Le genre Pneumocystis désigne un groupe de champignons opportunistes présentant une étroite spécificité d'hôte. Il détermine lors d'immunodépression sévère une infection pulmonaire grave, la pneumonie à Pneumocystis (PPC). La transmission de Pneumocystis par voie aérienne d'un hôte développant une PPC à un hôte susceptible a été démontrée à l'aide des modèles murins. Les travaux menés chez la souris ont montré également que des sujets immunocompétents colonisés par Pneumocystis murina peuvent transmettre le champignon à des souris immunodéprimées qui développeront une PPC ultérieurement. Les individus colonisés par Pneumocystis sp., ainsi que ceux développant une PPC, participeraient au réservoir du champignon. La survenue de cas groupés de PPC en milieu hospitalier est en faveur de la transmission interindividuelle de Pneumocystis jirovecii (P.jirovecii) chez l’homme. La détection de l'ADN de P.jirovecii dans l'air exhalé par les patients développant une PPC suggère que cette transmission se fait par voie aérienne. La caractérisation des populations infectées par P.jirovecii et la caractérisation génotypique du champignon au sein de son réservoir humain constituent la base de ce travail de recherche. Nous avons montré que la prévalence de la colonisation par P.jirovecii est faible chez les patients atteints de mucoviscidose et suivis dans notre CHU. La participation de ces patients au réservoir de P.jirovecii à Brest serait donc marginale. Cette faible prévalence pourrait être le reflet d'une faible circulation du champignon dans les communautés humaines dans notre région. Nous avons évalué le dosage du ß-1,3-D glucane sérique pour dépister les populations infectées. Ce dosage couplé à la détection de P.jirovecii dans les prélèvements respiratoires par la microscopie et la PCR, permet de différencier les patients développant une PPC et les patients présentant une colonisation pulmonaire par P.jirovecii. De plus, les premières données sur le ß-1,3-D glucane au cours de la primo-infection chez le nourrisson ont été obtenues.En termes de caractérisation de P.jirovecii dans notre région, l'analyse du locus dihydropteroate synthase (DHPS) a montré que: i) le lieu habituel de résidence plutôt que le lieu de diagnostic de l’infection à P.jirovecii serait un facteur prédictif d’infection par un mutant, ii) P.jirovecii pourrait circuler en France d’une région à une autre via des voyageurs infectés, iii) la prévalence de mutants potentiellement résistants chez les patients vivant effectivement à Brest était de 0%. L'analyse des séquences des "internal transcribed spacers" (ITS) 1 et 2 de P. jirovecii conforte l'hypothèse que les patients développant une PPC et les patients colonisés sont infectés par des populations fongiques présentant des caractéristiques identiques. Tous les patients, quelle que soit la présentation clinique de leur infection, constitueraient un réservoir unique et commun de P.jirovecii. Les travaux de génotypage ont constitué l'étape préalable nécessaire à l'analyse de cas groupés d'infections à P.jirovecii survenus chez des patients transplantés rénaux au CHU de Brest. Nous avons apporté des données originales sur le rôle des patients colonisés en tant que source potentielle de P. jirovecii dans un contexte d'acquisition et de transmission nosocomiales du champignon. Par ailleurs, la concordance partielle ou complète des génotypes ITS et DHPS dans les couples "prélèvements d'air–LBA" réalisés chez des patients développant une PPC est compatible avec l’exhalation du champignon et sa diffusion aérienne dans l’environnement hospitalier. Ces données apportent des arguments pour l'application de mesures de prévention des infections nosocomiales à P. jirovecii. Les précautions "gouttelettes" recommandées par la Société Française d'Hygiène Hospitalière devraient être appliquées a minima aux patients développant une PPC. Nous proposons leur extension aux patients colonisés par le champignon. / The genus Pneumocystis represents a group of opportunistic fungi that show strong host specificity. It is the cause of severe pneumonia (Pneumocystis Pneumonia [PCP]) in immunocompromised subjects. Pneumocystis transmission from a host with PCP to another susceptible host via the airborne route has been demonstrated in rodent models. Moreover, it has been established that Pneumocystis murina can be transmitted from immunocompetent mice, transiently colonized by the fungus, to immunocompromised susceptible mice that subsequently develop PCP. Colonized subjects and those developing PCP may be part of the fungus reservoir. Reports of PCP case cluster in hospital strongly suggest that Pneumocystis jirovecii (P.jirovecii) transmission in humans may also occur. P.jirovecii DNA detection in the air surrounding PCP patients is consistent with the transmission of P.jirovecii via the airborne route.Our goals were to characterize human populations infected with P.jirovecii and to characterize P.jirovecii within its human reservoir. We showed that P.jirovecii was rarely involved in pulmonary colonization in patients with cystic fibrosis monitored in the Brest Hospital. Thus this patient population was not part of the human reservoir of the fungus in our region (Brittany, Western France). This low prevalence of colonization may reflect a low level of P.jirovecii circulation within human communities in Brittany. In order to improve the identification of patients infected with P.jirovecii, we evaluated ß-1,3-D glucan detection in serum samples. We showed that serum ß-1,3-D glucan levels combined with P.jirovecii detection in pulmonary samples using microscopic examination and a PCR assay make it possible to distinguish between PCP and pulmonary colonization. Moreover the first data on ß-1,3-D glucan levels during primary infection were obtained.In order to characterize P.jirovecii in our region, we performed the typing of P.jirovecii isolates from infected patients monitored at Brest hospital, using the dihydropteroate synthase (DHPS) and the internal transcribed spacer (ITS) 1 and 2 locus analysis. DHPS typing showed that i) the usual city of patient residence rather that the