Carbapenem-resistant Acinetobacter baumannii in Brazil: susceptibility profile and diversity of oxacillinases / Acinetobacter baumannii resistente aos carbapenêmicos no Brasil: perfil de suscetibilidade e diversidade de oxacilinases

ABSTRACT Introduction: The Acinetobacter calcoaceticus-baumannii (ABC) complex includes five species, and the A. baumannii is the most important of them because it carries mechanisms of carbapenems resistance, especially the oxacillinases. Objectives: The objectives of this study were to identify the species of the ABC complex, to evaluate the susceptibility profile and to investigate the presence of oxacillinases in carbapenems-resistant isolates from four Brazilian States. Methods: In the study period, 92 isolates from Rio Grande do Sul (RS), Rio de Janeiro (RJ), Paraná (PR) and São Paulo (SP) were collected. The isolates were identified by matrix-assisted laser desorption ionization-time of fight mass spectrometry (MALDI-TOF MS) and sequencing of gyrB gene. Evaluation of susceptibility was performed by disk diffusion and broth microdilution. The presence of oxacillinases was performed by in-house multiplex polymerase chain reaction (PCR). Results: Ninety-one (99%) isolates were identified as A. baumannii by MALDI-TOF and sequencing. The majority of isolates (56; 61%) showed resistance to the six antimicrobial agents tested. Three isolates were resistant to polymyxin B [minimum inhibitory concentration (MIC) ≥ 4 µg/ml). Eighty (87%) isolates were positive to OXA-23-like, and twelve (13%) isolates to OXA-24-like. Conclusion: Our findings confirm the knowledge about the dissemination of the blaOXA-23 gene in Brazil and suggest the recent emergence and spread of blaOXA-24 gene, since it was identified in three of the four sampled states.

RESUMO Introdução: O complexo Acinetobacter calcoaceticus-baumannii (ABC) inclui cinco espécies, sendo A. baumannii a mais importante clinicamente por carrear muitos mecanismos de resistência aos carbapenêmicos, sobretudo as oxacilinases. Objetivos: Os objetivos deste estudo foram identificar as espécies do complexo ABC, avaliar o perfil de suscetibilidade e investigar a presença de oxacilinases em isolados resistentes aos carbapenêmicos provenientes de quatro estados brasileiros. Métodos: No período do estudo, foram coletados 92 isolados do Rio Grande do Sul (RS), do Rio de Janeiro (RJ), do Paraná (PR) e de São Paulo (SP). Os isolados foram identificados por matrix-assisted laser desorption ionization-time of fight mass spectrometry (MALDI-TOF MS) e sequenciamento do gene gyrB. A avaliação da suscetibilidade foi realizada por disco-difusão e microdiluição de caldo. A presença de oxacilinases foi realizada por reação em cadeia da polimerase (PCR) multiplex in house. Resultados: Noventa e um (99%) isolados foram identificados como A. baumannii por MALDI-TOF e pelo sequenciamento. A maioria dos isolados (56; 61%) apresentou resistência aos seis agentes antimicrobianos testados. Três isolados foram resistentes à polimixina B [concentração inibitória mínima (CIM) ≥ 4 µg/ml). Oitenta (87%) isolados foram positivos para OXA-23 e 12, (13%) para OXA-24. Conclusão: Nossos resultados confirmam a disseminação do gene blaOXA-23 no Brasil e sugerem a recente emergência e disseminação do gene blaOXA-24, uma vez que ele foi identificado em três dos quatro estados amostrados.

Acute effects of caffeine intake on athletic performance: A systematic review and meta-analysis / Efectos agudos de la ingesta de cafeína en el rendimiento atlético: Una revisión sistemática y meta-análisis

ABSTRACT Objective: Our objective was to perform a systematic review and meta-analysis of the research literature assessing the effect of caffeine on athletic performance. Methods: A total of 13 studies published between 2010 and 2015 were included in the meta-analysis of the effects of caffeine on maximum running distance (2 studies), time trial performance (7 studies), and muscle power (4 studies). The effect sizes were calculated as standardized differences in means (std in means). Meta-analysis was completed using a random effects model. Results: Caffeine supplementation did not increase maximum running distance (effect size= 0.37, p= 0.14) and muscle power (effect size= 0.17, p= 0.36). However, improvements were observed in the time trial performance (effect size= −0.40, p< 0.01). Subgroup analyses revealed that the improvement in time trial results may be related to the use of the 6 mg/kg of body weight of caffeine dose (effect size= −0.45, p= 0.01). Conclusion: Our meta-analysis showed that caffeine intake does not improve performance in maximum running distance and muscle power, but it seems to improve time trial performance. The effect of caffeine on time trial performance related to dose.

