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We report a large, hospital-wide outbreak of pseudobacteremia by Paenibacillus spp. In total, 139 patients presented at least 1 positive blood culture during a 13-month period. Microbiological experiments indicated that contaminated nonsterile gloves were associated with the pseudobacteremia episodes. The outbreak was resolved by discontinuing the use of the involved brand.

Background Dermatophytoses affect more than 20% of the world's population and is caused by filamentous fungi, mainly of the genus Trichophyton. The species identification through microscopic direct examination and culture methods is challenging, with molecular presenting high sensitivity and specificity. Although there are several therapy options for dermatophyte infections, treatment failures and antifungal resistance are growing concerns. Objective This study aimed to identify clinical isolates of Trichophyton spp. from southern Brazil using molecular methods and determine their in-vitro antifungal susceptibility. Material and Methods Seventy-five isolates were identified through sequencing of the ITS region. The exposure to seven antifungals drugs was performed according to protocol M28-A2 of the Clinical and Laboratory Standards Institute (CLSI). Results Sixty-one isolates (81%) were identified as T. interdigitale, which differs from the epidemiological data present in the literature. Thirteen isolates were identified as T. rubrum and one as T. tonsurans. Terbinafine was the most effective antifungal, followed by itraconazole and voriconazole, which is in accordance with the results reported in previous studies. Conclusions The use of molecular methods to identify Trichophyton spp. clinical isolates and the performance of susceptibility tests are relevant to epidemiological data, identification of the emergence of antifungal resistance, and to help to translate the in-vitro antifungal susceptibility results into clinical practice.

Objectives Polymyxin resistance has been increasing in many regions, and appropriate determination of polymyxin susceptibility is now a major challenge worldwide. Many clinical laboratories rely on gradient diffusion methods to assess polymyxin susceptibility, although broth microdilution (BMD) is the only method currently recommended by the CLSI and EUCAST. The aim of this study was to assess the performance of the polymyxin B (PMB) Etest in a setting with a high prevalence of KPC-producing Klebsiella pneumoniae (KPC-KP). Methods A commercial Etest susceptibility testing method was evaluated and compared with the reference BMD method, considering isolates with a minimum inhibitory concentration (MIC) ≤2 mg/L for PMB as susceptible to this drug. A total of 310 clinical KPC-KP isolates were evaluated. Results Susceptibility was significantly higher by Etest compared with BMD (82.6% vs. 75.8%). The MIC50, MIC90 and modal MICs for PMB were 0.25, 32 and 0.25 mg/L (27.1%) by BMD and 0.5, 16 and 0.5 mg/L (49.7%) by Etest, respectively. Although categorical agreement was 90.0%, there was poor essential agreement (50.6%). A high rate (34.7%) of very major errors (VMEs) and a relatively low rate (2.1%) of major errors were found. Conclusion The considerable number of resistant isolates in this study allowed an accurate estimation of VME rates and, consequently, a more comprehensive assessment of susceptibility testing for polymyxins. Etest did not meet fully the acceptance criteria for US FDA requirements. These data do not support the use of this commercial method for determining PMB MICs in carbapenem-resistant Enterobacterales populations.

Two hundred isolates of Enterobacterales were tested by Rapid Polymyxins NP for the detection of polymyxin resistance and compared to the reference test broth microdilution (BMD). The sensitivity and specificity of the NP test were 98% and the results are faster than the BMD, decreasing from approximately 24 to 2 h.

In Enterobacteriaceae, the blaOXA-48-like genes have been identified on plasmids in different regions of the world. The OXA-370 is a plasmid-encoded OXA-48-like enzyme reported in two distinct regions of Brazil. Recently, we demonstrate that the blaOXA-370 gene is disseminated among several Enterobacteriaceae species and clones, indicating a high potential for dissemination. In this work, we described for the first time the complete nucleotide sequence of six plasmids harboring the blaOXA-370 gene. Complete DNA sequencing using the Illumina platform and annotation of the plasmids showed that they belonged to incompatibility groups IncX and had in average 70 kbp. The blaOXA-370 gene is located in a composite transposon containing four genes encoding transposases, named Tn6435. In this study, highly similar plasmids were detected in different Enterobacteriaceae genera.

