Infecções por enterobacteriaceae resistente aos carbapenêmicos em hospital de ensino: epidemiologia e caracterização molecular

Introduction: The production of KPC (Klebsiella pneumoniae carbapenemase) has become an important mechanism of carbapenem-resistance among Enterobacteriaceae strains. In Brazil, KPC is already widespread and its incidence has increased significantly, reducing treatment options. The “perfect storm” combination of the absence of new drug developmentand the emergence of multidrug-resistant strains resulted in the need for the use of older drugs, with greater toxicity, such as polymyxins. Aims: To determine the occurrence of carbapenemase-producing strains in carbapenem-resistant Enterobacteriaceae isolated from patients with nosocomial infection/colonization during September/2014 to August/2015, to determine the risk factors associated with 30-day- mortality and the impact of inappropriate therapy. Materials and Methods: We performed a case control study to assess the risk factors (comorbidities, invasive procedures and inappropriate antimicrobial therapy) associated with 30-day-mortality, considering the first episode of infection in 111 patients. The resistance genes blaKPC, blaIMP, blaVIM and blaNDM-1 were detected by polymerase chain reaction technique. Molecular typing of the strains involved in the outbreak was performed by pulsed field gel electrophoresis technique. The polymyxin resistance was confirmed by the microdilution broth method. Results: 188 episodes of carbapenem-resistant Enterobacteriaceae infections/colonizations were detected; of these, 122 strains were recovered from the hospital laboratory. The presence of blaKPC gene were confirmed in the majority (74.59%) of these isolates. It was not found the presence of blaIMP , blaVIM and blaNDM-1 genes. K. pneumoniae was the most frequent microorganism (77,13%), primarily responsible for urinary tract infections (21,38%) and infections from patients of the Intensive Care Unit (ICU) (61,38%). Multivariate statistical analysis showed as predictors independently associated with mortality: dialysis and bloodstream infection. The Kaplan-Meier curve showed a lower probability of survival in the group of patients receiving antibiotic therapy inappropriately. Antimicrobial use in adult ICU varied during the study period, but positive correlation between increased incidence of strains and the consumption was not observed. In May and July 2015, the occurrence rates of carbapenem-resistant Enterobacteriaceae KPC-producing per 1000 patient-days were higher than the control limit established, confirming two outbreaks, the first caused by colistin-susceptible KPC-producing K. pneumoniae isolates, with a polyclonal profile and the second by a dominant clone of colistin-resistant (≥ 32 μg/mL) KPC-producing K. pneumoniae. The cross transmission between patients became clear by the temporal and spatial relationships observed in the second outbreak, since some patients occupied the same bed, showing problems in hand hygiene adherence among healthcare workers and inadequate terminal disinfection of environment. The outbreak was contained when the ICU was closed to new admissions. Conclusions: The study showed an endemicity of K. pneumoniae KPC-producing in adult ICU, progressing to an epidemic monoclonal expansion, resulted by a very high antibiotic consumption of carbapenems and polymyxins and facilitated by failures in control measures the unit.Coordenação de Aperfeiçoamento de Pessoal de Nível SuperiorFundação de Amparo a Pesquisa do Estado de Minas GeraisDissertação (Mestrado)Introdução: A produção de carbapenemases