The objectives of this research were to identify the individual ionization constants (pKa values) of lipopeptide (daptomycin), evaluate the factors of pH, concentration, temperature, and calcium ions on daptomycin aggregation in aqueous solutions, and elucidate the effects of conformation and aggregation on ionization and the interaction mechanism between polyamidoamine (PAMAM) dendrimers and daptomycin. Daptomycin is a cyclic anionic lipopeptide antibiotic. It is composed of 13 amino acids with six ionizable groups, four side-chain carboxylic acids and two side-chain amine residues. The pKa values for individual daptomycin residues have not been elucidated. The sequence-specific pKa values for the four acidic residues and one aromatic amine (Kyn-13) in daptomycin were determined in the monomeric state by TOCSY 2D 1H NMR. From the NMR pH titration, the estimated pKa values for Asp-3, Asp-9, and mGlu-12 were determined to be 4.15, 3.85, and 4.55 in the absence of salt, and 4.07, 3.83, and 4.39 in the presence of 150 mM NaCl, respectively. The pKa value for Asp-7 is estimated to be ~1.01 in the absence of salt and 1.31 in the presence of salt. The estimated Hill coefficients for Asp-7 were 0.72 and 1.31 in the absence and presence of salt, respectively. The increase in Hill coefficients from 0.72 to 1.31 with increasing salt concentration is consistent with the estimated lower pKa in the absence of salt and suggests that a salt bridge is formed in solution possibly between Asp-7 acidic group and the neighboring Orn-6 basic group. The pKa value of the aromatic amine (Kyn-13) was confirmed using UV and fluorescence spectroscopic titrations. Aggregation behavior and critical aggregation concentration (CAC) values of daptomycin were evaluated in the different pH aqueous solutions by using the complementary analytical techniques, fluorescence, dynamic and static light scattering, and NMR spectroscopy. Based on fluorescence resonance energy transfer (FRET) from donor Trp-1 to acceptor Kyn-13, the CAC values were determined by an upward inflection of the intrinsic fluorescence emission from Kyn-13 at 460 nm as a function of increasing daptomycin concentration. The pH-dependent CAC values were determined to be 0.14 mM at pH 3.0, 0.12 mM 4.0, and 0.20 mM at pH 2.5 and 5.0. The CAC values obtained by fluorescence spectroscopy were confirmed by dynamic light scattering and NMR spectroscopy. The effects of temperature and calcium ion on daptomycin aggregation were also discussed. The interaction mechanism between daptomycin and PAMAM dendrimers generation 5 and 6 was studied using fluorescence spectroscopy. The shapes of binding isotherms daptomycin were quantitatively described by one- and two-site binding models to estimate binding capacity and dissociation constants. Both solvent pH values and PAMAM generation size were shown to affect the binding model and parameters. The interaction between daptomycin and PAMAM dendrimer was proposed wherein the ionized Asp-3 and Asp-9 residues of daptomycin interact with PAMAM cationic surface amine.

Diese Arbeit befasst sich mit der Untersuchung des Metabolismus sowie der Reaktivität verschiedener Wirk- und Arzneistoffe mittels flüssigchromatographischer und massen-spektrometrischer Methoden, sie gliedert sich dabei in vier Projekte. Zur Bestimmung des Metabolitenprofils wurde ein passendes In-vitro-Inkubationssystem mit Cytochrom-P-450-Systemen entwickelt. So wurden der Metabolismus und die Pharmakokinetik der Mip-Inhibitoren SF110, SF235 und SF354 gegen Legionellen, sowie neuer antitrypanosomaler Verbindungen MB209, MB343 und MB444 und von Daptomycin bestimmt. Darüber hinaus wurde die antibakterielle Aktivität des Daptomycins gegenüber einem unbekannten Staphylokokkus-Stammes S. sciuri ermittelt. Außerdem wurden Reaktivitätsuntersuchungen neu synthetisierter Inhibitoren gegen Tuberkulose und S. aureus durchgeführt. Die untersuchten Mip-Inhibitoren lieferten ein Metabolitenprofil, welches durch Ester- und Amidhydrolysen sowie Hydroxylierungen geprägt wurde. Die Verbindung SF110 schien dabei bereits eine gewisse Instabilität der Esterbindung aufzuweisen, da auch im Blindwert entsprechende Spaltprodukte identifiziert werden konnten. Die Hauptmetabolite von SF235 und SF354 bildeten sich durch unterschiedliche Hydrolysen, da die Spaltung des Moleküls von den jeweiligen Substituenten abhängig ist. Innerhalb dieser Substanzklasse dominiert die mikrosomale Enzymkatalyse, da der größte metabolische Umsatz sowie die meisten Metabolite mittels mikrosomaler Fraktion des Menschen bzw. der Maus gefunden wurden. Die Klasse der Mip-Inhibitoren wird somit vor allem durch Cytochrom-P-450-Enzyme umgesetzt, wobei die Hydrophilie durch Einführung polarer OH-Gruppen der Moleküle erhöht wird. Die Hydroxylierung scheint dabei positionsspezifisch, bedingt