Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-09-20T11:52:49Z No. of bitstreams: 1 vanessacordeirodias.pdf: 663329 bytes, checksum: a6ecc4c9fdb1483811c9adc9cb8fad2c (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-09-26T20:23:46Z (GMT) No. of bitstreams: 1 vanessacordeirodias.pdf: 663329 bytes, checksum: a6ecc4c9fdb1483811c9adc9cb8fad2c (MD5) / Made available in DSpace on 2016-09-26T20:23:46Z (GMT). No. of bitstreams: 1 vanessacordeirodias.pdf: 663329 bytes, checksum: a6ecc4c9fdb1483811c9adc9cb8fad2c (MD5) Previous issue date: 2010-12-10 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / As infecções do trato urinário (ITU) são manifestações freqüentes na população, geralmente causadas por bacilos Gram-negativos. As β-lactamases são enzimas bacterianas que conferem resistência aos antimicrobianos do tipo β-lactâmicos (penicilinas, cefalosporinas, aztreonam e carbapenêmicos). A produção de β-lactamases de Espectro Estendido (ESBL) tem sido descrita como um importante mecanismo de resistência aos β-lactâmicos. De maneira geral, Escherichia coli e Klebsiella pneumoniae são as espécies bacterianas mais comumente encontradas produzindo ESBL, embora a detecção dessas enzimas já tenha sido observada em diversos gêneros dentro da família Enterobacteriaceae. O objetivo deste estudo foi avaliar os perfis de susceptibilidade a antimicrobianos e correlacionar os testes fenotípicos com a detecção de marcadores genéticos para produção de β-lactamases dos tipos ESBL, AmpC e KPC em enterobactérias associadas à etiologia de ITUs em pacientes atendidos em um Laboratório de Análises Clínicas da cidade de Juiz de Fora, MG. Para o estudo restrospectivo (20012008), 66.660 isolados de urina com suspeita de ITU foram analisadas, e após a identificação bioquímica, as linhagens de enterobactérias foram submetidas a testes de susceptibilidade aos antimicrobianos, pelo método de disco-difusão, de acordo com as normas do Clinical and Laboratory Standards Institute/CLSI. A detecção fenotípica da produção de ESBL foi feita através do teste de aproximação dos discos. Para o estudo prospectivo (2009), 12.304 amostras com suspeita de ITU foram avaliadas, e após a identificação bioquímica das linhagens, foram feitos os testes de susceptibilidade aos antimicrobianos e o teste de aproximação dos discos, para a detecção fenotípica da produção de ESBL. A identificação dos marcadores de β-lactamase (SHV, TEM, CTX-M, AMPc e KPC) foi feita por reação em cadeia da polimerase (PCR). De 416 linhagens produtoras de ESBL entre 2001- 2008, E. coli foi a mais freqüente (74,4%). Altos níveis de resistência foram obtidos para sulfazotrim, gentamicina e ciprofloxacina neste período. Todas as linhagens foram sensíveis ao imipenem. No estudo prospectivo, 105 linhagens produtoras de ESBL foram isoladas, sendo E. coli a mais freqüente (63%). Foi observado um alto índice de resistência a amoxacilina-clavulanato (80,8%), e aproximadamente 70% das amostras foram resistentes à associação trimetoprim/sulfametoxazol e as fluoroquionolonas (ciprofloxacina e ácido nalidíxico). Dentre as drogas utilizadas como substrato para detecção de ESBL, a cefotaxima foi o substrato com maior índice de resistência (86,6%), seguido de aztreonam (60,9%) e ceftazidima (55,2%). Entre as 105 linhagens recuperadas, todos os marcadores genéticos pesquisados para ESBL foram detectados. Considerando-se a freqüência de detecção dos marcadores genéticos, TEM foi o mais frequente (86,6%), seguido por SHV (59%), CTX-M (31,4%) e AMPc (27,6%). Em todas as linhagens bacterianas avaliadas, foi detectado pelo menos 1 dos marcadores genéticos associados à produção de β-lactamases (22,8%), 52,4% apresentaram 2 marcadores, 20% apresentaram 3 marcadores e 4,8% apresentaram 4 dos marcadores pesquisados. β-lactamases do tipo KPC não foram detectadas. O conhecimento da epidemiologia, dinâmica de disseminação e circulação destes marcadores genéticos de resistência a drogas constitui um dado clínico relevante, pois possibilita a instauração de uma terapia antimicrobiana mais adequada, bem como a construção de um banco de informações epidemiológicas, como ferramenta para contenção da expansão da disseminação dos genes de resistência aos antimicrobianos β-lactâmicos. / The urinary tract infections (UTI) are highly frequent within the population and usually caused by Gram-negative rods. The bacterial β-lactamases are enzymes which confer resistance against β-lactam antibiotics (penicillins, cephalosporins, aztreonam and carbapenems) amongst which Extended Spectrum β-Lactamases (ESBL) has been described as an important resistance mechanism to the β-lactam in Gram-negative bacteria. Generally, Escherichia coli and Klebsiella pneumoniae are the most frequent ESBL producing bacterial species, but its production by representatives of other bacterial genus within the Enterobacteriaceae family has already been documented. The aim of this study were to evaluate the antimicrobial susceptibility patterns and to correlate phenotypic tests with the detection of genetic markers for β-lactamases production such as ESBL, AmpC and KPC in enterobacteria associated to the UTI etiology in patients assisted at a Clinical Analyses Laboratory in Juiz de Fora, MG. From a retrospective study (2001-2008), 66.660 urine samples were analyzed, and the biochemically identified bacteria were submitted to antibiotic susceptibility testing by the disk-diffusion method, according to the Clinical Laboratory Standards Institute/CLSI guidelines. Further, phenotypic detection of the ESBL production was carried out through the disk approximation test. From a prospective study (2009), 12.304 samples were evaluated, and after the microbial identification, antibiotic susceptibility tests and disk approximation assays were performed, for ESBL phenotypic detection. Identification of β-lactamase genetic markers (SHV, TEM, CTX-M, AMPc and KPC) were performed through polymerase chain reaction (PCR). Out of 416 ESBL producing bacteria identified between 2001 and 2008, E. coli was the most frequent (74.4%). High resistance levels were obtained for trimethopim-sulfamethoxazole, gentamicin and ciprofloxacin in this period. All of the strains were sensitive to imipenem. Regarding the prospective study, 105 ESBL producing bacteria were isolated, being E. coli the most frequent (63%). A high resistance rate was observed against amoxacilin/clavulanic-acid (80.8%), and almost 70% of the samples were resistant to the association trimethopim-sulfamethoxazole and the fluoroquionolones (ciprofloxacin and nalidixic acid). Among the drugs for ESBL detection, the cefotaxime was the substrate with the highest resistance rate (86.6%), followed by aztreonam (60.9%) and ceftazidime (55.2%). Among these strains, all of the researched genetic markers for ESBL were detected. In regard to the frequency of detection of the genetic markers, TEM was the most frequent (86.6%), following by SHV (59%), CTX-M (31.4%) and AmpC (27.6%). In all of the bacterial strains it was detected at least 1 of the genetic markers associated to the production of β –lactamases. Two markers were detected in 52.4% and in 20% and 48%, at least 3 or 4 markers were detected, respectively. The KPC type β -lactamase was not detected. The knowledge about the epidemiology, spread dynamics and circulation of these resistance genetic markers to drugs among the different bacterial populations constitutes a relevant issue and makes possible the establishment of a more appropriated chemotherapy. Besides, the generation of basic epidemiological information may sustain for contention of the antimicrobial resistance and the spread of resistant genetic markers related to inactivation of β-lactam drugs.

