Síndrome de absceso hepático invasor por Klebsiella pneumoniae, serie de casos / Invasive liver abscess syndrome caused by Klebsiella pneumoniae, case series

Resumen Introducción: Los abscesos hepáticos primarios producidos por Klebsiella pneumoniae y las implicancias sistémicas relacionadas constituyen el síndrome de absceso hepático invasor por Klebsiella pneumoniae. Objetivo: Describir las características clínicas, epidemiológicas y la evolución de esta entidad en nuestro centro. Pacientes y Métodos: Cohorte retrospectiva de pacientes adultos internados en el Hospital Italiano de Buenos aires entre el 1 de enero de 2001 y el 1 de mayo de 2020. Se incluyeron pacientes con diagnóstico de absceso en cualquier órgano con aislamiento en cultivo de absceso o hemocultivo positivo para Klebsiella pneumoniae para ser analizadas las características epidemiológicas, clínicas y la evolución de aquellos con localización primaria hepática. Resultados: 10 pacientes fueron incluidos. Dos (20%) pacientes fueron orientales. La mediana de edad fue 69 años (IIC 64-79), nueve (90%) fueron hombres. La co-morbilidad más frecuente fue diabetes mellitus tipo 2 (40%). Cuatro (40%) pacientes tuvieron diseminación a otros órganos. La mediana de internación fue 21,5 días (IIC 15-43), 60% (n: 6) requirió internación en unidad de cuidados intensivos y 30% (n: 3) de los pacientes falleció. Conclusión: El síndrome de absceso hepático invasor por Klebsiella pneumoniae es una enfermedad infrecuente, potencialmente mortal. Este estudio intenta reportar las características de los pacientes con esta patología en nuestra población.

Abstract Background: Primary liver abscesses caused by Klebsiella pneumoniae and their related systemic complications produce the invasive liver abscess syndrome due to Klebsiella pneumoniae. Aim: To describe the clinical, epidemiological and evolution characteristics in our center. Methods: A retrospective cohort of hospitalized adults in Hospital Italiano de Buenos Aires between January 1st, 2001 and May 1st, 2020. We included patients with diagnosis of abscess in any organ with rescue in culture or positive blood culture for Klebsiella pneumoniae. Epidemiological, clinical characteristics and prognosis of those with hepatic primary localization were analyzed. Results: 10 patients were included. Two (20%) patients were Oriental. Median age was 69 years (interquartile range 64-79), nine (90%) were men. The most frequent comorbidity was type 2 diabetes (40%). Four (40%) patients had spread to other organs. The median hospitalization was 21.5 days (IIC 15-43), 60% (n: 6) were hospitalized in the intensive care unit and 30% (n: 3) died. Conclusions: The invasive liver abscess syndrome due to Klebsiella pneumoniae is a rare life-threatening disease. Our study reports the characteristics of patients with this syndrome in our population.

Caracterización clínica, epidemiológica y microbiológica de bacteriemias producidas por enterobacterias resistentes a carbapenems en un hospital universitario de Córdoba, Argentina / Clinical, epidemiological and microbiological characterization of bacteremia produced by carbapenem-resistant enterobacteria in a university hospital in Córdoba, Argentina

Resumen Introducción: Las enterobacterias son una causa principal de infecciones del torrente sanguíneo y su resistencia antimicrobiana se encuentra en aumento. Esto lleva a un incremento de la morbilidad-mortalidad y de los costos en la salud pública. Las enterobacterias resistentes a carbapenems representan un grave desafío a nivel global ya que existen escasas opciones terapéuticas disponibles. Objetivo: Caracterización clínico/microbiológica de las bacteriemias resistentes a carbapenémicos observadas en un período de 4 años. Material y Método: Estudio retrospectivo, observacional y descriptivo, sobre las bacteriemias por enterobacterias resistentes y sensibles a carbapenems. Resultados: Se analizó un total de 84 pacientes con bacteriemia por enterobacterias resistentes y sensibles a carbapenems. Entre las resistentes, observamos una mayor proporción de: tratamiento antimicrobiano previo, hospitalización en unidad de terapia intensiva (UTI), inicio de la bacteriemia en UTI y antecedentes de β-lactamasas de espectro extendido. Además, se detectó un amplio predominio de Klebsiella pneumoniae productor de KPC y una mortalidad atribuible de 52,4%. Discusión: El estudio posibilitó profundizar el conocimiento de una enfermedad emergente de elevada mortalidad, en vistas al diseño y aplicación de estrategias de control de infecciones y de esquemas de tratamiento efectivos adaptados a la epidemiologia local.

Abstract Background: Enterobacteriaceae are a major cause of bloodstream infections and their antimicrobial resistance continues to increase. This leads to higher morbidity-mortality rates and public health costs. Carbapenem-resistant Enterobacteriaceae represent a serious challenge globally, since there are few therapeutic options available. Aim: Clinical/microbiological characterization of the carbapenem-resistant bacteremia observed over a period of 4 years. Methods: Retrospective, observational and descriptive study about bacteremia caused by carbapenem-resistant and susceptible Enterobacteriaceae. Results: A total of 84 patients with bacteremia including carbapenem-resistant and susceptible Enterobacteriaceae were analyzed. We found that patients infected with carbapenem-resistant strains presented a higher proportion of: previous antibiotic treatment, hospitalization in intensive care unit (ICU), onset of the bacteremia during hospitalization in ICU and previous infection with extended-spectrum-beta-lactamase producing Enterobacteriaceae. Additionally, we observed a predominance of KPC-producing Klebsiella pneumoniae and an attributable mortality rate of 52.4%. Discussion: This study allowed for a better understanding of an emerging problem with high mortality, which in turn is useful for the design and adoption of infection control strategies and effective treatment regimens adapted to our local epidemiology.

