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Introducción: la diseminación de bacterias gramnegativas resistentes a carbapenémicos representa una causa importante de morbi-mortalidad, siendo una amenaza creciente para la salud pública y de gran preocupación en el mundo. Aunque la resistencia a carbapenémicos puede ser debida a varios mecanismos, el más relevante, clínica y epidemiológicamente, es por producción de enzimas. Objetivos: caracterizar fenotípica y genotípicamente carbapenemasas producidas por bacilos gramnegativos de importancia clínica aislados en hospitales de Paraguay en el año 2022 y evaluar la susceptibilidad a colistina. Metodología: estudio multicéntrico, retrospectivo, realizado en 1226 cepas remitidas al Laboratorio Central durante el año 2022 para su caracterización fenotípica y genotípica. Fueron realizados estudios de identificación (métodos convencionales), susceptibilidad a colistina (microdilución en caldo), y de confirmación de genes de resistencia (moleculares). Resultados: de las 1226 cepas estudiadas, 629 (51 %) correspondieron a no fermentadores (89 % Acinetobacter spp.) y 597 (49 %) a fermentadores (74 % Klebsiella pneumoniae). Las carbapenemasas confirmadas en A. baumannii fueron: OXA-23(94,9 %), NDM (3,1 %), OXA-23 + NDM (1,8 %) y OXA-23+NDM+OXA-58 (0,2 %); en K. pneumoniae: NDM (84,5 %), KPC (11,7 %), KPC+NDM (3,7 %) y NDM+OXA-48like (0,2 %); y en P. aeruginosa la prevalente fue NDM (50,9 %). La resistencia asociada a colistina, fue encontrada principalmente en K. pneumoniae (24 %). Conclusión: en nuestro país es endémica la circulación de bacterias productoras de carbapenemasa. La coproducción de estas enzimas está confirmada. NDM es la prevalente en Enterobacterales y P. aeruginosa y OXA-23 en A. baumannii. La alta resistencia asociada a colistina en K. pneumoniae hace imperiosa la necesidad de contar con nuevos antimicrobianos más efectivos para el tratamiento de las infecciones.

Introduction: the dissemination of Gram-negative bacteria resistant to carbapenems represents an important cause of morbidity and mortality, being a growing threat to public health and of great concern worldwide. Although resistance to carbapenems can be due to several mechanisms, the most relevant, clinically and epidemiologically, is enzyme production. The goals of this study were to phenotypically and genotypically characterize carbapenemases produced by clinically important Gram-negative bacilli (GNB) isolated in hospitals in Paraguay in 2022 and evaluate the susceptibility to colistin. Methodology: retrospective study, carried out on 1226 GNB strains sent to the Central Laboratory during 2022 for phenotypic and genotypic characterization. Identification studies were performed out by conventional methods, susceptibility to colistin by microdilution in broth, and molecular studies for the confirmation of resistance genes. Results: in total, of 1226 GNB isolates, 629 (51 %) were confirmed as non-carbohydrate-fermenting GNB (89 % Acinetobacter spp.) and 597 (49 %) as carbohydrate-fermenting GNB (74 % Klebsiella pneumoniae). Carbapenemases OXA-23 (94.9 %), NDM (3.1 %), OXA-23+NDM (1.8 %) and OXA-23+NDM+OXA-58 (0.2 %) were confirmed in Acinetobacter baumannii; in K. pneumoniae: NDM (84.5 %), KPC (11.7 %), KPC+NDM (3.7 %) and NDM+OXA-48like (0.2 %); and in P. aeruginosa the prevalent was NDM (50.9 %). Colistin-associated resistance was found mainly in K. pneumoniae (24%). Conclusions: in our country the circulation of carbapenemase-producing bacteria is endemic. The co-production of these enzymes is confirmed. NDM is prevalent in Enterobacterales and P. aeruginosa, and OXA-23 in A. baumannii. The high resistance associated with colistin in K. pneumoniae makes it imperative to have new, more effective antimicrobials for the treatment of infections.

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La estimulación magnética transcraneal repetitiva ha demostrado ser eficaz para el tratamiento de la depresión resistente, pero su duración estándar es prolongada. Este estudio evaluó la seguridad y eficacia del protocolo acelerado Lyford-Pike, que aplica 12.000 impulsos diarios (divididos en dos sesiones de 6000) durante 5 a 15 días, con una frecuencia de 10 Hz y al 120 % del umbral motor. Se incluyeron 39 pacientes con depresión resistente que continuaban en tratamiento con antidepresivos y psicoterapia. Las puntuaciones en el Inventario de Depresión de Beck (BDI-I) fueron medidas al inicio y a los días 5, 10 y 15. Los resultados mostraron que el 53,85 % de los pacientes remitieron al final del tratamiento, y el 61,54 % experimentaron una mejoría significativa. El protocolo fue bien tolerado, con un solo caso de cefalea transitoria como efecto adverso. Estos resultados sugieren que el protocolo Lyford-Pike es una opción eficaz y segura para la depresión resistente, aunque se necesitan estudios adicionales para evaluar su durabilidad a largo plazo.

Repetitive transcranial magnetic stimulation has proven effective for treating treatment-resistant depression, but the standard protocol is time-consuming. This study evaluated the safety and efficacy of the accelerated Lyford-Pike protocol, which delivers 12,000 pulses per day (divided into two sessions of 6,000) over 5 to 15 days, at a frequency of 10 Hz and 120% of the motor threshold. Thirty-nine patients, who continued with antidepressants and psychotherapy, were included. Beck Depression Inventory (BDI-I) scores were measured at baseline and on days 5, 10, and 15. Results showed that 53.85% of patients achieved remission by the end of treatment, and 61.54% experienced significant improvement. The protocol was well tolerated, with only one case of transient headache as an adverse event. These findings suggest that the Lyford-Pike protocol is an effective and safe option for, although further studies are needed to assess its long-term durability