INTRODUÇÃO: O aumento da incidência de infecções causadas por bactérias resistentes a múltiplos antimicrobianos limita cada vez mais as opções terapêuticas, dificultando o tratamento e aumentando os índices de morbidade e mortalidade, além dos gastos em saúde. Ao longo dos últimos cinco anos, essa limitação tem levado ao reestabelecimento do uso de antimicrobianos consideradas ultrapassados, como as polimixinas. Este grupo passou a ser utilizado com cada vez mais frequência no tratamento de infecções causadas por microrganismos gram-negativos resistentes aos carbapenêmicos. As enterobactérias, em particular a espécie Klebsiella pneumoniae, tem apresentado frequentemente esse perfil, porém, a resistência à polimixinas têm sido relatada, eliminando essa importante alternativa terapêutica. Apesar da importância do tema, são escassas as publicações sobre frequência de resistência às polimixinas em K. pneumoniae e a relação clonal entre isolados resistentes à polimixina B no Brasil. OBJETIVOS: Avaliar a relação genética, perfil de sensibilidade antimicrobiana e mecanismos de resistência às polimixinas em K. pneumoniae. MATERIAIS E MÉTODOS: A execução deste trabalho dividiu-se em duas partes principais: (i) levantamento de dados de culturas positivas para K. pneumoniae da rotina de pacientes hospitalizados em instituições atendidas pelo serviço de análises clínicas do Fleury Medicina e Saúde; (ii) confirmação das concentrações inibitórias mínimas (CIM) para polimixina B, avaliação da relação clonal por eletroforese em campos pulsados (PFGE),e sequenciamento de múltiplos loci (MLST), avaliação da integridade do gene mgrB e da presença do gene mcr-1 por PCR entre isolados resistentes à polimixina B e aos carbapenêmicos (CPRKp). RESULTADOS e CONCLUSÕES: Na análise de 3.085 isolados de K. pneumoniae obtidos de pacientes internados em 11 hospitais da Grande São Paulo entre os anos de 2011 e 2015, foi evidenciado um aumento estatisticamente significativo na resistência aos carbapenêmicos de 6,8% em 2011 para 35,5% em 2015. Em 2015, KPC foi detectada em 96,2% dos isolados resistentes aos carbapenêmicos. A distribuição das concentrações inibitórias mínimas de polimixina B entre todos os isolados de K. pneumoniae evidenciou uma distribuição bimodal com a CIM de 2 mg/L como o valor de ponto de corte para a susceptibilidade à polimixina B; assim, 3,6% do número total de isolados sensíveis aos carbapenêmicos foram interpretados como resistentes enquanto essa proporção foi de 22,5% entre as resistentes aos carbapenêmicos (CRKp). Entre esses últimos isolados também houve um aumento estatisticamente significativo na tendência anual de resistência à polimixina B, de 0% em 2011 para 27,1% em 2015. Estas taxas variaram de 0,7% em 2011 para 3,9% até junho de 2014 entre os sensíveis aos carbapenêmicos. Entre os antimicrobianos alternativos, a amicacina e a tigeciclina foram os compostos mais ativos. A análise por PFGE de 60 isolados de CPRKp obtidos de pacientes distintos nos anos de 2014 e 2015 evidenciou dois grandes grupos clonais: CPRKp1 e CPRKp2, os quais segundo a análise por MLST pertencem, respectivamente, aos grupos ST11 e ST437, ambos do complexo clonal 258. Foi observado o mesmo grupo ST entre isolados obtidos dentro de um mesmo hospital e também entre diferentes hospitais, públicos e privados. O mecanismo de resistência mais comum entre os isolados de CPRKp foi a presença de sequências de inserção interrompendo o gene mgrB. O gene mcr-1 não foi detectado em nenhum dos isolados. / INTRODUCTION: The increasing incidence of infections caused by bacteria resistant to multiple antimicrobials increasingly limits therapeutic options, making treatment difficult and increasing the morbidity and mortality and health spending. Over the past five years, this limitation has led to the reestablishment of the use of antimicrobials deemed outdated, such as polymyxins. This group is now used with increasing frequency to treat infections caused by carbapenem-resistant gram-negative microorganisms. Enterobacteria, especially Klebsiella pneumoniae, have often presented this profile, however, resistance to polymyxins have been also reported, eliminating this important therapeutic alternative. Despite the importance of this issue, the publications are scarce on the polymyxins resistance frequency in K. pneumoniae and clonal relationship among isolates resistant to polymyxin B in Brazil. OBJECTIVES: To evaluate the genetic relationship, antimicrobial susceptibility profile and polymyxin B resistance mechanisms in K. pneumoniae. MATERIALS AND METHODS: The execution of this work was divided into two main parts: (i) survey data on routine cultures positive for K. pneumoniae from patients hospitalized in institutions attended by the clinical analysis service of Fleury Health and Medicine; (ii) confirmation of to polymyxin B minimum inhibitory concentrations (MIC), evaluation of clonal relationship by electrophoresis pulsed field gel electrophoresis (PFGE), multilocus sequence typing (MLST), evaluation of the integrity of the mgrB gene and the presence of mcr-1 gene by PCR among isolates resistant to polymyxin B and carbapenems (CPRKp). RESULTS AND CONCLUSIONS: The analysis of 3,085 K. pneumoniae isolates obtained from inpatients from 11 hospitals in the São Paulo urban area between 2011 and 2015, has shown a statistically significant increase in carbapenem resistance from 6.8% in 2011 to 35.5% in 2015. In 2015, KPC was detected in 96.2% of isolates resistant to carbapenems. The polymyxin B MIC distribution of all Klebsiella pneumoniae showed a bimodal distribution with the MIC of 2 mg/L as the cutoff value for polymyxin B susceptibility; thus, 3.6% of the total number of isolates susceptible to carbapenems were interpreted as resistant while this proportion was 22.5% among carbapenem-resistant isolates (CRKp). Among these isolates there was also a statistically significant increase in the annual trend of polymyxin B resistance, from 0% in 2011 to 27.1% in 2015. These rates ranged from 0.7% in 2011 to 3.9% by June 2014 between carbapenem-susceptible isolates. Among alternative antimicrobials, amikacin and tigecycline were the most active compounds. The analysis by PFGE of 60 CPRKp isolates obtained from different patients in the years 2014 and 2015 showed two major clonal groups: CPRKp1 and CPRKp2, which according to the analysis by MLST belong respectively to ST11 and ST437 groups, both from clonal complex 258. We observed the same ST group of isolates obtained within a hospital and between different public and private hospitals. The most common mechanism of polymyxin B resistance among CPRKp isolates was the presence of insertion sequences interrupting the mgrB gene. The mcr-1 gene was not detected in any of the isolates.