Infection related to Klebsiella pneumoniae producing carbapenemase in renal transplant patients / Infección relacionada con Klebsiella pneumoniae productora de carbapenemasa en pacientes trasplantados renales

ABSTRACT Objective: To evaluate the risk factors related to Klebsiella pneumoniae carbapenemase infection after renal transplantation. Methods: This was a retrospective epidemiological (case-control) study, conducted from October 2011 to march 2016. Transplanted patients with infection by this bacteria during hospitalization were selected as cases. The controls were paired by age, sex, type of donor and transplant time. The proportion of cases and controls was 1:2. Results: Thirty hundred and five patients were included in the study (45 cases and 90 controls). The risk factors found for infection by KPC were: time of hospitalization after the transplant (OR: 4.82; CI95% 2.46-9.44), delayed kidney function (OR: 5.60; CI95% 1.91-11.01) and previous infectious for another microorganism ( OR: 34.13 CI95% 3.52-132.00). Conclusion: The risk of acquisition of this bacterium was directly related to invasive procedures and exposure to the hospital environment. The findings reinforce the importance of prevention measures and control of infection by this microorganism.

RESUMEN Objetivo: Evaluar los factores de riesgo relacionados con la infección por Klebsiella pneumoniae carbapenemasa después del trasplante renal. Método: Estudio retrospectivo epidemiológico (caso-control), realizado de octubre de 2011 a marzo de 2016. Pacientes transplantados con infección por esa bacteria durante la internación fueron seleccionados como casos. Los controles se parearon por edad, sexo, tipo de donante y tiempo de trasplante. La proporción de casos y controles fue de 1: 2. Resultados: Treinta y cinco pacientes fueron incluidos en el estudio (45 casos y 90 controles). Los factores de riesgo para la infección encontrados por KPC fueron: tiempo de hospitalización después del trasplante (OR: 4,82, IC95% 2,46-9,44), función renal retardada (OR: 5,60, IC95% 1, 91-11,01) y anterior infecciosa para otro microorganismo (OR: 34,13 IC95% 3,52-132,00). Conclusión: El riesgo de adquisición de esta bacteria estuvo directamente relacionado a procedimientos invasivos y exposición al ambiente hospitalario. Los hallazgos refuerzan la importancia de medidas de prevención y control de la infección por ese microorganismo.

Brote en simultáneo de Pseudomona aeruginosa y Klebsiella pneumoniae BLEE en una Unidad de Cuidados Intensivos Neonatal de Asunción, Paraguay / Simultaneous outbreak of Pseudomonas Aeruginosa and ESBL producing-Klebsiella Pneumoniae in a Neonatal Intensive Care Unit of Asunción, Paraguay

Las Infecciones Asociadas a las Atenciones Sanitarias (IAAS), constituyen un serio problema de salud pública. Se describe un brote de IAAS en una Unidad de Cuidados Intensivos Neonatales de Asunción y las medidas de control implementadas. Estudio descriptivo de serie de casos, entre el 26 de marzo y el 18 de abril del 2013. Fueron utilizados datos secundarios como historias clínicas, registros de enfermería, certificados de defunción, resultados de bacteriología, registros de control de IAAS. El universo estuvo constituido por 12 neonatos, en cuatro se aislaron Pseudomona aeruginosa y en tres Klebsiella pneumoniae BLEE. Predomino el sexo masculino (6/7), la media de edad de 2 días (rango:2-45 días), la mayoría prematuros (5/7). Todos con procedimientos invasivos durante la hospitalización. La tasa global de ataque fue 58% (7/12), con una tasa de ataque para P. aeruginosa de 33 % (4/12) y para K. pneumoniae BLEE de 38 % (3/12). La mortalidad global fue 29% (2/12) y la tasa de la letalidad atribuible a la infección por P. aeruginosa fue del 50% (2/4). Las medidas de control del brote fueron el aislamiento de los pacientes infectados, una enfermera por paciente, se intensifico los cuidados de bioseguridad para procedimientos invasivos y lavado de manos; suspensión de pacientes remitidos hasta que se asegurar el corte de transmisión. Se confirmó dos brotes simultáneos con agentes etiológicos diferentes, P. aeruginosa y K. pneumoniae BLEE. Es necesario reforzar las medidas de control de infecciones y lavado correcto de manos, de manera a prevenir brotes de IAAS en la UCIN(AU)

Multirresistencia de Escherichia coli y Klebsiella pneumoniae provenientes de pacientes con infección del tracto urinario adquirida en la comunidad / Escherichia coli and Klebsiellap neumoniae multiresistance from patients with urinary tract infection acquired in the community

Introducción: El incremento de la multirresistencia bacteriana constituye un problema de salud pública a nivel internacional. Objetivos: Determinar la susceptibilidad antimicrobiana y los patrones de multirresistencia en cepas de Escherichia coli y Klebsiella pneumoniae aisladas de urocultivos. Métodos: Se realizó un estudio descriptivo retrospectivo en el Centro Municipal de Higiene, Epidemiología y Microbiología, municipio Güines, provincia Mayabeque, Cuba, en el periodo comprendido de enero a diciembre de 2017. El estudio incluyó 250 cepas de Escherichia coli y 62 de Klebsiella pneumoniae aisladas e identificadas de muestras de orina de pacientes con infección del tracto urinario adquirida en la comunidad. La susceptibilidad antimicrobiana fue evaluada con el método de difusión en agar empleado la técnica de Kirby Bauer. Resultados: En Escherichia coli se observó niveles de resistencia superiores al 60 por ciento a los antimicrobianos ácido nalidíxico, cefotaxima, trimetoprim - sulfametoxazol y ceftazidima. La nitrofurantoína y la amikacina presentaron 88,8 por ciento y 83,8 por ciento de efectividad, respectivamente. Se apreció en Klebsiella pneumoniae altos valores de resistencia a ceftazidima, trimetoprim - sulfametoxazol y ácido nalidíxico. Amikacina, presentó niveles de sensibilidad de un 71 por ciento. La resistencia a las cefalosporinas de tercera generación se detectó en 78 (31,2 por ciento) de Escherichia coli y 26 (41,9 por ciento) de Klebsiella pneumoniae. De los aislados de Escherichia coli 143 (57,2 por ciento) y Klebsiella pneumoniae 35 (56,4 por ciento) presentaron multidrogoresistencia. Conclusiones: Existe la circulación de cepas resistentes a cefalosporinas de tercera generación y multidrogorresistentes causantes de infecciones de las vías urinarias adquiridas en la comunidad y se informa sobre los antibióticos (nitrofurantoína y amikacina) que podrían ser utilizados para combatirlas de forma empírica en esta área geográfica(AU)