do tipo KPC (Klebsiella pneumoniae carbapenemase) tem se tornado importante mecanismo de resistência aos carbapenêmicos entre os microrganismos da família Enterobacteriaceae. No Brasil, a enzima KPC já se encontra disseminada e sua incidência tem aumentado significativamente, diminuindo as opções de tratamento. A combinação perversa da redução do desenvolvimento de novos antibióticos, somado a emergência de cepas multirresistentes resultou na necessidade da utilização de drogas antigas, com maior toxicidade, como as polimixinas. Objetivos: Determinar a ocorrência de amostras produtoras de carbapenemases em representantes da família Enterobacteriaceae resistentes aos carbapenêmicos, isoladas de pacientes com infecção/colonização de natureza hospitalar, durante setembro de 2014 a agosto de 2015, além de determinar os fatores de risco associados a mortalidade e o impacto da terapia inapropriada. Material e métodos: Foi realizado estudo de coorte prospectiva com a avalição dos fatores de risco para mortalidade em 30 dias, considerando o primeiro episódio de infecção em 111 pacientes. Os genes de resistência blaKPC, blaIMP, blaVIM e blaNDM-1 foram detectados pela técnica de reação em cadeia da polimerase. A tipagem molecular das amostras foi realizada pela técnica eletroforese em campo pulsado. A resistência à colistina foi confirmada pelo método de microdiluição em caldo. Resultados: No total, 188 episódios de infecção/colonização por Enterobacteriaceae resistentes aos carbapenêmicos foram detectados, com 122 amostras recuperadas a partir do laboratório do hospital e, na maioria delas (74,59%), a presença do gene blaKPC foi confirmada. Não foram encontrados os genes blaIMP, blaVIM e blaNDM-1. K. pneumoniae foi o microrganismo mais frequente (77,13%), responsável principalmente por infecções do trato urinário (21,38%) e infecções em pacientes internados na Unidade de Terapia Intensiva (UTI) (61,38%). A análise estatística multivariada mostrou como preditores independentemente associados com a mortalidade: hemodiálise e infecção de corrente sanguínea. A curva de Kaplan-Meier evidenciou uma menor probabilidade de sobrevivência no grupo de pacientes que recebeu terapia antimicrobiana inapropriada. O consumo de antimicrobianos na UTI de adultos variou durante o período de estudo, entretanto nenhuma correlação positiva entre o aumento na incidência amostras e o consumo foi observada. Nos meses de maio e julho de 2015, a ocorrência de infecção/colonização por Enterobacteriaceae resistentes aos carbapenêmicos e produtoras do gene blaKPC por 1000 pacientes-dia, foram mais altas do que o limite estabelecido, confirmando dois surtos, o primeiro por amostras de K. pneumoniae produtoras de KPC e susceptíveis a colistina, com perfil policlonal e o segundo por um clone dominante de K. pneumoniae produtora de KPC e resistente a colistina (≥ 32 μg/mL). A transmissão cruzada entre os pacientes ficou clara pelas relações temporal e espacial observada no segundo surto, já que vários pacientes ocuparam o mesmo leito, evidenciando problemas na adesão à higiene de mãos por parte dos profissionais de saúde e a inadequação da desinfecção terminal do ambiente. O surto só foi contido após o fechamento da unidade para novas admissões. Conclusões: A investigação evidenciou, a princípio, uma endemicidade de amostras de K. pneumoniae produtoras de KPC na UTI de adultos, com evolução para uma situação epidêmica com expansão monoclonal quando do segundo surto, resultante de problemas de consumo muito alto de antibióticos (carbapenêmicos e polimixinas) e facilitada por falhas nas práticas de prevenção e controle na unidade

