[Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and MexicoAnálise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México]. / Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México.

Objective: To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods: An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results: The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions: The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

Objetivo: Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos: Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados: Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões: Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso considerar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México

[RESUMEN]. Objetivo. Contrastar las características del proceso de acreditación de establecimientos de salud en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México, con el fin de identificar elementos comunes y diferencias, y las lecciones aprendidas que puedan ser de utilidad para otros países y regiones. Métodos. Estudio observacional, analítico y retrospectivo en el que se usaron fuentes secundarias de libre acceso sobre acreditación y certificación de establecimientos de salud durante el período 2019-2021 en estos países y regiones. Se describen las características generales del proceso de acreditación y sus res- puestas a puntos clave del diseño de estos programas. Además, se generaron categorías de análisis para el avance en su implementación y su nivel de complejidad, y se resumen los resultados favorables y desfavorables informados. Resultados. Los componentes operativos del proceso de acreditación son peculiares de cada país, aunque comparten similitudes. El programa de Canadá es el único que contempla algún tipo de evaluación responsiva. Hay una amplia variación en la cobertura de establecimientos acreditados entre países (desde 1% en México a 34,7% en Dinamarca). Entre las lecciones aprendidas, se destacan la complejidad de aplicación del sistema mixto público-privado (Chile), el riesgo de una excesiva burocratización (Dinamarca) y la necesidad de incentivos claros (México). Conclusiones. Los programas de acreditación operan de forma peculiar en cada país o región, logran alcances diferentes y presentan problemáticas también diversas, de las que podemos aprender. Es necesario considerar los elementos que obstaculizan la implementación y generar adecuaciones para los sistemas de salud en cada país o región.

[ABSTRACT]. Objective. To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods. An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019–2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results. The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions. The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

[RESUMO]. Objetivo. Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos. Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados. Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões. Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso conside- rar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Gram-negative ESKAPE bacteria bloodstream infections in patients during the COVID-19 pandemic.

Bloodstream infections due to bacteria are a highly consequential nosocomial occurrences and the organisms responsible for them are usually multidrug-resistant. The aims of this study were to describe the incidence of bacteremia caused by Gram-negative ESKAPE bacilli during the COVID-19 pandemic and characterize the clinical and microbiological findings including antimicrobial resistance. A total of 115 Gram-negative ESKAPE isolates were collected from patients with nosocomial bacteremia (18% of the total bacteremias) in a tertiary care center in Mexico City from February 2020 to January 2021. These isolates were more frequently derived from the Respiratory Diseases Ward (27), followed by the Neurosurgery (12), Intensive Care Unit (11), Internal Medicine (11), and Infectious Diseases Unit (7). The most frequently isolated bacteria were Acinetobacter baumannii (34%), followed by Klebsiella pneumoniae (28%), Pseudomonas aeruginosa (23%) and Enterobacter spp (16%). A. baumannii showed the highest levels of multidrug-resistance (100%), followed by K. pneumoniae (87%), Enterobacter spp (34%) and P. aeruginosa (20%). The bla CTX-M-15 and bla TEM-1 genes were identified in all beta-lactam-resistant K. pneumoniae (27), while bla TEM-1 was found in 84.6% (33/39) of A. baumannii isolates. The carbapenemase gene bla OXA-398 was predominant among carbapenem-resistant A. baumannii (74%, 29/39) and bla OXA-24was detected in four isolates. One P. aeruginosa isolate was bla VIM-2 gene carrier, while two K. pneumoniae and one Enterobacter spp were bla NDM gene carriers. Among colistin-resistant isolates mcr-1 gene was not detected. Clonal diversity was observed in K. pneumoniae, P. aeruginosa and Enterobacter spp. Two outbreaks caused by A. baumannii ST208 and ST369 were detected, both belonging to the clonal complex CC92 and IC2. A. baumannii was associated with a death rate of 72% (28/32), most of them (86%, 24/28) extensively drug-resistant or pandrug-resistant isolates, mainly in patients with COVID-19 (86%, 24/28) in the Respiratory Diseases Ward. A. baumannii isolates had a higher mortality rate (72%), which was higher in patients with COVID-19. There was no statistically significant association between the multidrug-resistant profile in Gram-negative ESKAPE bacilli and COVID-19 disease. The results point to the important role of multidrug-resistant Gram-negative ESKAPE bacteria causing bacteremia in nosocomial settings before and during the COVID-19 epidemic. Additionally, we were unable to identify a local impact of the COVID-19 pandemic on antimicrobial resistance rates, at least in the short term.

