Infecções causadas por Candida tropicalis (C. tropicalis) são associados à elevada morbi-mortalidade, e foram consideradas como importantes causas de infecção de corrente sanguínea no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) de março de 1998 a março de 2001. Adicionalmente, são responsáveis pelo aumento do tempo e dos custos de hospitalização e necessidade de cuidados intensivos. Esse estudo tem como objetivo a caracterização molecular e perfil de sensibilidade de 61 isolados de C. tropicalis a partir de candidemias no HCFMUSP e Universidade Estadual de Campinas (UNICAMP), através das técnicas de amplificação aleatória do DNA polimórfico (RAPD), eletroforese em campo pulsátil (PFGE), tipagem de sequências de múltiplos locus gênicos (MLST) e antifungigrama por microdiluição pelos métodos propostos, Clinical and Laboratory Standards Institute (CLSI) e European Committee on Antibiotic Susceptibility Testing (EUCAST). A análise filogenética por RAPD evidenciou que os iniciadores P1 e P2 mostraram maior capacidade de discriminação que P3. Na análise por PFGE com enzimas de restrição SfiI, SmaI, BssHII e NaeI, a enzima BssHII mostrou maior poder discriminatório. MLST contribuiu com 36 novas diploid sequence type (DSTs) e 23 novos alelos, de acordo com o banco de dados oficial do MLST (http://pubmlst.org/ctropicalis/), representando o primeiro estudo que caracterizaram isolados sequenciais na América do Sul. Entre os isolados sequenciais de um mesmo paciente, as microvariações foram mais frequentes no fragmento de gene XYR1 em 8 pacientes e macrovariações ocorreram em quatro pacientes com mais de um isolado, destacando-se três que apresentaram diferença nos seis alelos estudados. A análise comparativa entre os métodos evidenciou diferenças entre os isolados múltiplos dos pacientes 3, 7 e 11, considerados diferentes pelos três métodos. O poder discriminatório foi de 83,47% para RAPD, 82,18% para PFGE e 97,4 % para MLST. Os resultados do antifungigrana mostraram concordância entre os métodos CLSI e EUCAST de 73,8% para o fluconazol, 67,2% para o itraconazol e 80,3% para o voriconazol. Do total de 61 isolados estudados, 3 isolados de diferentes pacientes foram resistentes ao fluconazol, com MIC de 64 g/mL. O fenômeno de trailing foi observado em 50% das amostras testadas frente ao fluconazol, 23% ao voriconazol e 21,3% ao itraconazol. O uso de pH 5,0 para re-análise do CLSI frente ao fluconazol revelou-se como uma ferramenta útil para esclarecer o perfil de sensibilidade de isolados que apresentaram o fenômeno de trailing. Não houve correlação entre perfil genético gerado pelas técnicas de caracterização molecular estudadas e o perfil fenotípico através do teste de sensibilidade aos antifúngicos / Infections caused by Candida tropicalis (C. tropicalis) have been characterized as important causes of candidemia at the Hospital of the Medical school, University of São Paulo (HCFMUSP) from March 1998 to March 2001 and are associated with high morbidity and mortality. Additionally, they have been related to higher hospitalization costs because of longer hospitalization times and intensive care needs. This study aims to analyze the molecular typing and antifungal susceptibility profile of 61 isolates of C. tropicalis from 41 patients with candidemia in HCFMUSP and University of Campinas (UNICAMP), through Random Amplified Polymorphic DNA (RAPD), Pulsed Field Gel Electrophoresis (PFGE), Multilocus Sequence Typing (MLST) and broth microdilution antifungal susceptibility methodologies proposed by Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antibiotic Susceptibility Testing (EUCAST). Phylogenetic analysis showed higher discriminatory power index of P1 and P2 primers than P3 by RAPD analysis. PFGE was performed with restriction enzymes SfiI, SmaI, NaeI and BssHII) and the enzyme BssHII presented the best performance. MLST analyses revealed 36 new diploid sequence type (DSTs) and 23 new alleles according to the C. tropicalis MLST database (http://pubmlst.org/ctropicalis/), representing the first study to characterize the sequential isolates of C. tropicalis candidemia in South America. Microvariation in a single gene was found in the sequential isolates from 8 patients. The main polymorphisms occurred in the alleles of the XYR1 gene. Macrovariation was detected in isolates from four patients, where 3 patients presented polimorphisms in six gene fragments. The comparative analysis revealed differences among sequential isolates from patients 3, 7 and 11, considered by three different methods. The discriminatory power was 83.47% for RAPD, 82.18% for PFGE and 97.4% for MLST. The agreement between the CLSI and EUCAST methods was 73.8% to fluconazole susceptibility, 67.2% to itraconazole and 80.3% to voriconazole. Of the 61 isolates tested, 3 isolates from different patients were resistant to fluconazole, MIC of 64 mg/mL. The trailing phenomenon was observed in 50% to fluconazole, 23% to voriconazole and 21.3% to itraconazole. Among the isolates studied, the use of pH 5.0 facilitated the determination of minimum inhibitory concentrations (MICs) for the re-analysis of fluconazole by CLSI, proving to be an important tool for the trailing phenomenon. No correlation was observed between genetic profile generated by the techniques of molecular characterization and phenotypic profile determined by susceptibility tests to antifungal drugs

O gênero Trichosporon é composto por leveduras artrosporadas do Filo Basidiomycota e é conhecido agente de infecção fúngica invasiva (IFI) em pacientes imunodeprimidos ou com outros fatores de risco. Em pacientes onco-hematológicos é a principal levedura responsável por IFI depois do gênero Candida. Entre as espécies responsáveis por infecções no homem encontram-se: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. A tecnologia de identificação de fungos por espectrometria de massa (SM) MALDI-TOF ainda carece de padronização para identificação de fungos do gênero Trichosporon, mas a literatura mostra resultados encorajadores. O objetivo deste estudo é padronizar a técnica de espectrometria de massa MALDI-TOF para a identificação das espécies do gênero Trichosporon de importância médica. O estudo foi realizado em cooperação entre a Divisão de Laboratório Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (DLC, HC-FMUSP), Instituto de Medicina Tropical da USP (IMT-USP), Instituto Adolfo Lutz (IAL) e Laboratoire de Parasitologie-Mycologie do Hospital Saint Antoine de Paris, vinculado ao grupo de pesquisa INSERM/UPMC UMR S945 \"Immunité et Infection\" Faculté de Medecine et Université Pierre et Marie Curie de Paris. Noventa e três cepas/isolados foram analisado(a)s, sendo dezenove cepas de referência adquiridas junto à coleção holandesa Centraalbureau Schimmelcultures (CBS), 19 isolados do HC-FMUSP e IAL, e 55 isolados de diferentes hospitais franceses. A identificação molecular foi realizada através do sequenciamento da região IGS1 do rDNA e foi considerada como método de referência. O protocolo de extração de proteínas foi estabelecido através da comparação do desempenho de três metodologias (Bruker®, Cassagne et al., Sendid et al.). Os espectros de massa foram obtidos no laboratório de bacteriologia do Hospital Saint Antoine de Paris através do aparelho Microflex LT®. A interpretação dos resultados qualitativos e quantitativos (logscore) foi realizada através do Software Biotyper 3.0®. O desempenho de identificação do banco de espectros de referência Biotyper 3.0® foi comparado a outros cinco bancos criados a partir de espectros de referência (ERs) derivados de 18 cepas de referência CBS, sete isolados clínicos e 11 ERs do banco Biotyper 3.0. O protocolo de extração de proteínas descrito por Sendid et al. foi escolhido como protocolo de referência pois os espectros produzidos tiveram logscore superiores àqueles obtidos através do método do fabricante. O banco de ERs Biotyper 3.0® apresentou 32,3% de identificações corretas das espécies, sendo que o banco de ERs in house (número 5, constituído cepas CBS e isolados clínicos) apresentou 98,5% de identificações de espécies. Espectros de referência do banco de dados Biotyper 3.0® foram submetidos à identificação com a utilização dos ERs criados a partir de cepas CBS e isolados clínicos e foram evidenciados com erros de identificação: T. mucoides (2), T. ovoides (1) e T. cutaneum (2). Após padronização do protocolo de extração e criação de banco de ERs com cepas CBS e isolados clínicos caracterizados pelo sequenciamento da região IGS, a SM por MALDI-TOF apresentou-se como potente uma ferramenta para a identificação de fungos do gênero Trichosporon. O banco de ERs Biotyper 3.0® apresentou um fraco desempenho, relacionado a ERs que foram criados a partir de cepas mal identificadas / Trichosporon spp. are arthrospored yeasts from the Filum Basidiomycota that are known to produce invasive fungal infection (IFI) in patients with immunosupression or other risk factors. After Candida, Trichosporon is the second genus of yeasts responsible for IFI in patients with onco-hematological diseases. The most important species related to human infection are: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. The technology of mass spectrometry (MS) for identification of Trichosporon species has not yet been standardized. However, preliminary promising results can be found in the literature. The objective of this study is to analyse and validate MS MALDI-TOF for the identification of Trichosporon species of medical relevance. This was a multicentric study with collaboration from the Central Laboratory Section from Clinics Hospital of the Medical School from the University of São Paulo (DLC-HCFMUSP), Tropical Medicine Institute from the University of São Paulo (IMT-USP), Instituto Adolfo Lutz (IAL) and Laboratoire de Parasitologie-Mycologie from the Hospital Saint Antoine of Paris and INSERM/UPMC UMR S945 \"Immunité et Infection\", Faculté de Medecine et Université Pierre et Marie Curie of Paris. Ninety three strains/isolates belonging to sixteen Trichosporon species were analysed. Nineteen were purchased from Centraalbureau Schimmelcultures (CBS) yeast collection, 19 belonged to HC-FMUSP and IAL collections, 55 belonged to different French collections. The reference identification method was the IGS1 rDNA sequencing. A protein extraction protocol was first established after comparing the performance of three different methodologies (Bruker(TM), Cassagne et al., Sendid et al.). The mass spectra were obtained through a Microflex LT(TM) mass spectrometer located at the bacteriology laboratory from Saint Antoine Hospital, Paris. Mass spectra, qualitative and quantitative results were produced through the software Biotyper 3.0(TM). The performance of the original main spectrum (MSP) library was compared to other 5 in house libraries built with the combination of MSPs derived from CBS strains (18), clinical strains (7) or (Bruker Daltonics/BD, Germany/USA) (11). The extraction protocol described by Sendid et al. showed better performance when compared to the manufacturer\'s one and was chosen for the subsequent extractions. Among the 6 different reference spectra databases tested, a specific one composed of 18 reference strains plus 7 clinical isolates (database 5) allowed the correct identification of 66 amongst 67 clinical isolates (98,5%). Biotyper 3.0 library produced only 32,3% of correct identifications. Biotyper\'s MSPs were submitted to cross-identification with MSPs derived from CBS strains and clinical isolates and misidentified original MSPs were identified: T. mucoides (2), T. ovoides (1) e T. cutaneum (2). While until now less widely applied to basidiomycetous fungi, MALDI-TOF appears to be a valuable tool for identifying clinical Trichosporon isolates at the species level. The MSP library Biotyper 3.0 showed a poorer performance which was due to misidentified strains utilized as reference for the MSPs

Infecções causadas por Candida tropicalis (C. tropicalis) são associados à elevada morbi-mortalidade, e foram consideradas como importantes causas de infecção de corrente sanguínea no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) de março de 1998 a março de 2001. Adicionalmente, são responsáveis pelo aumento do tempo e dos custos de hospitalização e necessidade de cuidados intensivos. Esse estudo tem como objetivo a caracterização molecular e perfil de sensibilidade de 61 isolados de C. tropicalis a partir de candidemias no HCFMUSP e Universidade Estadual de Campinas (UNICAMP), através das técnicas de amplificação aleatória do DNA polimórfico (RAPD), eletroforese em campo pulsátil (PFGE), tipagem de sequências de múltiplos locus gênicos (MLST) e antifungigrama por microdiluição pelos métodos propostos, Clinical and Laboratory Standards Institute (CLSI) e European Committee on Antibiotic Susceptibility Testing (EUCAST). A análise filogenética por RAPD evidenciou que os iniciadores P1 e P2 mostraram maior capacidade de discriminação que P3. Na análise por PFGE com enzimas de restrição SfiI, SmaI, BssHII e NaeI, a enzima BssHII mostrou maior poder discriminatório. MLST contribuiu com 36 novas diploid sequence type (DSTs) e 23 novos alelos, de acordo com o banco de dados oficial do MLST (http://pubmlst.org/ctropicalis/), representando o primeiro estudo que caracterizaram isolados sequenciais na América do Sul. Entre os isolados sequenciais de um mesmo paciente, as microvariações foram mais frequentes no fragmento de gene XYR1 em 8 pacientes e macrovariações ocorreram em quatro pacientes com mais de um isolado, destacando-se três que apresentaram diferença nos seis alelos estudados. A análise comparativa entre os métodos evidenciou diferenças entre os isolados múltiplos dos pacientes 3, 7 e 11, considerados diferentes pelos três métodos. O poder discriminatório foi de 83,47% para RAPD, 82,18% para PFGE e 97,4 % para MLST. Os resultados do antifungigrana mostraram concordância entre os métodos CLSI e EUCAST de 73,8% para o fluconazol, 67,2% para o itraconazol e 80,3% para o voriconazol. Do total de 61 isolados estudados, 3 isolados de diferentes pacientes foram resistentes ao fluconazol, com MIC de 64 g/mL. O fenômeno de trailing foi observado em 50% das amostras testadas frente ao fluconazol, 23% ao voriconazol e 21,3% ao itraconazol. O uso de pH 5,0 para re-análise do CLSI frente ao fluconazol revelou-se como uma ferramenta útil para esclarecer o perfil de sensibilidade de isolados que apresentaram o fenômeno de trailing. Não houve correlação entre perfil genético gerado pelas técnicas de caracterização molecular estudadas e o perfil fenotípico através do teste de sensibilidade aos antifúngicos / Infections caused by Candida tropicalis (C. tropicalis) have been characterized as important causes of candidemia at the Hospital of the Medical school, University of São Paulo (HCFMUSP) from March 1998 to March 2001 and are associated with high morbidity and mortality. Additionally, they have been related to higher hospitalization costs because of longer hospitalization times and intensive care needs. This study aims to analyze the molecular typing and antifungal susceptibility profile of 61 isolates of C. tropicalis from 41 patients with candidemia in HCFMUSP and University of Campinas (UNICAMP), through Random Amplified Polymorphic DNA (RAPD), Pulsed Field Gel Electrophoresis (PFGE), Multilocus Sequence Typing (MLST) and broth microdilution antifungal susceptibility methodologies proposed by Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antibiotic Susceptibility Testing (EUCAST). Phylogenetic analysis showed higher discriminatory power index of P1 and P2 primers than P3 by RAPD analysis. PFGE was performed with restriction enzymes SfiI, SmaI, NaeI and BssHII) and the enzyme BssHII presented the best performance. MLST analyses revealed 36 new diploid sequence type (DSTs) and 23 new alleles according to the C. tropicalis MLST database (http://pubmlst.org/ctropicalis/), representing the first study to characterize the sequential isolates of C. tropicalis candidemia in South America. Microvariation in a single gene was found in the sequential isolates from 8 patients. The main polymorphisms occurred in the alleles of the XYR1 gene. Macrovariation was detected in isolates from four patients, where 3 patients presented polimorphisms in six gene fragments. The comparative analysis revealed differences among sequential isolates from patients 3, 7 and 11, considered by three different methods. The discriminatory power was 83.47% for RAPD, 82.18% for PFGE and 97.4% for MLST. The agreement between the CLSI and EUCAST methods was 73.8% to fluconazole susceptibility, 67.2% to itraconazole and 80.3% to voriconazole. Of the 61 isolates tested, 3 isolates from different patients were resistant to fluconazole, MIC of 64 mg/mL. The trailing phenomenon was observed in 50% to fluconazole, 23% to voriconazole and 21.3% to itraconazole. Among the isolates studied, the use of pH 5.0 facilitated the determination of minimum inhibitory concentrations (MICs) for the re-analysis of fluconazole by CLSI, proving to be an important tool for the trailing phenomenon. No correlation was observed between genetic profile generated by the techniques of molecular characterization and phenotypic profile determined by susceptibility tests to antifungal drugs

