Ma, Hok Lun. / Thesis submitted in: December 2008. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves 233-273). / Abstracts in English and Chinese. / Abstract --- p.i / Abstract (Chinese version) --- p.v / Tables of contents --- p.vi / Acknowledgement --- p.xvi / List of figures --- p.xvii / List of tables --- p.xxi / List of abbreviations and symbols --- p.xxviii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Respiratory illnesses in children --- p.1 / Chapter 1.1.1 --- Worldwide burden of childhood pneumonia --- p.1 / Chapter 1.1.2 --- Further mortality related to childhood pneumonia --- p.4 / Chapter 1.2 --- Etiology agent of childhood respiratory illnesses --- p.5 / Chapter 1.2.1 --- Difficulties in determining etiological agent --- p.5 / Chapter 1.2.2 --- Overall situation of etiological agents in childhood pneumonia --- p.6 / Chapter 1.2.3 --- Relationship between age and pathogens --- p.9 / Chapter 1.2.4 --- "Relationship between serotypes, carriage and invasiveness" --- p.11 / Chapter 1.2.4.1 --- Carriage and Invasiveness --- p.12 / Chapter 1.2.4.2.1 --- Carriage of S. pneumoniae and H. influenzae in children in Hong Kong --- p.12 / Chapter 1.2.4.2.2 --- "Serotypes, carriage and invasiveness in S. pneumoniae" --- p.14 / Chapter 1.2.4.2.3 --- "Serotypes, carriage and invasiveness in H. influenzae" --- p.17 / Chapter 1.3 --- Epidemiology of antibiotic-resistant pathogens --- p.18 / Chapter 1.3.1 --- Molecular typing methods --- p.18 / Chapter 1.3.2 --- Spread of antibiotic-resistant pathogens --- p.20 / Chapter 1.3.2.1 --- Spread of antibiotic-resistant S. pneumoniae --- p.26 / Chapter 1.3.2.1.1 --- Spread of penicillin-resistant S. pneumoniae --- p.26 / Chapter 1.3.2.1.1.1 --- Spread of Spanish-23F-1 --- p.27 / Chapter 1.3.2.1.1.2 --- Spread of Spanish-6B-2 --- p.28 / Chapter 1.3.2.1.1.3 --- Spread of antibiotic-resistant S. pneumoniae clones in Hong Kong --- p.28 / Chapter 1.3.2.1.2 --- Spread of cephalosporin-resistant S. pneumoniae --- p.29 / Chapter 1.3.2.1.3 --- Spread of macrolide-resistant S. pneumoniae --- p.30 / Chapter 1.3.2.1.4 --- Spread of fluoroquinolone-resistant S. pneumoniae --- p.31 / Chapter 1.3.2.2 --- Spread of antibiotic-resistant H. influenzae --- p.32 / Chapter 1.3.2.2.1 --- Spread of β-lactam-resistant H. influenzae --- p.32 / Chapter 1.3.2.2.2 --- Spread of macrolide-resistant H. influenzae --- p.33 / Chapter 1.3.2.2.3 --- Spread of fluoroquinolone-resistant H. influenzae --- p.34 / Chapter 1.4 --- Mechanism of antibiotic-resistance in respiratory pathogens --- p.36 / Chapter 1.4.1 --- Mechanism of antibiotic-resistance in S. pneumoniae --- p.37 / Chapter 1.4.1.1 --- Mechanism of penicillin- and cephalosporin-resistance in S. pneumoniae --- p.37 / Chapter 1.4.1.1.1 --- Penicillin-binding protein (PBP)-mediated mechanism --- p.37 / Chapter 1.4.1.1.2 --- PBP-independent mechanisms --- p.49 / Chapter 1.4.1.1.2.1 --- "Murine peptide branching genes, murMN operon" --- p.49 / Chapter 1.4.1.1.2.2 --- "Two-component system, CiaRH" --- p.50 / Chapter 1.4.1.1.2.3 --- "Putative glycosyltransferase, CpoA" --- p.52 / Chapter 1.4.1.1.3 --- RNA and protein expression studies on S. pneumoniae for β-lactam-resistance --- p.52 / Chapter 1.4.1.1.3.1 --- RNA expression in penicillin-sensitive S. pneumoniae --- p.53 / Chapter 1.4.1.1.3.2 --- Protein expression in penicillin-resistant S. pneumoniae --- p.53 / Chapter 1.4.1.2 --- Mechanism of macrolide- and lincosamide- resistance in S. pneumoniae --- p.54 / Chapter 1.4.1.3 --- Mechanism of tetracycline-resistance in S. pneumoniae --- p.55 / Chapter 1.4.1.4 --- Mechanism of fluoroquinolone-resistance in S. pneumoniae --- p.55 / Chapter 1.4.2 --- Mechanism of antibiotic-resistant in H. influenzae --- p.56 / Chapter 1.4.2.1 --- Mechanism of β-lactam-resistance in H. influenzae --- p.56 / Chapter 1.4.2.1.1 --- β-lactamase-producing H. influenzae --- p.56 / Chapter 1.4.2.1.2 --- β-lactamase-negative ampicillin-resistant (BLNAR) H. influenzae --- p.58 / Chapter 1.4.2.1.2.1 --- Relationship between amino acid substitutions in PBP3 and β-lactam- resistance --- p.58 / Chapter 1.4.2.1.2.2 --- Relationship between amino acid substitutions in AcrR and β-lactam-resistance --- p.60 / Chapter 1.4.2.2 --- Mechanism of macrolide-resistance in H. influenzae --- p.61 / Chapter 1.4.2.3 --- Mechanism of fluoroquinolone-resistance in H. influenzae --- p.64 / Chapter 1.5 --- Impact of vaccination --- p.65 / Chapter 1.5.1 --- H. influenzae type b vaccination --- p.65 / Chapter 1.5.1.1 --- Efficacy of Hib conjugate vaccine --- p.66 / Chapter 1.5.1.2 --- Herd immunity related to Hib conjugate vaccine --- p.66 / Chapter 1.5.2 --- Pneumococcal vaccination --- p.66 / Chapter 1.5.2.1 --- Vaccine efficacy and herd immunity of pneumococcal vaccines --- p.67 / Chapter 1.5.2.2 --- Development of conjugate vaccines with higher valency --- p.67 / Chapter 1.5.2.3 --- Serotype replacement --- p.67 / Chapter 1.5.2.4 --- Development of pneumococcal vaccines with new targets --- p.69 / Chapter 1.6 --- Objectives of this study --- p.70 / Chapter Chapter 2 --- Materials and methods --- p.72 / Chapter 2.1 --- Collection and Identification of microorganisms --- p.72 / Chapter 2.1.1 --- Collection of S. pneumoniae and H. influenzae --- p.72 / Chapter 2.1.2 --- Identification of S. pneumoniae and H. influenzae --- p.73 / Chapter 2.2 --- Serotyping of S. pneumoniae and H. influenzae --- p.74 / Chapter 2.2.1 --- Serotyping by polymerase chain reaction (PCR) --- p.74 / Chapter 2.2.1.1 --- Preparation of crude DNA extract --- p.74 / Chapter 2.2.1.2 --- Screening for common serotypes by multiplex PCR --- p.74 / Chapter 2.2.1.3 --- Composition of PCR Mix --- p.77 / Chapter 2.2.1.4 --- Serotyping PCR conditions --- p.81 / Chapter 2.2.1.5 --- Gel Electrophoresis --- p.81 / Chapter 2.2.2 --- Serotyping by serum agglutination --- p.82 / Chapter 2.3 --- Antimicrobial susceptibility testing --- p.83 / Chapter 2.4 --- Clonal analysis of penicillin- and cephalosporin-resistant S. pneumoniae --- p.87 / Chapter 2.4.1 --- Pulsed-field Gel Electrophoresis (PFGE) --- p.87 / Chapter 2.4.1.1 --- Preparation of agarose plugs for PFGE --- p.87 / Chapter 2.4.1.2 --- Lysis of bacteria in agarose plugs --- p.89 / Chapter 2.4.1.3 --- Digestion of chromosomal DNA by restriction enzyme --- p.89 / Chapter 2.4.2 --- Multi-locus sequence typing (MLST) --- p.90 / Chapter 2.4.2.1 --- PCR amplification of house-keeping genes in MLST --- p.90 / Chapter 2.4.2.1.1 --- Preparation of DNA from agarose plugs --- p.92 / Chapter 2.4.2.1.2 --- Composition of PCR Mix --- p.92 / Chapter 2.4.2.1.3 --- MLST PCR conditions --- p.92 / Chapter 2.4.2.1.4 --- Gel Electrophoresis of MLST PCR products --- p.92 / Chapter 2.4.2.1.5 --- MLST PCR products purification --- p.93 / Chapter 2.4.2.2 --- Sequencing of housekeeping genes in MLST --- p.93 / Chapter 2.4.2.3 --- Sequencing analysis and sequence type (ST) determination in MLST --- p.94 / Chapter 2.4.3 --- Extended panel of antibiotic susceptibility testing on S. pneumoniae with known STs --- p.94 / Chapter 2.5 --- Analysis on potential penicillin- and cephalosporin-resistance mechanisms in S. pneumoniae --- p.96 / Chapter 2.5.1 --- Sequencing of potnetial penicillin- and cephalosporin- resistance determinants in S. pneumoniae --- p.96 / Chapter 2.5.1.1 --- Primer design of penicillin-binding protein (PBP) genes --- p.96 / Chapter 2.5.1.2 --- Primer design of non-PBP resistance determinants --- p.100 / Chapter 2.5.1.3 --- PCR amplification and sequencing of resistant determinants --- p.100 / Chapter 2.5.1.4 --- Sequence analysis --- p.100 / Chapter 2.5.2 --- Study on efflux mechanism of S. pneumoniae --- p.103 / Chapter 2.5.2.1 --- Modification of macrodilution for efflux assay --- p.103 / Chapter 2.5.2.2 --- Cefotaxime MIC determination with efflux inhibitors --- p.104 / Chapter 2.5.2.3 --- Determination of appropriate CCCP concentration --- p.105 / Chapter 2.5.2.4 --- Growth curve with efflux inhibitor --- p.105 / Chapter 2.5.3 --- Heteroresistance assay of S. pneumoniae --- p.106 / Chapter 2.5.4 --- "RNA expression study on penicillin- and cefotaxime-resistance determinants (pbp2x, pbpla and pbp2a) of S. pneumoniae" --- p.107 / Chapter 2.5.4.1 --- Growth of S. pneumoniae for RNA extraction --- p.107 / Chapter 2.5.4.2 --- RNA extraction and DNase digestion --- p.107 / Chapter 2.5.4.3 --- cDNA synthesis and real-time PCR --- p.108 / Chapter 2.6 --- Analysis on cephalosporin- and macrolide-resistance mechanisms in H. influenzae --- p.111 / Chapter 2.6.1 --- β-lactamase production of H. influenzae --- p.111 / Chapter 2.6.1.1 --- Nitrocefin Hydrolysis --- p.111 / Chapter 2.6.1.2 --- Screening for the presence of p-lactamase gene (blaTEM-1 and blaROB-1) by multiplex PCR --- p.111 / Chapter 2.6.2 --- PCR detection and sequencing of β-lactam- and macrolide- resistance determinants in H. influenzae --- p.113 / Chapter Chapter 3 --- Results of S. pneumoniae and H. influenzae children study --- p.116 / Chapter 3.1 --- Patient demographics of children study --- p.116 / Chapter 3.2 --- Serotype distributions --- p.117 / Chapter 3.2.1 --- Serotypes / serogroup distribution in S. pneumoniae --- p.117 / Chapter 3.2.2 --- Serotype distribution in H. influenzae children study --- p.120 / Chapter 3.3 --- Antibiotic susceptibilities and resistance antibiograms --- p.122 / Chapter 3.3.1 --- Antibiotic susceptibilities of S. pneumoniae --- p.122 / Chapter 3.3.2 --- Relationship between antibiotic resistance profiles and serotypes in S.pneumoniae --- p.126 / Chapter 3.3.3 --- Antibiotic susceptibilities of H. influenzae --- p.135 / Chapter 3.3.4 --- Antibiotic resistance profiles of H. influenzae --- p.138 / Chapter 3.4 --- Clonal analysis of penicillin- and cephalosporin-resistant S.pneumoniae --- p.139 / Chapter 3.4.1 --- Pulsed-field gel electrophoresis (PFGE) of S. pneumoniae --- p.139 / Chapter 3.4.2 --- Multi-locus sequence typing of S. pneumoniae --- p.141 / Chapter 3.5 --- Analysis of the penicillin- and cephalosporin-resistance determinants in S. pneumoniae --- p.143 / Chapter 3.5.1 --- "Sequence analysis of major pbp genes (pbp2x, pbpla and pbp2a)" --- p.143 / Chapter 3.5.2 --- "Sequence analysis of other potential penicillin- and cephalosporin- resistance determinants (pbp 1 b, pbp2b, pbp3, cpoA, ciaRH and murMN)" --- p.152 / Chapter 3.5.3 --- Sequence analysis of putative promoter sequences of pbp genes --- p.167 / Chapter 3.5.4 --- Efflux Inhibition Assay --- p.171 / Chapter 3.5.5 --- Heteroresistance Assay --- p.177 / Chapter 3.5.6 --- "RNA expression study on penicillin- and cephalosporin resistance determinants (pbp2x, pbpla and pbp2a)" --- p.179 / Chapter 3.6 --- Analysis of β-lactam-resistance determinants in H. influenzae --- p.185 / Chapter 3.6.1 --- β-lactamase production and blaTEM-1 promoter study --- p.185 / Chapter 3.6.2 --- "Sequence analysis of β-lactam-resistance determinants (ftsl, acrR genes, AcrAB-TolC efflux pump)" --- p.188 / Chapter 3.6.2.1 --- Sequence analysis offtsl --- p.188 / Chapter 3.6.2.2 --- Analysis of acrR and AcrAB-TolC efflux pump --- p.189 / Chapter 3.7 --- "Analysis of macrolide-resistance determinants in H, influenzae (AcrAB-TolC efflux pump, 23SrRNA, Ribosomal proteins L4 and L22)" --- p.199 / Chapter Chapter 4 --- Discussion on S. pneumoniae and H. influenzae children study --- p.204 / Chapter 4.1 --- Carriage rate of S. pneumoniae children collection --- p.204 / Chapter 4.2 --- Serotype distribution --- p.205 / Chapter 4.2.1 --- Serotype distribution and potential vaccine coverage in S. pneumoniae --- p.205 / Chapter 4.2.2 --- Serotype distribution in H. influenzae --- p.209 / Chapter 4.3 --- Antimicrobial resistance --- p.210 / Chapter 4.3.1 --- Antimicrobial resistance in S. pneumoniae --- p.210 / Chapter 4.3.2 --- Antimicrobial resistance in H. influenzae --- p.214 / Chapter 4.4 --- "Clonal analysis of high-level β-lactam-resistant S, pneumoniae" --- p.217 / Chapter 4.5 --- "β-lactam-resistance mechanisms in S, pneunomiae" --- p.220 / Chapter 4.6 --- Antimicrobial resistance mechanisms in H. influenzae --- p.224 / Chapter 4.6.1 --- β-lactam-resistance mechanism in β-lactamase-producing H. influenzae --- p.224 / Chapter 4.6.1.1 --- Variations in blaTEM-1 promoters in β-lactamase-producing H.influenzae --- p.224 / Chapter 4.6.1.2 --- β-lactam-resistance in β-lactamase-nonproducing H. influenzae --- p.225 / Chapter 4.6.2 --- Macrolide-resistance mechanisms in H. influenzae --- p.228 / Chapter Chapter 5 --- Conclusion and future studies --- p.230 / Chapter 5.1 --- "S, pneumoniae children study" --- p.230 / Chapter 5.2 --- H. influenzae children study --- p.231 / Chapter 5.3 --- Future studies --- p.232 / Bibliography --- p.233 / Appendix I 一 Sequence alignments and Tables --- p.274 / Appendix II 一 Materials and Methods --- p.313

Diss. (sammanfattning) Umeå : Umeå universitet, 2010. / Härtill 5 uppsatser.

