Occurrence of blaKPC gene in clinical isolates of Pseudomonas aeruginosa from Brazil

Pseudomonas aeruginosa is one of the main microorganisms causing healthcarerelated infections. The rise of carbapenem-resistant P. aeruginosa (CRPA) strains has become a serious public health problem. Dissemination of the enzyme Klebsiella pneumoniae carbapenemase (KPC) encoded by the blaKPC gene cause the inactivation of ß-lactam antibiotics being one of the mechanisms involved in this resistance. Given the above, the objective of this review was to evaluate the occurrence of the blaKPC gene in clinical isolates of P. aeruginosa in Brazil. For this, the online databases used were: Lilacs, SciELO and PubMed. The search for articles included articles published from 2012 to 2020, using the following keywords: blaKPC (KPC), Pseudomonas aeruginosa, and Brazil (in Portuguese and English). Initially, 30 publications eligible for inclusion in this review were identified. After the first analysis, two articles were excluded due to duplication. Subsequently, titles and abstracts were evaluated, 15 articles were excluded because they did not fit the theme, and 13 articles that met the inclusion criteria were read in full. In these studies, the presence of the blaKPC gene was investigated in 566 clinical isolates of P. aeruginosa in Brazil, with 86 (15.2%) positive samples found. Pernambuco was the state with the highest number of articles and positive samples, respectively, 38.5% (5/13), and 65.1% (56/86). This study reinforces the need to investigate the occurrence of this gene in all regions of the country in CRPA, aiming to understand how its dissemination occurs and to promote prevention and therapeutic strategies.

First report of the aac(6)-Ib-cr gene in Providencia stuartii isolates in Brazil

Abstract INTRODUCTION: The aac(6')-Ib-cr and bla KPC genes are spreading among Enterobacteriaceae species, including Providencia stuartii, in some countries of world. METHODS: These genes were investigated in 28 P. stuartii isolates from a public hospital in Recife, Pernambuco, Brazil, by PCR and sequencing. RESULTS: The aac(6')-Ib-cr gene was detected in 16 resistant isolates, and the bla KPC gene was seen in 14. CONCLUSIONS: The presence of these genes in P. stuartii multi- and extensively drug-resistant isolates indicates that the resistance arsenal of this species is increasing, thus limiting the therapeutic options.

Avaliação do kit Filaria Deteção; IgG4 produzido com o antígeno recombinante Wb123 para diagnóstico da filariose linfática no Brasil / Evaluation of the Filaria Detection; IgG4 kit employing recombinant Wb123 antigen for diagnosis of lymphatic filariasis in Brazil / Evaluación de pruebas de anticuerpos antifiláricos IgG4, fabricado con el antígeno recombinante Wb123, para el diagnóstico de la filariasis linfática en Brasil

RESUMO O Plano Global de Eliminação da Filariose Linfática, lançado pela Organização Mundial da Saúde em 2000, propõe o uso de testes de detecção de antígeno circulante filarial como ferramenta diagnóstica para avaliação e monitoramento das ações de controle da parasitose. Entretanto, esses testes, apesar de apresentarem alta sensibilidade, não conseguem detectar com eficiência a infecção em seu estágio inicial, quando ainda não existe a presença de helmintos adultos. Considerando essa limitação, a pesquisa de anticorpos antifilariais tem sido apontada como uma alternativa, uma vez que os anticorpos produzidos contra as larvas infectantes do parasito são detectados antes da presença de antígeno circulante filarial. O objetivo deste estudo foi definir o ponto de corte e avaliar a acurácia do kit Filaria Detect™ IgG4 produzido com o antígeno recombinante Wb123 para diagnóstico da filariose linfática no Brasil. Para isso, foi realizado um estudo de avaliação de teste diagnóstico, no qual foram utilizadas 256 amostras de soro: 79 (30,9%) obtidas de indivíduos microfilarêmicos e 177 (60,1%), de indivíduos amicrofilarêmicos e que testaram negativo para os testes imunológicos Bm14 CELISA e Og4C3 ELISA. A definição do ponto de corte ideal, bem como da acurácia do kit Filaria Detect™ IgG4, foi obtida através da construção de curvas ROC, sendo a densidade óptica de 0,239 aquela na qual o teste obteve melhor desempenho, com sensibilidade de 81,0% e especificidade de 96,6%. Os resultados obtidos demonstraram que o kit Filaria Detect™ IgG4 é uma ferramenta promissora para investigação e monitoramento de áreas submetidas ao tratamento em massa para filariose linfática.

ABSTRACT The Global Programme to Eliminate Lymphatic Filariasis, launched by the World Health Organization in the year 2000, proposes the use of circulating filarial antigen tests as a diagnostic tool to assess and monitor initiatives to control filarial infection. However, despite a high sensitivity, these tests are not efficient to detect infection at early stages, before worms have reached the adult stage. Considering this limitation, anti-filarial antibody testing has been suggested as an alternative, given that the antibodies produced against the larvae are detectable before the presence of circulating filarial antigen. The objective of the present study was to determine the diagnostic cut-off and the accuracy of the Filaria Detect™ IgG4 kit employing recombinant Wb123 antigen for diagnosis of lymphatic filariasis in Brazil. For that, we performed a diagnostic evaluation study in which 256 serum samples were analyzed: 79 (30.9%) obtained from microfilaremic individuals and 177 (60.1%) from amicrofilaremic individuals who tested negative with the Bm14 CELISA and Og4C3 ELISA immunologic tests. The ideal cutoff as well as the Filaria Detect™ IgG4 kit accuracy were determined based on ROC curve analyses, with an optical density of 0.239 identified as the cutoff with the best performance, with 81.0% sensitivity and 96.6% specificity. The results show that the Filaria Detect™ IgG4 kit is a promising tool for investigation and monitoring of areas undergoing mass drug administration for lymphatic filariasis.

