Introdução: Gestações múltiplas apresentam alta morbidade relacionada a fatores como prematuridade, baixo peso ao nascer e sepse. Em gemelares, a aquisição de imunidade passiva por meio do cordão umbilical e do colostro ainda não é bem conhecida. O objetivo geral do estudo foi descrever a concentração de IgG total e específico anti-Streptococcus B, antilipopolissacarídeos de Klebsiella pneumoniae e antilipopolissacarídeos de Pseudomonas aeruginosa no cordão umbilical de recém-nascidos gemelares e a concentração de IgA secretora total e específica destes anticorpos no colostro. O objetivo específico foi analisar a associação entre infecção neonatal e concentração dos anticorpos no sangue de cordão umbilical e no colostro. Métodos: estudo prospectivo transversal de uma coorte de recémnascidos gemelares internados no Centro Neonatal do Instituto da Criança do Hospital das Clínicas da FMUSP no período de 20 meses. Foram excluídos: recém-nascidos com malformação; mães com infecção ou imunodeficiência. Variáveis analisadas: idade gestacional; peso de nascimento; classificação gestacional; concentrações de IgG total e específicos e IgA total e específicas anti-Streptococcus B, antilipopolissacarídeos de Klebsiella pneumoniae e antilipopolissacarídeos de Pseudomonas aeruginosa no sangue de cordão umbilical e no colostro; nutrição enteral; episódios de infecção; desfecho. As dosagens de IgG total foram realizadas por nefelometria e dos demais anticorpos através de ensaio imunoenzimático. Os testes t-Student pareado ou teste de Wilcoxon pareado, teste de Mann-Whitney e teste de Kruskal-Wallis, foram utilizados, considerando-se significante p< 0,005. Resultados: Foram incluídos 57 pares de gêmeos, compondo a casuística de 114 recém-nascidos. A idade gestacional foi 36±1,65 semanas (média±DP) e o peso de nascimento foi 2.304,8 ± 460g (média±DP). As concentrações de anticorpos encontradas foram (média±DP): IgG total 835,71 ± 190,73 mg/dL, IgG anti-Streptococcus B 295,1 ± 250,66 UA/mL, IgG antilipopolissacarídeos de Pseudomonas aeruginosa 280,04 ± 498,66 UA/mL e IgG antilipopolissacarídeos de Klebsiella pneumoniae 504,75 ± 933,93 UA/mL; IgA total 210,2 ± 285,3 g/L, IgA anti-Streptococcus B 6640 ± 9526,8 UA/mL, IgA antilipopolissacarídeos de Pseudomonas aeruginosa 3231,0 ± 2935,2 UA/mL, IgA antilipopolissacarídeos de Klebsiella pneumoniae 3070,1±2886,6 UA/mL. A concentração de IgG total foi menor nos recém-nascidos prematuros (p < 0,001). Em gemelares com idade gestacional < 34 semanas a concentração de IgG total (p=0,013) e IgG antilipopolissacarídeos de Pseudomonas aeruginosa (p=0,032) foi menor. A concentração de anticorpos IgG antilipopolissacarídeos de Klebsiella pneumoniae foi menor nos recém-nascidos pequenos para a idade gestacional (p=0,013). No colostro, houve detecção de IgA total, IgA anti-Streptococcus B, IgA antilipopolissacarídeos de Klebsiella pneumoniae e antilipopolissacarídeos de Pseudomonas aeruginosa em 98,1% das mães. A concentração de IgA antilipopolissacarídeos de Pseudomonas aeruginosa foi menor no colostro das mães de recém-nascidos prematuros (p=0,013). A concentração de IgA antilipopolissacarídeos de Klebsiella pneumoniae foi menor no colostro das mães com parto antes de 34 semanas (p=0,001). Houve infecção em cinco recém-nascidos, cuja concentração de IgG total foi menor (p<0,05). Os neonatos que receberam colostro apresentaram menor incidência de infecção (p < 0,001). Conclusões: Os anticorpos IgG total e específicos foram detectados no sangue do cordão umbilical em todos os gemelares, comprovando sua passagem transplacentária. Houve diminuição significativa na concentração de anticorpos IgG total nos gemelares prematuros e de IgG total e IgG antilipopolissacarídeos de Pseudomonas aeruginosa nos gemelares com idade gestacional inferior