Participatory implementation of an antibiotic stewardship programme supported by an innovative surveillance and clinical decision-support system.

BACKGROUND: Antibiotic resistance will cause about 10 million deaths per year by 2050. Fighting antimicrobial resistance is a health priority. Interventions aimed to reduce antimicrobial resistance, such as antibiotic stewardship programmes (ASPs), must be implemented. To be effective, those interventions, and the implementation process, should be matched with social-cultural context. The complexity of ASPs can no longer be developed without considering both organizational and information systems. AIM: To support ASPs through the co-design and implementation, in collaboration with healthcare workers, of a surveillance and clinical decision-support system to monitor antibiotic resistance and improve antibiotic prescription. METHODS: The surveillance and clinical decision-support system was designed and implemented in three Portuguese hospitals, using a participatory approach between researchers and healthcare workers following the Design Science Research Methodology. FINDINGS: Based on healthcare workers' requirements, we developed HAITooL, a real-time surveillance and clinical decision-support system that integrates visualizations of patient, microbiology, and pharmacy data, facilitating clinical decision. HAITooL monitors antibiotic usage and rates of antibiotic-resistant bacteria, allowing early identification of outbreaks. It is a clinical decision-support tool that integrates evidence-based algorithms to support proper antibiotic prescription. HAITooL was considered valuable to support monitoring of antibiotic resistant infections and an important tool for ASP sustainability. CONCLUSION: ASP implementation can be leveraged through a surveillance and clinical decision-support system such as HAITooL that allows antibiotic resistance monitoring and supports antibiotic prescription, once it has been adapted to the context and specific needs of healthcare workers and hospitals.

Subcutaneous emphysema related to air-powder tooth polishing: a report of three cases.

Subcutaneous emphysema is a rare complication of dental procedures and can occasionally give rise to potentially life-threatening complications. We describe three cases of subcutaneous emphysema diagnosed in the same dental clinic. All cases occurred during tooth or implant cleaning using air polishing (KavoProphyflex® ) with a sodium bicarbonate powder (Air-N-Go Classic® ). The diagnosis was based on clinical findings and was confirmed radiologically. The cervical and facial regions were affected in all three cases, and spread to the mediastinum occurred in one case. All the episodes resolved within 3-5 days. Tooth cleaning using air polishing combined with an abrasive powder is a risk factor for subcutaneous emphysema, especially when the powder and device are from different manufacturers. Radiological assessment must be performed to rule out involvement of deep tissue planes.

GidB mutation as a phylogenetic marker for Q1 cluster Mycobacterium tuberculosis isolates and intermediate-level streptomycin resistance determinant in Lisbon, Portugal.

Development of streptomycin resistance in Mycobacterium tuberculosis is usually associated with mutations in rpsL and rrs genes, although up to 50% of clinical streptomycin-resistant isolates may present no mutation in either of these genes. In the present report we investigate the role of gidB gene mutations in streptomycin resistance. We have analyzed 52 streptomycin-resistant and 30 streptomycin-susceptible Mycobacterium tuberculosis clinical isolates by sequencing and endonuclease analysis of the gidB and rpsL genes. All clinical isolates were genotyped by 12-loci MIRU-VNTR. The gidB gene of 18 streptomycin-resistant isolates was sequenced and four missense mutations were found: F12L (1/18), L16R (18/18), A80P (4/18) and S100F (18/18). The remaining isolates were screened by endonuclease analysis for mutations A80P in the gidB gene and K43R in the rpsL gene. Overall, mutation A80P in the gidB gene was found in eight streptomycin-resistant isolates and 11 streptomycin-susceptible multidrug-resistant isolates. Also noteworthy, is the fact that gidB mutations were only present in isolates without rpsL and rrs mutations, all from genetic cluster Q1. Streptomycin quantitative drug susceptibility testing showed that isolates carrying the gidB A80P mutation were streptomycin intermediate-level resistant and that standard drug susceptibility testing yielded inconsistent results, probably due to borderline resistance. We conclude that gidB mutations may explain the high number of streptomycin-resistant strains with no mutation in rpsL or rrs. These mutations might occasionally confer low-level streptomycin resistance that will go undetected in standard susceptibility testing.