Made available in DSpace on 2015-07-22T20:49:51Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-08-25. Added 1 bitstream(s) on 2015-08-11T03:26:26Z : No. of bitstreams: 1 Publico-277.pdf: 1313299 bytes, checksum: d9efa7c459ef573a430330551e19f390 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Introdução: A educação e a atualização dos profissionais da área da saúde devem ser consideradas fundamentais como estratégias para o controle da resistência microbiana e a garantia da segurança na assistência aos pacientes. Objetivos: Produzir um programa nacional de ensino a distância sobre medidas de prevenção e controle da resistência microbiana em serviços de saúde e avaliar o impacto da aplicação desse programa no conhecimento de profissionais da área de saúde. Avaliar a percepção e atitude de profissionais que atuam em comissões de controle de infecção sobre o programa de controle de infecção em suas instituições. Método: O estudo foi realizado na Comissão de Epidemiologia Hospitalar da Disciplina de Infectologia e Departamento de Informática e Saúde da Universidade Federal de São Paulo. Foi aplicada metodologia a distância utilizando a plataforma Moodle. Foram desenvolvidos dois cursos: RMcontrole, período entre 15 de outubro e 14 de dezembro de 2007, direcionado a profissionais da área da saúde em geral e ATMracional, período de 18 de fevereiro a 18 de abril de 2008, direcionado a profissionais prescritores de antimicrobianos (médicos e dentistas). Os profissionais deveriam inscrever-se pelo site do curso. A seleção dos alunos priorizou profissionais das regiões Centro-Oeste e Norte do país com atuação na área de controle de infecção hospitalar. O curso foi oferecido gratuitamente aos profissionais e financiado pela Organização Pan-Americana da Saúde e Agência Nacional de Vigilância Sanitária. O programa envolveu a produção de uma mídia impressa, um CD-ROM, enviados para o endereço do profissional, além da criação de site na internet. As atividades de cada aluno foram monitoradas por tutores especialistas no controle de infecção hospitalar e para a aprovação no curso foi exigida pontuação de 70% nas atividades e nas avaliações propostas. As avaliações dos alunos foram realizadas no final de cada módulo e no final do curso. Um questionário foi aplicado para obtenção de dados demográficos e epidemiológicos de cada profissional. Resultados: O total de profissionais inscritos para o curso RMcontrole foi 6256 e para o curso ATMracional foi 2856, dentre os quais foram selecionados 1172 e 917 profissionais para cada curso, respectivamente. A taxa de desistência no curso RMcontrole foi de 9,1% e no curso ATMracional foi de 8,0%, a taxa de aprovação foi 96,4% e 93,5%, respectivamente. Para a maioria dos participantes esta foi a primeira participação em um curso a distância, porém poucos referiram dificuldades com o estudo via internet. A ferramenta de estudo preferida pela maioria dos profissionais foi a apostila impressa, mas aproximadamente 20,0% dos profissionais preferiram estudar via internet. A avaliação dos participantes sobre o conteúdo do curso mostrou que, em relação à abrangência e atualização do tema, mais de 95,5% ficaram satisfeitos ou muito satisfeitos. Análise das pontuações em ambos os cursos mostrou que houve diferença entre as notas iniciais e finais, permitindo-nos concluir que houve aquisição de conhecimento (p< 0,001). Conclusões: Este foi o primeiro curso nacional, gratuito, para treinamento de profissionais da área da saúde sobre resistência microbiana. Acreditamos que o aprimoramento desta metodologia permitirá o acesso ao conhecimento técnico a um grupo maior número de profissionais e poderá se transformar em um importante instrumento de formação na área de prevenção e controle de infecções relacionadas à assistência à saúde e no enfrentamento aos desafios da resistência microbiana. A avaliação da percepção e atitude de profissionais que atuam em comissões de controle de infecção sobre o programa de controle de infecção em suas instituições destacou informações importantes que poderão ser utilizadas pelas autoridades brasileiras para direcionar estratégias de melhoria dos programas de controle de infecção hospitalar de cada região do país. / Background: Education and updating of health professionals should be considered as an integral part of strategies to resistance control and to maintain quality of care and patient safety. Objective: To develop and apply a Web-based program on infection control practices and antimicrobial resistance for healthcare workers involved with healthcare-acquired infection from different demographic Brazilian regions, and to assess the knowledge and perceptions of participants. To evaluate the perception and attitude of professionals working in committees hospital infection control registered for the course of the infection control program in their institutions. Method: The study was conducted at the Division of Infectious Diseases and Department of Informatics and Health of Federal University of São Paulo. Were developed and implemented two courses: RMcontrole, directed to health professionals in general and ATMracional, directed only antimicrobial prescribers (physicians and dentists). Professionals should register on line in the site of the course. The selection of students prioritized professionals from the Midwest and North of the country involved in the area of hospital infection control. The course was offered free to the professionals. The program involved production of a printed booklet and a CD-ROM sent to the address of work, beyond the creation of website. One of the features of this work was the use of e-learning platform Moodle. The activities of each student tutors were monitored by specialists in hospital infection control and to pass the course was required score of 70% in the proposed activities and assessments. Results: The total number of professionals registered for the course RMcontrole was 6256 and the course was ATMracional 2856, among whom were selected in 1172 and 917 professionals for each course respectively. The dropout rate in the course RMcontrole was 9.1% and ATMracional was 8.0%, the approval rate was 96.4% and 93.5% and disapproval rate was 3.6% and 6.5 %, respectively. For most participants this was the first participation in a distance course even so, few students reported difficulties with the study via the Internet. The study tool preferred by most professional was the book printed, but approximately 20.0% of professionals reported prefer to study via the Internet. The assessment of participants on the course content showed that in relation to the scope and update more than 95.5% were satisfied or extremely satisfied. The discussions between tutors and participants surpassed the mark of 1,000 posts in each course. Analysis of the scores in both courses showed that there was difference between the initial and final notes, allowing us to conclude that there was knowledge acquisition (p <0.001). Conclusion: This was the first free national program for training health professionals on microbial resistance. We believe that the improvement of this methodology will allow access to technical knowledge to a broader number of professionals and may become an important tool for training in prevention and control of infections related to health care and in facing the challenges of antimicrobial resistance. The evaluation of the perception and attitude of professionals working in infection control committees on the program of infection control in their institutions highlighted important information that could be used by the Brazilian authorities to direct strategies to improve the programs of hospital infection control in each region of the country. / TEDE / BV UNIFESP: Teses e dissertações

INTRODUÇÃO: Nas últimas décadas, a resistência antimicrobiana tornou-se um problema de saúde pública em nível global. A interação entre o consumo de antibióticos e o desenvolvimento de resistência é de particular interesse com relação aos bacilos Gramnegativos (BGN), cuja crescente resistência aos antibióticos disponíveis tem representado um grande desafio ao tratamento das infecções por eles causadas. OBJETIVO: Avaliar o impacto da restrição ao uso da cefepima sobre o perfil de sensibilidade a antimicrobianos dos BGN envolvidos em infecções hospitalares em um hospital ortopédico terciário. MÉTODOS: Em maio de 2007, o uso da cefepima foi restrito no IOTHCFMUSP. Foram analisados e comparados os dados relativos a ocupação, mortalidade hospitalar e taxas gerais de infecção hospitalar em ambos os períodos, além dos dados relativos ao consumo de antimicrobianos e perfil de resistência dos BGN relacionados a infecções hospitalares de dois períodos: de maio de 2005 a maio de 2007 (24 meses anteriores à restrição ao uso da cefepima primeiro período) e maio de 2007 a maio de 2009 (24 meses posteriores à restrição segundo período). RESULTADOS: Não houve diferenças entre os dois períodos na média de permanência hospitalar em dias e na taxa de mortalidade hospitalar. Não houve diferença significante nas taxas gerais de infecção hospitalar entre os períodos. O consumo de amicacina, aztreonam, ertapenem e levofloxacino aumentou de forma estatisticamente significante (p<0,05) no segundo período, enquanto o consumo de cefepima, colistina