Syftet: Syftet med denna studie var att kartlägga magnitud och incidens av bakteriemi vid tandbehandling, vid egen munvård samt vid tuggning.Material och metod: En systematisk sökning i PubMed och Cochrane Library genomfördes. Den systematiska sökningen resulterade i 1113 artiklar. Titlar och abstrakt granskades med hjälp av tre oberoende bedömare. Totalt 90 artiklar lästes i fulltext. Granskningen av artiklar i fulltext genomfördes med hjälp av förutbestämda inklusions- och exklusionskriterier. Data extraherades ur utvalda artiklar och sammanställdes i en tabell.Resultat: Totalt inkluderades 42 artiklar. Resultaten visade hög incidens av bakteriemi vid tandextraktion och låg incidens vid avtryck, fastsättning/avlägsnande av ortodontiska band och separationsligatur, låg- och högvarvspreparation, samt suturtagning. Bland egna munaktiviteter hade tuggning och rengöring med tandpetare låg incidens medan tandborstning och rengöring med tandtråd hade högre incidens. Endast 16 artiklar redovisade magnitud och den redovisades med så låg noggrannhet att resultaten inte bedömdes användbara för att dra slutsatser.Slutsatser: Alla dentala ingrepp ingående i studiens sökning kan leda till bakteriemi av varierande grad. Egen munvård och tuggning kan leda till bakteriemi. Egen munvård och tuggning medför mindre risk för uppkomst av bakteriemi jämfört med de dentala åtgärder (tandextraktion, subgingival depuration och dentoalveolär kirurgi), där antibiotikaprofylax rekommenderas enligt Läkemedelsverket. / Aim: The purpose of this study was to identify the magnitude and incidence of bacteremia in dental procedures, at own routine mouth activities and at chewing.Materials and methods: A systematic search in PubMed and Cochrane Library database was done. This resulted in 1113 articles. Titles and abstracts were reviewed by three independent assessors. A total of 90 articles were read in full text applying the inclusion and exclusion criteria. Data were extracted from included articles. Results of bacteremia incidence were charted in a table.Results: Forty-two articles were included. The result showed a high incidence of bacteremia at extraction and low incidence at impression, rubberdam placement, removal or attachment of orthodontic bands and separator, fast and slow drill. Routine mouth activities like chewing and cleaning by toothpicks have low incidence while tooth brushing and flossing have higher incidence. Only 16 articles reported magnitude and it reported with as low accuracy that the results could not be used to draw any conclusion.Conclusions: All dental procedures that were found at the search concerning this study can lead to bacteremia in varying degree. Own routine mouth activities and chewing can lead to bacteremia. Routine daily mouth activities have less risk for the appearance of bacteremia compared with the dental measures (tooth extraction, subgingival scaling and dentoalveolar surgery) when antibiotic prophylaxis is recommended according to recommendations of Läkemedelsverket.

Introdução: Infecção de corrente sanguínea é uma das principais complicações dos pacientes transplantados de medula óssea. Poucos estudos avaliam os pacientes transplantados que realizam acompanhamento ambulatorial. Objetivos: Descrever o perfil dos agentes isolados de infecção de corrente sanguínea de pacientes transplantados que realizam acompanhamento ambulatorial no HCFMUSP. Avaliar a proporção e fatores de risco associados com internação e óbitos desses pacientes. Método: Análise retrospectiva dos prontuários de pacientes acompanhados no ambulatório de TMO que apresentaram hemocultura positiva colhida durante janeiro de 2004 a dezembro de 2008. Os dados foram analisados utilizando o Epi Info 3.5.1, o nível de significância adotado foi de 5%. Hospitalização e óbito em 30 dias foram os desfechos avaliados e foram calculados fatores de risco associados nas análises bivariada e multivariada. Resultados: Os principais agentes isolados foram S. maltophilia (15%), SCN (12%), Acinectobacter spp (9%). Dos episódios ocorridos, 88% eram monomicrobianos e 12% polimicrobianos, em ambas a ocorrência de gram-negativos foi predominante. A internação hospitalar ocorreu em 26% dos episódios, sendo encontrado na analise bivariada e multivariada como fator protetor a realização de transplante autólogo. O óbito em 30 dias ocorreu em 10% dos isolados e foi encontrado, na análise bivariada, como fator de risco o isolamento de gram-positivos e a presença de neutropenia grave. A análise multivariada encontrou como fator protetor para óbito em 30 dias o uso do score MASCC, não sendo evidenciados fatores de risco. Conclusões: Os gram-negativos foram os principais agentes isolados neste estudo, destacando-se o isolamento de Stenotrophomonas maltophilia. A ocorrência de hospitalização e óbito não foi elevada, o transplante autólogo foi fator protetor para hospitalização e o uso do score MASCC fator protetor pra óbito em 30 dias. Mais estudos que avaliem o tratamento ambulatorial de pacientes transplantados de medula óssea a fim de possibilitar uma melhor qualidade de vida desses pacientes são necessários / Introduction: bloodstream infection is one of the most common medical complications in bone marrow transplanted patients. A few studies in fact evaluate the transplanted patients that are under outpatient attendance. Objectives: Describe the isolated bloodstream infection agents profile on bone marrow transplanted patients that are under outpatient attendance at HCFMUSP. Evaluate the proportion and risk factors associated with hospitalization and death of such patients. Method: Retrospective analysis on patients records of the TMOs ambulatory that presents positive blood culture gathered between January 2004 and December 2008. All the data was analyzed using the software Epi Info version 3.5.1, the significance level adopted was of 5%. Hospitalization and death in 30 days were the outcomes evaluated and which the risk factors associated were calculated and compared through the analysis bivariate and multivariate. Results: The most important agents isolated were S. maltophilia (15%), SCN (12%), Acinectobacter spp (9%). From all the episodes that occurred, 88% were monomicrobial and 12% polimicrobial, in both the occurrence of gram-negative was predominant. The hospitalization happened in 26% of the episodes, being found as the protection factor to the autologous transplant on both analyses, bivariate and multivariate. On 10% of the isolated cases occurred death in 30 days, and it was found in the bivariate analysis as factor of risk the isolation of the gramnegative and the presence of serious neutropenia. The multivariate analysis found as protection factor for death in 30 days score MASCC score use and a part of that no risk factors were highlighted. Conclusion: The gram-negative were the most important isolated agents in this research, highlighting the isolation of Stenotrophomonas maltophilia. The occurrence of hospitalization and death wasnt high, being the autologous transplant a protection factor for hospitalization and the use of MASCC score the protection factor for death in 30 days. More research is necessary evaluating the outpatient treatment for bone marrow transplanted patients to make it possible a better life standard for those patients