Burkholderia vietnamiensis causing infections in noncystic fibrosis patients in a tertiary care hospital in Mexico.

Burkholderia cepacia complex (Bcc) species are opportunistic pathogens widely distributed in the environment and often infect people with cystic fibrosis (CF). This study aims to determine which genomovars of the Bcc can cause infections in non-CF patients from a tertiary care hospital in Mexico and if they carry virulence factors that could increase their pathogenicity. We identified 23 clinical isolates that carry the recA gene. Twenty-two of them belongs to the genomovar V (B. vietnamiensis) and one to the genomovar II (B. multivorans). Thirteen pulsotypes were identified among 22 B. vietnamiensis isolates. All clinical isolates produced biofilm were motile and cytotoxic on murine macrophage-like RAW264.7 and in A549 human lung epithelial cells. In conclusion, B. vietnamiensis causes infections in non-CF patients in a tertiary care hospital in Mexico, rapid identification of this pathogen can help physicians to establish a better antimicrobial treatment.

Pandrug-resistant Acinetobacter baumannii from different clones and regions in Mexico have a similar plasmid carrying the blaOXA-72 gene.

Background: Multidrug-resistant Acinetobacter baumannii is a common hospital-acquired pathogen. The increase in antibiotic resistance is commonly due to the acquisition of mobile genetic elements carrying antibiotic resistance genes. To comprehend this, we analyzed the resistome and virulome of Mexican A. baumannii multidrug-resistant isolates. Methods: Six clinical strains of A. baumannii from three Mexican hospitals were sequenced using the Illumina platform, the genomes were assembled with SPAdes and annotated with Prokka. Plasmid SPAdes and MobRecon were used to identify the potential plasmid sequences. Sequence Type (ST) assignation under the MLST Oxford scheme was performed using the PubMLST database. Homologous gene search for known virulent factors was performed using the virulence factor database VFDB and an in silico prediction of the resistome was conducted via the ResFinder databases. Results: The six strains studied belong to different STs and clonal complexes (CC): two strains were ST208 and one was ST369; these two STs belong to the same lineage CC92, which is part of the international clone (IC) 2. Another two strains were ST758 and one was ST1054, both STs belonging to the same lineage CC636, which is within IC5. The resistome analysis of the six strains identified between 7 to 14 antibiotic resistance genes to different families of drugs, including beta-lactams, aminoglycosides, fluoroquinolones and carbapenems. We detected between 1 to 4 plasmids per strain with sizes from 1,800 bp to 111,044 bp. Two strains from hospitals in Mexico City and Guadalajara had a plasmid each of 10,012 bp pAba78r and pAba79f, respectively, which contained the bla OXA-72 gene. The structure of this plasmid showed the same 13 genes in both strains, but 4 of them were inverted in one of the strains. Finally, the six strains contain 49 identical virulence genes related to immune response evasion, quorum-sensing, and secretion systems, among others. Conclusion: Resistance to carbapenems due to pAba78r and pAba79f plasmids in Aba pandrug-resistant strains from different geographic areas of Mexico and different clones was detected. Our results provide further evidence that plasmids are highly relevant for the horizontal transfer of antibiotic resistance genes between different clones of A. baumannii.

Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México / Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and Mexico / Análise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México

RESUMEN Objetivo. Contrastar las características del proceso de acreditación de establecimientos de salud en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México, con el fin de identificar elementos comunes y diferencias, y las lecciones aprendidas que puedan ser de utilidad para otros países y regiones. Métodos. Estudio observacional, analítico y retrospectivo en el que se usaron fuentes secundarias de libre acceso sobre acreditación y certificación de establecimientos de salud durante el período 2019-2021 en estos países y regiones. Se describen las características generales del proceso de acreditación y sus respuestas a puntos clave del diseño de estos programas. Además, se generaron categorías de análisis para el avance en su implementación y su nivel de complejidad, y se resumen los resultados favorables y desfavorables informados. Resultados. Los componentes operativos del proceso de acreditación son peculiares de cada país, aunque comparten similitudes. El programa de Canadá es el único que contempla algún tipo de evaluación responsiva. Hay una amplia variación en la cobertura de establecimientos acreditados entre países (desde 1% en México a 34,7% en Dinamarca). Entre las lecciones aprendidas, se destacan la complejidad de aplicación del sistema mixto público-privado (Chile), el riesgo de una excesiva burocratización (Dinamarca) y la necesidad de incentivos claros (México). Conclusiones. Los programas de acreditación operan de forma peculiar en cada país o región, logran alcances diferentes y presentan problemáticas también diversas, de las que podemos aprender. Es necesario considerar los elementos que obstaculizan la implementación y generar adecuaciones para los sistemas de salud en cada país o región.