a 34 semanas. No colostro houve detecção de IgA total e específica em 98,1% das mães. A concentração de IgA anti-lipopolissacarídeos de Pseudomonas aeruginosa foi menor no colostro das mães de gemelares prematuros. Nas mães com parto antes de 34 semanas houve diminuição da concentração de IgA antilipopolissacarídeos de Klebsiella pneumoniae, sugerindo que a prematuridade possa ter influenciado a transferência de anticorpos maternos pelo colostro. A maior incidência de infecção no grupo de recém-nascidos, que não receberam colostro e naqueles que apresentavam concentração sérica de IgG total significativamente menor, reforça a importância da proteção anti-infecciosa conferida pela imunidade passiva transferida da mãe / Introduction: Multiple pregnancies have high morbidity related to factors such as prematurity, low birth weight and sepsis. In twins, acquisition of passive immunity through the umbilical cord and colostrum is not yet known. The overall aim of the study was to describe the concentration of total and specific IgG antibodies anti-Streptococcus B, anti-lipopolysaccharide of Klebsiella pneumoniae and anti-lipopolysaccharide of Pseudomonas aeruginosa in the umbilical cord of newborn twins and the concentration of total and specific secretory IgA antibodies in the colostrum. The specific aim was to analyze the association between neonatal infection and antibody concentration in the umbilical cord blood and colostrum. Methods: A prospective cross-sectional study of a cohort of newborn twins admitted to the Neonatal Center of Children\'s Institute, University of São Paulo during the period of 20 months. Patients with malformations and mothers with infection or immunodeficiency were excluded from our analysis. Variables analyzed: gestational age; birth weight; sex; gestational classification; antibody concentrations of total and specific IgG and IgA anti-Streptococcus B, anti-lipopolysaccharide of Klebsiella pneumoniae and antilipopolysaccharide of Pseudomonas aeruginosa in umbilical cord blood and colostrum; enteral nutrition; infection episodes; outcome. Total IgG measurements were performed using nephelometry and the specific antibodies were evaluated by enzyme immunoassay. We used paired Student t test or Wilcoxon test, Mann-Whitney test and Kruskal-Wallis test considering significant p < 0.005. Results: During the study period a total of 57 pairs of twins were included, making the sample of 114 newborns. Gestational age was 36 ± 1.65 weeks (mean±SD) and birth weight was 2304.8 ± 460g (mean±SD). We found the following antibody concentrations (mean±SD): total IgG 835.71 ± 190.73 mg/dL, anti-Streptococcus B IgG 250.66 ± 295.1 AU/mL, anti-lipopolysaccharide of Pseudomonas aeruginosa IgG 280.04 ± 498.66 AU/mL and anti-lipopolysaccharide of Klebsiella pneumoniae IgG 504.75±933.93 AU/mL; total IgA 210.2 ± 285.3 g/L, anti- Streptococcus B IgA 6640±9526.8 AU/mL, anti-lipopolysaccharide of Pseudomonas aeruginosa IgA 3231.0±2935.2 AU/mL, antilipopolysaccharide Klebsiella pneumoniae IgA 3070.1±2886.6 AU/mL. The concentration of total IgG was lower in preterm infants (p < 0.001). In twins with gestational age < 34 weeks both total IgG concentration (p = 0.013) and anti-lipopolysaccharide of Pseudomonas aeruginosa IgG concentration (p = 0.032) were lower. The concentration of anti-lipopolysaccharide of Klebsiella pneumoniae IgG was lower in small for gestational age newborns (p=0,013). There was detection of total IgA and specific antibodies in the colostrum of 98.1% mothers. The concentration of anti-lipopolysaccharide of Pseudomonas aeruginosa IgA was lower in the colostrum of premature\'s mothers (p = 0.013). The concentration of anti-lipopolysaccharide of Klebsiella pneumoniae IgA was lower in the colostrum of mothers with delivery before 34 weeks (p = 