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INTRODUCTION. There is an important number of reports in Latin America, but there is a lack of data on acute promyelocytic leukemia (APL) in Ecuador., this is the main reason to carry out this study in the country, a disease that in recent decades has shown a significant improvement in survival. OBJECTIVES. To evaluate the overall survival (OS) and event-free survival (EFS), and also the demography, and the most relevant clinical and laboratorial findings. METHODS. We retrospectively reviewed the medical records of 48 patients with APL, diagnosed between January 2012 and December 2019. We collected the most relevant demographic, clinical and laboratorial characteristics, as well as data related to 30-day mortality, and 5 year­OS (overall survival) and EFS (event-free survival). RESULTS. Among the forty-eight (48) patients with acute promyelocytic leukemia, 44 patients received treatment, the mean number of days for the start of all trans retinoic acid (ATRA) and/or arsenic trioxide (ATO) was of 2.5 days from the moment of the diagnosis. 60.4% of patients were classified as low risk and 39.5% as high risk, according to the national comprehensive cancer network (NCCN). The early death rate was 31.2%, the main cause of which was sepsis, multidrug resistant (MDR) bacterias were isolated in 83% of the patients who took blood cultures and died of early sepsis. after a median follow-up of 35 months only one patient relapsed. the five-year OS and EFS was 51.2%; In the multivariate analysis, only age was identified as an adverse prognostic factor. DISCUSSION. Compared to prospective trials with ATRA-based regimens, we found an inferior OS, mainly because of a high-rate early death. if we compare our findings with other real-world reports, we will also show inferior results probably explained by the high rate of early death due to infection by MDR batteries, in addition to the early deaths caused by hemorrhages. CONCLUSION. The low rate of OS shown in this study, could be improved based on changes to optimize the ac-cess of the patients to an early diagnosis and treatment and the reduction of the unacceptably high rates of multidrug resistance bacterial infections in our setting.

INTRODUCCION. Existe un número importante de reportes en Latinoamérica, pero se carece de datos sobre la leucemia promielocítica aguda (LPA) en Ecuador, ésta es la principal razón para realizar este estudio en el país, enfermedad que en las últimas décadas ha mostrado una importante mejoría en la sobrevida. OBJETIVOS. Evaluar la sobrevida global (SG) y la sobrevida libre de eventos (SLE), así como la demografía y los hallazgos clínicos y laboratoriales más relevantes. MÉTODOS. Se revisaron retrospectivamente las historias clínicas de 48 pacientes con LPA, diagnosticados entre enero de 2012 y diciembre de 2019. Se recogieron las características demográficas, clínicas y datos de laboratorio más relevantes, así como datos relacionados con la mortalidad a 30 días, y a 5 años-OS (supervivencia global) y EFS (supervivencia libre de eventos). RESULTADOS. De los cuarenta y ocho (48) pacientes con leucemia promielocítica aguda, 44 pacientes recibieron tratamiento, la media de días para el inicio de ácido transretinoico total (ATRA) y/o trióxido de arsénico (ATO) fue de 2,5 días desde el momento del diagnóstico. El 60,4% de los pacientes fueron clasificados como de bajo riesgo y el 39,5% de alto riesgo, según la red nacional integral del cáncer (NCCN). La tasa de mortalidad precoz fue del 31,2%, cuya causa principal fue la sepsis, aislándose bacterias multirresistentes (MDR) en el 83% de los pacientes que se sometieron a hemocultivos y fallecieron por sepsis precoz. Tras una mediana de seguimiento de 35 meses, sólo un paciente sufrió una recaída, la SG y la SSC a cinco años fue del 51,2%; en el análisis multivariante, sólo la edad se identificó como factor pronóstico adverso. DISCUSIÓN. En comparación con los ensayos prospectivos con regímenes basados en ATRA, encontramos una SG inferior, principalmente debido a una alta tasa de muerte temprana. Si comparamos nuestros hallazgos con otros informes del mundo real, también mostraremos resultados inferiores probablemente explicados por la alta tasa de muerte temprana debida a infección por baterías MDR, además de las muertes tempranas causadas por hemorragias. CONCLUSIONES. La baja tasa de SG mostrada en este estudio, podría mejorarse en base a cambios para optimizar el acceso de los pacientes a un diagnóstico y tratamiento precoz y la reducción de las inaceptablemente altas tasas de infecciones bacterianas multirresistentes en nuestro medio.

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Resumen Aproximadamente el 30% de las personas con epilep sia será refractaria. Este manuscrito revisa las modalida des actuales y basadas en la evidencia de tratamientos no quirúrgicos para la epilepsia refractaria pediátrica, incluyendo estrategias farmacológicas y dietéticas.

Abstract Approximately 30% of people with epilepsy will be refractory. This manuscript reviews current evidence-based non-surgical treatment modalities for pediatric refractory epilepsy, including pharmacological and di etary strategies.

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Background: Colistin is an antibiotic with lipophilic and hydrophilic properties, effective against Enterobacterales and non-fermenter bacteria. Due to the emergence of multidrug-resistant Gram-negative bacilli, colistin is being once again reintroduced as a last resort for their treatment. Resistance is caused by mutations and some are plasmid-mediated. Aims and Objectives: The aim of the study was to determine antibiotic resistance patterns in Gram-negative bacilli and to detect colistin susceptibility patterns in multidrug-resistant Enterobacterales and Pseudomonas aeruginosa. Materials and Methods: This prospective cross-sectional study was carried out in the Department of Microbiology, Calcutta National Medical College and Hospital, using standard laboratory protocol and colistin susceptibility was determined by colistin broth disk elution (CBDE) method. Results: Out of a total of 80 patients infected with MDR isolates, 63.75% were male and 36.25% were female. The most common age group affected was 41–60 years. Multidrug- resistant (MDR) bacteria were most commonly isolated from urine samples, and Klebsiella pneumoniae was the most common MDR bacteria isolated. Overall, colistin resistance was 7.5% and it was found most commonly in K. pneumoniae. The use of broad-spectrum antibiotics was the most common risk factor for the emergence of MDR bacterial infections, including colistin resistance. Conclusion: The present study detects colistin resistance using a simple method – “CBDE test” which can be done in resource-poor settings and can guide clinicians to rationally use the medication as it may be used as an alternative treatment option for “Super bugs” and can even be used as the “last resort” in certain scenario.