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-21T11:23:35Z No. of bitstreams: 1 ritosantopereira.pdf: 1611336 bytes, checksum: 8393e7d27377653e27c6bd1d9654130b (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T18:43:36Z (GMT) No. of bitstreams: 1 ritosantopereira.pdf: 1611336 bytes, checksum: 8393e7d27377653e27c6bd1d9654130b (MD5) / Made available in DSpace on 2016-01-25T18:43:36Z (GMT). No. of bitstreams: 1 ritosantopereira.pdf: 1611336 bytes, checksum: 8393e7d27377653e27c6bd1d9654130b (MD5) Previous issue date: 2014-11-28 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / A resistência aos agentes antimicrobianos é um problema crescente, restringindo as opções de tratamento e resultando em falhas clinicas mais frequente. Carbapenemases são enzimas produzidas por bactérias Gram-negativas que conferem resistência aos β-lactâmicos. Klebsiella pneumoniae e Enterobacter aerogenes destacam-se pelo oportunismo e capacidade de produção destas enzimas e seu envolvimento nas infecções hospitalares. Nosso trabalho teve como objetivo avaliar os aspectos fisiológicos e moleculares relacionados à virulência e resistência aos carbapenêmicos em K. pneumoniae e E. aerogenes, isolados em um serviço de microbiologia clínica em um hospital terciário durante o ano de 2012. De maneira geral, 3437 espécimes clínicos coletados foram processados para isolamento microbiano. Amostras identificadas foram avaliadas quanto à susceptibilidade aos antimicrobianos e 42 enterobactérias resistentes aos carbapenêmicos foram consideradas. Foram realizados testes para avaliação da produção de carbapenemases, atividade hemolítica, estresse oxidativo, tolerância a biocidas e formação de biofilmes. Os microrganismos foram recuperados de urina, cateter, sangue e trato respiratório. Entre os pacientes, 61,9% eram de UTI. Os isolados apresentaram altos níveis de sensibilidade à amicacina e tigeciclina (>90%). Considerando-se a frequência dos marcadores genéticos, KPC foi a mais frequente (97,6%), seguido por TEM (95,2%), SHV (69,0%) e CTX-M (38,1%). Em todos os isolados avaliados, 2,4% apresentaram 1 marcador genético associado a resistência aos carbapenêmicos, 23,8% apresentaram 2 marcadores, 45,2% apresentaram 3 e 28,6% apresentaram 4. As espécies resistentes aos carbapenêmicos apresentaram características peculiares em relação às características fisiológicas avaliadas, sugerindo que essas bactérias possam apresentar comportamentos diferentes de microrganismos de mesma espécie sensíveis às drogas, com implicações não apenas para antibioticoterapia, mas também para sua virulência e persistência no ambiente nosocomial. Estes resultados confirmam a dificuldade de manejo terapêutico de pacientes com infecções associadas a microrganismos multi-resistentes e oportunistas com impactos diretos na mortalidade e no controle epidemiológico destes microrganismos nos centros de saúde. / The antimicrobial resistance is a growing problem, restricting treatment options and resulting in more frequent clinical failures. Carbapenemases are enzymes produced by Gram-negative bacteria which confer resistance to β-lactams. Klebsiella pneumoniae and Enterobacter aerogenes stand out by opportunism and production capacity of these enzymes and their involvement in nosocomial infections. Our study aimed to evaluate the virulence and related carbapenem resistance in K. pneumoniae and E. aerogenes physiological and molecular aspects, isolated from the Clinical Laboratory, in a tertiary hospital in the city of Juiz de Fora - Minas Gerais, during 2012. During the study period, 3437 clinical specimens were processed for microbial isolation. Identified samples were evaluated for antimicrobial susceptibility and 42 resistant Enterobacteriaceae to carbapenems were considered. Underwent tests for evaluation of carbapenemase production, hemolytic activity, biofilm formation, oxidative stress and biocides tolerance. The results showed that K. pneumoniae and E. aerogenes were recovered in urine, catheter, blood and respiratory tract. Among the patients, 61.9% were ICU. The isolates showed high levels of sensitivity to amikacin and tigecycline (>90%). Considering the frequency of genetic markers, KPC was the most common (97.6%), followed by TEM (95.2%), SHV (69.0%) and CTX-M (38.1%). In all isolates, 2.4% had one genetic marker associated with resistance to carbapenems, 23.8% had two markers, 45.2% had three and 28.6% had four. Carbapenemase producers showed particular characteristics regarding the assessed physiological characteristics, suggesting that these bacteria may exhibit different behaviors of microorganisms of the same species susceptible to carbapenem with implications not only for antibiotic therapy, but also for their virulence and persistence in the nosocomial environment. These results confirm the difficulty of therapeutic management of patients with infections associated with multi- resistant and opportunistic microorganisms with direct impacts on mortality and epidemiological control of these microorganisms in health centers.

