Infecções Urinárias e Gravidez - Diagnóstico, Terapêutica e Prevenção

Objectives: Literature review of classification, epidemiology, pathophysiology, microbiology, clinical presentation, diagnosis, complications, treatment and prevention of urinary tract infections (UTI) in pregnancy. Data Sources and Review Methods: Bibliographic research in Medline, through PubMed and Medscape, of systematic reviews, observational studies, clinical guidelines, meta-analyses and randomized controlled trials published between January 1992 and December 2010. Results: Asymptomatic bacteriuria occurs in 2 to 10% of pregnant women, 30% of which will develop acute pyelonephritis if left untreated. Treatment of asymptomatic bacteriuria has been shown to reduce the risk of pyelonephritis in pregnancy. Therefore, screening and treatment of this form of UTI has become a standard of obstetrical care, although the ideal duration of the treatment is still controverse. Acute pyelonephritis is one of the most common medical complications of pregnancy and may be associated with maternal, obstetric and perinatal complications. There is no clear consensus in the literature regarding antibiotic choice or duration of therapy for symptomatic UTI. Increasing antibiotic resistance complicates the choice of empirical regimens and local resistance rates need to be taken into account when deciding the therapy. Considering the high rate of recurrence of UTI during pregnancy, prophylactic measures need to be taken in pregnant women who have already experienced UTI during their current pregnancy. Conclusions: Although UTI is a generally benign condition in non-pregnant women, it may be a potentially serious complication during pregnancy. Early diagnosis and treatment of UTI during pregnancy are mandatory and can prevent severe maternal and perinatal complications.

Genotypic characterization of virulence factors in Escherichia coli strains from patients with cystitis

Adhesins (P-fimbriae, S-fimbriae, type 1 fimbriae and afimbrial adhesin), toxins (α-hemolysin and cytotoxic necrotizing factor type 1), iron acquisition systems (aerobactin) and host defense avoidance mechanisms (capsule or lipopolysaccharide) have been shown to be prevalent in Escherichia coli strains associated with urinary tract infections. In this work, 162 Uropathogenic Escherichia coli (UPEC) strains from patients with cystitis were genotypically characterized by polymerase chain reaction (PCR) assay. We developed three multiplex PCR assays for virulence-related genes papC, papE/F, papG alleles, fimH, sfa/foc, afaE, hly, cnf-1, usp, cdtB, iucD, and kpsMTII, all of them previously identified in UPEC strains. The PCR assay results identified 158 fimH (97.5%), 86 kpsMTII (53.1%), 53 papC/papEF/papG (32.7%), 45 sfa (27.8%), 42 iucD (25.9%), 41 hly (25.3%), 36 usp (22.2%), 30 cnf-1(18.5%) and 10 afa (6.2%) strains. No strain was positive for cdtB. In this work, we also demonstrated that adhesins may be multiple within a single strain and that several virulence genes can occur combined in association.