0.001). Five newborns were diagnosed with sepsis and in this group the concentration of total IgG was lower (p < 0.05). Neonates receiving colostrum had a lower incidence of infection (p < 0.001). Conclusion: This study showed detection of total and specific IgG antibodies in umbilical cord blood for all twin newborn, proving its transplacental passage. There was a significant decrease in the concentration of total IgG antibodies in premature twins and antilipopolysaccharide of Pseudomonas aeruginosa IgG in twins with gestational age less than 34 weeks. There was detection of total and specific IgA in the colostrum of 98.1% mothers. The concentration of anti-lipopolysaccharide of Pseudomonas aeruginosa IgA was lower in mothers of premature twins. Among the newborns with gestational age less than 34 weeks there was a decrease in the concentration of anti-lipopolysaccharide Klebsiella pneumoniae IgA, suggesting that prematurity may have influenced the transfer of maternal antibodies through colostrum. The highest incidence of infection in the newborn group who did not receive colostrum and in those who had significantly lower total IgG serum antibodies reinforces the importance of anti-infectious protection afforded by passive immunity transferred from the mother

O operon pst de P. aeruginosa codifica um transportador de fosfato de alta afinida-de e também a proteína PhoU que, em conjunto, atuam como repressores da ex-pressão do regulon Pho dessa espécie. A atividade de PhoU está também associada ao metabolismo de polifosfato (poliP), dado que mutantes phoU nulos apresentam um vasto acúmulo do biopolímero. Ensaios de &beta;-galactosidase mostraram uma alteração na expressão dos genes ppk e ppx, envolvidos no metabolismo de poliP, no mutante phoU. Observou-se que na cepa selvagem, a transcrição de ppk e de ppx não responde às limitações de Pi ou de nitrogênio, sendo esses genes altamente expressos em condições normais de crescimento. Além disso, determinou-se que ppk é co-transcrito com o gene hemB, os quais formam, portanto, um operon. O operon pst também foi analisado. Foi identificado por ensaios de northern blot o transcrito do primeiro gene do operon, pstS, que codifica uma proteína periplasmática. Também, foi identificado um promotor imediatamente a montante de phoU, o gene mais distal do operon, que permitiria sua expressão em condições normais do crescimento bacteriano. Por fim, determinou-se por ensaios de EMSA que as duas sequências consenso Pho box presentes no operon pst são completamente funcionais. / The pst operon in P. aeruginosa encodes a high-affinity phosphate transporter and the PhoU protein, which together act as repressors of Pho regulon of this species. The PhoU activity is also related with polyphosphate (polyP) metabolism, since phoU null mutants have a large accumulation of the biopolymer. &beta;-galactosidase assays allowed to confirm a change in the expression of ppk and ppx genes, in-volved in PolyP metabolism, in the phoU mutant. It was also evidenced that in the wild type strain, the ppk and ppx transcription does not respond to Pi or nitrogen starvation, and that these genes are highly expressed under conditions of normal growth. In addition, it was determined that ppk is co-transcribed with hemB, a gene involved in the synthesis of porphyrins, and they constitute therefore an operon. The pst operon was also examined. Was identified by northern blot the transcript of the first gene in the operon, pstS, which encodes a periplasmic protein. Also, a promoter was identified immediately upstream of phoU, the most distal gene in the operon, allowing its expression in normal conditions of bacterial growth. Finally, it was determined by EMSA that the two consensus sequences Pho box present in the pst operon are fully functional.

