ABSTRACT Naganishia albida (Cryptococcus albidus) is considered saprophytic fungi, and is rarely reported as a human pathogen. Cutaneous infections caused by non-neoformans cryptococcus are rare. We describe a case of an immunocompetent older male with cutaneous cryptococcosis caused by Naganishia albida following skin trauma, and conduct a literature review in PubMed, Lilacs, and Embase. Only six previous similar reports were found. The seven cases (including ours) were widely distributed geographically (Brazil, the US, the UK, Hungary, South Korea, and Iran), all males, and their ages varied, ranging from 14 to 86 years. Four individuals had underlying skin diseases (Sezary Syndrome, psoriasis, and skin rash without etiology) plus potentially immunosuppressive underlying conditions (diabetes mellitus, kidney transplantation, and the use of etanercept, adalimumab, and methylprednisolone). Cutaneous presentation was polymorphic, with lesions characterized as warts, ulcers, plaques, and even macules. Two patients presented disseminated disease. Serum cryptococcal antigen was negative in six patients, and diagnosis was made by fungal culture in all. There is a lack of data on optimal antifungal treatment and outcomes.

ABSTRACT Stenotrophomonas maltophilia has emerged as an important opportunistic pathogen in the last decade. Increased resistance to sulfamethoxazole/trimethoprim (SMX/TMP) has been reported in S. maltophilia strains in the past few years, leading to few therapeutic options. We conducted a prospective multicenter study at two Brazilian teaching hospitals that identified S. maltophilia isolates and evaluated their antimicrobial susceptibility profile, SMX/TMP resistance genes and their clonality profile. A total of 106 non-repeated clinical samples of S. maltophilia were evaluated. Resistance to SMX/TMP was identified in 21.6% of the samples, and previous use of SMX/TMP occurred in 19 (82.6%). PCR detected the sul1 gene in 14 of 106 strains (13.2%). Of these isolates, nine displayed resistance to SMX/TMP. The resistant strains presented a polyclonal profile. This opportunistic pathogen has emerged in immunocompromised hosts, with few therapeutic options, which is aggravated by the description of emerging resistance mechanisms, although with a polyclonal distribution profile.

ABSTRACT We described 235 bloodstream infection (BSI) episodes in 146 hematopoietic stem cell transplantation (HSCT) outpatients and evaluated risk factors for hospitalization and death. Records of outpatients presenting with positive blood cultures over a 5-year period (January 2005 to December 2008) were reviewed. Variables with p< 0.1 in bivariate analysis were used in a regression logistic model. A total of 266 agents were identified, being 175 (66.7%) gram-negative, 80 (30.3%) gram-positive bacteria and 9 (3.4%) fungi. The most common underlying disease was acute leukemia 40 (27.4%), followed by lymphoma non-Hodgkin 26 (18%) and 87 patients (59.6%) were submitted to allogeneic hematopoietic stem cell transplant (HSCT). BSI episodes were more frequent during the first 100 days after transplantation (183 or 77.8%), and ninety-one (38.7%) episodes of BSI occurred up to the first 30 days. Hospitalization occurred in 26% of the episodes and death in 10% of cases. Only autologous HSCT was protector for hospitalization. Although, central venous catheter (CVC) withdrawal and the Multinational Association of Supportive Care in Cancer (MASCC) score up to 21 points were protector factors for death in the bivariate analysis, only MASCC remained as protector.