O gênero Candida é responsável pela maioria das infecções fúngicas nosocomiais. A identificação do provável foco de origem é de extrema importância para elucidar a epidemiologia desse tipo de infecção e nesse sentido, a utilização de métodos de tipagem, que avaliam características fenotípicas e moleculares dos isolados, é essencial. Assim, o objetivo desse estudo foi tipar isolados de C. albicans, antes e após armazenamento e em diferentes ocasiões de coleta, a fim de verificar a manutenção dos biotipos apresentados, e o poder de discriminação dos métodos utilizados. Foi avaliada a microbiota leveduriforme da saliva de 73 estudantes universitários (tempo 0) sendo que após 180 dias (tempo 180) foi realizada nova coleta de saliva daqueles que apresentaram isolamento de C. albicans na primeira coleta. Os isolados foram analisados por ocasião das duas coletas, quanto à produção de exoenzimas fosfolipase e proteinase, pela morfologia das colônias, pelo perfil de suscetibilidade frente à anfotericina B, fluconazol e itraconazol e pela tipagem molecular por RAPD. As leveduras, após isoladas, foram armazenadas em ágar Sabouraud dextrose (ASD) e água destilada esterilizada. Após 180 dias, foram realizadas, novamente, as provas de tipagem. Todos isolados de C. albicans foram produtores de fosfolipase, nas duas coletas, embora tenha havido oscilação de atividade enzimática entre moderada e alta, no período. O enzimotipo prevalente nos tempos 0 e 180 foi, respectivamente, 22 e 32. Com relação à proteinase, 100% das leveduras apresentaram atividade moderada da enzima no tempo 0. No tempo 180 esse percentual foi de 85%, sendo que os demais não apresentaram atividade dessa enzima. Após armazenamento em ASD e água destilada, foi detectada alteração da atividade de ambas enzimas e conseqüente mudança de enzimotipos, em 40 e 30% dos isolados, respectivamente. Foram identificados 8 morfotipos diferentes de C.albicans no tempo 0 e apenas 50% foi mantido no tempo 180. O morfotipo mais comum foi 000-0. Após armazenamento, a maioria dos isolados apresentou alteração no morfotipo. Todos isolados mostraram-se sensíveis aos antifúngicos analisados nos tempos 0 e 180, denotando apenas um antifungotipo, o 111. Somente um isolado após estocagem em ASD, teve mudança de perfil de sensível para dose dependente ao itraconazol de modo que o antifungotipo foi alterado. A tipagem molecular por RAPD, com os primers OPA-09, OPB-11 e OPE-18, mostrou 19 tipos moleculares distintos entre os isolados obtidos na primeira coleta e permitiu identificar que um isolado de C.albicans obtido no tempo 180, não era relacionado ao obtido, do mesmo indivíduo, no tempo 0. Os demais mostraram perfil de fragmentos de DNA relacionado entre as coletas. Após estocagem, por ambos métodos, todos isolados mostraram correlação genética com o padrão obtido no tempo 0. Os resultados obtidos demonstram que os métodos de conservação aplicados neste estudo não permitem a manutenção da estabilidade das características fenotípicas avaliadas. Por outro lado, além da estabilidade dos biotipos gerados, a tipagem molecular por RAPD mostrou o melhor índice discriminatório, dentre as metodologias utilizadas, ratificando sua capacidade em diferenciar isolados, de uma mesma espécie e, portanto a sua utilidade em inquéritos epidemiológicos. / The Candida genus is responsible for most nosocomial fungal infections. The identification of the probable origin focus is very important to elucidate the epidemiology of this kind of infection and so, the usage of typing methods that evaluate phenotypic and molecular characteristics are essential. Therefore, the objective of this study was to type C. albicans isolates, before and after culture storage and in two different collection occasions to verify the biotype maintenance and the discriminatory power of the utilized methods. The salivary yeast microbiota of 73 university students (time 0) was evaluated and after 180 days (time 180) a new saliva collection of those that had presented C. albicans on the first collection was made. The isolates were analysed, in the two collection occasions on the basis of exoenzymes phospholipase and proteinase production, by colonial morphology, susceptibility profile to amphotericin B, fluconazole and itraconazole and according to molecular typing by RAPD. After isolation, the yeasts were storaged on Sabouraud dextrose agar (SDA) and in sterile distilled water. After 180 days, typing tests were carried out again. All C. albicans isolates were phospholipase productors, in both collections, even though enzyme activity had oscillated between moderate and high at that period. The prevalent enzymotype at time 0 and 180 were, respectively, 22 and 32. In relation to the proteinase, 100% of the yeasts showed moderate enzyme activity at time 0. At time 180, this percentage was 85%, and the others didn`t show enzyme activity. After storage on SDA and in distilled water, it was detected activity alteration of both enzymes and consequent enzymotype change, in 40 and 30% of isolates, respectively. Eight different C. albicans morphotypes were identified at time 0 and just 50% were maintained at time 180. The most common morphotype was 000-0. After storage most isolates presented changes in the morphotype. All isolates showed susceptibility to the analysed antifungals at times 0 and 180, showing just one antifungaltype, the 111. Only one isolate, after storage on SDA had a profile change from susceptible to dose dependent susceptible to itraconazole in a way that the antifungaltype wasn`t changed. The molecular typing by RAPD, with primers OPA-09, OPB-11 and OPE-18, showed 19 distinct molecular types among first collection isolates and allowed to identify that one C. albicans isolate from time 180 wasn`t related with the isolate obtained at time 0, from the same individual. The others showed DNA fragment profiles related between collection occasions. After storage by both methods, every isolate showed genetic relatedness with the profile obtained at time 0. The obtained results showed that the preservation methods used in this study don`t allow stability maintenance of the phenotypical characteristics evaluated. On the other hand, besides biotypes generated stability, the molecular typing by RAPD showed the best discriminatory index, between methodologies used, ratifying its ability in discriminating isolates of the same specie and so, its utility in epidemiological inquiries

Η διατήρηση της μικροβιολογικής ποιότητας του υδάτινου περιβάλλοντος είναι υψίστης σημασίας δεδομένων των κινδύνων που ενέχονται για τη δημόσια υγεία. Η αξιολόγηση της μικροβιολογικής ποιότητας των υδάτων πραγματοποιείται με την ανίχνευση της κοπρανώδους μόλυνσης και με τον έλεγχο της παρουσίας και συγκέντρωσης συγκεκριμένων μικροοργανισμών – δεικτών, όπως είναι η Escherichia coli. Ωστόσο, η απλή ανίχνευση κοπρανώδους μόλυνσης δεν επαρκεί για την υπόδειξη τρόπων εξυγίανσης και αντιμετώπισης του εκάστοτε προβλήματος. Οι δύο κύριες ομάδες στις οποίες διακρίνεται η κοπρανώδης μόλυνση είναι η ανθρώπινη και η ζωική, οι οποίες υποδηλώνουν πιθανή παρουσία διαφορετικών κάθε φορά παθογόνων μικροοργανισμών για τον άνθρωπο. Έτσι, προκειμένου να οριοθετηθεί ο κίνδυνος για τη δημόσια υγεία και να καθοριστούν μέτρα αντιμετώπισης της μόλυνσης ενδείκνυται ο προσδιορισμός της ανθρώπινης ή ζωικής προέλευσης της κοπρανώδους μόλυνσης. Στην παρούσα μελέτη αναπτύχθηκαν, εφαρμόστηκαν και αξιολογήθηκαν οι μέθοδοι: α)Έλεγχος πολλαπλής ανθεκτικότητας σε αντιβιοτικά (Multiple Antibiotic Resistance – MAR – φαινοτυπική μέθοδος) και β) PCR με τυχαία ενισχυμένα τμήματα πολυμορφικού DNA - Random Amplified Polymorphic DNA-PCR (RAPD-PCR – γονοτυπική μέθοδος), ως τεχνικές