Introduction: The increase of bacterial multiresistance constitutes a public health problem at the international level. Objectives: To determine antimicrobial sensitivity and multiresistance patterns in strains of Escherichia coli and Klebsiellapneumoniae isolated from urine cultures. Methods: A retrospective, descriptive study was conducted at the Municipal Center for Hygiene, Epidemiology and Microbiology, Güines municipality, Mayabeque Province, Cuba, in the period from January to December, 2017. The study included 250 Escherichia coli and 62 Klebsiellapneumoniae strains isolated and identified from urine samples from patients with urinary tract infection acquired in the community. Antimicrobial sensitivity was evaluated with the method of diffusion in agar using Kirby Bauer´s technique. Results: In Escherichia coli, resistance levels higher than the 60% were observed in antimicrobial nalidixic acid, cefotaxime, trimethoprim-sulfamethoxazole and ceftazidime. Nitrofurantoin and amikacin presented 88.8 percent and 83.8 percent of effectiveness, respectively. High values of resistance to ceftazidime, trimethoprim-sulfamethoxazole and nalidixic acid were present in Klebsiellapneumoniae. Amikacin presented sensitivity levels of 71 percent. Resistance to third-generation cephalosporins was detected in 78 (31.2 percent) of Escherichia coli and 26 (41.9 percent) Klebsiellapneumoniae. From the Escherichia coli and Klebsiellapneumoniae isolates, 143 (57.2 percent) and 35 (56.4 percent),respectively, presented multidrug resistance. Conclusions: There is circulation of strains which are resistant to third generation cephalosporins and multidrug resistants that cause urinary tract infections acquired in the community and there are reports on antibiotics (nitrofurantoin and amikacin) that might be used to combat them empirically in this geographical area(AU)

Carbapenem-resistant Klebsiella pneumoniae colonization in pediatric and neonatal intensive care units: risk factors for progression to infection

Abstract Background Little is known about factors associated with carbapenem-resistant Klebsiella pneumoniae infections in pediatric patients, who are initally colonized with carbapenem-resistant Klebsiella pneumoniae. Materials and methods A retrospective case–control study was conducted involving pediatric and neonatal intensive care units throughout a five-year period (January 2010–December 2014). Clinical and microbiological data were extracted from Hospital Infection Control Committee reports and patients’ medical records. Risk factors were assessed in carbapenem-resistant Klebsiella pneumoniae colonized patients who developed subsequent systemic infection (cases) and compared to carbapenem-resistant Klebsiella pneumoniae colonized patients who did not develop infection (controls). Results Throughout the study period, 2.6% of patients admitted to neonatal intensive care units and 3.6% of patients admitted to pediatric intensive care units had become colonized with carbapenem-resistant Klebsiella pneumoniae. After a mean of 10.6 ± 1.9 days (median: 7 days, range: 2–38 days) following detection of colonization, 39.0% of the carbapenem-resistant Klebsiella pneumoniae colonized patients in pediatric intensive care units and 18.1% of carbapenem-resistant Klebsiella pneumoniae colonized patients in neonatal intensive care units developed systemic carbapenem-resistant Klebsiella pneumoniae infection. Types of systemic carbapenem-resistant Klebsiella pneumoniae infections included bacteremia (n = 15, 62.5%), ventilator-associated pneumonia (n = 4, 16.6%), ventriculitis (n = 2, 8.3%), intraabdominal infections (n = 2, 8.3%), and urinary tract infection (n = 1, 4.1%). A logistic regression model including parameters found significant in univariate analysis of carbapenem resistant Klebsiella pneumoniae colonization and carbapenem resistant Klebsiella pneumoniae infection groups revealed underlying metabolic disease (OR: 10.1; 95% CI: 2.7–37.2), previous carbapenem use (OR: 10.1; 95% CI: 2.2–40.1), neutropenia (OR: 13.8; 95% CI: 3.1–61.0) and previous surgical procedure (OR: 7.4; 95% CI: 1.9–28.5) as independent risk factors for carbapenem-resistant Klebsiella pneumoniae infection in patients colonized with carbapenem-resistant Klebsiella pneumoniae. Out of 24 patients with carbapenem resistant Klebsiella pneumoniae infection, 4 (16.6%) died of carbapenem-resistant Klebsiella pneumoniae sepsis. Conclusion Asymptomatic colonization with carbapenem-resistant Klebsiella pneumoniae in intensive care units of pediatric departments should alert health care providers about forthcoming carbapenem-resistant Klebsiella pneumoniae infection. Those carbapenem-resistant Klebsiella pneumoniae colonized patients at risk of developing infection due to carbapenem-resistant Klebsiella pneumoniae may be targeted for interventions to reduce subsequent infection occurence and also for timely initiation of empirical carbapenem-resistant Klebsiella pneumoniae active treatment, when necessary.

Prevalencia de uropatógenos y sensibilidad antimicrobiana en lactantes menores de 2 años provenientes de la comunidad con diagnóstico de infección de vías urinarias / Prevalence of uropathogens and antimicrobial susceptibility in infants younger than 2 years of age from the community with a diagnosis of urinary tract infection

