Infections In Portugal Research Articles

Serotypes 1, 7F and 19A became the leading causes of pediatric invasive pneumococcal infections in Portugal after 7 years of heptavalent conjugate vaccine use

We characterized 353 isolates responsible for pediatric invasive pneumococcal infections (IPD) in Portugal between 2006 and 2008. Serotypes included in the seven-valent conjugate vaccine (PCV7) accounted for 17% of IPD. Serotypes 1, 7F and 19A were the most frequent causes of IPD and the later consolidated as the most frequent serotype among erythromycin and penicillin non-susceptible isolates. Serotype 1 was associated with older children and empyemas, while serotype 19A was associated with IPD in younger (<2 years) children. The higher valency vaccines PCV10 and PCV13 have a potentially superior coverage, 55% and 83% respectively, but non-vaccine serotypes are emerging as important causes of IPD. A decline of resistance with patient age was noted. Comparing with previous data from Portugal, this study showed a continued decline of PCV7 serotypes and that overall resistance has stabilized following the initial decline of the first post-PCV7 years.

Sexually transmitted infections and related sociodemographic factors in Lisbon’s major Venereology Clinic: a descriptive study of the first 4 months of 2007

To assess the prevalence of sexually transmitted infections (STI) and relationships between them and sociodemographic/behavioural data in the major Venereology Clinic in Lisbon. Every patient attending this STI clinic for the first time in the first 17 weeks of 2007 was enrolled in this study. Early syphilis, Chlamydia trachomatis infection, gonorrhoea, human immunodeficiency virus (HIV) first diagnosed and genital warts were considered for the study of statistical associations with sociodemographic/behavioural variables or other STI. Data were analysed with an exact significance level of 5%. A total of 743 patients were included. In women (n = 296), the only significant associations found were for C. trachomatis and being non-Caucasian (OR = 2.13, CI 1.17-3.9) or being younger than 25 years (OR = 1.9, CI 1.31-2.79). Men who have sex with men (176 of the 447 male patients) contributed to 39% of the STI, although more than half of the early syphilis, gonorrhoea and HIV cases were diagnosed in this group. Despite its limitations, our study allows some insight into the relationships between sociodemographic factors and STI in a selected population attending Lisbon's major Venereology Clinic. The results were similar to those of other European studies and to recent trends in STI, but differ in the association between C. trachomatis infection and non-Caucasian women, which is similar to cities with significant African minorities. Attention should be given to the associations found between men who have sex with men and STI such as gonorrhoea, syphilis and HIV, as these associations can lead to serious difficulties in the control of HIV infection in Portugal.

The Viriato Study

The Viriato study is a prospective, multicentre laboratory-based surveillance study of antimicrobial susceptibility in which 30 microbiology laboratories throughout Portugal are asked to isolate, identify and submit to a central laboratory for testing Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis responsible for community-acquired lower respiratory tract infections and Streptococcus pyogenes from tonsillitis. To monitor changes in antimicrobial resistance patterns of these frequent respiratory pathogens. Susceptibility was determined by disk diffusion (Kirby-Bauer) or using Etest strips following the Clinical and Laboratory Standards Institute guidelines. From 1999 to 2007 over 13 900 isolates were analysed. Among S. pneumoniae penicillin non-susceptibility decreased from 25% in 1999 to 18% in 2007 (p = 0.002) but resistance to macrolides showed a steady increase, reaching 20% in the last 6 years. Resistance to amoxicillin and the quinolones remained stable and very low (1-2%) throughout the study period. Antimicrobial resistance among H. influenzae and M. catarrhalis remained stable. The most significant resistance was to ampicillin, of 10-12% and greater than 80%, respectively, as a result of the production of beta-lactamases. Macrolide resistance among S. pyogenes was stable during 1999-2003 (20-23%) but after 2003 there was a steady decline in resistance, which in 2007 reached 10%. The Viriato surveillance study showed that penicillin remains the most active antimicrobial agent against S. pyogenes causing tonsillitis, and amoxicillin-clavulanate and the quinolones are the most active in vitro simultaneously against S. pneumoniae, H. influenzae and M. catarrhalis responsible for community-acquired lower respiratory tract infections in Portugal.