ABSTRACT Staphylococcus aureus (SA) is a commensal habitant of nasal cavities and skin. Colonization by community-acquired methicillin-resistant SA (CA-MRSA) is associated with infections in patients who have not been recently hospitalized. The aim of this study is to determine the prevalence of MRSA colonization in an outpatient population, currently unknown in Brazil. Three-hundred patients or caregivers from two teaching hospitals were included. A questionnaire was applied and nasal swabs were obtained from patients. Swabs were inoculated in brain heart infusion (BHI) with 2.5% NaCl and seeded in mannitol. Suspicious colonies were subjected to MALDI-TOF MS Microflex™ identification. Antimicrobial susceptibility test for oxacillin was performed for SA-positive samples by microdilution. Polymerase chain-reactions for detection of mecA and coA genes were performed for resistant samples. Data about MRSA carriers were compared with non-carriers. There were 127 S. aureus isolates, confirmed by MALDI-TOF. Only seven (2.3%) were MRSA and positive for mecA and coA genes. Factors associated with MRSA carriage were African ethnicity, skin diseases or antibiotic use. The majority of them were from Dermatology clinics. Prevalence of MRSA colonization in individuals from the community was low in our study (2.3%). This finding raises the hypothesis of inter-household transmission of SA, although we did not find any association between MRSA-colonization and the shared use of personal objects. Given the low prevalence of MRSA carriers observed, empirical antimicrobial coverage for MRSA in community-acquired infections should be not necessary.

RESUMOS. maltophilia contem um novo gene qnr cromossômico denominado Smqnr que contribui para baixa resistência intrínseca a quinolonas. Descrevemos Smqnr em 13 isolados clínicos de S. maltophilia de dois hospitais brasileiros, ao longo do período de dois anos. Os isolados foram identificados pela API 20 NE (bioMérieux, França). Susceptibilidade pelo método de microdiluição dos seguintes antibióticos trimetroprim/sulfametoxazol, ciprofloxacina, levofloxacina, minociclina, ceftazidima, cloranfenicol e ticarcilina/clavulanato foi realizada segundo o CLSI. Detecção do gene de Smqnr foi realizada por PCR. A sequência de Smqnr foi comparada com aquelas depositadas no GenBank. Foi realizada eletroforese em gel de campo pulsado (PFGE) de todos os isolados. Treze isolados contendo Smqnr foram sequenciados e identificados três variantes do gene Smqnr. Todos os 13 isolados de Smqnr apresentaram diferentes padrões por PFGE. Este é o primeiro relato de Smqnr em isolados de S. maltophilia no Brasil.

SUMMARYStenotrophomonas maltophilia contains a novel chromosomally-encoded qnr gene named Smqnr that contributes to low intrinsic resistance to quinolone. We described Smqnr in 13 clinical isolates of S. maltophilia from two Brazilian hospitals, over a 2-year period. The strains were identified by API 20 NE (bioMérieux, France). Susceptibility by microdilution method to trimetroprim/sulfamethoxazole, ciprofloxacin, levofloxacin, minocycline, ceftazidime, chloramphenicol and ticarcillin/clavulanate was performed according to CLSI. PCR detection of Smqnr gene was carried out. The sequence of Smqnr was compared with those deposited in GenBank. Pulsed-field gel electrophoresis (PFGE) of all strains was performed. Thirteen Smqnr positives isolates were sequenced and three novel variants of Smqnr were identified. All 13 Smqnr isolates had distinguishable patterns by PFGE. This is the first report of Smqnr in S. maltophilia isolated in Brazil.

OBJECTIVE: The objective of this study was to evaluate whether the outcomes of carbapenem-resistant Acinetobacter infections treated with ampicillin/sulbactam were associated with the in vitro susceptibility profiles. METHODS: Twenty-two infections were treated with ampicillin/sulbactam. The median treatment duration was 14 days (range: 3-19 days), and the median daily dose was 9 g (range: 1.5-12 g). The median time between Acinetobacter isolation and treatment was 4 days (range: 0-11 days). RESULTS: The sulbactam minimal inhibitory concentration (MIC) ranged from 2.0 to 32.0 mg/L, and the MIC was not associated with patient outcome, as 4 of 5 (80%) patients with a resistant infection (MIC≥16), 5 of 10 (50%) patients with intermediate isolates (MIC of 8) and only 1 of 7 (14%) patients with susceptible isolates (MIC ≤4) survived hospitalization. CONCLUSION: These findings highlight the need to improve the correlation between in vitro susceptibility tests and clinical outcome.

