Caracterización molecular de carbapenemasas en bacilos gramnegativos circulantes en hospitales de Paraguay. Primer cuatrimestre 2021 / Molecular characterization of carbapenemases in Gram-negative bacilli circulating in hospitals of Paraguay. First quarter of 2021

La resistencia a los antimicrobianos (RAM), representa un grave problema por el uso indiscriminado de antimicrobianos de amplio espectro. En nuestro país, durante el primer cuatrimestre del año, se observó un aumento inusual en el número de aislamiento de gérmenes multirresistentes, sobre todo de bacilos gramnegativos, los cuales fueron remitidos al laboratorio de referencia con el objetivo de caracterizar los genes de resistencia a los carbapenemes. Estudio observacional y prospectivo de corte transversal en 456 aislamientos de bacilos gramnegativos provenientes de 11 centros colaboradores de la Red Nacional de Vigilancia de la RAM, remitidos al Laboratorio Central de Salud Pública entre enero y abril de 2021, para la detección molecular (reacción en cadena de la polimerasa múltiple) de los genes de resistencia enzimática bla OXA-51, bla OXA-23, bla OXA-24, bla OXA-48, bla OXA-58, bla NDM, bla KPC, bla IMP, bla VIM. Trescientos sesenta correspondieron a bacilos gramnegativos no fermentadores: 346 Acinetobacter baumannii y 14 Pseudomonas aeruginosa; 96 fueron miembros de Enterobacterales, siendo prevalente Klebsiella pneumoniae (81). Todos los aislamientos de Acinetobacter baumannii resultaron ser productores de carbapenemasas: OXA-23 (94%), NDM (4%), NMD+OXA-58 (2%); en Pseudomonas aeruginosa, 7 de los 14 aislamientos (50%) fueron portadores de metalobetalactamasa del genotipo NDM (100%). Los genotipos NDM (92%) y KPC (8%) fueron confirmados en Enterobacterales. La resistencia plasmídica a carbapenemes es endémica en nuestro país, siendo prevalentes los genotipos OXA-23 en Acinetobacter baumannii y NDM en Pseudomonas aeruginosa y Enterobacterales

Antimicrobial resistance (AMR) represents a serious problem due to the indiscriminate use of broad-spectrum antimicrobials. During the first quarter of the year, an unusual increase in the number of isolation multi-resistant germs, especially gram-negative bacilli was observed, specially of Gram-negative bacilli which were referred to the reference laboratory in order to characterize the carbapenems resistance genes. Observational and prospective cross-sectional study in 456 isolates of Gram-negative bacilli from 11 collaborating centers of the National AMR Surveillance Network, referred to the Central Public Health Laboratory (LCSP) between January and April 2021, for molecular detection (multiple polymerase chain reaction) targeting the enzymatic resistance genes: bla OXA-51, bla OXA-23, bla OXA-24, bla OXA-48, bla OXA-58, bla NDM, bla KPC, bla IMP, bla VIM. Of the 456 isolates studied, 360 corresponded to non-fermenting Gram-negative bacilli, of which 346 were confirmed as Acinetobacter baumannii and 14 Pseudomonas aeruginosa; 96 were Enterobacterales, being Klebsiella pneumoniae (81) the most prevalent. All isolates of Acinetobacter baumannii carried genes encoding carbapenemases, being the OXA-23 (94%) followed by NDM (4%) and NDM +OXA-58 (2%). In Pseudomonas aeruginosa strains, 7 of the 14 isolates (50%) were carriers of NDM metallobetalactamase (100%). No carbapenemase gene was detected in the remaining 7. In all Enterobacterales strains, the presence of carbapenemases of the NDM (92%) and KPC (8%) genotypes were confirmed. Plasmid resistance to carbapenems is endemic in our country, being the OXA-23 genotypes prevalent in Acinetobacter baumannii and NDM in Pseudomonas aeruginosa and Enterobacterales

