Aim: This thesis aims to explore and investigate the level and process of adoption of Antimicrobial Stewardship Programmes (ASPs) and factors influencing their implementation in Saudi Ministry of Health (MOH) hospitals. The findings of this study will provide hospitals and policy makers with evidence-based recommendations on how barriers to ASPs adoption can be overcome, which will ultimately improve antimicrobial use and reduce antimicrobial resistance (AMR). Method: A mixed method approach was carried out using both qualitative and quantitative research methods. Semi-structured interviews were conducted with healthcare professionals in three Saudi hospitals to explore the enablers and barriers to their adoption of ASPs. A survey was then developed based on these findings to investigate the level of hospitals' adoption of ASPs and factors influencing their implementation at a national level. Further, a case study using in-depth interviews was utilised to understand the process of ASP adoption in a Saudi hospital, and how adoption challenges were addressed. Finally, a self-administered questionnaire was used to examine patients' knowledge and perceptions of antimicrobial use and resistance, and to evaluate the institutional role of patient education on antimicrobial use in two Saudi hospitals. The overall methodology of the research is summarised in Figure I. Results: Despite the introduction of a national ASP strategy, adoption of ASPs in Saudi MOH hospitals remains low. Organisational barriers such as the lack of senior management support, lack of supportive IT infrastructure and the shortage of ASP team members hinder hospitals' efforts to adopt ASPs. Further barriers relate to the lack of formal enforcement by MOH and the physicians fears of patients' complications and clinical liability. Patients admitted to Saudi hospitals lack knowledge and perceptions of AMR, and the adoption of ASPs may improve hospitals' role in patients' education. Conclusions: Despite the established benefits of ASPs, their adoption in Saudi MOH hospitals remains low. Urgent action is needed to address the strategies priorities associated with AMR, including access to antimicrobials, antimicrobial stewardship and education and research. Policy makers are urged to consider making ASPs adoption in hospitals a regulatory requirement supported by national guidelines and surveillance programmes. It is essential to increase the provision of ID and infection control residency and training programmes to meet the extreme shortage of ID physicians, pharmacists, microbiologists and infection control practitioners. Higher education institutions and teaching hospitals are required to introduce antimicrobial prescribing and stewardship competencies into undergraduate Medical, Pharmacy, Dental, Nursing and Veterinary curriculum, as well as introduction of AMR topics in order to increase knowledge and awareness of ASPs and AMR. Collaboration between ASPs adopting and non-adopting hospitals is essential to share implementation experience, strategies and solutions to overcome barriers. Healthcare specialised associations are needed to be part of AMR conversation and guide healthcare professionals' training and accreditation. Multiple stakeholders should be actively part of the conversations around tacking AMR. Primary care, secondary care, community pharmacies and policy makers should strive to create a shared culture of responsibility among all healthcare partners to improve antimicrobial therapy and reduce risks of AMR.

Os prejuízos causados por Escherichia coli patogênica para aves (APEC) na produção de aves é justificativa de pesquisas realizadas no mundo todo há décadas. Recentemente, o potencial zoonótico e a multirresistência das cepas desse patotipo têm sido alvo frequente dos trabalhos realizados com APEC. O objetivo desse trabalho foi caracterizar 225 cepas APEC isoladas de perus condenados por aerossaculite em abatedouros em relação à resistência a 14 antimicrobianos, perfil de virulência e grupos filogenéticos. 92% das amostras apresentaram perfil de multirresistência (MDR) e os índices mais altos de resistência foram a sulfonamidas (94%), tetraciclina (83%), eritromicina (82%), estreptomicina (60%), amoxicilina (53%) e ácido nalidíxico (48%). Metade das cepas foram classificadas no grupo filogenético B2 (50%), seguido por B1 (28,6%), grupo A (17,1%) e grupo D (4,8%). Os genes de virulência pesquisados tiveram prevalência de iroN (95%), iss (93%), cvi/cva (67%), iucD (67%), tsh (56%), irp2 (51%), ibeA (31%), vat (24%), neuS (19%), astA (17%) e papC (15%). Considerando o potencial zoonótico e a associação a um maior número de genes de virulência quando comparadas aos outros grupos filogenéticos, as cepas B2 foram selecionadas para pesquisa de integrons de classe 1 e clonalidade. As 112 amostras B2 eram pertencentes a 83 diferentes perfis ERIC, sendo classificadas como multiclonais. Os integrons de classe 1 estiveram presentes em 107 isolados (95,5%). Esses resultados demonstram que a maioria das cepas pesquisadas pertencia ao grupo mais virulento (B2) e relacionado a cepas ExPEC humanas. Aliado ao alto índice de multirresistência encontrado, esses dados sugerem que as aves podem servir como reservatório de cepas patogênicas e multirresistentes, tanto para humanos como para animais, reforçando a ideia de que as aves representem importante papel na cadeia epidemiológica das ExPEC. / Avian Pathogenic Escherichia coli (APEC) has been studied for decades because of its economic impact on the poultry industry. Recently, the zoonotic potential of APEC and multidrug-resistant strains have emerged. The aim of this study was to investigate the virulence profile, phylogenetic background and antimicrobial resistance in 225 strains of Escherichia coli isolated from turkeys presenting airsacculitis. The results showed that 92% of strains presented a multidrug-resistance (MDR) profile, and the highest levels of resistance were to sulfamethazine (94%), tetracycline (83%). Half of these strains (112/225) were classified in phylogenetic group B2, followed by groups B1 (28.6%), A (17.1%) and D (4.8%). The prevalence of virulence genes was as follows: iroN (95%), iss (93%), cvi/cva (67%), iucD (67%), tsh (56%), irp2 (51%), ibeA (31%), vat (24%) neuS (19%), astA (17%) and papC (15%). Considering the zoonotic potential and association to a greater number of virulence genes when compared to other phylogenetic groups, B2 strains were selected for screening of class 1 integrons and clonality. The 112 samples belonging to 83 ERIC profiles and classified as multiclonal. Class 1 integrons were present in 107 isolates (95.5%).These results demonstrate that the majority of the investigated strains belonged to group B2, which is more virulent and is related to human ExPEC strains. Coupled with the high rate of multidrug-resistance found, these data suggest that turkeys may serve as a reservoir for pathogenic and multidrug-resistance strains, for humans and animals, reinforcing the idea that poultry plays an important role in the epidemiological chain of ExPEC.

