Prevalence of blaKPC-2, blaKPC-3 and blaKPC-30-Carrying Plasmids in Klebsiella pneumoniae Isolated in a Brazilian Hospital.

Klebsiella pneumoniae carbapenemase (KPC) actively hydrolyzes carbapenems, antibiotics often used a last-line treatment for multidrug-resistant bacteria. KPC clinical relevance resides in its widespread dissemination. In this work, we report the genomic context of KPC coding genes blaKPC-2, blaKPC-3 and blaKPC-30 in multidrug-resistant Klebsiellapneumoniae isolates from Brazil. Plasmids harboring blaKPC-3 and blaKPC-30 were identified. Fifteen additional carbapenem-resistant K. pneumoniae isolates were selected from the same tertiary hospital, collected over a period of 8 years. Their genomes were sequenced in order to evaluate the prevalence and dissemination of blaKPC-harboring plasmids. We found that blaKPC genes were mostly carried by one of two isoforms of transposon Tn4401 (Tn4401a or Tn4401b) that were predominantly located on plasmids highly similar to the previously described plasmid pKPC_FCF3SP (IncN). The identified pKPC_FCF3SP-like plasmids carried either blaKPC-2 or blaKPC-30. Two K. pneumoniae isolates harbored pKpQIL-like (IncFII) plasmids, only recently identified in Brazil; one of them harbored blaKPC-3 in a Tn4401a transposon. Underlining the risk of horizontal spread of KPC coding genes, this study reports the prevalence of blaKPC-2 and the recent spread of blaKPC-3, and blaKPC-30, in association with different isoforms of Tn4401, together with high synteny of plasmid backbones among isolates studied here and in comparison with previous reports.

Clinical Applications of Point-of-Care Testing in Different Conditions.

BACKGROUND: The use of point-of-care testing (POCT) in different clinical applications is justified by the fact that the time to release the result is shortened, allowing the physician to define the diagnosis and most appropriate therapy in a shorter time. However, the negative aspects must also be highlighted and studied so that we can move forward with the use of these devices. These negative aspects include greater analytical imprecision compared to laboratory automation, the variability between different equipment from different manufacturers, the risk of inappropriate use, a low level of global regulation, higher costs compared with laboratory testing and cost ineffectiveness in terms of health care. Methods and. RESULTS: This review presents some clinical applications of POCT in different scenarios, such as for diabetes mellitus, infectious diseases, pediatrics, and chronic kidney disease, among others. CONCLUSIONS: We hope to see a global consensus on an acceptable quality standard for performing POCT that is adaptable, practical, and cost effective in primary care settings, ensuring patient safety, and minimizing the risk of harm.

Point-of-Care Testing: General Aspects.

Point-of-Care Testing (POCT) has been highlighted in the health care sector in recent decades. On the other hand, due to its low demand, POCT is at a disadvantage compared to conventional equipment, since its cost is inversely proportional to the volume of use. In addition, for the implementation of POCT to succeed, it is essential to rely on the work of a multidisciplinary team. The awareness of health professionals of the importance of each step is perhaps the critical success factor. The trend towards the continuous advancement of the use of POCT and the great potential of its contributions reinforce the need to implement quality management tools, including performance indicators, to ensure their results. This review presents some advantages and disadvantages concerning POCT and the real need to use it. A worldwide call for the availability of easy-to-use health technologies that are increasingly closer to the final user is one of the main reasons for this focus.

Subclinical Propionibacterium acnes infection estimation in the intervertebral disc (SPInE-ID): protocol for a prospective cohort.