ABSTRACT Objective. To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods. An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results. The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions. The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

RESUMO Objetivo. Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos. Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados. Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões. Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso considerar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Significance of Molecular Identification of Genomic Variants of Pseudomonas aeruginosa in Children with Cystic Fibrosis.

Pseudomonas aeruginosa is a significant cause of lung infections in patients with cystic fibrosis (CF). Pseudomonas produces a chronic infection that increases the morbidity and mortality in affected individuals. The rapid identification of Pseudomonas in these individuals enables conventional antimicrobial treatment to be started. However, over the years, treatment of P. aeruginosa has become problematic and very challenging due to their intrinsic and acquired antibiotic resistance. Microbiology plays an essential role in determining the antimicrobial susceptibility/resistance profiles of isolated strains, helping to optimize antimicrobial treatment for affected patients. In addition to the conventional susceptibility analysis, whole genome sequencing has emerged as a powerful tool for determining specific genomic variants, both in specific geographic areas and globally. Thus, molecular epidemiologic surveillance could help to establish a better treatment strategy and counter the spread of high-risk, P. aeruginosa variants among CF individuals.

SARS-CoV-2: Evolution and Emergence of New Viral Variants.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiological agent responsible for the coronavirus disease 2019 (COVID-19). The high rate of mutation of this virus is associated with a quick emergence of new viral variants that have been rapidly spreading worldwide. Several mutations have been documented in the receptor-binding domain (RBD) of the viral spike protein that increases the interaction between SARS-CoV-2 and its cellular receptor, the angiotensin-converting enzyme 2 (ACE2). Mutations in the spike can increase the viral spread rate, disease severity, and the ability of the virus to evade either the immune protective responses, monoclonal antibody treatments, or the efficacy of current licensed vaccines. This review aimed to highlight the functional virus classification used by the World Health Organization (WHO), Phylogenetic Assignment of Named Global Outbreak (PANGO), Global Initiative on Sharing All Influenza Data (GISAID), and Nextstrain, an open-source project to harness the scientific and public health potential of pathogen genome data, the chronological emergence of viral variants of concern (VOCs) and variants of interest (VOIs), the major findings related to the rate of spread, and the mutations in the spike protein that are involved in the evasion of the host immune responses elicited by prior SARS-CoV-2 infections and by the protection induced by vaccination.

Bacterial Subversion of Autophagy in Cystic Fibrosis.

Cystic fibrosis (CF) is a genetic disease affecting more than 70,000 people worldwide. It is caused by a mutation in the cftr gene, a chloride ion transporter localized in the plasma membrane of lung epithelial cells and other organs. The loss of CFTR function alters chloride, bicarbonate, and water transport through the plasma membrane, promoting the production of a thick and sticky mucus in which bacteria including Pseudomonas aeruginosa and Burkholderia cenocepacia can produce chronic infections that eventually decrease the lung function and increase the risk of mortality. Autophagy is a well-conserved lysosomal degradation pathway that mediates pathogen clearance and plays an important role in the control of bacterial infections. In this mini-review, we describe the principal strategies used by P. aeruginosa and B. cenocepacia to survive and avoid microbicidal mechanisms within the autophagic pathway leading to the establishment of chronic inflammatory immune responses that gradually compromise the lung function and the life of CF patients.