As infecções por Streptococcus pneumoniae (pneumococo) ainda desafiam os sistemas de saúde em todo mundo. Este é um estudo observacional, de seguimento retrospectivo, que avaliou aspectos microbiológicos e clínicos das cepas de pneumococo isoladas de pacientes com doença invasiva pneumocócica (DIP) isolados nos Departamentos Regionais de Saúde (DRS) de Araraquara, Barretos, Franca e Ribeirão Preto, em um período de 16 anos (1998-2013). As informações foram obtidas junto ao Instituto Adolfo Lutz e, no banco de dados do Hospital das Clínicas de Ribeirão Preto (HCRP). Analisou-se 796 linhagens, com predominio do gênero masculino (58,9%), da faixa etária de 20 a menores de 60 anos de idade (32,2%) e do período de 2003 a 2010 (60,2%). As DIPs mais comuns foram a meningite (45,7%) e a pneumonia (45,0%). Quanto aos sorotipos mais frequentes, observou-se em 83,3%: 14, 3, 19F, 1, 6A, 6B, 23F, 9V, 18C, 19A, 12F, 4, 7F, 5, 22F, 11A, 8, 9N, 10A e 15C, sendo o 14 o mais comum nos quatro DRS estudados. Os sorotipos 14, 3 e 19F foram mais frequentes na meningite, enquanto os sorotipos 14, 3 e 1 na pneumonia. Após 2010, verificou-se diminuição dos sorotipos 14, 1, 23F e 5 e aumento de 12F, 11A e 8, não contidos na vacina. A resistência à penicilina foi de 14,8%, sendo 3,0% resistência intermediária e 11,8% de resistência plena. Para ceftriaxona, 5,3% foram não sensíveis. A sensibilidade ao cloranfenicol, eritromicina e ceftriaxona manteve-se acima dos 90%, no período estudado. O maior nível de resistência foi observado para Sulfametoxazol/trimetoprim (49,4%). Destaca-se o aumento dos sorotipos 12F, 11A e 8 após a vacinação, considerando que nenhum deles compõe as vacinas conjugadas disponíveis. Observou-se variabilidade de resistência entre os diferentes sorotipos de pneumococo. A DIP mais frequente nos pacientes cadastrados no HCRP foi a pneumonia (67,8%), seguida da meningite (22,9%) tendo como sorotipos mais frequentes 14, 6A, 23F, 1, 3, 18C, 19F, 12F, 4,9V, 6B e 19A. Destes pacientes 67,5% apresentaram cura sem sequelas, 6,9% tiveram algum tipo de sequela e 25,6% evoluíram para óbito. A pneumonia causou 18,2% dos óbitos, principalmente na faixa etária de 20 a menores de 60 anos de idade. Os sorotipos 12F, 14, 18C, 9V, 18A, 19A e 23F foram responsáveis por 64,9% dos óbitos por meningite, enquanto os sorotipos 3, 14, 9V, 6B, 23F e 19F estiveram envolvidos em 63,4% das mortes por pneumonia. Entre os pacientes que morreram 68,2% tinham algum tipo de comorbidade, sendo HIV/AIDS, alcoolismo e câncer as mais comuns. A faixa etária com 60 anos ou mais foi a mais significativa (OR=4,2) para o insucesso, independente da presença de comorbidade. A presença do sorotipo 18C foi fator de risco significativo tanto na análise bruta (OR=3,8), quanto ao ajustar por comorbidade (OR=5,0) ou ajustada por idade (OR=5,4). O mesmo ocorreu para o sorotipo 12F (respectivamente, OR=5,1, OR=5,0 e OR=4,7). Observou-se alterações na circulação de alguns sorotipos de pneumococo no período pós VPC10. Ressalta-se a importância da continuidade da vigilância das DIPs, afim de determinar oscilações clínicas e microbiológicas da doença. Além disto, na era das vacinas conjugadas, o contínuo monitoramento sobre a distribuição de sorotipos na população é necessário para a avaliação do impacto e adequação da imunização / Infections by Streptococcus pneumoniae (pneumococcus) are still a challenge to health systems worldwide. An observational retrospective study was developed to assess microbiological and clinical aspects of pneumococcus strains isolated from patients with invasive pneumococcal diseases (IPD) which were isolated in the Regional Health Departments (DRS) of Araraquara, Barretos, Franca and Ribeirão Preto, in a period of 16 years (1998-2013). Data were obtained at the Adolfo Lutz Institute and in databases of the Clinics Hospital of Ribeirão Preto (HCRP). A total of 796 strains were analyzed, with prevalence of male individuals (58.9%), aged between 20 and 60 years (32.2%), and in the period between 2003 and 2010 (60.2%). The most common IPD were meningitis (45.7%) and pneumonia (45.0%). Regarding the most frequent serotypes, in 83.3% they were: 14, 3, 19F, 1, 6A, 6B, 23F, 9V, 18C, 19A, 12F, 4, 7F, 5, 22F, 11A, 8, 9N, 10A and 15C, with 14 being the most common in the four DRS studied. Serotypes 14, 3 and 19F were more frequent in meningitis, whereas serotypes 14, 3 and 1 were more frequent in pneumonia. After 2010, there