INTRODUCTION: Low back pain and vertebral endplate abnormalities are common conditions within the population. Subclinical infection caused by indolent pathogens can potentially lead to these findings, with differentiation between them notably challenging from a clinical perspective. Progressive infection of the intervertebral disc has been extensively associated with increasing low back pain, with Propionibacterium acnes specifically implicated with in relation to sciatica. The main purpose of this study is to identify if the presence of an infective pathogen within the intervertebral disc is primary or is a result of intraoperative contamination, and whether this correlates to low back pain. METHODS AND ANALYSIS: An open prospective cohort study will be performed. Subjects included within the study will be between the ages of 18 and 65 years and have a diagnosis of lumbar disc herniation requiring open decompression surgery. Excised herniated disc fragments, muscle and ligamentum flavum samples will be collected during surgery and sent to microbiology for tissue culture and pathogen identification. Score questionnaires for pain, functionality and quality of life will be given preoperatively and at 1, 3, 6 and 12 months postoperatively. A MRI will be performed 12 months after surgery for analysis of Modic changes and baseline comparison. The primary endpoint is the rate of disc infection in patients with symptomatic degenerative disc disease. The secondary endpoints will be performance scores, Modic incidence and volume. ETHICS AND DISSEMINATION: This study was approved by our Institutional Review Board and was only initiated after it (CAAE 65102617.2.0000.0071). Patients agreeing to participate will sign an informed consent form before entering the study. Results will be published in a peer reviewed medical journal irrespective of study findings. If shown to be the case, this would have profound effects on the way physicians treat chronic low back pain, even impacting health costs. TRIALS REGISTRATION NUMBER: NCT0315876; Pre-results.

Triazole Resistance Is Still Not Emerging in Aspergillus fumigatus Isolates Causing Invasive Aspergillosis in Brazilian Patients.

Aspergillus fumigatus azole resistance has emerged as a global health problem. We evaluated the in vitro antifungal susceptibility of 221 clinical A. fumigatus isolates according to CLSI guidelines. Sixty-one isolates exhibiting MICs at the epidemiological cutoff value (ECV) for itraconazole or above the ECV for any triazole were checked for CYP51A mutations. No mutations were documented, even for the isolates (1.8%) with high voriconazole MICs, indicating that triazoles may be used safely to treat aspergillosis in Brazil.

The changing epidemiology of Acinetobacter spp. producing OXA carbapenemases causing bloodstream infections in Brazil: a BrasNet report.

We evaluated the epidemiology of Acinetobacter spp. recovered from patients diagnosed with bloodstream infections in 9 tertiary hospitals located in all Brazilian geographic regions between April and August 2014. Although OXA-23-producing Acinetobacter baumannii clones were disseminated in most hospitals, it was observed for the first time the spread of OXA-72 among clonally related A. baumannii isolated from distinct hospitals. Interestingly, Acinetobacter pittii was the most frequent species found in a Northern region hospital. Contrasting with the multisusceptible profile displayed by A. pittii isolates, the tetracyclines and polymyxins were the only antimicrobials active against all A. baumannii isolates.

Accuracy of a vancomycin brain heart infusion screening plate for the screening of Staphylococcus aureus isolates with increased vancomycin minimum inhibitory concentrations.

Vancomycin susceptibility was determined in 125 S. aureus isolates by disk diffusion, microdilution, Etest and vancomycin brain heart infusion (BHI) plate. A 2.0 mg/L vancomycin BHI was highly sensitive (100% and 91% compared to Etest and microdilution) for detecting a MIC≥2 mg/L, and could be used as a simple and affordable screening test.

Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock--a quality improvement study.

BACKGROUND: There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes. MATERIAL: This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock. RESULTS: A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023). CONCLUSIONS: The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.

Bacteremia possibly caused by Curtobacterium spp found in a blood culture from a central venous line of a pediatric leukemia patient who underwent bone marrow transplantation: [letter to editor] / Bacteremia possivelmente causada por Curtobacterium spp encontrado na cultura do sangue de um cateter venoso num paciente pediátrico submetido a transplante de medula óssea: [carta ao editor]

Microbiologistas clínicos devem estar atentos à possibilidade debacteremia relacionada com cateter causada por infecçãodifteróide, como possivelmente foi o caso neste relato, no qual um menino de dois anos, portador de um cateter venoso central paratratamento de leucemia, apresentou pneumonia. A cultura dosangue obtido no cateter revelou Curtobacterium spp.