Disfunção Vesical, Infecção Urinária e Refluxo Vesico-Ureteral na Criança

Tem sido descrita uma correlação estreita entre infecção urinária, refluxo vesico-ureteral e disfunção miccional na criança. A obstrução funcional causada pela disfunção vesical/uretral representa um elevado risco de recorrência de infecção urinária, indução e perpetuação do refluxo (mesmo após correcção cirúrgica) é de lesão renal permanente. A normalização da alteração da micção como problema primário, é crítica na resolução de problemas secundários tais como a infecção urinária e o refluxo vesico-ureteral. Trinta e sete crianças com refluxo vesicoureteral secundário a disfunção miccional foram detectadas, avaliadas e tratadas entre 1990 e 1995 (5 anos). Foram estudados 49 ureteres. A infecção urinária foi o sintoma revelador em todas as crianças, ocorrendo entre 1 mês e os 13 anos de idade (mediana de 3,5 anos). Todas as crianças eram neurologicamente e estruturalmenle normais, detectando-se sintomatologia sugestiva de instabilidade ou imaturidade vesical em 34 (91,9%) e sugestiva de obstrução esfiocteriana funcional em três (8,1 %). Os estudos ecográfico e cistográfico efectuado em todas as crianças, com o apoio do estudo urodinâmico em 17 (45,9%) confirmaram o diagnóstico clínico. Em 29 (78,4%) das crianças foi efectuada cintigrafia com DMSA (Addo Dimercaptosuccínico), revelando cicatriz renal em 26 (89,6%) dos exames. Foi incentivado um programa de reeducação vesical e regularização dos hábitos intestinais em todas as crianças, associado a terapêutica anticolinérgica em 23 (62,2%) e/ou relaxantes musculares em três (8,1%) e fenoxibenzamina e algaliação intermitente (1,5 mês) em uma (2,7%), para além da quimioprofilaxia da infecção urinária instituida em 34 (91,9%) das crianças. Houve resolução completa da infecção urinária em 35 (94,6%) com redução da sua frequência nas outras duas (5,4%), cura do RVU em 32 (86,5%) e melhoria em quatro (10,8%). Verificou-se desaparecimento dos sinais de disfunção vesical em 22 (59,5%) casos com redução na intensidade e frequência em 14 (37,8%), mantendo-se uma criança (2,7%) com síndrome de urgência e refluxo vesico-ureteral inalterado. Estes dados implicam que a detecção e traramento da disfunção vesical/esfincteriana, são essenciais em todas as crianças com o complexo infecção urinária recorrente e refluxo vesicoureteral.

Anal squamous carcinoma: a new AIDS-defining cancer? Case report and literature review

Squamous anal cell carcinoma is a rare malignancy that represents the 1.5% to 2% of all the lower digestive tract cancers. However, an increased incidence of invasive anal carcinoma is observed in HIV-seropositive population since the widespread of highly active antiretroviral therapy. Human papillomavirus is strongly associated with the pathogenesis of anal cancer. Anal intercourse and a high number of sexual partners appear to be risk factors to develop anal cancer in both sexes. Anal pain, bleeding and a palpable lesion in the anal canal are the most common clinical features. Endo-anal ultrasound is the best diagnosis method to evaluate the tumor size, the tumor extension and the infiltration of the sphincter muscle complex. Chemoradiotherapy plus antiretroviral therapy are the recommended treatments for all stages of localized squamous cell carcinoma of the anal canal in HIV-seropositive patients because of its high rate of cure. Here we present an HIV patient who developed a carcinoma of the anal canal after a long time of HIV infection under highly active antiretroviral therapy with a good virological and immunological response.

Recém-nascidos no serviço de urgência pediátrica: casuística de um ano

Introdução: Os serviços de urgência pediátrica são ambientes particularmente deletérios para os recém-nascidos. A identifica - ção precoce da doença neste grupo é fundamental, uma vez que o atraso diagnóstico pode estar associado a consequências graves. A maioria dos sistemas de triagem utilizados nos serviços de urgência pediátrica não possui algoritmos específicos para os recém-nascidos. Este estudo teve como objetivos caracterizar os recém-nascidos que recorreram ao serviço de urgência pediátrica, analisar a sua categorização pelo Sistema de Triagem de Manchester e identificar fatores de risco associados ao internamento. Métodos: Estudo retrospetivo efetuado pela análise dos dados de recém-nascidos admitidos no serviço de urgência pediátrica no ano de 2012. Resultados: Foram incluídos 779 recém-nascidos com idade média de 16,78 dias. Os principais diagnósticos de admissão foram as infeções respiratórias (21,9%) e a cólica do lactente (21%). Ficaram internados 22,2%, sendo os principais motivos as infe - ções respiratórias baixas (19,7%), os episódios de apparent life threatening event (15%) e as gastroenterites agudas (10,8%). A presença de hipoxemia e a realização de exames complementares no serviço de urgência pediátrica associaram-se a maior taxa de internamento (p = 0,001), assim como a atribuição de nível de prioridade “urgente”, “muito urgente” ou “emergente” pelo Sistema de Triagem de Manchester (p = 0,001). Discussão: O recurso dos recém-nascidos ao serviço de urgência pediátrica neste hospital ocorre maioritariamente por situa- ções de doença aguda. Os diagnósticos de admissão mais frequentes apresentam pouca gravidade clínica, já que contribuem pouco para o número de internamentos. Verifica-se uma correlação entre o nível de prioridade atribuído pelo Sistema de Triagem de Manchester e a necessidade de internamento neste grupo etário.