city in which the diagnosis of P.jirovecii infection has been made is a predictor of mutants, ii) mutants can be imported from one region to another through infected visitors, iii) the prevalence of mutants potentially resistant to sulfonamides was 0% in patients who effectively lived in the Brest geographic area. Results of ITS analysis in PCP patients and colonized patients are consistent with the hypothesis that these 2 patient groups are infected with similar P.jirovecii populations. All infected patients, whatever their clinical presentation, may be part of a common and unique reservoir of the fungus. We investigated an outbreak of P.jirovecii infections in 18 renal transplant recipients using the same typing method combined with patient encounter analysis. The results provided evidence of the role of colonized patients as potential sources of P.jirovecii. The same typing method was applied to pairs of pulmonary samples and room air samples of PCP patients. Full or partial matches of P.jirovecii types in pulmonary and air sample pairs were observed. These results are consistent with P.jirovecii exhalation by PCP patients in their close environment. These data support arguments for applying droplet precautions, at least to PCP patients, to prevent P.jirovecii transmission, as recommended by the "Société française d'hygiène hospitalière". We suggest extending droplet precautions to colonized patients to achieve the prevention of P.jirovecii nosocomial infections.

The threat of antimicrobial resistance particularly in the intensive care unit has become a global issue. This study aimed to evaluate the effectiveness of antimicrobial stewardship in limiting the spread of antimicrobial resistance in the hospital’s ICU. The study further determined the deficiencies of the ASP and recommended strategies to remedy the identified deficiencies. A quasi-experimental descriptive quantitative design was used in this study. The study was conducted at the intensive care unit of an academic hospital. A structured questionnaire was used to extract information from patients’ medical records. This evaluation showed that the antimicrobial stewardship program had a sufficient impact on the appropriate use of antimicrobials in the hospital’s ICU. While there were a small (19.05 %) number of patients inappropriately prescribed antimicrobials, a moderate (35.59%) number of patients developed hospital acquired infections during the study period. In addition, the results revealed a lack of the facility’s leadership commitment to antimicrobial stewardship, which is crucial for ensuring the availability of human, financial and information technology resources Through the evaluation of the program the deficiency in the program’s performance can be identified and optimised. For the studied facility, the performance of the program could be improved by gaining the support of the facility leadership. The present study endorses the evaluation of health promotion initiatives to improve patients’ safety and outcome in healthcare institutions. Keywords / Health Studies / D. Litt. et Phil. (Health Studies)

Ce travail a pour objet l’étude et le développement d’un capteur électrochimique pour la détection sélective quantitative des analytes biologiques à l’échelle nano. Il se divise en deux parties après une présentation de l’état de l’art sur les maladies nosocomiales et les capteurs électrochimiques. Tout d’abord, nous avons développé un protocole spécifique qui repose sur la fonctionnalisation localisée de la microélectrode de travail par dépôt électrophorétique d'oxyde de graphène réduit/polyéthylènimine (rGO/PEI) pour amplifier le signal de détection. Le microsystème réalisé en salle blanche, a été exploité avec succès pour la détection sélective de la dopamine avec une limite de détection de 50 nM.Ensuite, nous avons utilisé la même plateforme constituée d’électrodes de plus grande taille (mm) pour la réalisation d’un capteur immunologique. Il a démontré son efficacité, de manière spécifique et sélective, pour discriminer la souche sauvage E. Coli UTI89 de UTI89 Δfim (sans opéron), avec une limite de détection de 10 cfu mL−1. En outre, le concept d’utilisation d’une électrode modifiée par rGO/PEI par la modification covalente avec des anticorps pathogènes est général. Il peut être facilement adapté à toute autre espèce pathogène, rendant l’approche générique. Le capteur a donc abouti à des résultats intéressants en milieu aqueux, sérique et urinaire, ce qui est essentiel pour son utilisation potentielle pour le diagnostic clinique des maladies pathogènes. / The purpose of this work concerns the study and development of an electrochemical sensor for both quantitative and selective detection of biological analytes at the nanoscale. It is divided into two parts after a presentation of the state of the art on nosocomial diseases and electrochemical sensors. First, we have developed a specific protocol based on the localized functionalization of the working microelectrode by electrophoretic deposition. The strategy is based on the localizedfunctionalization of the working microelectrode by electrophoretic deposition of reduced graphène oxide / polyethyleneimine (rGO / PEI) to amplify the detection signal. The microsystem built in a clean room has been successfully tested for the selective detection of dopamine with a detection limit of 50 nM. In addition, the microsystem showed good performance in detecting dopamine levels.Then, we have also used the same electrode platform at a larger scale (mm) for the specific and selective detection of the immunological sensor which has demonstrated its effectiveness in distinguishing the UTI89 E. Coli wild-type strain of UTI89 Δfim (without operon), with a detection limit of 10. cfu mL-1. In addition, the concept of rGO / PEI modified electrode by covalent modification with pathogenic antibodies is general and can be easily transposed to any other pathogenic species, making the approach very versatile and generic.The sensor works in aqueous, serum and urinary media, which is essential for its potential use in clinical diagnosis of pathogenic diseases.