Resistencia a múltiples antibióticos en serovariedades de Salmonella aisladas de muestras clínicas y alimentos / Resistance to multiple antibiotics in serovarities of Salmonella isolated from clinical samples and foods

Salmonella enterica es un patógeno transmitido por alimentos y agente etiológico de brotes alimentarios de gran impacto en la salud humana. El aumento de la resistencia bacteriana constituye una amenaza a la salud pública, la aparición de cepas de Salmonella con resistencia a múltiples antimicrobianos (MDR) fue descrita en humanos, alimentos y animales para consumo; por ello se considera muy importante conocer la situación epidemiológica local. El objetivo de este trabajo fue generar información sobre los serotipos circulantes, resistencia a los antibióticos y presencia de resistencia simultánea a múltiples fármacos en Salmonella provenientes de muestras clínicas humanas y muestras de alimentos en el periodo desde 2017 a 2019. Fueron analizadas un total de 668 cepas de Salmonella aisladas en los años 2017, 2018 y 2019 a partir de muestras clínicas humanas y de alimentos, en el Laboratorio Central de Salud Pública y/o remitidas por Laboratorios de la Red de Enteropatógenos. Se observaron serotipos muy diversos con prevalencia del serovar Heidelberg en alimentos y Typhimurium en muestras de humanos. Se encontró que el 45,4% de las cepas fueron sensibles a todos los antibióticos (ATB), el 35,6% fueron resistentes de 1 a 6 ATB y el 19% con sensibilidad intermedia; observándose mayor resistencia a Tetraciclina, Ác. Nalidíxico, Ampicilina y Nitrofurantoína, en menor grado se evidenció resistencia a cefalosporinas (C3ªG) y a ciprofloxacina. El 16.9% de las cepas presentaron resistencia múltiple (3 o más antibióticos) con 37 fenotipos distintos. Las serovariedades que presentaron mayor resistencia a los antimicrobianos fueron Heidelberg, Schwarzengrund y Typhimurium

Salmonella enterica is a foodborne pathogen and etiological agent of food outbreaks with a great impact on human health. The increase in bacterial resistance constitutes a threat to public health. The appearance of Salmonella strains with resistance to multiple antimicrobials (MDR) has already been described in humans, food and animals for consumption; for this reason, it is considered very important to know the local epidemiological situation. The target of this work was to generate information on circulating serotypes, antibiotic resistance and the presence of simultaneous resistance to multiple drugs in Salmonella from human clinical samples and food samples in the period from 2017 to 2019. A total of 668 Salmonella strains isolated in the years 2017, 2018 and 2019 were analyzed from human and food clinical samples, at the Central Public Health Laboratory and / or sent by Laboratories of the Enteropathogens Network. Very diverse serotypes were observed with prevalence of Heidelberg serovar in food and Typhimurium in human samples .It was found that 45,4% of the strains were sensitive to all antibiotics (ATB), 35,6% were resistant from 1 to 6 ATB and 19% with intermediate sensitivity; observing greater resistance to Tetracycline, Ác. Nalidixic, Ampicillin and Nitrofurantoin, to a lesser degree resistance to cephalosporins (C3ªG) and ciprofloxacin was evidenced. The 16.9% the strains presented multiple resistance (3 or more antibiotics) with 37 different phenotypes. The serovars with the highest antimicrobial resistance were Heidelberg, Schwarzengrund and Typhimurium

[Identification and susceptibility profile of Candida species isolated from hemocultures in hospitals in ParaguayIdentificação e perfil de sensibilidade de Candida spp. isoladas de hemoculturas em hospitais no Paraguai]. / Identificación y perfil de sensibilidad de Candida spp. aisladas de hemocultivos en hospitales de Paraguay.