Compendio Nacional de Insumos para la Salud: equidad y acceso universal / National Compendium of Health Commodities: equity and universal access

Resumen: México fue pionero en establecer catálogos para identificar y hacer asequibles insumos médicos para la atención de su población, incluyendo medicamentos, instrumental, equipos y material de curación. Hace medio siglo, en 1971, surgió en el Instituto Mexicano del Seguro Social la iniciativa del llamado Cuadro Básico, que se constituyó como una herramienta fundamental para el funcionamiento de las instituciones públicas de salud, con la cual se establecieron listados de insumos con probada eficacia y seguridad, con claves administrativas asignadas que permitieron su adquisición ordenada. En 2020 se llevó a cabo la transición del Cuadro Básico y Catálogo al Compendio Nacional de Insumos para la Salud, el cual recuperó el espíritu original de sus creadores como un documento vivo y en constante evolución, respaldado por una metodología rigurosa para la revisión de los insumos que se incluyen, basada en la evaluación de su efectividad, seguridad y calidad, y en criterios farmacoeconómicos y consensos interinstitucionales.

Abstract: Mexico pioneered the creation of catalogs for identification and access of the medical commodities necessary for public healthcare, including medicines, medical equipment and wound dressing supplies. Fifty years ago, in 1971, the Instituto Mexicano del Seguro Social started the initiative of the Basic Scheme (Cuadro básico), that became a fundamental tool for provision of healthcare in the public institutions through the establishment of listings of medical supplies with proved safety and efficacy, assigning administrative codes that allowed an orderly acquisition. On 2020, the Basic Scheme and Catalog underwent a transition towards the National Compendium of Health Commodities (Compendio Nacional de Insumos para la Salud), recovering the original spirit of their creators as a live document in constant evolution, supported by a rigorous methodology for the assessment of the medical commodities included, based on evaluations of effectiveness, safety and quality, pharmacoeconomic criteria and interinstitutional consensus.

Emergence of GES-19-producing Pseudomonas aeruginosa exoU+ belonging to the global high-risk clone ST235 in cystic fibrosis infection.

The emergence of high-risk clones of priority pathogens exhibiting convergence of antimicrobial resistance and virulence is a critical issue worldwide. In a previous study, an extensively drug-resistant Pseudomonas aeruginosa was isolated from a chronically colonized pediatric patient with cystic fibrosis (CF). In this study, we analyzed genomic data of this strain (CF023-Psa42), extracting clinically and epidemiologically relevant information (i.e., the antimicrobial resistome, virulome, and sequence type). In this regard, we report the emergence of GES-19 (extended-spectrum ß-lactamase)-producing P. aeruginosa with genotype exoU+. The CF023-Psa42 strain exhibited a broad resistome, belonging to the international high-risk clone sequence type ST235. The blaGES-19 gene was located on a class 1 integron, along to aac(6')-33, aac(6')-Ib-cr, blaOXA-2, aadA1, sul1, and qacEΔ1 resistance genes. Relevant virulence genes such as lasA (proteolysis and elastolysis), toxA (exotoxin A), alg (alginate biosynthesis operon), and exoU (toxin of type III secretion systems) were predicted. Our findings reveal the convergence of broad resistome and virulome in P. aeruginosa ST235. Genomic surveillance is essential to monitor the emergence and dissemination of priority pathogens with epidemiological success.

Dissemination of bla NDM- 1 Gene Among Several Klebsiella pneumoniae Sequence Types in Mexico Associated With Horizontal Transfer Mediated by IncF-Like Plasmids.

Nosocomial infections caused by multidrug-resistant (MDR) Klebsiella pneumoniae are a major health problem worldwide. The aim of this study was to describe NDM-1-producing K. pneumoniae strains causing bacteremia in a tertiary referral hospital in Mexico. MDR K. pneumoniae isolates were screened by polymerase chain reaction for the presence of resistance genes. In resistant isolates, plasmids were identified and conjugation assays were performed. Clonal diversity and the sequence types were determined by pulsed-field gel electrophoresis and multilocus sequence typing. A total of 80 K. pneumoniae isolates were collected from patients with bacteremia over a 1-year period. These isolates showed a level of resistance of 59% (47/80) to aztreonam, 56-60% (45-48/80) to cephalosporins, 54% (43/80) to colistin and 12.5% (10/80) to carbapenems. The carbapenem resistant isolates were bla NDM- 1 carriers and negative for bla KPC, bla NDM, bla IMP, bla VIM and bla OXA- 48 -like carbapenemases genes. Conjugative plasmids IncFIIA and IncF group with sizes of 82-195 kbp were carriers of bla NDM- 1, bla CTX-M- 15, bla TEM- 1, aac(6')-Ib and/or aac(3')-IIa. Clonal variability and nine different multilocus sequence types were detected (ST661, ST683, ST1395, ST2706, ST252, ST1198, ST690, ST1535, and ST3368) for the first time in the isolates carrying bla NDM- 1 in Mexico. This study demonstrates that bla NDM- 1 has remained within this hospital in recent years and suggests that it is currently the most prevalent carbapenemase among K. pneumoniae MDR strains causing bacteremia in Mexico. The horizontal transfer of bla NDM- 1 gene through IncF-like plasmids among different clones demonstrates the dissemination pathway of antimicrobial resistance and underscore the need for strong and urgent joint measures to control the spread of NDM-1 carbapenemase in the hospital.

