Comparative evaluation between diagnostic flows of tuberculosis in a high-complexity hospital before and after the introduction of the Xpert MTB/RIF molecular rapid test

Introdução: A tuberculose continua sendo um grave problema mundial, e vários fatores contribuem para a manutenção e perpetuação da doença. A pandemia por Coronavírus (COVID-19), reverteu os ganhos e atrasou a luta contra a tuberculose em vários anos. Estratégias como diagnosticar precocemente todas as formas de TB, com oferta universal de cultura e teste de sensibilidade, incluindo o uso de testes rápidos têm sido implantadas. Em 2010, o primeiro teste molecular rápido usado para detectar TB e testar resistência à rifampicina, Xpert® MTB/RIF (Cepheid, Sunnyvale, CA, EUA), foi recomendado para o diagnóstico de TB pulmonar(TBP) e detecção de resistência à rifampicina em adultos. O objetivo deste trabalho foi avaliar comparativamente os fluxogramas de diagnóstico da TBP e da tuberculose extrapulmonar (TBEP) antes e após a incorporação do XPERT MTB/RIF. Realizou-se um estudo descritivo e retrospectivo que buscou avaliar o significado da incorporação do XPERT MTB/RIF no fluxograma diagnóstico de um hospital terciário, avaliando percentual de diagnósticos confirmados, tempo para iniciar o tratamento, desde o início dos sintomas e após o primeiro atendimento do paciente que posteriormente confirmou TBP ou da TBEP, em um período antes e após a incorporação desta nova tecnologia. Foram 384 pacientes com, pelo menos, um exame laboratorial (microbiológico ou molecular) positivo, sendo 318 (82,8%) pacientes com amostras pulmonares positivas e 66 (17,2%) pacientes com amostras extrapulmonares positivas foi possível prover informação precoce sobre o perfil de susceptibilidade do M. tuberculosis identificado para a rifampicina, em 131 (89,8%), na TBP e 27 (87,10%) na TBEP. A mediana do tempo entre o diagnóstico etiológico confirmado no sistema do hospital (microbiológico e/ou molecular) e o início do tratamento na TBEP, antes do XPERT MTB/RIF foi de 5,5 dias e de um dia após a incorporação deste teste na rotina. A mediana (em dias) para o início do tratamento da TB-DR antes do XPERT MTB/RIF foi de 42 dias, e apenas um dia após a liberação do resultado do teste molecular no sistema laboratorial do hospital. Conclusão: A implantação do teste XPERT MTB/RIF, aumentou o percentual de diagnóstico precoce de TB confirmada, principalmente na TBEP, além de antecipar o tratamento da tuberculose resistente a drogas.Tuberculosis remains a serious worldwide problem, and several factors contribute to the maintenance and perpetuation of the disease. The Coronavirus (COVID-19) pandemic has reversed gains and set back the fight against tuberculosis by several years. Strategies such as early diagnosis of all forms of TB, with universal provision of culture and sensitivity testing, including the use of rapid tests, have been implemented. In 2010, the first rapid molecular test used to detect TB and test for rifampicin resistance, Xpert® MTB/RIF (Cepheid, Sunnyvale, CA, USA), was recommended for the diagnosis of pulmonary TB (PTB) and detection of rifampicin resistance in adults. The objective of this study was to evaluate the diagnostic flows for PTB and extrapulmonary tuberculosis (EPTB) before and after the incorporation of XPERT MTB/RIF. A descriptive and retrospective study was carried out that sought to evaluate the meaning of incorporating the XPERT MTB/RIF in the diagnostic flow of a tertiary hospital, evaluating the percentage of confirmed diagnoses, time to start treatment, from the onset of symptoms and after the first consultation for those who confirmed PTB or EPTB, in a period before and after the incorporation of this new technology. There were 384 patients with at least one positive laboratory test (microbiological or molecular), with 318 (82.8%) patients with positive lung samples and 66 (17.2%) patients with positive extrapulmonary samples with M. tuberculosis susceptibility identified to rifampicin, in 131 (89.8%) patients with PTB and 27 (87.10%) with EPTB. The median time between the etiological diagnosis confirmed in the hospital system (microbiological and/or molecular) and the beginning of treatment in EPBT, before XPERT MTB/RIF was 5.5 days and one day after the incorporation of this test in the routine. The median (in days) for initiation of DR-TB treatment before XPERT MTB/RIF was 42 days, and just one day after release of the molecular test result into the hospital\'s laboratory system. Conclusion: The implementation of the XPERT MTB/RIF test increased the percentage of early diagnosis of confirmed TB, mainly in EPBT, in addition to anticipating the treatment of drug-resistant tuberculosis

Nosocomial Outbreak of Extensively Drug-Resistant (Polymyxin B and Carbapenem) <i>Klebsiella pneumoniae</i> in a Collapsed University Hospital Due to COVID-19 Pandemic

We correlated clinical, epidemiological, microbiological, and genomic data of an outbreak with polymyxin B (PB)- and carbapenem-resistant Klebsiella pneumoniae during the COVID-19 pandemic. Twenty-six PB- and carbapenem-resistant K. pneumoniae were isolated from patients in the COVID-19 ICU (Intensive Care Unit), non-COVID-19 ICU (Intensive Care Unit), clinical, or surgical ward. Bacterial identification, drug susceptibility tests, and DNA sequencing were performed, followed by in silico resistance genes identification. All isolates showed extensively drug-resistant (XDR) phenotypes. Four different sequence types (ST) were detected: ST16, ST11, ST258, and ST437. Nineteen isolates were responsible for an outbreak in the ICU in September 2020. They belong to ST258 and harbored the 42Kb IncX3plasmid (pKP98M3N42) with the same genomic pattern of two K. pneumoniae identified in 2018. Twenty-four isolates carried bla-KPC-2 gene. No plasmid-mediated colistin (mcr) resistance genes were found. Eight isolates presented mgrB gene mutation. The clonal isolates responsible for the outbreak came from patients submitted to pronation, with high mortality rates in one month. XDR-K. pneumoniae detected during the outbreak presented chromosomal resistance to PB and plasmid-acquired carbapenem resistance due to KPC production in most isolates and 42Kb IncX3(pKP98M3N42) plasmid carrying blaKPC-2 was associated with ST258 isolates. The outbreak followed the collapse of the local healthcare system with high mortality rates