durch sterische Hinderungen oder dirigierende Einflüsse, abzulaufen. Stabilitätsvergleiche zwischen SF110, SF235 und SF354 zeigten, dass die Einführung einer Amidbindung anstelle der korrespondierenden Esterbindung die Substanzklasse maßgeblich metabolisch stabilisiert. Im Rahmen des murinen In-vivo-Metabolismus wurde beobachtet, dass SF235 einem deutlich stärkeren Metabolismus unterlag als SF354 und sich der Metabolismus vor allem innerhalb der ersten 30 min vollzog. Demgegenüber zeigten die In-vitro-Ergebnisse gegenteilige Ergebnisse, bei denen SF354 die am stärksten metabolisierte Substanz war. Diese widersprüchlichen Ergebnisse deuten darauf hin, dass In-vitro-Modelle nur als Anhaltspunkt verwendet werden sollten, um mögliche Trends abzuleiten. Metabolismusstudien der Chinolonamide, die gegen die afrikanische Schlafkrankheit wirken sollen, veranschaulichten, dass die größte enzymatische Umsetzung aller drei getesteten Verbindungen mittels cytosolischer Fraktion erfolgte. Die Enzymreaktionen werden vermutlich durch ALDH bzw. MAO dominiert und nicht durch CYP bzw. FMO. Die gebildeten Metabolite in den verschiedenen Fraktionen unterlagen (ω-1)-Oxidationen, N-Desalkylierungen, Amidhydrolysen und aromatischen Hydroxylierungen. Auffallend war, dass eine Hydroxylierung am aromatischen Benzylring nur erfolgen konnte, sofern der Benzylaromat keinen Fluorsubstitutenten trug, da dieser desaktivierend wirkte. Die aromatische Hydroxylierung am Chinolonamid erfolgte dagegen bei allen drei Substanzen. Es wurde somit lediglich eine Hydroxylierung am Benzylring von MB343 festgestellt. Die enzymatische Aktivität aller Substanzen folgte einer Reaktionskinetik 1. Ordnung. Die unterschiedlichen Stabilitäten der Substanzen zeigten einen deutlichen Trend: MB209 wurde, da es die instabilste Verbindung darstellt, im größten Maße umgesetzt, gefolgt von den stabileren Derivaten MB343 und MB444. Die Untersuchung der enzymatischen Aktivitäten zeigte, dass die drei Substanzen, verglichen mit der Leitstruktur GHQ168, eine um den Faktor zehn geringere Aktivität aufwiesen [19]. Aufgrund der eingeführten Fluoratome weisen die Substanzen somit eine wesentlich höhere Stabilität auf. Diese Ergebnisse wurden durch die Untersuchung der Halbwertszeit bestätigt, bei der MB444 den höchsten Wert besaß. Weiterhin ist die Position des Fluorsubstituenten am Chinolongerüst ausschlaggebend für die metabolische Stabilität, wobei MB444 aufgrund des para-Fluorsubstituenten am Chinolonamid die stabilste Verbindung darstellt. Durch Inkubation von Daptomycin mit unterschiedlichen S. sciuri-Isolaten wurde ein möglicher Inaktivierungsmechanismus beobachtet, bei dem das Antibiotikum durch Spaltung des cyclischen Aminosäureringes, durch Deacylierung des Fettsäureschwanzes, einer Kombination beider Mechanismen oder durch eine Spaltung des heteroaromatischen Ringsystems von Tryptophan inaktiviert wurde. Die Proteasen des Daptomycin-resistenten S. sciuri-Isolats TS92 führten zu einem Daptomycinabbau von 35 %, unabhängig von der eingesetzten Menge des Arzneistoffes. Das Ausmaß des Abbaus scheint darüber hinaus vom eingesetzten Inkubationsmedium abhängig zu sein, da die Proteasen voraussichtlich auf ein bestimmtes Nährmedium angewiesen sind. Der sensitive S. sciuri-Stamm TS93 lieferte die höchste Abbaurate an Daptomycin mit 55 % und widerlegt damit die Vermutung, dass Daptomycin die geringste antibakterielle Aktivität gegenüber diesem S. sciuri-Stamm aufweist. Im In-vitro-Metabolismus zeigte Daptomycin insgesamt eine sehr geringe Umsetzungsmenge mit maximal 5 % nach 4 h und einer geringen Metabolitenbildung. Hier wurde nur ein Metabolit gefunden, welcher auch mittels S. sciuri-Inkubation identifiziert wurde. Dieser Mechanismus könnte somit auf anderem Wege verlaufen. Die Reaktivitätsstudien der kovalenten Inhibitoren der FadA5-Thiolase gegen Tuberkulose zeigten, dass nur die Verbindungen C1 und C4 eine Reaktivität gegenüber der Aminosäure Cystein93 im aktiven Zentrum besaßen, die somit für den gewünschten Einsatzzweck geeignet sein könnten. Weiterhin wurde bei den kovalenten Inhibitoren der Enoyl-ACP-Reduktase mit dem Enzym FabI, welches im aktiven Zentrum ein Tyrosin besitzt, keine Reaktion festgestellt, da keine Addukte identifiziert wurden. Dies ist vermutlich auf die Unlöslichkeit im verwendeten TRIS-Puffer zurückzuführen. / This work deals with the investigation of the metabolism as well as the reactivity of different drug candidates as well as active pharmaceutical substances by means of liquid chromatographic and mass spectrometric methods. It is divided into four projects. In order to determine the metabolite profile, a suitable in-vitro incubation system using cytochrome P-450-systems was developed. Thus, the metabolism and pharmacokinetics of the Mip inhibitors SF110, SF235, and SF354 against