Les espèces bactériennes exhibent plusieurs états de structure de populations pouvant varier de clonale à panmictique selon l'importance des transferts horizontaux et la nature de leur écosystème. Dans mon travail de thèse, je me suis intéressé à trois espèces bactériennes, Staphylococcus aureus, Legionella pneumophila et Pseudomonas aeruginosa qui reflètent trois situations différentes. Afin de pouvoir décrire de façon rapide de grandes collections de souches, j'ai utilisé comme marqueurs de diversité le polymorphisme de séquences répétées en tandem appelées VNTRs, pour Variable Number Tandem Repeat. La méthode MLVA, ou Multiple Loci VNTR Analysis, est une méthode de typage moléculaire qui s’appuie sur l’étude concomitante du polymorphisme de plusieurs loci VNTRs. Dans un premier temps, j'ai conçu des protocoles de typage automatisés pour les trois espèces considérées, puis j'ai appliqué ces outils pour traiter de questions d'épidémiologie. S. aureus, espèce à structure clonale, est un pathogène majeur responsable notamment de toxi-infections alimentaires collectives (TIAC). Les travaux réalisés ont permis de démontrer la spécificité d’hôte de certains complexes clonaux et l’origine humaine des cas de TIAC. L. pneumophila est un pathogène de l’environnement dont la structure de population est atypique : présumée panmictique dans la nature, la bactérie semble connaitre une évolution clonale lorsque son écosystème est restreint, dans un milieu anthropique par exemple. L’étude épidémiologique menée sur la population de L. pneumophila dans la ville de Rennes a mis en évidence la présence d’un écotype, non impliqué dans les cas cliniques épidémiques, particulièrement adapté aux réseaux d’eau. P. aeruginosa, modèle de bactérie panmictique, colonise les bronches de patients atteints de mucoviscidose. Le suivi longitudinal de patients indique que les souches installées sont persistantes et quasi-exclusive de la niche qu’elles occupent. L’exploration de cette diversité du monde bactérien est un préalable à l’investigation épidémiologique des maladies infectieuses. Avec un même outil moléculaire de première intention, cette thèse retrace l’épidémiologie et la structure de trois espèces bactériennes très différentes. L’adaptation à un nouvel environnement (hôte animal, niche écologique, organe) est l'occasion d'expansions clonales. / Bacterial species exhibit diversity in their population structure varying from clonal to panmictic according to the abundance of horizontal transfer and the nature of their ecosystem. During my PhD, I focused on three bacterial species, Staphylococcus aureus, Pseudomonas aeruginosa and Legionella pneumophila, which reflect three different situations. To perform the characterisation of large strain collections, I studied the polymorphism of molecular markers called VNTRs for Variable Number Tandem Repeat. MLVA (Multiple Loci VNTR Analysis) is a PCR based typing method that relies on the concomitant analysis of several VNTRs loci. Initially, I designed automated typing protocols for the three species, then I applied these tools to address issues of epidemiology. S. aureus, a clonal species, is a major cause of food poisoning. The present work confirmed the existence of host-specific clonal complexes and demonstrated the predominantly human origin of foodborne disease cases. L. pneumophila is an environmental pathogen whose population structure is atypical: it is presumed panmictic in the environment but the bacterium expands clonally when the ecosystem is restricted, in an anthropogenic habitat for instance. A long-term epidemiological monitoring of L. pneumophila populations in the city of Rennes highlighted the presence of an ecotype, not involved in epidemic cases, particularly adapted to hot water supply systems. P. aeruginosa, a well-described panmictic bacterium, colonizes CF patients’ airways. The longitudinal monitoring of patients provided evidence that the settled strains were persistent and exhibited strong exclusivity for the occupied niche. Exploring the bacterial world diversity is a prerequisite for epidemiological investigation of infectious diseases. Using a first-line molecular tool, these works trace the epidemiology and the population structure of three bacterial species. The adaptation to a new environment (animal host, ecological niche, organ) generally results in clonal expansions.