προσδιορισμού και διάκρισης προέλευσης μικροοργανισμών. Κατά το πρώτο στάδιο καθορίστηκαν οι παράμετροι των μεθόδων για το διαχωρισμό στελεχών E. coli γνωστής προέλευσης (60 στελέχη απομονωμένα από ζωικά κόπρανα και 68 στελέχη από ανθρώπινα). Για το διαχωρισμό και κατηγοριοποίηση των στελεχών εφαρμόστηκαν η Ιεραρχική Ανάλυση Κατά Συστάδες και η Διαχωριστική Ανάλυση. Με τη MAR ανάλυση τα στελέχη E. coli εμφάνισαν διαφορετικούς συνδυασμούς ανθεκτικότητας και διαχωρίστηκαν βάσει της προέλευσής τους με μέσο ποσοστό σωστής ταξινόμησης (ARCC) 99,2%. Με την RAPD-PCR χρησιμοποιήθηκαν δύο εκκινητές ξεχωριστά (1254 & 1290) και τα 128 στελέχη E. coli γνωστής προέλευσης διαχωρίστηκαν σε ανθρώπινης και ζωικής πηγής με ARCC 98,4% και με τους δύο εκκινητές. Η διακριτική ικανότητα της RAPD-PCR με τους δύο εκκινητές ήταν D1254=0,97 & D1290=0,90. Επιπλέον, η αξιολόγηση της επαναληψιμότητας της RAPD-PCR και με τους δύο εκκινητές έδωσε ικανοποιητικά αποτελέσματα με την εμφάνιση ίδιων ηλεκτροφορητικών εικόνων για τα ίδια βακτηριακά στελέχη. Στη συνέχεια οι επιλεγμένες τεχνικές εφαρμόστηκαν για την ταξινόμηση και κατηγοριοποίηση στελεχών E. coli άγνωστης προέλευσης εκτιμώντας την ανθρώπινη ή ζωική πηγή τους βάσει του μοντέλου διαχωρισμού των E. coli γνωστής προέλευσης. Οι E. coli άγνωστης προέλευσης (234 στελέχη) απομονώθηκαν από δείγματα πόσιμου νερού δικτύου από 11 περιοχές και δείγματα μη επεξεργασμένων λυμάτων από τις εισόδους τεσσάρων σταθμών βιολογικού καθαρισμού (ΚΕΡΕΦΥΤ – Νομός Αττικής, ΨΥΤΤΑΛΕΙΑ – Νομός Αττικής, ΡΙΟ – Νομός Αχαΐας και ΠΑΤΡΑ - Νομός Αχαΐας). Τα 234 στελέχη με τη MAR ανάλυση ταξινομήθηκαν ως ανθρώπινα και ζωικά σε ποσοστά 46,6% και 53,4% αντίστοιχα. Τα αποτελέσματα ταξινόμησης ήταν διαφορετικά με τη μέθοδο RAPD-PCR. Με τον εκκινητή 1254 τα άγνωστα στελέχη προσδιορίστηκαν ως ανθρώπινα κατά το 64,9% και ως ζωικά κατά το 35,1%. Αντίστοιχα, με τον εκκινητή 1290 τα ποσοστά ήταν 60,3% ανθρώπινα και 39,7% ζωικά. Τα στελέχη του πόσιμου νερού που προέρχονταν από τους σταθμούς δειγματοληψίας που ήταν αστικά κέντρα χαρακτηρίστηκαν εξ ολοκλήρου ως ανθρώπινης προέλευσης. Αντίθετα, στις περιοχές δειγματοληψίας με ανεπτυγμένη κτηνοτροφία βρέθηκαν και στελέχη ζωικής προέλευσης, γεγονός που υποδηλώνει την είσοδο στο δίκτυο κοπρανώδους υλικού προερχόμενου από ζώα των συγκεκριμένων περιοχών, τα οποία ενδεχομένως να έχουν άμεση πρόσβαση στις πηγές και γεωτρήσεις. Όσον αφορά στο χαρακτηρισμό των E. coli που καταλήγουν στους αναφερόμενους βιολογικούς καθαρισμούς, η πλειοψηφία ανίχνευσης ανθρωπίνων στελεχών δηλώνει την πιθανή παρουσία στα ακατέργαστα λύματα πολλών ανθρωπίνων εντερικών παθογόνων σημαντικών για τη δημόσια υγεία. Δεδομένου ότι τα τελευταία χρόνια οι ερευνητές έχουν αποδυθεί σε μια προσπάθεια επαναχρησιμοποίησης επεξεργασμένων λυμάτων επισημαίνεται η ανάγκη επεξεργασίας τους σε διάφορα στάδια για τη διασφάλιση της δημόσιας υγείας. Παρατηρήθηκε συμφωνία αποτελεσμάτων με τη χρήση των δύο εκκινητών καθώς η διαφορά στα ποσοστά δεν ήταν στατιστικά σημαντική (P>0,05). Συγκρίνοντας τα αποτελέσματα που ελήφθησαν με τις δύο μεθόδους, τη φαινοτυπική (MAR ανάλυση) και τη γονοτυπική (RAPD-PCR), υπήρξε στατιστικά σημαντική διαφορά (P<0,05), με συνέπεια να τίθεται θέμα επιλογής της πιο ενδεδειγμένης μεθόδου τυποποίησης και διάκρισης περιβαλλοντικών μικροοργανισμών. H παρούσα μελέτη αναδεικνύει την RAPD-PCR ως μια γονοτυπική μέθοδο με ικανοποιητική διακριτική ικανότητα, ευαισθησία, επαναληψιμότητα υπό αυστηρά καθορισμένες συνθήκες και χαμηλού κόστους. Η ευκολία εφαρμογής για την τυποποίηση μεγάλου αριθμού βακτηριακών στελεχών, χωρίς την απαίτηση γνώσης της νουκλεοτιδικής αλληλουχίας του γενετικού υλικού την καθιστούν ιδιαίτερα προσιτή σε εργαστήρια μοριακής μικροβιολογίας, ως τεχνική διάκρισης προέλευσης της κοπρανώδους μόλυνσης στο υδάτινο περιβάλλον. / Maintenance of the microbiological quality and safety of water systems is imperative, as their faecal contamination may exact high risks to human health as well as result in significant economic losses. The microbiological quality of water systems is evaluated by detecting their faecal pollution and especially specific faecal indicators such as Escherichia coli. Simple detection of faecal pollution is not sufficient in order to apply appropriate management plans to remedy the problem and to prevent any further contamination. Human faecal material is generally perceived as constituting a grater human health risk than animal faecal material, considering that it is more likely to contain human-specific enteric pathogens. Thus, it would be desirable to determine the source of the faecal material, especially for the assessment of risk for public health and for the development of monitoring plans. In the present study the development and assessment of Multiple Antibiotic Resistance Analysis (MAR – phenotypic method) and Randomly Amplified Polymorphic DNA-PCR Analysis (RAPD-PCR – genotypic method) were established as microbial source tracking methods. Firstly, parameters of the two selected methods were determined for the discrimination of E. coli isolates of known source (60 isolates from animal faecal material & 68 isolates from human faecal material). Hierarchical Cluster Analysis and Discriminant Analysis were applied for the classification of the isolates. With MAR analysis E. coli isolates developed different resistance profiles and were discriminated according to their source with an average rate of correct classification (ARCC) of 85.2%. With RAPD-PCR analysis two different 10-nt primers of arbitrary sequence were used (1254 & 1290) and the 128 E. coli isolates of known origin were classified as human and animal with the following ARCC: ARCC1254= 87.5% & ARCC1290= 81.3%. The discriminatory power of RAPD-PCR with the two selected primers was D1254=0.97 & D1290=0.90. Furthermore, the assessment of reproducibility of RAPD-PCR analysis provided satisfactory results with both primers, as RAPD profiles were identical for the same bacterial isolates. The assessment of specificity of the method resulted in the discrimination among RAPD profiles of E. coli isolates and other reference bacteria. The selected methods were applied for the classification and the source tracking of E. coli isolates, derived from tap water and raw sewage samples. In total 234 E. coli strains were isolated from tap water from 11 areas and raw sewage samples from four treatment plants (KEREFYT – prefecture of Attiki, PSITALIA - prefecture of Attiki, RIO - prefecture of Achaia and PATRA - prefecture of Achaia). With MAR analysis the 234 isolates were classified as human and animal in percentages of 46.6% & 53.4%, respectively. Classification results were different with RAPD-PCR analysis. With primer 1254 the classification was: 64.9% of human origin and 35.1% of animal origin and with primer 1290 the classification was: 60.3% of human origin and 39.7% of animal origin. Isolates derived from tap water of urban areas were classified in total as of human origin. On the contrary, in areas with many farm breeders many isolates were classified as of animal origin, indicating presence of faecal material in the water systems derived animal activities. As far as E. coli isolates from raw sewage samples are concerned, the majority of them were classified as of human source, indicating the possible presence of other human enteric pathogens as well. Taking into account the fact that there has been an effort in order to reuse treated sewage, it seems necessary a multi-stage process to renovate wastewater before it re-enters a body of water. There was an agreement of results of classification obtained form the use of the two different primers as the percentages did vary statistically (P>0.05). Comparing results obtained from the two selected methods, the difference was statistically significant (P<0.05), raising a question of the appropriate method for the typing and discrimination of environmental microorganisms. The present study demonstrates RAPD analysis as a simple, cost effective genotypic method with satisfactory discriminatory power, sensitivity and reproducibility. It can be applied for the analysis of a large number of bacterial isolates without the prior knowledge of nucleotide sequence of DNA to be necessary. Finally, it may fulfil environmental for the determination of origin of faecal pollution protecting water resources and public health.