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Background: The resistance among pathogenic organisms to different antimicrobial drugs has emerged as a cause of public health threats all over the world. Antimicrobial resistance has been identified as one of the main concerns affecting health and the health economy in several reports, including those from the World Health Organization (WHO), the Infectious Diseases Society of America (IDSA), and the UK government. Among gram-negative bacteria, members of Enterobacteriaceae such as E. coli, Klebsiella sp., Enterobacter sp., Proteus sp. and among non-lactose fermenters, Pseudomonas sp., Acinetobacter sp. have been associated with multidrug-resistant bacterial infections. Methods: All clinical specimens (blood, respiratory samples, skin and soft tissue infections samples and urine samples) received in the Microbiology laboratory from various ICUs during the study period (January 2019 to December 2020) were included in the study. Retrospective analysis was performed. Results: Out of 21208 samples received 4514 samples were culture positives among which 2103 (46.5%) were from ICUs. Among the isolates, multidrug-resistant organisms (MDROs) were more than extensive drug-resistant (XDR) and pan-drug-resistant (PDR). Blood specimens only showed MDRs, no XDRs or PDRs, showing lesser antibiotic pressure whereas respiratory, skin, and soft tissue and urine specimens showed MDRs and PDRs, this may be due to positive antibiotic pressure due to overuse or misuse of antibiotics. Conclusion: This study highlights the fact that the burden of MDRs is more compared to XDR and PDRs which gives a ray of hope to still reduce these MDRs. It also enforces the need to prevent the emergence of XDRs and PDRs through proper infection prevention control practices and antibiotic stewardship programs and judicious use of available antibiotics.

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Introducción. El manejo adecuado de la tuberculosis multirresistente es una estrategia priorizada para el control de la tuberculosis en el mundo. Objetivo. Evaluar las diferencias entre las características demográficas y clínicas, y los indicadores programáticos de los pacientes con diagnóstico confirmado de tuberculosis pulmonar resistente a rifampicina o multirresistente en Buenaventura, frente a la cohorte de los demás municipios del Valle del Cauca entre 2013 y 2016. Materiales y métodos. Se desarrolló un estudio analítico de cohortes para comparar los registros de pacientes mayores de 15 años con tuberculosis multirresistente, del Programa de Tuberculosis de Buenaventura (con ácido paraaminosalicílico), frente a los demás municipios del Valle del Cauca (sin ácido paraaminosalicílico). Resultados. Se registraron 99 casos con una mediana de edad de 40 años (RIC = 26 - 53); en Buenaventura, el 56 % eran mujeres; en los demás municipios, predominaron los hombres (67 %); el 95 % de los evaluados tenía aseguramiento en salud. La comorbilidad más frecuente fue diabetes (14 %). Las reacciones adversas a medicamentos antituberculosos en Buenaventura fueron 1,3 veces más frecuentes que en los demás municipios (OR = 2,3; IC95 %: 0,993 - 5,568; p = 0,04). En Buenaventura falleció el 5 % de los casos frente al 15 % reportado en los demás municipios. No hubo fracasos con el tratamiento en Buenaventura, pero se reportó un 35 % de pérdida del seguimiento. El éxito del tratamiento fue mayor en Buenaventura en el 56 %. Conclusión. El programa fortalecido de Buenaventura presentó mejores resultados programáticos que los demás municipios del Valle del Cauca. El acceso a pruebas moleculares, la disponibilidad de tratamientos acortados y el seguimiento continuo para identificar reacciones adversas a medicamentos antituberculosos son un derrotero para todos los programas de control.

Introduction. Proper management of multidrug-resistant tuberculosis is a prioritized strategy for tuberculosis control worldwide. Objective. To evaluate differences concerning demographic and clinical characteristics and programmatic indicators of Buenaventura patient cohort with confirmed diagnosis of multidrug-resistant tuberculosis, compared to those of the other municipalities from Valle del Cauca, Colombia, 2013-2016. Materials and methods. We conducted an analytical cohort study to compare records of patients older than 15 years with multidrug-resistant tuberculosis included in the Programa de Tuberculosis de Buenaventura (with para-aminosalicylic acid) versus the other municipalities of Valle del Cauca (without para-aminosalicylic). Results. Ninety-nine cases were recorded with a median age of 40 years (IQR = 26 - 53); in Buenaventura, 56% of the patients were women, while in the other municipalities, men predominated with 67%; 95% had health insurance. The most common comorbidity was diabetes (14%). Adverse reactions to antituberculosis medications in Buenaventura were 1.3 times more frequent than in the other municipalities (OR = 2.3; 95% CI = 0.993 - 5.568; p = 0.04). In Buenaventura, the mortality rate was 5% compared to the 15% reported in the other municipalities. Treatment failures were not reported in Buenaventura, but 35% did not continue with the follow-up. Treatment success was higher in Buenaventura (56 %). Conclusion. A strengthened program in Buenaventura presented better programmatic results than those from the other municipalities of Valle del Cauca. Access to molecular tests, availability of shortened treatments, and continuous monitoring to identify adverse reactions to antituberculosis medications are routes for all other control programs.

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Abstract Introduction: The presence of secondary infections in critically ill patients and antibiotic resistance are often determining factors in the clinical evolution of these patients. Objective: To describe the pathogens isolated in blood cultures and tracheal secretion cultures in ICU patients with COVID-19 and to evaluate the association between the presence of secondary infections and 60-day mortality. Methods: Retrospective analytical cohort study conducted in 273 adults admitted to the ICU with COVID-19 at the Subred Integrada de Servicios de Salud del Sur - Hospital El Tunal, Bogotá, Colombia between April and December 2020. Data from records of blood or tracheal secretion cultures were collected. A bivariate analysis was performed using a Cox proportional-hazards regression model to assess the association between the development of secondary infections and 60-day mortality. Results: At least one positive blood culture was reported in 96/511 patients (18.8%). Of the 214 blood cultures performed within 48 hours after ICU admission, 7.7% were positive. A total of 127 germs were isolated from blood cultures - mostly gram-negative bacteria (61.4%) - followed by fungi (25.2%). Additionally, 39.5% were multidrug-resistant, and carbapenem resistance was the most common antibiotic resistance pattern (33.3% of all gram-negative bacteria isolates). Finally, in this cohort, the presence of secondary infections was not associated with 60-day mortality (HR: 1.012, 95%CI: 0.7211.420; p= 0.946). Conclusions: Although the prevalence of superinfection was moderately high, the prevalence of coinfection was low. Gram-negative bacteria were predominant, and almost one third of the germs were multidrug-resistant.