Avaliação de quatro kits comerciais para detecção rápida de antígenos de Rotavírus em amostras de fezes / Four kits evaluation for Rotavirus rapid antigen detection in stool samples

O Rotavírus é um dos principais agentes causadores de diarréia, sendo desejável o diagnóstico laboratorial de maior rapidez e acurácia para evitar a complicação por essa infecção. Nesse estudo, foram comparados os resultados obtidos por 4 diferentes kits comerciais para pesquisa de antígenos de rotavírus em 42 amostras de fezes: dois kits com metodologia de aglutinação em látexe dois kits de detecção combinada de Rotavírus e Adenovírus por imunocromatografia. A concordância entre os kits testados foi de 88%, sendo 16 amostras positivas e 21 negativas em todos os testes. Nas cinco amostras com resultados discordantes apenas um kit obteve resultado diferente dos demais, sendo estes, repetidos por outro executor. Essa repetição demonstrou interpretação diferenteem duas amostras por um dos testes de aglutinação de látex. As taxas de detecção pelos kits imunocormatográficos foi de 66% (18/42) e para os kits de aglutinação de látex foi de 38-40% (16 e 17/42). Os kits imunocromatográficos demonstraram total concordância coma maioria dos demais kits testados. Conclui-se que, apesar da boa concordância entre os kits avaliados, algumas metodologias podem apresentar problemas na aplicação prática, principalmente com a interpretação da aglutinação de látex.

A total of 42 stool specimens were tested for the presence of antigen rotavirus by two distinct enzyme immunoassays (EIA) and two latex agglutination tests (LAT). Overall concordance was 88%, with 16 positive and 21 negative results by all tests. Discordant results occurred when one test differed from the others and was repeated by other technician. These procedures change the interpretation of latex agglutination. Detection rate for two immunocromatographic tests were 66% (18/42) and two latex agglutination tests were 40% and 38% (17 and 16/42). The results show that each of the commercial assays evaluated could accurately detect rotavirus in the stools specimens. Comparative results demonstrate that sensitivity of latex agglutination tests was lower than immunocromatographic tests. In conclusion, those rapid tests could be detect differently antigen rotavirus, the latex agglutination methodology could be difficult interpretation and immunochromatographic technique do not require specialized equipment, showed higher sensitivity and was rapid and easy to perform in the routine clinical laboratory.

Risk factors for nosocomial bloodstream infection caused by multidrug resistant gram-negative bacilli in pediatrics.

The aim of this study was to identify the risk factors for nosocomial bloodstream infections by multidrug resistant Gram-negative bacilli. From November 2001 to December 2003, in the Pediatric Department of the Santa Casa de São Paulo, a retrospective case-control study was developed concerning patients who had nosocomial bloodstream infection caused by Gram-negative bacilli. Patients with multidrug resistant infections were designated as case patients, and control patients were those with an infection that did not meet the criteria for multidrug resistance. Previous use of central venous catheter and previous use of vancomycin plus third generation cephalosporins were associated to a higher chance of infections by multidrug resistant Gram-negative bacilli (Odds ratio--5.8 and 5.2, respectively). Regarding sensitivity of the isolated agents, 47.8% were multidrug resistant, 54.2% were Klebsiella spp. ESBL producers and 36.4% were imipenem resistant Pseudomonas aeruginosa. The lethality rate was 36.9% in the studied cases and this rate was significantly higher in the group of patients with multidrug resistant infections (p=0.013). Risk factor identification as well as the knowledge of the susceptibility of the nosocomial infectious agents gave us the possibility to perform preventive and control strategies to reduce the costs and mortality related to these infections.