e imipenem/cilastina diminuiu de forma significante (p<0,05). Não houve diferença na incidência de BGN como causadores de infecção hospitalar entre os dois períodos estudados. A. baumanii, P. aeruginosa, K. pneumoniae e Enterobacter spp. foram os BGN mais freqüentes em ambos os períodos. Após a restrição da cefepima, a sensibilidade de A. baumanii melhorou frente à gentamicina (p=0,001) e piorou frente ao imipenem (p<0,001). Não houve diferença no perfil de sensibilidade aos antimicrobianos testados para P. aeruginosa entre os dois períodos. No segundo período do estudo, a sensibilidade de K. pneumoniae melhorou frente ao ciprofloxacino (p=0,049). Após a restrição da cefepima, a sensibilidade de Enterobacter spp. melhorou de forma frente ao ciprofloxacino (p=0,043). Não houve alteração significativa na incidência de enterobactérias produtoras de betalactamase de espectro estendido (ESBL). CONCLUSÕES: Após a implantação da restrição à cefepima, não houve diferenças na incidência geral dos BGN como causadores de infecção. Para A. baumanii, após a restrição, houve melhora no perfil de sensibilidade frente à gentamicina e piora frente ao imipenem. Para P. aeruginosa, não houve alterações significantes no perfil de sensibilidade. Com relação a K. pneumoniae e Enterobacter spp. houve melhora significante na sensibilidade frente ao ciprofloxacino. Não houve diferenças nas incidências de K. pneumoniae e E. coli produtoras de ESBL entre os dois períodos estudados / BACKGROUND: In recent decades, antimicrobial resistance has become a public health problem globally. The interaction between antibiotic consumption and resistance development is of particular interest with respect to the Gramnegative bacilii (GNB), whose growing resistance to available antibiotics has represented a great challenge for the treatment of infections caused by them. OBJECTIVE: To evaluate the impact of the restriction on the use of cefepime on the profile of antimicrobial susceptibility of GNB involved in nosocomial infections in a orthopaedic tertiary hospital. METHODS: In May 2007, the use of cefepime was restricted at our hospital. We compared the data on occupation, hospital mortality rates and general hospital infection in two periods: from May 2005 to May 2007 (24 months prior to the restriction on the use of cefepime first period) and May 2007 to May 2009 (24 months after this restriction second period). Data on antimicrobial consumption and antimicrobial resistance profile of GNBrelated nosocomial infections in both periods were also analyzed and compared. RESULTS: There were no differences between the two periods in the average hospital stay in days and in hospital mortality rate. There was no significant difference in overall rates of nosocomial infection between periods. The use of amikacin, aztreonam, ertapenem and levofloxacin increased statistically significant (p <0.05) in second period, while consumption of cefepime, imipenem/cilastin and colistin decreased significantly (p <0.05). There was no difference in the incidence of GNB as agents in cases of nosocomial infection in the two periods studied. A. baumanii, P. aeruginosa, K. pneumoniae and Enterobacter spp. were the most frequent GNB in both periods. After the restriction of cefepime, the susceptibility of A. baumanii improved to gentamicin (p = 0.001) and worsened to imipenem (p <0.001). There was no difference in susceptibility to antimicrobials for P. aeruginosa between the two periods. In the second period of this study, the susceptibility of K. pneumoniae improved to ciprofloxacin (p = 0.049). After the restriction of cefepime, the susceptibility of Enterobacter spp. improved to ciprofloxacin (p = 0.043). There was no significant change in the incidence of Extented spectrum beta lacmamasis (ESBL)producing Enterobacteriaceae. CONCLUSIONS: After implementation of the restriction to cefepime, there was no difference in overall incidence of GNB as cause of infection. For A. baumanii, after the restriction, there was an improvement in the susceptibility to gentamicin and worsening to imipenem. For P. aeruginosa, no significant changes in susceptibility were observed. Regarding K. pneumoniae and Enterobacter spp. significant improvement in sensitivity to ciprofloxacin was observed. There were no differences in the incidence of ESBLproducing K. pneumoniae and E. coli between the two periods studied

A total of 842 single patient isolates of Salmonella spp. from the New Territories East Cluster hospitals, Hong Kong, were collected during 2002 and 2004. The most common Salmonella enterica serotype isolated was S. Enteritidis (29.7%, 250 of 842) followed by S. Typhimurium (13.7%, 115 of 842). The remaining 29.6% (249 of 842) belonged to 44 serotypes and 27.1% (228 of 842) were non-typeable. The majority of isolates were from patients aged two years or younger and were isolated during June to October of each of the three years. The susceptibilities to 19 antimicrobial agents of the 834 isolates that survived were tested. Resistant strains were investigated for [1] the mechanisms of resistance to fluoroquinolones and the third generation cephalosporins; [2] the genetic mechanisms of emergence of antibiotic-resistant salmonellae; and [3] their molecular epidemiology. / Less than half (46.9%, 391 of 834) of the isolates were susceptible to all the antimicrobial agents tested and 21.3% (178 of 834) were resistant to three and up to 14 in a total of 75 resistance patterns. Resistance to nalidixic acid increased from 18.9% (53 of 280) in 2002 to 36.6% (94 of 259) in 2004 (p &lt;0.001) while reduced susceptibility and resistance to ciprofloxacin increased from 17.9% (50 of 280) to 39.4% (102 of 259) (p &lt;0.001). All salmonellae remained susceptible to the third generation cephalosporins until 2003 when we isolated the first resistant isolate and two more in 2004. / No mutations in the quinolone resistance-determining region of target genes gyrA, gyrB, parC and parE were detectable in six of the 59 isolates that were resistant to 0.03 mg/l of ciprofloxacin and 14 that were susceptible to 0.03 mg/l of ciprofloxacin, all isolates being obtained in 2002. Forty-two isolates harboured one mutation, and one to eight harboured two to four mutations with those in positions Ser83 and/or Asp87 of the gyrA gene being the most common (89.8%, 53 of 59). No mutation was detected in the gyrB gene. A parC mutation at Ser80 was present only in strains with one or two gyrA mutation(s) while that at Thr57 could be present in strains without any other target gene mutations. A parE mutation (Ser458&rarr;Pro) was detected together with two gyrA and one parC mutations in only one isolate which was resistant to high concentrations of fluoroquinolones. Complementation experiments using a wild-type gyrA gene performed on isolates with gyrA gene mutations showed that mutations in gyrA contributed to fluoroquinolone-resistance. Only two among the 349 isolates that were obtained during 2002-2004 and resistant to 0.03 mg/l of ciprofloxacin harboured the qnr gene. / Of the three isolates that were resistant to the third generation cephalosporins, one, a S. Typhimurium, produced a beta-lactamase, CTX-M-9, of pI 8.1, and two, a S. Typhimurium and a S. Enteritidis, produced CTX-M-14, of pI 7.9. The blaCTX-M-9 gene was located on a class 1 integron on a 62 kb transferable plasmid and the blaCTX-M-14 gene was associated with the insertion sequence ISEcp1 and present on a 70 kb and a 92 kb transferable plasmid, respectively. This is the first report of a CTX-M-9 enzyme in S. Typhimurium in Hong Kong. (Abstract shortened by UMI.) / The MICs of nalidixic acid in the presence of 20 mg/l of Phe-Arg beta-naphthylamide (PAbetaN) for the 73 isolates that were tested for the presence of target gene mutations and S. Typhimurium ATCC 13311 were at least 4-fold lower than those of nalidixic acid in the absence of PAbetaN, indicating presence of an efflux system that could be inhibited by PAbetaN and of which nalidixic acid was a substrate. / Twenty-one isolates with different target gene mutations and fluoroquinolone susceptibilities were selected to investigate the effect of active efflux system, outer membrane permeability and target gene expression on fluoroquinolone-susceptibility. The amount of ciprofloxacin accumulated in the presence of carbonyl cyanide m-chloro-phenylhydrazone (CCCP) was significantly more than that in the absence of CCCP in 15 of these 21 strains, indicating presence of an efflux system that used proton motive force as energy. The amount of ciprofloxacin accumulated in 15 strains was significantly less than that in the standard strain (ATCC 13311) after the addition of CCCP, indicating that these strains were less permeable to ciprofloxacin than the standard strain. Real-time PCR experiments revealed that there were strains with overexpression of target genes as well as the acrB gene that codes for AcrB in the AcrAB-TolC efflux system. No aac(6')-Ib-cr was detected in our strains. / Jin, Yujuan. / "January 2008." / Adviser: M. L. Ling. / Source: Dissertation Abstracts International, Volume: 69-08, Section: B, page: 4543. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (p. 195-219). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract in English and Chinese. / School code: 1307.