Resumen Introducción: La presencia de infecciones secundarias en pacientes críticos y la resistencia a los antibióticos suelen ser factores determinantes en la evolución clínica de estos pacientes. Objetivo: Describir los patógenos aislados en cultivos de sangre y de secreciones traqueales en pacientes de la UCI con COVID-19 y evaluar la relación entre la presencia de infecciones secundarias y la mortalidad a 60 días. Métodos: Estudio de cohorte analítico retrospectivo realizado en 273 adultos ingresados a la UCI con COVID-19 de la Subred Integrada de Servicios de Salud del Sur - Hospital El Tunal, Bogotá, Colombia entre abril y diciembre de 2020. Se obtuvieron los datos de los registros de cultivos en sangre y en secreciones de la tráquea. Se llevó a cabo un análisis bivariado mediante un modelo de riesgos proporcionales o regresión de Cox para evaluar la relación entre el desarrollo de infecciones secundarias y la mortalidad a 60 días. Resultados: Se reportó al menos un cultivo en sangre positivo en 96/511 (18.8%). De los 214 cultivos de sangre realizados dentro de las 48 horas siguientes al ingreso a la UCI, 7,7% resultaron positivos. Se aislaron en total 127 gérmenes en los cultivos en sangre, en su mayoría bacterias gramnegativas (61,4%) - seguido de hongos (25,2%). Adicionalmente, 39.5% fueron multirresistentes, siendo la resistencia los carbapenémicos el patrón de resistencia a los antibióticos más frecuente (33,3% de todos los aislados de bacterias gramnegativas). Finalmente, la presencia de infecciones secundarias en esta cohorte no se asoció con mortalidad a 60 días (HR: 1,012, IC 95%: 0,721-1,420; p= 0,946). Conclusiones: A pesar de que la prevalencia de super infecciones fue moderadamente alta, la prevalencia de coinfección fue baja. Las bacterias gramnegativas fueron las predominantes y casi un tercio de los gérmenes eran multirresistentes.

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Las enterobacterias productoras de carbapenemasas desarrollan infecciones resistentes a los medicamentos en neumonía, infección del tracto urinario e infecciones relacionadas con dispositivos. Klebsiella pneumoniae, Escherichia coli y Enterobacter cloacae son amenazas de resistencia emergentes importantes a nivel mundial, lo que representa alta mortalidad y limitadas opciones de tratamiento. Objetivo: detectar la presencia de EPC de clase A, mediante la aplicación del test fenotípico de sinergia con ácido borónico en cepas de enterobacterias aisladas de superficies inertes en el Hospital Universitario Católico de Cuenca, Ecuador. Materiales y Métodos: estudio cuali-cuantitativo de tipo experimento puro de corte transversal y alcance exploratorio - descriptivo. Las enterobacterias se identificaron mediante test bioquímicos del sistema estandarizado API 20 E. Para la detección fenotípica de carbapenamasas de clase A se utilizó el método de sinergia de discos con ácido borónico y discos imipenem, meropenem y ertapenem. Resultados: se identificaron 25 géneros de enterobacterias, el 24 % fue Pseudomonas aeruginosam, el 20 % de enterobacterias fue productoras de carpapenemasas clase Am mientras que el 32 % fue resistente para los tres carbapenémicos en estudio, el 68 % mostró sensibilidad para imipenem, el 56 % para meropenem y 44 % para ertapenem. El 48 % de enterobacterias fueron resistentes a ertapenem, el 44 % a meropenem y 32 % a imipenem. Conclusiones: Enterobacterias como P. aureginosa, E. cloacae, Cronobacter spp. y E. coli presentan mecanismos de resistencia asociados a carbapenemasas clase A tipo KPC por lo que se recomienda vigilancia continua y estrategias de manejo para abordar la resistencia a carbapenémicos en entornos hospitalarios

Carbapenemase-producing Enterobacteriaceae develop drug-resistant infections in pneumonia, urinary tract infection, and device-related infections. Klebsiella pneumoniae, Escherichia coli, and Enterobacter cloacae are important emerging resistance threats globally, representing high mortality and limited treatment options. Objective: detect the presence of class A EPC, by applying the phenotypic synergy test with boronic acid in strains of enterobacteria isolated from inert surfaces at the Catholic University Hospital of Cuenca, Ecuador. Materials and Methods: Qualitative-quantitative study of pure cross-sectional experiment type and exploratorydescriptive scope. Enterobacteriaceae were identified using biochemical tests of the standardized API 20 E system. For the phenotypic detection of class A carbapenamases, the synergy method of disks with boronic acid and imipenem, meropenem and ertapenem disks was used. Results: 25 genera of enterobacteria were identified, 24 % were Pseudomonas aeruginosam, 20 % of enterobacteria were producers of class Am carbapenemases while 32 % were resistant to the three carbapenems under study, 68 % showed sensitivity to imipenem, 56 % for meropenem and 44 % for ertapenem. 48 % of enterobacteria were resistant to ertapenem, 44 % to meropenem and 32 % to imipenem. Conclusions: Enterobacteriaceae such as P. aureginosa, E. cloacae, Cronobacter spp. and E. coli present resistance mechanisms associated with class A carbapenemases type KPC, so continuous surveillance and management strategies are recommended to address resistance to carbapenems in hospital environments