Background: Infections caused by carbapenem-resistant Enterobacteriaceae such as Escherichia coli and Klebsiella pneumoniae are among the most urgent threats of the infectious disease realm. The incidence of these infections has only been increasing over the years and due to very limited treatment options, mortality is estimated at about 50%. Methods: To evaluate the in vitro activity of meropenem and polymyxin B against carbapenem-resistant Enterobacteriaceae, antimicrobial susceptibility testing and time-kill studies were performed on K. pneumoniae clinical isolates representing a wide range of meropenem resistance (MICs 4 – 128 mg/L). Results: Regrowth was observed at clinically relevant concentrations of meropenem alone (4, 16, and 64 mg/L) or polymyxin B alone (0.25 and 1 mg/L) within 24 hours. However, meropenem and polymyxin B in combination were consistently bactericidal, achieving synergistic activity in strains with lower meropenem resistance (MICs ≤32 mg/L). Conclusions: Our findings are in agreement with the limited available literature, but we add that the synergistic interaction between meropenem and polymyxin B is dependent on the degree of meropenem resistance in KPC-producing K. pneumoniae. This data suggests that lower level resistance to carbapenems may be amenable to antimicrobial combinations involving a carbapenem and a polymyxin.

by Tang Yan Chi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1999. / Includes bibliographical references (leaves 156-168). / Abstracts in English and Chinese. / ACKNOWLEDGEMENTS --- p.I / ABBREVIATIONS --- p.II / ABSTRACT --- p.V / ABSTRACT (CHINESE) --- p.VII / TABLE OF CONTENT --- p.1 / GENERAL INTRODUCTION --- p.4 / Chapter 1.1. --- Immunotherapy in Cancer --- p.4 / Chapter 1.1.2. --- Cytokines used in Immunotherapy in Cancer --- p.5 / Chapter 1.1.2.1. --- Interferons (IFNs) --- p.6 / Chapter 1.1.2.2. --- interleukins (ILs) --- p.11 / Chapter 1.1.2.3. --- Tumor Necrosis Factor-Alpha (TNF-α) --- p.14 / Chapter 1.2. --- Immunomodulatory and Anti-tumor Activities of Plant Polysaccharides --- p.17 / Chapter 1.3. --- Previous Studies on the Capsular Polysaccharides (CPS) from Klebsiella pneumoniae --- p.21 / Chapter 1.4. --- Activation of TNF-α Production from Macrophages by Bacterial Polysaccharides --- p.26 / Chapter 1.5. --- Chemotherapy of Cancer --- p.29 / Chapter 1.5.1. --- Types of Chemotherapeutic Drugs --- p.29 / Chapter 1.5.1.1. --- Alkylating Agents --- p.29 / Chapter 1.5.1.2. --- Plant Alkaloids --- p.31 / Chapter 1.5.1.3. --- Anti-metabolites --- p.32 / Chapter 1. 5.1.4. --- Antitumor Antibiotics --- p.32 / Chapter 1.5.2. --- Chemotherapeutic Drugs in this Project --- p.34 / Chapter 1.5.2.1. --- actinomycin D (ACT D) --- p.34 / Chapter 1.5.2.2. --- Cyclophosphamide (CY) --- p.35 / Chapter 1.5.2.3. --- Doxorubicin (Dox) --- p.37 / Chapter CHAPTER TWO --- AIM AND SCOPE OF THIS DISSERTATION --- p.40 / Chapter CHAPTER THREE --- MATERIALS AND METHODS --- p.42 / Chapter 3.1 --- MATERIALS --- p.42 / Chapter 3.1.1. --- Animals --- p.42 / Chapter 3.1.2. --- Klebsiella pneumoniae Serotype 1 and Serotype 24 --- p.42 / Chapter 3.1.3. --- Cell lines --- p.43 / Chapter 3.1.4. --- "Buffers, culture media and chemicals" --- p.43 / "POLYCLONAL RABBIT ANTI-ACTIVE ERK1/2, ANTI-ACTIVE JNK 1/2 AND ANTI-ACTIVE P38WERE FROM PROMEGA. POLYCLONAL RABBIT ANTI-TOTAL JNK1, ANTI-TOTAL P38WERE FROM SANTA CRUZ. MONOCLONAL ANTI-MOUSE TOTAL ERK1 AND POLYCLONAL ANTI-RABBIT TOTAL ERK2 WERE PURCHASED FROM ZYMED" --- p.50 / Chapter 3.2. --- METHODS --- p.51 / Chapter 3.2.1. --- "Extraction, Purification and Characterization of K1 and K24 Capsular Polysaccharides (CPS) from Klebsiella pneumoniae" --- p.51 / Chapter 3.2.1.1. --- Extraction and Purification of K1 and K24 Klebsiella Capsular Polysaccharides (CPS) --- p.51 / Chapter 3.2.1.2. --- Gel filtration of K1 and K24 Klebsiella Capsular Polysaccharides --- p.52 / Chapter 3.2.1.3. --- Characterization of K1 and K24 Capsular Polysaccharides --- p.52 / Chapter 3.2.3. --- Assay for Macrophage Activating Activities of Klebsiella Capsular Polysaccharides --- p.55 / Chapter 3.2.3.1. --- Tumour Necrosis Factor-α (TNF-α) Production by Peritoneal Macrophages --- p.55 / Chapter 3.2.3.2. --- Effect of Capsular Polysaccharides on the activities of MAPK family in murine macrophages --- p.56 / Chapter 3.2.4. --- Assay for Anti-Tumor Activities of Klebsiella Capsular Polysaccharides --- p.63 / Chapter 3.2.4.1. --- Assay of in vivo Suppression of EAT growth by K1 and K24 Capsular Polysaccharides --- p.63 / Chapter 3.2.4.2. --- Assay of the Effect of CPS on the Survival of EAT-Bearing Mice --- p.64 / Chapter 3.2.5. --- "Assay for Anti-Tumor Activities of Combined Treatment of Klebsiella Capsular Polysaccharides and Chemotherapeutic Drugs (Actinomycin D (Act D), Cyclophosphamide (CY) and Doxorubicin (Dox)" --- p.65 / Chapter 3.2.5.1. --- "Assay of the Cytotoxic Effect of Chemotherapeutic Drugs： Actinomycin D (Act D), Cyclophosphamide (CY) and Doxorubicin (Dox), on wehi-164 cell line" --- p.65 / Chapter 3.2.5.2. --- "Assay of the Combined Treatment of the CPS and Chemotherapeutic Drugs (Act D, CY and Dox) on WEHI-164 cell line in vitro" --- p.66 / Chapter 3.2.5.3. --- Assay for Anti-Tumor Effect of Chemotherapeutic Drugs (Act D，CY and Dox) on EAT-bearing Mice in vivo --- p.67 / Chapter 3.2.5.4. --- "Assay of the Combined Treatment of the CPS and Chemotherapeutic Drugs (Act D, CY and Dox) on EAT-bearing Mice in vivo" --- p.68 / Chapter 3.2.5.5. --- "Assay of the Combined Treatment of the CPS and Chemotherapeutic Drugs (Act D, CY and Dox) on the survival