Compendio Nacional de Insumos para la Salud: equidad y acceso universal.

México fue pionero en establecer catálogos para identificar y hacer asequibles insumos médicos para la atención de su población, incluyendo medicamentos, instrumental, equipos y material de curación. Hace medio siglo, en 1971, surgió en el Instituto Mexicano del Seguro Social la iniciativa del llamado Cuadro Básico, que se constituyó como una herramienta fun-damental para el funcionamiento de las instituciones públicas de salud, con la cual se establecieron listados de insumos con probada eficacia y seguridad, con claves administrativas asignadas que permitieron su adquisición ordenada. En 2020 se llevó a cabo la transición del Cuadro Básico y Catálogo al Compendio Nacional de Insumos para la Salud, el cual recuperó el espíritu original de sus creadores como un do-cumento vivo y en constante evolución, respaldado por una metodología rigurosa para la revisión de los insumos que se incluyen, basada en la evaluación de su efectividad, seguridad y calidad, y en criterios farmacoeconómicos y consensos interinstitucionales.

Pseudomonas Aeruginosa: Genetic Adaptation, A Strategy for its Persistence in Cystic Fibrosis.

Cystic fibrosis (CF) is a progressive autosomal recessive genetic disease that principally affects the respiratory and digestive systems. It is a chronic disease that has no cure. Symptoms often include chronic cough, lung infections, and shortness of breath. Children with cystic fibrosis present failure to thrive as manifested by low weight and height for age. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (cftr) gene that codes for a cell membrane protein of epithelial tissues and affects multiple organ systems in the human body. Mutations on the CFTR causes dysfunctional electrolyte regulation affecting intracellular water content. Defective CFTR function in airways produce a dehydrated and sticky mucus that leads the establishment of bacterial chronic infection that ultimate decrease the lung function. During the first decade of life, affected individuals are colonized principally by non typable Haemophilus influenzae and Staphylococcus aureus. During the second decade, Pseudomonas aeruginosa becomes the most dominant pathogen and persists throughout the remainder of their lives. In this work, we describe the mechanisms used by P. aeruginosa to adapt and persist in lungs of individuals with cystic fibrosis.

Guía bioética de asignación de recursos de medicina crítica del Consejo de Salubridad General en México / Bioethics guide on scarce medical resource allocation in Mexico

Resumen El tema bioético sobre la asignación de recursos escasos no es nuevo, todos los países que han sido gravemente afectados por el SARS-CoV-2 han tenido que desarrollar y utilizar guías de triaje. Esto resulta más adecuado pues así la asignación de recursos limitados se hace de manera ética y justa, y no de manera discrecional y abierta a la corrupción. En México, en anticipación a la fase exponencial de la pandemia por SARS-CoV-2, el 30 de abril el Consejo de Salubridad General publicó la Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia. Dicha guía tiene como base criterios de justicia social y parte de la tesis: todas las vidas tienen el mismo valor. Este texto tiene como objetivo proporcionar las razones bioéticas y biojurídicas que conforman esta guía de triaje en nuestro país. En resumen, proporciona una breve exploración de las razones éticas que justifican cierta manera específica de asignar recursos escasos en medicina crítica, así como del sustento procedimental apegado a los estándares en materia de derechos humanos.