Σκοπός της παρούσας ερευνητικής εργασίας ήταν η επιδημιολογική μελέτη των σταφυλοκοκκικών λοιμώξεων και κυρίως των λοιμώξεων από MRSA, τόσο στο ενδονοσοκομειακό περιβάλλον, όσο και στην κοινότητα, το διάστημα 2001-2006. Κατά τη διάρκεια της μελέτης, συλλέχθηκαν συνολικά 1922 στελέχη Staphylococcus aureus από όλες τις κλινικές και από διαφορετικούς ασθενείς στο Πανεπιστημιακό Γενικό Νοσοκομείο Πατρών (ΠΓΝΠ). Στη συνέχεια τα στελέχη ελέγχθηκαν για την παραγωγή της πρωτεΐνης PBP2α και την ύπαρξη του γονιδίου mecA για τον προσδιορισμό των ανθεκτικών στη methicillin στελεχών S. aureus (Methicillin-Resistant S. aureus, MRSA). Από το σύνολο των 1922 S. aureus, τα 757 (39.4%) χαρακτηρίσθηκαν ως MRSA. Γενικά, παρατηρήθηκε αύξηση του αριθμού των λοιμώξεων από S. aureus, με παράλληλη αύξηση του ποσοστού των MRSA λοιμώξεων, από 23% το 2001 στο 49% το 2006. Οι MRSA αποτελούν σοβαρό πρόβλημα για τα νοσοκομεία, αλλά και γενικότερα σε όλο το πληθυσμό, καθώς απομονώνονται με αυξανόμενη συχνότητα από την κοινότητα. Στο διάστημα που καλύπτει η παρούσα μελέτη, 2001-2006, το ποσοστό των στελεχών που απομονώθηκαν από την κοινότητα (Community-acquired MRSA, CA-MRSA) αυξήθηκε από 3% το 2001, σε 37% το 2006, ενώ εκείνο των ενδονοσοκομειακών στελεχών (Hospital-acquired MRSA, HA-MRSA), είναι ενθαρρυντικό ότι μειώθηκε από 20% το 2001, στο 12% το 2006. Για την επιδημιολογική μελέτη των λοιμώξεων που οφείλονται σε MRSA στελέχη, μέθοδος αναφοράς είναι η PFGE, κυρίως σε συνδυασμό και με υβριδισμό του χρωμοσωμικού DNA με ειδικούς ανιχνευτές. Oι μέθοδοι αυτές παρουσιάζουν δυσκολία στη σύγκριση των κλώνων μεταξύ των χωρών και έτσι αναπτύχθηκε η MLST, που βασίζεται στη εύρεση της νουκλεοτιδικής αλληλουχίας επτά συντηρημένων γονιδίων και επιτρέπει τον προσδιορισμό των κλωνικών συμπλεγμάτων (Clonal Complex, CC) με δυνατότητα άμεσης ταυτοποίησής τους. Τα MRSA που απομονώθηκαν κατατάχθηκαν σε επτά ST/SCCmec κλώνους, τους ST80/IV, ST5/IV, ST377/V, ST30/IVvar, ST239/III, ST225/NT και ST217/NT και πέντε κλωνικά συμπλέγματα (Πίνακας 46). Στα CA-MRSA επικρατεί ο ST80/IV, με μικρό ποσοστό να ανήκει και στον πρόσφατο τύπο ST377/V, ενώ στα HA-MRSA απαντώνται κυρίως οι ST239/III και ST30/IVvar. Η PVL είναι μια τοξίνη που καταστρέφει τα λευκοκύτταρα ανοίγοντας πόρους στην κυτταρική τους μεμβράνη, προκαλεί νέκρωση ιστών και νεκρωτική πνευμονία, κυρίως σε μικρά παιδιά, και κωδικοποιείται από τα γονίδια lukS-PV και lukF-PV. Το 74% των MRSA που μελετήθηκαν το διάστημα 2001-2006, έφεραν τα γονίδια αυτά, καταγράφοντας αύξηση από 33% το 2001, σε 88% το 2006. Τα PVL-θετικά MRSA ανήκουν στους κλώνους ST80/IV και ST377/V. Τα περισσότερα PVL-θετικά CA-MRSA της μελέτης μας απομονώθηκαν από λοιμώξεις δέρματος και μαλακών μορίων, ενώ τα PVL-θετικά HA-MRSA προέρχονταν από χειρουργικά τραύματα, κυρίως σε περιπτώσεις χρήσης προσθετικών υλικών. Ένα PVL-θετικό στέλεχος, που απομονώθηκε από αιματοκαλλιέργεια, προερχόταν από οστεομυελίτιδα. Πρόκειται για πρώτη αναφορά περιστατικών οξείας οστεομυελίτιδας, με αίτιο στελέχη CA-MRSA και MSSA που παράγουν PVL. Φαίνεται ότι η παρουσία των γονιδίων lukS-PV και lukF-PV συνδέεται κυρίως με λοιμώξεις που προκύπτουν δευτερογενώς σε τραύματα και επιπολής λοιμώξεις δέρματος και μαλακών μορίων, ενώ η απομόνωση PVL-θετικού στελέχους από οστεομυελίτιδα αποτελεί ένδειξη για την εμπλοκή της τοξίνης αυτής και στη παθογένεια εν τω βάθει λοιμώξεων. Εκτός από την PVL, σημαντικοί λοιμογόνοι παράγοντες και αίτια σοβαρών κλινικών συνδρόμων στον άνθρωπο θεωρούνται και οι τοξίνες της οικογένειας των υπεραντιγόνων, όπως η τοξίνη του συνδρόμου τοξικής καταπληξίας (TSST-1) και οι εντεροτοξίνες (SEs). Το γονίδιο tst κωδικοποιεί την παραγωγή της TSST-1, ενώ το οπερόνιο egc (enterotoxin gene cluster) την έκφραση πρωτεϊνών που μοιάζουν στη δομή και αλληλουχία με τις εντεροτοξίνες. Στα MRSA της συλλογής μας, τα γονίδια tst και egc2 ανιχνεύθηκαν μόνο στον κλώνο ST30/IV και δε βρέθηκαν ποτέ να συνυπάρχουν με τα γονίδια της PVL. Ανιχνεύθηκαν και συνδυασμοί των γονιδίων tst και του οπερονίου egc στους κλώνους ST80/IV και ST239/III, που σημαίνει ότι τα γονίδια αυτά διασπείρονται με οριζόντια μεταφορά, ενώ τα γονίδια lukS-PV και lukF-PV, που εντοπίστηκαν αποκλειστικά στους κλώνους ST80/IV ST377/V και χωρίς να συνυπάρχουν με γονίδια υπεραντιγόνων, φαίνεται ότι μεταφέρονται πιο ειδικά. Προϊόν της παρούσας ερευνητικής εργασίας ήταν η ανάπτυξη μεθοδολογίας για την ποσοτικοποίηση με αλυσιδωτή αντίδραση πολυμεράσης πραγματικού χρόνου, του γονιδίου tst σε στελέχη S. aureus που ήταν ανθεκτικά στη methicillin, κατατάσσονταν σε διαφορετικούς κλώνους και έφεραν ποικίλα γονίδια τοξινών. Για τη σήμανση και παρακολούθηση των προϊόντων χρησιμοποιήθηκε το SYBR Green I (SG), που είναι μη ειδικός τρόπος σήμανσης. Η χρήση του SYBR Green I κάνει τη μέθοδο εύχρηστη, αφού μπορεί η χρωστική να προστεθεί απλά στο υπόλοιπο μίγμα της αντίδρασης και φθηνή, επειδή δε χρειάζεται να σχεδιαστούν καινούριοι, ειδικοί εκκινητές. Οι αντιδράσεις απόλυτης ποσοτικοποίησης, που πραγματοποιήθηκαν με τη συγκεκριμένη μέθοδο, είχαν υψηλή απόδοση (2.04) και τα αποτελέσματα ήταν συνεχή και επαναλαμβανόμενα, γεγονός που σημαίνει ότι μπορεί να εφαρμοσθεί στη ρουτίνα του κλινικού εργαστηρίου για τη γρήγορη ανίχνευση και ποσοτικοποίηση του γονιδίου tst στα κλινικά στελέχη. Επί πλέον αποδείχθηκε με τη στατιστική ανάλυση, ότι στελέχη που απομονώθηκαν από λοιμώξεις μαλακών μορίων συνέθεταν υψηλότερα ποσά tst. Για τον υπολογισμό των λόγων έκφρασης του γονιδίου tst, στη σχετική ποσοτικοποίηση εφαρμόσθηκαν δυο μαθηματικά μοντέλα (2-ΔΔCt και Pfaffl). Συγκρίνοντας τα αποτελέσματα από τους δυο διαφορετικούς τρόπους υπολογισμού, βρέθηκαν διαφορές στα επίπεδα έκφρασης ίδιων στελεχών και καταλήξαμε στο συμπέρασμα ότι το μαθηματικό μοντέλο του Pfaffl είναι πιο ακριβές και αξιόπιστο, καθώς συνυπολογίζει την απόδοση της αντίδρασης. / The purpose of this study was to establish the clonality and evolution of CA-MRSA (Community-acquired MRSA, CA-MRSA) and HA-MRSA (Hospital-acquired MRSA, HA-MRSA), as well as the epidemiology of MRSA (Methicillin-Resistant S. aureus, MRSA) infections, during 2001-2006. In total 1922 Staphylococcus aureus strains were collected from patients with different pathologies admitted at the University Hospital of Patras. Among them 757 (39.4%) strains were MRSA. The prevalence of MRSA infections rose from 23% in 2001 to 49% in 2006. MRSA is a major problem worldwide in the nosocomial setting and the community. During 2001-2006 CA-MRSA isolated with an increasing rate from 3% in 2001 to 37% in 2006, while HA-MRSA decreased from 20% in 2001 to 12% in 2006. The epidemiological study of MRSA infections was based on PFGE, the “gold standard” of typing methods and hybridization with specific DNA probes. However, for the full characterization of a strain it is recommended the application of the multilocus sequence typing (MLST), since it is a highly discriminatory method and permits to compare the results from different laboratories. MLST represents a major advance since it relates organisms on the basis of the nucleotide sequences of ~450 bp internal fragments of seven conserved housekeeping genes resulting to the determination of Sequence Types (ST) and Clonal Complexes (CC). MRSA of our collection belonged to seven ST/SCCmec clones (ST80/IV, ST5/IV, ST377/V, ST30/IVvar, ST239/III, ST225/NT and ST217/NT) and five Clonal Complexes. Most CA-MRSA isolates belonged to ST80/IV clone and a small percentage to the newly described clone, ST377/V, while HA-MRSA strains were mainly characterized as ST239/III and ST30/IVvar clones. PVL is a bicomponent toxin associated with skin and soft tissue infections, but also with necrotizing pneumonia, especially in children. In total 74% of MRSA were positive for the PVL genes rising from 33% in 2001 to 88% in 2006. PVL-positive MRSA strains belonged to ST80/IV and ST377/V clones. Most PVL-positive CA-MRSA isolated from skin and soft tissue infections, while PVL-positive HA-MRSA isolated from surgical wounds, especially when prosthetic devices were used. In one patient acute staphylococcal osteomyelitis (AO) was diagnosed, due to MRSA carrying the PVL genes. This is the first description of CA-MRSA producing PVL as causative agents of AO suggesting that PVL-positive S. aureus can be isolated from patients with invasive musculo-skeletal infections, including acute childhood osteomyelitis, as well as among patient with skin and soft-tissue infections. Staphylococcal enterotoxins, enterotoxin-like superantigens (enterotoxin gene operon, egc) and the toxic shock syndrome toxin-1 that belong to the pyrogenic toxin superantigens (PTSAgs) are considered major virulence factors. The genotype tst/egc belonged only to ST30/IV clone and never coexisted with the PVL genes. Other combinations of genes were also detected belonging to clones ST80/IV and ST239/III, suggesting the horizontal transfer of those genes. On the contrary, the PVL genes were detected only in ST80/IV and ST377/V clones, meaning a more specific way of spread. A real-time PCR assay was developed for the quantification of tst gene in methicillin-resistant S. aureus using SYBR Green I (SG) chemistry, which is an easy and cost-effective approach to real-time, since it does not require the design of sequence specific probes and new primers. By the developed method of absolute quantification the results were reproducible and constant, meaning that the assay can be applied in the routine laboratory. The statistically significant difference of tst gene expression among strains associated with SSTIs, suggests that such strains may be the cause of TSS among patients. For the calculation of expression ratios in the relative quantification we applied two mathematical models (2-ΔΔCt and Pfaffl). Comparing ratios derived from the two mathematical methods we found variations, allowing us to suggest the use of the Pfaffl model as the more precise and reliable method.