Die Mehrzahl der jährlich 400.000 bis 600.000 Krankenhausinfektionen in Deutschland wird von Erregern der sog. ESCAPE-Gruppe (Enterococcus faecium, Staphylococcus aureus, Clostridium difficile, Acinetobacter baumannii, Pseudomonas aeruginosa und verschiedene Enterobacteriaceae, u.a. Klebsiella pneumoniae) verursacht. Besondere Sorge bereitet dabei die Ausbreitung von K. pneumoniae-Stämmen mit enzymvermittelter Resistenz gegenüber Carbapenem-Antibiotika (K. pneumoniae-Carbapenemase, KPC) und die Zunahme von C. difficile-Infektionen (CDI) durch hypervirulente Epidemiestämme (z.B. Ribotyp 027). Die spezifischen Erfahrungen eines prolongierten Ausbruchsgeschehens durch einen KPC-bildenden K. pneumoniae-Stamm (KPC-KP) am Leipziger Universitätsklinikum machen deutlich, dass bei diesem Erregertyp ein hohes Transmissionspotential bei enormer Tenazität (Umweltresistenz) zu berücksichtigen ist, ein Versagen von Standardhygienemaßnahmen in Betracht zu ziehen ist, und Infektionsketten oftmals unklar bleiben. Die Anwendung von Antibiotika ist bei KPC-KP-Infektionen auf einzelne Substanzen (Colistin, Tigecyclin, Gentamicin) beschränkt und vor allem bei immunsupprimierten Patienten (z.B. Lebertransplantierte) mit einem relevanten Risiko des Therapieversagens behaftet. Die Therapie von CDI wird gerade bei Immunsupprimierten durch eine steigende Zahl an Rezidiven erschwert, die teilweise antibiotisch (Vancomycin, Fidaxomicin) nicht beherrschbar sind, so dass alternative Therapieverfahren wie die fäkale Bakterientherapie („Stuhltransplantation“) zur Anwendung kommen. CDI-Rezidive, aber auch eine dauerhafte intestinale Besiedelung mit multiresistenten Enterobakterien wie KPC-KP, scheinen neben wirtsspezifischen Faktoren der Immunantwort durch eine Dysregulation der physiologischen intestinalen Standortflora mit Störung der Kolonisationsresistenz bedingt zu sein. Der Versuch einer Eradikationsbehandlung von Patienten mit persistierender intestinaler Besiedelung durch KPC-KP mittels oraler Applikation der nicht resorbierbaren Antibiotika Colistin und Gentamicin ist mit einem relevanten Risiko der Entstehung von Sekundärresistenzen behaftet. Die Zulassung neuer, besser wirksamer Antibiotika ist für die nächsten Jahre nicht in Sicht, so dass der Infektionsprävention überragende Bedeutung zukommt. Die Erfahrungen der KPC-Ausbruchsbewältigung am Leipziger Universitätsklinikum zeigen, dass nahezu lückenlose Compliance bei der Händedesinfektion, rigoros praktizierte und kontrollierte Barriere- und Isolationsmaßnahmen, Optimierung des Gebrauchs von Breitspektrum-Antibiotika (sog. „Antibiotic Stewardship“) und systematisches mikrobiologisches Erregerscreening dabei unabdingbar sind. Nachhaltige Verbesserungen hinsichtlich der globalen Ausbreitung von multiresistenten Krankenhausbakterien werden sich nur durch grundlegende Umgestaltungen in Umwelt, Landwirtschaft, Tierzucht und Gesundheitswesen mit sparsamer und möglichst gezielter Anwendung von Antibiotika erzielen lassen. Um Risikopopulationen hospitalisierter Patienten vor potentiell lebensbedrohlichen Erregertransmissionen effektiv schützen zu können, sind erweiterte Surveillance und konsequent umgesetzte krankenhaushygienische Maßnahmen erforderlich.