Denmark 14 -230 Clone as an Increasing Cause of Pneumococcal Infection in Portugal within a Background of Diverse Serotype 19A Lineages

Pneumococci of serotype 19A are increasingly found to be the cause of infection in various geographic regions. We have characterized the serotype 19A isolates (n = 288) found among pneumococci responsible for infections (n = 1,925) and pneumococci recovered from asymptomatic carriers (n = 1,973) in Portugal between 2001 and 2006. We show that despite the existence of serotype 19A clones that have a greater potential to cause invasive disease or an enhanced colonization capacity, the lineage that is increasing as a cause of infection in Portugal is a multiresistant clone that is competent at both. The expanding Denmark(14)-230 clone found in Portugal is disseminated in other Mediterranean countries, where it is also increasingly responsible for invasive infections in both children and adults. The lineages driving the rise of serotype 19A infections in Asia and the United States (sequence type 320 [ST320] and ST199) are either absent or account for only a small proportion of isolates in Portugal. These data highlight the importance of locally circulating clones with the ability to compete in the nasopharyngeal niche in the emergence of the serotype 19A lineages which are an increasing cause of infection in various geographic regions.

First survey for Babesia bovis and Babesia bigemina infection in cattle from Central and Southern regions of Portugal using serological and DNA detection methods

Incidence of bovine babesiosis in Portugal is currently unknown. In this study, a first survey of Babesia bovis and Babesia bigemina infection in cattle was carried out using blood samples from 406 clinically healthy individuals from different districts from Central and Southern regions of Portugal and analyzed by indirect enzyme linked immunosorbent assay (iELISA) and nested polymerase chain reaction (nPCR). Overall, serological testing revealed that 79% and 52% of cattle were positive for B. bovis and B. bigemina antibodies, respectively, whereas nPCR testing detected 71% and 34% cattle infected with B. bovis and B. bigemina protozoan, respectively. This is the first report of the prevalence of B. bovis and B. bigemina in cattle obtained by serological and DNA analysis studies in Central and Southern regions of Portugal. These data suggests high incidence of Babesia sp. infection in Portugal and can be used for designing adequate control programs.

Epidemiological study of genotypes of hepatitis B virus in northern Portugal

While the overall prevalence of hepatitis B virus (HBV) infection in Portugal is around 1%, there are no published studies examining HBV genotypes in this country. This study aimed to survey HBV genotypes in the northern Portugal and to examine the possible associations between genotypes and gender, viral transmission routes, viral markers, viral load, and biochemical tests of liver function. The study sample consists of 340 patients with HBV infection of whom 42.9% were women. Tests were carried out for HBV genotypes and biochemical liver function while demographic information, including alcohol intake, was obtained from the patient files. The results indicate the predominance of genotype D (60.3%) and genotype A (31.5%). Intrafamilial transmission was predominant in female patients, while males were infected in equal proportions by perinatal, sexual, and intrafamilial transmission. Absence of HBeAg was found in a significantly smaller proportion of female patients with genotype D as compared to A (56.6% vs. 82.1%, P = 0.028). High viral load was associated significantly and independently with genotype D and HBeAg. Both alanine and aspartate aminotransferases (ALT and AST) were associated with gender and HBeAg. Thus, genotypes A and D were found to be the most prevalent in the north of Portugal. Patients infected with genotype D had higher levels of HBV DNA. HBeAg was associated with genotype D, viral load, and ALT and AST.

Resistance to bacitracin inStreptococcus pyogenesfrom oropharyngeal colonization and noninvasive infections in Portugal was caused by two clones of distinct virulence genotypes

During 2000-2007 in Lisbon, we identified 45 bacitracin-resistant Streptococcus pyogenes isolates among 1629 isolates: 24 from oropharyngeal healthy carriers (out of 1026), 21 from patients with noninvasive infections (out of 559) and zero from invasive infections (out of 44). Forty-four of those isolates, mainly of colonization, are low-level bacitracin-resistant members of the cMLS(B)-macrolide-resistant and tetracycline-susceptible emm28/ST52 clone previously detected in Europe, but only among clinical samples. One high-level bacitracin-resistant isolate, associated with a tonsillitis/pharyngitis episode, is cMLS(B)-macrolide-resistant and tetracycline-resistant member of the emm74/ST120 lineage, which was not previously known to include bacitracin-resistant isolates. The bcrABDR operon encoding an ATP-binding cassette transporter in Enterococcus faecalis was not detected among these bacitracin-resistant S. pyogenes strains. Virulence profiling indicated that genes coding for exotoxins and superantigens seem to be clone specific. This study provides an increased knowledge about specific bacitracin-resistant S. pyogenes strains, which may be useful in future investigations aiming to understand the mechanism(s) leading to bacitracin resistance and the cause(s) for differences in colonization and/or dissemination potential.