Factors associated with complete endoscopic resection of an invasive adenocarcinoma in a colorectal adenoma.

BACKGROUND AND OBJECTIVE: endoscopic polypectomy may allow curative resection of invasive adenocarcinoma on colorectal adenoma. Our goal was to determine the factors associated with complete endoscopic resection of invasive adenocarcinoma. METHODS: retrospective observational study. We included 151 patients with invasive adenocarcinoma on adenomas endoscopically resected between 1999 and 2009. We determined those variables independently related to incomplete resection by a logistic regression. Relation was expressed as Odds Ratio (OR) and its 95% confidence interval (95% CI). RESULTS: patients were predominantly male (66.2%) and their mean age was 68.03 ± 10.65 years. Colonoscopy was completein 84% of the patients and 60.3% had synchronous adenomas. Invasive adenocarcinoma was mainly located in distal colon (90.7%) and morphology was pedunculated in 75.5%. The endoscopic averagesize was 22.61 ± 10.86 mm. Submucosal injection was required in 32.5%. Finally, the resection was in one piece in 73.5% and incomplete in 8.6% of the adenocarcinomas. Factors independently associated with incomplete endoscopic resection were size (mm) (OR 1.08, 95% CI 1.03-1.14, p = 0.002), sessile or flat morphology (OR 8.78, 95% CI 2.24-34.38, p = 0.002) and incomplete colonoscopy (OR 4.73, 95% CI 1.15-19.34, p = 0.03). CONCLUSIONS: endoscopic polypectomy allows complete resection of 91.4% of invasive adenocarcinomas on colorrectal adenoma in our series. Factors associated with incomplete resection were the size of the lesion, sessile or flat morphology and incomplete colonoscopy.

Immunohistochemical alterations in invasive adenocarcinoma in endoscopically resected adenoma and factors associated with risk of residual or recurrent disease.

AIM: We determined the pattern of immunohistochemical expression in invasive adenocarcinoma in endoscopically resected adenoma, its relationship with the risk of residual or recurrent disease and the related factors. METHOD: We included individuals with malignant polyps resected endoscopically in the period 1999-2009. Clinical and endoscopic data were collected. All histological specimens were re-analysed. CD44, matrix metalloproteinase 9 (MMP-9), vascular endothelial growth factor-ß (VEGF-ß), ß-catenin, laminin and cyclooxygenase 2 (COX-2) expression were determined by immunohistochemistry. A multivariate logistic regression was performed to determine variables independently associated with the risk of residual or recurrent disease. RESULTS: One-hundred and fifty-one malignant polyps (114 pedunculated; mean size ± SD=22.61 ± 10.86 mm) were resected endoscopically. Resection was fragmented and incomplete in 26.5% and 8.6% of patients, respectively. Surgical resection was performed on 71 (47%) patients. After a median follow-up of 44 months, residual (n=12) or recurrent (n=6) disease was detected in 17 patients. Conventional histology showed that 32.1% met high-risk histological criteria. Immunohistochemical expression was positive for CD44, MMP-9, VEGF-ß, ß-catenin, laminin and COX-2 in 63.3%, 25.3%, 45%, 38.8%, 79% and 34.5% of specimens, respectively, with no differences between both groups. Variables associated with residual or recurrent disease in the univariate analysis were: nonpedunculated morphology (P=0.07); fragmented (P<0.001) or incomplete resection (P<0.001); margin infiltration (P=0.04); and histological high-risk lesion (P=0.003). Finally, incomplete resection (OR=12.16, 95% CI=3.15-46.98; P<0.001) and histological high risk (OR=4.73, 95% CI=1.33-16.74; P=0.002) were independently associated with the risk of residual or recurrent disease. CONCLUSION: Immunohistochemistry could not predict residual or recurrent disease. Only incomplete excision and histological high risk did so. The factors independently associated were histological high-risk lesion and incomplete resection.

[Invasive basal cell carcinoma of the scalp. A clinical case]. / Carinoma basocelular invasivo de cuero cabelludo. Caso clínico.