The emergence of resistance to polymyxins in KPC-producing Klebsiella pneumoniae isolates has been a major clinical problem. This study evaluated the molecular mechanisms associated with polymyxin B (PMB) resistance that emerged in a previously PMB-susceptible KPC-2-producing K. pneumoniae during PMB therapy for a bloodstream infection in a neutropenic patient. The first isolate (PMB-susceptible) was obtained while the patient was receiving meropenem and other isolates were recovered from 2 sets of blood cultures in different dates while the patient was receiving PMB therapy (4 of 6 blood cultures bottles yielded isolates with full PMB resistance). The population analysis profile of the first isolate revealed the growth of resistant subpopulations with PFGE profile distinct from the parental isolate but undistinguishable from those obtained in subsequent days under PMB exposure. Resistant subpopulations were obtained from all parental PMB-susceptible and in one PMB-resistant isolate recovered from the patient. The molecular mechanism observed in the hetero-resistant subpopulations (IS1-like in mgrB-promoter region, increased rstB transcription with no mutation and non-identified mechanism) differed from those found in the PMB-resistant isolates, in which no mutation or transcriptional alterations were detected. This study showed that the mechanism of resistance to PMB that emerged during PMB therapy was not related to those observed in subpopulations selected in vitro from PMB-susceptible isolates recovered from the patient. The absence of mutations in the former isolates may be due to adaptive resistance occurred because of sub-optimal PMB levels as well as amikacin and meropenem used in combination.

In Enterobacteriaceae , the bla NDM genes have been found in many different genetic contexts, and a wide diversity of plasmid scaffolds bearing those genes has been found. In August 2013, we identified NDM-1-producing Escherichia coli and Enterobacter hormaechei strains from a single rectal swab sample from a patient hospitalized in Rio de Janeiro, Brazil, who had no history of travel abroad. Complete DNA sequencing using the Illumina platform and annotation of the two plasmids harboring the bla NDM-1 gene, one from each strain, showed that they belonged to incompatibility groups IncFII K and IncX3 and harbored a novel transposon named Tn 3000 . Similar genetic structures have been identified among other isolates in Brazil but also on plasmids from other continents. Our findings suggest that the bla NDM-1 gene may be transmitted by Tn 3000 in different parts of the world.

We evaluated the performance of OXA-48 K-SeT assay for detecting OXA-370 directly from spiked rectal swabs and blood culture vials. The limit of detection of this test was 10 4 UFC/mL for rectal swabs. Detection of the OXA-370-producing isolates was successfully achieved directly from positive blood culture vials independent of growing conditions.

OXA-370 is a recently described OXA-48 variant that has only been described in a few Enterobacter spp. and Klebsiella pneumoniae isolates. The purpose of this study is to assess the prevalence of OXA-370-producing isolates in carbapenem-nonsusceptible Enterobacteriaceae recovered from 28 hospitals from Brazil. Real-time PCR was used to determine the presence of bla NDM-1, bla KPC-2, bla VIM-type, bla GES-type, bla OXA-48-like, and bla IMP-type genes. A total of 4,451 Enterobacteriaceae were screened. The gene bla OXA-48-like was detected in 74 (2.5%) isolates, mostly of Enterobacter spp. (44.6% E. cloacae and 2.7% E. aerogenes) and Klebsiella spp. (31.1% K. pneumoniae and 6.7% K. oxytoca), followed by Escherichia coli, (6.7%), Morganella morganii, (2.7%), Citrobacter freundii (1.3%), Proteus mirabilis (1.3%), Providencia stuartii (1.3%), and Serratia spp. (1.3%). These isolates were from five hospitals, 67 (90.5%) from the hospital where the bla OXA-370 was first described. Sequencing of bla OXA-48-like was performed in 52 isolates, including E. cloacae, E. aerogenes, K. pneumoniae, K. oxytoca, E. coli, and C. freundii; all presenting 100% identity with bla OXA-370. PFGE revealed the presence of distinct clones among K. pneumoniae, E. cloacae, K. oxytoca, and E. coli. Susceptibility rates to meropenem, imipenem, and ertapenem among OXA-370-producing isolates were 92.3%, 78.8%, 7.7% respectively; the MIC50 /MIC90 were 0.38/2 mg/L and 1/3 mg/L for meropenem and imipenem respectively. Overall, antimicrobial susceptibility analysis suggests that OXA-370 lacks carbapenemase activity. Our study demonstrated that the bla OXA-370 gene is disseminated among several Enterobacteriaceae species and clones, indicating a high potential for dissemination.

