Gonorrhea in a Tertiary Care Portuguese Hospital: A 10-year Retrospective Study of the Evolution of Cases and Drug Resistance of the Isolates. / Estudio retrospectivo acerca de la evolución y el desarrollo de resistencias antimicrobianas en casos diagnosticados de gonorrea en un hospital de nivel terciario en Portugal durante 10 años.

BACKGROUND: Sexually Transmitted Infections remain a major public health concern worldwide. Although traditionally considered treatable, the emergence of Neisseria gonorrhoeae resistance to antimicrobials is currently a serious problem. The goal of this study was to evaluate the incidence and trends of antimicrobial resistance over the last 10 years in N. gonorrhoeae isolates from a Portuguese Centre. METHODS: Laboratorial confirmed N. gonorrhoeae infections diagnosed between 2009 and 2018 were evaluated. Susceptibilities to penicillin, tetracycline, ciprofloxacin, azithromycin and cefotaxime were studied, along with demographic and clinical characteristics. RESULTS: From 2009 to 2018, 440 cases of N. gonorrhoeae infection were diagnosed in our center, with a significant yearly increase (p<0.05). Most cases occurred in males (97.9%), with a median age of 25 years. In 88.7% of the cases, treatment with ceftriaxone plus azithromycin was used. Resistances to penicillin, tetracycline and ciprofloxacin remained high throughout the study period. CONCLUSIONS: Antimicrobial resistance of N. gonorrhoeae appeared shortly after the introduction of antimicrobials. To combat this problem, improved surveillance and more studies combining susceptibility and epidemiological data are needed. In our population, N. gonorrhoeae remains highly susceptible to the antibiotics currently recommended for its treatment, whereas ciprofloxacin, azithromycin (in monotherapy) and penicillin should be avoided as empirical treatment.

Evolving epidemiology of carbapenemase-producing Enterobacteriaceae in Portugal: 2012 retrospective cohort at a tertiary hospital in Lisbon.

Despite great efforts to enhance European epidemiological surveillance on carbapenemase-producing Enterobacteriaceae (CPE), information from several countries remains scarce. To address CPE epidemiology in Portugal, we have undertaken a retrospective cohort study of adults with CPE cultures identified in the microbiology laboratory of a tertiary hospital, in 2012. Sixty patients from 25 wards or intensive care units were identified. This is, to the best of our knowledge, the first report of clinical data on CPE in Portugal. It shows a hospital-wide CPE dissemination and alerts us to an evolving epidemiological situation not previously described.

Epidemiological survey of the first case of vancomycin-resistant Staphylococcus aureus infection in Europe.

We report on the follow-up and epidemiological study triggered by the isolation of the first vancomycin-resistant Staphylococcus aureus (VRSA) detected in Europe. The patient and 53 close contacts were screened for S. aureus colonization and all isolates recovered were characterized by multiple molecular typing methods. The VRSA remained confined to the infected foot of the patient and was not detected in any of the close contacts. Nasal colonization with S. aureus was detected in 20 subjects, of whom 15 carried methicilin-susceptible isolates with the remaining five harbouring methicilin-resistant S. aureus (MRSA). The majority of the isolates belonged to clones that have been previously shown to be prevalent in Portugal, both in the hospital setting and in the community. Only one isolate, an MRSA, was closely related to the VRSA. Like most of the characterized VRSA isolates from other countries, the VRSA isolated in Portugal belonged to clonal complex (CC) 5. Despite the absence of VRSA dissemination, the recent increase in the incidence of lineages belonging to CC5 in some European countries, including Portugal, may result in more frequent opportunities for the emergence of VRSA.

Persistence of uropathogenic Escherichia coli strains in the host for long periods of time: relationship between phylogenetic groups and virulence factors.

Escherichia coli cause the majority of urinary tract infections (UTIs). Virulence plays an important role in the initial stages of interaction with the host, facilitating colonization of the urinary tract tissue. The purpose of this study was to assess whether there is a relationship between virulence and antibiotic resistance in the persistence of uropathogenic E. coli strains. This study included five patients with UTI between 2001 and 2009. The antibiotic resistance phenotype of 29 E. coli isolates was determined by the disk diffusion method. Clonal relationship was determined through M13 polymerase chain reaction (PCR) fingerprinting. Phylogeny, virulence factors, ß-lactamases, and replicon typing were studied through PCR. Antibiogram profiles were found from different patients and corresponded to CTX-M-2, CTX-M-15, CTX-M-32, and TEM-52 enzymes. Plasmids belonged essentially to incompatibility group IncF. No clonal relationship was observed among isolates from different patients, except for patients 4 and 5. Phylogenetic group A was predominant. Our work showed that commensal group A possesses the same virulence factors as the pathogenic groups B1 and D. E. coli common pilus and type 1 fimbriae could play an important role in the persistence in the host and in symptomatic UTI, respectively, which, combined with extended-spectrum ß-lactamases (ESBLs), are a cause of the dissemination of microorganisms in the hospital and the community.

Group A Streptococci from carriage and disease in Portugal: evolution of antimicrobial resistance and T antigenic types during 2000-2002.