of eat-bearing mice in vivo" --- p.72 / Chapter CHAPTER FOUR --- "EXTRACTION, PURIFICATION & CHARACTERIZATION OF KLEBSIELLA K1 & K24 CAPSULAR POLYSACCHARIDES" --- p.76 / Chapter 4.1. --- Extraction and Purification of K1 and K24 Capsular Polysaccharides from Klebsiella pneumoniae Serotype 1 and Serotype 24 --- p.76 / Chapter 4.2. --- Gel Filtration Chromatography of K1 and K24 Capsular Polysaccharides --- p.77 / Chapter 4.3. --- Characterization of K1 and K24 Capsular Polysaccharides --- p.81 / Chapter CHAPTER FIVE --- EFFECT OF THE K1 & K24 CAPSULAR POLYSACCHARIDES ON THE MACROPHAGE ACTIVITIES --- p.83 / Chapter 5.1. --- Effect ofK1 and K24 Capsular Polysaccharides on the in vitro induction of TNF- α Production of Murine Peritoneal Macrophages --- p.83 / Chapter 5.2. --- Effect of Capsular Polysaccharides on the activities of MAPK family in murine macrophages --- p.87 / Chapter CHAPTER SIX --- ANTI-TUMOR ACTIVITIES ON MURINE TUMOR CELL LINES OF KLEBSIELLA K1 &K24 CAPSULAR POLYSACCHARIDES --- p.94 / Chapter 6.1. --- Effect of K1 and K24 Capsular Polysaccharides on the In vivo Anti-tumor Activities on EAT-bearing Mice --- p.94 / Chapter 6.2. --- In vivo Anti-tumor Effect on the Survival of EAT-Bearing Mice by Treatment of K1 and K24 CPS --- p.97 / Chapter CHAPTER SEVEN --- "ANTI-TUMOR ACTIVITIES OF COMBINED TREATMENT OF KLEBSIELLA K1 &K24 CAPSULAR POLYSACCHARIDES AND CHEMOTHERAPEUTIC DRUGS: ACTINOMYCIN D, CYCLOPHOSPHAMIDE AND DOXORUBICIN" --- p.100 / Chapter 7.1. --- "Cytotoxic Effect Chemotherapeutic Drugs： Actinomycin D (Act D), Cyclophosphamide (CY) and Doxorubicin (Dox), on WEHI-164 cell line" --- p.100 / Chapter 7.2. --- "Cytotoxic Effect of the Combined Treatment of the CPS and the Chemotherapeutic Drugs (Act D, CY and Dox), on WEHI-164 cell line" --- p.104 / Chapter 7.3. --- "Anti-Tumor Effect of Chemotherapeutic Drugs (Act D, CY and Dox) on EAT-bearing Mice in vivo" --- p.111 / Chapter 7.4. --- "Combined Treatment of the CPS and Chemotherapeutic Drugs (Act D, CY and Dox) on the EAT Growth in vivo" --- p.115 / Chapter 7.5. --- "Combined Treatment of the CPS and Chemotherapeutic Drugs (Act D, CY and Dox) on the Survival of EAT-bearing Mice in vivo" --- p.122 / Chapter CHAPTER EIGHT --- GENERAL DISCUSSION --- p.135 / Chapter 8.1. --- "Extraction, Purification and Characterization of K1 and K24 Capsular Polysaccharides from Klebsiella pneumoniae Serotype 1 and Serotype 24" --- p.135 / Chapter 8.2. --- Effect of K1 and K24 Capsular Polysaccharides on the Macrophage Activation --- p.140 / Chapter 8.3. --- Anti-tumor Activities on Murine Tumor Cell LInes of Klebsiella K1 and K24 Capsular Polysaccharides --- p.145 / Chapter 8.4. --- "Anti-tumor Activities of Combined Treatment of K1 and K24 Capsular Polysaccharides and Chemotherapeutic Drugs： Actinomycin D, Cyclophosphamide and Doxorubicin" --- p.148 / Chapter CHAPTER NINE --- CONCLUSIONS AND FUTURE PERSPECTIVES --- p.152 / BIBLIOGRAPHY --- p.156

Orientador: Mara Correa Lelles Nogueira / Coorientador: Doroti de Oliveira Garcia / Banca: Ana Cristina Gales / Banca: Afonso Luis Barth / Banca: Aripuanã Sakura Aranha Watanabe / Banca: Margarete Teresa Gottardo de Almeida / Resumo: O aumento nas taxas de infecção por K. pneumoniae produtoras de KPC tornou-se um sério problema de saúde pública mundial. Estas enzimas hidrolizam carbapenêmicos, oxyimino-cefalosporinas, cefamicinas e não são inibidas por inibidores das -lactamases tais como o ácido clavulânico, sulbactam e tazobactam. Além disso, em plasmídeos que carreiam o gene blaKPC, geralmente são encontrados genes de resistência a outros antimicrobianos, como quinolonas e aminoglicosídeos. Deste modo, o objetivo deste estudo foi investigar, de forma comparativa, a presença de genes de resistência aos aminoglicosídeos, quinolonas e - lactâmicos entre K. pneumoniae produtoras de KPC, provenientes de diversos hospitais da cidade de São Paulo e de um hospital terciário localizado em São José do Rio Preto, região noroeste do estado de São Paulo. A similaridade genética e a relação clonal entre as cepas isoladas em cada região também foram determinadas. Foram estudadas cem cepas de K. pneumoniae produtoras de KPC, sendo cinquenta de hospitais da cidade de São Paulo, armazenadas na coleção do Instituto Adolfo Lutz de São Paulo, denominadas SP, e cinquenta do Hospital de Base de São José do Rio Preto, denominadas KP. O gene blaCTX-M foi detectado em 76% das cepas KP e em 58% das cepas SP. Entre as cepas KP, 68,4% apresentaram blaCTX-M-15, 23,7% blaCTX-M-2, 2,6%% blaCTX-M-59, 2,6% blaCTX-M-15 e blaCTX-M-59 simultaneamente e 2,6% não identificado. Entre as cepas SP, 51,7% apresentaram blaCTX-M-2, 37,9% blaCTX-M-15, 2,5% blaCTX-M-15 e blaCTX-M-2 simultaneamente e 5% blaCTX-M-14. Dos sete genes de AMEs investigados, foram detectados cinco, sendo aph(3')-VI, aph(3')-Ia, aac(6')- Ib, aac(3)-Ia e aac(3)IIa, distribuídos entre 95% das cepas, sem diferença entre KP e SP. Dos sete genes de metiltransferases 16S RNAr, apenas o gene rmtB foi detectado, em duas cepas SP. Quanto aos genes determinantes de resistência às quinolonas, 42% das cepas KP... / Abstract: The increase in infection rates by KPC producing K. pneumoniae is a serious global public health problem. These enzymes hydrolyze carbapenems, oxyimino-cephalosporins, cephamycins, and -lactamase inhibitors such as clavulanic acid, sulbactam and tazobactam. In addition, the plasmids carrying blaKPC genes generally harbor other antimicrobial resistance genes. Thus, the aim of this study was to investigate, in a comparative way, the presence of genes conferring resistance to