[Truncated abstract] The prinicipal aim of this thesis was to explore the relationship between 3rd generation cephalosporin antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea (CDAD). This antibiotic class has been implicated in the aetiology of CDAD; therefore restriction of these antibiotics via antibiotic policies represents a potential strategy for prevention and control of CDAD. Successful control of CDAD in hospitals translates to improved quality of care for patients, and a reduction of pressure on hospital resources. Therefore, the objectives of this study were to determine whether 3rd generation cephalosporins were related to CDAD, to evaluate the effect of changes to antibiotic policy on the incidence of CDAD, and to determine the impact of CDAD on patient length of stay and hospital costs. The study was conducted in Sir Charles Gairdner Hospital (SCGH), a public teaching hospital located in Perth, the capital city of the state of Western Australia. Evidence for an association between 3rd generation cephalosporins and CDAD was obtained from studies of ecologic- and individual-level data. A time series analysis of the relationship between monthly consumption of 3rd generation cephalosporins and the incidence of CDAD in SCGH was undertaken covering the period 1994 to 2000. The results demonstrated a positive relationship between the use of 3rd generation cephalosporins and CDAD. A matched case-control study that involved 193 adult inpatients diagnosed with CDAD and 386 adult inpatients without CDAD, selected from the period 1996 to 2000, was conducted. Information was collected on exposure to 3rd generation cephalosporin antibiotics during hospitalisation, as well as exposure to other antibiotics and medications, procedures, and comorbidities. Results from conditional logistic regression analyses found CDAD cases were six times more likely to be exposed to 3rd generation cephalosporins during their admission, prior to the onset of diarrhoea, than controls (adjusted odds ratio [OR] = 6.17, 95% confidence interval [CI] = 1.56-24.37). Approximately one third of CDAD in the study population could be attributed to 3rd generation cephalosporins. CDAD cases were also four times more likely to have been exposed to either amoxicillin-clavulanate or ticarcillin-clavulanate (adjusted OR=4.23, 95% CI=1.81-9.93). In October 1998, an antibiotic policy was introduced at SCGH that restricted the use of ceftriaxone, the 3rd generation cephalosporin most commonly used by the hospital. During 1999 and 2000, the incidence of CDAD halved as ceftriaxone consumption fell in response to this policy. The effect of this policy was demonstrated in the time series model; during the post-policy period the relationship between ceftriaxone and CDAD that was evident prior to the policy was cancelled out. From the individual-level data, obtained from the case-control study, a reduction in the prevalence of exposure to 3rd generation cephalosporins from 11% to 1% accounted for a 30% reduction in the incidence of CDAD. Data from the case-control study was also used to analyse the independent contribution of CDAD to length of stay and admission costs using multiple linear regression

This thesis deals with the handling of waste and linen. It is divided into a theoretical and practical part.The theoretical part describes the history of Česky Krumlov hospital and is followed by an in-depth look at the history and development of the handling of waste and linen in a medical facility etc. In the practical part of the research qualitative-quantitative methods were used in the form of observation, interview, questionnaire and secondary data analysis. In Česky Krumlov Hospital I observed the ongoing activities and gathered data. The research sample for the interview consisted of 10 respondents. The questionnaires consisted of 21 questions. A secondary analysis of operating rules, guidelines and waste management legislation was used. The main objectives of the research were to compare the system of waste and linen handling in Česky Krumlov hospital with applicable legislation and rules of operation. In so doing, to determine whether there are shortcomings in the separation of waste and the handling of laundry and in which department(s). In addition, to compare the production of waste in amount and time with regards to the use of disposable devices and instruments. Finally, to monitor the way employees separate waste in the hospital and compare the approach to it between smokers and non-smokers.For the purpose of this research five research questions and four hypotheses were put forward: V1: Does the procedure for handling waste meet legislative requirements and the current operating system? V2: Does the system of separation and disposal of waste differ in individual departments and if so why? V3: Can a more effective system for waste management be found? V4: Does the procedure for handling linen meet legislative requirements and the current operating system? V5: Can a more effective way of handling laundry be found? H1: The attitude to the separation of waste is different in smokers and non-smokers. H2: The sorting method depends on education. H3: The sorting method depends on the job position. H4: The sorting method depends on the amount of work experience of employees. Interviews were transcribed using MS Word 2007, and then processed using XMind 6. The hypotheses were statistically analyzed.In addition, information from my observations, interviews and the operating rules and directives for hospital staff helped me to answer the research questions. On the basis of the statistical findings all the hypotheses, with exception to H1, were confirmed. Hypothesis H1 was refuted. During the work all the objectives were met with exception to the fifth objective where problems relating to the quality of services provided by the laundry in České Budějovice Hospital, a.s. were identified. A comparison of the waste management system in Česky Krumlov Hospital a.s. with its operating rules, guidelines and legislation shows that overall the procedures correspond. There were just a few exceptions in the form of unlocked containers for infectious waste and a lack of signatures on labels of some of the staff responsible. During my observation no errors occurred in the separation of waste. The hospital has established a uniform system, whereby the procedures only vary according to the type of waste. The established system of waste separation in Česky Krumlov Hospital a.s. is very good, fully compliant with legislative requirements and is efficient. When comparing the production of general waste over time, the amount is decreasing. However, the amount of hazardous waste being produced is increasing. It was found that the attitude to waste separation does not differ in smokers and non-smokers and that university-educated workers separate less waste at work than others due to the type of job within the organization. Nurses recycle more and more responsibly. The same can be observed for employees with more work experience. I found minor discrepancies in the handling of laundry and the current operating rules.