Basal cell carcinoma is the most frequent skin malignant neoplasm, although it doesn't usually compromise a vital risk. However, there are cases in which their local aggressiveness is very important, and it get deep structures. We present a 62 years old female operated several times because multifocal basal cell carcinoma on her scalp. She consulted with a wide local recidive affecting dura mater and superior sagittal sinus. We show the clinical case and the surgical treatment employed realized by Plastic and Neurosurgery Departments.

Identification of the plasmid-encoded qacA efflux pump gene in meticillin-resistant Staphylococcus aureus (MRSA) strain HPV107, a representative of the MRSA Iberian clone.

Meticillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial bacterium for which prevention and control measures consist mainly of the application of biocides with antiseptic and disinfectant activity. In this study, we demonstrated the presence of the plasmid-located efflux pump gene qacA in MRSA strain HPV107, a clinical isolate representative of the MRSA Iberian clone. The existence of efflux activity in strain HPV107 due to the QacA pump was also established and this QacA efflux activity was linked with a phenotype of reduced susceptibility towards several biocide compounds. No association could be made with antibiotic resistance. This work emphasises the potential of QacA pump activity in the maintenance and dissemination of important MRSA strains in the hospital setting and, increasingly, in the community.

Carcinoma basocelular invasivo de cuero cabelludo. Caso clínico / Invasive basal cell carcinoma of the scalp. A clinical case

El Carcinoma basocelular es el tumor maligno más frecuente de la piel, aunque generalmente no supone un riesgo vital para el paciente. Sin embargo, existen casos en los que su agresividad local es muy importante, llegando a invadir estructuras profundas. Presentamos el caso de una paciente de 62 años de edad, que había sido reviamente intervenida en varias ocasiones de basaliomas multifocales en cuero cabelludo. Se presentó conuna amplia recidiva local, con invasión de la duramadre y del seno longitudinal superior.Describimos el caso clínico y el tratamiento quirúrgico realizado conjuntamente por los Servicios de Cirugía Plástica y Neurocirugía (AU)

Basal cell carcinoma is the most frequent skin malignant neoplasm, although it doesn’t usually compromise a vital risk. However, there are cases in which their local aggressiveness is very important, and it get deepstructures. We present a 62 years old female operated several times because multifocal basal cell carcinoma on her scalp. She consulted with a wide local recidive affecting dura mater and superior sagittal sinus.We show the clinical case and the surgical treatment employed realized by Plastic and Neurosurgery Departments (AU)

Physiological characterisation of the efflux pump system of antibiotic-susceptible and multidrug-resistant Enterobacter aerogenes.

Enterobacter aerogenes predominates amongst Enterobacteriaceae species that are increasingly reported as producers of extended-spectrum beta-lactamases. Although this mechanism of resistance to beta-lactams is important, other mechanisms bestowing a multidrug-resistant (MDR) phenotype in this species are now well documented. Amongst these mechanisms is the overexpression of efflux pumps that extrude structurally unrelated antibiotics prior to their reaching their targets. Interestingly, although knowledge of the genetic background behind efflux pumps is rapidly advancing, few studies assess the physiological nature of the overall efflux pump system of this, or for that matter any other, bacterium. The study reported here evaluates physiologically the efflux pump system of an E. aerogenes ATCC reference as well as two strains whose MDR phenotypes are mediated by overexpressed efflux pumps. The activities of the efflux pumps in these strains are modulated by pH and glucose, although the effects of the latter are essentially restricted to pH 8, suggesting the presence of two general efflux pump systems, i.e. proton-motive force-dependent and ABC transporter types, respectively.

Identification of nontuberculous mycobacteria in clinical samples using molecular methods: a 3-year study.

Nontuberculous mycobacteria (NTM) are being increasingly isolated in clinical laboratories and present technical and therapeutic challenges. In the present study, we report our experience with the identification of NTM received from 12 Lisbon hospitals over a 3-year period using GenoType Mycobacterium (CM/AS) assays (HAIN Lifescience GmbH, Nehren, Germany). Together, the two kits identified 96.6% of all NTM isolates tested. Among the 18 NTM species identified, Mycobacterium avium complex was the most frequent, although it accounted for only 34% of all NTM. Introducing these methods for the rapid identification of NTM highlights the importance of NTM as potential pathogens and assisted the selection of adequate therapy.