20 Years of HIV‐2 Infection in Portugal: Trends and Changes in Epidemiology

20 Years of HIV‐2 Infection in Portugal: Trends and Changes in Epidemiology

Detection of the Pandemic O25-ST131 Human Virulent Escherichia coli CTX-M-15-Producing Clone Harboring the qnrB2 and aac ( 6 ′)- Ib-cr Genes in a Dog

Detection of the Pandemic O25-ST131 Human Virulent <i>Escherichia coli</i> CTX-M-15-Producing Clone Harboring the <i>qnrB2</i> and <i>aac</i> ( <i>6</i> ′)- <i>Ib-cr</i> Genes in a Dog

Lymphangitis in aPortuguese Patient Infected withRickettsia sibirica

Lymphangitis in a<b />Portuguese Patient Infected with<i>Rickettsia sibirica</i>

Visceral leishmaniasis and HIV infection in the HAART era

Visceral Leishmaniasis is an endemic infection in Portugal, as well as in other Mediterranean basin countries, where it has become a frequent complication of HIV infection. There are several studies published about Leishmania/HIV co-infection, however some particularities of its epidemiology, pathogenesis and especially of its treatment and prophylaxis remain unclear and undefined. The authors review some aspects of this co-infection, particularly epidemiology, clinical classic manifestations and laboratory features, diagnosis, treatment, prophylaxis and prevention and report the casuistic of the Infectious Diseases Department of the University Hospital of Coimbra during the last ten years (1996-2006) in the HAART (<<highly active antiretroviral therapy>>) era. Visceral Leishmaniasis behaves as an opportunistic infection in HIV-infected patients and should be considered as an AIDS-defining disease. Nowadays and according to World Health Organization, VL is the second most important protozoan disease and one of the most neglected; therefore the establishment of treatment and prophylaxis guidelines is urgent.

Analysis of group B streptococcal isolates from infants and pregnant women in Portugal revealing two lineages with enhanced invasiveness.

The populations of group B streptococcus (GBS) associated with vaginal carriage in pregnant women and invasive neonatal infections in Portugal were compared. GBS isolates were characterized by serotyping, pulsed-field gel electrophoresis (PFGE) profiling, and multilocus sequence typing (MLST). Serotypes III and V accounted for 44% of all colonization isolates (n = 269), whereas serotypes III and Ia amounted to 69% of all invasive isolates (n = 64). Whereas serotype Ia was associated with early-onset disease (EOD), serotype III was associated with late-onset disease (LOD). Characterization by PFGE and MLST identified very diverse populations in carriage and invasive disease. Serotype Ia was represented mainly by a single PFGE cluster defined by sequence type 23 (ST23) and the infrequent ST24. In contrast, serotype III was found in a large number of PFGE clusters and STs, but a single PFGE cluster defined by ST17 was found to be associated with invasive disease. Although serotype III was associated only with LOD, ST17 showed an enhanced capacity to cause both EOD and LOD. Our data reinforce the evidence for enhanced invasiveness of ST17 and identify a lineage expressing serotype Ia capsule and represented by ST23 and ST24 as having enhanced potential to cause EOD.

Molecular epidemiology and prevalence of drug resistance-associated mutations in newly diagnosed HIV-1 patients in Portugal