Abstract The bioethical inquiry about allocating fairly scarce health resources is not new, all countries around the world that were seriously afflicted by SARS-CoV-2 have issued triage guidelines in order to address the dilemmas raised by the pandemic. There is no question about the need to create bioethical guidelines, since its creation provides a degree of certainty that fair and ethical decisions are taken. This also prevents that decisions are made in solitary and maybe motivated by corrupted actions. In Mexico, the creation of this guideline was a proactive and preventive measure to what was unavoidable, the exponential contagion phase of the pandemical scenario caused by Covid-19. On April 30, 2020 the General Sanitary Council published the Bioethical Guide to Allocate Scarce Resources on Critical Care Medicine in Emergency Situation. This guide has at its core that principle of utmost importance in social justice which main thesis is: "All lives have the same value". The aim of this contribution is to provide the ethical and legal principles established in the aforementioned bioethical guideline. In sum, a brief exploration of the ethical reasons that support a specific way to allocate scarce health resources is provided, as well as the foundations of the procedural part from a human rights-based approach.

Interferon-gamma-activated macrophages infected with Burkholderia cenocepacia process and present bacterial antigens to T-cells by class I and II major histocompatibility complex molecules.

Burkholderia cenocepacia is an emerging opportunistic pathogen for people with cystic fibrosis and chronic granulomatous disease. Intracellular survival in macrophages within a membrane-bound vacuole (BcCV) that delays acidification and maturation into lysosomes is a hallmark of B. cenocepacia infection. Intracellular B. cenocepacia induce an inflammatory response leading to macrophage cell death by pyroptosis through the secretion of a bacterial deamidase that results in the activation of the pyrin inflammasome. However, how or whether infected macrophages can process and present B. cenocepacia antigens to activate T-cells has not been explored. Engulfed bacterial protein antigens are cleaved into small peptides in the late endosomal major histocompatibility class II complex (MHC) compartment (MIIC). Here, we demonstrate that BcCVs and MIICs have overlapping features and that interferon-gamma-activated macrophages infected with B. cenocepacia can process bacterial antigens for presentation by class II MHC molecules to CD4+ T-cells and by class I MHC molecules to CD8+ T-cells. Infected macrophages also release processed bacterial peptides into the extracellular medium, stabilizing empty class I MHC molecules of bystander cells. Together, we conclude that BcCVs acquire MIIC characteristics, supporting the notion that macrophages infected with B. cenocepacia contribute to establishing an adaptive immune response against the pathogen.

[Bioethics guide on scarce medical resource allocation in Mexico]. / Guía bioética de asignación de recursos de medicina crítica del Consejo de Salubridad General en México.

The bioethical inquiry about allocating fairly scarce health resources is not new, all countries around the world that were seriously afflicted by SARS-CoV-2 have issued triage guidelines in order to address the dilemmas raised by the pandemic. There is no question about the need to create bioethical guidelines, since its creation provides a degree of certainty that fair and ethical decisions are taken. This also prevents that decisions are made in solitary and maybe motivated by corrupted actions. In Mexico, the creation of this guideline was a proactive and preventive measure to what was unavoidable, the exponential contagion phase of the pandemical scenario caused by Covid-19. On April 30, 2020 the General Sanitary Council published the Bioethical Guide to Allocate Scarce Resources on Critical Care Medicine in Emergency Situation. This guide has at its core that principle of utmost importance in social justice which main thesis is: "All lives have the same value". The aim of this contribution is to provide the ethical and legal principles established in the aforementioned bioethi-cal guideline. In sum, a brief exploration of the ethical reasons that support a specific way to allocate scarce health resources is provided, as well as the foundations of the procedural part from a human rights-based approach.

El tema bioético sobre la asignación de recursos escasos no es nuevo, todos los países que han sido gravemente afectados por el SARS-CoV-2 han tenido que desarrollar y utilizar guías de triaje. Esto resulta más adecuado pues así la asignación de recursos limitados se hace de manera ética y justa, y no de manera discrecional y abierta a la corrupción. En México, en anticipación a la fase exponencial de la pandemia por SARS-CoV-2, el 30 de abril el Consejo de Salubridad General publicó la Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia. Dicha guía tiene como base criterios de justicia social y parte de la tesis: todas las vidas tienen el mismo valor. Este texto tiene como objetivo propor-cionar las razones bioéticas y biojurídicas que conforman esta guía de triaje en nuestro país. En resumen, proporciona una breve exploración de las razones éticas que justifican cierta manera específica de asignar recursos escasos en medicina crítica, así como del sustento procedimental apegado a los estándares en materia de derechos humanos.