Risk factors for nosocomial bloodstream infection caused by multidrug resistant gram-negative bacilli in pediatrics

The aim of this study was to identify the risk factors for nosocomial bloodstream infections by multidrug resistant Gram-negative bacilli. From November 2001 to December 2003, in the Pediatric Department of the Santa Casa de São Paulo, a retrospective case-control study was developed concerning patients who had nosocomial bloodstream infection caused by Gram-negative bacilli. Patients with multidrug resistant infections were designated as case patients, and control patients were those with an infection that did not meet the criteria for multidrug resistance. Previous use of central venous catheter and previous use of vancomycin plus third generation cephalosporins were associated to a higher chance of infections by multidrug resistant Gram-negative bacilli (Odds ratio - 5.8 and 5.2, respectively). Regarding sensitivity of the isolated agents, 47.8 percent were multidrug resistant, 54.2 percent were Klebsiella spp. ESBL producers and 36.4 percent were imipenem resistant Pseudomonas aeruginosa. The lethality rate was 36.9 percent in the studied cases and this rate was significantly higher in the group of patients with multidrug resistant infections (p=0.013). Risk factor identification as well as the knowledge of the susceptibility of the nosocomial infectious agents gave us the possibility to perform preventive and control strategies to reduce the costs and mortality related to these infections.

Métodos bacteriológicos de triagem em infecçöes do trato urinário na infäncia e adolescência / Bacteriological methods for screening urinary tract infections during chilhood and adolescence

A cultura quantitativa da urina é considerada o exame laboratorial "padräo-ouro" para o diagnóstico da infecçäo no trato urinário (ITU). O objetivo deste trabalho foi avaliar: a correlaçäo da urocultura quantitativa realizada por métodos clássicos com o uso do laminocultivo; o desempenho dos métodos de triagem em relaçäo à cultura; e a evidência de indicaçäo de algum dos métodos de triagem citados anteriormente, para diagnóstico de ITU.(au)

High frequency of colonization and absence of identifiable risk factors for methicillin-resistant Staphylococcus aures (MRSA) in Intensive Care Units in Brazil

Colonization of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) is of increasing concern. To evaluate this problem in Intensive Care Units (ICUs) in Brazil, we studied 100 patients admitted to two ICUs from april to june, 1997. Of the 100 patients, 70 were male, 53 were age 60 years or older, 55 were previously hospitalized, 78 were transferred to the ICU from other hospital units, 49 had received antibiotic therapy, and 66 had undergone recent surgery. Nasal and axillary swab cultures were obtained on admission and every 48 hours thereafter until discharge. MRSA were identified by plating any cultured S. aureus on Mueller-Hinton agar containing 6µg/ml of oxacillin. At the time of admission, 46 (46 percent) of the patients were colonized with MRSA. No associated risk factors for acquiring MRSA (age, previous hospitalization, prior surgery) could be identified. Of the 54 patients negative for MRSA on admission, 28 (52 percent) became colonized while in the ICU. Sixteen (22 percent) of the 74 colonized patients (colonized either on admission or during ICU stay) had associated respiratory or urinary tract infections due to MRSA, and 9 (56 percent) died. No correlation with special risk factors (invasive procedures, antibiotic use, age, chronic disease) was identified. MRSA occurred frequently, but there was minimal evidence of associated risk factors. Thus, control of MRSA cannot be accomlished by targeting special factors alone, but requires attention to preventing microbial spread in all areas. Of special concern is the high frequency of acquiring the organism in the ICU (52 percent). Education concerning the importance of hand washing, environmental surface cleaning, and barrier protection from infected patients is needed.

Estudo bacteriológico da secreçäo de orelha média em crianças com otite média secretora crônica / Bacteriological study of middle ear secretion in children with cronical otitis media

Foram submetidos a exame bacteriológico 51 aspirados de secreçäo de orelha média obtidos de 29 crianças com idade entre 1 ano e 8 meses e 12 anos, com diagnóstico de otite média secretora crônica rebelde ao tratamento clínico. Obteve-se crescimento bacteriano em 23,5 por cento das culturas, com predominância do Staphilococcus aureus (41,7 por cento), seguido pelo Streptococcus pneumoniae (16,7 por cento), Haemophilus influenzae (8,3 por cento) e Pseudomonas aeruginosa (8,3 por cento). Näo houve crescimento de bactérias anaeróbias