Thilani Indunika Udayanthi Ahangama Marasinghe. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 156-168). / Abstracts in English and Chinese. / ABSTRACT (ENGLISH VERSION) --- p.I / ABSTRACT (CHINESE VERSION) --- p.IV / DECLARATION --- p.VI / ACKNOWLEDGEMENTS --- p.VII / TABLE OF CONTENTS --- p.IX / LIST OF TABLES --- p.XIII / LIST OF FIGURES --- p.XVI / LIST OF APPENDICES --- p.XVIII / LIST OF ABBREVIATIONS --- p.XIX / Chapter CHAPTER 1 - --- INTRODUCTION --- p.1 / Chapter 1.1 --- Antimicrobial resistance --- p.1 / Chapter 1.1.1 --- Global emergence of drug-resistant organisms --- p.1 / Chapter 1.1.2 --- Resistance problem in Hong Kong --- p.5 / Chapter 1.1.2.1 --- Antimicrobial resistance of bacterial isolates in hospital --- p.5 / Chapter 1.1.2.2 --- Antimicrobial resistance of bacterial isolates from community --- p.8 / Chapter 1.1.3 --- Dynamics of resistance --- p.11 / Chapter 1.1.4 --- Mechanisms of antimicrobial resistance --- p.12 / Chapter 1.1.4.1 --- Enzymatic inactivation or modification --- p.12 / Chapter 1.1.4.2 --- Alteration of target site --- p.13 / Chapter 1.1.4.3 --- Impaired permeability --- p.13 / Chapter 1.1.4.4 --- Efflux pumps --- p.14 / Chapter 1.1.4.5. --- Alteration of metabolic pathway --- p.14 / Chapter 1.1.5 --- Association between antimicrobial use and resistance --- p.16 / Chapter 1.1.6 --- Clinical and economic impact of resistance --- p.17 / Chapter 1.1.7 --- Measures to minimize resistance in healthcare setting --- p.19 / Chapter 1.2 --- Antimicrobial classes --- p.21 / Chapter 1.2.1 --- β-Lactams --- p.21 / Chapter 1.2.2 --- Glycopeptides --- p.23 / Chapter 1.2.3 --- Quinolones --- p.24 / Chapter 1.2.4 --- Oxazolidinones-Linezolid --- p.25 / Chapter 1.3 --- Antimicrobial Stewardship Program (ASP) --- p.26 / Chapter 1.3.1 --- Definition --- p.26 / Chapter 1.3.2 --- Strategies --- p.27 / Chapter 1.3.3 --- Multidisciplinary Antimicrobial Management Team --- p.29 / Chapter 1.3.4 --- Limitations --- p.30 / Chapter 1.3.5 --- Experience in ASP --- p.30 / Chapter 1.4 --- ASP in Hong Kong --- p.36 / Chapter 1.4.1 --- Implementation at Prince of Wales Hospital --- p.36 / Chapter 1.4.2 --- Targeted antimicrobials --- p.38 / Chapter 1.5 --- Extended-Spectrum β-Lactamases (ESBLs) --- p.40 / Chapter 1.5.1 --- Classification of β-lactamases --- p.40 / Chapter 1.5.2 --- Definition of ESBLs --- p.42 / Chapter 1.5.3 --- Types of ESBLs --- p.42 / Chapter 1.5.4 --- Epidemiology of ESBLs --- p.44 / Chapter 1.5.5 --- ESBL detection --- p.46 / Chapter 1.5.6 --- Risk factors for acquisition of ESBL-producing organisms --- p.49 / Chapter 1.5.7 --- Clinical and economic impact of infections caused by ESBL- producing organisms --- p.50 / Chapter 1.5.8 --- Treatment options for infections caused by ESBL-producing organisms --- p.51 / Chapter 1.5.8.1 --- Carbapenems --- p.52 / Chapter 1.5.8.2 --- Noncarbapenems --- p.54 / Chapter 1.5.8.2.1 --- "Quinolones, aminoglycosides and sulfonamides" --- p.54 / Chapter 1.5.8.2.2 --- Cephalosporins --- p.55 / Chapter 1.5.8.2.3 --- β-Lactam/β-lactamase inhibitor combinations --- p.56 / Chapter 1.6. --- Objectives of the study --- p.58 / Chapter CHAPTER 2 - --- METHODS --- p.60 / Chapter 2.1 --- Data collection --- p.60 / Chapter 2.2 --- ESBL detection at PWH --- p.60 / Chapter CHAPTER 3 - --- OBJECTIVE 1 --- p.62 / Chapter 3.1 --- Title:-The impact of an Antimicrobial Stewardship Program on broad spectrum antimicrobials within a Medical Department in a Hong Kong tertiary care hospital --- p.62 / Chapter 3.2 --- Method --- p.62 / Chapter 3.2.1 --- Study setting --- p.62 / Chapter 3.2.2 --- Study design and sample --- p.62 / Chapter 3.2.3 --- Definitions --- p.63 / Chapter 3.2.4 --- Data collection --- p.64 / Chapter 3.2.5 --- Data analysis --- p.65 / Chapter 3.2.5.1 --- Outcome measures --- p.65 / Chapter 3.2.5.2 --- Statistical analysis --- p.65 / Chapter 3.3 --- Results --- p.66 / Chapter 3.3.1 --- Patient characteristics --- p.66 / Chapter 3.3.2 --- Clinical characteristics --- p.66 / Chapter 3.3.2.1 --- Source of infection --- p.66 / Chapter 3.3.2.2 --- Severity of infection-Intervention period --- p.69 / Chapter 3.3.2.3 --- Healthcare-associated infections (HAIs) --- p.69 / Chapter 3.3.3 --- Prescribing practices --- p.71 / Chapter 3.3.3.1 --- Prescriptions reviewed and pattern of antibiotic prescription --- p.71 / Chapter 3.3.3.2 --- Indication --- p.73 / Chapter 3.3.3.2.1 --- Appropriateness of indication --- p.73 / Chapter 3.3.3.2.2 --- Appropriate indications of use-Individual targeted antimicrobials --- p.75 / Chapter 3.3.3.2.3 --- Inappropriate antimicrobial use --- p.77 / Chapter 3.3.4 --- Recommendations made and acceptance --- p.79 / Chapter 3.3.5 --- Outcome measures --- p.81 / Chapter 3.3.5.1 --- Multivariate model of appropriate antimicrobial use --- p.81 / Chapter 3.3.5.2 --- Multivariate model of all-cause mortality --- p.82 / Chapter 3.3.5.3 --- Treatment outcome-intervention period --- p.85 / Chapter 3.3.6 --- Antimicrobial consumption --- p.86 / Chapter 3.3.6.1 --- Targeted antimicrobials --- p.86 / Chapter 3.3.6.2 --- Other antimicrobials --- p.86 / Chapter 3.3.7 --- Bacterial susceptibility --- p.89 / Chapter 3.3.7.1 --- Escherichia coli --- p.89 / Chapter 3.3.7.1.1 --- Resistance rates to amoxicillin/clavulanate --- p.89 / Chapter 3.3.7.1.2 --- ESBL-producing Escherichia coli --- p.89 / Chapter 3.3.7.2 --- Methicillin resistant-Staphylococcus aureus (MRSA) --- p.92 / Chapter 3.3.7.3 --- Pseudomonas aeruginosa --- p.93 / Chapter 3.3.7.3.1 --- Susceptibility rates to targeted antimicrobials --- p.93 / Chapter 3.3.7.3.2 --- Susceptibility rates to other antimicrobials --- p.93 / Chapter 3.4 --- Discussion --- p.97 / Chapter 3.4.1 --- Background characteristics of patients who were prescribed targeted antimicrobials --- p.97 / Chapter 3.4.2 --- Healthcare-associated infections (HAIs) --- p.98 / Chapter 3.4.3 --- Impact of ASP on appropriateness of antimicrobial prescription --- p.99 / Chapter 3.4.4 --- Compliance to recommendations --- p.101 / Chapter 3.4.5 --- Clinical impact of ASP --- p.101 / Chapter 3.4.6 --- Impact of ASP on antimicrobial consumptions --- p.103 / Chapter 3.4.7 --- Impact of ASP on antimicrobial resistance --- p.105 / Chapter 3.4.8 --- Influential factors associated with appropriate antimicrobial use --- p.108 / Chapter 3.4.9 --- Limitations --- p.109 / Chapter 3.4.10 --- Areas for further evaluation --- p.111 / Chapter CHAPTER 4 - --- OBJECTIVE II --- p.114 / Chapter 4.1 --- Title:-Treatment outcome and factors affecting treatment outcome of patients with bacteremia due to extended-spectrum β-lactamases-producing organisms receiving carbapenems or β-lactam/β-lactamase inhibitor combinations --- p.114 / Chapter 4.2 --- Method --- p.114 / Chapter 4.2.1 --- Study setting --- p.114 / Chapter 4.2.2 --- Study design and sample --- p.114 / Chapter 4.2.3 --- Definitions --- p.115 / Chapter 4.2.4 --- Data collection --- p.117 / Chapter 4.2.5 --- Data analysis --- p.118 / Chapter 4.2.5.1 --- Outcome measures: --- p.118 / Chapter 4.2.5.2 --- Statistical analysis: --- p.118 / Chapter 4.3 --- Results --- p.119 / Chapter 4.3.1 --- Patient characteristics --- p.120 / Chapter 4.3.2 --- Predisposing factors --- p.120 / Chapter 4.3.3 --- Clinical characteristics --- p.122 / Chapter 4.3.3.1 --- Type and source of infection --- p.123 / Chapter 4.3.3.2 --- Severity of illness markers --- p.123 / Chapter 4.3.4 --- Outcome measures --- p.125 / Chapter 4.3.4.1 --- Treatment outcome and reasons for therapeutic failure --- p.125 / Chapter 4.3.4.2 --- Factors associated with therapeutic failure --- p.127 / Chapter 4.3.4.2.1 --- Univariate analysis of variables to be associated with therapeutic failure --- p.127 / Chapter 4.3.4.2.2 --- Multivariate model of treatment failure --- p.129 / Chapter 4.3.4.3 --- Factors associated with all-cause mortality --- p.130 / Chapter 4.3.4.3.1 --- Univariate analysis of variables to be associated with all-cause mortality --- p.130 / Chapter 4.3.4.3.2 --- Multivariate model of all-cause mortality --- p.133 / Chapter 4.3.5 --- Subgroup analysis --- p.134 / Chapter 4.3.5.1 --- Carbapenem versus Cefoperazone/sulbactam --- p.134 / Chapter 4.3.5.2 --- Carbapenem versus Piperacillin/tazobactam --- p.141 / Chapter 4.3.5.3 --- Carbapenem versus Amoxicillin/clavulanate --- p.144 / Chapter 4.3.5.4 --- Comparison of treatment outcome --- p.147 / Chapter 4.4 --- Discussion --- p.148 / Chapter 4.4.1 --- Predisposing factors --- p.148 / Chapter 4.4.2 --- Treatment outcome --- p.149 / Chapter 4.4.3 --- Limitations and areas for further study --- p.153 / Chapter CHAPTER 5 - --- CONCLUSIONS --- p.154 / REFERENCES --- p.156 / APPENDICES --- p.169

<p>Uvod: Antimikrobna rezistencija bakterija predstavlja globalni problem. Najvažniji faktor za njen nastanak je neadekvatna primena antibiotika, koja podrazumeva: Upotrebu antibiotika bez odgovarajuće dijagnoze, neadekvatan izbor leka, dužinu<br />primene i doziranje. Zbog specifičnosti populacije vitalno ugroženih bolesnika u jedinicama intenzivne terapije (JIT) i bolničkih infekcija uzrokovanih multirezistentnim bakterijama, primena antibiotika je na ovim odeljenjima učestala. Pokazana je povezanost između razvoja antimikrobne rezistencije i veličine potro&scaron;nje antibiotika u JIT. Cilj: Analiza primene antibiotika prema indikacijama na Klinici za anesteziju i intenzivnu terapiju, KC Vojvodine, zatim analiza stanja antimikrobne rezistencije<br />najče&scaron;ćih uzročnika bolničkih infekcija i analiza korelacije između navedenih uzročnika bolničkih infekcija i empirijski primenjivane antibiotske terapije na Klinici za anesteziju i intenzivnu terapiju. Materijal i metode: Prospektivna, opservaciona studija, sprovedena u jednogodi&scaron;njem period, u JIT, Klinike za anesteziju i intenzivnu terapiju, uključila je 856 ispitanika, oba pola, starijih od 18 godina kod kojih je tokom hospitalizacije u JIT bio primenjen antibiotik. Ispitanici su, radi prikupljanja podataka, bili podeljeni u dve grupe u zavisnosti od toga da li su imali bolničku infekciju ili ne. Adekvatnost primene antibiotika je analizirana prema indikacijama (hirur&scaron;ka profilaksa, bolničke infekcije, vanbolničke infekcije i drugo), a u odnosu na izbor antibiotika, dužinu primene, režim doziranja, veličinu pojedinačne doze i način promene terapije (prema preporukama farmakoterapijskog vodiča The Sanford guide to antimicrobial therapy i antimikrobnoj osetljivosti bakterijskih uzročnika bolničkih infekcija u JIT. Za izračunavanje potro&scaron;nje antibiotika u JIT kori&scaron;ćena je ATC/DDD metodologija. Podaci o antimikrobnoj osetljivosti dobijeni su iz rezultata mikrobiolo&scaron;ke obrade uzorkovanog materijala. Statistička analiza je izvr&scaron;ena pomoću statističkog paketa IBM SPSS 21 Statistics. Podaci su predstavljeni tabelarno i grafički, obrađeni su standardnim statističkim testovima, a statistička značajnost određivanja je bila na nivou p&lt; 0,05. Ispitivanje povezanosti između potro&scaron;nje anibiotika i antimikrobne rezistencije urađeno je primenom Pirsonovog koeficijenta korelacije. Rezultati: Izbor antibiotika kod bolesnika u JIT nije bio adekvatan u 52,19% preskripcija. Izbor empirijski indikovanih antibiotika za lečenje bolničkih infekcija nije bio u skladu antimikrobnom osetljivo&scaron;ću izolovanog uzročnika u 78,44% preskripcija. Izbor antibiotika za hirur&scaron;ku profilaksu nije bio adekvatan u 55,6% preskripcija. Antimikrobna rezistencija Acinetobacter spp.na karbapeneme, fluorohinolone i cefalosporine bila je preko 90%, na aminoglikozide preko 70%. Klebsiella pneumoniae bila je rezistentna na fluorohinolone i cefalosporine 80%, dok je na grupu karbapenema bila 18%. Pseudomonas aeruginosa je bio rezistentan na karbapeneme i aminoglikozide preko 50%, na antipseudomonasne cefalosporine preko 40%. Na kolistin nije zabeležena rezistencija ni jedne izolovane bakterijske vrste. Značajna pozitivna korelacija zabeležena je između potro&scaron;nje empirijski indikovanog meropenema i rezistencije Acinetobacter spp. Zaključak: U vise od 50% slučajeva primena antibiotika u JIT nije bila u skladu sa stanjem antimikrobne rezistencije bakterijskih uzročnika bolničkih infekcija i savremenim farmakoterapijskim protokolima. Antimikrobna rezistencija Acinetobacter spp, Klebsiellae pneumoniae и Pseudomonas aeruginosae je iznosila preko 20% na antibiotike preporučene savremenim farmakoterapijskim smernicama, osim u slučaju rezistencije Klebsiellaе pneumoniae na grupu karbapenema. Između pojave rezistencije Acinetobacter spp. i potro&scaron;nje empirijski indikovanog meropenema utvrđena je statistički značajna pozitivna povezanost, dok za druge dve navedene bakterijske vrste ova povezanost nije bila statistički značajna. Na osnovu podataka o najče&scaron;ćim bakterijskim uzročnicima i njihovoj antimikrobnoj osetljivosti za empirijsku<br />terapiju pneumonija mogao bi biti preporučen jedino kolistin, dok bi za lečenje urinarnih infekcija mogao biti preporučen imipenem ili meropenem. Potrebno je promeniti farmakoterapijski pristup u primeni antibiotika u JIT.