal foi obtido pela cintilografia com DMSA cinco meses, no mínimo, após o tratamento da infecção urinária; em 40 crianças, o exame foi repetido após período de seis meses a seis anos. RESULTADOS: 45 crianças (77,6%) eram meninas e 13 (22,4%) eram meninos, 51,7% com idade menor ou igual a 2 anos. A incidência de cicatriz renal foi de 55,2%. Houve maior proporção significativa de cicatrizes renais no sexo feminino, na presença do sintoma febre e no refluxo dilatado (III, IV e V). Presença de febre e sexo feminino foram fatores de risco significativos na ocorrência de cicatriz renal (febre - OR= 6,19, e sexo feminino - OR= 4,12). Houve tendência da presença de cicatriz renal em maiores de 2 anos. O intervalo entre início dos sintomas e a primeira consulta foi maior nas crianças com cicatrizes renais. Novas cicatrizes renais foram observadas em 12,5%. CONCLUSÃO: a presença de febre e sexo feminino foram fatores de risco para presença de cicatrizes renais, principalmente no refluxo vesicoureteral dilatado. A alta incidência de cicatrizes renais neste estudo pode estar relacionada ao retardo do diagnóstico do refluxo vesicoureteral.

Late presentation of posterior urethral valve: two case reports

CONTEXTO: Válvula de uretra posterior (VUP) é uma conhecida malformação congênita urinária, geralmente diagnosticada em exames ultra-sonográficos pré-natais ou ao nascimento. Raramente, esta doença pode ser encontrada em adolescentes e em adultos. RELATO DE CASOS: Este artigo mostra dois casos de VUP, encontrados em um adolescente e em um adulto. Ambos apresentavam sinais clínicos de infecção do trato urinário e sintomas obstrutivos infravesicais. Os diagnósticos foram realizados por uretrocistografia miccional e uretrocistoscopia. Fulguração endoscópica das válvulas foi o tratamento de escolha para ambos os casos. O acompanhamento demonstrou melhora importante dos sintomas após o tratamento.

Is the ultrasound-estimated bladder weight a reliable method for evaluating bladder outlet obstruction?

OBJECTIVETo evaluate the correlation between ultrasound-estimated bladder weight (UEBW) in patients with different degrees of bladder outlet obstruction (BOO).METHODSWe evaluated 50 consecutive non-neurogenic male patients with lower urinary tract symptoms (LUTS) referred to urodynamic study (UDS). All patients self-answered the International Prostate Score Symptoms (IPSS) questionnaire. After the UDS, the bladder was filled with 150 mL to determine UEBW.Patients with a bladder capacity under 150 mL, a previous history of prostate surgery or pelvic irradiation, an IPSS score <8, a bladder stone or urinary tract infection were excluded.After a pressure-flow study, the Schafer linear passive urethral resistance relation nomogram was plotted to determine the grade of obstruction: Grades I-II/VI were defined as mild obstruction, Grades III-IV/VI as moderate obstruction, and Grades V-VI/VI as severe obstruction.RESULTSThe UEBW was 51.7 +/- 26.9, 54.1 +/- 30.0 and 54.8 +/- 28.2 in patients with mild, moderate and severe BOO, respectively (P = 0.130). The UEBW allowed us to define four groups: (i) UEBW < 35 g; (ii) 35 g <= UEBW < 50 g; (iii) 50 g <= UEBW < 70 g; and (4) UEBW >= 70 g.We did not find any differences in age, prostate weight, IPSS, PVR, cystometric bladder capacity, presence of detrusor overactive and degree of obstruction in the aforementioned groups.CONCLUSIONDespite the fact that some studies have emphasized the value of UEBW as an efficient non-invasive method for evaluating lower urinary tract obstruction, our study suggests that UEBW does not present any individual correlation with LUTS or objective measurements of BOO.