RESUMEN En el programa mundial de eliminación de la filariasis linfática, puesto en marcha por la Organización Mundial de la Salud en el año 2000, se propone el uso de pruebas de detección del antígeno filárico circulante como instrumento de diagnóstico para la evaluación y el seguimiento de las medidas de control de la parasitosis. Sin embargo, esas pruebas, a pesar de tener un alto grado de sensibilidad, no permiten detectar con eficiencia la infección en su fase inicial, cuando todavía no existen helmintos adultos. En vista de esa limitación, se ha señalado como una opción el estudio de anticuerpos antifiláricos, puesto que los anticuerpos producidos contra las larvas infectantes del parásito se detectan antes de la existencia de antígeno filárico circulante. El objetivo de este estudio fue definir el punto de corte y evaluar la exactitud del estuche Detect™ para pruebas de anticuerpos antifiláricos IgG4, fabricado con el antígeno recombinante Wb123, para el diagnóstico de la filariasis linfática en Brasil. Para ello, se realizó un estudio de evaluación de la prueba diagnóstica, en el cual se utilizaron 256 muestras de suero, a saber, 79 (30,9%) obtenidas de personas microfilarémicas y 177 (60,1%) de personas amicrofilarémicas, que arrojaron resultados seronegativos en las pruebas inmunológicas CELISA Bm14 y ELISA Og4C3. La definición del punto de corte ideal y de la exactitud del estuche Detect™ se obtuvo con la construcción de curvas de la característica operativa del receptor (ROC); una densidad óptica de 0,239 marcó el mejor nivel de desempeño de la prueba, con una sensibilidad de 81,0% y una especificidad de 96,6%. Los resultados obtenidos demostraron que el estuche Detect™ es un instrumento prometedor para la investigación y el seguimiento de las regiones donde se realiza un tratamiento masivo de la filariasis linfática.

Phenotypic and genotypic analysis of biofilm production by Pseudomonas aeruginosa isolates from infection and colonization samples

Abstract INTRODUCTION: Pseudomonas aeruginosa is an opportunistic pathogen associated with healthcare-related infections, affecting mainly patients with underlying diseases and immunosuppression. This microorganism has several virulence mechanisms that favour its pathogenesis, including the production of biofilm. This study aimed to analyze the phenotypic production of biofilms, the occurrence of quorum sensing (QS) genes, and the clonal profile of clinical isolates of P. aeruginosa from colonized/infected patients in a tertiary hospital in Recife-PE. METHODS: We obtained 21 isolates that were classified as infection isolates (II), and 10 colonization isolates (CI). The phenotypic analysis for biofilm production was performed quantitatively. The QS genes were detected by specific PCRs, and the clonal profile was assessed using ERIC-PCR. RESULTS: Of the 31 isolates, 58.1 % (18/31) were biofilm producers, of which 70 % (7/10) were CI and classified as weakly adherent; 52.4 % (11/21) of the II produced biofilms, and were classified as weak (38.1 %, (8/21)), moderate (9.5 %, (2/21)), and strongly adherent (4.8 %, (1/21)). All isolates harbored the QS genes analyzed. In the clonal analysis, 26 distinct genetic profiles were identified, highlighting the presence of a clone in four samples, i.e., one infection isolate, and 3 colonization isolates. CONCLUSIONS: The detection of biofilm formation is important in P. aeruginosa in addition to the identification of colonization and infection isolates, especially from complex environments such as ICUs. Further, we define a strategy for monitoring and analyzing P. aeruginosa strains that can potentially cause infections in hospitalized patients.

Occurrence of the vanA gene in Staphylococcus epidermidis from nasopharyngeal secretion of Health-Care Workers, Recife, Brazil

Abstract INTRODUCTION: The increasing reports of vancomycin-resistant Staphylococcus strains (VRS) haves caused concern worldwide, from the laboratory detection to patient management. This study aimed to identify the occurrence of VRS strains among healthcare professionals from a university hospital. METHODS: A total of 102 Staphylococcus sp. isolates from healthcare professionals, obtained in a previous study were evaluated according to standard techniques for VRS detection. RESULTS: After screening inoculation of plates containing 6µg/ml of vancomycin, 19 resistant isolates were identified. The susceptibility profile to other antimicrobials revealed 18 multidrug resistant isolates. The minimum inhibitory concentration (MIC) was determined by E-test and broth microdilution. According to E-tests, of 19 isolates grown in BHI-V6, four isolates presented MIC ≥ 128 µg/ml, seven with MIC ranging from 4 to 8 µg/ml, and eight with MIC ≤ 2µg/ml. By broth microdilution, 14 isolates presented MIC ≤ 2 µg/ml and five with MIC ≥ 16µg/ml. The presence of the gene vanA was determined by PCR in the five resistant isolates, and this gene was detected in one of the strains. Furthermore, among the 19 strains, the gene mecA was found in 13 (39,4%) isolates, including the strain carrying the gene vanA. CONCLUSIONS: Based on these results, we highlight the presence of one strain carrying both vanA and the mecA genes, as well as multidrug-resistant strains colonizing healthcare professionals, and their importance as potential vectors to spread strains carrying resistance genes in the hospital environment.