Enterobacteriaceae produtoras de carbapenemases desenvolvem infecções resistentes a medicamentos em pneumonia, infecção do trato urinário e infecções relacionadas a dispositivos. Klebsiella pneumoniae, Escherichia coli e Enterobacter cloacae são importantes ameaças emergentes de resistência em todo o mundo, representando alta mortalidade e opções de tratamento limitadas. Objetivo: detectar a presença de CPE classe A, aplicando o teste de sinergia fenotípica com ácido borônico em cepas de enterobactérias isoladas de superfícies inertes no Hospital Universitário Católico de Cuenca, Equador. Materiais e Métodos: estudo cualitativo quantitativo, do tipo experimento transversal puro e escopo exploratório-descritivo. As enterobactérias foram identificadas por meio de testes bioquímicos do sistema padronizado API 20 E. Para a detecção fenotípica das carbapenamases classe A foi utilizado o método de sinergia de discos com ácido borônico e discos de imipenem, meropenem e ertapenem. Resultados: foram identificados 25 gêneros de enterobactérias, 24 % eram Pseudomonas aeruginosam, 20 % das enterobactérias eram produtoras de carbapenemases da classe Am enquanto 32 % eram resistentes aos três carbapenêmicos em estudo, 68 % apresentaram sensibilidade ao imipenem, 56 % ao meropenem e 44. % para ertapenem. 48 % das enterobactérias eram resistentes ao ertapenem, 44 % ao meropenem e 32 % ao imipenem. Conclusões: Enterobacteriaceae como P. aureginosa, E. cloacae, Cronobacter spp. e. coli apresentam mecanismos de resistência associados às carbapenemases classe A tipo KPC, portanto estratégias contínuas de vigilância e manejo são recomendadas para abordar a resistência aos carbapenêmicos em ambientes hospitalares.

ABSTRACT

Cerca de um terço das pessoas com transtornos depressivos não modifica seu estado psíquico após o uso de dois ou mais medicamentos, sendo classificadas com depressão resistente ao tratamento. Nessas pessoas, medos intensos podem agravar a depressão, especialmente em cenários ameaçadores como uma pandemia. Portanto, é crucial validar instrumentos psicométricos que facilitem a detecção de reações às pandemias, como a COVID-19, nessa população. O objetivo principal deste estudo é validar a Escala de Medo da COVID-19 em adultos com depressão resistente ao tratamento. Trata-se de um estudo transversal e analítico, realizado em uma instituição psiquiátrica pública no Rio de Janeiro, envolvendo usuários diagnosticados com depressão resistente ao tratamento que atenderam aos critérios de elegibilidade para participar da pesquisa. Foi realizado um cálculo amostral com parâmetros de precisão de 5% e um nível de confiança de 95%, resultando em uma amostra ideal de, no mínimo, 103 indivíduos. O estudo teve uma taxa de adesão de 79,5%, resultando em 140 participantes. A coleta de dados ocorreu de agosto de 2021 a janeiro de 2023, de forma remota, utilizando a Escala de Medo da COVID-19, o Inventário de Depressão de Beck e um questionário sociodemográfico, via formulário on-line. A análise descritiva dos dados foi feita no SPSS®, enquanto a Análise Fatorial Confirmatória foi realizada no software Jeffreys's Amazing Statistics Program (JASP), utilizando o método robusto DWLS, com a colaboração de um psicometrista. Os resultados da validação indicaram que a Escala de Medo da COVID-19 é uma ferramenta confiável e válida para medir o medo da COVID-19 em adultos com depressão resistente ao tratamento, ampliando seu escopo de utilização. A análise estatística revelou que os itens da escala apresentaram boas cargas fatoriais, demonstrando excelente aderência à variável latente. A unidimensionalidade do instrumento foi confirmada, eliminando a possibilidade de dupla saturação. Os resultados mostraram associações significativas entre a depressão severa e o medo intenso da COVID-19 em algumas variáveis sociodemográficas, indicando que certos grupos de usuários com depressão resistente foram mais vulneráveis ao medo da COVID-19 e ao agravamento da depressão durante a pandemia. Além disso, os participantes com medo intenso da COVID-19 apresentaram níveis mais elevados de sintomas depressivos, sugerindo uma interação entre o medo da COVID-19 e a gravidade da depressão. O medo intenso refletiu mentalmente e fisicamente em sintomas de ansiedade e ataques de pânico. Os cuidados de enfermagem pós-pandemia, à luz da Teoria da Maré, podem criar um sistema de suporte que identifica e lida com esses riscos, e pode apoiar e empoderar a pessoa no enfrentamento da depressão de forma proativa. Assim, os resultados desta tese permitem aos enfermeiros fazer a prospecção de ações em saúde mental para estabelecer relações mais significativas e colaborativas com os usuários, facilitando a construção de uma rede de apoio que trabalhe ativamente para reduzir a agravamento da depressão no período pós pandemia.

About one-third of people with depressive disorders do not change their psychological state after using two or more medications, being classified as having treatment-resistant depression. In these individuals, intense fears can exacerbate depression, especially in threatening scenarios such as a pandemic. Therefore, it is crucial to validate psychometric instruments that facilitate the detection of reactions to pandemics, such as COVID-19, in this population. The main objective of this study is to validate the COVID-19 Fear Scale in adults with treatment-resistant depression. This is a cross-sectional and analytical study conducted in a public psychiatric institution in Rio de Janeiro, involving users diagnosed with treatment-resistant depression who met the eligibility criteria to participate in the research. A sample calculation was performed with 5% precision parameters and a 95% confidence level, resulting in an ideal sample of at least 103 individuals. The study had an adherence rate of 79.5%, resulting in 140 participants. Data collection took place from August 2021 to January 2023, remotely, using the COVID-19 Fear Scale, the Beck Depression Inventory, and a sociodemographic questionnaire via an online form. Descriptive data analysis was done in SPSS®, while Confirmatory Factor Analysis was performed in Jeffreys's Amazing Statistics Program (JASP) software, using the robust DWLS method, with the collaboration of a psychometrician. The validation results indicated that the COVID-19 Fear Scale is a reliable and valid tool for measuring fear of COVID-19 in adults with treatment-resistant depression, expanding its scope of use. The statistical analysis revealed that the scale items presented good factor loadings, demonstrating excellent adherence to the latent variable. The unidimensionality of the instrument was confirmed, eliminating the possibility of double saturation. The results showed significant associations between severe depression and intense fear of COVID-19 in some sociodemographic variables, indicating that certain groups of patients with treatment-resistant depression were more vulnerable to fear of COVID-19 and worsening depression during the pandemic. Additionally, participants with intense fear of COVID-19 showed higher levels of depressive symptoms, suggesting an interaction between fear of COVID-19 and the severity of depression. Intense fear manifested mentally and physically in symptoms of anxiety and panic attacks. Post-pandemic nursing care, in light of the Tidal Model, can create a support system that identifies and addresses these risks, and can support and empower individuals to proactively cope with depression. Thus, the results of this thesis allow nurses to prospect mental health actions to establish more meaningful and collaborative relationships with patients, facilitating the construction of a support network that actively works to reduce the worsening of depression in the post-pandemic period.