OBJECTIVE: To report the species identified in candidemia isolated in hospitals in Paraguay, their distribution by age groups, and their susceptibility to fluconazole, voriconazole, and amphotericin B. METHODS: Retrospective study of candidemia reported to the Central Health Public Laboratory by seven hospitals between 2010 and 2018. Identification and susceptibility testing were performed using the automated Vitek 2® system. RESULTS: 520 cases of candidiasis were reported. The prevalent species were Candida albicans (34.4%), C. parapsilosis (30.4%), C. tropical (25.4%), C. glabrata (4.8%), and C. krusei (2.1%). Less frequent species were: C. lusitaniae (1.2%), C. guilliermondii (1%), C. famata (0.3%), C. rugous (0.2%), and C. kefyr (0.2%). Candidiasis was most prevalent in the elderly (48.5%) and adults (29.9%). C. parapsilosis was most frequent in newborns and infants, and C. tropical in pediatric patients; 2.8% and 0.6% of C. albicans and 4.4% and 2.5% of C. parapsilosis were resistant, respectively, to fluconazole and voriconazole; 8% of C. glabrata were resistant to fluconazole and two isolations showed a minimum inhibitory concentration for voriconazole greater than 0.25 mg/L. CONCLUSIONS: This is the first report on candidemias in hospitals of Paraguay. Together with other studies, it will improve knowledge about this infection in the country.

OBJETIVO: Relatar as espécies identificadas em candidemias isoladas em hospitais do país, apresentar a sua distribuição por faixa etária e determinar a sua sensibilidade ao fluconazol, voriconazol e anfotericina B. MÉTODOS: Estudo retrospectivo de candidemias notificadas por sete hospitais ao Laboratório Central de Saúde Pública no período de 2010 a 2018. A identificação e o antifungigrama foram realizados pelo sistema automatizado Vitek®2. RESULTADOS: Foram notificados 520 casos de candidemia. As espécies predominantes foram Candida albicans (34,4%), C. parapsilosis (30,4%), C. tropicalis (25,4%), C. glabrata (4,8%) e C. krusei (2,1%). Outras espécies menos frequentes foram: C. lusitaniae (1,2%), C. guilliermondii (1%), C. famata (0,3%), C. rugosa (0,2%) e C. kefyr (0,2%). As candidemias em pacientes idosos (48,5%) e adultos (29,9%) foram as mais prevalentes. C. parapsilosis foi a espécie mais frequente em recém-nascidos e lactentes, e C. tropicalis predominou em pacientes pediátricos. Ao todo, 2,8% e 0,6% dos casos de C. albicans e 4,4% e 2,5% dos de C. parapsilosis foram resistentes a fluconazol e voriconazol, respectivamente. Além disso, 8% dos casos de C. glabrata foram resistentes ao fluconazol, e duas amostras isoladas apresentaram uma concentração inibitória mínima para voriconazol acima de 0,25 mg/L. CONCLUSÕES: Este é o primeiro estudo sobre candidemias em hospitais do Paraguai, o que, juntamente com outros estudos, permitirá conhecer melhor esta infecção no país.

Identificación y perfil de sensibilidad de Candida spp. aisladas de hemocultivos en hospitales de Paraguay

[RESUMEN]. Objetivo. Reportar las especies identificadas en candidemias aisladas en hospitales del país, su distribución según los grupos etarios y determinar la sensibilidad a fluconazol, voriconazol y anfotericina B. Métodos. Estudio retrospectivo de candidemias reportados por siete hospitales al Laboratorio Central de Salud Pública en el período 2010 - 2018. La identificación y el antifungigrama fueron realizados en el sistema automatizado Vitek®2. Resultados. Se informaron 520 casos de candidemias. Las especies prevalentes fueron Candida albicans (34,4%), C. parapsilosis (30,4%), C. tropicalis (25,4%), C. glabrata (4,8%), C. krusei (2,1%). Otras menos frecuentes fueron: C. lusitaniae (1,2%), C. guilliermondii (1%), C. famata (0,3%), C. rugosa (0,2%) y C. kefyr (0,2%). Las candidemias en ancianos (48,5%) y adultos (29,9%) fueron las más prevalentes. C. parapsilosis fue más frecuente en recién nacidos y lactantes y C. tropicalis en pacientes pediátricos. El 2,8 % y 0,6% de C. albicans y el 4,4% y 2,5% de C. parapsilosis fueron resistentes a fluconazol y voriconazol, respectivamente. El 8% de C. glabrata fue resistente a fluconazol y dos aislamientos presentaron una concentración inhibitoria mínima para voriconazol mayor que 0,25 mg/L. Conclusiones. Este es el primer reporte de candidemias en hospitales de Paraguay que, junto a otros estudios, permitirá un mejor conocimiento de esta infección en el país.