Biofilm production by clinical isolates of Pseudomonas aeruginosa and structural changes in LasR protein of isolates non biofilm-producing

ABSTRACT Introduction: Biofilm production is an important mechanism for the survival of Pseudomonas aeruginosa and its relationship with antimicrobial resistance represents a challenge for patient therapeutics. P. aeruginosa is an opportunistic pathogen frequently associated to nosocomial infections, especially in imunocompromised hosts. Objectives: Analyze the phenotypic biofilm production in P. aeruginosa isolates, describe clonal profiles, and analyze quorum sensing (QS) genes and the occurrence of mutations in the LasR protein of non-biofilm producing isolates. Methods: Isolates were tested for biofilm production by measuring cells adherence to the microtiter plates. Clonal profile analysis was carried out through ERIC-PCR, QS genes were by specific PCR. Results: The results showed that 77.5% of the isolates were considered biofilm producers. The results of genotyping showed 38 distinct genetic profiles. As for the occurrence of the genes, 100% of the isolates presented the lasR, rhlI and rhlR genes, and 97.5%, presented the lasI gene. In this study nine isolates were not biofilm producers. However, all presented the QS genes. Amplicons related to genes were sequenced in three of the nine non-biofilm-producing isolates (all presenting different genetic similarity profile) and aligned to the sequences of those genes in P. aeruginosa strain PAO1 (standard biofilm-producing strain). Alignment analysis showed an insertion of three nucleotides (T, C and G) causing the addition of an amino acid valine in the sequence of the LasR protein, in position 53. Conclusion: The modeling of the resulting LasR protein showed a conformational change in its structure, suggesting that this might be the reason why these isolates are unable to produce biofilm.

Interaction study between vancomycin and liposomes containing natural compounds against methicillin-resistant Staphylococcus aureus clinical isolates

ABSTRACT The treatment of infections caused by resistant microorganisms is limited, and vancomycin (VAN) treatment failures for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are not uncommon, even when MRSA clinical isolates are susceptible to VAN. Thus, this study proposed the association of VAN with usnic acid and ß-lapachone encapsulated into liposomes as a novel therapeutic option for infections caused by MRSA. Liposomes containing ß-lap (ß-lap-lipo) or usnic acid (UA-lipo) were prepared by the thin lipid film hydration method followed by sonication. Antimicrobial activity against MRSA clinical isolates was investigated by the microdilution method according to the Clinical and Laboratory Standards Institute (CLSI). The interaction studies were carried out using the checkerboard method and epsilometer test (Etest). The interaction between VAN and ß-lap or ß-lap-lipo was synergistic (FICI = 0.453 and FICI = 0.358, respectively). An additive interaction between VAN and UA (FICI = 0.515) was found. UA-lipo resulted in synergism with VAN (FICI = 0.276). The Etest reproduced the results obtained by the checkerboard method for approximately 82% of the analysis. Thus, the present study demonstrated that VAN in combination with UA-lipo, ß-lap or ß-lap-lipo synergistically enhanced antibacterial activity against MRSA

Detection of multidrug-resistant Pseudomonas aeruginosa harboring bla GES-1 and bla GES-11 in Recife, Brazil

Abstract INTRODUCTION: Pseudomonas aeruginosa, an important pathogen globally, presents several resistance mechanisms. This study aimed to investigate the presence of bla GES in clinical isolates of Pseudomonas aeruginosa obtained from various clinical specimens from patients admitted to three different hospitals in Recife, Brazil. The Guiana extended spectrum beta-lactamase (GES) enzymes are responsible for conferring broad spectrum resistance to beta-lactam drugs, including the carbapenems. METHODS: A total of 100 carbapenem-resistant P. aeruginosa isolates underwent polymerase chain reaction (PCR) testing to identify bla GES, bla KPC, bla SPM-1, bla IMP, and bla VIM. Additionally, PCR products positive for bla GES were sequenced. The clonal profiles of these same isolates were then determined by means of enterobacterial repetitive intergenic consensus (ERIC)-PCR analysis. RESULTS: PCR analysis revealed that four isolates harbored bla GES; DNA sequencing showed that two harbored bla GES-1 and two bla GES-11. Beta-lactamase genes bla SPM-1, bla IMP, bla VIM, and bla KPC were investigated; none of these genes was detected. Automated susceptibility testing methods (Vitek®2, bioMérieux) showed that the bla GES-1-positive isolates were only susceptible to polymyxin B. The patterns obtained with ERIC-PCR methods showed clonal relationship between the two isolates that harbored bla GES-11, whereas different clonal profiles were found in the isolates harboring bla GES-1. CONCLUSIONS: We detected the presence of bacterial isolates positive for two different variants of the enzyme GES in three different hospitals from Recife, Brazil. These enzymes have a great capacity for dissemination among Gram-negative bacteria and confer broad-spectrum resistance to beta-lactam antibiotics and to the carbapenems.

Análise da produção de biofilme por isolados clínicos de Pseudomonas aeruginosa de pacientes com pneumonia associada à ventilação mecânica / Analysis of biofilm production by clinical isolates of Pseudomonas aeruginosa from patients with ventilator-associated pneumonia

RESUMO Objetivo: Avaliar fenotipicamente a produção de biofilme por isolados clínicos de Pseudomonas aeruginosa de pacientes com pneumonia associada à ventilação mecânica. Métodos: Foram analisados 20 isolados clínicos de P. aeruginosa, sendo 19 provenientes de amostras clínicas de aspirado traqueal e uma de lavado broncoalveolar. A avaliação da capacidade de P. aeruginosa em produzir biofilme foi verificada por duas técnicas, sendo uma qualitativa e outra quantitativa. Resultados: A técnica qualitativa mostrou que apenas 15% dos isolados foram considerados produtores de biofilme, enquanto que a quantitativa demonstrou que 75% dos isolados foram produtores de biofilme. Os isolados produtores de biofilme apresentaram o seguinte perfil de suscetibilidade: 53,3% eram multidroga-resistentes e 46,7% eram multidroga-sensíveis. Conclusão: A técnica quantitativa foi mais eficaz para detecção da produção de biofilme em comparação com a qualitativa. Para a população bacteriana analisada, a produção de biofilme independeu do perfil de suscetibilidade das bactérias, demonstrando que a falha terapêutica pode estar relacionada com a produção de biofilme, por impedir a destruição das bactérias presentes nesta estrutura, ocasionando complicações da pneumonia associada à ventilação mecânica, incluindo infecções extrapulmonares, e dificultando o tratamento da infecção.