An AcrAB-mediated multidrug-resistant phenotype is maintained following restoration of wild-type activities by efflux pump genes and their regulators.

In this study, we aimed to answer the following question: 'How does a bacterium become so resistant to a given antibiotic even though the levels of antibiotic to which it has become resistant remained constant in the patient?'Escherichia coli AG100 strain induced to high-level resistance due to overexpression of an AcrAB efflux pump was serially cultured in 10mg/L tetracycline for 60 passages. Between each passage it became increasingly resistant to tetracycline, beta-lactams and quinolones with concomitant restoration of wild-type AcrAB activity. Because the multidrug-resistant phenotype could not be reversed with transfer to drug-free medium or with efflux pump inhibitors, it may have resulted from activation of a 'mutator gene' system that reduced the 'energy consumption' associated with an overexpressed efflux pump system.

Targeting human macrophages for enhanced killing of intracellular XDR-TB and MDR-TB.

Although many compounds have been described to inhibit the replication of drug-susceptible and drug-resistant strains of Mycobacterium tuberculosis, most of these studies only evaluate their in vitro activity. There is a lack of studies that show whether any of these agents can kill these organisms at the site where they normally reside post infection, namely, the macrophage of the lung parenchyma. It is the aim of this mini-review to identify agents that have been shown to enhance the killing of intracellular drug-susceptible, multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) strains by non-killing macrophages. Because these agents appear to promote their activity by affecting the transport of K(+) and Ca(2+) from the phagolysosome containing the bacteria, and thereby promoting its acidification and activation of hydrolases that will eventually kill the organism, the authors suggest that compounds that are known to affect the transport of K(+) and Ca(2+) should be considered for possible activity against intracellular MDR- and XDR-TB.

New methods for the identification of efflux mediated MDR bacteria, genetic assessment of regulators and efflux pump constituents, characterization of efflux systems and screening for inhibitors of efflux pumps.

We have developed a number of methods that identify efflux pump mediated multi-drug resistant bacteria, characterize efflux systems and screen for inhibitors of efflux pumps. These approaches were complemented by the quantification of the expression of genes that regulate and code for constituents of efflux pumps. The methods described are easy to use, reproducible and for the most part, require instrumentation normally present in a clinical bacteriology laboratory. Because each method provides good reproducibility, they lend themselves for inter-laboratory use.

Comparison of molecular typing methods for characterization of Staphylococcus epidermidis: proposal for clone definition.

In the present study we give some direction on the selection of the most appropriate typing method(s) to be used for the characterization of Staphylococcus epidermidis, in view of the most recent findings on the evolution, population structure, and epidemiology of this species. In order to achieve this aim, quantitative assessment of the correlation of the results of three typing methods--pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and staphylococcal chromosomal cassette mec (SCCmec) typing, which target different regions of the chromosome that evolve at different rates--was performed. In order to evaluate the discriminatory ability and the strength and direction of the correlation of the different typing methods, Simpson's index of diversity (SID), the adjusted Rand coefficient (AR), and the Wallace coefficient (W) were calculated. PFGE was the most discriminatory method (SID = 99%), followed by MLST (SID = 90%) and SCCmec typing (SID = 75%). The values of AR and W (0.10 < AR < 0.30; 0.50 < W < 0.75) indicated that the partition of the same isolate collection by PFGE, MLST, and SCCmec typing provided results that had only a poor correlation with each other. However, the information provided by the combination of PFGE and SCCmec enabled the prediction of the results obtained by MLST at the level of the clonal complex with a high degree of precision (W > 0.90). We propose that clones of S. epidermidis be defined by the combination of the PFGE type followed by the SCCmec type, which provides reliable information on the short-term epidemiology and the ability to predict with consistency long-term clonal evolution.

Inferring a population structure for Staphylococcus epidermidis from multilocus sequence typing data.