aminoglycosides, quinolones and -lactams between KPC producing K. pneumonia from various hospitals in São Paulo City and from a tertiary hospital located in Sao Jose do Rio Preto, northwest of São Paulo state. The genetic similarity and the clonal relationship among strains were also determined. One hundred isolates were studied: fifty from different hospitals in São Paulo (named SP), and fifty from the "Hospital de Base de São José do Rio Preto" (named KP). The blaCTX-M gene was detected in 76% of the KP strains and in 58% of the SP strains. Among the KP strains, 68.4% had blaCTX-M-15, 23.7% blaCTX-M-2, 2.6% blaCTX-M-59, 2.6% blaCTX-M-15 and blaCTX M-59 simultaneously, and 2.6% were unidentified. Among the SP strains, 51.7% presented blaCTX-M-2, 37.9% blaCTX-M-15, 2.5% blaCTX-M-15 and blaCTX-M-2 simultaneously, and 5% blaCTX-M-14. Regarding the genes for AMEs, among the seven types investigated, five were detected: aph (3') -VI, aph (3 ') - Ia, aac (6') - Ib, aac (3) -Ia and aac (3) IIa were detected among 95% of the strains, and no difference was observed between KP and SP strains. Among the seven genes for 16S rRNA methyltransferases, only the rmtB was detected, in two SP strains. Concerning genes that determine resistance to quinolones, 42% of he KP and 14% of the SP strains showed qnrB. The oqxAB gene was detected in 56% and 2% of the SP and KP strains, respectively. Molecular typing by ERIC-PCR revealed that genetical... / Doutor

Submitted by Sara Ribeiro (sara.ribeiro@ucb.br) on 2018-04-16T14:40:02Z No. of bitstreams: 1 FernandaNomiyamaFigueiredoDissertacao2018.pdf: 2178476 bytes, checksum: 23f38c14567d00ff189eaef20f904495 (MD5) / Approved for entry into archive by Sara Ribeiro (sara.ribeiro@ucb.br) on 2018-04-16T14:40:47Z (GMT) No. of bitstreams: 1 FernandaNomiyamaFigueiredoDissertacao2018.pdf: 2178476 bytes, checksum: 23f38c14567d00ff189eaef20f904495 (MD5) / Made available in DSpace on 2018-04-16T14:40:47Z (GMT). No. of bitstreams: 1 FernandaNomiyamaFigueiredoDissertacao2018.pdf: 2178476 bytes, checksum: 23f38c14567d00ff189eaef20f904495 (MD5) Previous issue date: 2018-03-06 / Klebsiella pneumoniae is one of the main bacterial agents that may cause infections related to health care assistance. K. pneumoniae frequently carries the resistance gene K. pneumoniae carbapenemase (KPC). Currently, tigecycline can be considered one of the last therapeutic options for KPC, but reports of tigecycline-resistant KPC isolates are on the rise, being indicated as most common mechanism the increased AcrAB-TolC efflux pump system expression. However, molecular tigecycline resistance mechanisms associated to AcrAB-TolC still remains obscure. Thus, the main goal of this study was to verify if tigecycline resistance can be related to the presence of mutations in the regulatory genes of AcrAB-TolC, AcrR and RamR. Therefore, 32 K. pneumoniae isolates were used, identification and antibiogram performed using Vitek 2 systems. The minimum inhibitory concentrations were confirmed using E-test. Primers were designed in order to verify mutations within AcrR and RamR genes. PCR analysis showed that the mutations found within these genes were transversions (94% for AcrR and 90% for RamR) and transitions (6% for AcrR and 10% for RamR). Nevertheless among the mutations, no distinction between tigecycline susceptible and resistant isolates was found. Some of the transversions caused change in the amino acid encoding 6 in AcrR and 15 in RamR. Presence of these types of mutations evaluation can be seen as the first bacterial resistance study step, as it may be caused by oxidative damage for bacterial DNA, frequently caused by antibiotic selective pressure. Tigecycline resistance found in this study`s clinical isolates may be associated to alterations in another genes that can trigger mechanisms associated to this antibiotic. / Klebsiella pneumoniae consiste em um dos principais agentes bacterianos causadores de infec????es relacionadas ?? assist??ncia ?? sa??de (IRAS). K. pneumoniae carrega frequentemente o gene de resist??ncia K. pneumoniae carbapenemase (KPC). Atualmente, a tigeciclina pode ser considerada uma das ??ltimas op????es terap??uticas para KPC, mas os relatos de isolados de KPC resistentes a tigecilina est??o em ascens??o, sendo a hiperexpress??o da bomba de efluxo AcrAB-TolC indicado como mecanismo mais comum. No entanto, os mecanismos moleculares de resist??ncia ?? tigeciclina associada ao AcrAB-TolC permanecem obscuros. Desta forma o objetivo deste trabalho foi verificar se a resist??ncia a tigeciclina pode estar relacionada ?? presen??a de muta????es nos genes ArcR e RamR, reguladores de AcrAB-TolC. Para tanto, 32 isolados de K. pneumoniae foram utilizados, sendo a identifica????o e o antibiograma feitos utilizando o sistema Vitek 2. A confirma????o das concentra????es inibit??rias m??nimas (CIMs) foram realizadas por E-test. Iniciadores foram desenhados para verifica????o de muta????es nos genes (AcrR e RamR). As an??lises por PCR mostraram que as muta????es encontradas nos genes AcrR e RamR foram substitui????es por transvers??o (94% e 90% para AcrR e RamR respectivamente) e transi????o (6% e 10% para AcrR e RamR respectivamente), por??m n??o foi identificada distin????o da presen??a de muta????es entre isolados sens??veis e resistentes a tigeciclina. Algumas tranvers??es ocasionaram mudan??a na codifica????o do amino??cido, sendo 6 em AcrR e 15 em RamR. A avalia????o da presen??a desses tipos de muta????es consiste em um primeiro passo para o estudo da resist??ncia bacteriana, j?? que pode ser causada por dano oxidativo ao DNA bacteriano, frequentemente ocasionado por press??o seletiva dos antibi??ticos. A resist??ncia a tigeciclina encontrada nos isolados cl??nicos do presente estudo, provavelmente pode estar associada a altera????es em outros genes desencadeadores de mecanismos de resist??ncia a tigeciclina.