A doença de Chagas é caracterizada por um amplo espectro de manifestações clínicas, que vão desde a ausência de sintomas à doença grave com comprometimento cardíaco e/ou digestivo. A influência do parasito, Trypanosoma cruzi (T. cruzi), agente etiológico da doença, nessas apresentações clínicas têm sido largamente estudada, não se tendo demonstrado o papel da diversidade genética de populações de T. cruzi na determinação das diferentes formas clínicas em humanos. Este trabalho teve como objetivos: a) geral: analisar as características moleculares de T. cruzi em pacientes com doença de Chagas com e sem imunodepressão (infecção por HIV e transplante de órgãos com e sem reativação); b) específicos: 1. Analisar comparativamente isolados do parasito quanto à distribuição em DTU; 2. Relacionar os resultados obtidos pela análise molecular do gene ND7 com a forma clínica e origem; 3. Avaliar por LSSP-PCR a variabilidade da sequência do kDNA de T. cruzi diretamente de amostras biológicas assim como em isolados de T. cruzi obtidos pelos exames de hemocultura/xenodiagnóstico; 4. Comparar os padrões polimórficos obtidos por LSSP-PCR em amostras repetidas de um mesmo paciente no mesmo sítio ou distintos sítios biológicos. Foram incluídos, após aprovação do protocolo na CAPPesq e mediante assinatura de TCLE, 106 pacientes com doença de Chagas crônica ou com imunossupressão, provenientes dos ambulatórios e enfermarias do HCFMUSP, além de 75 indivíduos controle, com provas sorológicas e moleculares negativas. Foram analisadas 187 amostras isoladas de hemocultura/xenodiagnóstico e 236 diretamente de amostras sanguíneas de pacientes. Os seguintes grupos foram constituídos: Agudo-AG, Crônico-CR, Crônico Imunodeprimido-CRI (doenças autoimunes/neoplasias), Coinfecção-CO (infecção por HIV/T.cruzi), Coinfecção-CO/RE (infecção por HIV/T.cruzi e reativação da doença de Chagas), Transplantado-TX, Transplantado-TX/RE (Transplantado com reativação da doença de Chagas). Foram identificados DTU TcI, TcV, TcVI e em maior número TcII, por ensaios de tipagem molecular do parasito, com distribuição estatisticamente significantemente de acordo com a naturalidade dos pacientes (P=0,013). Quanto ao gene ND7, observou-se que a banda de ~900 bp ocorreu em 83,0% das amostras das regiões norte, nordeste, centro-oeste e Bolívia e a de ~400pb em 54% das amostras nas regiões sul e sudeste brasileiras sendo esta diferença estatisticamente significante (P < 0,001). A comparação dos perfis observados por LSSP-PCR a partir de amostras extraídas diretamente do sangue e de isolados obtidos de hemocultura/xenodiagnóstico mostrou maior variabilidade em amostras sanguíneas, confirmada pelo dendrograma. Adicionalmente, o estudo de amostras repetidas do mesmo paciente permitiu confirmar a maior variabilidade nas amostras diretamente extraídas do sangue, com mudança dos padrões durante e após o tratamento com reaparecimento de perfis antigos não presentes no período prétratamento imediato, além de presença de perfis diferentes em distintos sítios biológicos do mesmo paciente. O encontro de DTU diferentes de TcII nos grupos CR/CRI e AG enfatiza a necessidade de atentar para a diferença em limiares de reatividade segundo DTU na análise da parasitemia por PCRq (quantitativa), conforme registrado na literatura. Os dados observados por LSSP-PCR acrescentam informações adicionais não revelados por tipagem molecular, representando novos desafios para o entendimento da relação hospedeiro-parasito em pacientes com doença de Chagas sem e com imunossupressão, ao lado de fatores como nível de parasitemia e pressão seletiva de medicamentos antiparasitários e imunossupressores / Chagas\' disease is characterized by a broad spectrum of clinical manifestations, ranging from asymptomatic cases to severe cardiovascular and/or gastrointestinal involvement. The clinical presentations are thought to be determined primarily by genetic diversity of populations of Trypanosoma cruzi (T. cruzi), but no correlation was clearly demonstrated yet. This study aimed to: a) general: to analyze the molecular characteristics of T. cruzi in patients with Chagas\' disease with and without immunosuppression (HIV infection and organ transplantation with or without reactivation); b) specifics: 1.To analyze comparatively isolates from the parasite as for the distribution in DTU; 2. To describe the results obtained by molecular analysis of gene ND7 in relationship with the clinical form and origin; 3. To assess by LSSP-PCR the variability of the sequence of the T. cruzi kDNA directly from biological samples, as well as in T. cruzi isolates obtained by examination of blood culture/xenodiagnosis; 4. To compare the polymorphic patterns obtained by LSSP-PCR in repeated samples of the same patient on the same site or different biological sites. After approval of the protocol in CAPPesq and by signing an informed consent, 106 patients with chronic Chagas disease or immunosuppression, from the HCFMUSP\'s clinics and wards, and 75 control subjects with negative serological and molecular tests were included. They were analyzed 187 isolated samples from blood culture/xenodiagnosis and 236 directly from blood samples of patients. The following groups were formed: Acute-AC, Chronic-CR, Chronic immunocompromised-CRI (autoimmune diseases/ neoplasms), Coinfection-CO (HIV/T. cruzi infection), Coinfection-CO/RE (HIV/T. cruzi and reactivation of Chagas disease), Transplantation-TX, Transplantation-TX/RE (Transplantation/ with reactivation of Chagas\' disease). DTU TcI, TcV, TcVI and higher TcII number were identified for molecular typing assays of the parasite and the distribution of DTU was statistically significant according to patient´s naturality (P=0.013). As for ND7 gene, was observed that the band of ~ 900 bp was prevalent in 83% of the samples in the North, Northeast, Midwest regions and Bolivia and the band of ~400bp occurred in 54% of the samples of Brazilian\' South and Southeast regions, this distribution was statistically significant (P < 0.001). The comparison between the profiles observed by LSSP-PCR from samples taken directly from blood and isolates obtained from blood culture/xenodiagnosis showed greater variability in blood samples, confirmed by dendrogram. Additionally, the study of repeated samples from the same patient allowed to confirm the greater variability in blood samples taken directly, with changing patterns during and after the treatment with reappearance of old profiles not present in the immediate pre-treatment period, and the presence of different profiles at different biological sites in the same patient. The presence of other DTUs than TcII in chronic and chronic immunosuppressed patients and AC groups emphasizes the need to pay attention to the different reactivity thresholds for the various DTU in the analysis of parasitaemia by PCRq (quantitative), according to the data registered in the literature. The results observed by LSSP-PCR add further information not revealed by molecular typing, representing new challenges for the understanding of the host-parasite relationship in patients with Chagas\' disease with and without immunosuppression, alongside factors such as level of parasitaemia and selective pressure of antiparasitic drugs and immunosuppressive