RESUMEN Objetivo: Realizar una revisión sistemática y meta-análisis de la literatura de investigación que evalúa el efecto de la cafeína en el rendimiento atlético. Método: Un total de 13 estudios publicados entre 2010 y 2015 fueron incluidos en el meta-análisis de los efectos de la cafeína sobre la distancia máxima de carrera (2 estudios), el tiempo de prueba (7 estudios) y la potencia muscular (4 estudios). Los tamaños del efecto se calcularon como diferencias estandarizadas en las medias (std en los medias), y el meta-análisis se completó utilizando un modelo de efectos aleatorios. Resultados: La suplementación con cafeína no aumentó la distancia máxima de funcionamiento (tamaño del efecto= 0.37, p= 0.14) ni la potencia muscular (tamaño del efecto= 0.17, p= 0.36). Sin embargo, se observaron mejoras en el rendimiento del ensayo con tiempo (tamaño del efecto= −0.40, p< 0,01). Los análisis de subgrupos revelaron que la mejora en los resultados de los ensayos a tiempo podía estar relacionada con el uso de la dosis de 6 mg/kg de peso corporal de cafeína (tamaño del efecto= −0.45, p = 0.01). Conclusiones: El meta-análisis demostró que la ingesta de cafeína no mejora el rendimiento en la distancia máxima de carrera ni la potencia muscular, pero parece mejorar el rendimiento de la prueba de tiempo. Este efecto potencial de la cafeína en el rendimiento de la prueba de tiempo estuvo relacionado con la dosis.

Antimicrobial resistance in Enterobacteriaceae in Brazil: focus on ß-lactams and polymyxins

ABSTRACT During the last 30 years there has been a dissemination of plasmid-mediated β-lactamases in Enterobacteriaceae in Brazil. Extended spectrum β-lactamases (ESBL) are widely disseminated in the hospital setting and are detected in a lower frequency in the community setting. Cefotaximases are the most frequently detected ESBL type and Klebsiella pneumoniae is the predominant species among ESBL producers. Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae became widely disseminated in Brazil during the last decade and KPC production is currently the most frequent resistance mechanism (96.2%) in carbapenem resistant K. pneumoniae. To date KPC-2 is the only variant reported in Brazil. Polymyxin B resistance in KPC-2-producing K. pneumoniae has come to an alarming rate of 27.1% in 2015 in São Paulo, the largest city in Brazil. New Delhi metallo-β-lactamase was detected in Brazil in 2013, has been reported in different Brazilian states but are not widely disseminated. Antimicrobial resistance in Enterobacteriaceae in Brazil is a very serious problem that needs urgent actions which includes both more strict adherence to infection control measures and more judicious use of antimicrobials.

Antimicrobial susceptibility of Brazilian Clostridium difficile strains determined by agar dilution and disk diffusion

Abstract Clostridium difficile is a leading cause of diarrhea in hospitalized patients worldwide. While metronidazole and vancomycin are the most prescribed antibiotics for the treatment of this infection, teicoplanin, tigecycline and nitazoxanide are alternatives drugs. Knowledge on the antibiotic susceptibility profiles is a basic step to differentiate recurrence from treatment failure due to antimicrobial resistance. Because C. difficile antimicrobial susceptibility is largely unknown in Brazil, we aimed to determine the profile of C. difficile strains cultivated from stool samples of inpatients with diarrhea and a positive toxin A/B test using both agar dilution and disk diffusion methods. All 50 strains tested were sensitive to metronidazole according to CLSI and EUCAST breakpoints with an MIC90 value of 2 μg/mL. Nitazoxanide and tigecycline were highly active in vitro against these strains with an MIC90 value of 0.125 μg/mL for both antimicrobials. The MIC90 were 4 μg/mL and 2 μg/mL for vancomycin and teicoplanin, respectively. A resistance rate of 8% was observed for moxifloxacin. Disk diffusion can be used as an alternative to screen for moxifloxacin resistance, nitazoxanide, tigecycline and metronidazole susceptibility, but it cannot be used for testing glycopeptides. Our results suggest that C. difficile strains from São Paulo city, Brazil, are susceptible to metronidazole and have low MIC90 values for most of the current therapeutic options available in Brazil.

Emergence of Acinetobacter baumannii ST730 carrying the blaOXA-72 gene in Brazil

Over the last decade, Acinetobacter baumannii resistant to carbapenems has emerged in many medical centres and has been commonly associated with high morbimortality. In Brazil, this resistance is mainly attributed to the spread of OXA-23-producing clones and, to a lesser extent, to OXA-143-producing clones. Here, we describe, for the first time, two OXA-72-producing A. baumannii isolates in southern Brazil to a broad spectrum of antibiotics, except polymyxin B and tigecycline. Molecular typing by multilocus sequence typing (MLST) demonstrated that both OXA-72-producing isolates belong to a new sequence type (ST), ST730, which was recently identified in OXA-23-producing A. baumannii isolates in São Paulo, Brazil. We demonstrate that the two A. baumannii ST730 isolates carrying blaOXA-72share a common ancestral origin with the blaOXA-23producers in Brazil. This observation reinforces the importance of strain-typing methods in order to clarify the dynamics of the emergence of new clones in a geographic region.

Antimicrobial resistance in Enterobacteriaceae in Brazil: focus on -lactams and polymyxins

ABSTRACT During the last 30 years there has been a dissemination of plasmid-mediated -lactamases in Enterobacteriaceae in Brazil. Extended spectrum -lactamases (ESBL) are widely disseminated in the hospital setting and are detected in a lower frequency in the community setting. Cefotaximases are the most frequently detected ESBL type and Klebsiella pneumoniae is the predominant species among ESBL producers. Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae became widely disseminated in Brazil during the last decade and KPC production is currently the most frequent resistance mechanism (96.2%) in carbapenem resistant K. pneumoniae. To date KPC-2 is the only variant reported in Brazil. Polymyxin B resistance in KPC-2-producing K. pneumoniae has come to an alarming rate of 27.1% in 2015 in São Paulo, the largest city in Brazil. New Delhi metallo--lactamase was detected in Brazil in 2013, has been reported in different Brazilian states but are not widely disseminated. Antimicrobial resistance in Enterobacteriaceae in Brazil is a very serious problem that needs urgent actions which includes both more strict adherence to infection control measures and more judicious use of antimicrobials.

Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report

Rothia aeria is an uncommon pathogen mainly associated with endocarditis in case reports. In previous reports, endocarditis by R. aeria was complicated by central nervous system embolization. In the case we report herein, endocarditis by R. aeria was diagnosed after acute self-limited diarrhea. In addition to the common translocation of R. aeria from the oral cavity, we hypothesize the possibility of intestinal translocation. Matrix-assisted laser desorption ionization-time of flight mass spectrometry and genetic sequencing are important tools that can contribute to early and more accurate etiologic diagnosis of severe infections caused by Gram-positive rods.

Efeito da penicilina G a cada três semanas sobre o surgimento de Streptococcus viridans resistentes à penicilina na microflora oral / Effect of penicillin G every three weeks on oral microflora by penicillin resistant Viridans Streptococci

FUNDAMENTO: Penicilina G benzatina a cada 3 semanas é o protocolo padrão para a profilaxia secundária para febre reumática recorrente. OBJETIVO: Avaliar o efeito da penicilina G benzatina em Streptococcus sanguinis e Streptococcus oralis em pacientes com doença valvular cardíaca, devido à febre reumática com recebimento de profilaxia secundária. MÉTODOS: Estreptococos orais foram avaliados antes (momento basal) e após 7 dias (7º dia) iniciando-se com penicilina G benzatina em 100 pacientes que receberam profilaxia secundária da febre reumática. Amostras de saliva foram avaliadas para verificar a contagem de colônias e presença de S. sanguinis e S. oralis. Amostras de saliva estimulada pela mastigação foram serialmente diluídas e semeadas em placas sobre agar-sangue de ovelhas seletivo e não seletivo a 5% contendo penicilina G. A identificação da espécie foi realizada com testes bioquímicos convencionais. Concentrações inibitórias mínimas foram determinadas com o Etest. RESULTADOS: Não foram encontradas diferenças estatísticas da presença de S. sanguinis comparando-se o momento basal e o 7º dia (p = 0,62). No entanto, o número existente de culturas positivas de S. oralis no 7º dia após a Penicilina G benzatina apresentou um aumento significativo em relação ao valor basal (p = 0,04). Não houve diferença estatística existente entre o momento basal e o 7º dia sobre o número de S. sanguinis ou S. oralis UFC/mL e concentrações inibitórias medianas. CONCLUSÃO: O presente estudo mostrou que a Penicilina G benzatina a cada 3 semanas não alterou a colonização por S. sanguinis, mas aumentou a colonização de S. oralis no 7º dia de administração. Portanto, a susceptibilidade do Streptococcus sanguinis e Streptococcus oralis à penicilina G não foi modificada durante a rotina de profilaxia secundária da febre reumática utilizando a penicilina G. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Benzathine penicillin G every 3 weeks is the standard protocol for secondary prophylaxis for recurrent rheumatic fever. OBJECTIVE: Assess the effect of Benzathine penicillin G on Streptococcus sanguinis and Streptococcus oralis in patients with cardiac valvular disease due to rheumatic fever receiving secondary prophylaxis. METHODS: Oral streptococci were evaluated before (baseline) and after 7 days (day 7) with Benzathine penicillin G in 100 patients receiving routine secondary rheumatic fever prophylaxis. Saliva samples were evaluated for colony count and presence of S. sanguinis and S. oralis. Chewing-stimulated saliva samples were serially diluted and plated onto both nonselective and selective 5% sheep blood agar containing penicillin G. The species were identified using conventional biochemical tests. Minimal inhibitory concentrations were determined with the Etest. RESULTS: No statistical differences were found in the presence of S. sanguinis comparing baseline and day 7 (p = 0.62). However, the existing number of positive cultures of S. oralis on day 7 after Benzathine penicillin G presented a significant increase compared to baseline (p = 0.04). No statistical difference was found between baseline and day 7 concerning the number of S. sanguinis or S. oralis CFU/mL and median minimal inhibitory concentrations. CONCLUSION: This study showed that Benzathine penicillin G every 3 weeks did not change the colonization by S. sanguinis, but increased colonization of S. oralis on day 7 of administration. Therefore, susceptibility of Streptococcus sanguinis and Streptococcus oralis to penicillin G was not modified during the penicillin G routine secondary rheumatic fever prophylaxis. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Caracterização de betalactamases de espectro ampliado e KPC em Enterobacter cloacae e Enterobacter aerogenes isoladas de casos de infecções relacionadas aos cuidados com a saúde em pacientes atendidos em hospitais da cidade de São Paulo / Characterization of extended spectrum beta-lactamases and KPC in Enterobacter cloacae and Enterobacter aerogenes cultivated from cases of healthcare-associated infections in patients from hospitals in the city of São Paulo