Legionella, as well as of new antitrypanosomal compounds MB209, MB343, and MB444 and of daptomycin were determined. In addition, the antibacterial activity of daptomycin against an unknown Staphylococcus strain S. sciuri was determined. In addition, reactivity studies of newly synthesized inhibitors against tuberculosis and S. aureus were performed. The Mip inhibitors investigated showed a metabolite profile being characterized by ester and amide hydrolysis as well as hydroxylation. The ester moiety of compound SF110 seemed to be unstable, as metabolites could be also identified in the negative control. The major metabolites of SF235 and SF354 were formed by different hydrolyses, whereby the cleavage mechanism of the molecule is dependent on the respective substituents. The substance class is dominated by microsomal enzyme catalysis, as the highest metabolic turnover and, eventually, the most metabolites were found using a microsomal fraction of the human and mouse. The class of Mip inhibitors is thus represented mainly by cleavage due to cytochrome P-450 enzymes, wherein the hydrophilicity of the substrate is increased by introducing polar hydroxyl groups. Hydroxylation seems to be site specific due to steric hindrance or directing influences. Comparing the stability of SF110, SF235, and SF354 revealed that introducing an amide bond instead of an ester bond significantly stabilizes the substance class metabolically. In murine in vivo metabolism results, SF235 was found to be metabolized more significantly than SF354 within the first 30 min of incubation. In contrast, the in vitro results showed the opposite. SF354 was the most metabolized substance. The contradictory results suggest that in vitro models should only be used as an indicator to derive possible trends. Metabolism studies of quinolonamides active against African sleeping sickness, demonstrated that the highest enzymatic conversion of all three tested compounds was caused by the cytosol fraction. The enzyme reactions are probably catalyzed by ALDH or MAO and not by CYP or FMO, respectively. The formed metabolites found in various fractions were subject to (ω-1)-oxidations, N-dealkylations, amide hydrolyses, and hydroxylations. It was observed that hydroxylation could only take place on the aromatic benzyl ring if it did not carry any fluorine substituents having a deactivating effect. The aromatic hydroxylation of the quinolonamide, however, was carried out in all three substances. Thus, only hydroxylation on the benzyl ring of MB343 was observed. The enzymatic activity of all substances followed a first-order kinetic. The different stabilities of the substances had a clear trend: MB209 showed the highest enzymatic activity as it represents the most unstable compound, followed by MB343 and MB444. The enzymatic activities of the three substances were ten times lower compared to the enzymatic activity of lead structure GHQ168 [19], which exhibits a much higher stability due to the fluorine atoms. These results were confirmed by a half-life study in which MB444 was the most stable compound. The position of the fluorine substituent on the quinolone determines the metabolic stability, making MB444 the most stable compound because it carries a p-fluorine substituent on the quinolonamide. When incubating Daptomycin with different S. sciuri isolates, a possible inactivation mechanism of the antibiotic agent was observed in which the cyclic amino acid ring was opened, the fatty acid tail deacylated, or a combination of both mechanisms as well as the heteroaromatic ring system of tryptophan was cleaved. The proteases of the daptomycin-resistant S. sciuri isolate TS92 led to a daptomycin degradation of 35%, regardless of the initial concentration used. The degradation also seems to depend on the incubation medium since the proteases probably rely on a specific nutrient medium. The sensitive S. sciuri strain TS93 showed the highest degradation rate of daptomycin with 55 % and thus refutes the assumption that it has the smallest antibacterial sensitivity against daptomycin. Overall, DAP showed a very low in vitro metabolism with a conversion rate of maximum 5% after 4 h and a low metabolic rate. Here, only one metabolite could be found which was also identified by means of S. sciuri incubation. Thus, this mechanism could proceed in a different way. The reactivity studies of the covalent inhibitors of the thiolase of the FadA5 enzyme against tuberculosis showed that only compounds C1 and C4 targeted cysteine93, thus being suitable for the desired purpose. Furthermore, no reaction was observed for in the covalent inhibitors of the enoyl-ACP reductase with the enzyme FabI, which carries a tyrosine in the active site, since no adducts were identified. This is probably due to the insolubility in the TRIS buffer.