RESUMEN Introducción: la infección urinaria (IU) es una patología frecuente en los niños. La prevalencia de los uropatógenos varía de acuerdo a las regiones geográficas e incluso entre los diferentes centros asistenciales. El conocimiento de dicha prevalencia y de la sensibilidad a los antimicrobianos ayuda a la elección de la antibioticoterapia empírica inicial, permitiendo de esa manera, el control del cuadro agudo y evitando la resistencia bacteriana. Objetivo determinar la sensibilidad de los uropatógenos a los antimicrobianos obtenidos de urocultivos de niños menores de 24 meses con diagnóstico de IU provenientes de la comunidad. Material y métodos: estudio observacional, descriptivo, retrospectivo, de corte transverso. Se analizaron los expedientes clínicos y resultados de urocultivos de lactantes menores de 24 meses internados en el Departamento de Pediatría del Hospital Nacional en el período comprendido entre enero de 2012 a diciembre de 2014 , con diagnóstico de IU. Resultados: los uropatógenos más frecuentemente obtenidos fueron: Escherichia coli (67,6%) seguido de Klebsiella pneumoniae (18,3%), Enterobacter cloacae (8,4%), Pseudomonas aeruginosa (2,8%) y otros en 2,9%. La sensibilidad de la E. coli a la ciprofloxacina, las cefalosporinas y aminoglucósidos fue alta. El 14,6% de Escherichia coli fue productora de betalactamasa de espectro extendido (BLEE). El 100% de las cepas de Klebsiella pneumoniae fuer sensible a amikacina, ciprofloxacina y acidonalidíxico. Conclusiones: el germen más frecuentemente encontrado fue E. coli, seguido de la Klebsiella pneumoniae. El tratamiento de elección recomendado es la combinación de cefalospinas de primera generación asociado a aminoglucósidos, ya que con este esquema se cubrirá más del 95% de los uropatógenos causantes de infección de vías urinarias de la comunidad. Los gérmenes productores de infección urinaria atípica, deberán ser investigados.

ABSTRACT Introduction Urinary tract infection (UTI) is a common pathology in children. The prevalence of uropathogens varies according to geographic regions and even between different care centers. Knowledge of this prevalence and antimicrobial susceptibility helps to choose the initial empirical antibiotic therapy, thus allowing the control of the acute condition and avoiding bacterial resistance. Objective to determine the sensitivity of uropathogens to antimicrobials obtained from urine cultures of children younger than 24 months with diagnosis of UTI from the community. Material and methods: observational, descriptive, retrospective, cross-sectional study. We analyzed the clinical records and results of urine cultures of infants under 24 months admitted to the Department of Pediatrics of the National Hospital in the period between January 2012 and December 2014, diagnosed as UI. Results: the most frequent uropathogen was Escherichia coli (67.6%) followed by Klebsiella pneumoniae (18.3%), Enterobacter cloacae (8.4%), Pseudomonas aeruginosa (2.8%) and others in 2, 9%. The sensitivity of E. coli to ciprofloxacin, cephalosporins and aminoglycosides was high. 14.6% of Escherichia coli was a producers of extended spectrum betalactamase (ESBL). 100% of Klebsiella pneumoniae strains was a sensitive to amikacin, ciprofloxacin and acidonaldehyde. Conclusions: the more frequent germ found was E. coli, followed by Klebsiella pneumoniae. The recommended treatment of choice is the combination of first-generation cephalosporins associated with aminoglycosides, as this scheme will cover more than 95% of the uropathogens that cause urinary tract infection in the community. Germs producing atypical urinary infection should be investigated.

Prevalencia de infecciones intrahospitalarias en el Servicio de Clínica Médica del Hospital Regional de Encarnación 2014-2015 / Prevalence of intrahospital infections in the Internal Medicine Service of the Regional Hospital of Encarnación 2014-2015

RESUMEN Introducción: las infecciones asociadas a cuidados de la salud, conocidas también como infecciones nosocomiales (IN), son un problema relevante de salud pública, se asocian con altas tasas de morbilidad y mortalidad, lo que se traduce en un incremento en los días de hospitalización y los costos de atención. Objetivos: determinar los gérmenes intrahospitalarios más frecuentes y su sensibilidad antibiótica en la sala de Clínica Médica del Hospital Regional de Encarnación periodo 2014-2015. Metodología: estudio descriptivo, observacional de corte transversal, prospectivo, de prevalencia y con componente analítico. Resultados: se evaluaron pacientes hospitalizados encontrándose 114 (6%) pacientes con infecciones intrahospitalarias. El perfil epidemiológico se caracterizó por predomino del sexo femenino (53%), con edad media 56,5 ± 22,5 años y una estancia hospitalaria prolongada. Los aislamientos fueron más frecuentes en orina. Las comorbilidades más frecuentes fueron la hipertensión arterial y la diabetes mellitus. El germen más frecuente aislado fue Klebsiella pneumoniae, con una sensibilidad solo a amikacina y cabapenemes, con 64% BLEE(+) y 20% KPC, seguido por Echerichia coli y Staphylococcus aureus con buena sensibilidad a oxacilina. Conclusión: se halló 6% de infecciones intrahospitalarias y el germen más frecuente fue K. pneumoniae

ABSTRACT Introduction: infectious related to health care, also known as nosocomial infections (NI) are an important public health problem, are associated with high rates of morbidity and mortality, resulting in an increase in days of hospitalization and costs. Objectives: to determine the most frequent nosocomial germs and antibiotic sensitivity in a Medical Ward of the Regional Hospital of Encarnación 2014-2015. Methodology: descriptive, observational cross-sectional study with prospective approach, and analytical component. Results: Hospitalized patients were evaluated and were found 114 (6%) patients with nosocomial infections, below the global average. The epidemiological profile, were characterized by predominance of females 53%, aged 56.5 ± 22.5 years. And a prolonged hospital stay. The germs more common commouly isolated were in urine, the more frequent comorbidities were hypertension and diabetes mellitus. The most frequent isolated germ was Klebsiella pneumoniae, with a sensitivity only to amikacin and Cabapenemes, followed by a Escherichia coli and Staphylococcus aureus oxacillin with good sensitivity. Conclusions: 6% of nosocomial infections were found and the more frequent isolated germ was K. pneumoniae

Caracterización molecular de un brote de Klebsiella pneumoniae resistente a carbapenémicos en un hospital de alto nivel de complejidad de Medellín, Colombia / Molecular characterization of an outbreak of carbapenem-resistant Klebsiella pneumoniae in a tertiary care hospital in Medellín, Colombia