Entre os casos de transmissão de agentes infecciosos por transfusão, a contaminação bacteriana ocupa o primeiro lugar no número de eventos, morbidade e mortalidade. Isto ocorre principalmente em transfusões de concentrados de plaquetas, que são armazenados à temperatura ambiente e sob agitação constante, condições propícias ao crescimento bacteriano. A cultura automatizada é adotada por alguns bancos de sangue para detecção de contaminação bacteriana, mas a um custo elevado, e oferecendo tempo inadequado na realização frente ao curto período de validade dos concentrados de plaquetas, de apenas 5 dias. Recentemente, alguns grupos vem avaliando a utilização de métodos de amplificação molecular, como um ensaio de PCR em tempo real baseado no gene de RNA ribossômico (16S RNAr), um método prático, uma vez que um par de iniciadores/sonda permite a detecção da mais ampla gama de bactérias. O objetivo do nosso trabalho foi estabelecer um método semi-automatizado de amplificação de DNA para a triagem universal de bactérias em concentrados de plaquetas. Concentrados de plaquetas foram contaminados com suspensões de cinco bactérias diferentes, Staphylococcus aureus, Staphylococcus hominis, Staphylococcus epidermidis, Enterobacter cloacae e Serratia marcescens, em 1 e 10 unidades formadoras de colônia (UFC)/mL, simulando a contaminação que ocorre durante a doação de sangue. Os concentrados de plaquetas foram armazenados à temperatura ambiente sob agitação durante 5 dias e alíquotas de 1 mL foram colhidas a cada 24 horas. A presença de bactérias foi investigada por PCR em tempo real e pelo ensaio eBDS (Enhanced Bacterial Detection System, PALL) como um método de referência. O DNA foi extraído no sistema automatizado MagNA Pure 96 (Roche). A amplificação por PCR em tempo real foi realizada com um conjunto de iniciadores universais e sonda alvo do gene de 16S RNAr em paralelo a um alvo de DNA mitocondrial como controle interno. A mistura de amplificação foi tratada com etídio-monoazida (EMA) seguido por fotoativação, para eliminar a contaminação com DNA bacteriano em reagentes. Com o PCR em tempo real foi possível detectar a presença de todas as espécies bacterianas testadas com uma concentração inicial de 10 UFC/mL 24 horas após a contaminação, com exceção de Staphylococcus hominis. Além disso, detectou-se a presença das bactérias Staphylococcus aureus, Serratia marcescens e Enterobacter cloacae com uma concentração inicial de 1 UFC/mL. Durante o período de estudo foram realizados 26.728 testes eBDS, com 9 resultados positivos. 800 amostras foram testadas simultaneamente pelo eBDS e PCR em tempo real, apenas uma das amostras contaminadas estava entre as testadas por ambos os testes. A incidência da contaminação bacteriana de CPs foi de 1:2.969, semelhante a outros trabalhos. Os resultados do teste molecular podem ser obtidos em 4 horas. O ensaio de PCR em tempo real pode ser uma boa alternativa aos métodos convencionais de cultura na triagem de contaminação bacteriana em concentrados de plaquetas, permitindo a detecção de bactérias, mesmo com uma quantidade inicial baixa de microrganismos, apresentando boa sensibilidade e resultados rápidos. / Among cases of transfusion transmission of infectious agents, bacterial contamination ranks first in the number of events, morbidity and mortality. This occurs mainly by transfused platelets, which are stored at room temperature and under constant agitation what favors bacterial growth. Automated culture is adopted by some blood banks for screening of bacterial contamination, but this is expensive and has a relatively long turnaround time. Recently, some groups have evaluated the use of molecular amplification methods such as real-time PCR based on the highly conserved 16S rRNA gene; this allows a single pair of \'universal\' primers/probe to detect a very broad range of bacteria. The aim of our work was to establish a semi-automated high-throughput DNA amplification method for universal screening of bacteria in platelet concentrates. Platelet concentrates were spiked with suspensions of Staphylococcus aureus, Staphylococcus hominis, Staphylococcus epidermidis, Enterobacter cloacae and Serratia marcescens to 1 and 10 colony-forming units (CFU)/mL, to simulate contamination occurring during blood donation or processing. The platelet concentrates were stored at room temperature under agitation for 5 days and 1 mL aliquots were drawn every 24 hours. The presence of bacteria was investigated by real-time PCR and by the eBDS assay (Enhanced Bacterial Detection System, PALL) as a reference method. DNA was extracted by using a Large Volume kit in the MagNA Pure 96 (Roche) system. Real-time PCR amplification was performed with a set of universal primers and probe targeting the 16S rRNA gene. Co-amplification of human mitochondrial DNA served as an internal control. The amplification mixture was treated with ethidium monoazide (EMA) followed by photoactivation to eliminate contamination with spurious bacterial DNA in reagents. By the real-time PCR it was possible to detect the presence of all bacterial species tested with an initial concentration of 10 CFU/mL 24 hours after contamination of platelet concentrates, except for Staphylococcus hominis. The PCR assay also detected the presence of bacteria Serratia marcescens and Enterobacter cloacae with an initial concentration of 1 CFU/mL. During the study period, 26.728 eBDS tests were performed, with 9 positive results. Eight hundred samples were tested simultaneously by eBDS and real-time PCR, only one of the contaminated samples was among those evaluated by both methods. The incidence of bacterial contamination on platelets concentrates was 1: 2.969, similar to other reports. The results of the molecular test could be obtained in 4 hours. The real-time PCR assay may be a good alternative to conventional culture methods in the screening of bacterial contamination of platelet concentrates, enabling bacterial detection even with a low initial concentration of microorganisms, whilst offering good sensitivity and a fast turnaround time.