Background Drug resistance transmission in newly diagnosed, drug-naïve HIV-1 infected individuals has been previously reported, with rates ranging from 5 to 27%. The aim of this study is to investigate the prevalence of resistance-associated mutations in drug-naïve, newly diagnosed patients, as well as monitoring the diversity of HIV-1 strains circulating in Portugal. Methods One hundred eighty samples from newly diagnosed patients were prospectively collected during 2003, according to the distribution of HIV-1 infections in Portugal. Epidemiological, clinical and laboratory data was collected using a standardized form. Population sequencing was performed using an automated sequencer (ABI Prism 3100, Applied Biosystems) and a commercially available assay (ViroSeq HIV-1 Genotyping System, v2.0, Abbott). Stanford HIV Sequence Database was used for interpretation of resistance data; subtyping was performed using the REGA Subtyping Tool. When subtype was unassigned, further analysis was done using an alignment with reference sequences, and phylogenetic tools like Simplot and PHYLIP. Mutations listed by the International AIDS Society-USA were considered, except E44D and V118I. Results Patient population included 124 males (69%) and 56 females (31%), the median age being 35. Western Europe was the main region of origin (77.2%), followed by Africa (18.3%), South America (2.8%) and Asia (1.1%). The most common route of transmission was heterosexual contact (54.4%), followed by intravenous drug use (20%), homo/bisexual individuals (19.4%) and blood transfusion (0.6%). The commonest subtypes were B (41.7%) and G (29.4%), while other non-B subtypes rated 12.8% and recombinant forms represented 16.1% of the samples. Fourteen patients (7.78%) were identified as carrying resistance-associated mutations. Ten were resistant to drugs from one class, three to drugs from two classes and one to drugs from all three classes. No statistically significant associations were found between age, gender, route of transmission, subtype and resistance. Conclusions The identification of newly diagnosed individuals carrying resistance-associated mutations confirms that drug resistance transmission is a public health problem in Portugal, with a possible impact on prevention, treatment and monitoring of HIV-1 infections.

The Viriato Study: Update of antimicrobial susceptibility data of bacterial pathogens from community-acquired respiratory tract infections in Portugal in 2003 and 2004

The Viriato Study is a nationwide, prospective, multicenter surveillance study of the antimicrobial susceptibility of bacterial pathogens commonly associated with community-acquired respiratory tract infections in Portugal. In 2003 and 2004 a total of 2945 isolates was recovered in the 29 laboratories that participated in the study. Testing was undertaken in a central laboratory. Of the 513 Streptococcus pyogenes strains isolated from patients with acute tonsillitis all were susceptible to penicillin and other beta-lactams but 18.9% were resistant to erythromycin, clarithromycin and azithromycin. The M phenotype dominated (67%), conferring resistance to erythromycin (MIC90=16mg/L), clarythromycin and azithromycin, but susceptibility to clindamycin (MIC90=0.094mg/L). From patients with lower respiratory tract infection 1,300 strains of Streptococcus pneumoniae, 829 of Haemophilus influenzae, and 303 of Moraxella catarrhalis were studied. Among S. pneumoniae isolates 18.4% were resistant to penicillin (3.5% showing high-level resistance), 7.1% to cefuroxime, 0.5% to amoxicillin and amoxicillin/clavulanate, 18.8% to erythromycin, clarithromycin and azithromycin, 14.9% to tetracycline, 16.5% to co-trimoxazol, and 0.4% to levofloxacin. Beta-lactamases were produced by 10.0% of H. influenzae and 96.4% of M. catarrhalis. In H. influenzae resistance to clarithromycin was 5.5% and to cotrimoxazole was 13.4%. Most strains were susceptible to amoxicillin/clavulanate, cefuroxime, azithromycin, tetracycline and ciprofloxacin. In M. catarrhalis resistance to co-trimoxazole was 27.1% and to tetracycline 1.0%. All strains were susceptible to amoxicillin/clavulanate, cefuroxime, clarithromycin, azithromycin and ciprofloxacin. Penicillin was the most active antimicrobial agent against S. pyogenes and amoxycillin / clavulanate and the quinolones the most active in vitro simultaneously against S. pneumoniae, H. influenza and M. catarrhalis.