O ambiente hospitalar é um local que requer cuidados especiais. No caso de reformas e até mesmo construções um cuidado maior é necessário, já que demolições, lixamentos e outros tipos de intervenções podem gerar aerossóis. Nos aerossóis estão presentes fungos que ao serem inalados por pacientes imunocomprometidos ou transplantados apresentam grande probabilidade de provocar infecções graves, que em muitos casos são letais. Face ao exposto, o presente trabalho tem como objetivo caracterizar a ocorrência de fungos em argamassas de revestimento no ambiente hospitalar. A pesquisa foi realizada em paredes de alvenaria do Hospital de Clínicas, da Universidade Federal do Paraná, de onde foram extraídas amostras da região da superfície, da argamassa e do bloco cerâmico. As amostras foram semeadas em placas de Petri e RODAC® contendo Ágar Sabouraud Dextrose e incubadas a 25oC durante sete dias. Após esse período o crescimento de fungos nas placas foi analisado. A variação da temperatura e umidade foi monitorada por meio de sistema remoto e manual. A argamassa dos ambientes avaliados teve seus valores de resistência à tração e teor de umidade determinados. Das 150 amostras coletadas 39% apresentaram crescimento positivo com a seguinte distribuição de fungos: Aspergillus (presente em 28% das amostras), Absidia (21%), Cladosporium (18%), Rhizopus (10%), Rhodotorulla (8%), Fusarium (6%), Penicillium (3%), A. flavus, demais fungos e outros fungos filamentosos (2%) cada. Nos substratos do interior das paredes pesquisadas foram identificadas três espécies diferentes de Aspergillus: A. flavus, A. fumigatus e A.niger. Todas as espécies de Aspergillus encontradas podem causar aspergilose invasiva e, por isso, oferecem sérios riscos à saúde de pacientes imunocomprometidos. Em uma das paredes avaliadas o teor de umidade encontrado foi igual a 12% e a resistência à tração foi nula. O estudo evidenciou a presença de fungos oportunistas, tais como Aspergillus e Fusarium, tanto nas amostras de argamassa quanto nas de bloco cerâmico retiradas do interior das paredes dos ambientes pesquisados. / The hospital is a place that requires special care. In terms of reforms and even buildings, this site requires even greater care since, demolition, sanding and other types of interventions can generate aerosols. In aerosols, commonly called dust, fungi are present is high the probability of the fungi be aspirated by immunocompromised patients in a hospital. This microorganisms can germinate and cause severe infections and lethal in many cases. The present work has as its object to identify and characterize the occurrence of fungi in mortar coating in the hospital environment. The survey was conducted in masonry walls of the Clinics Hospital, Federal University of Paraná, in which were extracted samples of the surface, of the mortar and of the ceramic block. Samples were plated on Petri plates containing Sabouraud Dextrose Agar, incubated at 25 ° C for seven days, and after this period was analyzed fungal growth. The environments had their temperature and humidity monitored by a remote and manual system during one year. The mortar coating these environments was also investigated with respect to tensile strength and moisture content. Of the samples collected 39% showed growth of colonies with the following distribution of microorganisms: Aspergillus (28% of the samples), Absidia (21%), Cladosporium (18%), Rhizopus (10%), Rhodotorulla (8%), Fusarium (6%), Penicillium (2%), A. flavus, other genera and other filamentous fungi (2%). Within the substrate researched were identified three different species of Aspergillus: A. A.flavus, A.fumigatus and A.niger. All species of Aspergillus found cause invasive aspergillosis and therefore offer a serious risk to immunocompromised patients. In one of the walls evaluated the moisture content was equal 12% and the tensile strength was zero. The study revealed the presence of opportunistic fungi such as Aspergillus, Fusarium, among others, in the mortar and in the ceramic block inside the wall of the environments studied.