was a decrease in serotypes 14, 1, 23F and 5, and an increase in 12F, 11A and 8, which are not included in the vaccine. Resistance to penicillin was 14.8%, with 3.0% being intermediate, and 11.8% full resistance. For ceftriaxone, 5.3% were not sensitive. Sensitivity to chloramphenicol, erythromycin and ceftriaxone remained over 90% in the studied period. The highest level of resistance was observed for Sulfamethoxazole/trimethoprim (49.4%). It is noteworthy that there was an increase in the s serotypes 12F, 11A and 8 after vaccination, considering that none of them make up the combined vaccines available. Resistance varied among the different serotypes of pneumococcus. The most frequent IPD in the patients registered in the HCRP was pneumonia (67.8%), followed by meningitis (22.9%), with the most frequent serotypes being 14, 6A, 23F, 1, 3, 18C, 19F, 12F, 4, 9V, 6B and 19A. Of these patients, 67.5% were cured without sequela, 6.9% had some sort of sequela and 25.6% evolved to death. Pneumonia caused 18.2% of the deaths, mainly in the age range between 20 and 60 years. Serotypes 12F, 14, 18C, 9V, 18A, 19A and 23F were responsible for 64.9% of the deaths by meningitis, whereas serotypes 3, 14, 9V, 6B, 23F and 19F were involved in 63.4% of the deaths by pneumonia. Among the patients who died, 68.2% had some sort of comorbidity, with HIV/AIDS, alcoholism and cancer being the most common. The age range over 60 years was the most significant (OR=4.2) for failure, regardless of the presence of a comorbidity. The presence of serotype 18C was a significant risk factor both in the gross analysis (OR=3.8), and in the adjustment as for comorbidity (OR=5.0) or age (OR=5.4). This was also true for the serotype 12F (respectively, OR=5.1, OR=5.0 and OR=4.7). There were alterations in the circulation of some pneumococcus serotypes in the period after VPC10. it is emphasized the importance of continued monitoring of DIPs, in order to determine clinical and microbiological fluctuations of the disease. In addition, in the era of combined vaccines, it is necessary to keep monitoring the distribution of serotypes in the population to assess the impact and adequacy of immunization

Made available in DSpace on 2016-04-28T20:15:24Z (GMT). No. of bitstreams: 1 2007- Ingrid Annes Pereira.pdf: 915318 bytes, checksum: 2dd2600d64dd3aa95cfa91ab1bd4177c (MD5) Previous issue date: 2007-02-28 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / Antimicrobial resistance is a complex question that concerns a variety of bacterial species and resistance mechanisms, which in part can be transmitted from pet animals to the owners by theirs strict contact. The prescription of antimicrobial agents in the veterinary practices, without previous identification of the etiologic agent and its antimicrobial susceptibility pattern associated with the large use of antimicrobials applied in human medicine represent a potential source for the spread of resistant strains in animal reservoir. Azithromycin widely used in human medicine, presents bacteriostatic activity against several infectious agents, and recently it was released in Brazilian veterinary practices as an alternative for the treatment of urinary, respiratory, oral and skin infections. This work evaluated the activity pattern of azithromycin to different bacterial infections from pet animals, by the identification of the etiologic agent and its antimicrobial susceptibility pattern, and also determinate MIC values and evaluate cross-resistance to oxacilin and azithromycin in Staphylococcus spp., as a proposal to construct the real frame of azithromycin resistance in our region so as its use represent a reliable alternative in veterinary medicine. The samples were collected from different sites of infection in dogs and cats, like otitis externa, pyoderma, infections from the urinary, reproductive and respiratory tract, oral and conjuntival mucosas. The most prevalent bacterial agents were coagulase-positive Staphylococcus spp., followed by Entorabacteiaceae, coagulase-negative Staphylococcus spp., and Pseudomonas spp.. The isolates were most sensible to ampicilin+sulbactam, gentamicin, fluoroquinolones and some cephalosporins. The bacterial isolates showed an expressive azithromycin resistance, with exception of the isolates from urinary tract infection. Different tests were used to access the activity pattern of azithromycin, such as Disc Diffusion and Broth