Chio Weng Fan. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 131-149). / Abstracts in English and Chinese. / Acknowledgments --- p.i / Abstract --- p.ii / Contents --- p.iv / List of tables --- p.ix / List of figures --- p.x / List of abbreviation --- p.xii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Biology of Staphylococci --- p.1 / Chapter 1.1.1 --- Taxonomy --- p.1 / Chapter 1.1.2 --- Characteristics of S. aureus --- p.2 / Chapter 1.2 --- Methicillin-resistant Staphylococcus aureus --- p.1 / Chapter 1.2.1 --- Description of MRSA --- p.7 / Chapter 1.2.2 --- Antibiotic Resistance of MRSA --- p.7 / Chapter 1.2.2.1 --- Resistance to β-lactam Antibiotics --- p.8 / Chapter 1.2.2.1.1 --- Production of β-lactamase --- p.8 / Chapter 1.2.2.1.2 --- Penicillin-binding Protein PBP2a --- p.8 / Chapter 1.2.2.1.3 --- Borderline Methicillin Resistance --- p.11 / Chapter 1.2.2.2 --- Resistance to Antibiotics other than β-lactams --- p.11 / Chapter 1.2.3 --- Epidemiology of MRSA --- p.15 / Chapter 1.2.3.1 --- Clinical Significance of MRSA --- p.15 / Chapter 1.2.3.1.1 --- Evolution of MRSA --- p.16 / Chapter 1.2.3.1.2 --- Epidemiology of MRSA Worldwide --- p.17 / Chapter 1.2.3.2 --- MRSA in Hong Kong --- p.21 / Chapter 1.3 --- Strain Typing for MRSA --- p.26 / Chapter 1.3.1 --- Phenotypic Methods --- p.27 / Chapter 1.3.1.1 --- Antibiotic Susceptibility Test --- p.27 / Chapter 1.3.1.2 --- Bacteriophage Typing --- p.28 / Chapter 1.3.1.3 --- Multilocus Enzyme Electrophoresis --- p.29 / Chapter 1.3.2 --- Genotypic Methods --- p.30 / Chapter 1.3.2.1 --- Analysis of Chromosomal DNA --- p.30 / Chapter 1.3.2.1.1 --- Pulsed-field Gel Electrophoresis (PFGE) --- p.30 / Chapter 1.3.2.1.2 --- Amplified Fragment Length Polymorphism (AFLP) --- p.31 / Chapter 1.3.2.2 --- Analysis of Gene Polymorphism --- p.32 / Chapter 1.3.2.2.1 --- PCR-Restriction Length Polymorphism (PCR-RFLP) --- p.32 / Chapter 1.3.2.2.2 --- Random Amplification of Polymorphic DNA (RAPD) --- p.33 / Chapter 1.3.2.2.3 --- Nucleotide Sequence Typing --- p.33 / Chapter 1.3.2.2.3.1 --- A Typing --- p.33 / Chapter 1.3.2.2.3.2 --- Multilocus Sequence Typing --- p.33 / Chapter 1.3.2.3 --- Hybridization by Southern Blotting --- p.34 / Chapter 1.3.2.3.1 --- MecA/Tn544 Probe Typing --- p.34 / Chapter 1.3.2.3.2 --- Binary Typing --- p.34 / Chapter 1.3.2.4 --- Analysis of Plasmid DNA --- p.35 / Chapter 1.4 --- Objectives of the Project --- p.37 / Chapter Chapter 2 --- Materials & Methods --- p.38 / Chapter 2.1 --- Bacterial Isolates & Culture Conditions --- p.38 / Chapter 2.1.1 --- Study Period & Sample Sources --- p.38 / Chapter 2.1.2 --- Selection of Bacterial Isolates --- p.38 / Chapter 2.1.3 --- Reference Strains --- p.38 / Chapter 2.1.4 --- Culture & Storage Conditions --- p.39 / Chapter 2.1.5 --- Identification of MRSA --- p.39 / Chapter 2.2 --- Antibiotic Susceptibility Testing --- p.40 / Chapter 2.3 --- PCR for MecA Gene --- p.43 / Chapter 2.3.1 --- DNA Preparation and Primer Design for mecA Gene --- p.43 / Chapter 2.3.2 --- PCR Amplification of mecA Gene --- p.45 / Chapter 2.3.2.1 --- Master Mix Preparation --- p.45 / Chapter 2.3.2.2 --- Polymerase Chain Reaction --- p.45 / Chapter 2.3.2.3 --- Analysis of PCR Products by Agarose Gel Electrophoresis --- p.45 / Chapter 2.3.2.4 --- Precautions to Avoid Cross-contamination --- p.46 / Chapter 2.4 --- Pulsed-field Gel Electrophoresis (PFGE) --- p.47 / Chapter 2.4.1 --- PFGE Protocol --- p.47 / Chapter 2.4.1.1 --- DNA Preparation for PFGE --- p.47 / Chapter 2.4.1.2 --- Restriction Enzyme Digestion --- p.48 / Chapter 2.4.1.3 --- Pulsed-field Gel Electrophoresis --- p.48 / Chapter 2.4.1.4 --- Standards & Markers for PFGE --- p.48 / Chapter 2.4.2 --- Optimization of PFGE --- p.49 / Chapter 2.4.3 --- Computer Analysis of PFGE Patterns --- p.49 / Chapter 2.5 --- Amplified Fragment Length Polymorphism (AFLP) --- p.52 / Chapter 2.5.1 --- Amplified Fragment Length Polymorphism Protocol --- p.52 / Chapter 2.5.1.1 --- DNA Preparation --- p.52 / Chapter 2.5.1.2 --- Enzyme Digestion & Ligation --- p.53 / Chapter 2.5.1.3 --- PCR for AFLP --- p.53 / Chapter 2.5.1.4 --- Gel Electrophoresis for AFLP --- p.54 / Chapter 2.5.1.5 --- Standards & Markers for AFLP --- p.55 / Chapter 2.5.2 --- Computer Analysis for AFLP Patterns --- p.55 / Chapter 2.6 --- Phage Typing --- p.58 / Chapter 2.6.1 --- Phages & Propagating Strains --- p.58 / Chapter 2.6.2 --- Phage Typing Protocol --- p.58 / Chapter 2.6.3 --- Data Analysis and Results Interpretation for Phage Tying --- p.62 / Chapter 2.7 --- Other Typing Methods --- p.63 / Chapter 2.7.1 --- PCR Restriction Fragment Length Polymorphism for the coa gene --- p.63 / Chapter 2.7.1.1 --- Primer Design --- p.63 / Chapter 2.7.1.2 --- DNA Preparation --- p.63 / Chapter 2.7.1.3 --- Optimization of PCR --- p.63 / Chapter 2.7.1.3.1 --- PCR Amplification --- p.64 / Chapter 2.7.1.3.2 --- Restriction Enzyme Digestion --- p.64 / Chapter 2.7.2 --- Multilocus Sequence Typing --- p.64 / Chapter 2.7.2.1 --- Preparation of Chromosomal DNA --- p.65 / Chapter 2.7.2.2 --- PCR for MLST Gene --- p.65 / Chapter 2.7.2.3 --- Purification of DNA for Sequencing --- p.67 / Chapter 2.7.2.4 --- PCR for