O gênero Trichosporon é composto por leveduras artrosporadas do Filo Basidiomycota e é conhecido agente de infecção fúngica invasiva (IFI) em pacientes imunodeprimidos ou com outros fatores de risco. Em pacientes onco-hematológicos é a principal levedura responsável por IFI depois do gênero Candida. Entre as espécies responsáveis por infecções no homem encontram-se: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. A tecnologia de identificação de fungos por espectrometria de massa (SM) MALDI-TOF ainda carece de padronização para identificação de fungos do gênero Trichosporon, mas a literatura mostra resultados encorajadores. O objetivo deste estudo é padronizar a técnica de espectrometria de massa MALDI-TOF para a identificação das espécies do gênero Trichosporon de importância médica. O estudo foi realizado em cooperação entre a Divisão de Laboratório Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (DLC, HC-FMUSP), Instituto de Medicina Tropical da USP (IMT-USP), Instituto Adolfo Lutz (IAL) e Laboratoire de Parasitologie-Mycologie do Hospital Saint Antoine de Paris, vinculado ao grupo de pesquisa INSERM/UPMC UMR S945 \"Immunité et Infection\" Faculté de Medecine et Université Pierre et Marie Curie de Paris. Noventa e três cepas/isolados foram analisado(a)s, sendo dezenove cepas de referência adquiridas junto à coleção holandesa Centraalbureau Schimmelcultures (CBS), 19 isolados do HC-FMUSP e IAL, e 55 isolados de diferentes hospitais franceses. A identificação molecular foi realizada através do sequenciamento da região IGS1 do rDNA e foi considerada como método de referência. O protocolo de extração de proteínas foi estabelecido através da comparação do desempenho de três metodologias (Bruker®, Cassagne et al., Sendid et al.). Os espectros de massa foram obtidos no laboratório de bacteriologia do Hospital Saint Antoine de Paris através do aparelho Microflex LT®. A interpretação dos resultados qualitativos e quantitativos (logscore) foi realizada através do Software Biotyper 3.0®. O desempenho de identificação do banco de espectros de referência Biotyper 3.0® foi comparado a outros cinco bancos criados a partir de espectros de referência (ERs) derivados de 18 cepas de referência CBS, sete isolados clínicos e 11 ERs do banco Biotyper 3.0. O protocolo de extração de proteínas descrito por Sendid et al. foi escolhido como protocolo de referência pois os espectros produzidos tiveram logscore superiores àqueles obtidos através do método do fabricante. O banco de ERs Biotyper 3.0® apresentou 32,3% de identificações corretas das espécies, sendo que o banco de ERs in house (número 5, constituído cepas CBS e isolados clínicos) apresentou 98,5% de identificações de espécies. Espectros de referência do banco de dados Biotyper 3.0® foram submetidos à identificação com a utilização dos ERs criados a partir de cepas CBS e isolados clínicos e foram evidenciados com erros de identificação: T. mucoides (2), T. ovoides (1) e T. cutaneum (2). Após padronização do protocolo de extração e criação de banco de ERs com cepas CBS e isolados clínicos caracterizados pelo sequenciamento da região IGS, a SM por MALDI-TOF apresentou-se como potente uma ferramenta para a identificação de fungos do gênero Trichosporon. O banco de ERs Biotyper 3.0® apresentou um fraco desempenho, relacionado a ERs que foram criados a partir de cepas mal identificadas / Trichosporon spp. are arthrospored yeasts from the Filum Basidiomycota that are known to produce invasive fungal infection (IFI) in patients with immunosupression or other risk factors. After Candida, Trichosporon is the second genus of yeasts responsible for IFI in patients with onco-hematological diseases. The most important species related to human infection are: T. asahii, T. inkin, T. mucoides, T. dermatis, T. jirovecii, T. ovoides, T. cutaneum, T. montevideense, T. domesticum, T. asteroides, T. coremiiforme, T. faecale, T. dohaense, T. lactis, T. japonicum. The technology of mass spectrometry (MS) for identification of Trichosporon species has not yet been standardized. However, preliminary promising results can be found in the literature. The objective of this study is to analyse and validate MS MALDI-TOF for the identification of Trichosporon species of medical relevance. This was a multicentric study with collaboration from the Central Laboratory Section from Clinics Hospital of the Medical School from the University of São Paulo (DLC-HCFMUSP), Tropical Medicine Institute from the University of São Paulo (IMT-USP), Instituto Adolfo Lutz (IAL) and Laboratoire de Parasitologie-Mycologie from the Hospital Saint Antoine of Paris and INSERM/UPMC UMR S945 \"Immunité et Infection\", Faculté de Medecine et Université Pierre et Marie Curie of Paris. Ninety three strains/isolates belonging to sixteen Trichosporon species were analysed. Nineteen were purchased from Centraalbureau Schimmelcultures (CBS) yeast collection, 19 belonged to HC-FMUSP and IAL collections, 55 belonged to different French collections. The reference identification method was the IGS1 rDNA sequencing. A protein extraction protocol was first established after comparing the performance of three different methodologies (Bruker(TM), Cassagne et al., Sendid et al.). The mass spectra were obtained through a Microflex LT(TM) mass spectrometer located at the bacteriology laboratory from Saint Antoine Hospital, Paris. Mass spectra, qualitative and quantitative results were produced through the software Biotyper 3.0(TM). The performance of the original main spectrum (MSP) library was compared to other 5 in house libraries built with the combination of MSPs derived from CBS strains (18), clinical strains (7) or (Bruker Daltonics/BD, Germany/USA) (11). The extraction protocol described by Sendid et al. showed better performance when compared to the manufacturer\'s one and was chosen for the subsequent extractions. Among the 6 different reference spectra databases tested, a specific one composed of 18 reference strains plus 7 clinical isolates (database 5) allowed the correct identification of 66 amongst 67 clinical isolates (98,5%). Biotyper 3.0 library produced only 32,3% of correct identifications. Biotyper\'s MSPs were submitted to cross-identification with MSPs derived from CBS strains and clinical isolates and misidentified original MSPs were identified: T. mucoides (2), T. ovoides (1) e T. cutaneum (2). While until now less widely applied to basidiomycetous fungi, MALDI-TOF appears to be a valuable tool for identifying clinical Trichosporon isolates at the species level. The MSP library Biotyper 3.0 showed a poorer performance which was due to misidentified strains utilized as reference for the MSPs

O gênero Candida é responsável pela maioria das infecções fúngicas nosocomiais. A identificação do provável foco de origem é de extrema importância para elucidar a epidemiologia desse tipo de infecção e nesse sentido, a utilização de métodos de tipagem, que avaliam características fenotípicas e moleculares dos isolados, é essencial. Assim, o objetivo desse estudo foi tipar isolados de C. albicans, antes e após armazenamento e em diferentes ocasiões de coleta, a fim de verificar a manutenção dos biotipos apresentados, e o poder de discriminação dos métodos utilizados. Foi avaliada a microbiota leveduriforme da saliva de 73 estudantes universitários (tempo 0) sendo que após 180 dias (tempo 180) foi realizada nova coleta de saliva daqueles que apresentaram isolamento de C. albicans na primeira coleta. Os isolados foram analisados por ocasião das duas coletas, quanto à produção de exoenzimas fosfolipase e proteinase, pela morfologia das colônias, pelo perfil de suscetibilidade frente à anfotericina B, fluconazol e itraconazol e pela tipagem molecular por RAPD. As leveduras, após isoladas, foram armazenadas em ágar Sabouraud dextrose (ASD) e água destilada esterilizada. Após 180 dias, foram realizadas, novamente, as provas de tipagem. Todos isolados de C. albicans foram produtores de fosfolipase, nas duas coletas, embora tenha havido oscilação de atividade enzimática entre moderada e alta, no período. O enzimotipo prevalente nos tempos 0 e 180 foi, respectivamente, 22 e 32. Com relação à proteinase, 100% das leveduras apresentaram atividade moderada da enzima no tempo 0. No tempo 180 esse percentual foi de 85%, sendo que os demais não apresentaram atividade dessa enzima. Após armazenamento em ASD e água destilada, foi detectada alteração da atividade de ambas enzimas e conseqüente mudança de enzimotipos, em 40 e 30% dos isolados, respectivamente. Foram identificados 8 morfotipos diferentes de C.albicans no tempo 0 e apenas 50% foi mantido no tempo 180. O morfotipo mais comum foi 000-0. Após armazenamento, a maioria dos isolados apresentou alteração no morfotipo. Todos isolados mostraram-se sensíveis aos antifúngicos analisados nos tempos 0 e 180, denotando apenas um antifungotipo, o 111. Somente um isolado após estocagem em ASD, teve mudança de perfil de sensível para dose dependente ao itraconazol de modo que o antifungotipo foi alterado. A tipagem molecular por RAPD, com os primers OPA-09, OPB-11 e OPE-18, mostrou 19 tipos moleculares distintos entre os isolados obtidos na primeira coleta e permitiu identificar que um isolado de C.albicans obtido no tempo 180, não era relacionado ao obtido, do mesmo indivíduo, no tempo 0. Os demais mostraram perfil de fragmentos de DNA relacionado entre as coletas. Após