Microdiluition that detected 48,6% and 55% of resistants Staphylococcus spp., and 55,3% e 72,7% of resistants Gram-negative rods. Staphylococcus aureus MIC50 were 4,0 μg/mL, S. intermedius 1,0 μg/mL, coagulasenegative Staphylococcus ≥512 μg/mL and Gram-negative rods were 256 μg/mL. In nine (15%) isolates of oxacilin-resistant and mecA-positive Staphylococcus spp. were also possible detect azithromycin resistance. For this reasons, the laboratories investigations are necessary for the identification of the etiologic agents of bacterial infections and to determine its susceptibility to antimicrobials, for the best choice of treatment, and to impair the emergence of resistant bacteria that can be transmitted between animals and human, like what happens in oxacilin-resistant Staphylococcus spp.. The emergence of azithromycin resistance leads to the necessity of reliable data on the concern of the activity pattern of this antimicrobial and its contribution for the veterinary medicine practices without producing impact in development and spread of resistant strains. / A resist?ncia antimicrobiana ? um problema complexo, que envolve in?meras esp?cies bacterianas e diferentes mecanismos, podendo ter sua transmiss?o facilitada pelo estreito conv?vio entre animais de companhia e seus propriet?rios. A pr?tica de prescrever antibioticoterapia sem pr?via identifica??o do agente etiol?gico e do seu perfil de suscetibilidade associada ao amplo uso de antimicrobianos aplicados ? medicina humana representam potenciais fatores para a dissemina??o de cepas resistentes em reservat?rios animais. A azitromicina, j? amplamente utilizada no tratamento de infec??es em humanos, apresenta atividade bacteriost?tica contra uma gama de agentes infecciosos e est? dispon?vel atualmente para a cl?nica veterin?ria brasileira como alternativa de tratamento em processos infecciosos dos sistemas genito-urin?rio, respirat?rio, oral e pele. Dessa forma, o presente estudo avaliou o espectro de atividade da azitromicina, em diversos processos infecciosos bacterianos de animais de companhia, estabelecendo o pat?geno prevalente, seu perfil de suscetibilidade aos f?rmacos de elei??o, al?m de determinar a CIM da azitromicina e avaliar a poss?vel resist?ncia cruzada em Staphylococcus spp. oxacilina e azitromicina-resistentes, de forma a obter dados significativos para a constru??o do quadro real de resist?ncia ? azitromicina em nossa regi?o, para que seu uso represente uma alternativa terap?utica confi?vel em Medicina Veterin?ria. As amostras estudadas foram coletadas de diferentes processos infecciosos de c?es e gatos, tais como, otites externas, piodermas, infec??es do trato genito-urin?rio, respirat?rio, cavidade oral e da mucosa conjuntival. Os agentes bacterianos mais prevalentes foram Staphylococcus spp. coagulasepositivos, seguidos pelas enterobact?rias, Staphylococcus spp. coagulase-negativos e Pseudomas spp. De modo geral, os isolados foram mais sens?veis a ampicilina+sulbactam, gentamicina, fluoroquinolonas e algumas cefalosporinas. A azitromicina apresentou percentuais de resist?ncia significativos, com exce??o dos isolados de infec??es do trato urin?rio. Diferentes testes foram utilizados para avalia??o do perfil de atividade da azitromicina dentre estes, a Difus?o em Disco e a Microdilui??o em Caldo, detectaram resist?ncia em 48,6% e 55% dos isolados de Staphylococcus spp., respectivamente e 55,3% e 72,7% dos bastonetes Gram-negativos. A CIM50 para S. aureus foi 4,0 μg/mL, para S. intermedius 1,0 μg/mL, Staphylococcus spp. coagulase-negativos ≥512 μg/mL e bastonetes Gram-negativos 256 μg/mL. Em nove isolados (15%) de Staphylococcus spp. resistentes ? oxacilina e mecA positivos foi poss?vel tamb?m detectar resist?ncia ? azitromicina. Logo, a investiga??o laboratorial de doen?as bacterianas ? necess?ria para identificar o agente etiol?gico e determinar a suscetibilidade aos antimicrobianos a fim de selecionar o f?rmaco ideal e limitar o desenvolvimento de resist?ncia, uma vez que bact?rias resistentes podem ser transmitidas entre animais e desses para o homem, como j? observado em isolados de Staphylococcus spp. resistentes ? oxacilina. O desenvolvimento de resist?ncia a azitromicina aponta para a necessidade de estudos que forne?am dados confi?veis a respeito do perfil de atividade desse f?rmaco de forma a contribuir na terap?utica veterin?ria sem causar impacto no desenvolvimento e dissemina??o de cepas resistentes.