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[Truncated abstract] Pseudomonas aeruginosa, an important opportunistic pathogen, is resistant to a wide array of functionally and structurally diverse antimicrobial agents including antibiotics, disinfectants and biocides. P. aeruginosa is more resistant than other Gram negative bacteria to tea tree oil (TTO), the essential oil steam distilled from the leaves of Melaleuca alternifolia and comprised of over 100 terpene hydrocarbon components and their oxygenated derivatives. TTO is an established topical antimicrobial agent, with antibacterial, antiviral and antifungal properties. Intrinsic antimicrobial resistance mechanisms in P. aeruginosa include the low permeability of the outer membrane and expression of multi-drug efflux pumps. A series of multi-drug efflux mutants from the resistance-nodulation-cell division family was obtained and their susceptibility to TTO and several components examined. This demonstrated that TTO and the components terpinen-4-ol, 1,8-cineole and a-terpineol were substrates of MexAB-OprM, using both pump deletion mutants and the pump inhibitor Phe-arg ß-naphthylamide dihydrochloride. In complementation studies, the addition of mexAB-oprM to deletion mutants restored susceptibility to these agents to that of the wild-type, confirming the role of MexAB-OprM in tolerance to TTO and these three components. ... An increase in susceptibility to ticarcillin and Timentin occurred in PAO1 following serial subculture in terpinen-4-ol. Susceptibility to ticarcillin has been associated with expression of the MexCD-OprJ system in P. aeruginosa. A library of transposon mutants was created to find additional mechanisms by which P. aeruginosa could tolerate TTO. The library yielded a total of 20 mutants that were more susceptible than parental strains to TTO and/or terpinen-4-ol. The insertion site of the transposon was identified in 14 mutants and, in four mutants, this was a gene related to flagellar biosynthesis. Flagella deficient mutants have previously demonstrated enhanced susceptibility to the membrane-disrupting surfactant sodium dodecyl sulfate and this echoes the increased susceptibility to TTO and terpinen-4-ol observed. Three non-sibling surA mutants were also identified. SurA is involved in the correct folding of outer membrane proteins, including porins, in Gram negative bacteria: surA mutants of Escherichia coli have phenotypes that are characteristic of a defective cell envelope, including an increased susceptibility to hydrophobic agents. The increase in susceptibility to hydrophobic TTO and terpinen-4-ol in the surA mutants is consistent with this and represents the first report linking SurA function to antimicrobial resistance in P. aeruginosa. In conclusion, several Mex efflux systems of P. aeruginosa including MexAB-OprM, MexCD-OprJ and MexEF-OprN, as well as the LPS core, outer membrane integrity and a functioning flagella biosynthetic pathway contribute to the tolerance of this organism to TTO and/or several components.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / ExoU, uma citotoxina produzida pelo patógeno oportunista Pseudomonas aeruginosa e translocada para o citossol de células hospedeiras via sistema de secreção do tipo III, é associada à gravidade de infecções agudas. Estudos anteriores realizados em nosso laboratório relataram a potente atividade pró-inflamatória de ExoU, responsável por um intenso recrutamento de neutrófilos para o sítio de infecção. No presente trabalho, o efeito de ExoU na modulação da ativação do fator transcricional NF-&#954;B e na regulação da expressão e da secreção da quimiocina para neutrófilos IL-8 foi avaliado em culturas de células epiteliais respiratórias e endoteliais humanas infectadas com a cepa PA103 de P. aeruginosa (produtora de ExoU) ou com a mutante deletada no gene exoU, PA103&#954;exoU. Análises por RT-PCR semi-quantitativo mostraram que a infecção pela cepa produtora de ExoU levou ao aumento dos níveis de mRNA de IL-8, enquanto ensaios de alteração da mobilidade eletroforética (EMSA), supershift e com gene repórter mostraram que ExoU induziu a translocação nuclear do heterodímero transativador p65/p50 de NF-&#954;B e a ativação da transcrição de genes dependente deste fator transcricional. Adicionalmente, o tratamento das culturas celulares com um inibidor de NF-&#954;B antes da infecção bacteriana reduziu significativamente os níveis de mRNA de IL-8 e da secreção desta quimiocina. Em conjunto, estes resultados mostram que ExoU ativa NF-&#954;B e, consequentemente, estimula a expressão e a secreção de IL-8 por células epiteliais respiratórias e células endoteliais infectadas com P. aeruginosa / ExoU, a cytotoxin produced by the opportunistic pathogen Pseudomonas aeruginosa that is translocated into host cell cytosol by the type three secretory system, has been associated with severity of acute infections. We have previously described the potent ExoU proinflammatory activity, which accounts for a market recruitment of neutrophils to infected tissues. In this present study, the effect of ExoU on the activation of the transcriptional factor NF-&#61547;B and on the regulation of the expression and secretion of the chemokine IL-8 was investigated in human epithelial respiratory and endothelial cell cultures infected with the ExoU-producing PA103 P. aeruginosa or with the bacterial mutant with the deletion of the exoU gene PA103&#61508;exoU. By semi-quantitative RT-PCR, ExoU was shown to significantly increase the expression of IL-8 mRNA. By electrophoretic mobility shift assay (EMSA), supershift and reporter assay ExoU was shown to induce the nuclear translocation of the NF-&#954;B p65/p50 transactivator heterodimer as well as the NF-&#954;B-dependent transcriptional activity. In addition, treatment both the IL-8 mRNA expression and the protein secretion. Together, our results show that ExoU activates NF-&#61547;B and stimulates IL-8 expression and secretion by P. aeruginosa-infected human epithelial respiratory and endothelial cells