Host defense peptides (HDPs) provide innate immune defense against invasive S. aureus infection. Recent studies suggest potential cross-resistance between HDPs and the lipopeptide antibiotic, daptomycin (DAP). Isolates that exhibit DAP non-susceptible phenotypes may have virulence advantages and pose challenges to effective treatment. The current studies were performed to compare the efficacies and mechanisms of action of native and engineered HDPs vs. clinical S. aureus strain pairs which differed in susceptibility to daptomycin in vitro. Ultrasensitive radial diffusion and multi-colored flow cytometry were employed to analyze distinctive susceptibilities and mechanisms of resistance, respectively. Overall efficacies were greater vs. DAP-susceptible (DSSA) vs. DAP non-susceptible (DNSA) S. aureus isolates for some but not all HDPs. Efficacy profiles of certain HDPs were influenced by pH, regardless of whether the particular isolate was DSSA or DNSA phenotype. Mechanistically, DSSA and DNSA isolates differed in responses to specific HDPs regarding cell energetics, membrane permeability, cytoplasm membrane turnover, and cell death protease induction. DSSA and DNSA strain pairs exhibited non-identical mechanisms of resistance to HDPs. At pH 7.5, as expected, HDPs hNP-1 and RP-1 exerted significantly greater efficacy on susceptible control strain ISP479C vs. its resistant counterpart ISP479R. These data suggest different mechanisms of HDP resistance are active in differing DNSA strains. These preliminary results are under further investigation, as are the genetic determinant(s) that may emerge during infection. If substantiated, these findings would imply multiple modes of survival of S. aureus in the face of DAP or HDPs.

Staphylococcus aureus est une des espèces bactériennes les plus fréquemment responsable des cas d’endophtalmie et d’arthrite aiguës chez l’homme. Nous avons étudié la pharmacodynamie oculaire du linézolide et de la daptomycine, ainsi que leur toxicité, dans un modèle d’endophtalmie expérimentale chez le lapin. Il est apparu que seule une dose très élevée delinézolide administrée par voie intravitréenne (30mg/0,1mL) présentait une efficacité bactérioclinique. Aucune altération de la fonction visuelle n’a été mise en évidence. La dose intravitréenne efficace de daptomycine (1mg/0,1mL) était quant à elle responsable d’une altération significative de l’intégrité fonctionnelle de la rétine. Enfin, la pharmacodynamie de ces deux antibiotiques dans le compartiment oculaire présentait des différences significatives avec les autres sites tissulaires d’infection étudiés à ce jour. Dans la deuxième partie de nos travaux nous nous sommes intéressés à une nouvelle technique d’IRM, associée à des particules d’USPIOs (Ultrasmall SuperParamagnetic Iron Oxide). Nous avons montré que cette techniqued’imagerie permettait d’une part la mise en évidence de l’infiltration des macrophages dans la synoviale infectée, et, d’autre part, la visualisation de la guérison de l’articulation, contrairement à l’imagerie conventionnelle à base de chélates de gadolinium. Cette technique innovante offre donc une nouvelle dimension à l’imagerie ostéo-articulaire grâce à une mise en évidence in vivo plus spécifique des phénomènes pathologiques. / Staphylococcus aureus (S. aureus) is a frequent cause of acute endophthalmitis and arthritis in humans. In the first part, we investigated the ocular pharmacodynamics and safety of two recently approved antistaphylcoccal antibiotics, linezolid and daptomycin. Only a very high intravitreal dose of linezolid (30 mg / 0.1 mL) showed a bactericidal and clinical efficacy. Suchintraocular concentrations appeared to be safe for the retinal function, and linezolide could be considered as a promising therapeutic alternative. The effective intravitreal dose of daptomycin (1 mg / 0.1 mL) was responsible for a significant impairment of the functional integrity of the retina. Finally, the ocular pharmacodynamics of these two antibiotics showed special features in comparison with the one of other types of tissue infection. In a second part, we evaluated a newimaging method in experimental infectious arthritis, by using MRI enhanced by ultrasmall superparamagnetic iron oxide (USPIO). We first showed this method can depict the macrophage infiltration in infected synovium, and secondly it can demonstrate resolution of joint infection, in contrast to conventional MRI performed by gadolinium chelates. This in vivo non invasive imaging method therefore presents a new dimension in musculoskeletal imaging by accurately helping monitor bacterial joint infection.