Despite its importance as a human pathogen, information on population structure and global epidemiology of Staphylococcus epidermidis is scarce and the relative importance of the mechanisms contributing to clonal diversification is unknown. In this study, we addressed these issues by analyzing a representative collection of S. epidermidis isolates from diverse geographic and clinical origins using multilocus sequence typing (MLST). Additionally, we characterized the mobile element (SCCmec) carrying the genetic determinant of methicillin resistance. The 217 S. epidermidis isolates from our collection were split by MLST into 74 types, suggesting a high level of genetic diversity. Analysis of MLST data using the eBURST algorithm revealed the existence of nine epidemic clonal lineages that were disseminated worldwide. One single clonal lineage (clonal complex 2) comprised 74% of the isolates, whereas the remaining isolates were clustered into 8 minor clonal lineages and 13 singletons. According to our evolutionary model, SCCmec was acquired at least 56 times by S. epidermidis. Although geographic dissemination of S. epidermidis strains and the value of the index of association between the alleles, 0.2898 (P < 0.05), support the clonality of S. epidermidis species, examination of the sequence changes at MLST loci during clonal diversification showed that recombination gives rise to new alleles approximately twice as frequently as point mutations. We suggest that S. epidermidis has a population with an epidemic structure, in which nine clones have emerged upon a recombining background and evolved quickly through frequent transfer of genetic mobile elements, including SCCmec.

Genetic diversity among methicillin-resistant Staphylococcus epidermidis (MRSE).

We selected 106 methicillin-resistant Staphylococcus epidermidis (MRSE) and 22 methicillin-susceptible S. epidermidis (MSSE) hospital isolates--each with a different PFGE pattern--for more detailed documentation of genetic diversity. The 106 MRSE isolates showed extensive variation in the SmaI DNA fragments hybridizing with the DNA probe for mecA, the molecular size of which varied from as low as 20 kb up to over 500 kb. Parallel variation was also observed in the size of DNA fragments hybridizing with the chromosomal genes orfX and gyrA, and this was also observed in MSSE isolates. In contrast, SmaI fragments associated with the housekeeping genes murE and aroE, both located distantly from orfX, showed little size variation. Typing for the mec complex and ccr identified 10 different SCCmec structures and a large number of strains (21 isolates) that were non-typeable. The majority of strains studied (36%) carried a SCCmec type IV-like structure, including strains with non-related PFGE profiles. On the other hand, closely related strains often carried different types of SCCmec. The findings indicate that the acquisition and/or loss of mobile genetic elements, including various structural types of SCCmec, may occur frequently in the vicinity of the orfX gene on the S. epidermidis chromosome.

Identification of coagulase-negative staphylococci other than Staphylococcus epidermidis by automated ribotyping.

As routine identification of coagulase-negative staphylococci is problematic, the performance of automated ribotyping was evaluated for identification of coagulase-negative staphylococci other than Staphylococcus epidermidis. In total, 177 isolates were tested, comprising 149 isolates from blood samples, 15 isolates that were not identified by internal transcribed spacer (ITS)-PCR in a previous study, and 13 reference strains. The identification results were compared with those obtained by the API 20 Staph system, with standard phenotypic and molecular methods as reference. Most (n = 166; 93.8%) isolates were identified correctly by automated ribotyping. For 61 isolates, API 20 Staph and ribotyping were in agreement, but for 105 isolates, ribotyping provided correct identification and API 20 Staph did not. Four isolates not identified by automated ribotyping were recognised correctly by API 20 Staph. The remaining seven isolates could not be identified by either of the two methods. Automated ribotyping was able to distinguish Staphylococcus capitis reliably from Staphylococcus caprae. The results demonstrate the value of automated ribotyping for identification of coagulase-negative Staphylococcus (CoNS) isolates from human sources and may help to clarify the clinical relevance of CoNS species. In addition, automated ribotyping was able to detect polymorphisms that may be useful for epidemiological purposes within S. capitis, Staphylococcus hominis, Staphylococcus haemolyticus, Staphylococcus simulans, S. caprae, Staphylococcus warneri, Staphylococcus lugdunensis, Staphylococcus schleiferi, Staphylococcus sciuri, Staphylococcus pasteuri and Staphylococcus xylosus.