Antimicrobials are unique drugs in that they target "infectious" or "transferable" diseases. There is considerable evidence linking increasing antimicrobial use withincreasing resistance. Resistant bacteria do not know the boundaries, either between countries or within a society between hospital and primary care. Inappropriate prescribing of antimicrobials in hospitals therefore has consequences for whole communities and problems may spread both nationally and internationally. The gathering of reliable measurements of antibiotic use in hospitals employing standardised methods is essential to building an evidence base and highlighting inconsistencies at national and international levels. In this study, after data processing, validating and record linkage, a method forelectronic conversion of drug supply data to the ATC/DDD classification and forlongitudinal analysis was established for Tayside and then for a set of Europeanhospitals. Time series analysis and interrupted time series analysis were described and used for longitudinal surveillance and interventional study of antimicrobial use. This thesis explores issues concerning the evolution and management of hospital antimicrobial use using a wide range of methods. A series of drug utilisation research studies were implemented as the basis of research methods that, in combination of previously described methods, provided novel studies. No single measure can currently capture all of the aspects of hospital antibiotic use. However, a combination of detailed, point prevalence data from individual patients with longitudinal analysis of total consumption can provide meaningful data for comparison between hospitals and for analysis of the relationship between use and outcome. Additionally, there is a need to apply standard processes and novel methods to produce more meaningful surveillances. Longitudinal and point prevalence surveillances together with an explanation ofvariations in hospital characteristics are used to produce a set of coherent measurements of hospital antimicrobial use. Administrative data for longitudinal surveys requires continuous quality control.Whereas drug utilisation researchers and clinicians should target a set of indicators for interventional studies, large studies at national or international level need central data processing by country to identify targets for evaluation and for interventional studies. Support from experts in other fields is needed to address any shortcomings that may be experienced during continuous antibiotic drug utilisation monitoring at national and international levels.

Bactérias resistentes aos antimicrobianos representam um risco, não apenas para a saúde animal, como também para a saúde pública. As bactérias comensais, como Escherichia coli, são consideradas um bom indicador do padrão de resistência de uma população microbiana, uma vez que, por residirem no intestino, estão submetidas à constante pressão de seleção resultante da administração de antimicrobianos, podendo sobreviver ao processo de abate de suínos e chegar aos consumidores. Neste sentido, os objetivos deste estudo foram: i. avaliar a frequência de resistência antimicrobiana fenotípica e a presença de grupos clonais em E. coli isoladas de fezes e carcaças suínas; ii. determinar o perfil fenotípico e genotípico de resistência aos antimicrobianos em isolados multirresistentes de E. coli provenientes de carcaças de suínos e identificar grupos clonais presentes em carcaças suínas; iii. comparar o perfil fenotípico de resistência antimicrobiana em isolados de E. coli de fezes de suínos submetidos a diferentes protocolos de administração de antimicrobianos via ração; iv. descrever o perfil da microbiota intestinal de suínos submetidos a diferentes protocolos de uso de antimicrobianos via ração. Para isto, três etapas distintas foram realizadas. Na etapa 1, dois ciclos de amostragem foram conduzidos em três matadouros-frigoríficos (A, B, C) de suínos, sendo coletado fezes depositadas no piso da pocilga de espera e suabes de superfície de carcaças na etapa de pré-resfriamento. Escherichia coli foi isolada dessas duas origens e avaliada quanto à resistência aos antimicrobianos. Além disso, 92 isolados de ambas as origens apresentando perfil de multirresistência foram submetidos à análise por Pulsed-field gel eletrophoresis (PFGE). Para a etapa 2, os isolados multirresistentes provenientes de carcaças foram submetidos a novos testes de sensibilidade antimicrobiana e de acordo com o perfil fenotípico foram pesquisados quanto aos genes de resistências e submetidos à técnica de PFGE. Em relação a etapa 3, quatro grupos de suínos que utilizavam protocolos distintos de uso de antimicrobianos via ração foram acompanhados em todas as fases zootécnicas e avaliados quanto a frequência de resistência antimicrobiana de E. coli e perfil bacteriano da microbiota intestinal através do sequenciamento de duas regiões do gene 16S rRNA. Entre os 674 isolados de E. coli da etapa 1 apenas 7,4% foram susceptíveis a todos os antimicrobianos testados. As maiores frequências de resistência foram identificadas frente à tetraciclina (85,9%), ampicilina (73,0%), sulfonamida (70,0%), florfenicol (65,0%) e ácido nalidíxico (58,9%). Do total de isolados de E. coli, 79,5% (536/674) foram classificados como multirresistentes. A análise de macro restrição (PFGE), conduzida em isolados apresentando perfis de multirresistência mais prevalentes, demonstrou que isolados de fezes e carcaças eram na maioria dos casos relacionados (similaridade ≥70%) nos três matadouros-frigoríficos. Dos isolados multirresistentes provenientes das carcaças, dez novos antimicrobianos foram testados; em relação a esses, as maiores frequências