What is known and objective: Treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia is a long-standing challenge to health care, often complicated by metastatic infections, treatment failure and mortality. When MRSA bacteraemia persists despite adequate initial treatment, current Infectious Diseases Society of America guidelines recommend evaluation and removal of possible sources of infection. In addition, a change in therapy may be considered. The objective of this review was to explore the therapeutic options for the treatment of persistent MRSA bacteraemia. Methods: A literature search of PubMed, MEDLINE and Google Scholar was performed using the following search terms: [methicillin-resistant Staphylococcus aureus OR MRSA] AND [bacteraemia OR bloodstream infection] AND [persistent OR persistence OR refractory OR treatment failure OR salvage] AND treatment. We evaluated relevant, adult, English-language, peer-reviewed studies published between 1985 and May 2018. In vitro and animal studies were considered as supportive of in vivo data. Results and discussion: Randomized, controlled trials are lacking. However, case series and case reports support multiple treatment options including high-dose daptomycin in combination with an antistaphylococcal β-lactam, ceftaroline, trimethoprim-sulfamethoxazole (TMP-SMX) or fosfomycin; ceftaroline alone or in combination with vancomycin or TMP-SMX; linezolid alone or in combination with a carbapenem, or telavancin. What is new and conclusion: Given the heterogeneity of the data, a preferred regimen has not emerged. Prescribers must take into consideration recent exposure, source control, and available synergy and clinical data. Further comparative trials are needed to establish a preferred regimen and the creation of a universal treatment algorithm.

Staphylococci are bacterial species where some strains can be found in the human microbiome. If the bacteria infect other body parts it could cause mild to life-threatening infections. The infection should be treated with an effective antibiotic where the bacteria strain’s antibiotic sensibility should be tested. One of the most trustworthy laboratory methods is the broth microdilution (BMD) method. BMD is based on exposing bacteria to different concentrations of different antibiotics to determine the minimum inhibitory concentration (MIC) a specific bacteria strain has, and thus the kind of antibiotic the bacteria strain is most susceptible to. A sensititre plate with 96 wells is used containing freeze-dried antibiotics in varied concentrations. Therefore, the microbiologic laboratory at Gävle Hospital wants to implement BMD as a routine analyzing method where a so-called SEMSE7 sensititre plate verification is needed. The verification is essential to ensure the plate’s performance and ability to give reliable results which was the purpose of this study. Obtained results were compared to reference laboratory values, where 100 % accordance regarding ± one dilution step was obtained of all MIC-values (90 % limit) and 94,3 % accordance regarding the SIR-system (90 % limit). Contrariwise, one very major error, and one major error were obtained which means 5,7 % where the limit was at 3 %. Furthermore, concerning the plate’s performance 97,3 % accordance was obtained regarding ± one dilution step (90 % limit). Most verification requirements were fulfilled but completion is needed before implementing BMD as a routine analysis method.