ABSTRACT

Background: Pseudomonas aeruginosa are known for their multiple mutations and rapid acquirement of antimicrobial resistance genes. The presence of metallo-?-lactamase (MBL) is the commonest reason for the treatment failure in carbapenem therapy. Production of extended spectrum ?-lactamase (ESBL) in these isolates makes the treatment more challenging. Due to the importance of the carbapenems in resistant infection management, finding the true frequencies of such enzymes is imperative. Methods: A total of 446 samples were collected from the admitted patients with infected burn, surgical wound, and endotracheal tube in situ. Isolation and identification of organisms and antimicrobial susceptibility testing were done by established methods. Identification of P. aeruginosa was confirmed by polymerase chain reaction (PCR). Production of ESBLs was detected phenotypically by double disc synergy, and MBL by double-disc synergy, combined disc, and modified Hodge test. Genes encoding ESBLs and MBLs were detected by PCR. Results: Among the 446 samples, 84.31% yielded growth, from which 232 (61.70%) were P. aeruginosa. Among the P. aeruginosa, 72 (31.03%) were resistant to imipenem. Phenotypically, 57 (79.17%) of these strains were ESBL and all were MBL producers. blaOXA-10 was the most common ESBL encoding gene (29.83%). blaNDM-1 was the most prevalent MBL encoding gene (34.72%). Moreover, 27 (38%) imipenem resistant P. aeruginosa had concurring ESBL and MBL genes.

ABSTRACT

Background: Antimicrobial Resistance is a major concern. The rising trend has created a nuisance affecting the global economy and sustainable development Goals. Data about antimicrobial resistance therefore might help in knowing the trends and acting. Critical care patients are prone to develop nosocomial infections. A brief knowledge about this would help in the judicious use of antibiotics. This multicentric study was undertaken to understand the trends in the prevalence of antimicrobial resistance pattern, Multidrug Resistance (MDR)/ Extensive Drug Resistance (XDR)/Pan-drug Resistance (PDR), among GNB isolates from respiratory, urinary, and bloodstream samples from Indian ICUs. Methods: This is a retrospective study done in 16 Indian adult intensive care units (ICUs). The sensitivity pattern of defined GNB isolates against defined antibiotics was analyzed. Results: A total of 20,874 isolates of A. baumannii, P. aeruginosa, K. pneumoniae, and E. coli from the included samples were obtained A. baumannii, P. aeruginosa species showed a higher prevalence of XDR than MDR whereas K. pneumonia detected MDR. Among all the GNBs in this study, A. baumannii was the most carbapenem-resistant organism (XDR) and K. pneumoniae demonstrated the highest percentage of PDR strains both being higher in the respiratory and bloodstream isolates than that in the urinary isolates. Conclusion: This study shows high Prevalence of MDR/XDR GNB is high in Indian ICUs. Using the right antibiotic or introducing various strategies along with infection control measures can help in reducing antimicrobial resistance.

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Background: Drug-resistant tuberculosis (DR-TB) is a form of antimicrobial resistance that is difficult and costly to treat. It is caused by TB bacteria that are resistant to at least one of the first-line existing TB medications, resulting in fewer treatment options and increasing mortality rates. Treatment for this form of TB, known as DR-TB, requires a minimum of 18-24 months of treatment with drugs that are less effective, more toxic, and more expensive than those needed for drug-susceptible TB. Methods: This was a retrospective review of secondary data for patients diagnosed with DR-TB in Kenya from 2014 to 2019. Each patient had a two-year follow-up period to monitor sputum conversion time and the associated factors. The enrolled patients comprised all patients diagnosed with DR-TB within the 47 counties in Kenya and enrolled at any drug-resistant registered treatment center. Results: A total of 2674 patients were enrolled for review to establish factors associated with conversion and we only found out that the type of resistance a patient enrolled on gender, intensive phase regiment, modification of intensive phase, and waiting time before treatment initiation were the only significant factors that would influence when a patient would convert from being sputum positive to negative. Conclusions: Patients with resistant TB require correct diagnosis and timely start of medication with good follow-up to avoid being lost to follow-up or failing on the medication started. Additionally, healthcare workers need continuous training to gain more knowledge in case of detection for patients coming to hospitals.

ABSTRACT

Antimicrobial resistance causes substantial risks to human health globally, and millions of people die worldwide due to multiple drug resistances. Beta-lactam drugs are common for curing infections, and resistance to these drugs cause serious threat to humans. The resistance is acquired by the gram-negative Pseudomonas aeruginosa by producing beta-lactamases such as metallo beta-lactamase (MBL), extended-spectrum beta-lactamase enzymes (ESBL), and AmpC ?-lactamases. Hence, this study was intended to detect the occurrence of MBL, ESBL, and AmpC ?-lactamases producing P. aeruginosa and to evaluate antibiotic sensitivity at the Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India. A total of 163 P. aeruginosa were isolated from the different samples of patients, such as urine, blood, sputum, pus, and pleural fluids. The P. aeruginosa was characterized morphologically, biochemically, and with matrix-assisted laser desorption ionization-time of flight mass spectrometry. Their antibiotic sensitivity was evaluated by the Kirby-Baur disc diffusion method. Antibiotic sensitivity tests of P. aeruginosa showed 163/163 were susceptible to Polymyxin-B, 78/163 and 65/163 were resistant against Ceftazidime (CAZ) and IMP antibiotics, respectively. The IMP, CAZ, and cefoxitin-resistant isolates were selected and further evaluated for ESBL, MBL, and AmpC enzyme production. In conclusion, the findings of this study indicated a significant presence of ESBL, MBL, and AmpC enzyme-producing P. aeruginosa among the patients. The ESBL prevalence was much higher in indoor patients than in outdoor patients. The total prevalence of MBL-producing strains in Imipenem-resistant P. aeruginosa (IRPA) was (46/62) 74.19%, which is an alarming signal. There was a higher prevalence of IRPA MBL-producing strains in indoor patients (36/46) 78.6% as compared to outdoor patients (10/16) 62.50%. Identification of bronchoalveolar lavage and sputum was also done using the Biofire Film Array, which revealed the resistant genes, including NDM (20 genes), CTX-M (17 genes), OXA-48-like (9 genes), VIM (5 genes), and IMP (2 genes). Antibiotics like cefotaxime and CAZ have less effect, but carbapenems and aminoglycosides are the best options for treating ESBL-producing P. aeruginosa. Drugs not recommended for treating this pathogen are penicillins and sulfonamides like co-trimoxazoles. Strict infection control measures, careful monitoring of antibiotic administration, and routine screening for ESBL-producing strains are advised before treating the patients.