Efeito protetor da microbiota cecal congelada e liofilizada sobre a infecção experimental de frangos de corte por Salmonella enterica sorovar Enteritidis

Estudaram-se os efeitos do tratamento de frangos de corte com microbiota cecal anaeróbia liofilizada (MCL) e congelada (MCC) sobre a infecção do trato digestivo das aves por Salmonella enterica sorovar Enteritidis. Foi usada microbiota intestinal sem prévia identificação bacteriana. A infecção foi persistente, em ordem, no ceco, inglúvio e duodeno. A infecção também foi autolimitante nos grupos tratados e no controle. Não ocorreu diferença entre o grupo-controle positivo e os tratados com MCL ou MCC. Houve redução da colonização do ceco no período de 12 dias após o desafio nos grupos tratados com MCL e MCC, o que não ocorreu no grupo-controle positivo. Não houve variação entre os tratamentos com MCL e MCC quanto às características pesquisadas. A S. Enteritidis reduziu o ganho de peso médio nas aves inoculadas. Os tratamentos com MCL e MCC minimizaram a redução de peso nos grupos infectados.

Perfil de sensibilidade e multirresistência em linhagens de Escherichia coli isoladas de infecção do trato urinário, de piometra e de fezes de cães

Susceptibility profile and multiple drug resistance in 158 E. coli strains isolated from urinary tract infection (UTI), pyometra, and feces of dogs were studied. Norfloxacin, ciprofloxacin, and enrofloxacin were the most-effective drugs (>60%) for E. coli strains. High rates of resistance to antimicrobials were observed in 60% or more of the isolated strains using sulfametoxazole/trimetoprim. Multiple drug resistance for three or more antimicrobials was observed in two (47.1%) strains isolated from UTI, seven (13.5%) from pyometra, and four (7.3%) from feces. From these, 17 (33.3%), one (1.9%), and three (5.5%), respectively, showed multiple resistance to five or more drugs.

A histological study of the seminal vesicle of the armoured catfish Corydoras aeneus

Most species of Corydoras exhibited a reproductive behaviour called 'T-position', and exhibited an accessory gland in the male genital tract, called the seminal vesicle. It appeared that both the structure and the composition of the fluid varied considerably between the species investigated. Consequently, different opinions were proposed regarding the possible role of seminal vesicle on this particular reproductive behaviour. Male adults of Corydoras aeneus were collected, anaesthetized, and samples of seminal vesicle were fixed in Bouin's solution. The sections were stained with haematoxylin-eosin and periodic acid Schiff. The seminal vesicle showed a system of anastomosed secretory tubules, forming a vesicular collective network, which gave rise to the vesicular ducts. The latter fused with the testicular efferent ducts and formed the spermatic ducts. Considering this fusion, when the sperm cells reached the spermatic ducts, the fluid produced at the seminal vesicle covered them. Histochemical studies evidenced the presence of neutral and acid glycosaminoglycans in the seminal fluid. Considering the reproductive behaviour of C. aeneus, it is believed that the protection associated with the immobilization of the sperm cells assures the sperm integrity during the passage through female's intestine until fertilization.

Evaluation of the Diramic system for urine cultures

O sistema Diramic foi avaliado para o diagnóstico das infecções do trato urinário (ITU). O sistema Diramic foi desenvolvido em Cuba e possibilita resultados de diagnóstico das infecções do trato urinário (ITU) em quatro horas e baseia-se na variação da turvação do crescimento microbiano no meio de cultura após incubação a 37ºC/4 horas. 396 amostras de urinas provenientes de ambulatórios e enfermarias do HC da FMB-UNESP-Botucatu/SP foram analisadas pelo sistema Diramic. O método da alça calibrada (AC) foi adotado como método de referência. A taxa de coincidência entre os dois métodos foi de 96,46% (382 amostras de urina), não havendo diferença significativa entre os resultados obtidos nos dois métodos. Os resultados para sensibilidade e especificidade foram 84,37 e 98,80% respectivamente e 10 resultados no Diramic foram falsos negativos (2,5%) e 4 falso positivos (1,01%). Os microrganismos identificados nas urinas positivas foram Escherichia coli (68,75%), Klebsiella pneumoniae (10,94%), leveduras (6,25%), Pseudomonas aeruginosa (4,69%), Enterobacter cloacae (3,12%) e Proteus mirabilis, Staphyloccocus coagulase negativo, Morganella morganii e Citrobacter freundii também foram identificadas (1,56% para cada espécie). O método Diramic foi eficiente na triagem das urinoculturas, porém verificou-se algumas restrições quanto ao diagnóstico das infecções do trato urinário quando causadas por leveduras e em pacientes submetidos a antibioticoterapia.