Estima-se que 30% da população mundial esteja colonizada por Staphylococcus aureus. Indivíduos portadores de HIV/AIDS possuem maiores riscos de colonização e infecções causadas por S. aureus resistente à meticilina (MRSA), devido a seu estado imunológico comprometido, frequente uso de antibióticos e reinternações hospitalares. Linhagens de MRSA emergiram na década de 60, logo após a introdução da meticilina, devido a aquisição de genes que codificam proteínas ligadoras de penicilinas modificadas, mecA e mecC, contidos no elemento genético móvel SCCmec (do inglês, Staphylococcal Cassete Chromossome). Este estudo buscou caracterizar amostras de MRSA de pacientes com HIV/AIDS, isoladas no primeiro e sétimo dia de internação no hospital, e de seus profissionais de saúde, do Hospital das Clínicas de Ribeirão Preto, no período de abril de 2011 a maio de 2013. Os objetivos foram caracterizar fenotípica e genotipicamente os isolados de MRSA e comparar as linhagens, a fim de observar se havia disseminação entre os pacientes ou entre estes e profissionais de saúde relacionados. Foi realizada caracterização por perfil de sensibilidade, determinação do elemento SCCmec, eletroforese em campos pulsados (PFGE, do inglês, Pulsed Field Gel Electrophoresis) e tipagem por sequenciamento de Multilocus (MLST). Foram pesquisados os tipos de hemólise produzidos e a presença de gene para produção da Leucocidina Panton Valentine (PVL). Vinte pacientes encontravam-se colonizados no primeiro dia de internação, treze após uma semana e três profissionais da saúde estavam colonizados durante o estudo. Quando excluídas as amostras consideradas duplicatas, SCCmecIV foi o elemento predominante. Grande variedade clonal de MRSA foi encontrada nos pacientes, totalizando 11 pulsotipos. ST239-SCCmecIII, relacionado ao Clone Endêmico Brasileiro (BEC), foi isolado de pacientes logo no primeiro dia de internação, provavelmente devido à prévia internação. O profissional de saúde P1 apresentou colonização por MRSA caracterizado como pulsotipo E, que persistiu após o tratamento para descolonização. P1 foi tratado novamente e posteriormente foi observado isolado com pulsotipo J, sugerindo ser um clone diferente dos anteriores, mas ainda com linhagem ST105-SCCmecII. Apenas um isolado, do paciente 5, apresentou grande similaridade (92,3%) com um isolado do profissional de saúde (P1). Entretanto, houve intervalo de 10 meses entre as coletas e não há indício de transmissão direta de uma pessoa para outra. Presença do gene da PVL foi encontrada em apenas dois isolados. Três amostras de MRSA foram caracterizadas como hVISA (do inglês, heterogeneous Vancomycin Intermediate Staphylococcus aureus) e dois deles possuíam resistência intermediária à teicoplanina. Um isolado apresentou resistência à daptomicina em 48h de incubação com uma população heterogênea detectada. Todos foram sensíveis a quinupristina-dalfopristina, linezolida e tigeciclina. Concluímos que não houve disseminação de uma linhagem específica entre os pacientes, ou entre profissionais de saúde e pacientes e não foi observada relação entre o tempo de estadia no hospital e aquisição de uma linhagem em específico. No entanto, algumas linhagens com perfis de resistência muito preocupantes, como hVISA e com heterorresistência à daptomicina, foram isoladas e requerem atenção e monitoramento, com programas de vigilância e adoção de práticas de segurança e higiene no trabalho por parte dos profissionais de saúde. / It is estimated that 30 % of the world population is colonized by Staphylococcus aureus. Individuals with HIV/AIDS have a higher risk of colonization and infection caused by methicillin-resistant S. aureus (MRSA), due to their compromised immune system, frequent use of antibiotics and hospital readmissions. Strains of MRSA emerged in the 60s, shortly after the introduction of methicillin. Such resistance is caused by acquisition of genes encoding modified penicillin binding proteins, mecA and mecC, contained in the mobile genetic element SCCmec (Staphylococcal Cassette Chromosome). This study aimed to characterize MRSA isolated from patients with HIV/AIDS, in the first and seventh day of hospitalization, and their health care professionals, at the Clinical Hospital of Ribeirão Preto, in the period of April 2011 to May 2013. The objectives were to characterize phenotypic and genotypically MRSA isolates in order to observe if there was some lineage spread among patients or between these and related health professionals. MRSA isolates were characterized by susceptibility profile, SCCmec element typing, pulsed field gel electrophoresis (PFGE) and multilocus sequencing typing (MLST). Pattern of hemolysis and the presence of the gene for production of Leukocidin Panton Valentine (PVL) were determined. Twenty patients were colonized on the first day of hospitalization, thirteen patients in a week and only three health care professionals were colonized during the study. SCCmecIV was the predominant element when samples considered duplicates were excluded. Large variety of MRSA clones was found in patients with 11 pulsotypes. ST239-SCCmecIII, related to Brazilian Endemic Clone (BEC), was isolated from patients on the first day of hospitalization, probably due to previous hospital admission. Professional P1 was colonized by MRSA isolate characterized as pulsotype E which persisted after treatment for decolonization. P1 was treated again and was observed with a pulsotype J isolate, which suggests being a different clone of the same lineage ST105-SCCmecII. Only one sample, from patient 5, showed high similarity (92.3 %) with this health professional isolate (P1). However, there was an interval of 10 months between the collections and there is no evidence of direct transmission from one person to another. Presence of the PVL gene was found in only two isolates. Three MRSA isolates were characterized as hVISA (heterogeneous Vancomycin Intermediate S. aureus) and two of them were also intermediate resistant to teicoplanin. One isolate showed resistance to daptomycin in 48h incubation and heterogeneous population was detected. All isolates were susceptible to quinupristin-dalfopristin, linezolid and tigecycline. We conclude that no spread of a particular strain was found among patients or between health care professionals and patients, and no relationship between duration of hospital stay and acquisition of a specific lineage was observed. However, some strains with resistance profiles very threatening, as hVISA and heteroresistant to daptomycin, were isolated and require attention and monitoring, with surveillance programs and use of safety practices and hygiene by health professionals.