Precious transition metals: the importance of Zn2+, Mn2+ and Cu2+ in the human pathogen Enterococcus faecalis

Dissertation presented to obtain the Ph.D degree in Biology

Non-clinical isolates bring new findings on enterococcal virulence

Dissertation presented to obtain the PhD degree in Biology

Diagnóstico Pré-Natal das Anomalias do Tracto Urinário e Valor da Cistografia Miccional no Estudo Evolutivo Pós-Natal

A utilização sistemática da cistouretrografia miccional, no âmbito da investigação pós-natal das anomalias fetais do aparelho urinário, é controversa. A possibilidade de diagnosticar refluxo vesico-ureteral (RVU) antes de surgir infecção urinária é aliciante pela influência que pode ter na história natural da nefropatia do refluxo. Neste artigo, partindo de uma série de 116 casos de anomalia fetal do aparelho urinário num período de 5 anos, apresentam-se as características e evolução de 19 casos de RVU. A cistouretrografia miccional (CUM) efectuada em 109 casos (94%) identificou RVU em 19 (17.4%). Predominou o sexo masculino (5:1). Em 13 casos (19 unidades renais refluentes) o RVU era a única anomalia urinária detectada (grupo I); em 6 casos (8 unidades refluentes) o RVU estava associado a outras anomalias do tracto urinário (grupo II). Em 10 unidades refluentes do grupo I (55%) a avaliação ecográfica pós-natal foi considerada normal. Uma ecografia pós-natal normal não exclui a existência de RVU e, de acordo com os nossos resultados, todos os casos de dilatação da pélvis renal fetal beneficiam, no período pós-natal, de controlos ecográficos seriados e da realização de CUM. A confirmação precoce de RVU e a consequente instituição de quimioprofilaxia podem contribuir para a redução da morbilidade associada à infecção urinária e à nefropatia de refluxo.

Enterococcus faecalis V583 prophages: Dynamic interactions and contribution to bacterial pathogenic traits

Dissertation presented to obtain the Ph.D degree in Biology.

Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance

INTRODUCTION: This study aimed to determine the epidemiology of the three most common nosocomial infections (NI), namely, sepsis, pneumonia, and urinary tract infection (UTI), in a pediatric intensive care unit (PICU) in a developing country and to define the risk factors associated with NI. METHODS: We performed a prospective study on the incidence of NI in a single PICU, between August 2009 and August 2010. Active surveillance by National Healthcare Safety Network (NHSN) was conducted in the unit and children with NI (cases) were compared with a group (matched controls) in a case-control fashion. RESULTS: We analyzed 172 patients; 22.1% had NI, 71.1% of whom acquired it in the unit. The incidence densities of sepsis, pneumonia, and UTI per 1,000 patients/day were 17.9, 11.4, and 4.3, respectively. The most common agents in sepsis were Enterococcus faecalis and Escherichia coli (18% each); Staphylococcus epidermidis was isolated in 13% of cases. In pneumonias Staphylococcus aureus was the most common cause (3.2%), and in UTI the most frequent agents were yeasts (33.3%). The presence of NI was associated with a long period of hospitalization, use of invasive devices (central venous catheter, nasogastric tube), and use of antibiotics. The last two were independent factors for NI. CONCLUSIONS: The incidence of NI acquired in this unit was high and was associated with extrinsic factors.