Sequencing --- p.67 / Chapter 2.7.2.5 --- Sequencing by Automatic DNA Analyzer & Data Analysis --- p.68 / Chapter Chapter 3 --- Results --- p.69 / Chapter 3.1 --- Bacterial Isolates --- p.69 / Chapter 3.2 --- Antibiotic Susceptibility Testing --- p.72 / Chapter 3.3 --- PCR for MecA Gene --- p.78 / Chapter 3.4 --- Pulsed-field Gel Electrophoresis --- p.80 / Chapter 3.4.1 --- Optimization of PFGE --- p.80 / Chapter 3.4.2 --- Analysis of PFGE Profiles --- p.83 / Chapter 3.5 --- Amplified Fragment Length Polymorphism --- p.95 / Chapter 3.6 --- Phage Typing --- p.102 / Chapter 3.7 --- Other Typing Methods --- p.109 / Chapter 3.7.1 --- PCR Restriction Fragment Length Polymorphism for the Coa Gene --- p.109 / Chapter 3.7.1.1 --- Optimization of PCR conditions for the Coa Gene --- p.109 / Chapter 3.7.1.2 --- Analysis of MRSA by PCR-RFLP of the coa Gene --- p.109 / Chapter 3.7.2 --- Multilocus Sequence Typing --- p.115 / Chapter Chapter 4 --- Discussion --- p.116 / Chapter 4.1 --- Evaluation of Typing methods for MRSA --- p.116 / Chapter 4.1.1 --- Antibiotic Susceptibility Testing --- p.116 / Chapter 4.1.2 --- Phage Typing --- p.117 / Chapter 4.1.3 --- Pulsed-field Gel Electrophoresis --- p.118 / Chapter 4.1.4 --- Amplified Fragment Length Polymorphism --- p.119 / Chapter 4.1.5 --- PCR-Restriction Fragment Length Polymorphism for the Coa Gene --- p.120 / Chapter 4.1.6 --- Multilocus Sequence Typing --- p.121 / Chapter 4.1.7 --- Conclusion for Method Evaluation --- p.122 / Chapter 4.2 --- "Analysis of Results of Antibiotic Susceptibility Test, Phage Typing, PFGE, AFLP, PCR-RFLP (Coa) & MLST" --- p.124 / Chapter 4.2.1 --- Correlation between Methods --- p.124 / Chapter 4.2.2 --- Clinical Correlation --- p.125 / Chapter 4.2.3 --- Correlation between MRSA Isolates at PWH and Reference Strains --- p.128 / Chapter 4.3 --- Future Research --- p.129 / Chapter 4.4 --- Conclusion --- p.130 / Reference List --- p.131 / Appendix I Reagent & Material Lists for Methods --- p.150 / Appendix II Buffers & Media --- p.156 / Appendix III Coa Gene Sequences of Isolates from PWH and Reference Strains --- p.158 / Appendix IV Unique antibiotic resistance profiles --- p.165 / "Appendix V Details of MRSA iolates selected for AFLP, Phage typing and MLST" --- p.166

Introdução: Tem sido um desafio determinar o verdadeiro impacto clínico do Acinetobacter spp., devido a predileção desse microrganismo em colonizar e infectar pacientes críticos, os quais apresentam prognóstico ruim independente de complicações infecciosas secundárias. Objetivo: Avaliar se a sobrevida de pacientes com bacteremia por Acinetobacter spp. é menor em relação a de pacientes com bacteremia causada por outras bactérias prevalentes em unidade de terapia intensiva. Método: Trata-se de um estudo de coorte retrospectivo de pacientes internados nas unidades de terapia intensiva do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, que desenvolveram bacteremia no período de 1 de janeiro de 2010 a 31 de dezembro de 2011. Pacientes com bacteremia por Acinetobacter spp. foram comparados a pacientes com bacteremia causada por outros patógenos (Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter spp., Enterococcus spp. e Pseudomonas aeruginosa). Foi realizada análise de sobrevida em 30 dias. O método de Kaplan-Meier e teste de log-rank foram usados para determinar a sobrevida global. Fatores prognósticos potenciais foram identificados por análise bivariada e regressão multivariada de Cox. Resultados: 141 pacientes foram avaliados. Não houve diferenças entre os pacientes com bacteremia por Acinetobacter spp. e outros patógenos com relação à idade, sexo, APACHE II, índice de comorbidade de Charlson e tipo de infecção. A análise bivariada mostrou que idade > 60 anos, diabetes mellitus, infecção por Acinetobacter spp., tratamento inadequado, score de Pitt > 3, presença de choque séptico, uso de ventilação mecânica, uso de acesso central e número de falência de órgãos > 2 foram significativamente associados a pior prognóstico. Foram realizados dois modelos de análise de regressão logística. O modelo A mostrou que tratamento inadequado e score de Pitt > 3 pontos foram estatisticamente associados com letalidade. No modelo B, infecção por Acinetobacter spp. (HR = 1,93 IC 95%: 1,25-2,97) e idade > 60 anos foram fatores prognósticos independentes. Conclusão: Pacientes com bacteremia por Acinetobacter spp. apresentaram menor sobrevida em relação a pacientes com bacteremia causada por outras bactérias prevalentes em unidade de terapia intensiva / Introduction: It has been challenging to determine the true clinical impact of Acinetobacter spp., given the predilection of this pathogen to colonize and infect critically ill patients, who often have a poor prognosis irrespective of secondary infective complications. Objective: The aim of this study was to assess whether the survival of patients with Acinetobacter spp. bacteremia is lower than that of patients with bacteremia caused by other bacteria prevalent in intensive care unit. Setting: A retrospective review of medical records was conducted for all patients admitted to the ICUs who developed bacteremia from January 