ABSTRACT Objective: To phenotypically evaluate biofilm production by Pseudomonas aeruginosa clinically isolated from patients with ventilator-associated pneumonia. Methods: Twenty clinical isolates of P. aeruginosa were analyzed, 19 of which were from clinical samples of tracheal aspirate, and one was from a bronchoalveolar lavage sample. The evaluation of the capacity of P. aeruginosa to produce biofilm was verified using two techniques, one qualitative and the other quantitative. Results: The qualitative technique showed that only 15% of the isolates were considered biofilm producers, while the quantitative technique showed that 75% of the isolates were biofilm producers. The biofilm isolates presented the following susceptibility profile: 53.3% were multidrug-resistant, and 46.7% were multidrug-sensitive. Conclusion: The quantitative technique was more effective than the qualitative technique for the detection of biofilm production. For the bacterial population analyzed, biofilm production was independent of the susceptibility profile of the bacteria, demonstrating that the therapeutic failure could be related to biofilm production, as it prevented the destruction of the bacteria present in this structure, causing complications of pneumonia associated with mechanical ventilation, including extrapulmonary infections, and making it difficult to treat the infection.

Phenotypic and molecular characterization of resistance to macrolides, lincosamides and type B streptogramin of clinical isolates of Staphylococcus spp. of a university hospital in Recife, Pernambuco, Brazil

Abstract Introduction There is a mechanism of macrolide resistance in Staphylococcus spp. which also affects the lincosamides and type B streptogramins characterizing the so-called MLSB resistance, whose expression can be constitutive (cMLSB) or inducible (iMLSB) and is encoded mainly by ermA and ermC genes. The cMLSB resistance is easily detected by susceptibility testing used in the laboratory routine, but iMLSB resistance is not. Therapy with clindamycin in cases of infection with isolated iMLSB resistance may fail. Objective To characterize the phenotypic (occurrence of cMLSB and iMLSB phenotypes) and molecular (occurrence of ermA and ermC genes) profiles of MLSB resistance of clinical isolates of susceptible and methicillin-resistant Staphylococcus aureus and CNS (coagulase-negative Staphylococcus) from patients of a university hospital, in Pernambuco. Methods The antimicrobial susceptibility of 103 isolates was determined by the disk diffusion technique in Mueller–Hinton agar followed by oxacillin screening. The iMLSB phenotype was detected by D test. Isolates with cMLSB and iMLSB phenotypes were subjected to polymerase chain reaction (PCR) for the detection of ermA and ermC genes. Results The cMLSB and iMLSB phenotypes were respectively identified in 39 (37.9%) and five (4.9%) isolates. The iMLSB phenotype was found only in four (10.8%) methicillin-susceptible S. aureus and one (4.5%) methicillin-resistant S. aureus. In the 44 isolates subjected to PCR, four (9.1%) only ermA gene was detected, a lower frequency when compared to only ermC 17 (38.6%) gene and to one (2.3%) isolate presenting both genes. Conclusion In the Staphylococcus spp. analyzed, the ermC gene was found more often than the ermA, although the iMLSB phenotype had been less frequent than the cMLSB. It was important to perform the D test for its detection to guide therapeutic approaches.

Prevalence and risk of potentially adverse drug interactions in the treatment of acute alcohol poisoning

ABSTRACT The aim of this paper is to determine the profile of acute alcohol poisoning and to estimate the risk of potentially adverse drug interactions (ADIs) in patients intoxicated by alcohol when attended in emergency care at hospital. A descriptive serial cross-sectional study was performed with 4,271 individuals intoxicated by alcohol, from January 2009 to July 2011. Possible correlations were measured by Pearson's chi-square test. The data show high consumption in the population, especially in males between 25 and 59 years. The main circumstances for poisoning were alcohol misuse (96.3%). After treatment complete recovery from the signs or symptoms of the poisoning was observed in 96.88% cases; and death in 0.70%. The demonstration of potential risk for ADIs in medical care included 300 medical records which contained a history of acute alcohol poisoning. Possible drug-drug interactions (44.2%) and drug-alcohol interactions (55.8%) were demonstrated in 60.60% of analyzed medical records. Among these cases, 3%, 92.4% and 4.6% were classified as mild, moderate and severe, respectively. The measurement of ADIs aims to prevent clinical complications in medical care for alcohol misuse disorders.

RESUMO O objetivo deste trabalho foi definir o perfil de intoxicação alcoólica aguda e estimar o risco de interações medicamentosas adversas (IMAs) potenciais em pacientes com intoxicação alcoólica atendidos na emergência hospitalar. Um estudo descritivo, serial, de corte transversal foi realizado com 4.271 indivíduos com intoxicação alcoólica, de janeiro 2009 a julho 2011. Correlações foram medidas pelo teste qui-quadrado. Os dados mostram alto consumo na população estudada, especialmente em homens de 25 a 59 anos. A principal circunstância de intoxicação foi o abuso (96,3%). Após tratamento, cura foi observada em 96,88% dos casos e morte em 0,7%. O risco de IMAs potenciais no atendimento médico incluiu 300 prontuários médicos com histórico de intoxicação alcoólica aguda. Possíveis interações medicamentosas (44,2%) e interações fármaco-álcool (55,8%) foram observadas em 60,6% dos prontuários analisados. Entre elas, 3%, 92,4% e 4,6% foram classificadas como leve, moderada e grave, respectivamente. A medição das IMAs visa a prevenir complicações clínicas no atendimento dos agravos devido ao abuso de álcool.

Infection by multidrug-resistant Elizabethkingia meningoseptica: case reports / Infecção por Elizabethkingia meningoseptica multirresistente: relato de casos

We report two cases of sepsis in critically ill patients in two tertiary care hospitals in Recife-PE, Brazil. The first case is an 87-year-old patient with chronic myeloid leukemia and sepsis; and the second case is a 93-year-old patient with prostate cancer and septic shock caused by multidrug-resistant (MDR) Elizabethkingia meningoseptica.