INTRODUÇÃO: O tratamento das infecções relacionadas à assistência à saúde, causadas por enterobactérias, representa um desafio crescente, em função do aumento da prevalência de resistência aos betalactâmicos, em particular às cefalosporinas de terceira e quarta gerações e carbapenêmicos. Os mecanismos de resistência mais relevantes a essas classes de antimicrobianos, em enterobactérias, é a produção de betalactamases de espectro ampliado e carbapenemases. Os objetivos do estudo foram: (1) determinar a frequência e caracterizar betalactamases de espectro ampliado (ESBL); (2) determinar a frequência e caracterizar o gene blaKPC-2; (3) avaliar a relação clonal entre isolados produtores de ESBL ou KPC, uma coleção de isolados do gênero Enterobacter cultivadas de casos de infecções relacionadas aos cuidados com a saúde diagnosticadas em pacientes atendidos em hospitais da cidade de São Paulo. MÉTODOS: Foram estudadas 141 isolados do gênero Enterobacter quanto à produção de ESBL pelo método de Jarlier e colaboradores, concentrações inibitórias mínimas para cefotaxima, cefepima e ceftazidima pelo método da diluição em ágar, halo de inibição para ertapenem pelo método de Kirby-Bauer e presença de genes que codificam ESBL ou KPC, por PCR. RESULTADOS: A frequência de isolados produtores de ESBL, quando utilizado o método de Jarlier e colaboradores foi de 22,7%. Os genes que codificam cefotaximases foram detectados em 34,4% dos isolados com teste fenotípico positivo para ESBL, e houve predomínio do grupo da CTX-M-8, enquanto os genes que codificam variantes SHV foram detectados em 18,7% dos produtores de ESBL. Os genes blaTEM-1 e blaOXA-1 foram detectados em 62,5%; 12,5% dos isolados com teste fenotípico positivo para ESBL, mas não são ESBLs. Não houve detecção do gene que codifica a enzima BES-1 na amostragem. O gene blaKPC-2 foi detectado em três dos 15 isolados produtores de ESBL e resistentes ao ertapenem. Os perfis obtidos por ERIC-PCR sugerem a disseminação...

INTRODUCTION: The treatment of healthcare associated infections caused by enterobacteria represents a growing challenge due to the increasing prevalence of beta-lactam resistance, particularly to third and fourth generations cephalosporins and carbapenems. The main mechanisms of resistance to these antimicrobial classes are the production of extended spectrum beta-lactamases and carbapenemases. The objectives of this study were: (1) determine the frequency and characterize extended spectrum beta-lactamases; (2) determine the frequency and characterize blaKPC; (3) evaluate the clonal relation among ESBL or KPC producers, in a collection of Enterobacter isolates cultivated from cases of healthcare associated infections in patients from hospitals located in the city of São Paulo. METHODS: A total of 141 Enterobacter isolates were studied concerning ESBL production using the method from Jarlier and colleagues, minimum inhibitory concentrations for cefotaxime, ceftazidime and cefepime by agar dilution method, inhibition zone for ertapenem by by Kirby-Bauer method and the presence of genes coding for ESBLs or KPCs, by PCR. RESULTS: The frequency of ESBL producers using Jarlier´s method was 22.7%. Genes coding for cefotaximases were detected in 34.4% of isolates with a positive test for ESBl and CTX-M-8 group was predominant, but blaSHV variants were also detected in 18.7% of the ESBL producres. blaTEM-1, and blaOXA-1 genes were detected in 62.5%; 12.5% of all isolates with a positive phenotypic test for ESBL, but there are not ESBLs. The blaKPC-2 gene was detected in three among 15 ESBL producers that were also resistant to ertapenem. ERIC-PCR profiles suggest the dissemination of an E. aerogenes clone among hospitals. CONCLUSIONS: The predominant ESBL determinants in the sample analyzed derive from blaCTX-M. The presence of the same clonal groups in different hospitals indicates inter-hospital dissemination. The presence of KPC producing Enterobacter is...

Análise eletromiográfica dos músculos masseter, temporal e trapézio em diferentes condições da lordose cervical / Electromyographic analysis of masseter, temporalis and trapezius muscles in different conditions of the cervical lordosis

Desequilíbrios osteomioarticulares da região cervical e craniomandibular têm sido referenciados como fontes potenciais de disfunções da articulação temporomandibular. O presente estudo objetivou analisar a atividade eletromiográfica (EMG) dos músculos masseter, temporal anterior e trapézio, bilateralmente, com a coluna cervical em posição lordose fisiológica (LF) e em posição de hiperlordose ( HL), induzida através da colocação de um rolo de espuma com raio de 5 cm, nas condições de repouso e durante oclusão dentária com força máxima. 10 indivíduos saudáveis (5 homens e 5 mulheres), sem acometimento da articulação temporomandibular ou da coluna cervical foram voluntários no estudo, sendo observado que em condição de repouso o músculo masseter direito apresentou maior atividade EMG na postura de LF (7.0+-1.uV) em relação à postura de HL ( 6.1+-1.ouV) (p<0.05), já o músculo trapézio esquerdo apresentou maior atividade EMG na postura de HL (9.2+-1.O uV) se comparada à postura de LF (7.0+-O.6uV)(p<0.05), durante o ato de oclusão dentária com força máxima houve maior ativação do músculo trapézio direito na postura de HL (9.6+-1.8uV) se comparada à postura de LF (6.6+-1.3.uV) (p<0.05). Os dados deste estudo apontam para uma potencial influência do input sensorial da região cervical na ativação do músculo masseter e trapézio, sendo recomendada a realização de estudos que reproduzam a metodologia aqui aplicada a amostras de indivíduos portadores de disfunção da articulação temporomandibular.