O ambiente hospitalar é um local que requer cuidados especiais. No caso de reformas e até mesmo construções um cuidado maior é necessário, já que demolições, lixamentos e outros tipos de intervenções podem gerar aerossóis. Nos aerossóis estão presentes fungos que ao serem inalados por pacientes imunocomprometidos ou transplantados apresentam grande probabilidade de provocar infecções graves, que em muitos casos são letais. Face ao exposto, o presente trabalho tem como objetivo caracterizar a ocorrência de fungos em argamassas de revestimento no ambiente hospitalar. A pesquisa foi realizada em paredes de alvenaria do Hospital de Clínicas, da Universidade Federal do Paraná, de onde foram extraídas amostras da região da superfície, da argamassa e do bloco cerâmico. As amostras foram semeadas em placas de Petri e RODAC® contendo Ágar Sabouraud Dextrose e incubadas a 25oC durante sete dias. Após esse período o crescimento de fungos nas placas foi analisado. A variação da temperatura e umidade foi monitorada por meio de sistema remoto e manual. A argamassa dos ambientes avaliados teve seus valores de resistência à tração e teor de umidade determinados. Das 150 amostras coletadas 39% apresentaram crescimento positivo com a seguinte distribuição de fungos: Aspergillus (presente em 28% das amostras), Absidia (21%), Cladosporium (18%), Rhizopus (10%), Rhodotorulla (8%), Fusarium (6%), Penicillium (3%), A. flavus, demais fungos e outros fungos filamentosos (2%) cada. Nos substratos do interior das paredes pesquisadas foram identificadas três espécies diferentes de Aspergillus: A. flavus, A. fumigatus e A.niger. Todas as espécies de Aspergillus encontradas podem causar aspergilose invasiva e, por isso, oferecem sérios riscos à saúde de pacientes imunocomprometidos. Em uma das paredes avaliadas o teor de umidade encontrado foi igual a 12% e a resistência à tração foi nula. O estudo evidenciou a presença de fungos oportunistas, tais como Aspergillus e Fusarium, tanto nas amostras de argamassa quanto nas de bloco cerâmico retiradas do interior das paredes dos ambientes pesquisados. / The hospital is a place that requires special care. In terms of reforms and even buildings, this site requires even greater care since, demolition, sanding and other types of interventions can generate aerosols. In aerosols, commonly called dust, fungi are present is high the probability of the fungi be aspirated by immunocompromised patients in a hospital. This microorganisms can germinate and cause severe infections and lethal in many cases. The present work has as its object to identify and characterize the occurrence of fungi in mortar coating in the hospital environment. The survey was conducted in masonry walls of the Clinics Hospital, Federal University of Paraná, in which were extracted samples of the surface, of the mortar and of the ceramic block. Samples were plated on Petri plates containing Sabouraud Dextrose Agar, incubated at 25 ° C for seven days, and after this period was analyzed fungal growth. The environments had their temperature and humidity monitored by a remote and manual system during one year. The mortar coating these environments was also investigated with respect to tensile strength and moisture content. Of the samples collected 39% showed growth of colonies with the following distribution of microorganisms: Aspergillus (28% of the samples), Absidia (21%), Cladosporium (18%), Rhizopus (10%), Rhodotorulla (8%), Fusarium (6%), Penicillium (2%), A. flavus, other genera and other filamentous fungi (2%). Within the substrate researched were identified three different species of Aspergillus: A. A.flavus, A.fumigatus and A.niger. All species of Aspergillus found cause invasive aspergillosis and therefore offer a serious risk to immunocompromised patients. In one of the walls evaluated the moisture content was equal 12% and the tensile strength was zero. The study revealed the presence of opportunistic fungi such as Aspergillus, Fusarium, among others, in the mortar and in the ceramic block inside the wall of the environments studied.