de resistências foram à cloranfenicol (86,4%), estreptomicina (65,8%) e trimetoprima (57%). Cada matadouro-frigorífico apresentou um perfil distinto de multirresistência predominante. Nos isolados submetidos à pesquisa de genes de resistência, foram detectados por ordem de frequência: strA (83,3%); aac(3)IVa (70%); tetB (70%); sul2 (60%); floR (56,6%); tetA (50%); aph(3)Ia (43,3%); sul3 (26,6%) e blaTEM (10%); três grupos de isolados relacionados (similaridade ≥ 70%) foram encontrados na análise por PFGE. Em relação à etapa 3, os grupos com diferentes protocolos de uso antimicrobianos via ração não apresentaram alteração significativa no perfil de microbiota intestinal e contagem de E. coli; entretanto, os perfis fenotípicos de resistência antimicrobiana foram distintos entre os grupos. O grupo que recebia protocolo com uso alternado de antimicrobianos de seis classes distintas apresentou maior frequência de resistência e multirresistência. De acordo com os resultados encontrados protocolos de uso continuado de antimicrobianos na criação de suínos gera uma pressão seletiva, resultando em cepas multirresistentes que podem sofrer propagação no ambiente e na cadeia de produção de alimentos. Considerando os perfis de resistência encontrados em E. coli originada de carcaças suínas e fezes, em todas as etapas deste trabalho, observou-se que essas cepas são selecionadas na granja pelo uso de antimicrobianos, chegaram ao pré-abate, disseminaram-se na linha de abate e contaminar a carcaça. O uso prudente de antimicrobianos é amplamente citado em toda a literatura científica veterinária e, conforme nossos resultados demonstraram, deve ser incluído entre as metas da suinocultura brasileira. / Bacteria resistant to antimicrobials present a hazard not only for animal health but public health too. Commensal bacteria, such as Escherichia coli, are considered a good indicator of microbial population resistance, because they live in gut and are subjected to constant pressure resulting selection of the administration of antibiotics, may survive in slaughtering process and get consumers. In this sense, the aims of this study were: i. to evaluate the frequency of antimicrobial phenotype resistance and presence of clonal groups for E. coli isolated from feces and pig carcasses; ii. to determine phenotypic profile and antimicrobial genotypic resistance in multiresistant E. coli isolated from pig carcasses and identify clonal groups present in pig carcasses; iii. to compare phenotypic profile of antimicrobial resistance in E. coli from swine feces submitted to different antimicrobial in-feed protocols; iv. to describe gut microbiota profile in pigs submitted to different antimicrobial in-feed protocols. For this, three steps were performed. In step 1, two sampling cycles were conducted in three slaughterhouses (A, B, C) of pigs being collected feces deposited in pen floor and pre-chill carcasses. Escherichia coli was isolated from these two sources and evaluated for antimicrobial resistance. In addition, 92 isolates with multidrug resistance profile were analyzed by pulsed-field gel eletrophoresis (PFGE). In step 2, isolated from carcasses and multiresistant underwent new antimicrobial susceptibility testing and in accordance with the phenotypic profile were screened for the resistance gene and PFGE. In step 3, four groups of pigs used different antimicrobial in-feed protocols were followed in all phases and evaluated frequency of antimicrobial resistance and gut bacterial profile by sequencing two regions of 16S rRNA. Among the 674 E. coli isolates from step 1 just 7.4% were susceptible to all antibiotics. The highest frequencies of resistance were: tetracycline (85.9%), ampicillin (73.0%), sulfonamide (70.0%), florfenicol (65.0%) and nalidixic acid (58.9%). Of total E. coli isolates, 79.5% (536/674) were multidrug. Macrorestriction analysis (PFGE), conducted in isolates with profiles more prevalent multidrug resistance showed that isolated from feces and carcasses were in most cases related (≥70% similarity) in the three slaughterhouses. The multiresistant isolates from carcasses, ten new antibiotics were tested, with greatest frequency in add antimicrobial resistance were: chloramphenicol (86.4%), streptomycin (65.8%) and trimethoprim (57%). Each slaughterhouse showed a distinct profile of resistance and number of resistance markers. Isolates submitted to research genes were detected in order of frequency: strA (83.3%); aac(3)IV (70%); tetB (70%); sul2 (60%); floR (56.6%); tetA (50%); aph(3)Ia (43.3%); sul3 (26.6%) and blaTEM (10%); and three related groups (similarity ≥ 70%) were formed in PFGE. For step 3, groups with different antimicrobial in-feed had no significant change in gut microbiota profile and E. coli counts; however the phenotypic profiles of antimicrobial resistance were different between the groups. The group receiving protocol with alternate use of antimicrobials six different classes showed higher frequency of resistance and multidrug resistance. According to the results, different protocols of antimicrobial in pig farming creates a selective pressure, resulting in multi-drug resistant strains that may contribute to spread environment and in food production chain. Considering the resistance profiles found in E. coli originated from swine carcasses and feces, in all stages of this work, it was observed that these strains were selected for in farm by use of antimicrobials, reached the pre-slaughter, spread in the slaughterhouse and carcasses. The concept of prudent use of antimicrobials is widely quoted in all the veterinary scientific literature and, as our results showed, it should be included among the goals of the Brazilian pig farming.