Unbalance in the skeletal system of the cervical and craniomandibular regions have benn indicated as potentials sources of temporomandibular dysfunctions. This study aims to analysis the electromyographical activity(EMG) of masseter, anterior temporal and upper trapezius muscles, bilaterally, with the cervical spine in physiological lordosis (PL) and in hiperlordosis (HL) positions, induced by roll placement with 5 cm of ray. In both positions the EMG was recorded during rest and dental occlusion with maximal effort. 10 health subjects (5 men and 5 women) without history of temnporomandibular or cervical spine disease participated in the estudy. In rest condition the EMG activity of right masseter muscle in PL posture ((7.0+-1.uV) was greater than HL ( 6.1+-1.ouV) (p<0.05), the left trapezius muscle showed greater EMG activity in the HL (9.2+-1.O uV) in relation to the PL posture (7.0+-O.6uV)(p<0.05), the EMG activity of the right trapezius muscle in the posture (9.6+-1.8uV) was greater than the PL (6.6+-1.3.uV) (p<0.05) during the occlusion acts. The results obtained indicate the potential influence of the sensorial input of the cervical region in the masseter and trapezius muscle activities. We recommend that more studies are made reproducing this methodology, applying to the subjects with temporomandibular disorders.

Influências da barra infracapital sobre alterações posturais proprioceptivas ascendentes / Influences of the infracaptal bar on ascending proprioceptives postural alterations

A postura deve ser harmônica, equilibrada, com gasto energético mínimo necessário, para que não ocorra adaptações e lesões futuras. O pé é um dos principais captores, recebendo influências propriceptivas ascendentes para o ajuste postural. A utilização de palmilhas proprioceptivas com apoios previne e trata alterações posturais, sendo essencial para uma melhor qualidade de vida. O objetivo deste estudo foi analisar as influências da barra infracapital sobre a postura de indivíduos com alterações posturais proprioceptivas ascendentes, analisando o alinhamento de algumas estruturas ósseas previamente marcadas e relacionar o comprimento da mão com a lateralidade. A amostra foi constituída por 10 voluntários de ambos os sexos, com idade entre 20 e 30 anos. O estudo foi um ensaio clínico controlado. O experimento foi mensurado pela biofotometria e analisado pelo software Sapo, sendo assim analisado o alinhamento de estruturas ósseas previamente marcadas. Os dados foram exportados para o Excel e transformados em variação percentual, analisados pela estatística descritiva e aplicado o teste t de Student com nível de significância de (p<0,05). A partir dos resultados obtidos pode-se concluir que a barra infracapital influencia nas alterações posturais proprioceptivas ascendentes, melhorando o alinhamento das estruturas corporais, possivelmente através do reequilíbrio do tônus postural e das cadeias musculares, quando utilizadas no local indicado. A lateralidade não mostrou relação com o comprimento do membro superior. Porém sugere-se um novo estudo com um número maior de voluntários para comparação dos resultados.

The attitude should be harmonious, balanced, with minimum energy expenditure necessary for that does not occurtions and injuries in the future. The foot is a major captors, receiving influences proprioceptives upside to the postural adjustment. The use of insoles proprioceptives, with support prevents and treats the postural alterations being essencial for a better quality of life. The objective of this study was to analyze the influence of the bar infracapital about the posture of individuals with postura alterations proprioceptives upside, analyzing the alignment of some bony structures previously marked and linking the length of the hand with dominant side. The sample was composed of 10 volunteers of both sexes, aged 20 and 30 years. The study was a controlled clinical try. The experiment was measured by biofotometria and analyzed by the software "Sapo" and therefore considered the alignment of bony structures previously marked. The data were exported to Excel and transformed into percent variation, analyzed by descriptive statistics and applied the Student t the with significance level of (p<0.05). From the results it can be concluded that the bar infracapital influences in postural alteration proprioceptives upside, improving the alignment of body structures through the rebalancing of postural tone and muscle of the chains, when used in the place indicated. The dominant side didn't show relation with the length of the upper limb. But it is suggested a new study with a larger number of volunteers.

Antibiotic resistance and trend of urinary pathogens in general outpatients from a major urban city

OBJECTIVE: We assessed the antimicrobial resistance patterns of pathogens responsible for urinary tract infections (UTI) in outpatients in São Paulo, Brazil, as well as the Escherichia coli antimicrobial resistance trend. MATERIALS AND METHODS: Outpatients urine cultures were collected from January 2000 to December 2003. Statistical analysis considered positive results for one bacterial species with colony count > 100,000 CFU/mL. Stratification was done on age group and gender. Statistical tests used included chi-square and the chi-square test for trend to evaluate differences between susceptibility rates among age groups and ordering in the E. coli resistance rates per year, respectively. RESULTS: There were 37,261 positive results with Enterobacteriaceae isolated in 32,530 (87.3 percent) and Gram-positive cocci in 2,570 (6.9 percent) cultures. E. coli had the highest prevalence (71.6 percent). Susceptibility tests were performed in 31,716 cultures. E. coli had elevated resistance rates (> 30 percent) to ampicillin, trimethoprim-sulfamethoxazole, and tetracycline. Significant differences between age groups and ordering among years were observed. CONCLUSIONS: The use of trimethoprim-sulfamethoxazole is precluded in the population studied due to elevated resistance rates (> 30 percent) among most prevalent pathogens. Significant resistance rate differences among age groups and years were observed, particularly for fluoroquinolones. Fluoroquinolones should be used with caution. Nitrofurantoin should be used as empirical therapy for primary, non-complicated urinary tract infections.