Factors of poor prognosis of visceral leishmaniasis among children under 12 years of age. A retrospective monocentric study in Belo Horizonte, State of Minas Gerais, Brazil, 2001-2005

INTRODUTION: A major concern with the visceral leishmaniasis (VL) is its high lethality rate, even with proper treatment. Low age, prior malnutrition, disease duration prior to diagnosis, severe anemia, fever for more than 60 days, diarrhea and jaundice are known poor prognostic factors. The goals of this study are to describe the clinical and laboratory characteristics of VL among children under 12 years of age and to identify the factors associated with VL poor outcome. METHODS: Two hundred and fifty children under 12 years of age with confirmed VL admitted to Hospital João Paulo II (FHEMIG), Belo Horizonte, Brazil, between January 2001 and December 2005 were evaluated retrospectively. The primary outcome was the poor clinical evolution: sepsis, and/or pneumonia, and/or urinary tract infection, and/or of bleeding (expect epistaxis), and/or severe neutropenia (neutrophil < 500 cells/mm3). Odds ratio (crude and adjusted) and its 95% confidence interval for each variable were calculated. Values less than 0.05 were considered significant. RESULTS: Average age was 3.3 years (3.6 months-11.6 years), 71.2% were younger than 5 years and 47.2% lived in Metropolitan Area of Belo Horizonte. The mean fatality rate was 3.6%. Sixty-six (26.4%) patients presented poor evolution. After a multivariate analysis, age <18 months, abnormal respiratory physical examination on hospital admission, and platelets <85,000/mm3 remained associated with increased chance of poor evolution. CONCLUSIONS: The results suggest that patients aged between 12 and 18 months, with platelet counts bellow 85,000/mm3, and respiratory abnormalities at admission should be considered potentially severe.

Active surveillance to determine the impact of methicillin resistance on mortality in patients with bacteremia and influences of the use of antibiotics on the development of MRSA infection

Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is among the most important pathogens of nosocomial infections, mainly in intensive care units (ICUs), and accounts for 40-60% of all healthcare-associated S. aureus infections. We evaluated the incidence of nosocomial infection by S. aureus, identified the risk factors for MRSA infection, and evaluated the effect of resistance to methicillin on mortality in patients. Methods We conducted MRSA surveillance at a university hospital in Brazil from January 1, 2010, to December 31, 2010, and performed a retrospective case-control matched study to evaluate the frequency of subsequent MRSA bacteremia and death among patients. We evaluated and compared the risk factors between patients with MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infection. Results Sepsis was the most common cause of infection (17.7/1,000 patient-days), followed by surgical site (11.4/1,000 patient-days), pneumonia (4.1/1,000 patient-days), and urinary tract infection (2.4/1,000 patient-days). The significant risk factors were time of hospitalization, use of central vascular catheter (CVC), urinary catheter, nasogastric tube, parenteral nutrition, tracheostomy, mechanical ventilation, and previous antibiotic administration, the latter of which was the only independent risk factor for MRSA infection. Mortality was significantly higher in patients with MRSA. The number of antibiotics tested was not related to increases in the frequency of MRSA/1,000 patient-days. The incidence of mortality attributable to MRSA (bloodstream infection) BSI was 50%. Conclusions Surveillance results showed that the use of high levels of antibiotics was directly related to the development of MRSA infection, and the mortality attributable to MRSA in patients with bacteremia was significant.