Introducción. La resistencia a los carbapenémicos constituye una seria amenaza para la salud pública a nivel mundial, ya que estos antibióticos son una de las últimas opciones terapéuticas contra las bacterias multirresistentes. La caracterización molecular de los brotes causados por bacterias resistentes aporta información relevante para el diseño de estrategias de control de infecciones. Objetivo. Describir las características moleculares de un brote de Klebsiella pneumoniae resistente a carbapenémicos ocurrido en un hospital de alto nivel de complejidad de Medellín entre 2010 y 2011. Materiales y métodos. A partir de una colección de cepas del brote ocurrido en la institución hospitalaria, se recuperaron 84 aislamientos de 32 pacientes infectados y 52 colonizados. La identificación y la sensibilidad de los aislamientos se establecieron mediante el sistema Vitek2 ® . La detección de carbapenemasas se hizo mediante el test de Hodge modificado y usando la reacción en cadena de la polimerasa. La relación genética entre los aislamientos se evaluó mediante electroforesis en gel de campo pulsado y tipificación de secuencias de locus múltiple. Resultados. Todos los aislamientos analizados fueron multirresistentes; el análisis molecular reveló que todos eran portadores del gen bla KPC-3 . El análisis genético mostró que los aislamientos de pacientes infectados y colonizados (58/64 aislamientos) estaban estrechamente relacionados (>80 %) y pertenecían al linaje ST258. Conclusión. Mediante el empleo de técnicas de tipificación molecular fue posible confirmar un brote ocasionado por K. pneumoniae ST258 portador del bla KPC-3 con un perfil de multirresistencia, el cual había sido asociado a uno anterior ocurrido en otro hospital de Medellín. El ST258 es un clon de alto riesgo presente a nivel mundial, lo que debe alertar sobre la posible diseminación de resistencia en el país. El empleo de herramientas moleculares en la vigilancia epidemiológica, es útil para evaluar la diseminación de microorganismos de interés en salud pública.

Introduction: Resistance to carbapenems is considered to represent a serious threat to public health at the global level, since these antibiotics are one of the last therapeutic options for the treatment of multidrug-resistant bacteria. Molecular characterization of outbreaks due to resistant bacteria provides information that can be used in the design of infection control strategies. Objective: To describe the molecular characteristics of an outbreak of carbapenem-resistant Klebsiella pneumoniae that occurred in a tertiary care hospital in Medellín in 2010-2011. Materials and methods: Eighty-four isolates were obtained from a collection of strains associated with the hospital outbreak, of which 32 were from patients infected at that time and 52 were carriers. Identification and susceptibility of the isolates was performed using Vitek2 ® . Carbapenemases were detected using a modified Hodge test and polymerase chain reaction. Genetic relationships between the isolates were evaluated using pulsed field gel electrophoresis and multiple locus sequence typing. Results: All the isolates analyzed were multidrug resistant; molecular analysis revealed that all harbored bla KPC-3 . The genetic analysis showed that 58/64 of the isolates from both infected and colonized patients were closely related (Dice similarity index >80%) and belonged to the ST258 lineage. Conclusion: Using molecular typing techniques it was possible to confirm the occurrence of an outbreak caused by K. pneumoniae ST258, a carrier of bla KPC-3 with a multidrug-resistant profile which had been associated with a previous outbreak in another hospital in the city of Medellín. ST258 is a high risk clone at the global level, demonstrating the potential for dissemination of resistance in this country. Implementation of molecular tools in support of epidemiological surveillance is useful for evaluating the spread of microorganisms of public health significance.

Prevalência de infecção hospitalar pela bactéria do gênero klebsiella em uma unidade de terapia intensiva / Prevalence of hospital infection with the bacteria klebsiella in an intensive care unit

Este estudo objetivou determinar a prevalência de infecção hospitalar pela bactéria Klebsiella pneumoniae na Unidade de Terapia Intensiva adulto de um hospital público de ensino, Hospital e Maternidade Therezinha de Jesus no período de 2012 a 2013. MÉTODOS: O estudo é descritivo transversal do tipo retrospectivo com análise de prontuários médicos e resultados das hemoculturas, uroculturas, lavado traqueal e swabs dos pacientes internados nesse setor incluindo exames realizados no período acima citado, com amostragem de 34 casos confirmados de infecção hospitalar (IH) por Klebsiella pneumoniae e processados pelo Software SPSS. RESULTADOS: A distribuição de frequência de pacientes em tratamento intensivo no período estudado compreendeu a população de 193 indivíduos, sendo que 17,09% desenvolveram infecção hospitalar pela bactéria acima citada. CONCLUSÃO: concordamos que os números obtidos neste estudo condizem com os demais hospitais de ensino, o que não significa que é um parâmetro que não pode ser mudado, pelo contrário, com esta análise pretendemos implantar medidas eficazes de controle de contaminação assim como ações educativas para os demais profissionais da saúde (acadêmicos e residentes principalmente) no nosso hospital, minimizando os desfechos ruins.

This study aimed to determine the prevalence of nosocomial infection by the bacterium Klebsiella pneumoniae in adult intensive care unit of a public teaching hospital, Hospital and Maternity Therezinha of Jesus in the period 2012-2013. METHODS: The study is a retrospective cross-sectional with analysis of medical records and results of blood cultures, urine, tracheal aspirates and swabs of hospitalized patients in this sector including examinations performed above mentioned period, with sampling of 34 confirmed cases of Klebsiella pneumoniae IH and processed by SPSS software. RESULTS: The frequency distribution of patients in intensive care during the study period comprised the population of 193 individuals, and 17.09% developed nosocomial infection by the bacteria mentioned above. CONCLUSION: We agree that the figures obtained in this study are consistent with other teaching hospitals, which means that it is not a parameter that can not be changed, however, with this analysis we intend to implement effective measures to control contamination as well as educational activities for other health professionals (mainly academics and residents) in our hospital, minimizing poor outcomes.