Deep stromal mycobacterial keratitis: viable bacteria after six months of treatment: case report and literature review

O objetivo do caso é descrever a presença de micobactérias viáveis em pacientes com ceratite, 6 meses após tratamento intensivo. A identificação de espécies, foi efetuada usando método PRA (polymerase chain reaction seguida pela restriction endonuclease analysis). Clonalidade foi avaliada pelos métodos RAPD (randomly amplified polymorphic DNA) e ERIC-PCR (enterobacterial repetitive intergenic consensus - polymerase chain reaction). Paciente refere trauma com corpo estranho metálico há 3 semanas. A cultura da córnea revelou Mycobacterium abscessus. Após 6 meses de tratamento tópico e sistêmico, paciente apresentava-se sem inflamação, sendo considerado clinicamente curado. Realizou-se então, uma ceratoplastia penetrante com intuitos ópticos. A cultura da córnea transplantada revelou micobactérias de mesma origem clonal. O achado mais interessante neste relato, foi a positividade da cultura da córnea transplantada após 6 meses de intenso tratamento específico. Ao nosso conhecimento, esse é o primeiro caso relatado na literatura mostrando essa possibilidade em tratamento de ceratites por micobactérias. Assim, os pacientes com ceratite por Mycobacterium abscessus podem apresentar bactérias viáveis após longo tempo de tratamento específico e precisam ser seguidos cuidadosamente por um longo período de tempo.

Antimicrobial susceptibility of Gram-negative bacteria in Brazilian hospitals: the MYSTIC Program Brazil 2003

Establish the susceptibility pattern of Gram-negative bacteria causing infections in ICU patients, MYSTIC Program Brazil 2003. Gram-negative bacteria (n = 1,550) causing nosocomial infections were collected at 20 Brazilian centers. The central laboratory confirmed the identification and performed the susceptibility tests by Etest methodology (AB Biodisk, Solna, Sweden) for meropenem, imipenem, ciprofloxacin, ceftazidime, cefepime, cefotaxime, piperacillin/tazobactam, gentamicin, and tobramycin. Interpretation criteria used were according to National Committee for Clinical Laboratory Standards (NCCLS). Pseudomonas aeruginosa (30.3 percent) was the most frequent isolate, followed by E. coli (18.6 percent), Klebsiella pneumoniae (16.9 percent), Acitenobacter baumannii (8.8 percent), and Enterobacter cloacae (7.1 percent). Pseudomonas aeruginosa (n=470) isolates presented susceptibility rates of 64 percent to meropenem, 63.8 percent to piperacillin/tazobactam, 63.4 percent to amikacin, 58.7 percent to imipenem. Acitenobacter baumannii presented susceptibility rates to meropenem of 97.1 percent, and 73 percent to tobramycin. E. coli and K. pneumoniae were highly susceptible to both carbapenems.Carbapenem resistance among the Enterobacteriaceae is still rare in the region. Acitenobacter baumannii and P. aeruginosa presented elevated resistance rates to all antimicrobials. Since they play an important role in nosocomial infections in this environment, the use of empirical combination therapy to treat these pathogens may be justified.

Performance de três métodos na avaliação da similaridade genética de isolados do grupo Mycobacterium chelonae-abscessus / Performance of three typing methods for the evaluation of genetic similarity of Mycobacterium chelonae-abscessus group isolates

Objetivo: Avaliar a concordância entre os métodos PRA-ITS e PRA-hsp65 na identificação das espécies do Grupo Mycobacterium chelonae-abscessus e a eficácia de PFGE, RAPO-PCR e ERIC-PCR na avaliação da similaridade genética de isolados de Mycobacterium chelonae e M. abscessus. Métodos: Um total de 98 isolados de M. chelonae e M. abscessus isolados em surtos ou não relacionados foram analisados por PRA-hsp65, PRA-ITS, ERIC-PCR, RAPD e PFGE. Resultados: Os isolados de M. chelonae dos surtos apresentaram perfil de PRA-ITS do genótipo M. chelonae 11. Os isolados do surto Mi apresentaram perfis de PRA-hsp65 com fragmentos de 310 e 130 bp após clivagem dos amplicons de hsp65 com BstEII e fragmentos de 200-70-60-55 após clivagem dos amplicons de hsp65 com Haelll. Os isolados de M. abscessus apresentaram o perfil de PRA-hsp65 M. abscessus I , 11 ou 111 e PRA-ITS M. abscessus I. Os isolados de M. chelonae apresentaram perfis de ERIC-PCR, RAPO e PFGE indistinguíveis quando pertencentes a um mesmo surto e distintos quando comparados surtos diferentes. Os isolados de M. abscessus apresentaram perfis de ERIC-PCR, RAPD e PFGE indistinguíveis ou similares quando pertencentes a um mesmo surto e distintos quando comparados surtos diferentes. Conclusões: Houve concordância de 100 por cento entre PRA-hsp65 e PRA-ITS quando analisados os isolados de M. chelonae e M. abscessus implicados em surtos. Uma nova variante alélica de hsp65 M. abscessus 111 causou um surto de ceratite na cidade de São Paulo. Uma variante alélica de hsp65, M. immunogenum 11, causou o primeiro surto descrito na literatura para esta espécie. ERIC-PCR apresentou o maior poder discriminatório para análise de clonalidade em M. abscessus. PFGE não deve ser utilizada para avaliação de clonalidade em isolados de genótipo hsp65 M. abscessus I que necessitam de tiouréia para impedir degradação de seu DNA durante a corrida eletroforética. Os métodos com o maior poder discriminatório para M. chelonae foram PFGE e RAPO com oligonucleotídeo RAPD1.