</p> / <p>Uvod: Antimikrobna rezistencija bakterija predstavlja globalni problem. Najvažniji faktor za njen nastanak je neadekvatna primena antibiotika, koja podrazumeva: Upotrebu antibiotika bez odgovarajuće dijagnoze, neadekvatan izbor leka, dužinu<br />primene i doziranje. Zbog specifičnosti populacije vitalno ugroženih bolesnika u jedinicama intenzivne terapije (JIT) i bolničkih infekcija uzrokovanih multirezistentnim bakterijama, primena antibiotika je na ovim odeljenjima učestala. Pokazana je povezanost između razvoja antimikrobne rezistencije i veličine potro&scaron;nje antibiotika u JIT. Cilj: Analiza primene antibiotika prema indikacijama na Klinici za anesteziju i intenzivnu terapiju, KC Vojvodine, zatim analiza stanja antimikrobne rezistencije<br />najče&scaron;ćih uzročnika bolničkih infekcija i analiza korelacije između navedenih uzročnika bolničkih infekcija i empirijski primenjivane antibiotske terapije na Klinici za anesteziju i intenzivnu terapiju. Materijal i metode: Prospektivna, opservaciona studija, sprovedena u jednogodi&scaron;njem period, u JIT, Klinike za anesteziju i intenzivnu terapiju, uključila je 856 ispitanika, oba pola, starijih od 18 godina kod kojih je tokom hospitalizacije u JIT bio primenjen antibiotik. Ispitanici su, radi prikupljanja podataka, bili podeljeni u dve grupe u zavisnosti od toga da li su imali bolničku infekciju ili ne. Adekvatnost primene antibiotika je analizirana prema indikacijama (hirur&scaron;ka profilaksa, bolničke infekcije, vanbolničke infekcije i drugo), a u odnosu na izbor antibiotika, dužinu primene, režim doziranja, veličinu pojedinačne doze i način promene terapije (prema preporukama farmakoterapijskog vodiča The Sanford guide to antimicrobial therapy i antimikrobnoj osetljivosti bakterijskih uzročnika bolničkih infekcija u JIT. Za izračunavanje potro&scaron;nje antibiotika u JIT kori&scaron;ćena je ATC/DDD metodologija. Podaci o antimikrobnoj osetljivosti dobijeni su iz rezultata mikrobiolo&scaron;ke obrade uzorkovanog materijala. Statistička analiza je izvr&scaron;ena pomoću statističkog paketa IBM SPSS 21 Statistics. Podaci su predstavljeni tabelarno i grafički, obrađeni su standardnim statističkim testovima, a statistička značajnost određivanja je bila na nivou p&lt; 0,05. Ispitivanje povezanosti između potro&scaron;nje anibiotika i antimikrobne rezistencije urađeno je primenom Pirsonovog koeficijenta korelacije. Rezultati: Izbor antibiotika kod bolesnika u JIT nije bio adekvatan u 52,19% preskripcija. Izbor empirijski indikovanih antibiotika za lečenje bolničkih infekcija nije bio u skladu antimikrobnom osetljivo&scaron;ću izolovanog uzročnika u 78,44% preskripcija. Izbor antibiotika za hirur&scaron;ku profilaksu nije bio adekvatan u 55,6% preskripcija. Antimikrobna rezistencija Acinetobacter spp.na karbapeneme, fluorohinolone i cefalosporine bila je preko 90%, na aminoglikozide preko 70%. Klebsiella pneumoniae bila je rezistentna na fluorohinolone i cefalosporine 80%, dok je na grupu karbapenema bila 18%. Pseudomonas aeruginosa je bio rezistentan na karbapeneme i aminoglikozide preko 50%, na antipseudomonasne cefalosporine preko 40%. Na kolistin nije zabeležena rezistencija ni jedne izolovane bakterijske vrste. Značajna pozitivna korelacija zabeležena je između potro&scaron;nje empirijski indikovanog meropenema i rezistencije Acinetobacter spp. Zaključak: U vise od 50% slučajeva primena antibiotika u JIT nije bila u skladu sa stanjem antimikrobne rezistencije bakterijskih uzročnika bolničkih infekcija i savremenim farmakoterapijskim protokolima. Antimikrobna rezistencija Acinetobacter spp, Klebsiellae pneumoniae i Pseudomonas aeruginosae je iznosila preko 20% na antibiotike preporučene savremenim farmakoterapijskim smernicama, osim u slučaju rezistencije Klebsiellae pneumoniae na grupu karbapenema. Između pojave rezistencije Acinetobacter spp. i potro&scaron;nje empirijski indikovanog meropenema utvrđena je statistički značajna pozitivna povezanost, dok za druge dve navedene bakterijske vrste ova povezanost nije bila statistički značajna. Na osnovu podataka o najče&scaron;ćim bakterijskim uzročnicima i njihovoj antimikrobnoj osetljivosti za empirijsku<br />terapiju pneumonija mogao bi biti preporučen jedino kolistin, dok bi za lečenje urinarnih infekcija mogao biti preporučen imipenem ili meropenem. Potrebno je promeniti farmakoterapijski pristup u primeni antibiotika u JIT.</p> / <p>Introduction: Antimicrobial resistance is a global health problem.The most important factor in the development of antimicrobial resistance is inadequate use of antibiotics, which means: inadequate diagnosis of bacterial infection, inadequate antibiotic choice, dosage and duration of therapy. Specificities of critically ill patients and nosocomial infections caused by multidrug-resistant pathogens are important reasons for large antibiotic consumption in ICU settings. Many studies have confirmed a positive correlation between antibiotic use and antimicrobial resistance. Aims: The aims of this study were: to analyze the use of antibiotics at the ICU of the Clinic for anesthesia and intensive care at the Clinical Centre of Vojvodina, according to indications for antibiotic treatment; to analyze the pattern of antimicrobial resistance ofthe most common bacteria causing hospital acquired infections in our participants and to analyze the correlation between the consumption of empirically indicated antibiotics and antimicrobial resistance pattern. Methodology: Prospective observational study was conducted during a one-year period at the Clinic for anesthesia and intensive care, Clinical Centre of Vojvodina. The study included 856 participatns, aged over 18 years and of both genders. The participants were divided into two cohorts, depending on whether they showed symptoms of hospital-acquired infection or not. Adequacy of antibiotic use was analyzed with regard to indication for antibiotic treatment (surgical prophylaxis, treatment of hospital acquired infection, outpatient infection or other) and with regard to antibiotic choice, dosage and duration of treatment. An adequate antibiotic choice was compared to the resistance pattern of positive bacterial isolates as outlined by The Sanford guide to antimicrobial therapy). To calculate the consumption of antibiotics in ICU we used ATC/DDD methodology. Data on antibacterial sensitivity was obtained from the results of microbiological analysis of sample materials. IBM SPSS version 21 was used for statistical analysis, standard statistical tests were applied. The results were presented in tables and graphs. Statistically significant correlation was set at the value of p˂0.05. Pearson correlation coefficient was used to measure the strength between variables. Results: Antibiotic choice was inadequate in 52,19% of all antibiotic prescriptions for all indications. Antibiotic choice in surgical prophylaxis was inadequate in 55,59% of prescriptions for this indication. Inadequate choice of empirically indicated antibiotics (for treatment of hospital-acquired infections) according to antimicrobial resistance