2010 through December 2011. Patients with Acinetobacter spp. were compared with those with other pathogens (Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter spp., Enterococcus spp., Pseudomonas aeruginosa). We did a 30-day survival analysis. The Kaplan-Meier method and log-rank test were used to determine the overall survival. Potential prognostic factors were identified by bivariate and multivariate Cox regression analysis. Results: 141 patients were evaluated. No differences between patients with Acinetobacter spp. and other pathogens were observed with regard to age, sex, APACHE II score, Charlson Comorbidity Score and type of infection. Bivariate analysis showed that age > 60 years, diabetes mellitus, Acinetobacter spp. infection, inappropriate treatment, Pitt Bacteremia score >3, presence of septic shock, mechanical ventilation, use of central line and number of organ failures > 2 were significantly associated with a poor prognosis. We did two models of logistic regression analysis. Model A showed that inappropriate treatment and Pitt score > 3 points were statistically associated with mortality. In model B, Acinetobacter spp. infection (HR= 1.93, 95%CI: 1.25-2.97) and age > 60 years were independent prognostic factors. Conclusion: Patients with Acinetobacter spp. bacteremia had lower survival compared with patients with bacteremia caused by other bacteria prevalent in intensive care unit

Paez JIG. Fatores associados à mortalidade em infecções nosocomiais por Stenotrophomonas maltophilia [dissertação]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2007. 154p. Infecção de corrente sanguínea (ICS) e pneumonia por S. maltophilia são associadas á alta mortalidade. A identificação de fatores relacionados à mortalidade em pacientes com infecções por esse agente pode permitir intervenções no sentido de diminuir a sua mortalidade. Realizamos um estudo retrospectivo com 60 pacientes com ICS ou pneumonia de origem hospitalar no Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-FMUSP) durante o período de 30 de julho de 1999 a 30 de julho de 2005. Analisamos os fatores de risco relacionados à mortalidade global e a mortalidade nos primeiros 14 dias da infecção por meio de um estudo de coorte retrospectivo comparando os pacientes que apresentaram óbito com os que não apresentaram óbito.As seguintes características foram encontradas na população estudada no momento da infecção, 57 (85%) dos pacientes receberam antibióticos prévios, 88% tinham cateter venoso central, 57% estavam em uso de ventilação mecânica, 35% em uso de quimioterapia e 75% estavam internados em unidade de cuidado intensivo. Neoplasia foi a principal doença de base presente em 45%. Choque séptico foi descrito em 30% dos casos, a média de pontuação na escala de APACHE II foi de 17 pontos e a média de pontuação da escala SOFA foi de 7 pontos. Foram diagnosticadas 8 pneumonias e 52 ICS, 47% foram ICS primárias, entre estas 13% foram ICS relacionadas ao cateter. Foram diagnosticadas também 40% ICS secundárias, sendo o principal foco pulmonar (18%). 27% das infecções foram polimicrobianas. Os fatores de risco independentes associados à mortalidade nos primeiros 14 dias identificados na análise multivariada foram, pontuação maior que 6 no índice SOFA (RR=18,9. IC95%=2,4-146,2) e presença de choque séptico (RR=11,6. IC95%=1,3-105,9). O fator de risco associado à mortalidade global na análise multivariada foi, pontuação maior que 6 no índice SOFA (RR=37,1. IC95%=2,8-494,3). A instituição de terapia antimicrobiana inadequada para o tratamento das infecções por S. maltophilia foi freqüente, sendo observada em 40 (85%) pacientes, principalmente por atraso no inicio e por tempo curto de tratamento. Não houve diferença estatística quando comparado o tratamento adequado do tratamento inadequado. A curva de sobrevida de Kaplan-Meier mostrou que pacientes com APACHE II >20 e SOFA > 10 tinham respectivamente uma chance de sobrevida menor que 8% e menor que 10% (P=<0.001) até 21 dias após a primeira cultura positiva. A mortalidade global foi de 75% e a mortalidade nos primeiros 14 dias de infecção foi de 38%. Estes resultados mostram que infecções por S. maltophilia acontecem em pacientes gravemente doentes com múltiplos fatores de risco e que os fatores associados à mortalidade são principalmente relacionados ao estado da condição clínica de base e gravidade do paciente. / Paez JIG. Factors associated with mortality in Nosocomial infections with Stenotrophomonas maltophilia [dissertation]. São Paulo: ?Faculdade de Medicina, Universidade de São Paulo?; 2007. 154p. Bloodstream infections (BSI) and pneumonia caused by Stenotrophomonas maltophilia are associated with high mortality. A retrospective study with 60 patients with nosocomial BSI and pneumonia was done at the Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-FMUSP). Cases were selected from July 30, 1999 through July 30, 2005. Risk factors associated with overall mortality and 14-day mortality after the onset of infection were accessed. 