Perfil de sensibilidade a antimicrobianos de bactérias isoladas do trato respiratório baixo de pacientes internados em hospital brasileiros - Resultados do Programa SENTRY, 1997 e 1998 / Antimicrobial suspeceptibility of bacteria isolated from the lower respiratory tract of impatients with pneumonia in Brazilian hospital - Results from the SENTRY surveillance program, 1997 and 1998

INTRODUÇÄO: Pneumonia hospitalar é a mais fatal das infecçöes hospitalares, com taxas de mortalidade de 30 a 60 por cento. Estima-se que 15 por cento de todas as mortes associadas à hospitalizaçäo estejam diretamente relacionadas a pneumonia hospitalar. O SENTRY é um estudo de vigilância de resistência a antimicrobianos envolvendo centros médicos em todo o mundo. OBJETIVO: Avaliar a sensibilidade a antimicrobianos de bactérias isoladas no trato respiratório baixo de pacientes com pneumonia internados em hospital brasileiro. MATERIAL E MÉTODOS: Foram avaliadas 525 amostras bacterianas de 11 hospitais brasileiros, como parte do programa SENTRY. Os isolados foram testados por microdiluiçäo em caldo contra um grande número de antimicrobianos. RESULTADOS: As cinco espécies mais freqüentes foram (n/por cento): Pseudomonas aeruginosa (158/30,1 por cento), Staphylococcus aureus (103/19,6 por cento), acinetobacter spp. (68/13,0 por cento), Klebsiella spp. (50/9,5 por cento), e Enterobacter spp. (44/8,4 por cento). Essas cinco espécie representam mais de 80 por cento de toda a amostragem. A P. aeruginosa apresentou altas taxas de resistência à maioria dos antimicrobianos testados. As maiores taxas de sensibilidade foram apresentadas por piperacilina/tazobactam (71,5 por cento) e meropenem (69,0 por cento). Os compostos com maior atividade in vitro contra Acinetobacter spp. foram imipenem e meropenem (80,9 por cento de sensibiliade) seguido pela tetraciclina (63,2 porcento). A sensibilidade das amostras de Klebsiella spp. foi muito baixa. MIC = ug/mL para ceftriaxona ou ceftazidima, indicando produçäo de ESBL, foram os cabapenens (100 por cento de sensibilidade) e as quinolonas (92,0 por cento de sensibilidade). Ceftrixona foi ativa contra somente 56,8 por cento da amostras de Enterobacter spp. (MIC50, ó 1ug/mL), enquanto a cefapima foi detectada em 43,7 por cento dos isolados de S. aureus. As drogas mais ativas contra essa espécie foram: vancomicina, teicoplanina, quinupristin-dalfopristin e linezolida. CONCLUSÄO: Os resultados do presente estudo mostraram alta prevalência de Acinetobacter spp. e altas taxas de resistência entre bacilos gram-negativos quando comparados com resultados de estudos norte-americanos e europeus

Atividade in vitro de gatifloxacina e outros antimicrtobianos frente a 1885 isolados clínicos em 11 centros no Brasil / In vitro evaluation of gatifloxacin and other antimicrobials against 1885 clinical isolates from eleven Brazilian Centers

O objetivo do presente estudo foi avaliar a atividade in vitro de uma nova fluoroquinolona, a gatifloxacina em comparaçäo com ciprofloxacina, levofloxacina, trovafloxacina, azitromicina, claritromicina, cefuroxima, amoxicilina-ácido clavulânico, amicacina e gentamicina, frente a isolados bacterianos de diferentes processos patológicos de pacientes em 11 centros diferentes de sete Estados do Brasil. As amostras foram testadas pelo método de Etest e a interpretaçäo dod resultados de acordo ao descrito pelo National Committee for Clinical Laboratory Standards (NCCLS). As porcentagens de bactérias sensíveis à gatifloxacina foram: Haemophilus influenzae (107 cepas) 98,9 porcento; Moraxella catarrhalis (101 cepas) 100 porcento Streptococcus pneumoniae (126 cepas) 100 porcento; Streptococcus pyogenes (135 cepas) 100 porcento; Enterobacteriaceae (797 cepas) 81,2 porcento e Pseudomonas aeruginosa(216 cepas) 57,4 porcento. Gatifloxacina foi de duas a seis vezes mais ativa frente a Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus pyogenes que levofloxacina e ciprofloxacina. Frente a Moraxella catarrhalis a atividade das quatro quinolonas estudadas foi similar. Frente a Enterobacteriacea a ciprofloxacina foi de uma a duas vezes mais ativa que gatifloxacina e levofloxacina. O amplo espectro de atividade da gatifloxacina indica que esta droga pode ser especialmente útil para o tratamento das infecçöes bacterianas comuns, como säo as respiratórias, urinárias e de parte moles.(au)

Results of the 1997 SENTRY Antimicrobial Surveillance Program in three Brazilian medical centers