Estima-se que 30% da população mundial esteja colonizada por Staphylococcus aureus. Indivíduos portadores de HIV/AIDS possuem maiores riscos de colonização e infecções causadas por S. aureus resistente à meticilina (MRSA), devido a seu estado imunológico comprometido, frequente uso de antibióticos e reinternações hospitalares. Linhagens de MRSA emergiram na década de 60, logo após a introdução da meticilina, devido a aquisição de genes que codificam proteínas ligadoras de penicilinas modificadas, mecA e mecC, contidos no elemento genético móvel SCCmec (do inglês, Staphylococcal Cassete Chromossome). Este estudo buscou caracterizar amostras de MRSA de pacientes com HIV/AIDS, isoladas no primeiro e sétimo dia de internação no hospital, e de seus profissionais de saúde, do Hospital das Clínicas de Ribeirão Preto, no período de abril de 2011 a maio de 2013. Os objetivos foram caracterizar fenotípica e genotipicamente os isolados de MRSA e comparar as linhagens, a fim de observar se havia disseminação entre os pacientes ou entre estes e profissionais de saúde relacionados. Foi realizada caracterização por perfil de sensibilidade, determinação do elemento SCCmec, eletroforese em campos pulsados (PFGE, do inglês, Pulsed Field Gel Electrophoresis) e tipagem por sequenciamento de Multilocus (MLST). Foram pesquisados os tipos de hemólise produzidos e a presença de gene para produção da Leucocidina Panton Valentine (PVL). Vinte pacientes encontravam-se colonizados no primeiro dia de internação, treze após uma semana e três profissionais da saúde estavam colonizados durante o estudo. Quando excluídas as amostras consideradas duplicatas, SCCmecIV foi o elemento predominante. Grande variedade clonal de MRSA foi encontrada nos pacientes, totalizando 11 pulsotipos. ST239-SCCmecIII, relacionado ao Clone Endêmico Brasileiro (BEC), foi isolado de pacientes logo no primeiro dia de internação, provavelmente devido à prévia internação. O profissional de saúde P1 apresentou colonização por MRSA caracterizado como pulsotipo E, que persistiu após o tratamento para descolonização. P1 foi tratado novamente e posteriormente foi observado isolado com pulsotipo J, sugerindo ser um clone diferente dos anteriores, mas ainda com linhagem ST105-SCCmecII. Apenas um isolado, do paciente 5, apresentou grande similaridade (92,3%) com um isolado do profissional de saúde (P1). Entretanto, houve intervalo de 10 meses entre as coletas e não há indício de transmissão direta de uma pessoa para outra. Presença do gene da PVL foi encontrada em apenas dois isolados. Três amostras de MRSA foram caracterizadas como hVISA (do inglês, heterogeneous Vancomycin Intermediate Staphylococcus aureus) e dois deles possuíam resistência intermediária à teicoplanina. Um isolado apresentou resistência à daptomicina em 48h de incubação com uma população heterogênea detectada. Todos foram sensíveis a quinupristina-dalfopristina, linezolida e tigeciclina. Concluímos que não houve disseminação de uma linhagem específica entre os pacientes, ou entre profissionais de saúde e pacientes e não foi observada relação entre o tempo de estadia no hospital e aquisição de uma linhagem em específico. No entanto, algumas linhagens com perfis de resistência muito preocupantes, como hVISA e com heterorresistência à daptomicina, foram isoladas e requerem atenção e monitoramento, com programas de vigilância e adoção de práticas de segurança e higiene no trabalho por parte dos profissionais de saúde. / It is estimated that 30 % of the world population is colonized by Staphylococcus aureus. Individuals with HIV/AIDS have a higher risk of colonization and infection caused by methicillin-resistant S. aureus (MRSA), due to their compromised immune system, frequent use of antibiotics and hospital readmissions. Strains of MRSA emerged in the 60s, shortly after the introduction of methicillin. Such resistance is caused by acquisition of genes encoding modified penicillin binding proteins, mecA and mecC, contained in the mobile genetic element SCCmec (Staphylococcal Cassette Chromosome). This study aimed to characterize MRSA isolated from patients with HIV/AIDS, in the first and seventh day of hospitalization, and their health care professionals, at the Clinical Hospital of Ribeirão Preto, in the period of April 2011 to May 2013. The objectives were to characterize phenotypic and genotypically MRSA isolates in order to observe if there was some lineage spread among patients or between these and related health professionals. MRSA isolates were characterized by susceptibility profile, SCCmec element typing, pulsed field gel electrophoresis (PFGE) and multilocus sequencing typing (MLST). Pattern of hemolysis and the presence of the gene for production of Leukocidin Panton Valentine (PVL) were determined. Twenty patients were colonized on the first day of hospitalization, thirteen patients in a week and only three health care professionals were