Estudo Viriato: Actualização de dados de susceptibilidade aos antimicrobianos de bactérias responsáveis por infecções respiratórias adquiridas na comunidade em Portugal em 2003 e 2004

The Viriato Study is a nationwide, prospective, multicenter surveillance study of the antimicrobial susceptibility of bacterial pathogens commonly associated with community-acquired respiratory tract infections in Portugal. In 2003 and 2004 a total of 2945 isolates was recovered in the 29 laboratories that participated in the study. Testing was undertaken in a central laboratory. Of the 513 Streptococcus pyogenes strains isolated from patients with acute tonsillitis all were susceptible to penicillin and other beta-lactams but 18.9% were resistant to erythromycin, clarithromycin and azithromycin. The M phenotype dominated (67%), conferring resistance to erythromycin (MIC90=16mg/L), clarythromycin and azithromycin, but susceptibility to clindamycin (MIC90=0.094mg/L). From patients with lower respiratory tract infection 1,300 strains of Streptococcus pneumoniae, 829 of Haemophilus influenzae, and 303 of Moraxella catarrhalis were studied. Among S. pneumoniae isolates 18.4% were resistant to penicillin (3.5% showing high-level resistance), 7.1% to cefuroxime, 0.5% to amoxicillin and amoxicillin/ clavulanate, 18.8% to erythromycin, clarithromycin and azithromycin, 14.9% to tetracycline, 16.5% to co-trimoxazol, and 0.4% to levofloxacin. Beta-lactamases were produced by 10.0% of H. influenzae and 96.4% of M. catarrhalis. In H. influenzae resistance to clarithromycin was 5.5% and to cotrimoxazole was 13.4%. Most strains were susceptible to amoxicillin/clavulanate, cefuroxime, azithromycin, tetracycline and ciprofloxacin. In M. catarrhalis resistance to co-trimoxazole was 27.1% and to tetracycline 1.0%. All strains were susceptible to amoxicillin/clavulanate, cefuroxime, clarithromycin, azithromycin and ciprofloxacin. Penicillin was the most active antimicrobial agent against S. pyogenes and amoxycillin / clavulanate and the quinolones the most active in vitro simultaneously against S. pneumoniae, H. influenza and M. catarrhalis.Rev Port Pneumol 2006; XII (1): 9-29

Risk of HIV/AIDS infection. Access and utilization of health services in a migrant community.

The recent trend concerning HIV/AIDS infection in Portugal has been worsening, with a total of 18995 cases of infection notified by the end of 2001. African immigrants are generally regarded as a particularly vulnerable group to this problem. Data on health service utilisation also indicates that they are under -- represented among service users, particularly for Sexual and Reproductive Health. The main objectives of this study were to characterise the resident population, to identify and understand knowledge, attitudes and practices regarding HIV/AIDS problems, and obstacles to service utilisation. The study was conducted among individuals aged fifteen years and above, living in a migrant community in the Greater Lisbon area. Data has been collected through community surveys and collective interviews. Results suggest that existing beliefs, attitudes and knowledge may, though indirectly, increase the risk for infection among the residents of the study area. Some of the factors that may act as deterrents to service utilisation are identified. The results of the study stress the need for government health policies and activities from other agencies focusing on improved access to health services for ethnic minorities, as well as intervention programs tailored specifically towards the needs of each community.

Neisseria meningitidis C:2b:P1.2,5 with intermediate resistance to penicillin, Portugal.

For 1 year, serogroup, serotype, serosubtype, and penicillin susceptibility of meningococci circulating in various regions in Portugal were evaluated. Most frequent phenotypes were B:4:P1.15 (13.4%) and C:2b:P1.2,5 (75.9%), which are also common in Spain. Overall, 27.5% of C:2b:P1.2,5 strains showed intermediate resistance to penicillin. Laboratory-based surveillance of meningococcal infection in Portugal provides important information to assess the adequacy of public health measures.

Streptococcus agalactiae in a large Portuguese teaching hospital: antimicrobial susceptibility, serotype distribution, and clonal analysis of macrolide-resistant isolates.

Group B streptococci are emerging as a cause of serious infection worldwide. The capsular polysaccharides are not only important virulence factors but also the target of vaccine development efforts. Serotypes III (24.6%), V (23.4%), Ia (17.8%), and II (16.3%) were the most prevalent among 252 Streptococcus agalactiae isolates collected during 1999-2002 in the largest hospital of Lisbon, Portugal. The substantial proportion of bacteremic patients (17 neonates and 21 adults) in this period illustrates the present importance of S. agalactiae as a cause of invasive disease. All isolates were fully susceptible to penicillin (MIC(50) = 0.064 microg/ml; MIC(90) = 0.094 microg/ml, range 0.008-0.094), cefotaxime, chloramphenicol, ofloxacin, and vancomycin. Resistance was found to tetracycline (75.4%), erythromycin (10.7%), and clindamycin (9.9%). Of the 27 erythromycin-resistant isolates, 70.4% had the cMLS(B), 22.2% the iMLS(B), and 7.4% the M phenotype. All isolates presenting the M phenotype carried the mef(A) gene, whereas the erm(B) gene was found in a large fraction of MLS(B) isolates (n = 17) and only a small proportion (n = 7) the erm(A) gene [erm(TR) variant]. All isolates carried a single macrolide-resistance determinant. Macrolide resistance was not attributable to a single clone as evidenced by distinct serotype and pulsed-field gel electrophoretic profiles. Careful surveillance of S. agalactiae invasive infections in Portugal is essential, and the treatment or intrapartum prophylaxis of patients who are allergic to penicillin should be guided by contemporary resistance patterns observed in the country.