Reportamos dois casos de sepse em pacientes criticamente debilitados em dois hospitais com nível de complexidade terciária em Recife-PE, Brasil. O primeiro caso, paciente de 87 anos com leucemia mieloide crônica e sepse; o segundo, paciente com 93 anos de idade com câncer de próstata apresentava choque séptico causado por Elizabethkingia meningoseptica multirresistente.

The occurrence and dissemination of methicillin and vancomycin-resistant Staphylococcus in samples from patients and health professionals of a university hospital in Recife, State of Pernambuco, Brazil

Introduction Methicillin-resistant Staphylococcus aureus (MRSA) strains have been responsible for many nosocomial outbreaks. Within hospitals, colonized employees often act as reservoirs for the spread of this organism. This study collected clinical samples of 91 patients admitted to the intensive care unit (ICU), hemodialysis/nephrology service and surgical clinic, and biological samples from the nasal cavities of 120 professionals working in those environments, of a University Hospital in Recife, in the State of Pernambuco, Brazil. The main objective of this study was to determine the occurrence and dissemination of methicillin- and vancomycin-resistant Staphylococcus spp. Methods The isolates obtained were tested for susceptibility to oxacillin and vancomycin and detection of the mecA gene. In addition, the isolates were evaluated for the presence of clones by ribotyping-polymerase chain reaction (PCR). Results MRSA occurrence, as detected by the presence of the mecA gene, was more prevalent among nursing technicians; 48.1% (13/27) and 40.7% (11/27) of the isolates were from health professionals of the surgical clinic. In patients, the most frequent occurrence of mecA-positive isolates was among the samples from catheter tips (33.3%; 3/9), obtained mostly from the hemodialysis/nephrology service. Eight vancomycin-resistant strains were found among the MRSA isolates through vancomycin screening. Based on the amplification patterns, 17 ribotypes were identified, with some distributed between patients and professionals. Conclusions Despite the great diversity of clones, which makes it difficult to trace the source of the infection, knowledge of the molecular and phenotypic profiles of Staphylococcus samples can contribute towards guiding therapeutic approaches in the treatment and control of nosocomial infections. .

Candida famata-induced fulminating cholecystitis

Lithiasic cholecystitis is classically associated with the presence of enterobacteria, such as Escherichia coli, Enterococcus, Klebsiella, and Enterobacter, in the gallbladder. Cholecystitis associated with fungal infections is a rare event related to underlying conditions such as diabetes mellitus, steroid use, and broad-spectrum antibiotic use for prolonged periods, as well as pancreatitis and surgery of the digestive tract. Here, we present the first reported case of a gallbladder infection caused by Candida famata.

Phenotypic methods for determination of methicillin resistance in Staphylococcus spp. from health care workers / Métodos fenotípicos para determinação da resistência à meticilina em Staphylococcus spp. de profissionais de saúde

INTRODUCTION: Staphylococcus spp. is an important healthcare-associated pathogen and the identification of methicillin-resistant strains in samples of colonization may provide data to assist in the antimicrobial therapy success. OBJECTIVES: To determine the occurrence of colonization by methicillin-resistant Staphylococcus spp. (MRS), through the detection of the mecA gene and to evaluate different phenotypic methods for the presumptive detection of methicillin resistance in samples of the anterior nasal cavity and hands of the health care personnel of a university hospital in the state of Pernambuco, Brazil. METHODS: We selected the 28 isolates of Staphylococcus spp., which showed an intermediate or resistant phenotypic profile for oxacillin, detected by the Kirby Bauer technique. The methods used were disk-diffusion tests for cefoxitin, minimal inhibitory concentration by E-test for oxacillin, screening for oxacillin resistance and mecA gene detection by polymerase chain reaction (PCR). RESULTS: About the phenotypic methods utilized, only the E-test of oxacillin did not show a statistically significant difference in relation to PCR for the mecA gene detection, considered the gold standard. CONCLUSION: The E-test of oxacillin was the best of the phenotypic methods utilized. It is necessary to correctly detect MRS in healthy individuals, because they can act as carriers and can therefore be a potential source of microorganisms involved in hospital infections.

INTRODUÇÃO: Staphylococcus spp. é um importante patógeno associado aos cuidados em saúde, e a identificação de isolados resistentes à meticilina em amostras de colonização pode fornecer dados para auxiliar no sucesso da terapia antimicrobiana. OBJETIVOS: Determinar a ocorrência de colonização por Staphylococcus spp. resistentes à meticilina (MRS) por meio da detecção do gene mecA e avaliar diferentes métodos fenotípicos para a detecção presuntiva da resistência à meticilina em amostras da cavidade nasal anterior e das mãos de profissionais de saúde de um hospital universitário no Estado de Pernambuco, Brasil. MÉTODOS: Foram selecionados 28 isolados de Staphylococcus spp. que mostraram perfil intermediário ou resistente à oxacilina, detectado pela técnica de Kirby Bauer. Os métodos utilizados foram o teste de disco difusão de cefoxitina, concentração inibitória mínima pelo E-test de oxacilina, screening para avaliação da resistência à oxacilina e reação em cadeia da polimerase (PCR) para detecção do gene mecA. RESULTADOS: Dos métodos fenotípicos utilizados, apenas o E-test de oxacilina não mostrou diferença estatística significante em relação à PCR para a detecção do gene mecA, considerado o método padrão-ouro. CONCLUSÃO: O E-test de oxacilina foi o melhor método fenotípico utilizado. É necessário detectar corretamente o MRS em indivíduos saudáveis, pois eles podem atuar como portadores, sendo uma fonte potencial de microrganismos envolvidos em infecções hospitalares.