pattern occurred in 78,44% of all prescription for this indication. The three the most important bacterial causative agents of hospital acquired infections in ICU were: Acinetobacter spp, Klebsiella pneumonia and Pseudomonas aeruginosa. The resistance of Acinetobacter spp. to antibiotic groups was as follows: to carbapenems, fluoroquinolones and cephalosporins over 90% and to aminoglycosides over 70%. The antimicrobial resistance of Klebsiella pneumoniae was: to fluoroquinolones and cephalosporins over 80% and to carbapenems up to 20%. The resistance pattern of Pseudomonas aeruginosa was as follows: to carbapenems and aminoglykozides over 50%, and to antipseudomonal cephalosporins over 40%. Statistically significant correlation was found between the consumption of empirically prescribed meropenem and antimicrobial resistance of Acinetobacter spp. Conclusion:In more than 50% of antibiotic prescriptions at ICU, regardless of indication, the choice of prescribed antibiotics was inadequate. Antimicrobial resistance pattern of Acinetobacter spp, Klebsiella pneumoniae and Pseudomonas aeruginosa to antibiotics recomennded by contemporary guidelines for antimicrobial therapy was over 20%, except in the case of the resistance of Klebsiellae peneumoniae to carbapenems. Statistically significant correlation was found between the consumption of empirically prescribed meropenem and antimicrobial resistance of Acinetobacter spp. No statistically significant correlation was observed in the other two bacterial strains. Initial, empiric therapy for nosocomial pneumonia in our ICU, should be colistin, and for urinary tract infection imipenem or meropenem. It is important to change antibiotic prescribing praxis in ICU.</p>

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 5 uppsatser.

Diss. Linköping : Linköpings universitet, 2007.

Submitted by Priscila Nascimento (pnascimento@icict.fiocruz.br) on 2013-04-10T13:59:40Z No. of bitstreams: 2 Patricia_M_Lima_Dois.doc: 131072 bytes, checksum: 98e1ab34d602b80d18a06d92c6bc168a (MD5) Patricia_M_Lima_um.pdf: 1534203 bytes, checksum: e84c34b0ca61e948c1a489cec5fb02f9 (MD5) / Approved for entry into archive by Priscila Nascimento(pnascimento@icict.fiocruz.br) on 2013-04-10T14:30:12Z (GMT) No. of bitstreams: 2 Patricia_M_Lima_Dois.doc: 131072 bytes, checksum: 98e1ab34d602b80d18a06d92c6bc168a (MD5) Patricia_M_Lima_um.pdf: 1534203 bytes, checksum: e84c34b0ca61e948c1a489cec5fb02f9 (MD5) / Made available in DSpace on 2013-04-10T14:30:13Z (GMT). No. of bitstreams: 2 Patricia_M_Lima_Dois.doc: 131072 bytes, checksum: 98e1ab34d602b80d18a06d92c6bc168a (MD5) Patricia_M_Lima_um.pdf: 1534203 bytes, checksum: e84c34b0ca61e948c1a489cec5fb02f9 (MD5) Previous issue date: 2011 / Fundação Oswaldo Cruz. Instituto Oswaldo Cruz. Rio de Janeiro, RJ, Brasil. / Klebsiella sp. é uma bactéria ubíqua, responsável por infecções nosocomiais oportunistas. Linhagens multirresistentes a antibióticos têm se tornado um problema cada vez mais freqüente no mundo todo. Estudos objetivando a determinação do potencial patogênico dos isolados ambientais são escassos. K. pneumoniae de origem ambiental poderia estar atuando como reservatório de genes de resistência que eventualmente poderiam ser transferidos e levar ao aparecimento linhagens multirresistentes. Nosso objetivo é determinar o perfil de resistência aos antimicrobianos de isolados clínicos e ambientais de K. pneumoniae, determinar os genótipos circulantes e sua clonalidade e caracterizar a genética da resistência observada. A susceptibilidade a 9 classes de antibióticos foi determinada para os 76 isolados clínicos e ambientais. De modo geral, os isolados clínicos mostraram-se resistentes a maioria das classes de antibióticos testadas, enquanto os isolados ambientais mostraram-se suscetíveis às diferentes classes. A pesquisa por elementos genéticos associados a resistência a antibióticos mostrou a presença de integron de classe 1 entre os isolados clínicos e integron de classe 2 em isolados ambientais. Os principais cassetes identificados no integron de classe 1 foram acetilt- e adenil-transferases ou dihidrofolatoredutase, os cassetes mais frequentemente encontrados nessa classe. No integron de classe 2, foi caracterizado o arranjo sat-aadA. Essa é a primeira identificação de integron de classe 2 em isolado ambiental de K. pneumoniae. A caracterização da relação genética entre os isolados, utilizando MLST, mostrou a existência de 45 sequencias-tipo(STs), das quais 24 novas. A análise por MLST mostrou que existe uma linhagem principal, distribuída pelo Brasil. Identificamos STs pandêmicos: ST11, ST23, ST37, ST423 e ST437 e sua distribuição mostra a existência de complexos clonais distribuídos em diferentes regiões geográficas do Brasil. / Klebsiella sp. Are ubiquitous bacteria associated with opportunistic nosocomial infections. Multiresistant strains to antibiotics have become an increasingly common problem worldwide. Studies focused on determining the pathogenic potential of environmental isolates are scarce. K. pneumoniae environmental strains could be acting as reservoirs of resistance genes that could be transferred and eventually lead to the emergence of multiply antibiotic-resistant strains. Our aim is to determine the antimicrobial resistance profiles of clinical and environmental K. pneumoniae strains, characterize the circulating genotypes and their clonality, and investigate the presence of genetic elements associated with the resistance observed, in Brazil. The susceptibility to nine classes of antibiotics was determined for 76 clinical and environmental isolates. There is a prevalence of the multidrug resistant phenotype (MDR) within the clinical isolates, whilst the environmental isolates are susceptible to different classes of antibiotics. The search for genetic elements associated with antibiotic resistance revealed the presence of class 1 and class 2 integrons among clinical and environmental isolates, respectively. The main gene cassettes present in class 1 integrons were aac and aad (acetylt- and adenyl-transferases) or dfr (dihydrofolateredutase), the most commonly found in class 1 integrons. The class 2 integron harbored the sat-aadA arrangement. This is the first observation of class 2 integrons in environmental K. pneumoniae isolates. Using the MLST approach, the genetic relationship among the strains showed 45 sequence-types (STs), of which 24 have not been described yet. The MLST analysis revealed a major K. pneumoniae lineage distributed throughout Brazil. Pandemic STs were identified among the clinical strains: ST11, ST23, ST37, ST423 and ST437. Their distribution shows the existence of clonal complexes throughout geographic regions of Brazil.