57 (85%) patients had received previous antimicrobial therapy, 88% had CVC, 57% mechanical ventilation and 75% stay in intensive care unit in the onset of infection. Malignancy (45%) was the most frequent underlying diseases. From 60 patients, 30% had septic shock, the mean of APACHE II score was 17 points and the mean of SOFA index was 7 points. A total of 60 infections were identified. Among these, 8 were pneumonias and 52 BSI, that for this turn, 33% were primary BSI, 13% were CVC-related and 40% secondary. 35% of the infections were polymicrobial. Risk factors associated with 14-day mortality after the onset of infections in the multivariate analysis were, SOFA index > 6 points (RR=18.9. 95%CI=2.4-146.2) and septic shock (RR=11.6. 95%IC=1.3-105.9). Risk factor associated with overall mortality was SOFA index > 6 points, (RR=37.1. 95%IC=2.8-494.3). Used of inappropriate antimicrobial therapy was observed in 40 (85%) patients, of whom received therapy with more 72 hours and received therapy for an insufficient length of time and there was no difference when compared appropriated and non-appropriated therapy. Kaplan-Meier estimations curves showed that patients with APACHE II >20 and SOFA > 10 had respectively a survival chance less than 8% and less than 10% (P=<0.001) at 21 days after the first positive S. maltophilia culture. The overall mortality and 14-day mortality after the onset of infections rates were 75% and 38% respectively. Our results showed that infections caused by S. maltophilia occur in critically ill patients with multiple risk factors and that the most important risk factors associated with mortality are the initial clinical condition and severity of diseases.

Submitted by Erika Demachki (erikademachki@gmail.com) on 2014-10-14T17:05:51Z No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2014-10-16T18:46:31Z (GMT) No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-10-16T18:46:31Z (GMT). No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-10-15 / Studies have shown that periodontal disease affects approximately 85 % of dogs older than three years of age, being responsible for inflammation and destruction of the tooth supporting tissues. This study aimed at evaluating the relationship between periodontal disease and glomerulonephritis in dogs. We evaluated and classified 61 dogs with periodontal disease into groups according to the severity of the case. Clinical evaluation consisted of complete blood count, serum biochemistry (urea, creatinine, total protein, albumin, cholesterol and phosphorus), blood pressure measurement, urinalysis and urinary biochemistry (GGT, ALP, protein and creatinine), and determination of urine protein:creatinine ratio. Of the 14 dogs with glomerulonephritis compatible alterations at the first exam, nine were submitted to a second laboratory evaluation, after periodontal treatment, in order to verify if they continued with persistent proteinuria associated with inactive urinary sediment. Of these, eight dogs continued to show abnormalities suggestive of glomerulonephritis, even after periodontal treatment. The diagnostic tools used in this study allowed to identify and characterize both glomerulonephritis secondary to periodontal disease, establishing a relationship between them and tubular damage and urinary tract infections that occur concurrently with periodontal disease. These findings help to establish the use of early markers of kidney injury in clinical laboratory tests, in order to prevent the process evolution, promoting animal welfare and contributing to increase longevity of dogs. / Estudos mostram que a doença periodontal acomete cerca de 85% de cães acima dos três anos de idade, sendo responsável pela inflamação e destruição dos tecidos de sustentação do dente. Este estudo teve como objetivo avaliar a relação existente entre a doença periodontal e a glomerulonefrite em cães. Sessenta e um cães com doença periodontal foram avaliados e classificados em grupos, conforme a gravidade, além da avaliação clínica foram realizados hemograma, bioquímica sérica (ureia, creatinina, proteínas totais, albumina, colesterol e fósforo), mensuração da pressão arterial, urinálise e bioquímica urinária (GGT, ALP, proteína e creatinina), com determinação da razão proteína:creatinina urinária. Dos 14 cães com alterações compatíveis para glomerulonefrite neste primeiro exame, após o tratamento periodontal, nove deles foram submetidos a uma segunda avaliação laboratorial, com o intuito de verificar se continuavam com a proteinúria persistente associado ao sedimento urinário inativo. Destes, oito cães continuaram apresentando alteração sugestiva de glomerulonefrite, mesmo após a realização do tratamento periodontal. As ferramentas de diagnóstico utilizadas em conjunto neste estudo permitiram identificar e caracterizar a glomerulonefrite secundária à doença periodontal, estabelecendo uma relação entre elas, além dos danos tubulares e infecções do trato urinário que ocorrem concomitantemente à doença periodontal. Esse conhecimento auxilia na instituição do uso de marcadores precoces de lesão renal na prática clínica de exames laboratoriais, com a finalidade de impedir a evolução do processo, promovendo bem-estar animal e contribuindo para o aumentando da longevidade dos cães.