Prevalencia de infección por Entamoeba histolytica en escuelas públicas de la ciudad de Maceió, Alagoas, Brasil / Prevalence of infection caused by Entamoeba histolytica in public schools of Maceio city, Alagoas, Brazil

Introducción: la prevalencia de amebiasis ha tenido que ser reevaluada desde que fue demostrada la existencia de dos especies de Entamoeba indistinguibles morfológicamente, pero diferentes en cuanto a su capacidad de producir enfermedad: Entamoeba histolytica (patógena) y Entamoeba dispar (no patógena). Con el empleo de procedimientos capaces de identificar características antigénicas específicas es posible hacer la diferenciación y evaluar la prevalencia real de amebiasis (es decir, de infecciones producidas por Entamoeba histolytica). Objetivo: determinar la prevalencia de infección por el complejo E. histolytica/E. dispar y, más tarde, de infección por la especie Entamoeba histolytica en muestras fecales de estudiantes de escuelas públicas de Maceió, Alagoas, Brasil. Métodos: primero se realizó la detección microscópica de infección por el complejo E. histolytica/E. dispar en muestras fecales de 1 798 estudiantes (para ello, se empleó la técnica de concentración en formol-éter). A continuación, se confirmó la infección por el mencionado complejo mediante el empleo del ensayo inmunoenzimático ENZYMEBA. Posteriormente, a las muestras confirmadas positivas al complejo E. histolytica/E. dispar se les aplicó el procedimiento inmunoenzimático E. histolytica II®, que detecta de modo específico una adhesina de la especie Entamoeba histolytica. Resultados: el empleo de la observación microscópica de heces y del ensayo ENZYMEBApermitió demostrar una prevalencia de infección por el complejo E. histolytica/E. dispar de 3,8 %. La utilización del procedimiento E. histolytica II® condujo al hallazgo de una prevalencia de infección por la especie Entamoeba histolytica de 1,0 %. La observación microscópica de heces presentó un bajo valor predictivo positivo (26,4 %) para la detección de Entamoeba histolytica respecto al ensayo E. histolytica II®. Conclusiones: aunque las cifras de prevalencia encontradas son bajas, este estudio demuestra por primera vez la ocurrencia de infección por Entamoeba histolytica en Maceió, Alagoas, Brasil. A pesar de que el examen microscópico de heces no es un procedimiento apropiado para el diagnóstico de amebiasis, puede ser utilizado como prueba de descarte en estudios epidemiológicos. La demostración de infección por Entamoeba histolytica en muestras positivas a infección por el complejo E. histolytica/E. dispar puede ser realizada mediante ensayos para la detección específica de coproantígenos del parásito, como Entamoeba histolytica II®.

Introduction: distribution of amebiasis has been reevaluated since it was demonstrated that two morphologically indistinguishable species of Entamoeba exist, but they differ in their capacity to cause disease: Entamoeba histolytica (pathogenic) and Entamoeba dispar (nonpathogenic). The use of techniques to identify specific antigenic characteristics makes it possible to establish differential diagnosis and to assess the actual prevalence of amebiasis cases (caused only by Entamoeba histolytica). Objective: to determine the prevalence of infection by Entamoeba histolytica/Entamoeba dispar complex and, in a second phase, the prevalence of infection by Entamoeba histolytica in stool samples of students from public schools in Maceió, Alagoas, Brazil. Methods: screening of Entamoeba histolytica/Entamoeba dispar complex infection cases was carried out by formol-ether concentration technique on stool samples of 1 798 students. The infection caused by this complex was confirmed with an enzyme linked immunosorbent assay (ENZYMEBA). Positive samples were then analyzed with a specific ELISA (Entamoeba histolytica II®) in order to detect an adesin only present in Entamoeba histolytica. Results: the microscopic observation of feces and the Enzymeba test allowed demonstrating the prevalence of Entamoeba histolytica/Entamoeba dispar infection amounting to 3.8 %. The Entamoeba histolytica II procedure showed the prevalence of infection by Entamoeba histolytica of 1.0%. Therefore, the microscopy presented a low predictive positivity value (26.4%) for detection of Entamoeba histolytica compared to Entamoeba histolytica II® method. Conclusions: although the prevalence figures are not high, the study shows for the first time the occurrence of Entamoeba histolytica in Maceió, Alagoas, Brazil. In spite of the fact that the optical microscopic test of feces is not the appropriate technique for amebiasis diagnosis, it can be used as a screening method in epidemiological studies. Cases of Entamoeba histolytica infection in positive samples by microscopy can be confirmed by using a specific test for detection of the parasite coproantigen like Entamoeba histolytica II®.

Phenotypic and molecular characterization of antimicrobial resistance and virulence factors in Pseudomonas aeruginosa clinical isolates from Recife, State of Pernambuco, Brazil / Caracterização fenotípica e molecular de fatores de resistência a antimicrobianos e virulência de isolados clínicos de Pseudomonas aeruginosa de Recife, Estado de Pernambuco, Brasil

INTRODUCTION: The emergence of carbapenem resistance mechanisms in Pseudomonas aeruginosa has been outstanding due to the wide spectrum of antimicrobial degradation of these bacteria, reducing of therapeutic options. METHODS: Sixty-one clinical strains of P. aeruginosa isolated from five public hospitals in Recife, Pernambuco, Brazil, were examined between 2006 and 2010, aiming of evaluating the profiles of virulence, resistance to antimicrobials, presence of metallo-β-lactamase (MBL) genes, and clonal relationship among isolates. RESULTS: A high percentage of virulence factors (34.4% mucoid colonies; 70.5% pyocyanin; 93.4% gelatinase positives; and 72.1% hemolysin positive) and a high percentage of antimicrobial resistance rates (4.9% pan-resistant and 54.1% multi-drug resistant isolates) were observed. Among the 29 isolates resistant to imipenem and/or ceftazidime, 44.8% (13/29) were MBL producers by phenotypic evaluation, and of these, 46.2% (6/13) were positive for the blaSPM-1 gene. The blaIMP and blaVIM genes were not detected. The molecular typing revealed 21 molecular profiles of which seven were detected in distinct hospitals and periods. Among the six positive blaSPM-1 isolates, three presented the same clonal profile and were from the same hospital, whereas the other three presented different clonal profiles. CONCLUSIONS: These results revealed that P. aeruginosa is able to accumulate different resistance and virulence factors, making the treatment of infections difficult. The identification of blaSPM-1 genes and the dissemination of clones in different hospitals, indicate the need for stricter application of infection control measures in hospitals in Recife, Brazil, aiming at reducing costs and damages caused by P. aeruginosa infections.