As infecções por Streptococcus pneumoniae (pneumococo) ainda desafiam os sistemas de saúde em todo mundo. Este é um estudo observacional, de seguimento retrospectivo, que avaliou aspectos microbiológicos e clínicos das cepas de pneumococo isoladas de pacientes com doença invasiva pneumocócica (DIP) isolados nos Departamentos Regionais de Saúde (DRS) de Araraquara, Barretos, Franca e Ribeirão Preto, em um período de 16 anos (1998-2013). As informações foram obtidas junto ao Instituto Adolfo Lutz e, no banco de dados do Hospital das Clínicas de Ribeirão Preto (HCRP). Analisou-se 796 linhagens, com predominio do gênero masculino (58,9%), da faixa etária de 20 a menores de 60 anos de idade (32,2%) e do período de 2003 a 2010 (60,2%). As DIPs mais comuns foram a meningite (45,7%) e a pneumonia (45,0%). Quanto aos sorotipos mais frequentes, observou-se em 83,3%: 14, 3, 19F, 1, 6A, 6B, 23F, 9V, 18C, 19A, 12F, 4, 7F, 5, 22F, 11A, 8, 9N, 10A e 15C, sendo o 14 o mais comum nos quatro DRS estudados. Os sorotipos 14, 3 e 19F foram mais frequentes na meningite, enquanto os sorotipos 14, 3 e 1 na pneumonia. Após 2010, verificou-se diminuição dos sorotipos 14, 1, 23F e 5 e aumento de 12F, 11A e 8, não contidos na vacina. A resistência à penicilina foi de 14,8%, sendo 3,0% resistência intermediária e 11,8% de resistência plena. Para ceftriaxona, 5,3% foram não sensíveis. A sensibilidade ao cloranfenicol, eritromicina e ceftriaxona manteve-se acima dos 90%, no período estudado. O maior nível de resistência foi observado para Sulfametoxazol/trimetoprim (49,4%). Destaca-se o aumento dos sorotipos 12F, 11A e 8 após a vacinação, considerando que nenhum deles compõe as vacinas conjugadas disponíveis. Observou-se variabilidade de resistência entre os diferentes sorotipos de pneumococo. A DIP mais frequente nos pacientes cadastrados no HCRP foi a pneumonia (67,8%), seguida da meningite (22,9%) tendo como sorotipos mais frequentes 14, 6A, 23F, 1, 3, 18C, 19F, 12F, 4,9V, 6B e 19A. Destes pacientes 67,5% apresentaram cura sem sequelas, 6,9% tiveram algum tipo de sequela e 25,6% evoluíram para óbito. A pneumonia causou 18,2% dos óbitos, principalmente na faixa etária de 20 a menores de 60 anos de idade. Os sorotipos 12F, 14, 18C, 9V, 18A, 19A e 23F foram responsáveis por 64,9% dos óbitos por meningite, enquanto os sorotipos 3, 14, 9V, 6B, 23F e 19F estiveram envolvidos em 63,4% das mortes por pneumonia. Entre os pacientes que morreram 68,2% tinham algum tipo de comorbidade, sendo HIV/AIDS, alcoolismo e câncer as mais comuns. A faixa etária com 60 anos ou mais foi a mais significativa (OR=4,2) para o insucesso, independente da presença de comorbidade. A presença do sorotipo 18C foi fator de risco significativo tanto na análise bruta (OR=3,8), quanto ao ajustar por comorbidade (OR=5,0) ou ajustada por idade (OR=5,4). O mesmo ocorreu para o sorotipo 12F (respectivamente, OR=5,1, OR=5,0 e OR=4,7). Observou-se alterações na circulação de alguns sorotipos de pneumococo no período pós VPC10. Ressalta-se a importância da continuidade da vigilância das DIPs, afim de determinar oscilações clínicas e microbiológicas da doença. Além disto, na era das vacinas conjugadas, o contínuo monitoramento sobre a distribuição de sorotipos na população é necessário para a avaliação do impacto e adequação da imunização / Infections by Streptococcus pneumoniae (pneumococcus) are still a challenge to health systems worldwide. An observational retrospective study was developed to assess microbiological and clinical aspects of pneumococcus strains isolated from patients with invasive pneumococcal diseases (IPD) which were isolated in the Regional Health Departments (DRS) of Araraquara, Barretos, Franca and Ribeirão Preto, in a period of 16 years (1998-2013). Data were obtained at the Adolfo Lutz Institute and in databases of the Clinics Hospital of Ribeirão Preto (HCRP). A total of 796 strains were analyzed, with prevalence of male individuals (58.9%), aged between 20 and 60 years (32.2%), and in the period between 2003 and 2010 (60.2%). The most common IPD were meningitis (45.7%) and pneumonia (45.0%). Regarding the most frequent serotypes, in 83.3% they were: 14, 3, 19F, 1, 6A, 6B, 23F, 9V, 18C, 19A, 12F, 4, 7F, 5, 22F, 11A, 8, 9N, 10A and 15C, with 14 being the most common in the four DRS studied. Serotypes 14, 3 and 19F were more frequent in meningitis, whereas serotypes 14, 3 and 1 were more frequent in pneumonia. After 2010, there was a decrease in serotypes 14, 1, 23F and 5, and an increase in 12F, 11A and 8, which are not included in the vaccine. Resistance to penicillin was 14.8%, with 3.0% being intermediate, and 11.8% full resistance. For ceftriaxone, 5.3% were not sensitive. Sensitivity to chloramphenicol, erythromycin and ceftriaxone remained over 90% in the studied period. The highest level of resistance was observed for Sulfamethoxazole/trimethoprim (49.4%). It is noteworthy that there was an increase in the s serotypes 12F, 11A and 8 after vaccination, considering that none of them make up the combined vaccines available. Resistance varied among the different serotypes of pneumococcus. The most frequent IPD in the patients registered in the HCRP was pneumonia (67.8%), followed by meningitis (22.9%), with the most frequent serotypes being 14, 6A, 23F, 1, 3, 18C, 19F, 12F, 4, 9V, 6B and 19A. Of these patients, 67.5% were cured without sequela, 6.9% had some sort of sequela and 25.6% evolved to death. Pneumonia caused 18.2% of the deaths, mainly in the age range between 20 and 60 years. Serotypes 12F, 14, 18C, 9V, 18A, 19A and 23F were responsible for 64.9% of the deaths by meningitis, whereas serotypes 3, 14, 9V, 6B, 23F and 19F were involved in 63.4% of the deaths by pneumonia. Among the