Vancomicina é o antimicrobiano de escolha no tratamento de bacteremias causadas por estafilococos resistentes à meticilina. No entanto, estudos recentes têm reportado que a vancomicina apresenta atividade reduzida contra Staphylococcus aureus resistentes à meticilina com concentrações inibitórias mínimas (CIMs) próximas do limite do ponto de corte de suscetibilidade, conforme critérios do CLSI, indicando falha terapêutica. Entretanto, existem poucos estudos à respeito dos Staphylococcus sp. coagulase negativa resistentes à meticilina (SCoNRM). Ademais, para determinação da CIM, deveria ser utilizado o método de referência microdiluição em caldo (MDC), mas a maioria dos laboratórios clínicos utiliza a técnica de Etest ou sistemas automatizados. Alguns estudos com S. aureus demonstraram discrepâncias entre MDC e Etest, contudo não existem dados referentes aos SCoN. Os objetivos deste estudo foram avaliar a correlação entre as CIMs de vancomicina determinadas pelas técnicas de MDC e Etest em 130 SCoNRM isolados de hemocultura, bem como verificar a relação entre valores de CIM e falha terapêutica entre pacientes com bacteremia por SCoNRM tratados com este antimicrobiano. A maioria dos resultados de CIM por MDC (98,5%) foram ≤1,0 mg/mL, enquanto o Etest apresentou 72,3% de CIM ≥ 1,5 mg/mL. As CIMs de vancomicina obtidas por Etest foram, em geral, uma a duas diluições maiores do que as CIMs obtidas por MDC. Os resultados indicam que a técnica de Etest gera valores de CIM consistentemente maiores do que os obtidos por MDC nos SCoNRM. Apenas 37 (28,5%) dos 130 pacientes com hemocultura positiva para SCoNRM apresentaram dados clínicos compatíveis com bacteremia. A maioria dos pacientes com bacteremia comprovada (n=24) apresentaram CIMs de vancomicina ≥1,5 mg/mL, sendo que 13 pacientes (35,1%) obtiveram CIM < 1,5 mg/mL. Este estudo não observou relação estatisticamente significativa entre valores de CIM de vancomicina que pudessem ser associados com falha terapêutica em pacientes com bacteremia por SCoNRM. / Vancomycin is the first-line therapy for methicillin-resistant staphylococci bacteremia. However, recent studies have reported that vancomycin demonstrates reduced activity against methicillin-resistant Staphylococcus aureus bacteremia, with vancomycin MICs at the high end of the CLSI susceptibility range indicating treatment failure. There is, however, little data considering methicillin-resistant coagulase-negative staphylococci (MRCoNS) bacteremia. Besides, the reference method that should be used for MIC determination is the broth microdilution (BMD), but many clinical laboratories use the commercial Etest technique or automated systems. Some reports have showed a growing number of vancomycin MIC discrepancies between BMD and Etest method for S. aureus, but there are no studies about CoNS. The aims of this study were to evaluated the correlation between the vancomycin MIC determined by the Etest and the BMD method for a total of 130 MRCoNS bloodstream isolates as well as to examine the relationship between vancomycin MICs and failure among patients with MRCoNS bacteremia treated with vancomycin. The vast majority (98.5%) of MIC results by BMD were ≤1.0 mg/mL in contrast to MIC by Etest which majority (72.3%) was ≥1.5 mg/mL. The vancomycin MICs obtained by the Etest for the same isolates were, in general, one to twofold higher than those obtained by the BMD method. The results indicate that the Etest provides vancomycin MIC values consistently higher than those obtained by BMD method for MRCoNS. Only 37 (28.5%) out of the 130 patients with a positive MRCoNS bloodstream culture met the eligibility criteria to be considered bacteremic. The majority of these patients (n = 24, 64.9%) presented vancomycin MIC ≥ 1.5 mg/mL, in opposite to 13 patients (35.1%) with MIC < 1.5 mg/mL. This study did not observe any statistical significative relationship between vancomycin MIC and treatment failure.

Introdução: Tem sido um desafio determinar o verdadeiro impacto clínico do Acinetobacter spp., devido a predileção desse microrganismo em colonizar e infectar pacientes críticos, os quais apresentam prognóstico ruim independente de complicações infecciosas secundárias. Objetivo: Avaliar se a sobrevida de pacientes com bacteremia por Acinetobacter spp. é menor em relação a de pacientes com bacteremia causada por outras bactérias prevalentes em unidade de terapia intensiva. Método: Trata-se de um estudo de coorte retrospectivo de pacientes internados nas unidades de terapia intensiva do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, que desenvolveram bacteremia no período de 1 de janeiro de 2010 a 31 de dezembro de 2011. Pacientes com bacteremia por Acinetobacter spp. foram comparados a pacientes com bacteremia causada por outros patógenos (Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter spp., Enterococcus spp. e Pseudomonas aeruginosa). Foi realizada análise de sobrevida em 30 dias. O método de Kaplan-Meier e teste de log-rank foram usados para determinar a sobrevida global. Fatores prognósticos potenciais foram identificados por análise bivariada e regressão multivariada de Cox. Resultados: 141 pacientes foram avaliados. Não houve diferenças entre os pacientes com bacteremia por Acinetobacter spp. e outros patógenos com relação à idade, sexo, APACHE II, índice de comorbidade de Charlson e tipo de infecção. A análise bivariada mostrou que idade > 60 anos, diabetes mellitus, infecção por Acinetobacter spp., tratamento inadequado, score de Pitt > 3, presença de choque séptico, uso de ventilação mecânica, uso de acesso central e número de falência de órgãos > 2 foram significativamente associados a pior prognóstico. Foram realizados dois modelos de análise de regressão logística. O modelo A mostrou que tratamento inadequado e score de Pitt > 3 pontos foram estatisticamente associados com letalidade. No modelo B, infecção por Acinetobacter spp. (HR = 1,93 IC 95%: 1,25-2,97) e idade > 60 anos foram fatores prognósticos independentes. Conclusão: Pacientes com bacteremia por Acinetobacter spp. apresentaram menor sobrevida