Morphology and histology of male and female reproductive systems in the inseminating species Scoloplax distolothrix (Ostariophysi : Siluriformes : Scoloplacidae)

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Virulence factors of uropathogenic Escherichia coli from a University Hospital in Ribeirão Preto, São Paulo, Brazil

O objetivo do trabalho foi determinar a ocorrência de fatores de virulência, tais como, a expressão de fímbrias, produção de hemolisina, colicina e aerobactina em 100 cepas de Escherichia coli isoladas de pacientes ambulatoriais e hospitalizados de um hospital universitário de nível de atendimento terciário, entre os meses de julho e agosto de 2000, que apresentavam sinais clínicos e laboratoriais de infecção do trato urinário (ITU). Foram pesquisados os genes pap, afa e sfa responsáveis pela expressão de fímbrias através da técnica de PCR. A freqüência dos fatores de virulência entre as cepas estudadas foi de 96,0%, 76,0% e 24,0% para hemolisina, aerobactina e colicina respectivamente, e a prevalência dos genes para os sistemas de adesinas fimbriais foi de 32,0%, 19,0% e 11,0% para os genes pap, sfa e afa respectivamente. As cepas isoladas dos pacientes ambulatoriais exibiram um número maior de fatores de virulência quando comparadas com aquelas provenientes de indivíduos hospitalizados.

Lactate in Bitches with Pyometra

Lactate is a compound produced by the anaerobic metabolism of glucose, and hyperlactataemia occurs when the rate of production of lactate exceeds the rate of elimination. This occurs in situations of hypoxia and tissue hypoperfusion. Lactate has been considered a useful prognostic indicator in critically ill patients. Pyometra is a disease of adult female dogs characterized by inflammation of the uterus with an accumulation of exudate, which occurs during the luteal phase. It is one of the most common diseases that occur in the genital tract of female dogs. A total of 31 dogs were diagnosed with pyometra. The diagnosis was confirmed at ultrasonography. of the 31 dogs, 25 females had open cervix pyometra and six had closed cervix pyometra. Plasma lactate concentrations were determined by an enzymatic colorimetric method. The average concentration (+/- SD) of plasma lactate in all 31 bitches with pyometra was 3.55 +/- 0.46 mm. Healthy dogs had plasma lactate concentrations between 0.3 and 2.5 mm (mean +/- SD). Concentrations ranged from 0.8 to 2.9 mm when plasma lactate was measured with a portable device and 0.42.6 mm with the blood gas analyser. Even though plasma lactate values vary between several studies and equipment used to measure concentrations, our results for dogs with pyometra are higher indicating hyperlactataemia (Thorneloe et al. , Can Vet J 48, 283288). Plasma lactate in dogs with closed cervix pyometra was mean +/- SD and in dogs with open cervix pyometra, it was mean +/- SD. The plasma lactate concentration in dogs with pyometra was higher than in healthy bitches, and there was no influence of patency of the cervix on the concentration of plasma lactate concentrations. Plasma lactate concentrations were similar for animals with open and closed pyometra (3.54 +/- 0.52 to 3.64 +/- 1.03 mm).