Risk factors for infection with carbapenem-resistant Klebsiella pneumoniae: a case-case-control study / Factores de riesgo para infección con Klebsiella pneumoniae resistente a carbapenémicos: estudio caso-caso-control

Objective: To evaluate the association between quinolone exposure and the emergence of carbapenem-resistant Klebsiella pneumoniae (CRKP) and to estimate CRKP-specific mortality. Methods: Case-case-control study implemented in a tertiary care institution. Three groups of patients were analyzed: 61 consecutive cases of infection with CRKP (Group I); 61 randomly chosen cases of patients infected with carbapenem-sensitive Klebsiella pneumoniae (CSKP; Group II); and 122 randomly chosen controls without CRKP or CSKP infection. Matching was based on the length of stay in intensive care unit and the date of bacterial isolation. An active search was performed for patients with CRKP and CSKP infection, and prospective cases were included in the study. We compared the results for Groups I and II against those for the controls by using two conditional logistic regression analyses that included infection as the dependent variable and controlled for time at risk and co-morbidities. Results: Exposure to quinolones was not associated with CRKP infection: no association was found in the analysis of CRKP with the controls (OR = 1.7; 95% CI: 0.2-6.5) or in the analysis of CSKP against the controls (OR = 0.6; 95% CI: 0.2-1.6). Use of carbapenems (OR = 3.3; 95% CI: 1.2-9.3) and colonization with CRKP (OR = 3.3; 95% IC: 1.2-9.3) were specific risk factors for infection with CRKP. Mortality associated with CRKP was 61.3%. Conclusion: No association was found between exposure to quinolones and infection with CRKP; however, colonization by CRKP and use of carbapenems are risk factors for infection with CRKP.

Resumen Objetivo: Evaluar la asociación entre la exposición a quinolonas y la aparición de infección por Klebsiella pneumoniae resistente a Carbapenémicos (CRKP) y estimar la mortalidad específica por CRKP. Métodos: Estudio caso-caso-control realizado en una institución de tercer nivel de atención. Se adelantó búsqueda activa y prospectiva de los casos. Se analizaron tres grupos: 61 casos consecutivos de infección por CRKP, 61 casos elegidos al azar de los pacientes con infección por Klebsiella pneumoniae sensible a Carbapenémicos (CSKP) y 122 controles sin infección por CRKP ni por CSKP, elegidos al azar. Se realizó emparejamiento por estancia en unidad de cuidados intensivos y fecha del aislamiento bacteriano. Los datos se extractaron de la historia clínica electrónica. Se comparó los casos CRKP y los casos CSKP contra los controles mediante dos análisis de regresión logística condicional, con la infección como variable dependiente y controlando por el tiempo en riesgo y la comorbilidad. Resultados: La exposición a quinolonas no se asoció a infección con CRKP: no se encontró asociación en el análisis de CRKP contra controles (OR 1.7 IC 95%: 0.2-6.5) ni en el análisis de CSKP contra controles (OR 0.6 IC 95%: 0.2-1.6). El uso de carbapenémicos (OR 3.3 IC 95%: 1.2-9.3) y la colonización por KPRC (OR 16,2 IC 95%: IC 95%: 3.3-79.1) fueron factores de riesgo específicos para infección por CRKP. La mortalidad específica asociada a CRKP fue de 61.3%. Conclusión: No se encontró asociación entre la exposición a quinolonas y la infección por KPRC, pero la colonización por CRKP y el uso de carbapenémicos son factores de riesgo asociados a la infección por KPRC.

Factores de riesgo asociados al aislamiento de Escherichia coli o Klebsiella pneumoniae productoras de betalactamasas de espectro extendido en un hospital de cuarto nivel en Colombia / Risk factors associated with the isolation of extended spectrum betalactamases producing Escherichia coli or Klebsiella pneumoniae in a tertiary care hospital in Colombia

Introducción. Las betalactamasas de espectro extendido (BLEE) son un fenómeno de resistencia emergente de particular incidencia en América Latina. En Colombia existe poca información sobre los factores de riesgo asociados con su adquisición. Objetivo. Determinar los factores de riesgo que están asociados a la infección o colonización por Escherichia coli o Klebsiella pneumoniae productoras de BLEE en pacientes mayores de 18 años. Materiales y métodos. Se llevó a cabo un estudio de casos y controles con relación 1:1 en pacientes con aislamientos de E. coli o K. pneumoniae productoras de BLEE en cualquier tipo de muestra durante el periodo de enero de 2009 a noviembre de 2011 en el Hospital Universitario de San José. Resultados. Se estudiaron 110 casos y 110 controles; 62,7 % correspondió a E. coli y 37,3 %, a K. pneumoniae . Como factores de riesgo independiente en el análisis multivariado se encontraron la insuficiencia renal crónica (OR=2,99; IC 95%, 1,10-8,11; p=0,031), la cirugía urológica (OR=4,78; IC 95%, 1,35-16,87; p=0,015), el antecedente de uso de antibióticos en los tres meses anteriores (OR=2,24; IC 95%, 1,09-4,60; p=0,028), el origen hospitalario de la infección (OR=2,92; IC 95%, 1,39-6,13; p=0,004) y la hospitalización previa (OR=1,59; IC 95%, 1,03-2,46; p=0,036). Conclusión. Anticiparse al patrón de resistencia del microorganismo que infecta a un paciente con base en los factores de riesgo asociados permitiría la elección de un tratamiento antibiótico empírico apropiado, con el fin de lograr la disminución de la morbimortalidad de los pacientes.

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Comportamiento de casos de Klebsiella pneumoniae productora de carbapenemasas en pacientes con cáncer de un hospital de tercer nivel de Bogotá, D.C. / Behavior of carbapenemase-producing Klebsiella pneumoniae cases in cancer patients at a third level hospital in Bogotá, D.C.

Introducción. La presencia en los hospitales de enterobacterias productoras de carbapenemasas es cada vez más frecuente. Los pacientes con cáncer en estado avanzado requieren medios invasivos para el diagnóstico, el tratamiento o los cuidados paliativos, así como el uso de antimicrobianos de amplio espectro para tratar infecciones secundarias, lo cual aumenta su propensión a las infecciones causadas por estas bacterias. Objetivo. Informar el comportamiento de Klebsiella pneumoniae productora de carbapenemasas de tipo KPC en el Instituto Nacional de Cancerología de Bogotá, entre enero de 2010 y diciembre de 2012. Materiales y métodos. Mediante el análisis de la base de datos y de los registros de los pacientes con aislamientos de K. pneumoniae productores de carbapenemasas de tipo KPC, a cargo del comité de infecciones de la institución, se identificaron y describieron las características epidemiológicas de los casos detectados. La determinación de brotes se efectuó con herramientas de control estadístico de calidad. Resultados. Entre enero de 2010 y diciembre de 2012 se identificaron 45 pacientes con aislamiento de K. pneumoniae productor de carbapenemasas de tipo KPC en alguna muestra. Hubo más aislamientos en pacientes de cáncer con tumores sólidos. La identificación se logró más frecuentemente en muestras de orina; el 17,7 % de los casos correspondió a colonización y el 82,3 %, a infección; 35,5 % (16/45) de los pacientes sobrevivió. Durante este periodo se identificaron dos brotes que se controlaron aplicando una estrategia multimodal. Conclusiones. Se encontró que la presencia de KPC fue más frecuente en infecciones que en colonizaciones. Durante estos dos años ocurrieron dos brotes que fueron controlados limitando la transmisión cruzada de bacterias multirresistentes por medio de estrategias de control convencionales.