[ABSTRACT]. Objective. To report the species identified in candidemia isolated in hospitals in Paraguay, their distribution by age groups, and their susceptibility to fluconazole, voriconazole, and amphotericin B. Methods. Retrospective study of candidemia reported to the Central Health Public Laboratory by seven hospitals between 2010 and 2018. Identification and susceptibility testing were performed using the automated Vitek 2® system. Results. 520 cases of candidiasis were reported. The prevalent species were Candida albicans (34.4%), C. parapsilosis (30.4%), C. tropical (25.4%), C. glabrata (4.8%), and C. krusei (2.1%). Less frequent species were: C. lusitaniae (1.2%), C. guilliermondii (1%), C. famata (0.3%), C. rugous (0.2%), and C. kefyr (0.2%). Candidiasis was most prevalent in the elderly (48.5%) and adults (29.9%). C. parapsilosis was most frequent in newborns and infants, and C. tropical in pediatric patients; 2.8% and 0.6% of C. albicans and 4.4% and 2.5% of C. parapsilosis were resistant, respectively, to fluconazole and voriconazole; 8% of C. glabrata were resistant to fluconazole and two isolations showed a minimum inhibitory concentration for voriconazole greater than 0.25 mg/L. Conclusions. This is the first report on candidemias in hospitals of Paraguay. Together with other studies, it will improve knowledge about this infection in the country.

[RESUMO]. Objetivo. Relatar as espécies identificadas em candidemias isoladas em hospitais do país, apresentar a sua distribuição por faixa etária e determinar a sua sensibilidade ao fluconazol, voriconazol e anfotericina B. Métodos. Estudo retrospectivo de candidemias notificadas por sete hospitais ao Laboratório Central de Saúde Pública no período de 2010 a 2018. A identificação e o antifungigrama foram realizados pelo sistema automatizado Vitek®2. Resultados. Foram notificados 520 casos de candidemia. As espécies predominantes foram Candida albicans (34,4%), C. parapsilosis (30,4%), C. tropicalis (25,4%), C. glabrata (4,8%) e C. krusei (2,1%). Outras espécies menos frequentes foram: C. lusitaniae (1,2%), C. guilliermondii (1%), C. famata (0,3%), C. rugosa (0,2%) e C. kefyr (0,2%). As candidemias em pacientes idosos (48,5%) e adultos (29,9%) foram as mais prevalentes. C. parapsilosis foi a espécie mais frequente em recém-nascidos e lactentes, e C. tropicalis predominou em pacientes pediátricos. Ao todo, 2,8% e 0,6% dos casos de C. albicans e 4,4% e 2,5% dos de C. parapsilosis foram resistentes a fluconazol e voriconazol, respectivamente. Além disso, 8% dos casos de C. glabrata foram resistentes ao fluconazol, e duas amostras isoladas apresentaram uma concentração inibitória mínima para voriconazol acima de 0,25 mg/L. Conclusões. Este é o primeiro estudo sobre candidemias em hospitais do Paraguai, o que, juntamente com outros estudos, permitirá conhecer melhor esta infecção no país.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) clones from Paraguayan children.