em relação a pacientes com bacteremia causada por outras bactérias prevalentes em unidade de terapia intensiva / Introduction: It has been challenging to determine the true clinical impact of Acinetobacter spp., given the predilection of this pathogen to colonize and infect critically ill patients, who often have a poor prognosis irrespective of secondary infective complications. Objective: The aim of this study was to assess whether the survival of patients with Acinetobacter spp. bacteremia is lower than that of patients with bacteremia caused by other bacteria prevalent in intensive care unit. Setting: A retrospective review of medical records was conducted for all patients admitted to the ICUs who developed bacteremia from January 2010 through December 2011. Patients with Acinetobacter spp. were compared with those with other pathogens (Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter spp., Enterococcus spp., Pseudomonas aeruginosa). We did a 30-day survival analysis. The Kaplan-Meier method and log-rank test were used to determine the overall survival. Potential prognostic factors were identified by bivariate and multivariate Cox regression analysis. Results: 141 patients were evaluated. No differences between patients with Acinetobacter spp. and other pathogens were observed with regard to age, sex, APACHE II score, Charlson Comorbidity Score and type of infection. Bivariate analysis showed that age > 60 years, diabetes mellitus, Acinetobacter spp. infection, inappropriate treatment, Pitt Bacteremia score >3, presence of septic shock, mechanical ventilation, use of central line and number of organ failures > 2 were significantly associated with a poor prognosis. We did two models of logistic regression analysis. Model A showed that inappropriate treatment and Pitt score > 3 points were statistically associated with mortality. In model B, Acinetobacter spp. infection (HR= 1.93, 95%CI: 1.25-2.97) and age > 60 years were independent prognostic factors. Conclusion: Patients with Acinetobacter spp. bacteremia had lower survival compared with patients with bacteremia caused by other bacteria prevalent in intensive care unit

Vancomicina é o antimicrobiano de escolha no tratamento de bacteremias causadas por estafilococos resistentes à meticilina. No entanto, estudos recentes têm reportado que a vancomicina apresenta atividade reduzida contra Staphylococcus aureus resistentes à meticilina com concentrações inibitórias mínimas (CIMs) próximas do limite do ponto de corte de suscetibilidade, conforme critérios do CLSI, indicando falha terapêutica. Entretanto, existem poucos estudos à respeito dos Staphylococcus sp. coagulase negativa resistentes à meticilina (SCoNRM). Ademais, para determinação da CIM, deveria ser utilizado o método de referência microdiluição em caldo (MDC), mas a maioria dos laboratórios clínicos utiliza a técnica de Etest ou sistemas automatizados. Alguns estudos com S. aureus demonstraram discrepâncias entre MDC e Etest, contudo não existem dados referentes aos SCoN. Os objetivos deste estudo foram avaliar a correlação entre as CIMs de vancomicina determinadas pelas técnicas de MDC e Etest em 130 SCoNRM isolados de hemocultura, bem como verificar a relação entre valores de CIM e falha terapêutica entre pacientes com bacteremia por SCoNRM tratados com este antimicrobiano. A maioria dos resultados de CIM por MDC (98,5%) foram ≤1,0 mg/mL, enquanto o Etest apresentou 72,3% de CIM ≥ 1,5 mg/mL. As CIMs de vancomicina obtidas por Etest foram, em geral, uma a duas diluições maiores do que as CIMs obtidas por MDC. Os resultados indicam que a técnica de Etest gera valores de CIM consistentemente maiores do que os obtidos por MDC nos SCoNRM. Apenas 37 (28,5%) dos 130 pacientes com hemocultura positiva para SCoNRM apresentaram dados clínicos compatíveis com bacteremia. A maioria dos pacientes com bacteremia comprovada (n=24) apresentaram CIMs de vancomicina ≥1,5 mg/mL, sendo que 13 pacientes (35,1%) obtiveram CIM < 1,5 mg/mL. Este estudo não observou relação estatisticamente significativa entre valores de CIM de vancomicina que pudessem ser associados com falha terapêutica em pacientes com bacteremia por SCoNRM. / Vancomycin is the first-line therapy for methicillin-resistant staphylococci bacteremia. However, recent studies have reported that vancomycin demonstrates reduced activity against methicillin-resistant Staphylococcus aureus bacteremia, with vancomycin MICs at the high end of the CLSI susceptibility range indicating treatment failure. There is, however, little data considering methicillin-resistant coagulase-negative staphylococci (MRCoNS) bacteremia. Besides, the reference method that should be used for MIC determination is the broth microdilution (BMD), but many clinical laboratories use the commercial Etest technique or automated systems. Some reports have showed a growing number of vancomycin MIC discrepancies between BMD and Etest method for S. aureus, but there are no studies about CoNS. The aims of this study were to evaluated the correlation between the vancomycin MIC determined by the Etest and the BMD method for a total of 130 MRCoNS bloodstream isolates as well as to examine the relationship between vancomycin MICs and failure among patients with MRCoNS bacteremia treated with vancomycin. The vast majority (98.5%) of MIC results by BMD were ≤1.0 mg/mL in contrast to MIC by Etest which majority (72.3%) was ≥1.5 mg/mL. The vancomycin MICs obtained by the Etest for the same isolates were, in general, one to twofold higher than those obtained by the BMD method. The results indicate that the Etest provides vancomycin MIC values consistently higher than those obtained by BMD method for MRCoNS. Only 37 (28.5%) out of the 130 patients with a positive MRCoNS bloodstream culture met the eligibility criteria to be considered bacteremic. The majority of these patients (n = 24, 64.9%) presented vancomycin MIC ≥ 1.5 mg/mL, in opposite to 13 patients (35.1%) with MIC < 1.5 mg/mL. This study did not observe any statistical significative relationship between vancomycin MIC and treatment failure.