Pseudomonas aeruginosa Isolates From a Cohort of Mexican Children With Cystic Fibrosis Show Adaptation to a Chronic Phenotype.

BACKGROUND: Long-term persistence of Pseudomonas aeruginosa in the lung of individuals with cystic fibrosis (CF) is associated with progressive selection of diverse genotypes and phenotypes. This bacterial adaptation leads to chronic infection and increased morbidity and mortality. The aim of this study was to establish the prevalence, clonal relatedness, antimicrobial susceptibility and virulence-associated phenotypes of P. aeruginosa isolates in a cohort of 50 Mexican children with CF-associated chronic lung infection. METHODS: Clonal relatedness of P. aeruginosa isolates was verified by pulsed-field gel electrophoresis. The antimicrobial susceptibility was determined by an automated system that performs bacterial identificación and antibiotic susceptibility testing (VITEK 2) and/or broth microdilution method. Biofilm formation was quantified with the crystal violet method; swarming motility was measured on soft agar, and susceptibility to normal human serum determined by reduction of colony formed units (CFUs). RESULTS: High prevalence of P. aeruginosa colonization among Mexican children with CF was confirmed; 20% (10/49) of clones identified showed a multidrug-resistant phenotype and 8.2% (4/49) an extensive drug resistance phenotype; 26.5% (13/49) of the isolates were resistant to colistin, 42.9% (21/49) presented a phenotype of adaptation associated with chronic infection and 79.6% (39/49) showed increased ability to survive in normal human serum. CONCLUSIONS: This cohort of children with CF reveals that colonizing P. aeruginosa strains predominantly display resistance to several first-line antibiotics, although most isolates were susceptible to meropenem and tobramycin; 42.9% of isolates showed a phenotype consistent with adaptation to chronic lung infection.

Carbapenem-Resistant Acinetobacter baumannii in Three Tertiary Care Hospitals in Mexico: Virulence Profiles, Innate Immune Response and Clonal Dissemination.

Acinetobacter baumannii is one of the most important nosocomial pathogens distributed worldwide. Due to its multidrug-resistance and the propensity for the epidemic spread, the World Health Organization includes this bacterium as a priority health issue for development of new antibiotics. The aims of this study were to investigate the antimicrobial resistance profile, the clonal relatedness, the virulence profiles, the innate host immune response and the clonal dissemination of A. baumannii in Hospital Civil de Guadalajara (HCG), Hospital Regional General Ignacio Zaragoza (HRGIZ) and Pediatric ward of the Hospital General de México Eduardo Liceaga (HGM-P). A total of 252 A. baumannii clinical isolates were collected from patients with nosocomial infections in these hospitals between 2015 and 2016. These isolates showed a multidrug-resistant profile and most of them only susceptible to colistin. Furthermore, 83.3 and 36.9% of the isolates carried the bla OXA- 24 and bla TEM- 1 genes for resistance to carbapenems and ß-lactam antibiotics, respectively. The clonal relatedness assessed by pulsed-field gel electrophoresis (PFGE) and by multi-locus sequence typing (MLST) demonstrated a genetic diversity. Remarkably, the ST136, ST208 and ST369 that belonged to the clonal complex CC92 and ST758 and ST1054 to the CC636 clonal complex were identified. The ST136 was a high-risk persistent clone involved in an outbreak at HCG and ST369 were related to the first carbapenem-resistant A. baumannii outbreak in HRGIZ. Up to 58% isolates were able to attach to A549 epithelial cells and 14.5% of them induced >50% of cytotoxicity. A549 cells infected with A. baumannii produced TNFα, IL-6 and IL-1ß and the oxygen and nitrogen reactive species that contributes to the development of an inflammatory immune response. Up to 91.3% of clinical isolates were resistant to normal human serum activity. Finally, 98.5% of the clinical isolates were able to form biofilm over polystyrene tubes. In summary, these results demonstrate the increasingly dissemination of multidrug-resistant A. baumannii clones in three hospitals in Mexico carrying diverse bacterial virulence factors that could contribute to establishment of the innate immune response associated to the fatality risks in seriously ill patients.