Klebsiella pneumoniae (KP) pertence à família Enterobacteriaceae e é frequentemente isolada em infecções nosocomiais, reportada globalmente como uma das mais importantes causas de bacteremias. O seu tratamento usual com β-lactâmicos foi posto a prova na década de 80, com o surgimento de cepas produtoras de β-lactamases de espectro estendido (ESBLs), e posteriormente com as carbapenemases, como sua principal representante Klebsiella pneumoniae carbapenemase (KPC), capazes de hidrolisar todos os β-lactâmicos. Apesar das limitadas opções, em geral as Klebsiella pneumoniae produtoras de KPC (KP-KPC) apresentam susceptibilidade às polimixinas, aminoglicosídeos e tigeciclina, que são comumente aplicadas em regimes terapêuticos combinados, dependente dos perfis de sensibilidade ou resistência a estas drogas, mas dos quais ainda não há informações suficientes para a definição do tratamento mais adequado. A escassez de opções terapêuticas é um dos fatores que contribuem para os altos índices de mortalidade das infecções por K. pneumoniae, de cerca de 40%. Assim, se fazem necessárias avaliações dos perfis fenotípicos de isolados de KP-KPC e a caracterização da disseminação deste mecanismo de resistência, avaliando a presença de perfis clonais relacionados dentro da população. A partir deste cenário, os objetivos deste trabalho foram determinar as concentrações inibitórias mínimas (CIMs) frente à polimixina B (PMB), meropenem (MEM) e tigeciclina (TGC), os perfis de sensibilidade frente a outras drogas comumente utilizadas no tratamento destas infecções, assim como caracterizar molecularmente as amostras resistentes à PMB. Para a determinação das CIMs e dos perfis de susceptibilidade foram utilizadas as técnicas de microdiluição em caldo e disco-difusão, respectivamente, e o perfil molecular foi analisado através de técnica de macrorestrição de DNA seguida por PFGE. Foram incluídas neste estudo 158 amostras isoladas de corrente sanguínea, de quatro hospitais terciários de Porto Alegre. Destas 158 amostras, nenhuma foi sensível a MEM de acordo com o Clinical and Laboratory Standard Institute (CLSI), 118 (74,7%) a PMB utilizando a recomendação do European Committee on Antimicrobial Susceptibility Testing (EUCAST), e 94 (59.5%) à TGC considerando EUCAST ou 137 (86.7%) de acordo com o Food and Drug Administration (FDA). Um total de 48 (30.4%), 28 (17.7%) e 16 (10.1%) isolados foram considerados sensíveis à amicacina (AMK) de acordo com CLSI, EUCAST e USCAST, respectivamente, e 11 (7.0%), 9 (5.7%) e 9 (5.7%) reportados como sensíveis à gentamicina (GEN) de acordo com CLSI, EUCAST e USCAST, respectivamente. Doxiciclina foi o antimicrobiano mais ativo (24, 60.0%) frente aos 40 (25,3%) isolados resistentes a PMB. Destes 40 isolados, 29(72.5%) foram caracterizados molecularmente sendo encontrados 18 clones, dos quais cinco perfis clonais foram identificados em mais de um hospital. Neste estudo, pudemos demonstrar um importante aumento nos níveis de resistência às polimixinas, acompanhado por um desafiador perfil de susceptibilidade frente as outras opções terapêuticas disponíveis, ainda que os índices de sensibilidade destas drogas variem de acordo com os pontos de corte de cada comitê. Quanto à caracterização molecular, a detecção de dezoito clones diferentes e a presença do mesmo perfil em mais de um hospital provavelmente estão associadas à emergência de resistência mediada por mutações, assim como a um processo de disseminação horizontal. / Klebsiella pneumoniae (KP) belongs to the family Enterobacteriaceae and is frequently isolated in nosocomial infections, reported globally as one of the most important causes of bacteremia. Its usual β-lactam treatment was challenged in the 1980s with the emergence of extended-spectrum β-lactamase producing (ESBLs) strains, and later with carbapenemases, as its main representative Klebsiella pneumoniae carbapenemase (KPC), capable of hydrolyze all β-lactam. Despite the limited options, KPC-producing Klebsiella pneumoniae (KPC-KP) are generally susceptible to polymyxins, aminoglycosides and tigecycline, which are commonly applied in combination therapy regimens depending on levels of sensitivity or resistance to these drugs, but of which there is still insufficient information to define the most appropriate treatment. The scarcity of therapeutic options is one of the factors that contribute to the high mortality rates of K. pneumoniae infections, of around 40%. Thus, it is necessary to evaluate the phenotypic profiles of KPC-KP isolates and the characterization of the dissemination of this resistance mechanism, evaluating the presence of related clonal profiles within the population. From this scenario, the objectives of this study were to determine the minimum inhibitory concentrations (MICs) against polymyxin B (PMB), meropenem (MEM) and tigecycline (TGC) by broth microdilution and the susceptibility profiles to aminoglycosides and other drugs by disk-diffusion method, as well as to evaluate the molecular profile of KPC-KP isolates from four tertiary hospitals in Porto Alegre. A total of 158 samples were included in this study, where none were sensitive to MEM according to the Clinical and Laboratory Standard Institute (CLSI), 118 (74.7%) to PMB using the recommendation of the European Committee on