Les rejets urbains par temps de pluie dégradent l’état écologique des écosystèmes aquatiques et peuvent induire une exposition des populations humaines aux contaminants chimiques et microbiens (bactéries, virus, parasites). L’objectif de ce travail de thèse était d’évaluer les effectifs et de prédire le devenir de bactéries pathogènes introduites dans les milieux aquatiques par une source majeure comme les eaux usées rejetées par des dispositifs tels que les déversoirs d’orage (DO) et les lagunes d’épuration (WWTL). La répartition d’un agent pathogène fortement liée aux milieux hydriques, Pseudomonas aeruginosa, a été comparée avec celles observées pour des indicateurs de contaminations fécales (E. coli et les entérocoques intestinaux), mais également avec celle de l’espèce pathogène Aeromonas caviae. La dangerosité des formes retrouvées dans ces milieux a été évaluée par approches moléculaires (PFGE et MLST). Les résultats obtenus montrent un fort apport en P. aeruginosa via les eaux usées, avec un effet significatif sur les effectifs observés en fonction de l’intensité des pluies et des périodes de temps sec, et les fluctuations du régime hydrologique et des paramètres physico-chimiques. Une grande diversité infra-spécifique des P. aeruginosa, et la capacité de certains génotypes à s’installer durablement dans ces milieux (macrophytes et périphyton) ont été observées. Certaines souches ont par ailleurs montré une parenté avec des lignées d’infections communautaires, ou encore des clones épidémiques majeurs (PA14 et C). Des études en microcosme ont été effectuées pour valider les interactions observées avec certains macrophytes, et identifier des propriétés d’adhérence bactérienne (dont les lectines) impliquées dans ces interactions. Ces travaux ont impliqué une analyse de la distribution des gènes lecA et lecB, codant des lectines chez P. aeruginosa, et une étude de leurs ligands. Le gène lecA a été localisé dans une zone de forte plasticité génomique. Ces travaux ont permis la description d’une nouvelle structure de l’adhésine LecB / Urban wet-weather discharges degrade the ecological status of aquatic ecosystems and may expose human populations to chemical and microbial contaminants (bacteria, viruses, parasites). The aim of this thesis was to evaluate the numbers and predict the fate of pathogenic bacteria introduced into aquatic ecosystems by a major source like wastewater from devices such as combined sewer overflows (CSO) and wastewater treatment lagoons (WWTL). The distribution of a human pathogen closely linked to hydric environments, Pseudomonas aeruginosa, was compared with those observed for fecal indicators (E. coli and intestinal enterococci), but also with that of Aeromonas caviae pathogenic species. Dangerousness of strains found in these environments was evaluated by molecular approaches (PFGE and MLST). Obtained results showed a high contribution of wastewater in P. aeruginosa release, with a significant effect of rainfall intensity and preceding dry periods, in addition to changes in hydrological regime and physico-chemical parameters on recorded data. A large infra-specific diversity was observed within P. aeruginosa and the ability of some genotypes to colonize permanently aquatic surfaces (macrophytes and periphyton) were observed. Some strains showed a kinship with lineages of community infections or major epidemic clones (PA14 and C). Microcosm studies were performed to validate observed interactions with macrophytes, and to identify bacterialadhesion properties (including lectins) involved in these interactions. These investigations involved analysis of the distribution of lectin encoding loci lecA and lecB within P. aeruginosa, and a study of their ligands. lecA was located in a highly unstable genomic region. This work allowed the description of a new structure of the adhesin LecB

La résistance bactérienne aux antibiotiques dans les établissements de santé complique la prise en charge thérapeutique et entraîne une surmortalité des patients infectés. L'objectif de ce travail était d'évaluer différentes approches ayant pour finalité la prévention et la maîtrise des infections nosocomiales. Ce travail s'articule autour de trois questions : (i) Existe-t-il une stratégie de promotion d'un juste usage des antibiotiques à privilégier ? (ii) Comment évaluer la performance en matière d'hygiène des mains ? (iii) Quelles mesures pouvons-nous proposer pour limiter la diffusion de P. aeruginosa ?Nous avons d'abord montré que la diffusion de recommandations sous la forme de guides régionaux ou de messages de pharmacovigilance était suivie d'une modification des prescriptions antibiotiques conformes aux recommandations.Ensuite, nous