Natural variation of the nef gene in human immunodeficiency virus type 2 infections in Portugal.

Human immunodeficiency virus type 2 (HIV-2) infections cause severe immunodeficiency in humans, although HIV-2 is associated frequently with reduced virulence and pathogenicity compared to HIV-1. Genetic determinants that play a role in HIV pathogenesis are relatively poorly understood but nef has been implicated in inducing a more pathogenic phenotype in vivo. However, relatively little is known about the role of nef in HIV-2 pathogenesis. To address this, the genetic composition of 44 nef alleles from 37 HIV-2-infected individuals in Portugal, encompassing a wide spectrum of disease associations, CD4 counts and virus load, has been assessed. All nef alleles were subtype A, with no evidence of gross deletions, truncations or disruptions in the nef-encoding sequence; all were full-length and intact. HIV-2 long terminal repeat sequences were conserved and also indicated subtype A infections. Detailed analysis of motifs that mediate nef function in HIV-1 and simian immunodeficiency virus, such as CD4 downregulation and putative SH2/SH3 interactions, revealed significant natural variation. In particular, the central P(104)xxPLR motif exhibited wide interpatient variation, ranging from an HIV-1-like tetra-proline structure (PxxP)(3) to a disrupted minimal core motif (P(104)xxQLR). The P(107)-->Q substitution was associated with an asymptomatic phenotype (Fisher's exact test, P=0.026) and low virus loads. These data indicate that discrete differences in the nef gene sequence rather than gross structural changes are more likely to play a role in HIV-2 pathogenesis mediated via specific functional interactions.

Genital infection by Chlamydia trachomatis in Lisbon: prevalence and risk markers.

There is little information about the prevalence and risk markers for Chlamydia trachomatis infections in Portugal. Our aim was to assess the prevalence of C. trachomatis genital infection and to study variables associated with this infection in a group of sexually active women aged < or =30 years living in the Lisbon area and to estimate the prevalence of C. trachomatis infection among partners of infected patients. A systematic sample of women observed in general practice family planning and teenager clinics was collected. A questionnaire was administered, followed by a pelvic examination. A first-catch urine sample was taken for polymerase chain reaction (PCR) Amplicor assay. When a sample tested positive, the woman was invited to obtain a urine sample from her partner. Socio-demograhic, behavioural and clinical variables were studied and their association with the PCR Amplicor result was assessed. A total of 1108 women, aged between 14 and 30 years, were studied. Fifty-one women (4.6% of total sample) tested positive for C. trachomatis. The prevalence of infection was slightly higher in patients aged < or =19 years (5.3%) than in age groups 20-25 (4.8%) and 26-30 years (3.9%). African ethnicity was related to a higher percentage of infection than European ethnicity: 9.8% versus 3.8%, P= 0.0067. Use of condoms "sometimes/never" was associated with a higher prevalence of infection: 5.2% versus 2.3% in those responding "always/almost always" (P= 0.0447). An altered cervix was associated with a higher prevalence of infection: 7.3% versus 3.7% with a normal cervix (P= 0.0106). Urine samples were obtained from 16 partners of infected patients. Six partners (37.5%) tested positive for C. trachomatis. A 4.6% prevalence of C. trachomatis genital infection was found. African ethnicity, using condoms "sometimes/never" and an altered cervix were associated with C. trachomatis infection, but showed low positive predictive value for C. trachomatis infection. Younger age may be associated with a slight increase in risk. Contact tracing for diagnosis and treatment remains a difficult issue to approach effectively.