Com a finalidade de estudar resistência a antimicrobianos, sorotipos e quadro clínico de Streptococcus pneumoniae em São Paulo, Brasil, foram avaliados 50 pacientes com culturas positivas: 7 foram considerados portadores e 43 infectados. Pneumonia e meningite foram as infecções mais freqüentes. A letalidade foi de 34% e doenças de base estiveram presentes em 70%. Resistência relativa a penicilina ocorreu em 24% e a resistência completa não foi detectada. Resistência a tetraciclina ocorreu em 32% e a sulfametoxazol/trimetoprim em 32% e houve uma cepa com sensibilidade intermediária a eritromicina. Não houve resistência a cloranfenicol, rifampicina ou vancomicina. Em 62% dos casos houve resistência a pelo menos uma das drogas testadas. Resultados de sensibilidade utilizando o E-teste resultaram semelhantes aos pelo método de diluição em ágar. Houve 24 sorotipos diferentes e 74% das cepas pertenciam a sorotipos vacinais incluindo todas as cepas resistentes a penicilina. Neste estudo Streptococcus pneumoniae causou infecções graves e houve uma alta incidência de resistência a drogas comumente utilizadas. Os autores recomendam a vigilância rotineira para resistência e o uso adequado de vacinação, além da restrição do uso inadequado de antimicrobianos.

To study resistance to antimicrobials, serotypes and clinical features of S. pneumoniae in S. Paulo, Brazil, 50 patients with a positive culture were evaluated: 7 were considered carriers and 43 had pneumococcal infections. Pneumonia and meningitis were the most commom infections. Mortality was 34% and underlying diseases were present in 70%. Relative resistance to penicillin occurred in 24% and complete resistance was not detected. Resistance to tetracycline was 32% and to sulfamethoxazole/trimethoprim 32%; one strain had intermediate susceptibility to erythromycin; no resistance was present for chloramphenicol, rifampin or vancomycin. Resistance to at least one of the drugs tested occurred in 62%. Results by the E-test for penicillin were similar to those by the agar dilution method. There were 24 different serotypes and 74% of the strains belonged to the 23-valent vaccine including all the penicillin-resistant strains. In this study S. pneumoniae caused severe infections and presented a high resistance rate to commonly used antimicrobials. Routine surveillance of resistance and the use of vaccination, as well as the restriction of inappropriate use of antimicrobials, are recommended in São Paulo, Brazil.

Na última década, a Legionella sp tem surgido como uma causa importante de pneumonia, tanto hospitalar quanto comunitária. Depois da detecção de um surto hospitalar numa unidade de Transplantados Renais, amostras de soro estocado em laboratório foram testadas para anticorpos anti-Legionella pneumophila sorogrupo 1. Cinco casos de Doença dos Legionários foram revistos. Os aspectos clínicos e laboratoriais eram semelhantes aos esperados em pneumonias de outras etiologias, mas houve a presença de icterícia importante em 2 casos. Dentre os 5 casos apresentados neste estudo, 2 foram de aquisição nosocomial e 3 foram comunitários. Já foi descrito um surto de infecção hospitalar por Legionella pneumophila sorogrupo 1 no nosso meio³. Em 1989 foi descrito o primeiro caso de pneumonia por Legionella pneumophila no nosso meio². No entanto pouca importância é dada a este agente etiológico quando se considera o tratamento empírico das pneumonias comunitárias. Este estudo sugere que a real incidência de pneumonia causada por Legionella sp está sendo subestimada e os autores enfatizam a importância de considerar a Doença dos Legionários no tratamento empírico de pneumonias adquiridas na comunidade

Legionella sp has been emerging over the last decade as an important cause of pneumonia both hospital and community-acquired. Following an outbreak in a Renal - Transplant Unit stocked serum was tested for antibodies against Legionella pneumophila serogroup 1, and 5 cases of Legionnaires' Disease were reviewed. Two of the cases were nosocomial and three cases were community - acquired. Clinical and laboratorial aspects were similar to those expected for other causes of pneumonia, however jaundice was encountered in two cases. This study suggests that the real incidence of pneumonia caused by Legionella sp is being underestimated and the authors emphasize the importance of considering Legionnaires' Disease when empirically treating community - acquired pneumonia