Summary Chromoblastomycosis is a chronic mycosis that affects the skin and subcutaneous tissues caused by several genera of dematiaceous fungi. There is not a treatment of choice. Thus, tools that help guide clinical practice are fundamental. In this sense, antifungal activity tests in vitro could be useful. However, trials with chromoblastomycosis agents are scarce. The aim of this study was to evaluate both the in vitro susceptibility of 60 chromoblastomycosis agents to five antifungals and the combination of amphotericin B (AMB) and terbinafine (TRB). TRB, itraconazole (ITZ) and ketoconazole (KTZ) were, in this order, the drugs which showed better activity against the chromoblastomycosis agents. The less active drugs were voriconazole (VRZ) and AMB. The more differentiated group was Exophiala spinifera. Cladophialophora carrionii and Fonsecaea spp. are significantly more susceptible to KTZ than Phialophora verrucosa, whereas C. carrionii is significantly more sensitive to VRZ than P. verrucosa and E. spinifera. Assays in this direction allow the knowledge of the susceptibility of the causative agents which may help the management of patients with this disease. This study includes the largest number of these agents and of genera found in the literature.

The yeasts of the genus Candida infect skin, nails, and mucous membranes of the gastrointestinal and the genitourinary tract. The aim of this study was to determine the prevalence of dermatomycoses caused by Candida spp., and their etiological aspects in the metropolitan area of Porto Alegre, Brazil. A retrospective study with data obtained from tertiary hospital patients, from 1996 to 2011, was performed. The analyzed parameters were date, age, gender, ethnicity, anatomical region of lesions, and the direct examination results. For all the statistical analyses, a = 0.05 was considered. Among positive results in the direct mycological examination, 12.5% of the total of 4,815 cases were positive for Candida spp. The angular coefficient (B) was -0.7%/ year, showing a decrease over the years. The genus Candida was more prevalent in women (15.9% of women versus 5.84% of men), and in addition, women were older than men (54 versus 47 years old, respectively). There was no difference between ethnic groups. The nails were more affected than the skin, with 80.37% of the infections in the nails (72.9% in fingernails and 7.47% in toenails). Our study corroborates the literature regarding the preference for gender, age, and place of injury. Moreover, we found a decrease in infection over the studied period.

We report a case of an 80-year-old Brazilian man, farmer, with lesions on the dorsum of the hand. A direct mycological examination, cultivation and microculture slide observation was performed. The sequencing of ITS1-5.8S rDNA-ITS2 region was carried out and the etiological agent confirmed as Exophiala spinifera. The in vitro susceptibility of this isolate to antifungal agents alone and in combination was evaluated. This is the third case of phaeohyphomycosis caused by Exophiala spinifera in Brazil.

FUNDAMENTOS: As dermatofitoses apresentam alta prevalência na população em geral e, principalmente, em pacientes com insuficiência renal crônica, necessitando tratamento com antifúngicos tópicos e/ou sistêmicos, cuja eficácia precisa ser avaliada. Estudos in vitro para avaliar a ação de antifúngicos são raros, especialmente, em fungos filamentosos. OBJETIVO: Avaliar o perfil de suscetibilidade de diferentes espécies de dermatófitos, isolados de pacientes com insuficiência renal crônica, em relação a nove antifúngicos disponíveis comercialmente para o tratamento de dermatofitoses. MÉTODO: Analisaram-se 26 isolados de dermatófitos de pacientes com insuficiência renal crônica em relação a nove antifúngicos (cetoconazol, ciclopirox olamina, fluconazol, griseofulvina, itraconazol, miconazol, piroctona olamina, terbinafina e tioconazol) pelo método de microdiluição em caldo proposto pelo Clinical and Laboratory Standards Institute (CLSI), com modificações para dermatófitos. RESULTADOS: Entre os antifúngicos testados, a terbinafina e o tioconazol obtiveram os melhores resultados de sensibilidade e o fluconazol apresentou baixa atividade, especialmente para as amostras da espécie M. gypseum. O ciclopirox olamina, apesar de menos eficaz que a terbinafina, também mostrou resultados satisfatórios. CONCLUSÕES: De modo geral, o perfil de sensibilidade dos antimicóticos testados seguiu o padrão de resultados mostrados por estudos anteriores, ratificando a necessidade de conhecimento da espécie causadora de dermatofitose, devido à variação do perfil de suscetibilidade entre as espécies. Além disso, nossos resultados demonstram a importância da realização de ensaios de sensibilidade in vitro, pois alguns isolados da mesma espécie apresentaram diferente perfil de sensibilidade. BACKGROUND: The prevalence of dermatophytosis in the general population is high, particularly in patients with chronic renal failure. Treatment requires the use of topical and/or systemic antifungal drugs. The efficacy of antifungal agents for the treatment of dermatophytosis has yet to be evaluated. Studies evaluating the in vitro activity of antifungal agents are rare, particularly in filamentous fungi. OBJECTIVE: To evaluate the susceptibility profile of different species of dermatophytes isolated from patients with chronic renal failure to nine antifungal drugs available on the market for the treatment of dermatophytosis. METHODS: Twenty-six isolates of dermatophytes obtained from patients with chronic renal failure were analyzed with respect to their susceptibility to nine antifungal agents (ketoconazole, ciclopirox olamine, fluconazole, griseofulvin, itraconazole, miconazole, piroctone olamine, terbinafine and tioconazole), using the broth microdilution method proposed by the Clinical and Laboratory Standards Institute (CLSI) and adapted for dermatophytes. RESULTS: Of the antifungal agents tested, the best results in terms of sensitivity were found with terbinafine and tioconazole, while the antifungal activity of fluconazole was found to be weak, particularly against strains of M. gypseum. Ciclopirox olamine, although less effective than terbinafine, also yielded satisfactory results. CONCLUSIONS: In general, the sensitivity profile of the antifungal agents tested in this study was similar to results obtained in previous studies, confirming the need to determine which species is causing the dermatophytosis given that antifungal susceptibility varies from one species to another. Furthermore, the present findings show the importance of conducting in vitro sensitivity tests, since the sensitivity profile may differ among isolates of the same species.