INTRODUÇÃO: A emergência de mecanismos de resistência aos carbapenêmicos em Pseudomonas aeruginosa tem se destacado devido ao amplo espectro de degradação de antimicrobianos, reduzindo as opções terapêuticas. MÉTODOS: Sessenta e um isolados de P. aeruginosa procedentes de cinco hospitais públicos de Recife, Pernambuco, Brasil, entre 2006 e 2010, foram analisadas, com o objetivo de avaliar o perfil de virulência, resistência aos antimicrobianos, a presença de genes metalo-β-lactamase (MBL) e a relação clonal entre os isolados. RESULTADOS: Foi observada uma elevada produção de fatores de virulência na amostra (34,4% colônias mucoides; 70,5% piocianina; 93,4% gelatinase e 72,1% hemolisina), bem como um elevado percentual de resistência (4,9% isolados panresistentes e 54,1% multirresistentes). Dentre os 29 isolados resistentes ao imipenem e/ou ceftazidima, 44,8% (13/29) apresentaram MBL por meio da pesquisa fenotípica, e destes, 46,2% (6/13) foram positivos para o gene blaSPM-1, não havendo detecção dos genes blaIMP e blaVIM. A tipagem molecular revelou 21 perfis genéticos dos quais sete foram detectados em hospitais e períodos distintos, e dos isolados blaSPM-1 positivos, três apresentaram o mesmo perfil clonal e foram procedentes do mesmo hospital, enquanto que os outros três isolados blaSPM-1 positivos apresentaram perfis clonais distintos. CONCLUSÕES: Estes resultados revelam que a P. aeruginosa é capaz de acumular diferentes fatores de virulência e resistência, dificultando o tratamento das infecções. A identificação de genes blaSPM-1 e disseminação de clones sugere a necessidade de aplicação mais rigorosa de medidas de controle de infecção nos hospitais de Recife, visando reduzir custos e danos provocados por este tipo de infecção.

Severity of atopic dermatitis and Ascaris lumbricoides infection: an evaluation of CCR4+ and CXCR3+ helper T cell frequency / Gravidade da dermatite atópica e infecção por Ascaris lumbricoides: uma avaliação da frequência de células T auxiliares CCR4+ e CXCR3+

INTRODUCTION: Ascaris lumbricoides-infected patients present lower prevalence of severe atopic dermatitis. METHODS: Peripheral blood of infected children with atopic dermatitis was assessed by flow cytometry of the frequency of Th1 and Th2 cells through the expression of CXCR3 and CCR4 chemokine receptors, respectively. RESULTS: Helminth-free patients with atopic dermatitis presented a high frequency of CCR4+Th2 cells. Parasitized patients with atopic dermatitis showed a lower frequency of CXCR3+Th1 cells compared to infected individuals only. CONCLUSIONS: Ascariasis modifies the blood traffic of Th2 cells in atopic dermatitis patients, while the allergic disease down-regulates the traffic of Th1 cells in parasitized patients.

INTRODUÇÃO: Pacientes infectados com Ascaris lumbricoides apresentam menor prevalência de dermatite atópica grave. MÉTODOS: Sangue periférico de crianças infectadas com dermatite atópica foi analisado por citometria de fluxo quanto à frequência de células Th1 e Th2 pela expressão de receptores de quimiocina CXCR3 e CCR4, respectivamente. RESULTADOS: Pacientes sem helmintos com dermatite atópica apresentaram alta frequência de células Th2CCR4+. Pacientes parasitados com dermatite atópica apresentaram menor frequência de células Th1CXCR3+ comparados aos indivíduos apenas infectados. CONCLUSÕES: Ascaridiases altera o tráfego sanguíneo de células Th2 em pacientes com dermatite atópica, enquanto a doença alérgica diminui o tráfego de células Th1 em pacientes parasitados.

Antimicrobial resistance profile of Staphylococcus aureus isolates obtained from skin and soft tissue infections of outpatients from a university hospital in Recife -PE, Brazil / Perfil de resistência antimicrobiana de isolados de Staphylococcus aureus provenientes de infecções de pele e tecidos moles de pacientes ambulatoriais de um hospital universitário em Recife - PE, Brasil

BACKGROUND: Staphylococcus aureus has a notable ability to acquire resistance to antibiotics, and methicillin resistance represents a growing public health problem. Methicillin-resistant S. aureus (MRSA) has also become important outside the hospital environment, particularly in the United States. In Brazil, since 2005, cases of community skin infections caused by MRSA have been reported, but resistance studies involving outpatients are scarce. OBJECTIVE: To know the resistance profile of S. aureus involved in skin and soft tissue infections of patients seen at the Dermatology outpatient clinic of a university hospital in Recife, Pernambuco State, northeastern Brazil. METHODS: Prospective study involving 30 patients with skin and soft tissue infections, seen at the Dermatology outpatient clinic from May until November 2011. To evaluate the susceptibility of S. aureus to antibiotics, the disk diffusion method and oxacillin screening agar were used. RESULTS: From a total of 30 samples of skin lesions, 19 (63%) had positive culture for S. aureus. The following resistance patterns of S. aureus were observed: penicillin, 95%; tetracycline, 32%; erythromycin, 21%; gentamicin, 16%; cefoxitin, 11%; oxacillin, 11%; trimethoprim-sulfamethoxazole, 11%; chloramphenicol, 11%; clindamycin, 5% ; and ciprofloxacin, 0%. One of the identified MRSA was obtained from a patient without risk factors for its acquisition, and was resistant, beyond to the beta-lactams, only to tetracycline. CONCLUSIONS: With regard to the resistance patterns of S. aureus, resistances to tetracycline, erythromycin and gentamicin were the highest. It was documented, for the first time in Pernambuco, a case of skin infection caused by community-associated MRSA.