The SENTRY Antimicrobial Surveillance Program began in January, 1997, and is designed to monitor nosocomial and selected community acquired infections via a worldwide surveillance network of sentinel hospitals distributed equally by geographic location and size. Three sites in Brazil - Rio de Janeiro, Florianópolis, and Säo Paulo - participated in the SENTRY Antimicrobial Surveillance Program stet. Rank order of occurrence and antimicrobial susceptibillity of pathogenic species causing bloodstream infections, pneumonia, wound or skin and soft tissue infections, and urinary tract infections (UTI) in hospitalized patients were determined by collecting consecutive isolates over a specified period of time. Antimicrobial susceptibilities of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis obtained from outpatients with respiratory tract infections were also evaluated. The isolates for the evaluated infections were: 1) bloodstream - 20 consecutive isolates in each calendar month during a 12-month period; 2) pneumonia - 100 consecutive isolates over a 6 month period; 3) wound or skin and soft tissue - 50 consecutive isolates over a 3 month period; and 4) UTI - 50 consecutive isolates over a 3 month period. Each hospital also contributed, over a 6 month period, consecutive clinically significant outpatient isolates (one isolate per patient) of S. pneumoniae, H. influenzae, and M. catarrhalis that were considered pathogens in respiratory tract infections. Data collected for each isolate included species identification, antimicrobial susceptibility profile, data of isolation, and specimen type. Molecular studies were performed on selected isolates. A total of 1,241 bacterial strains were obtained; the majority were cultured from hospitalized patients, while 139 were fastidious organisms from community acquired respiratory tract infections. Gram-negative bacilli and S. aureus were the predominant pathogens, and Enterobacter spp. was a significant pathogen. The predominance of P. aeruginosa and Acinetobacter spp. and the significant levels of resistence to most agents are of major concern, as is the epidemic rate of ESBL-producing strains of Klebsiella spp. and E. coli in Brazil, which is much higher than rates seen in other areas of the world. Resistance among P. aeruginosa and the Enterobacteriaceae to fluoroquinolones, oxacillin-resistant S. aureus, and penicillin- and trimethoprim-sulfamethoxazole-resistant pneumococci were other...

Comparative in vitro activity of meropenem versus other extended-spectrum antimicrobial agents against 2.085 clinical isolates tested in 13 Brazilian Centers

Meropenem is a parenteral carbapenem antibacterial agent with a very broad spectrum of antibacterial activity. It is the second agent of its class to become available in Brazil. The in vitro antibacterial activity of meropenem was compared with imipenem and four other antimicrobial agents in a multicenter study. This study involved 13 clinical microbiology laboratories, 10 of which came from 8 Brazilian states. A total of 2,085 clinical isolates consecutively collected between December 1995 and March 1996 were susceptibility tested using the Etest and following the NCCLS procedures. Meropenem inhibited more than 90 percent of isolates of Enterobacteriaceae at 0.5µg/mL, except for Citrobacter sp. (1µg/ml). Generally, meropenem was slightly more active than imipenem against Gram-negative organisms and its spectrum of antimicrobial activity was broader than those of all other drugs tested. Against Pseudomonas aeruginosa, meropenem (MIC50, 0.38µg/ml) was approximately 8-fold more active than imipenem (MIN 50,3µg/mL). Imipenem was two-to eight-fold more active than meropenem against some Gram-positive specees oxacillin, including Enterococcus faecalis (MIC 50 of 0.75µg/mL and 2µg/mL respectively), oxacillin-susceptible Staphylococcus aureus (MIC 50 of 0.47µg/mL and 0.094µg/mL), oxacillin-susceptible Staphylococcus epidermidis (MIC 50 of 0.064µg/mL and 0.5mg/mL). Against Streptococcus sp. meropenem was slightly more active than imipenem (MIC 50, 0.016µg/mL). The results of this study may be used to guide empiric therapy in Brazil and indicates that meropenem may have an important role in the treatment of infections caused by multiresistant strains of bacteria.

Antimicrobial susceptibility of Klebsiella pneumoniae producing extended-spectrum ß-lactamase (ESBL) isolated in hospitals in Brazil

The prevalence of Klebsiella pneumoniae producing extended-spectrum ß-lactamase (ESBL) has been increasing all over the world. Infections caused by ESBL producing isolates are difficult to detect with current susceptibility test, and are difficult to treat. ESBLs confer resistence to all currently available ß-lactam, except carbapenems. In addition, ESBL, production is usually associated with resistence to other classes of antimicrobial agents such as aminoglycosides and quinolones. The objective of this study was to evaluate in vitro susceptibility patterns of ESBL producing K. pneumoniae isolated in Brazil. Seventy-two strains were tested using E test against 30 antimicrobial agents, inclusing carbapenems, second and third generation cephalosporins, aminoglycosides, quinolones, and some new compounds. The most active compounds (i.e. 100 percent susceptibility) were meropenem (MIC90,0.125µg/mL), imipenem (MIC90,0.25µg/mL), and cefotetan (MIC90,2µg/mL). Ciprofloxacin (MIC90, 1µg/mL, 94 percent susceptibility) and cefepime (MIC90, 6µg/mL, 92 percent susceptibility), were also very active against our collection of ESBL producing K. pneumoniae. None of the six aminoglycosides showed good activity against these strains (16 percent to 41 percent susceptibility) and only 39 percent of the isolates were susceptible to piperacillin/tazobactam. The results of our study indicated that the carbapenems are most active compounds against ESBL producing K.pneumoniae in Brazil, and ciprofloxaxin remains very active against these strains. Cefotetan and cefepine were also very active against ESBL producing K.pneumoniae in Brazil; however, further studies are necessary to evaluate the role of these cephalosporins in the treatment of infections due to ESBL producing strains.