Summary Objectives To evaluate the emergence of New Delhi metallo-β-lactamase 1 (NDM-1)-producing Enterobacteriaceae isolates in Brazil. Methods From April to October 2013, following the detection of the first NDM-1-producing isolate, a surveillance study was performed for the detection of bla NDM-1 among Enterobacteriaceae isolates with reduced susceptibility to carbapenems in 17 hospitals of Porto Alegre, Brazil. Real-time PCR was used to determine the presence of carbapenemase genes, which were further sequenced. Clonal relatedness was assessed by pulsed-field gel electrophoresis (PFGE). Results A total of 1134 isolates were evaluated. bla NDM-1 was detected in 11 (0.97%) isolates: nine Enterobacter cloacae complex (eight belonging to a single clone recovered from two distinct hospitals and the other strain from a third hospital) and two Morganella morganii (belonging to a single clone recovered from one hospital). Most isolates presented high-level resistance to carbapenems. Conclusions NDM-1-producing Enterobacteriaceae have emerged rapidly in the hospitals of the Brazilian city where they were first detected. The emergence of NDM-1 in Brazil is of great concern, since it is a severe threat to antimicrobial therapy against Enterobacteriaceae in this country.

SUMMARY Pityriasis versicolor is the most common of the diseases caused by Malasseziayeasts. The aim of this study is to determine the prevalence of pityriasis versicolor and its etiological aspects in the metropolitan area of Porto Alegre, Brazil. A retrospective crosssectional study with data from patients of a reference hospital from 1996 to 2011 was performed. Collected data included: date, age, gender, ethnicity, anatomical region of lesion and the direct mycological examination results. Among the positive results in the direct mycological examination, 5.8% (2,239) were positive for pityriasis versicolor. The angular coefficient (B) was -0.3%/year, showing a decrease over the years. The disease was more prevalent in men (7.1% of men versus 5.1% of women that underwent the direct mycological examination); younger age (median 31 years old); "pardo" and black people (3.7% more than expected in the sample); trunk (73.44% of the affected anatomic sites). Lesions in rare sites (groin, genitals, legs, feet and hands) were also observed in this study. In conclusion, due to the decrease in the prevalence of pityriasis versicolor, long-term epidemiological studies in the metropolitan area of Porto Alegre, Brazil, are needed to continue the monitoring of this disease. RESUMO Pitiríase versicolor é a mais comum das doenças causadas pelas leveduras do gênero Malassezia. O objetivo do trabalho foi determinar a prevalência de pitiríase versicolor e seus aspectos etiológicos na região metropolitana de Porto Alegre, Brasil. Foi realizado um estudo retrospectivo transversal com dados de pacientes de hospital de referência entre 1996 a 2011. Os dados coletados foram: data, idade, gênero, etnia, local anatômico da lesão e resultados do exame micológico direto. Dentre os resultados positivos do exame micológico direto, 5,8% (2.239) foram positivos para pitiríase versicolor. O coeficiente angular (B) foi -0,3%/ ano, mostrando uma diminuição ao longo dos anos. A doença foi mais prevalente em homens (7,1% dos homens versus 5,1% das mulheres que se submeteram ao exame micológico direto); jovens (mediana de 31 anos); pardos e pretos (3,7% acima do esperado para a amostra); tronco (73,4% dos locais anatômicos afetados). Lesões em locais raros (virilha, genitálias, pernas, pés e mãos) também foram observadas no estudo. Em conclusão, devido à diminuição da prevalência de pitiríase versicolor, estudos epidemiológicos de longo prazo são necessários para continuar o monitoramento da doença na região metropolitana de Porto Alegre, Brasil.