FUNDAMENTOS: O Staphylococcus aureus possui uma notável habilidade de adquirir resistência antimicrobiana, sendo a resistência à meticilina um problema de saúde pública crescente. O S. aureus resistente à meticilina (MRSA) vem se tornando importante também fora do ambiente hospitalar, particularmente nos Estados Unidos. No Brasil, desde 2005, têm sido relatados casos de infecções cutâneas comunitárias causadas por MRSA, porém estudos de resistência envolvendo pacientes ambulatoriais são escassos. OBJETIVO: Conhecer o perfil de resistência de S. aureus envolvidos em infecções de pele e partes moles de pacientes atendidos no ambulatório de Dermatologia de um hospital universitário de Recife, Pernambuco. MÉTODO: Estudo prospectivo envolvendo 30 pacientes com infecções de pele e tecidos moles atendidos no ambulatório de Dermatologia de maio a novembro de 2011. Para avaliação da suscetibilidade dos S. aureus aos antibióticos foram utilizados teste de disco-difusão e placa de screening de oxacilina. RESULTADOS: Das 30 amostras analisadas, 19 (63%) tiveram cultura positiva para S. aureus. Os seguintes padrões de resistência dos S. aureus foram observados: penicilina, 95%; tetraciclina, 32%; eritromicina, 21%; gentamicina, 16%; cefoxitina, 11%; oxacilina, 11%; sulfametoxazol-trimetoprima, 11%; clorafenicol, 11%; clindamicina, 5%; e ciprofloxacina, 0%. Um dos MRSA identificados foi obtido de paciente sem fatores de risco para sua aquisição, e além de aos betalactâmicos, mostrou-se resistente apenas à tetraciclina. CONCLUSÕES: Em relação aos padrões de resistência dos S. aureus, destacaram-se as resistências à tetraciclina, eritromicina e gentamicina. Documentou-se, pela primeira vez em Pernambuco, um caso de infecção cutânea causada por MRSA associado à comunidade.

Multidrug resistance genes, including blaKPC and blaCTX-M-2, among Klebsiella pneumoniae isolated in Recife, Brazil / Genes de multirresistência, incluindo blaKPC e blaCTX-M-2, em Klebsiella pneumoniae isoladas em Recife, Brasil

INTRODUCTION: The prevalence of cephalosporins and carbapenem-resistant Klebsiella pneumoniae strains is rising in Brazil, with potential serious consequences in terms of patients' outcomes and general care. METHODS: This study characterized 24 clinical isolates of K. pneumoniae from two hospitals in Recife, Brazil, through the antimicrobial susceptibility profile, analyses of β-lactamase genes (blaTEM, blaSHV,blaCTX-MblaKPC, blaVIM, blaIMP, and blaSPM), plasmidial profile and ERIC-PCR (Enterobacterial repetitive intergenic consensus-polymerase chain reaction). RESULTS: ERIC-PCR and plasmidial analysis grouped the isolates in 17 and 19 patterns, respectively. Six isolates from one hospital presented the same pattern by ERIC-PCR, indicating clonal dissemination. All isolates presented blaSHV, 62.5% presented blaCTX-M-2, 29% blaTEM, and 41.7% blaKPC. Metallo-β-lactamase genes blaand blawere not detected. Eleven isolates were identified carrying at least 3 β-lactamase studied genes, and 2 isolates carried blaSHVblaTEM, blaCTX-M-2 and blaKPC simultaneously. CONCLUSIONS: The accumulation of resistance genes in some strains, observed in this study, imposes limitations in the therapeutic options available for the treatment of infections caused by K. pneumoniae in Recife, Brazil. These results should alert the Brazilian medical authorities to establish rigorous methods for more efficiently control the dissemination of antimicrobial resistance genes in the hospital environment.

INTRODUÇÃO: A prevalência de cepas de Klebsiella pneumoniae resistentes a cefalosporinas e carbapenêmicos está aumentando no Brasil, com sérias consequências em termos de desfechos dos pacientes e cuidados gerais. MÉTODOS: Este estudo caracterizou 24 isolados clínicos de K. pneumoniae provenientes de dois hospitais de Recife, Brasil, através do perfil de susceptibilidade a antimicrobianos, análise de genes de β-lactamase (blaTEM,blaSHV,blaCTX-MblaKPC,blaVIM, blaIMP,and blaSPM), perfil plasmidial e ERIC-PCR (Enterobacterial repetitive intergenic consensus-polymerase chain reaction). RESULTADOS: A análise da ERIC-PCR e do perfil plasmidial agrupou os isolados em 17 e 19 perfis, respectivamente. Seis isolados de um hospital apresentaram o mesmo padrão de ERIC-PCR, indicando disseminação clonal. Todos os isolados apresentaram blaSHV, 62,5% apresentaram blaCTX-M-2, 29% blaTEM e 41,7% blaKPC. Genes de metalo-β-lactamase blaVIM, blaIMP e blaSPM não foram detectados. Onze isolados foram identificados carreando, pelo menos, três dos genes de β-lactamase estudados, dentre estes, dois isolados continham blaSHV,blaTEM, blaCTX-M-2 e blaKPC simultaneamente. CONCLUSÕES: O acúmulo de genes de resistência em algumas cepas, observado nesse estudo, impõem limitações nas opções terapêuticas disponíveis para o tratamento de infecções causadas por K. pneumoniae em Recife, Brasil. Estes resultados devem alertar as autoridades médicas brasileiras para estabelecer rigorosos métodos para controlar eficientemente a disseminação de genes de resistência a antimicrobianos no ambiente hospitalar.