Exploring the staphylococcus aureus in patients infected of the tertiary-care university hospital: results of the retrospective cohort study

Objective: To establish a baseline of knowledge regarding about inappropriate therapy, virulence and resistance in a cohort of patients infected with S. aureus. Methods: Retrospective cohort study in tertiary-care university hospital was employed to evaluate the risk factors and the impact of inappropriate therapy among patients with Staphylococcus aureus infections, resistance and virulence. To assess the presence of the genes was performed PCR. Results: Patients with MRSA were older and hospitalized 17 days longer than those with MSSA infection, which were in ICU with a bloodstream infection. 50.0% received inadequate antibiotic therapy and we found virulence factors associated with MRSA (mecA, LukS, fnbB and clfA genes). Conclusion: These data show that surveillance studies related to Staphylococcus aureus infections remain essential to identify resistance and inform policy on resistance

Carbapenem-resistant Acinetobacter baumannii in Minas Gerais state: hospital epidemiology, multidrug resistance and dissemination of high-risk clones

Introduction: The spread of Acinetobacter baumannii associated with the emergence of resistance genotypes to carbapenems is of great concern worldwide. Aims: To understand hospital epidemiology as well as the current dissemination of high-risk clones in clinical strains of A. baumannii resistant to carbapenems. Materials and methods: The study was conducted in two stages. First, an epidemiological study was conducted using a cohort of 489 patients with carbapenem-resistant A. baumannii infection from 2013 to 2017 hospitalized at Hospital de Clínicas (HC-UFU), considering the first episode. Secondly, a molecular study of samples recovered from HC-UFU was carried out, along with isolates of A. baumannii recovered from other hospitals in Minas Gerais (MG) state, were selected to be typed by the MLST sequencing technique (Multilocus Sequence Typing, Pasteur scheme) and, of these, the whole-genome of one strain was sequenced using an Illumina Next-Seq 500 paired-end reads (150 bp). Polymerase chain reaction (PCR) were used to detect the oxacillinase genes (blaOXA-51, blaOXA-23, blaOXA-24, blaOXA-58 e blaOXA-143) and other carbapenemases (blaNDM-1, blaKPC, blaIMP-1, blaVIM-1, blaTEM). Results: In the epidemiological study, an incidence of carbapenem-resistant A. baumannii infection of 0.7/1000 patient-days were found, with most patients with respiratory tract infections (54.7%), predominantly hospitalized in the intensive care (ICU). In November 2014, the infection rates exceeded the established limits, confirming an outbreak of multi-resistant A. baumannii infection. The frequency of mortality was high (39%) and the multivariate analysis showed that the related risk factors were the presence of sepsis and antimicrobial inappropriate therapy. It was found that 93.9% of the patients had infections with the multidrug resistant microorganism (MDR) and 41.5% with the extensively resistant microorganism (XDR). 94.5% of the 107 strains recovered and tested, recovered from the HC-UFU, were positive for the blaOXA-23 gene. On the molecular stage, 12 clinical strains of A. baumannii, obtained from different hospitals of MG state were selected. Seven strains (58.3%) were positive for the blaOXA-23 gene and one (8.3%) was positive for the blaNDM-1 gene. These 12 strains, along with two selected isolates from the HC-UFU, were typed by MLST, the result showed clonal dissemination of seven STs and four clonal complexes (CC), with predominance of ST/CC79 as well as the identification of two new STs, ST1465/CC216, and ST1466/CC79. Whole-genome sequencing of the positive sample for the blaNDM-1 gene was carried out, which was carried by an unusual plasmid (pAb17), in which some genes of the Tn125 transposon were lost. Besides, on the chromosome, the strain reported here presented blaOXA-106 gene, a variant of blaOXA-51 gene, and blaADC-25 with ISAba1 upstream. Conclusions: The study showed endemicity of A. baumannii MDR at HC-UFU, with a high frequency of the