Introduction: Dermatophytoses are considered a public health problem. The objectives of this study were to determine the evolution of their prevalence in the metropolitan area of Porto Alegre, Brazil, and to analyze the dermatophyte species distribution according to body site and demographic characteristics of the patients. Methodology: This work was a retrospective analysis of data from patients attending a tertiary care hospital during 1996–2011. Results: There were 9,048 cases with cultures positive for dermatophytes. Trichophyton rubrum occurred in 59.6% of the cases, followed by Trichophyton interdigitale (34%), Microsporum canis (2.6%), Epidermophyton floccosum (1.5%), Microsporum gypseum (1.3%), and Trichophyton tonsurans (0.9%). The angular coefficients for T. interdigitale , E. floccosum , T. rubrum , and M. canis were +1.119, +0.211, -0.826 and -0.324% per year, respectively. Males presented higher prevalence of infection (79.3% versus 53.9%). Tinea unguium occurred in 48.5% of the cases, followed by tinea pedis (33.1%). T. rubrum was the predominant species in all regions of the body except the scalp, where M. canis was responsible for 75% of the cases. Conclusion: Monitoring of the evolution of dermatophytosis tracks changes in prevalence over the years and may assist practical measures for the public health control of this disease.

Sporotrichosis is a subacute or chronic mycosis caused worldwide by the dimorphic species complex, Sporothrix schenckii. We studied 85 isolates recovered in Brazil to verify their identification and evaluate their in vitro antifungal susceptibility patterns. Based on phenotypic tests (microscopic features, ability to grow at 30 ◦ Ca nd 37 ◦ C, colony diameters, as well as assimilation of sucrose and raffinose) and molecular assays (amplification of a fragment of the calmodulin gene), the strains were identified as S. schenckii, S. brasiliensis and S. globosa, with a predominance of S. schenckii isolates. There was 37.7% disagreement between the phenotypic and genotypic identification methodologies. In general, terbinafine was the most active drug, followed by ketoconazole and itraconazole, and the less active fluconazole and voriconazole. Five isolates (one S. globosa and four S. schenckii) were found to be itraconazole-resistant strains but, in general, there were no differences in the in vitro antifungal susceptibility profiles among the Sporothrix species.

The class D β-lactamase OXA-48 ([1][1]) and its variants have emerged as important determinants of carbapenem resistance in Enterobacteriaceae, representing a public health concern in some countries ([2][2][–][3][4][4]). The objective of this study was to report a new OXA-48 variant. In May 2013

The prevalence of dermatophytosis in the general population is high, particularly in patients with chronic renal failure. Treatment requires the use of topical and/or systemic antifungal drugs. The efficacy of antifungal agents for the treatment of dermatophytosis has yet to be evaluated. Studies evaluating the in vitro activity of antifungal agents are rare, particularly in filamentous fungi.To evaluate the susceptibility profile of different species of dermatophytes isolated from patients with chronic renal failure to nine antifungal drugs available on the market for the treatment of dermatophytosis.Twenty-six isolates of dermatophytes obtained from patients with chronic renal failure were analyzed with respect to their susceptibility to nine antifungal agents (ketoconazole, ciclopirox olamine, fluconazole, griseofulvin, itraconazole, miconazole, piroctone olamine, terbinafine and tioconazole), using the broth microdilution method proposed by the Clinical and Laboratory Standards Institute (CLSI) and adapted for dermatophytes.Of the antifungal agents tested, the best results in terms of sensitivity were found with terbinafine and tioconazole, while the antifungal activity of fluconazole was found to be weak, particularly against strains of M. gypseum. Ciclopirox olamine, although less effective than terbinafine, also yielded satisfactory results.In general, the sensitivity profile of the antifungal agents tested in this study was similar to results obtained in previous studies, confirming the need to determine which species is causing the dermatophytosis given that antifungal susceptibility varies from one species to another. Furthermore, the present findings show the importance of conducting in vitro sensitivity tests, since the sensitivity profile may differ among isolates of the same species.