estocagem, por ambos métodos, todos isolados mostraram correlação genética com o padrão obtido no tempo 0. Os resultados obtidos demonstram que os métodos de conservação aplicados neste estudo não permitem a manutenção da estabilidade das características fenotípicas avaliadas. Por outro lado, além da estabilidade dos biotipos gerados, a tipagem molecular por RAPD mostrou o melhor índice discriminatório, dentre as metodologias utilizadas, ratificando sua capacidade em diferenciar isolados, de uma mesma espécie e, portanto a sua utilidade em inquéritos epidemiológicos. / The Candida genus is responsible for most nosocomial fungal infections. The identification of the probable origin focus is very important to elucidate the epidemiology of this kind of infection and so, the usage of typing methods that evaluate phenotypic and molecular characteristics are essential. Therefore, the objective of this study was to type C. albicans isolates, before and after culture storage and in two different collection occasions to verify the biotype maintenance and the discriminatory power of the utilized methods. The salivary yeast microbiota of 73 university students (time 0) was evaluated and after 180 days (time 180) a new saliva collection of those that had presented C. albicans on the first collection was made. The isolates were analysed, in the two collection occasions on the basis of exoenzymes phospholipase and proteinase production, by colonial morphology, susceptibility profile to amphotericin B, fluconazole and itraconazole and according to molecular typing by RAPD. After isolation, the yeasts were storaged on Sabouraud dextrose agar (SDA) and in sterile distilled water. After 180 days, typing tests were carried out again. All C. albicans isolates were phospholipase productors, in both collections, even though enzyme activity had oscillated between moderate and high at that period. The prevalent enzymotype at time 0 and 180 were, respectively, 22 and 32. In relation to the proteinase, 100% of the yeasts showed moderate enzyme activity at time 0. At time 180, this percentage was 85%, and the others didn`t show enzyme activity. After storage on SDA and in distilled water, it was detected activity alteration of both enzymes and consequent enzymotype change, in 40 and 30% of isolates, respectively. Eight different C. albicans morphotypes were identified at time 0 and just 50% were maintained at time 180. The most common morphotype was 000-0. After storage most isolates presented changes in the morphotype. All isolates showed susceptibility to the analysed antifungals at times 0 and 180, showing just one antifungaltype, the 111. Only one isolate, after storage on SDA had a profile change from susceptible to dose dependent susceptible to itraconazole in a way that the antifungaltype wasn`t changed. The molecular typing by RAPD, with primers OPA-09, OPB-11 and OPE-18, showed 19 distinct molecular types among first collection isolates and allowed to identify that one C. albicans isolate from time 180 wasn`t related with the isolate obtained at time 0, from the same individual. The others showed DNA fragment profiles related between collection occasions. After storage by both methods, every isolate showed genetic relatedness with the profile obtained at time 0. The obtained results showed that the preservation methods used in this study don`t allow stability maintenance of the phenotypical characteristics evaluated. On the other hand, besides biotypes generated stability, the molecular typing by RAPD showed the best discriminatory index, between methodologies used, ratifying its ability in discriminating isolates of the same specie and so, its utility in epidemiological inquiries

L’objectif de ces travaux de thèse a été de contribuer à la compréhension de la physiopathologie des infections sur matériel ostéo-articulaire (IMOA) à C. acnes. Dans un premier temps, nous avons typé par MLST 108 isolats de C. acnes responsables de 34 cas d’IMOAs monomicrobiennes et corrélé les résultats de typage aux données clinico-biologiques. Nous avons ainsi montré que les IMOAs à C. acnes correspondent à 2 entités cliniques : i) les cas « homotypiques » qui sont des vraies infections dues à un clone de C. acnes responsable d’une réponse inflammatoire de l’hôte ii) les cas hétérotypiques qui sont une colonisation ou contamination itérative du matériel ostéo-articulaire en l’absence de réponse inflammatoire de l’hôte. Ces données de typage ont souligné les limites de la définition microbiologique actuelle d’une IMOA quand il s’agit de C. acnes et la nécessité d’intégrer un outil moléculaire fiable dans le diagnostic microbiologique de routine de ces infections. Nous avons par conséquent évalué la technique SLST développée pour un typage rapide et optimal de C. acnes en routine. Le pouvoir discriminant de cette technique était insuffisant suggérant que seule la mise en place du NGS en temps réel dans les laboratoires de microbiologie pourrait répondre au besoin de typage moléculaire pour améliorer le diagnostic microbiologique de ces infections.Nos résultats de typage ont montré que la clonalité de l’infection plutôt que le complexe clonal (CC) est le principal facteur déterminant du processus physiopathologique et inflammatoire de l’IMOA à C. acnes. Cette conclusion est concordante avec les résultats que nous avons obtenus dans un modèle in vitro d’infection de macrophages THP-1 par C. acnes. Grâce à ce modèle, nous avons pu montrer que la réponse inflammatoire in vitro de nos isolats est souche –et non CC– dépendante. De plus, les réponses inflammatoires in vitro et in vivo n’étaient pas corrélées. Ceci souligne les limites des modèles in vitro dans l’étude de la physiopathologie des IMOAs à C. acnes dans lesquels l’adaptation de la bactérie à l’hôte est complètement négligée lors de l’étude de la réponse immune. Dans la dernière partie de ce travail, nous avons confirmé l’importance de l’environnement dans le conditionnement du comportement de la bactérie. Nous avons mené une étude comparative des caractéristiques culturales ex vivo et ex vitro de nos isolats de C. acnes. Nous avons montré l’impact du CC et des conditions environnementales, par extension la pression que peut exercer l’hôte, sur le profil cultural de C. acnes. En conclusion, nos travaux montrent qu’une approche multifactorielle, intégrant à la fois la génomique et la réponse de l’hôte, est nécessaire pour comprendre la physiopathologie des IMOAs à C. acnes. / The aim of this thesis was to contribute to the understanding of the physiopathology of C. acnes orthopedic-device related infections (ODRI). Firstly, we typed by MLST 108 C. acnes isolates responsible for 34 cases of monomicrobial ODRIs and correlated typing results with bio-clinical data. We have shown that C. acnes ODRIs correspond to two clinical entities: i) "homotypic" cases corresponding to true infections with a single pathogenic clone of C. acnes eliciting an inflammatory response ii) heterotypic cases corresponding to colonization or iterative contamination of the implant without systemic inflammatory response. These typing data highlighted the limitations of the current microbiological definition of ODRI when it comes to C. acnes and the need to incorporate a reliable molecular tool into the routine microbiological diagnosis of these infections. We therefore evaluated the SLST technique developed for a rapid and optimal typing of C. acnes. The discriminating power of this technique was insufficient suggesting that only the establishment of real-time NGS in microbiology laboratories could improve the microbiological diagnosis. Our typing results showed that the clonal status of the infection and not CC is the main determining factor in the physiopathological and inflammatory process of C. acnes ODRI. This conclusion is consistent with our results obtained on an in vitro model of a macrophage THP-1 infection. Using this model, we have shown that the in vitro inflammatory response of our isolates is strain- and non-CC-dependent. In addition, the in vitro and in vivo inflammatory responses were not correlated. This underscores the limitations of in vitro models in the study of C. acnes ODRIs in which the adaptation of the bacteria to the host is completely neglected during the study of the immune response. Finally, we confirmed the importance of the environment in the conditioning of the behavior of the bacterium. We conducted a comparative study of the ex vivo and ex vitro growth characteristics of our C.acnes isolates. We have shown the impact of CC and environmental conditions, by extension the pressure that can exert the host, on the cultural profile of C. acnes. In conclusion, our work shows that a multifactorial approach, integrating both genomics and host response, is needed to understand the physiopathology of C. acnes ODRI.