Introduction: The presence of carbapenemase-producing Enterobacteriaceae in hospitals is increasingly common. Patients with advanced cancer who require invasive means for diagnosis, treatment or palliative care, and the use of broad-spectrum antimicrobials to treat secondary infections show increased susceptibility to infections caused by these bacteria. Objective: To report the behavior of carbapenemase-producing Klebsiella pneumoniae (CPKP) isolates at the Instituto Nacional de Cancerología in Bogotá between January 2010 and December 2012. Materials and methods: By analyzing the database kept by the infection committee of the institution, as well as the records of patients with CPKC isolates, we identified and described the epidemiology of detected cases. Outbreaks were determined by using quality control statistical tools. Results: Between January 2010 and December 2012, we found 45 patients with CPKC isolates recovered from any sample. There were more isolates from patients with malignant solid tumors. CPKC isolates from urine samples were more often recovered; 17.7% of CPKC isolates corresponded to colonization, and 82.3% to infection; 35.5% of patients (16/45) survived. We identified two outbreaks during this period, which were controlled using a multimodal approach. Conclusions: This study found that CPKC presence is more frequent as infection than as colonization. During the two years of the study we detected two outbreaks, which were controlled by limiting multi-resistant bacteria cross transmission using conventional control strategies.

Prevalence of two multidrug-resistant Klebsiella species in an Indian teaching hospital and adjoining community

The Gram-negative pathogenic bacteria Klebsiella oxytoca and Klebsiella pneumoniae produce the extended spectrum beta -lactamase [ESBL] and cephalosporinase enzymes and are the major causes of hospital acquired [HA] infections and epidemics in non-hygienic communities in the majority of developing countries. The prevalence of multidrug resistance among 445 strains of K. oxytoca and K. pneumoniae isolated from clinical samples of patients with gastrointestinal infections over a period of 42 months in the hospital was recorded, along with the sensitivity patterns to 23 antibiotics, including third-generation cephalosporin and fluoroquinolone antibiotics, using the disk-diffusion method. Of 175 K. oxytoca isolates, 143 were ESBL positive and 117 were fluoroquinolone resistant. Of 270 K. pneumoniaeisolates, 200 were ESBL positive and 195 were independently fluoroquinolone resistant. The HA samples yielded more isolates than the community acquired [CA] samples for each species. The K. oxytoca strains were resistant to cefepime, gatifloxacin, ciprofloxacin, ceftazidime, levofloxacin and imipenem, whereas the K. pneumoniae strains were highly resistant to ampicillin, norfloxacin, ciprofloxacin, gatifloxacin, ofloxacin, amoxyclav, ceftazidime, cefepime, cefixime, piperacillin and imipenem. The ESBL-producing and fluoroquinolone-resistant K. pneumoniae strains were more prevalent than the K. oxytoca strains in the HA/CA samples. The minimum inhibitory concentration values of the third-generation cephalosporins: cefotaxime and ceftazidime and the fluoroquinolones: ciprofloxacin and levofloxacin against both species of Klebsiella confirmed the resistance in the current/coveted treatment options. Patients with other bacterial infections had a relatively higher probability of infection with ESBL-producing and fluoroquinolone-resistant Klebsiella strains. The data presented here highlight the alarming state of Klebsiellainfection dynamics in the hospital and adjoining communities

Emergencia de la resistencia a colistina en Klebsiella pneumoniae. Caracterización microbiológica y epidemiológica de aislamientos productores y no productores de carbapenemasa de tipo KPC / [Emergence of colistin-resistant Klebsiella pneumoniae. Microbiological and epidemiological characterization of the isolates producing and non-producing KPC-type carbapenemase].

Sixty-four colistin-resistant Klebsiella pneumoniae isolates recovered from clinical specimens from 57 patients admitted to Hospital de Clinicas Jose de San Martin during the period 2010-2012 were studied to describe the microbiological and epidemiological characteristics and factors associated with the emergence of colistin-resistance. Fifty-four colistin-susceptible K. pneumoniae isolates from the same period were also included in the study. The genetic relatedness among the isolates was studied by a PCR assay. Fifty percent of the resistant isolates were KPC-2 producers, 45.3

were ESBL producers and 4.7

only showed resistance to aminopenicilins. All KPC-producers (resistant and susceptible to colistin) were genotipically indistinguishable except for one, whereas the presence of 7 clonal types, which were different from the ones identified in the colistin-susceptible isolates, were detected among ESBL producers. The previous use of colistin was the main factor associated with the acquisition of resistance, and in the case of non-KPC producers the stay in ICU was another significant factor observed. Colistin resistance emerged in our hospital in the year 2010, reaching 3

in nosocomial isolates and maintaining this rate in successive years, due to the selection of resistant subpopulations in the epidemic clonal type in KPC-producers and due to the dispersion of colistin-resistant clonal types in non-KPC producing-isolates.

Outbreak of carbapenem-resistant Klebsiella pneumoniae: two-year epidemiologic follow-up in a tertiary hospital

This study describes a carbapenem-resistant Klebsiella pneumoniae (CRKP) outbreak that occurred from October 2008-December 2010. Polymerase chain reaction assays were performed to detect the blaKPC gene and molecular typing was performed using pulsed-field gel electrophoresis (PFGE). There were 33 CRKP infections; PFGE revealed five genotypes: genotype A in five (15%), B in 18 (55%), C in eight (24%) and two unique profiles. Genotype B was disseminated in all hospital units and belonged to the same clone identified in 11 different hospitals in the state of São Paulo. Sixteen (48%) patients died. Seven isolates (21%) were resistant to polymyxin B and 45% were resistant to tigecycline and amikacin.