Antibacterial, anti-swarming and anti-biofilm formation activities of Chamaemelum nobile against Pseudomonas aeruginosa

AbstractINTRODUCTION:Chamomile ( Chamaemelum nobile ) is widely used throughout the world, and has anti-inflammatory, deodorant, bacteriostatic, antimicrobial, carminative, sedative, antiseptic, anti-catarrhal, and spasmolytic properties. Because of the increasing incidence of drug-resistant bacteria, the development of natural antibacterial sources such as medical herbs for the treatment of infectious diseases is necessary. Extracts from different plant parts such as the leaves, flowers, fruit, and bark of Combretum albiflorum, Laurus nobilis , and Sonchus oleraceus were found to possess anti-quorum sensing (QS) activities. In this study, we evaluated the effect of C. nobile against Pseudomonas aeruginosa biofilm formationMETHODS:The P. aeruginosa samples were isolated from patients with different types of infection, including wound infection, septicemia, and urinary tract infection. The flowers of C. nobile were dried and the extract was removed using a rotary device and then dissolved in dimethyl sulfoxide at pH 7.4. The microdilution method was used to evaluate the minimum inhibitory concentration (MIC) of this extract on P. aeruginosa , and biofilm inhibition was assayed.RESULTS:Eighty percent of the isolated samples (16/20) could form a biofilm, and most of these were isolated from wound infections. The biofilm inhibitory concentration of the C. nobile extract was 6.25-25mg/ml, whereas the MIC was 12.5-50mg/ml.CONCLUSIONS:The anti-QS property of C. nobile may play an important role in its antibacterial activity, thus offering an additional strategy in the fight against bacterial infections. However, molecular investigation is required to explore the exact mechanisms of the antibacterial action and functions of this phytocompound.

Influence of a subinhibitory concentration of vancomycin on the in vitro expression of virulence-related genes in the vancomycin-resistant Enterococcus faecalis

ABSTRACTINTRODUCTION:Exposure to subinhibitory concentrations (SICs) of antimicrobials may alter the bacterial transcriptome.METHODS: Here, we evaluated the expression of nine virulence-related genes in vancomycin-resistant enterococci (VRE) urinary tract infection isolates grown at SICs of vancomycin.RESULTS:A Subinhibitory concentrations of vancomycin interferes with gene modulation, but does not affect the phenotype of a VRE strain in vitro .CONCLUSIONS:Subinhibitory concentrations of vancomycin may regulate the expression of virulence factors in vivo or contribute to the selection of vancomycin-resistant strains.

Relationship between plasma creatinine concentration and glomerular filtration in preterm newborn infants

Fluid management and dosage regimens of drugs in preterm infants should be based on the glomerular filtration rate. The current methods to determine glomerular flitration rate are invasive, time-consuming, and expensive. In contrast, creatinine clearance can be easy obtained and quickly determined. The purpose of this study was to compare plasma creatinine on the third and seventh day of life in preterm newborn infants, to evaluate the influence of maternal creatinine, and to demonstrate creatinine clearance can be used as a reliable indicator of glomerular filtration rate. We developed a prospective study (1994) including 40 preterm newborns (gestational age < 37 weeks), average = 34 weeks; birth weight (average) = 1840 g, in the first week of life. Inclusion criteria consisted of: absence of renal and urinary tract anomalies; O2 saturation 3 92%; adequate urine output (>1ml/kg/hr); normal blood pressure; absence of infections and no sympathomimetic amines in use. A blood sample was collected to determine plasma creatinine (enzymatic method) on the third and seventh day of life and creatinine clearance (CrCl) was obtained using the following equation: , k = 0.33 in preterm infant All plasma creatinine determinations showed normal values [third day: 0.78 mg/dl ± 0.24 (mean ± SD)and seventh day: 0.67 mg/dl ± 0.31 - (p>0.05)]. Also all creatinine clearance at third and seventh day of life were normal [third day: 19.5 ml/min ± 5.2 (mean ± SD) and seventh day: 23.8 ml/min ± 7.3 - (p>0,05)]. All preterm infants developed adequate renal function for their respective gestational age. In summary, our results indicate that, for clinical practice, the creatinine clearance, using newborn length, can be used to estimate glomerular filtration rate in preterm newborn infants.