avons évalué le niveau de performance des établissements de santé en matière d'hygiène des mains en étudiant plus particulièrement l'indicateur de consommation de solution hydro-alcoolique (ICSHA). Nous avons ainsi pu montrer que le nombre minimal d'opportunité d'hygiène des mains servant à son calcul, était sous-estime. Dans une autre étude, nous avons été confrontés aux limites liées à sa construction, ces dernières étant en partie responsable de l'absence de relation observée entre cet indicateur et la prévalence des infections associées aux dispositifs invasifs.Enfin, nous avons montré que la charge en soins et la contamination des réseaux d'eau propre des établissements de santé étaient des facteurs de risque contextuels d'acquisition du bacille pyocyanique. Un autre travail a mis en évidence que les réseaux d'eau usée étaient impliqués dans la diffusion extra-hospitalière de souches résistantes. Une étude est actuellement en cours pour évaluer l'intérêt d'une approche globale associant dépistage et précautions complémentaires chez les patients porteurs de P. aeruginosa.En conclusion, si ce travail confirme l'efficacité de certaines actions de prévention tout en mettant en avant les limites d'autres approches, il ne permet pas de privilégier une stratégie particulière. Il apparaît ainsi nécessaire de mettre en place des stratégies globales et transversales allant au-delà des seuls établissements de santé / Bacterial resistance to antibiotics in health care facilities complicates the therapeutic burden and increased mortality of infected patients. The objective of this work was to evaluate different approaches which aim was to prevent and control hospital-acquired infections. This work focuses on three issues: (i) Is there a strategy already in place to promote the appropriate use of antibiotics? (ii) How can we evaluate performance in terms of hand hygiene? (iii) What measures can we implement to limit the spread of P. aeruginosa?We first showed that the distributions of regional guidelines or drug monitoring alerts were followed by a change in the uptake of antibiotic prescriptions in line with such recommandations.Then we evaluated the performance of health care facilities for hand hygiene, focusing especially on the index of consumption of alcohol-base hand-rub solution. We showed that the number of alcohol-based hand-rub is far higher than that defined by the French Ministry of Health. In another study, we were faced with limitations in its construction, the latter being partly responsible for the lack of a relationship between this indicator and the prevalence of invasive devices associated with infections.Finally, we have shown that the burden of care and the contamination of clean water networks of health facilities were contextual risk factors for acquisition of Pseudomonas aeruginosa. Another study showed that wastewater networks were involved in extra-hospital spread of resistant strains. A study is currently underway to assess the value of a global approach combining screening and additional precautions in patients with P. aeruginosa.In conclusion, this study confirms the effectiveness of some preventive measures while underlining the limitations of other approaches. However it does not promote a particular strategy. Because in terms of BMR, it is necessary to define global and cross-sectorial strategies which go beyond the health care facilities

P. aeruginosa é um importante agente de infecções relacionadas à assistência em saúde. Habitualmente, o estabelecimento de infecções agudas é precedido pela colonização das mucosas dos pacientes. Não se sabe, porém, se os processos infecciosos são causados pelas próprias cepas bacterianas colonizadoras ou por outras com que os pacientes entrem em contato, dotadas ou não de maior potencial de virulência ou de resistência a antimicrobianos que as tornem mais eficientes como agentes infecciosos. Assim, este estudo teve como objetivos i) investigar a existência de potenciais diferenças entre amostras de P. aeruginosa que causaram apenas colonização e aquelas responsáveis por infecção, isoladas de um mesmo paciente, quanto a seus fenótipos de virulência e de não susceptibilidade a antimicrobiamos; ii) pesquisar a existência de associação entre características dos paciente, incluindo o tipo de evolução clínica, com as demais variáveis estudadas. No estudo foram incluídos 21 pacientes que desenvolveram infecção por P. aeruginosa durante sua internação no Centro de Terapia Intensiva do Hospital Universitário Clementino Fraga Filho, entre abril de 2007 e abril de 2008. De cada paciente foram selecionadas duas amostras bacterianas: a primeira isolada durante o episódio de infecção e a amostra colonizadora obtida imediatamente antes da ocorrência da infecção. As amostras selecionadas foram estudadas quanto a i) expressão de três mecanismos de virulência (citotoxicidade, aderência a células epiteliais respiratórias humanas e capacidade de formação de biofilme); ii) presença de genes codificadores das proteínas efetoras do sistema de