INTRODUCTION: Staphylococcus aureus is considered one of the most important human pathogens, and its levels of resistance to methicillin have increased even in strains isolated from people without nosocomial risk factors. Molecular analysis is essential for understanding the patterns of dissemination. The objective of this study was to identify community-acquired methicillin-resistant S. aureus (CA-MRSA) clones that infected Paraguayan children patients in two periods of time. METHODOLOGY: An observational, descriptive study was designed to determine the genetic variability of 115 isolates of CA-MRSA recovered from children who attended four reference centers in Paraguay between 2009-2010 and 2012-2013. RESULTS: The combined use of Pulsed Field Gel Electrophoresis (PFGE), Multi-Locus Sequencing Typing, Multi-Locus Variable Analysis (MLVA) and Spa typing techniques allowed the identification of two dominant clones: ST30-IV-t019 (77%) and ST5-IV-t311 (10%), and the establishment of the former as the leading cause of CA-MRSA infections in children during the study period. CONCLUSIONS: This is the first study that provides epidemiological information as well as microbiological and molecular characteristics of CA-MRSA isolates recovered from children from Asunción and the Central Department of Paraguay.

Escherichia coli metalobetalactamasa en un hospital de alta complejidad en Paraguay

Ante la aparición de Escherichia coli con New Delhi metalobetalactamasa en un hospital de alta complejidad en Paraguay, se resalta la importancia de vigilar y detectar mecanismos de resistencias así como establecer oportunamente medidas de prevención y control de la infección por microorganismos multirresistentes causantes de brotes y relacionados con un incremento en la morbilidad y mortalidad asociada a los cuidados de salud.

With the emergence of Escherichia coli with New Delhi metallobetalactamase in a hospital of high complexity in Paraguay, the importance of monitoring and detecting resistance mechanisms is highlighted and is consider timely to establish measures for prevention and control of multiresistent microorganisms that causes an outbreak of infections They are related with an increased of morbidity and mortality associated with health care.

BASAL-BOLUS REGIMEN WITH INSULIN ANALOGUES VERSUS HUMAN INSULIN IN MEDICAL PATIENTS WITH TYPE 2 DIABETES: A RANDOMIZED CONTROLLED TRIAL IN LATIN AMERICA.

OBJECTIVE: Few randomized studies have focused on the optimal management of non-intensive care unit patients with type 2 diabetes in Latin America. We compared the safety and efficacy of a basal-bolus regimen with analogues and human insulins in general medicine patients admitted to a University Hospital in Asunción, Paraguay. METHODS: In a prospective, open-label trial, we randomized 134 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dL to a basal-bolus regimen with glargine once daily and glulisine before meals (n = 66) or Neutral Protamine Hagedorn (NPH) twice daily and regular insulin before meals (n = 68). Major outcomes included differences in daily BG levels and frequency of hypoglycemic events between treatment groups. RESULTS: There were no differences in the mean daily BG (157 ± 37 mg/dL versus 158 ± 44 mg/dL; P = .90) or in the number of BG readings within target <140 mg/dL before meals (76% versus 74%) between the glargine/glulisine and NPH/regular regimens. The mean insulin dose in the glargine/glulisine group was 0.76 ± 0.3 units/kg/day (glargine, 22 ± 9 units/day; glulisine, 31 ± 12 units/day) and was not different compared with NPH/regular group (0.75 ± 0.3 units/kg/day [NPH, 28 ± 12 units/day; regular, 23 ± 9 units/day]). The overall prevalence of hypoglycemia (<70 mg/dL) was similar between patients treated with NPH/regular and glargine/glulisine (38% versus 35%; P = .68), but more patients treated with human insulin had severe (<40 mg/dL) hypoglycemia (7.6% versus 25%; P = .08). There were no differences in length of hospital stay or mortality between groups. CONCLUSION: The basal-bolus regimen with insulin analogues resulted in equivalent glycemic control and frequency of hypoglycemia compared to treatment with human insulin in hospitalized patients with diabetes.