blaOXA-23 gene in recovered isolates, in addition to a higher risk of death in patients with severe infections receiving antimicrobial inappropriate definitive therapy. It also showed dissemination of different STs of A. baumannii MDR in the state of Minas Gerais, the predominance of ST/CC79, the identification of two new STs, in addition to the emergence of the blaNDM-1 gene in A. baumannii in MG.CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível SuperiorCNPq - Conselho Nacional de Desenvolvimento Científico e TecnológicoFAPEMIG - Fundação de Amparo a Pesquisa do Estado de Minas GeraisTese (Doutorado)Introdução: A disseminação de Acinetobacter baumannii associada à emergência de genótipos de resistência aos carbapenêmicos, é de grande preocupação no mundo todo. Objetivos: Compreender a epidemiologia hospitalar bem como a atual disseminação de clones de alto risco em cepas clínicas de A. baumannii resistentes aos carbapenêmicos. Materiais e métodos: O estudo foi conduzido em duas etapas. Primeiramente, foi realizado estudo epidemiológico através de uma coorte de 489 pacientes internados no Hospital de Clínicas (HC-UFU), com infecção por A. baumannii resistente aos carbapenêmicos no período de 2013 a 2017, considerando o primeiro episódio. Em segundo, foi realizado um estudo molecular de amostras recuperadas do HC-UFU, juntamente com isolados de A. baumannii recuperados de outros hospitais de Minas Gerais (MG), os quais foram selecionados para serem tipadas pela técnica de sequenciamento de MLST (Multilocus Sequence Typing, esquema Pasteur) e, destas, uma amostra foi selecionada para o sequenciamento de genoma completo a partir da plataforma NextSeq 500 (Illumina) utilizando leituras paired-end de 150 pb. Todas as cepas foram submetidas à reação em cadeia da polimerase (PCR) para detecção dos genes de oxacilinases (blaOXA-51, blaOXA-23, blaOXA-24, blaOXA-58 e blaOXA-143) e outras carbapenemases (blaNDM-1, blaKPC, blaIMP-1, blaVIM-1, blaTEM). Resultados: No estudo epidemiológico, foi encontrada incidência de infeção por A. baumannii resistente aos carbapenêmicos de 0,7/1000 pacientes-dia, com a maioria dos pacientes com infecção de trato respiratório (54,7%), predominantemente internados na unidade de terapia intensiva (UTI). Em novembro de 2014 os índices de infecção ultrapassaram os limites estabelecidos, confirmando um surto de infecção por A. baumannii multirresistente. A frequência de mortalidade foi elevada (39%) e a análise multivariada mostrou que os fatores de risco relacionados foram presença de sepse e antibioticoterapia definitiva inapropriada. Foi verificado que 93,9% dos pacientes tiveram infecções por isolados multirresistentes (MDR) e 41,5% por isolados extensivamente resistente (XDR). 94,5% das 107 cepas recuperadas e testadas, recuperadas do HC-UFU, foi positiva para o gene blaOXA-23. Na etapa molecular, foram selecionadas 10 amostras clínicas de A. baumannii, obtidas de diferentes hospitais do estado de MG. Sete amostras (58,3%) foram positivas para o gene blaOXA-23 e uma (8,3%) foi positiva para o gene blaNDM-1. Estas 10 amostras, juntamente com duas amostras selecionadas do HC-UFU, foram tipadas por MLST, e observou-se disseminação clonal de sete STs e quatro complexos clonais (CC), com predominância do ST/CC79 bem como a identificação de dois STs novos, ST1465/CC216, e ST1466/CC79. Foi realizado o sequenciamento de genoma completo da cepa positiva para o gene blaNDM-1, o qual era carreado por um plasmídeo incomum (pAb17), cujo transposon Tn125 sofreu perda de genes. Além disso, a amostra possuía no cromossomo gene blaOXA-106, variante de blaOXA-51, além do gene blaADC-25 com ISAba1 upstream. Conclusões: O estudo evidenciou endemicidade de A. baumannii MDR no HC-UFU, com elevada frequência do gene blaOXA-23 nos isolados recuperados, além de maior risco de evolução para óbito em pacientes com infecções graves recebendo antibioticoterapia definitiva inapropriada. Também mostrou disseminação de diferentes STs de A. baumannii MDR no estado de Minas Gerais, com predominância do ST/CC79 e a identificação de dois novos STs, além da emergência do gene blaNDM-1 em A. baumannii em nosso estado