In this study, we analyzed the antimicrobial resistance properties and T antigenic types of 511 isolates collected in Lisbon district, Portugal, from throat swabs of healthy subjects (n=341), during 2000-2002 and from diverse infection sites (n=170) of outpatients and inpatients, during 1999-2002. Erythromycin resistance was higher in tonsillitis/pharyngitis (27.4%) and skin infection isolates (21.1%), than in carriage and invasive isolates (

Growth of Mycobacterium tuberculosis in conventional BacT/ALERT FA blood culture bottles allows reliable diagnosis of Mycobacteremia.

The conventional BacT/ALERT FA blood cultures supported the ample growth of Mycobacterium tuberculosis in seeding experiments and appeared to perform as reliably as the BACTEC Myco/F-Lytic vials in the recovery of M. tuberculosis from blood in HIV-infected patients. Overall, blood cultures were positive in 39% of patients with tuberculosis.

Case of aortic endocarditis caused by Lactobacillus casei.

A case of Lactobacillus aortic valve endocarditis in a 53-year-old immunocompetent patient with past history of rheumatic fever is reported. Clinical symptoms began after a dental extraction and the patient's diet included several yogurts per day. Blood, bone marrow cultures and the replaced aortic valve were positive for Lactobacillus: The clinical isolate was identified as Lactobacillus casei by 16S rDNA sequencing.

Molecular characterization of a new class 3 integron in Klebsiella pneumoniae.

Klebsiella pneumoniae FFUL 22K was isolated in April 1999 from the urine of an intensive care unit patient in Portugal. The strain showed an extended-spectrum cephalosporin resistance profile. A typical synergistic effect between cefotaxime or cefepime and clavulanic acid was observed. An Escherichia coli transformant displayed a similar resistance phenotype and harbored a ca. 9.4-kb plasmid (p22K9). Cloning experiments revealed that the extended-spectrum beta-lactamase was encoded by bla(GES-1), previously described in class 1 integrons from K. pneumoniae ORI-1 and Pseudomonas aeruginosa Pa695. Further sequence analysis demonstrated that the bla(GES-1) gene cassette was located on a new class 3 integron. The integron was 2863 bp long and consisted of an intI3 integrase gene, an attI3 recombination site, two promoter regions, and two gene cassettes. The IntI3 integrase was 98.8% identical to that of Serratia marcescens AK9373. The bla(GES-1) gene cassette was inserted at the attI3 site. The second gene cassette was the result of a fusion event between bla(OXA-10)-type and aac(6')-Ib gene cassettes and conferred resistance to kanamycin. This is the second class 3 integron reported and the first time that the bla(GES-1) gene cassette has been found on an integron belonging to this class, highlighting the considerable heterogeneity of their genetic environment and the spread of gene cassettes among different classes of integrons.

Survey of Klebsiella pneumoniae producing extended-spectrum beta-lactamases at a Portuguese hospital: TEM-10 as the endemic enzyme.

One hundred and thirty-eight isolates of Klebsiella pneumoniae showing resistance to ceftazidime were isolated from different wards of the Hospital de Santa Maria, Lisbon. The genomic DNA of the isolates was analysed by pulsed-field gel electrophoresis (PFGE) and two patterns were predominant. In all isolates the presence of a single large plasmid of about 50 kb suggested that propagation of the outbreak prominently involved plasmid spread. The deduced amino acid sequence indicated the presence of a TEM-10 beta-lactamase. This extended-spectrum beta-lactamase was present among K. pneumoniae isolates, was widely disseminated in different wards and remained persistent as a result of an outbreak involving the dissemination of both the multi-resistance plasmids harbouring the bla gene and the isolates themselves.

Molecular typing and exopolysaccharide biosynthesis of Burkholderia cepacia isolates from a Portuguese cystic fibrosis center.

This work describes the first epidemiological survey of Burkholderia cepacia involved in pulmonary infections among the Portuguese population with cystic fibrosis (CF) who attended the major CF treatment Center in Lisbon at Sta. Maria Hospital from 1995 to the end of 1997. The characterization of the genomic relatedness of the isolates was based on the analysis of their ribopatterns (with EcoRI) followed by construction of a ribotype-based phylogenetic tree. This study was complemented with macrorestriction fragment analysis by pulsed-field gel electrophoresis. After optimization of the solid growth medium, we found that exopolysaccharide (EPS) production by B. cepacia CF isolates is not as rare a phenomenon as was thought before; indeed, 70% of the isolates examined were EPS producers.

[Nosocomial infection in a pediatric intensive care unit]. / Infecção nosocomial numa unidade de cuidados intensivos pediátricos.