The present study sought to establish relationships that exist between the management of solid waste with infectious cases of Infections Related to Health Care (IRHC) in the Adult Intensive Care Unit (ICU-A) of the Emergency Hospital of Sergipe (EHSE), this study aimed to assess the relationship between generators disease vectors found in the referenced industry and infectious waste generated in this health unit. Therefore, it is necessary to: determine how is the handling of infectious solid waste in the ICU-A of a EHSE sector ; identify how the management of infectious waste enables the development of vectors for IRHC , and finally check the preparation of professionals to manage these wastes . Should point out that this is an exploratory research and the field of knowledge was exploited by the inductive method. The literature and empirical basis, about the information necessary for the interpretation and analysis of data is delineated by access to the records of the Committee on Hospital Infection Control (CHIC), which contains the indices of nosocomial infection from 2008 to 2011 and the rules techniques and resolutions codified in chips summaries. Contacts with professionals working in ICU-A and CHIC, support staff and coordination respectively, were also established standardized interviews were conducted, which follow a prescribed script, see Appendix D. The instruments for data collection were used unstructured observation, the field notebook and camera for the purpose of use of the uses of expressions, fragments and images about the current functioning of infectious solid waste management, which are developed based on content analysis. As for the results it was found that among the types of waste generated in the ICU-A EHSE, the sharps are the ones that can be associated with the spread of infectious diseases, these arising from accidents at the time of its disposal, and its occurrence in mostly with housekeeping staff who deal with this type of waste that is commonly and improperly arranged by the clinic staff. However, it became clear that a correct and efficient management of such wastes may prevent scratches and damage in transforming health promotion, and the development of practices for the principles of reverse logistics. / O presente estudo procurou estabelecer que relações existem entre o gerenciamento de resíduos sólidos infectantes com os casos de Infecções Relacionadas à Assistência à Saúde (IRAS) na Unidade de Terapia Intensiva Adulta (UTI-A) do Hospital de Urgência de Sergipe (HUSE), este estudo teve como propósito avaliar a relação entre vetores geradores de doenças encontrados no setor referenciado e os resíduos infectantes gerados nesta unidade de saúde. Para tanto, faz-se necessário: averiguar como é feito o manejo de resíduos sólidos infectantes no setor da UTI-A do HUSE; identificar de que forma o manejo de resíduos infectantes propicia o desenvolvimento de vetores para IRAS; e por fim verificar o preparo dos profissionais para o manejo desses resíduos. Convém pontuar que se trata de uma pesquisa de caráter exploratório e o campo de conhecimento foi explorado pelo método indutivo. A pesquisa bibliográfica e de base empírica, acerca das informações necessárias para interpretação e análise dos dados se delineou mediante o acesso aos registros da Comissão de Controle de Infecção Hospitalar (CCIH), na qual constam os índices de infecção hospitalar de 2008 a 2011 e a normas técnicas e resoluções sistematizadas em fichas resumos. Também foram estabelecidos contatos com os profissionais que trabalham na UTI-A e na CCIH, pessoal de apoio e coordenação respectivamente, foram realizadas entrevistas padronizadas, as quais seguem um roteiro previamente estabelecido, ver apêndice D. Como instrumentos para a coleta de dados foram utilizados a observação não estruturada, o caderno de campo e a máquina fotográfica para efeito de utilização dos usos de expressões, fragmentos e imagens sobre o atual funcionamento da gestão de resíduos sólidos infectantes, sendo estas desenvolvidas com base na análise de conteúdo. Quanto aos resultados foi constatado que dentre os tipos de resíduos gerados na UTI-A do HUSE, os perfurocortantes são os únicos que podem estar associados à propagação de doenças infecciosas, estas, decorrentes de acidentes no momento de sua disposição, sendo sua ocorrência em maior parte com funcionários da limpeza que lidam com este tipo de resíduo e que é comumente disposto inadequadamente pela equipe clínica. No entanto, evidenciou-se que um gerenciamento correto e eficiente desses resíduos pode prevenir riscos e transformar dano em promoção da saúde, como o desenvolvimento de práticas voltadas para os princípios da logística reversa.

Orientador: Maria Luiza Moretti / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-13T02:52:37Z (GMT). No. of bitstreams: 1 Kuboyama_RogerioHakio_D.pdf: 1899697 bytes, checksum: 863826cd141f1e5f89eb90d272c0c330 (MD5) Previous issue date: 2009 / Resumo: Os objetivos do presente estudo, conduzido retrospectivamente, utilizando cepas isoladas de espécimens clínicos obtidos de pacientes internados em dois hospitais brasileiros entre fevereiro de 2001 e junho de 2004 foram descrever: a presença de cepas de Klebsiella pneumoniae produtoras de beta-lactamases de espectro estendido (ESBLs), o melhor método e o substrato preferido para os testes de triagem e de confirmação da produção de ESBLs, a relação epidemiológica das cepas obtidas e analisar os fatores de risco para infecção por cepa produtora de ESBLs. A fim de investigar a relação genética das cepas, foram utilizadas as análises do DNA plasmidial