Lorenada Silveira Derengowski Laboratóriode Biologia Molecular, CEL by mpp15079


									616                                         Letters to the Editor / International Journal of Antimicrobial Agents 34 (2009) 605–616

References                                                                                median age being 28 with a range from 16 to 80. Most patients
                                                                                          were previously healthy and had no risk factors but one third were
[1] Ramage G, Vandewalle K, Wickes BL, López-Ribot JL. Characteristics of biofilm          asthmatic and a quarter of the female patients were pregnant. Pre-
    formation by Candida albicans. Rev Iberoam Micol 2001;18:163–70.
[2] Chandra J, Kuhn DM, Mukherjee PK, Hoyer LL, McCormick T, Ghannoum MA.                 viously healthy non-pregnant patients recovered quickly with a
    Biofilm formation by the fungal pathogen Candida albicans: development, archi-         median length of hospital stay of only 2 days. Six patients (12%)
    tecture, and drug resistance. J Bacteriol 2001;183:5385–94.                           required assisted ventilation of whom three were asthmatic and
[3] Baker CA, Desrosiers K, Dolan JW. Propranolol inhibits hyphal development in
    Candida albicans. Antimicrob Agents Chemother 2002;46:3617–20.
                                                                                          two pregnant.
[4] Ueno Y, Maruyama N, Kanno M, Watanabe T, Ogasawara A, Mikami T, et al. Effect             We did not give antibacterial agents routinely to our patients.
    of propranolol on hyphae formation signal in Candida albicans. Biol Pharm Bull        Five of the 50 patients were admitted because of hypotension
[5] Ramage G, Saville SP, Thomas DP, López-Ribot JL. Candida biofilms: an update.
                                                                                          and they received a fluid challenge together with antibacterials in
    Eukaryot Cell 2005;4:633–8.                                                           accordance with our sepsis protocol. Blood pressure in all of these
[6] Nailis H, Vandenbroucke R, Tilleman K, Deforce D, Nelis H, Coenye T. Monitoring       patients became normal within a few hours and antibacterials were
    ALS1 and ALS3 gene expression during in vitro Candida albicans biofilm formation
                                                                                          stopped within 48 h in all cases. Only one patient developed com-
    under continuous flow conditions. Mycopathlogia 2009;167:9–17.
[7] Nobile CJ, Nett JE, Andes DR, Mitchell AP. Function of Candida albicans adhesin       plications suggestive of bacterial superinfection. This previously
    Hwp1 in biofilm formation. Eukaryot Cell 2006;5:1604–10.                               healthy 40-year-old man remained pyrexial at 3 days after admis-
                                                                                          sion and became hypoxic on exertion and on the third day a chest
                                    Lorena da Silveira Derengowski                        X-ray showed new lobar consolidation. He was commenced on par-
   Laboratório de Biologia Molecular, CEL/IB Universidade de Brasília,                    enteral penicillin and clarithromycin but 2 days later developed
                                                   Brasília-DF, Brazil                    a pleural effusion which proved to be an empyema when it was
                                                                                          drained. This required decortication; he became apyrexial 2 days
                                                    Alex Leite Pereira
                                                                                          afterwards and made an uncomplicated recovery thereafter. Bacte-
         Laboratório de Microbiologia, CEL/IB Universidade de Brasília,
                                                                                          rial cultures were negative. Several of the ventilated patients were
                                                    Brasília-DF, Brazil
                                                                                          given antibacterial agents but in none was there clear evidence of
                                               Alan Carvalho Andrade                      bacterial superinfection, intensive care having been required for
                                   Embrapa/CENARGEN, Brasília-DF, Brazil                  respiratory failure at a point when X-rays showed streaky consoli-
                                                                                          dation consistent with a primary viral pneumonitis.
                                                 Cynthia Maria Kyaw
                                                                                              In conclusion, our limited experience suggests that bacterial
         Laboratório de Microbiologia, CEL/IB Universidade de Brasília,
                                                                                          superinfection is an uncommon complication in patients infected
                                                    Brasília-DF, Brazil
                                                                                          with the current epidemic strain of swine influenza. This is in
                                              Ildinete Silva-Pereira ∗                    agreement with recent experience in California [2]. We do not
   Laboratório de Biologia Molecular, CEL/IB Universidade de Brasília,                    believe that antibacterials should be administered routinely to
                                                   Brasília-DF, Brazil                    these patients and in our single patient whom we believe to have
                                                                                          had a bacterial superinfection there was ample time to make a con-
                       ∗ Corresponding  author. Tel.: +55 61 3307 2423;                   sidered judgement on appropriate treatment. Hypotension does
                                                 fax: +55 61 3349 8411.                   appear to be a presenting feature of this infection and it is clearly
                       E-mail address: xocolau@unb.br (I. Silva-Pereira)                  prudent to manage these patients for possible bacterial sepsis but
                                                                                          our experience suggests that rapid recovery (and negative bacte-
doi:10.1016/j.ijantimicag.2009.08.010                                                     rial cultures) can be taken to indicate a purely viral aetiology and
                                                                                          antibacterial agents can safely be stopped at an early stage.
Antibacterial agents in patients with swine flu                                                Funding: No funding sources.
                                                                                              Competing interests: None.
Sir,                                                                                          Ethical approval: Not required.

    Your editorial [1] has prompted me to write about our experi-                         References
ence with a local epidemic of swine flu in June and July 2009 in the
hope that it will assist colleagues in deciding when to use antibac-                      [1] Geddes AM. Influenza and bacterial pneumonia. Int J Antimicrob Agents
terials in patients with this infection. At the start of the epidemic                         2009;34:293–4.
                                                                                          [2] CDC. Hospitalized patients with novel influenza A (H1N1) virus – California,
we established criteria for hospital admission which were based                               April–May 2009. MMWR 2009;58:1–5.
on earlier experience of the epidemic from the USA and Australia.
Patients were admitted if they fulfilled World Health Organisation                                                                           Christopher Ellis ∗
criteria for swine flu and, additionally, were either hypoxic (on                                Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK
pulse oximetry) or hypotensive. Patients meeting influenza diag-
nostic criteria who had significant asthma, or who were pregnant                                                                       ∗ Tel.: +44 0 121 424 2000.
or obese, were reviewed immediately by an experienced clinician                                         E-mail address: christopher.ellis@heartofengland.nhs.uk
who decided whether or not to admit them to hospital.
    Using these criteria we admitted 50 patients in whom swine                            doi:10.1016/j.ijantimicag.2009.09.002
influenza was subsequently confirmed over a 3-week period, the

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