patients who died, 68.2% had some sort of comorbidity, with HIV/AIDS, alcoholism and cancer being the most common. The age range over 60 years was the most significant (OR=4.2) for failure, regardless of the presence of a comorbidity. The presence of serotype 18C was a significant risk factor both in the gross analysis (OR=3.8), and in the adjustment as for comorbidity (OR=5.0) or age (OR=5.4). This was also true for the serotype 12F (respectively, OR=5.1, OR=5.0 and OR=4.7). There were alterations in the circulation of some pneumococcus serotypes in the period after VPC10. it is emphasized the importance of continued monitoring of DIPs, in order to determine clinical and microbiological fluctuations of the disease. In addition, in the era of combined vaccines, it is necessary to keep monitoring the distribution of serotypes in the population to assess the impact and adequacy of immunization

abstract: Dielectrophoresis (DEP) is a technique that influences the motion of polarizable particles in an electric field gradient. DEP can be combined with other effects that influence the motion of a particle in a microchannel, such as electrophoresis and electroosmosis. Together, these three can be used to probe properties of an analyte, including charge, conductivity, and zeta potential. DEP shows promise as a high-resolution differentiation and separation method, with the ability to distinguish between subtly-different populations. This, combined with the fast (on the order of minutes) analysis times offered by the technique, lend it many of the features necessary to be used in rapid diagnostics and point-of-care devices. Here, a mathematical model of dielectrophoretic data is presented to connect analyte properties with data features, including the intercept and slope, enabling DEP to be used in applications which require this information. The promise of DEP to distinguish between analytes with small differences is illustrated with antibiotic resistant bacteria. The DEP system is shown to differentiate between methicillin-resistant and susceptible Staphylococcus aureus. This differentiation was achieved both label free and with bacteria that had been fluorescently-labeled. Klebsiella pneumoniae carbapenemase-positive and negative Klebsiella pneumoniae were also distinguished, demonstrating the differentiation for a different mechanism of antibiotic resistance. Differences in dielectrophoretic behavior as displayed by S. aureus and K. pneumoniae were also shown by Staphylococcus epidermidis. These differences were exploited for a separation in space of gentamicin-resistant and -susceptible S. epidermidis. Besides establishing the ability of DEP to distinguish between populations with small biophysical differences, these studies illustrate the possibility for the use of DEP in applications such as rapid diagnostics. / Dissertation/Thesis / Doctoral Dissertation Chemistry 2019

Thesis (M.Sc. (Pharmacology)) -- University of Limpopo, 2018. / Refer to the document

Parmi les stratégies d'amélioration des traitements des infections bactériennes chroniques, visant à accroître l'activité bactéricide ou à limiter la sélection de résistances, le développement de combinaisons d'antibiotiques existants constitue une stratégie prometteuse. L'objectif de cette thèse était d'évaluer l'efficacité d'une combinaison d'antibiotiques sur un biofilm bactérien dans un système in vitro dynamique qui permet de simuler les concentrations d'antibiotiques observées chez les patients traités. Nous avons montré que pour des infections complexes dues à de fortes charges bactériennes ou à la présence d'un biofilm, les études dans le système in vitro dynamique menées sur plusieurs jours apportaient plus d'informations sur l'efficacité d'une combinaison d'antibiotiques que des techniques standardisées menées avec des concentrations d'antibiotiques stables au cours du temps. Nous avons aussi montré que sur un biofilm, même si certaines associations n'ont pas d'impact sur la biomasse du biofilm elles permettent en revanche de maintenir des populations moins sensibles aux antibiotiques à des seuils relativement bas, alors que les mêmes antibiotiques utilisés seuls favorisent l'émergence de résistances au cours du traitement. Enfin, des essais préliminaires pour mimer des infections comme les mammites bovines ou les cystites ont montré que ce système pouvait être plus largement utilisé pour l'optimisation des schémas thérapeutiques en médecine humaine et en médecine vétérinaire. / Among strategies to improve the treatment of chronic bacterial infections by increasing the bactericidal activity or by limiting the selection of resistance, the development of combinations of existing drugs is a promising strategy. The aim of this thesis was to evaluate the efficacy of a combination of antibiotics on a bacterial biofilm in a dynamic in vitro system which allows to simulate the concentrations observed in patients. We have shown that for complicated infections due to large bacterial loads or to biofilms, in vitro dynamic studies over several days provided more information on the efficacy of a combination of antibiotics than classical methods conducted with constant antibiotic concentrations over time. We have also shown that on a biofilm, even if associations do not have an impact on the overall size of the biofilm, they maintain less-susceptible populations at relatively low levels, whereas the same antibiotics promote the emergence of resistance during treatment when used alone. Finally, preliminary trials to mimic infections such as bovine mastitis or cystitis have shown that this system could be more widely used for the optimization of dosage regimens in human medicine and veterinary medicine.