secreção do tipo 3 (SST3 - exoS, exoT, exoU e exoY); iii) perfil de susceptibilidade a antimicrobianos, iv) perfil de fragmentação do DNA cromossômico por eletroforese em gel de campo pulsado (PFGE). As amostras bacterianas obtidas de infecções agudas foram significativamente mais citotóxicas que aquelas obtidas de colonização. Embora sem diferença estatística, a citotoxicidade das amostras que causaram infecção em pacientes que evoluíram para óbito foi superior à citotoxicidade das amostras de pacientes que sobreviveram. O gene que codifica a toxina ExoU foi detectado em 16 amostras (38%), sendo nove de colonização e sete de infecção. Não houve diferença significativa entre as amostras de colonização e infecção quanto à aderência, produção de biofilme, expressão dos genes do SST3 e não-susceptibilidade às diferentes classes de antimicrobianos. Também não foi encontrada associação entre a não-susceptibilidade à quinolona, ou a outras classes de antimicrobianos, e a presença do gene exoU. As 42 amostras de P. aeruginosa estudadas foram incluídas em 20 genótipos. Em 10 deles foi detectado o gene exoU. Amostras de um mesmo genótipo foram uniformes quanto à expressão dos genes do SST3 e a não-susceptibilidade aos antimicrobianos, mas não quanto às outras variáveis estudadas. Em apenas sete pacientes (33,3%), as amostras de colonização e de infecção pertenciam ao mesmo genótipo. Assim, nesse estudo, o estabelecimento do processo infeccioso resultou não da perda do equilíbrio estabelecido entre os mecanismos de agressão das amostras colonizadoras e os de defesa do hospedeiro e sim da introdução de nova cepa bacteriana no organismo hospedeiro, cepa esta dotada de maior potencial citotóxico. / P. aeruginosa is an important agent of healthcare-associated infections. The establishment of acute infectious episodes is usually preceded by colonization of patient mucosa. However, it remains unknown whether the infectious processes are caused by bacterial strains previously colonizing the patient or by additional strains the patient may come into contact. These new isolates may carry greater virulence potential or antibiotic resistance that makes them more efficient as an infecting agent. Thus, the objetives of the present study were i) to investigate the existence of potential differences between P. aeruginosa isolates obtained from a colonized mucosa and isolates accounting for infectious processes, recovered from the same patient, with respect to virulence phenotypes and non-susceptibility to antimicrobial agents; ii) to investigate the existence of association between patient features, including the type of clinical outcome, with bacterial characteristics. The study included 21 patients who developed P. aeruginosa infection during their stay in the Intensive Care Unit of the University Hospital Clementino Fraga Filho, from April 2007 to April 2008. Two P. aeruginosa isolates were selected from each patient: the first isolate recovered from the infectious episode and the colonizing isolate obtained immediately before the onset of the infection. Features from the isolates investigated included: i) expression of three virulence mechanisms (cytotoxicity, adherence to human respiratory epithelial cells and biofilm formation); ii) presence of the genes encoding type III secretion system effector proteins (TTSS, exoS , exoT , exoU and exoY); iii) antimicrobial susceptibility profile; iv) profile of the bacterial chromossomic DNA fragmentation following analysis by pulsed-field gel electrophoresis (PFGE). The bacterial isolates obtained from acute infections were significantly more cytotoxic than colonizing strains. Moreover, bacteria accounting for infectious episodes in patients who died were more cytotoxic than those recovered from patients who survived, although the differences were not statistically significant. The ExoU toxin encoding gene was detected in 16 (38%) P. aeruginosa isolates: nine colonizing and seven infecting strains. There was no significant difference between colonizing and infecting samples in their adherence, biofilm production, expression of TTSS genes and non- susceptibility to different classes of antimicrobials. There was also no association between non-susceptibility to quinolone, or to any other class of antimicrobial agents, and the presence of the exoU gene. Twenty PFGE genotypes were identified. Isolates from 10 genotypes harboured the exoU gene. Isolates included in the same PFGE genotype exhibited a similar profile of TTSS genes and non-susceptibility to antimicrobials, but not always a similar profile of expression the other variables investigated. In only seven patients (33.3%), the colonizing and infecting isolates belonged to a same genotype. Thus, in this study, the establishment of the infectious process did not result from the loss of the equilibrium established between the aggression mechanisms of colonizing bacteria and host defense but rather from the introduction, in the host organism, of a new bacterial strain, endowed with a greater cytotoxic potential.