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Background: Blood stream infections (BSI) are one of the major life-threatening infections responsible for prolonged hospital stays and significant mortality. It can be a community-acquired or hospital-acquired infection. A proper antibiotic policy can help in the selection of a proper antibiotic to reduce mortality and increase the patients’ outcomes. Aims and Objectives: The objectives of the study are to identify the organism causing BSI and determine its antibiotic susceptibility pattern. Materials and Methods: The present study was conducted in the Department of Microbiology, SBKS MI & RC, Piparia, over a period of 18 months and included 397 clinically suspected cases of BSIs after approval from HREC. Positive blood cultures indicated by the BACTEC 9050 were processed for further identification and antibiotic susceptibility testing by conventional methods according to standard laboratory techniques. Results: Out of 397 samples, 104 (26.19%) were positive, and 13 microorganisms were isolated. Staphylococcus aureus and Klebsiella spp. were the most frequently isolated organisms. Imipenem and vancomycin were highly effective antibiotics. The study showed 37.84% extended-spectrum beta-lactamase producers among Klebsiella and Escherichia coli. S. aureus showed 47.82% methicillin-resistant Staphylococcus aureus. Conclusion: This study was intended to serve as a reference to guide clinicians in applying appropriate empirical therapy and the best regimen based on the local condition to improve the overall outcome of the patients’ management.

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Antimicrobial resistance (AMR) is identified as the fourth leading cause of mortality in Jordan. However, there is a scarcity of data addressing the demographics and clinical characteristics associated with AMR against commonly used antibiotics in Western Jordan. To address this knowledge gap, a retrospective analysis was undertaken on the microbiology records of AMR at Al-Hussein/Salt Hospital in Jordan West from October 2020 to December 2022 and included 2893 reports. Two machine learning (ML) models, specifically categorization regression trees (CARTs) and random forests (RFs) were trained using microbiology reports and then utilized to forecast the AMR for different categories of antibiotics. The most commonly isolated microorganisms were Escherichia coli (53.3%), Klebsiella pneumoniae, and Staphylococcus aureus. Bacterial strains belonging to the Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species category demonstrated elevated levels of resistance. The RF model demonstrated superior accuracy compared to the CART, exhibiting a range of 0.64–0.99. This finding suggests a significant level of dependability in the predictive capability of the RF models in forecasting AMR patterns. AMR is susceptible to the impact of demographic factors such as age, sex, and bacterial species. This study emphasized the significance of monitoring AMR to facilitate the administration of appropriate antibiotic therapy.

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Resumen Introducción: El estado epiléptico refractario (EER) constituye una emergencia médica grave, donde la crisis no cede a pesar del tratamiento farmacológico convencional. Se describe como estado epiléptico superrefractario (EESR) la continua presencia de episodios con una duración de 24 horas o más. Este reporte de caso detalla la complejidad en el manejo y explora un enfoque multidisciplinario. Presentación del caso: Paciente masculino de 32 años con antecedente de epilepsia focal secundaria a traumatismo craneoencefálico en la niñez, quien ingresó en contexto de EESR, el cual recibió coma barbitúrico, plasmaféresis y dieta cetogénica. En los exámenes, la resonancia magnética reveló una lesión en la región frontotemporal insular derecha; en la tomografía por emisión de positrones se observaron zonas de hipermetabolismo y en el videoelectroencefalograma una continua actividad epileptiforme. Se optó por la cirugía paliativa, logrando la resolución exitosa del EESR y una clasificación Engels IA a los 14 meses. Discusión: El EESR es un evento neurológico crítico con pronóstico reservado y opciones terapéuticas desafiantes. Se describen opciones terapéuticas desde anticonvulsivantes, inmunoterapia y cirugía, donde el abordaje quirúrgico emerge como una opción eficaz, especialmente en casos con lesiones estructurales. La identificación temprana y la terapia adecuada son vitales para prevenir complicaciones. Conclusiones: El EESR representa un desafío crítico con alta carga de morbimortalidad, sin embargo, la cirugía de epilepsia muestra promisorios resultados en el contexto de causa cerebral estructural, responsable de la actividad epileptiforme. Se destaca la importancia de la identificación temprana y el manejo quirúrgico paliativo como opción viable, mejorando la calidad de vida de los pacientes.

Abstract Introduction: Refractory Status Epilepticus (RSE) is a serious medical emergency where the seizure does not subside despite conventional pharmacological treatment. The continuous presence of episodes lasting 24 hours or more is described as super-refractory status epilepticus (SRSE). This case report details the complex in teraphy management and explores a multidisciplinary approach. Case presentation: A 32-year-old male with a history of focal epilepsy secondary to head trauma in childhood. Enters emergency with a RSE episode. Barbiturate coma, plasmapheresis and ketogenic diet were administered. The Magnetic Resonance Imaging revealed a lesion in the right fronto-temporo-insular cortex, areas of hypermetabolism on Positron Emission Tomography and continuous epileptiform activity on video-electroencephalogram. Palliative surgery was chosen, achieving successful resolution of the SRSE and Engel Scale IA classification at 14 months of follow up. Discussion: The SRSE is a critical neurological event with a guarded prognosis and complex therapeutic options. Therapeutic options are described from anticonvulsants, immunotherapy and surgery. The surgical approach emerges as an effective option, especially in cases with structural injuries. Early identification and appropriate therapy are vital to prevent complications. Conclusions: SRSE represents a critical challenge with a high burden of morbidity and mortality. However, epilepsy surgery shows promising results in the context of the structural brain cause responsible for epileptiform activity. The importance of early identification and palliative surgical management as a viable option is highlighted, improving the quality of life of patients.