e do DNA cromossômico por eletroforese em campo pulsátil (PFGE). Um total de 89 cepas de K. pneumoniae foram coletadas de diversos sítios anatômicos. Os espécimens clínicos mais comuns dos quais foram isoladas cepas produtoras foram urina (12,4%) e sangue (10,1%). Utilizando os critérios estabelecidos pelo CLSI (testes de triagem), 35 (39,3%) cepas de K. pneumoniae foram consideradas possivelmente produtoras de ESBLs, enquanto que o teste de aproximação de discos (DDAT) revelou distorções características nas zonas de inibição produzidas pela molécula do clavulanato em 96, 62,5, 50, 18,8 e 12,5% das cepas ao redor dos discos contendo aztreonam, cefotaxima, ceftazidima, ceftriaxona e cefpodoxima, respectivamente. Das 89 cepas, 32 (36%) foram consideradas produtoras de ESBLs baseadas no teste confirmatório pelo método Oxoid de discos-combinados. O disco contendo cefotaxima foi capaz de confirmar 100 % dos produtores de ESBLs enquanto que o disco contendo ceftazidima deixou de confirmar 2 cepas produtoras. Dez e 32 diferentes perfis plasmidiais foram observados dentre as cepas de K. pneumoniae produtoras e não produtoras, respectivamente. A PFGE demonstrou melhor poder discriminatório fornecendo 15 e 55 perfis de DNA cromossômico dentre as cepas ESBLs-positivas e ESBLs-negativas, respectivamente. Da análise univariada, as variáveis significativamente associadas com infecção por cepas de K. pneumoniae produtoras de ESBLs foram: uso de cefalosporinas de quarta geração, de lincosamida, de carbapenêmicos, de glicopeptídeos, cirurgia recente, traqueostomia, idade, dias em uso de lincosamida, dias em uso de glicopeptídeos, número total de antibióticos e duração da terapia antimicrobiana. Ao realizar a análise multivariada, utilizando um modelo de regressão logística que incluía as variáveis estatisticamente significantes da análise univariada (P < 0,05), número total de antibióticos permaneceu como única variável independente para infecção por cepa de K. pneumoniae produtora de ESBLs (OR, 1,60; IC95%, 1,194-2,145.; P = 0,0017). Os dados obtidos revelam: uma taxa relativamente alta da produção de ESBLs em cepas de K. pneumoniae obtidas de pacientes das instituições estudadas; a insuficiência da análise plasmidial na elucidação da relação genética dentre as cepas produtoras de ESBLs; aztreonam como melhor substrato indicador da produção presuntiva de ESBLs e cefotaxima como o melhor substrato no teste confirmatório pelo método Oxoid de discoscombinados / Abstract: The objectives of this study conducted restrospectively using strains isolated from clinical specimens obtained from patients hospitalized in two Brazilian hospitals between February 2001 to June 2004 were to describe the presence of extended-spectrum b-lactamase (ESBL)-producing Klebsiella pneumoniae strains, the best method and the preferred substrate for screening and confirming ESBL production and the epidemiological relatedness of ESBL-producing strains and analyse the risk factors for infection due to ESBL-producing K. pneumoniae. To investigate the genetic relatedness of the strains, plasmid analysis and chromosomal DNA analysis by pulsed-field gel electrophoresis were used. A total of 89 K. pneumoniae were collected from diverse body sites. The most commom specimens yielding ESBL-producing strains were urine (12.4%) and blood (10.1%). Using CLSI criteria (ESBL screening breakpoints), 35 K. pneumoniae (39.3%) had presumptive ESBL phenotype, while using the double-disk approximation test (DDAT) characteristic clavulanate-induced distortions of inhibition zones were found in 96, 62.5, 50, 18.8 and 12.5% of the strains around the disks containing aztreonam, cefotaxime, ceftazidime, ceftriaxone and cefpodoxime, respectively. Of 89 isolates, 32 (36%) produced ESBL based on the confirmatory Oxoid combination disk method. The disk containing cefotaxime was able to confirm 100% of the ESBL producers while the disk containing ceftazidime was not able to confirm 2 ESBL-positive strains. Ten and 32 different plasmid profiles were observed among the ESBL-producing K. pneumoniae and non ESBL producers, respectively. Pulsed-field gel electrophoresis showed the best discriminatory power giving 15 and 55 different chromosomal DNA profiles among the ESBL-positive and ESBL-negative K. pneumoniae, respectively. From univariate analysis, variables significantly associated with infection by an ESBL-producing strain of K. pneumoniae included the following: use of 4st-generation cephalosporins, lincosamide, carbapenems, glycopeptides, recent surgery, tracheostomy, age, days in using of lincosamide, days in using of glycopeptides, total number of antibiotics and duration of the antimicrobial therapy. The only variable that remained independent risk factor for acquiring infection due to ESBL-producing K. pneumoniae after multivariable analysis using a logistic regression model, which included the variables associated with acquiring infection by ESBL-producing K. pneumoniae by univariate analysis (P < 0.05), was total number of antibiotics (OR, 1.60; 95%CI, 1.194-2.145; P = 0.0017). In summary, these data indicate that ESBL-producing K. pneumoniae occur at a relatively high incidence at our institutions and the plasmid analysis is not sufficient to identify relationships between ESBL-producing strains of K. pneumoniae. The ESBL screening breakpoints and DDAT with aztreonam appear to be good indicators in presumptive detection of ESBL-producing strains and the cefotaxime used in the Oxoid combination disk method constituted the best substrate in the confirmatory test / Doutorado / Ciencias Basicas / Doutor em Clínica Médica