Resultados de miringoplastia Inlay com cartilagem de tragus / Inlay tragus cartilage miringoplasty results

A utilização de cartilagem de tragus para o fechamento de perfurações de membrana timpânica (MT) com acesso transcanal foi primeiramente descrito por Eavey em 1998 com excelentes resultados quanto à pega do enxerto e vantagens como facilidade técnica, rapidez e conforto pós-operatório ao paciente. OBJETIVO: Avaliar os resultados da miringoplastia inlay com cartilagem de tragus em pacientes operados no serviço de Otorrinolaringologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo nos últimos três anos. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Foram utilizadas para esse estudo 32 cirurgias realizadas no serviço de Otorrinolaringologia do Hospital das Clínicas de Ribeirão Preto no período de 2000 a 2003 em pacientes com diagnóstico de otite média crônica simples com perfuração de membrana timpânica de até 5mm de diâmetro e sem contra-indicações para realização de procedimento transcanal. RESULTADOS: Foi observado fechamento completo das perfurações de MT em 28 cirurgias das 32 realizadas perfazendo 87,5 por cento de sucesso. DISCUSSÃO: O presente estudo manteve o alto índice de sucesso no fechamento de perfurações de MT com os princípios da técnica de Eavey descrito em estudos anteriores, mesmo com algumas modificações em relação à técnica original. CONCLUSÃO: A miringoplastia inlay com cartilagem de tragus em forma de asa de borboleta tem alto índice de sucesso no fechamento das perfurações de MT de até 5mm de diâmetro em casos de otite média crônica simples com orelha média saudável. Promove, ainda, maior conforto e menor morbidade ao paciente.

Identification of clinical staphylococcal isolates from humans by internal transcribed spacer PCR.

The emergence of coagulase-negative staphylococci not only as human pathogens but also as reservoirs of antibiotic resistance determinants requires the deployment and development of methods for their rapid and reliable identification. Internal transcribed spacer-PCR (ITS-PCR) was used to identify a collection of 617 clinical staphylococcal isolates. The amplicons were resolved in high-resolution agarose gels and visually compared with the patterns obtained for the control strains of 29 staphylococcal species. Of the 617 isolates studied, 592 (95.95%) were identified by ITS-PCR and included 11 species: 302 isolates of Staphylococcus epidermidis, 157 of S. haemolyticus, 79 of S. aureus, 21 of S. hominis, 14 of S. saprophyticus, 8 of S. warneri, 6 of S. simulans, 2 of S. lugdunensis, and 1 each of S. caprae, S. carnosus, and S. cohnii. All species analyzed had unique ITS-PCR patterns, although some were very similar, namely, the group S. saprophyticus, S. cohnii, S. gallinarum, S. xylosus, S. lentus, S. equorum, and S. chromogenes, the pair S. schleiferi and S. vitulus, and the pair S. piscifermentans and S. carnosus. Four species, S. aureus, S. caprae, S. haemolyticus, and S. lugdunensis, showed polymorphisms on their ITS-PCR patterns. ITS-PCR proved to be a valuable alternative for the identification of staphylococci, offering, within the same response time and at lower cost, higher reliability than the currently available commercial systems.

Low prevalence of methicillin-resistant strains among Staphylococcus aureus colonizing young and healthy members of the community in Portugal.

Recent reports suggest that methicillin-resistant Staphylococcus aureus (MRSA) may be emerging as a community pathogen. In Portuguese hospitals, the incidence of MRSA among disease causing isolates is extremely high (48-50%). To determine the prevalence of MRSA in the Portuguese community, nasal samples were obtained from 823 draftees, 484 nonmedical university students, and 107 high-school students. In addition, throat samples were obtained from the 823 draftees and S. aureus isolates were also recovered from 283 (13%) nasopharyngeal samples obtained from 2,111 children attending day-care centers. The rate of nasal colonization of S. aureus was 34%, 25%, and 46% for draftees, nonmedical university students, and high-school students, respectively. The rate of pharyngeal colonization of the draftees was 33%. Of the 1,001 S. aureus isolates obtained, seven were MRSA and eight were borderline oxacillin-resistant S. aureus (BORSA). By molecular typing techniques, five of the seven MRSA were identified as belonging to one of three highly epidemic clones, the Brazilian, Iberian, and Pediatric clones of MRSA, which were identified as endemic in Portuguese hospitals. The eight BORSA were all members of clones previously identified in international samples. In spite of the extremely high prevalence of MRSA in Portuguese hospitals, the carriage rate of MRSA in healthy and young individuals remains low.