Antimicrobial Susceptibility Testing (EUCAST), and 94 (59.5%) to TGC considering EUCAST or 137 (86.7% %) according to Food and Drug Administration (FDA). A total of 48 (30.4%), 28 (17.7%) and 16 (10.1%) isolates were considered susceptible to amikacin (AMK) according to CLSI, EUCAST and USCAST, respectively, and 11 (7.0%), 9 %) and 9 (5.7%) reported as sensitive to gentamicin (GEN) according to CLSI, EUCAST and USCAST, respectively. Doxycycline was also the most active antimicrobial (24, 60.0%) against 40 (25.3%) PMB resistant isolates. Of these 40 isolates, 29 (72.5%) were clonally related, resulting in 18 clones, where five profiles were identified in more than one hospital. In this study, we could demonstrate an important increase in the levels of resistance to polymyxins, accompanied by a challenging profile of susceptibility to other drugs, although the sensitivity indexes of the latter vary significantly according to the breakpoints of each committee. As for molecular characterization, the detection of eighteen different clones and the presence of the same profile in more than one hospital are probably associated with the emergence of resistance mediated by mutations, as well as a process of horizontal dissemination.

The aim of this study was to determine the prevalence of extended-spectrum b-lactamase (ESBL)- producing Klebsiella pneumoniae isolated from urinary tract and bloodstream infections in a rural hospital in Manhic¸a, Mozambique. ESBLs were investigated among ceftriaxone-non-susceptible K. pneumoniae clinical isolates recovered between 2004 and 2009. Characterisation of blaCTX-M, blaSHV, blaOXA and blaTEM genes was performed by PCR and sequencing. Epidemiological relationships were established by phylogenetic analysis, repetitive extragenic palindromic PCR (REP-PCR), pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST), whilst plasmid transferability was evaluated by conjugation. In addition,the presence of class 1 and 2 integrons was studied.A total of 19 K. pneumoniae were analysed. The blaCTX-M-15 gene was found in all strains. Other ESBL genes were found concomitantly, including blaSHV-5, blaSHV-2, blaSHV-2A, blaSHV-12 and blaSHV-38. In addition, other b-lactamases such as blaTEM-1 and blaOXA-30 were also detected. REP-PCR identified 15 different epidemiological profiles. MLST analysis also showed great variability of sequence types. The blaCTX-M-15 gene showed a high transfer capacity. The presence of class 1 integrons was high. High levels of multidrug resistance were also found. In conclusion, these data show the dominance of the CTX-M-type ESBL, particularly CTX-M-15, supporting its worldwide dissemination, including in areas with limited access to third-generation cephalosporins. This finding is a matter of concern for clinical management as third-generation cephalosporins are an alternative for treating severe cases of multidrug-resistant infections in this community. / Revisión por pares

Klebsiella pneumoniae is a Gram negative, enteric bacterium that frequently causes disease in immunocompromised individuals. These types of infections are often associated with the presence of indwelling medical devices, which provide a site for the organism to attach and subsequently form a biofilm. A key component in K. pneumoniae biofilm formation in vitro is type 3 fimbriae. The two main components of this project have been to determine if type 3 fimbriae are an in vivo virulence factor using a mouse model of catheter associated urinary tract infection (CAUTI) and to examine the mechanism by which the production of type 3 fimbriae are regulated. Using a mouse model in which a silicone tube is implanted into the bladder of mice, mimicking the effects of catheterization, we have been able to show that type 3 fimbriae are required for colonization and persistence. Using different time points and conditions, we demonstrated that there are conditions when type 3 fimbriae alone are sufficient for colonization and other conditions where both type 1 and type 3 fimbriae have unique roles in colonization and persistence. Additionally, competition experiments showed that neither fimbrial mutant alone, or a double mutant in type 1 and type 3 fimbriae could compete with wildtype K. pneumoniae. In most animals, only wild-type bacteria were recovered by 24 hours post-inoculation. This work reinforced the role of type 1 fimbriae in pathogenesis and showed, for the first time, a role for type 3 fimbriae using an in vivo model. Our early work has indicated that type 3 fimbriae are regulated at least in part by the intracellular levels of the secondary messenger molecule cyclic di-GMP. Downstream from the type 3 fimbrial operon a gene encoding a phosphodiesterase is present; the product of this gene breaks down cyclic di-GMP. In the absence of this gene the levels of type 3 fimbrial expression are increased. Also adjacent to the mrk operon is a two-gene operon containing the determinants we have named mrkH and mrkI. mrkH encodes a PilZ domain containing protein, which we have shown binds cyclic di-GMP. Using a transcriptional fusion we have shown that the mrk gene promoter is activated modestly in the presence of MrkH, but when MrkH and MrkI are both present the activity is increased 100-fold. This has lead to the hypothesis that MrkH and MrkI interact, which we have been able to demonstrate using copurification procedures. This interaction appears to occur in a cyclic di-GMP dependent manner with the resulting protein complex binding to the mrk promoter region and activating the expression of type 3 fimbriae.