Higher Prevalence of Klebsiella pneumoniae Extended-Spectrum beta-Lactamase in Patients on Renal Replacement Therapy

The prevalence of antibiotic resistance is higher in patients undergoing renal replacement therapy (RRT) than in patients who did not undergo RRT. We investigated the presence of KP (Klebsiella pneumoniae) in patients who underwent RRT. All data were collected retrospectively by accessing patient medical records from 2004 to 2011 for the culture results of all patients who were positive for KP. We grouped the patients by the presence of extended-spectrum beta-lactamase (ESBL) into a KP ESBL(-) group (KP[-]) and a KP ESBL(+) group (KP[+]). In total, 292 patients (23.1%) were in the KP(+) group, and 974 patients (76.9%) were in the KP(-) group. A greater percentage of KP(+) was found in patients who underwent RRT (7.5%) than in patients who did not undergo RRT (3.2%) (OR, 2.479; 95% CI,1.412-4.352). A Cox's hazard proportional model analysis was performed, and for patients with pneumonia, the risk of KP(+) was 0.663 times higher in patients who had lower albumin levels, 2.796 times higher in patients who had an inserted Levin tube, and 4.551 times higher in patients who underwent RRT. In conclusion, RRT can be a risk factor for KP(+) in patients with pneumonia.

Risk factors for KPC-producing Klebsiella pneumoniae bacteremia

The molecular epidemiology of carbapenemase-producing Klebsiella pneumoniae (KPC) has been largely investigated, but limited clinical information is available. A case-control study was performed to evaluate the risk factors for KPC bacteremia in hospitalized patients. Cases were patients with KPC bacteremia and controls were patients with non-KPC bacteremia. A total of 85 patients were included, 18 (21.2%) were KPC, and 67 (78.8%) were non-KPC (40 [59.7%] of them were extended-spectrum beta-lactamase producers). All KPC isolates were type 2 producers. These isolates belong to five distinct clones. Multivariate analysis showed that age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02 - 1.11; p = 0.004), presence of mechanical ventilation (OR, 11.1; 95% CI, 1.92 - 63.3; p = 0.007) and fluoroquinolone exposure during hospitalization (OR, 28.9; 95% CI, 1.85 - 454.6; p = 0.02) were independent risk factors for KPC in patients with K. pneumoniae bacteremia. Factors associated with severity of illness, such as age and mechanical ventilation, seem to be the main risks factors for KPC. Fluoroquinolones use might be a risk factor for KPC bacteremia. Further investigations on risk factors for KPC are warranted.

Incidence of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in patients with urinary tract infection / Incidência de Klebsiella pneumoniae produtoras de beta-lactamases de espectro estendido em pacientes com infecção do trato urinário

CONTEXT AND OBJECTIVES: Resistant bacteria are emerging worldwide as a threat to favorable outcomes from treating common infections in community and hospital settings. The present investigation was carried out to study the incidence of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in patients with urinary tract infection in different seasons of the year, in order to determine the prevalence of the genes blaTEM, blaSHV and blaCTX-M, which are responsible for ESBL production among ESBL-producing K. pneumoniae, in three cities in Iran, and to investigate the antimicrobial susceptibility pattern of K. pneumoniae in different seasons. DESIGN AND SETTING: Retrospective study carried out among patients with urinary tract infections in five hospitals in Iran. METHOD: Two hundred and eighty-eight clinical isolates of K. pneumoniae were collected between March 2007 and April 2008 from five hospitals in three cities in Iran. ESBLs were identified by phenotypic and genotypic methods. ESBL-producing Klebsiella pneumoniae were evaluated against non-beta-lactam antibiotics. Genes coding for ESBLs (blaSHV, TEM and CTX-M) were screened. RESULTS: Among the 288 clinical isolates of K. pneumoniae, 37.7 percent, 46.7 percent and 15.6 percent were obtained from hospitals in Ilam, Tehran and Tabriz, respectively, of which 39.4 percent, 50.7 percent and 45.8 percent were ESBL-producing K. pneumoniae in Ilam, Milad and Emam Reza hospitals, respectively. CONCLUSION: According to the results from this study, resistance to third-generation cephalosporins is higher during the cold months than during the warm months.

CONTEXTO E OBJETIVOS: As bactérias resistentes estão surgindo em todo o mundo como uma ameaça ao resultado favorável no tratamento de infecções comuns em ambientes comunitários e hospitalares. O presente estudo foi realizado com o objetivo de avaliar a incidência de Klebsiella pneumoniae produtoras de beta-lactamases de espectro estendido (BLEEs) em pacientes com infecção do trato urinário em diferentes estações do ano, para verificar a prevalência dos genes blaTEM, blaSHV e blaCTX-M responsáveis para a produção de BLEEs em K. pneumoniae productoras de BLEEs, em três cidades do Irã, e investigar o perfil de sensibilidade antimicrobiana de K. pneumoniae em diferentes estações. DESENHO E LOCAL: Estudo retrospectivo realizado em pacientes com infecções do trato urinário em cinco hospitais no Irã. MÉTODO: Duzentos e oitenta e oito isolados clínicos de K. penumoniae foram coletados entre março de 2007 e abril de 2008 em cinco hospitais de três cidades no Irã. BLEEs foram identificados por métodos fenotípicos e genotípicos. K. pneumoniae produtoras de BLEEs foram avaliadas contra antibióticos não beta-lactâmicos. Os genes codificadores de BLEEs (blaSHV, TEM e CTX-M) foram investigados. RESULTADOS: Entre os 288 isolados clínicos de K. pneumoniae, 37,7 por cento, 46,7 por cento e 15,6 por cento eram provenientes dos hospitais em Ilam, Tehran e Tabriz, respectivamente, dos quais 39,4 por cento, 50,7 por cento e 45,8 por cento eram K. pneumoniae produtoras de BLEEs nos hospitais em Ilam, Milad e Eman Reza, respectivamente. CONCLUSÃO: De acordo com os resultados deste estudo, a resistência às cefalosporinas de terceira geração é maior nos meses frios do que nos meses quentes.