UNLABELLED: Patients in intensive care units (ICU) are 3 to 4 times more prone to nosocomial infection (NI) than patients in general wards owing to the severity of their pathology and the frequent use of invasive procedures. The aim of this study was to establish the incidence of NI in an ICU and the associated risk factors. PATIENTS AND METHODS: During 18 months, all patients with severity scores III and IV (Clinical Classification System) were studied, (n = 575). The admissions were mainly due to accidents (24.7%), neurological (19.1%), surgical (17.2%), respiratory (11.1%) and infectious (7.0%) disease. The mean duration of stay was 2.4 days. The mortality was 5.2%. The evaluation protocol of these patients included determination of the PRISM score, registration of every invasive procedure and daily search for clinical and laboratory signs of infection. NI was defined according to the criteria of the Centers for Disease Control. Both the intrinsic and extrinsic risk factors were analysed and in the statistical analysis the null hypothesis was rejected at the significance level of p < 0.05. RESULTS: The incidence of NI was 7.6%. The infections occurred in the respiratory tract in 20 patients, bloodstream in 8, genito-urinary tract in 2, central nervous system in 2, skin in 2, gastrointestinal tract in 2, eyes in 1 and surgical wound in 1. There were isolates in 60.6%. The mean duration of stay was longer in patients with NI (9.8 versus 1.9). The factors most closely associated with NI were higher PRISM scores, malnutrition, immunodeficiency failure of 2 or more organs, administration of antibiotic since admission or corticosteroids and simultaneous use of 3 or more invasive procedures. The risk of pneumonia was significantly increased in patients with mechanical ventilation and all the patients with bacteremia had central venous catheters. The mortality was higher in the group with NI (18.2%) than in the group without NI (4.4%). CONCLUSIONS: The incidence of NI is acceptable in our ICU. The most frequent location was the respiratory tract (52.6%). The pathogens most frequently isolated in this ICU were Gram negative rods. The risk of NI increased in more debilitated patients with more severe disease who were administered antibiotic or corticosteroids and submitted to more invasive procedures.

[Multicenter study of isolated micro-organisms resistant to antimicrobials in 10 Portuguese hospitals in 1994]. / Estudo multicêntrico de microrganismos isolados e de resistência aos antimicrobianos em dez hospitais Portugueses em 1994.

In 1994, Microbiology Laboratories of ten Portuguese hospitals analysed isolated microorganisms found in blood and urine samples and studied antimicrobial susceptibilities of the most frequent bacterial pathogens. From 63780 blood samples, the most frequent were Staphylococcus spp. and from 69189 urine samples significant numbers of Escherichia coli, Enterococcus spp., Pseudomonas aeruginosa and Candida spp. were isolated. Escherichia coli strains (c.7000) revealed a low percentage of resistance to antibiotics with the exceptions of ampicillin (48%) and co-trimoxazol (25%). Klebsiella pneumoniae isolates (c.2000) revealed important resistance to ampicillin (98%), cephalotin (31%), co-trimoxazol (38%) and gentamicin (28%), while values for 3rd generation cephalosporins varied among hospitals, with several strains showing phenotype of extended-spectrum beta-lactamase. A great variation in resistance values of P. aeruginosa (c.4000) was found in relation to the antibiotics as well as to the hospitals. Resistance to methicillin in S. aureus (c.6000) was high, reaching an average of 47%, and it was even higher with S. epidermidis (c.3000) and S. haemolyticus (c.650). Only vancomycin was always active against these strains. In E. faecalis (c.2500) resistance was of 2% to ampicillin, 35% to gentamicin, 45% to streptomycin and 1% to vancomycin. E. faecium isolates (c.300) showed the most worrying results with 70% resistance to ampicillin, 42% to gentamicin, 59% to streptomycin and 9% (30 strains isolated in 5 hospitals) to vancomycin. Vancomycin resistant strains were also resistant to all other antibiotics.

[A case of Legionella pneumophila pneumonia]. / Um caso de pneumonia por Legionella pneumophila.

Legionella pneumophila is an uncommon cause of pneumonia, mainly in children. We present a case with aggressive disease and unfavourable outcome. The diagnosis was established by serum antibody detection and immunofluorescence and culture of a fragment of lung tissue obtained at necropsy. We focus the importance of this aetiology in nosocomial pneumonia and community-acquired pneumonia with an atypical evolution. The need for specific therapy and some preventive measures are also stressed.

[The microbiological profile of nosocomial infection in a respiratory intensive care unit]. / Perfil microbiológico da infecção nosocomial numa unidade de cuidados intensivos respiratórios.

In 1987, in the Respiratory Intensive Care Unit of Santa Maria Hospital we developed a nosocomial surveillance program with specially created software that provides knowledge of NI in the ICU at any moment. The information gathered along the time is particularly useful in the correlation of the risk factors, the most frequent microorganisms and in the institution of empiric antibiotic therapy. Out of 2528 patients admitted in our ICU for the last 6 years (87/92), 10% had bacteriologically identified NI. Almost (93%) of them had occurred in mechanically ventilated patients, which corresponds to 20.7% NI in those patients. The gram-negative appeared in 63.37%, with the predominance of Enterobacteriaceae. From the gram-positives the most frequent were Staphylococcus spp. Their meticiline resistance was worrisome. NI patients had significantly higher severity and therapeutic intervention scores. Mechanical ventilation period was 4 fold higher and mortality 2.5 times higher in the patients with this complication.