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Despite global efforts to control and eradicate tuberculosis (TB), it remains a significant source of morbidity and mortality worldwide. Drug-resistant TB (DRTB) is a significant public health threat with implications for global health security, economic burden, and access to quality care. To address this challenge, continued investment in research, surveillance, and innovative strategies is crucial. Collaboration among international organizations, governments, and health-care systems is crucial to tackle this global health concern effectively. Bedaquiline (BDQ), a diarylquinoline drug, is indicated for combination therapy in adult patients with pulmonary multidrug-resistant TB (MDRTB). The Food and Drug Administration (FDA) granted accelerated approval in December 2012, based on analysis of time to sputum culture conversion from two phase 2 trials. The World Health Organization (WHO) published interim policy guidance for BDQ in conjunction with WHO-recommended MDRTB treatments in June 2013. The European Medicines Agency authorized Delamanid as a first-in-class bicyclic nitroimidazole for treating MDRTB, which has been used in 89 and 54 nations due to its quick acquisition of resistance. To prevent resistance, combined therapy with additional anti-TB drugs is advised, along with proper use and drug resistance monitoring. Pretomanid received approval from the US FDA in August 2019 after a phase III trial yielded encouraging results. The bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) regimen, a component of the BPaLM regimen, has been approved for treating adults with extensive pulmonary DRTB or treatment-intolerant or non-responsive MDRTB. This significant advancement in management offers improved clinical outcomes and quality of life for MDRTB patients. The inclusion in the WHO guidelines is encouraging for global combat against DRTB. Researchers have identified and investigated new drug targets within the TB pathogenesis, offering promising avenues for the development of innovative anti-TB drugs. Advances in pediatric TB treatment have made significant progress, focusing on improved diagnostic methods, effective drug treatments, and global initiatives. Nanotechnology has shown promising potential in various fields, including medicine and TB treatment.

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Background: Despite advancements in contemporary detection and treatment, hospital-acquired infections remain a major issue for international health systems. Potential infections can be found on healthcare personnel's mobile phones. Despite the considerable risk of contamination, cell phones are rarely sanitized and are frequently handled without properly washing hands before or after patient examinations and specimen processing. This study aimed to separate, characterize, and quantify the various kinds of bacteria and their susceptibility to antibiotics from the mobile phones of both healthcare and non-healthcare personnel. Methods: Samples were taken aseptically by rolling over the exposed surfaces of the inoculated mobile phones on the agar plates, which were subsequently incubated aerobically. After incubation, the plates were examined for growth. Following accepted microbiological practices, bacteria were discovered and antibiotic sensitivity was assessed. Results: Out of 50 mobile swabs of each category, 58% of samples were culture-positive in healthcare workers (HCW) and 20% in non-healthcare workers. The most common pathogen isolated was Staphylococcus aureus i.e. 23(46%). Out of 23, (5) were MRSA and (18) were MSSA. MRSA isolation, in doctors 2(7.6%), 2(12.5%) in nurses and 1(12.5%) in ward boy. According to our research, healthcare workers' mobile phones have unquestionably been colonized by microorganisms. It can transmit not just messages but also microorganisms that cause illness. Conclusion: Therefore, the study highlights the necessity of reducing the spread of infection via cell phone use by adhering to stringent hand hygiene guidelines and refraining from using cell phones when providing patient care or performing therapeutic operations. Using additional disinfectants or 70% isopropyl alcohol, disinfect it.

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Background: Colistin is the last resort drug to treat multidrug-resistant organisms. The most common isolate obtained in the healthcare is Klebsiella sp., which is usually resistant to carbapenems owing to carbapenem-resistant genes. This study was undertaken to analyze the resistance trend of Klebsiella sp. and its sensitivity to beta-lactams, beta-lactams inhibitor combinations, carbapenems, and aminoglycoside. Emphasis was laid on finding the possibilities of colistin salvage strategies and placement of ceftazidime-avibactam in the antibiotic policy. Methods: Data from India and clinical samples isolating Klebsiella species were included. Genes included in the study were AMP C, TEM, CTXM1, KPC, OXA, NDM, and SHV. Antibiotics included in the study were amikacin, gentamicin, ceftriaxone, cefepime, ceftazidime, ciprofloxacin, amoxiclavulanic acid, ampicillin-sulbactam, pipercillin tazobactam, ceftazidime avibactam, Imipenem, meropenem, tigecycline, colistin, minocycline, aztreonam. Results: Among 10524 isolates from India (2004-2021), 7910 were Gram negatives. 1996 (25.23%) isolates of Klebsiella species were identified. 65.76% were males. Antibiotic Sensitivity pattern was analyzed. Carbapenem resistance was found in 49.04%. Among Carbapenem-resistant isolates, the NDM gene was detected in 51.14%, and 93.67% were sensitive to ceftazidime avibactum in the remaining 48.86% isolates. Genes were analyzed. A 2x2 chi-squire test revealed that the OXA gene was connected with carbapenem resistance towards Klebsiella isolates (OR: 103 (44.8-236.8), p=0.001). Moreover, the effect of the OXA gene on ceftazidime avibactam resistance was found to be null (p>0.05). Conclusion: This study concludes that ceftazidime-avibactam is a good alternative among NDM-negative carbapenem-resistant isolates and can be a treatment option. Routine testing of ceftazidime avibactam with aztreonam in ICU isolates is to be done. This study emphasizes detecting resistant genes in all critical cases to avoid accidental use of antibiotics, which is one of the leading causes of antibiotic resistance. Colistin antibiotics should be reserved for isolates where all the drug combinations fail