Employee Recruitment and Selection in CIDEM Hranice, a.s. Company

Import 05/08/2014Tato práce řeší výběr a získávání zaměstnanců ve společnosti CIDEM Hranice, a.s. Cílem práce je zhodnotit současný stav získávání a výběru zaměstnanců ve společnosti CIDEM Hranice a navrhnout opatření pro zlepšení tohoto procesu. Zaměřila jsem se na podrobnou analýzu tohoto procesu. Na základě odborné literatury jsou vysvětleny důležité pojmy, které se týkají získávání a výběru zaměstnanců v teoretické části. Tyto poznatky jsou poté převedeny do praktické úrovně za pomoci interních dokumentů podniku. Pro analýzu procesu byl sestaven dotazník, který byl distribuován zaměstnancům podniku. Získaná data byla zpracována pomocí datové matice a převedena do grafické podoby. Hlavním výsledkem práce jsou návrhy a doporučení pro organizaci v procesu získávání a výběru zaměstnanců.This thesis deals with employee selection and acquirement in the company CIDEM Hranice, a.s. The goal of this thesis is to evaluate current state of emplyee selection and acquirement process in the company CIDEM Hranice and suggest steps to improve this process. My aim is to do a thorough analysis of this process. Based on a technical literature, the important terms concerning employee selection and acquirement are explained in the theoretical part of the thesis. This knowledge is then transferred to practical level using internal documentation of the company. For the purpose of process analysis, a quistionaire was created and distributed to the employees of the company. Collected data was processed using data matrix and rendered to graphical output. Main outcome of this thesis is collection of suggestions and recommendations for improving the process of employee selection and acquirement.115 - Katedra managementuvýborn

Clinical and Molecular Epidemiology of Multidrug-Resistant P. aeruginosa Carrying aac(6')-Ib-cr, qnrS1 and blaSPM Genes in Brazil.

We described a comprehensive analysis of the molecular epidemiology of multidrug-resistant (MDR) P. aeruginosa. Molecular analysis included typing by Pulsed Field Gel Electrophoresis, identification of genes of interest through PCR-based assays and sequencing of target genes. Case-control study was conducted to better understand the prognostic of patients and the impact of inappropriate therapy in patients with bacteremia, as well as the risk factors of MDR infections. We observed a high rate of MDR isolates (40.7%), and 51.0% of them was independently associated with inappropriate antibiotic therapy. Bacteremia was detected in 66.9% of patients, and prolonged hospital stay was expressive in those resistant to fluoroquinolone. Plasmid-mediated quinolone resistance genes (PMQR), qnrS1 and aac(6')Ib-cr, were detected in two different nosocomial isolates (5.3%), and the aac(6')-Ib7 variant was detected at a high frequency (87.5%) in those negative to PMQR. The presence of mutations in gyrA and parC genes was observed in 100% and 85% of selected isolates, respectively. Isolates harboring PMQR genes or mutations in gyrA and parC were not closely related, except in those containing SPM (São Paulo metallo-β-lactamase) clone. In addition, there is no study published in Brazil to date reporting the presence of Pseudomonas aeruginosa isolates harboring both qnrS1 and aac(6')Ib-cr genes, with alarming frequency of patients with inappropriate therapy

Endemic level of carbapenem resistant <i>P</i>. <i>aeruginosa</i> bacteremia per 1000 patient-days from March 2009 to December 2012.

<p>Endemic level of carbapenem resistant <i>P</i>. <i>aeruginosa</i> bacteremia per 1000 patient-days from March 2009 to December 2012.</p

Phenotypic and genotypic profile of resistance, hospital unit and the date of isolation of <i>P</i>. <i>aeruginosa</i> samples characterized by PFGE.

<p>Phenotypic and genotypic profile of resistance, hospital unit and the date of isolation of <i>P</i>. <i>aeruginosa</i> samples characterized by PFGE.</p

Characterization of resistance mechanisms in carbapenem-resistant <i>P</i>. <i>aeruginosa</i> isolates, both multidrug-resistant and extensively drug-resistant.

<p>Characterization of resistance mechanisms in carbapenem-resistant <i>P</i>. <i>aeruginosa</i> isolates, both multidrug-resistant and extensively drug-resistant.</p