colonized during the study. SCCmecIV was the predominant element when samples considered duplicates were excluded. Large variety of MRSA clones was found in patients with 11 pulsotypes. ST239-SCCmecIII, related to Brazilian Endemic Clone (BEC), was isolated from patients on the first day of hospitalization, probably due to previous hospital admission. Professional P1 was colonized by MRSA isolate characterized as pulsotype E which persisted after treatment for decolonization. P1 was treated again and was observed with a pulsotype J isolate, which suggests being a different clone of the same lineage ST105-SCCmecII. Only one sample, from patient 5, showed high similarity (92.3 %) with this health professional isolate (P1). However, there was an interval of 10 months between the collections and there is no evidence of direct transmission from one person to another. Presence of the PVL gene was found in only two isolates. Three MRSA isolates were characterized as hVISA (heterogeneous Vancomycin Intermediate S. aureus) and two of them were also intermediate resistant to teicoplanin. One isolate showed resistance to daptomycin in 48h incubation and heterogeneous population was detected. All isolates were susceptible to quinupristin-dalfopristin, linezolid and tigecycline. We conclude that no spread of a particular strain was found among patients or between health care professionals and patients, and no relationship between duration of hospital stay and acquisition of a specific lineage was observed. However, some strains with resistance profiles very threatening, as hVISA and heteroresistant to daptomycin, were isolated and require attention and monitoring, with surveillance programs and use of safety practices and hygiene by health professionals.

Purpose: This study seeks to determine the incidence of vancomycin-resistant enterococci (VRE) infection in high-risk neutropenic fever patients colonized with VRE and to determine patient characteristics associated with VRE infection. Methods: We conducted a retrospective, single-center, unmatched case-control study. Fifty-three VRE-colonized, high-risk patients with neutropenic fever were identified between January 2006 and February 2009. The two most common diagnoses/conditions included acute myeloid leukemia and hematopoietic stem cell transplantation. Data collected included days of neutropenia, days of fever, demographic data, culture results, and antimicrobial therapy. Results: Twenty of the 53 patients (38%) with VRE colonization developed a VRE infection. The most common VRE infections were bacteremias (26%). The presence of neutropenia lasting longer than 7 days was associated with the development of VRE infection in this high-risk population colonized with VRE. The timeframe to develop VRE infection varied from 1 day to 2 weeks. Conclusion: For patients colonized with VRE, approximately 38% of high-risk neutropenic patients developed a VRE infection. This is the first study to specifically evaluate the incidence of VRE infections in febrile neutropenic patients colonized with VRE. Future research into the use and efficacy of empiric VRE coverage is needed.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This work presents the development and validation of analytical methods to assay daptomycin injection. Daptomycin is a drug of a new class of antibiotics, known as cyclic lipopeptides. It was approved in USA in 2003 and in Brazil in 2009. Up to now, there are no reports about methods to assay the drug in pharmaceutical products, both in scientific literature or in official compendia. Methods to identify daptomycin in raw material were realized as solubility, melting point, infrared spectrophotometry (IR), ultraviolet spectrophotometry (UV) and differential scanning calorimetry (DSC) and they showed appropriate results. The following methods to assay daptomycin injection were developed and validated: high performance liquid chromatography (HPLC), microbiological assay (turbidimetric) and UV-spectrophotometry. All of them were validated according current guidelines, by the following parameters: specificity, linearity, precision, accuracy and robustness, being all the requirements met. The mean values of daptomycin assay by the three methods were: 100,23 ± 0,59% (HPLC); 100,96 ± 2,58% (turbidimetric assay) and 98,98 ± 1,35% (UV-spectrophotometry). They were compared by ANOVA, which indicated that HPLC and turbidimetric assay are interchangeable. The stress testing showed that daptomycin is very susceptible to alkaline medium and that the degradation follows first order kinetic, in the conditions adopted. It was found that the degradation product(s) of daptomycin do not have antimicrobial activity. Considering their characteristics, HPLC and turbidimetric assays can be used in routine quality control and in stability studies of daptomycin injection. / Este trabalho apresenta o desenvolvimento e validação de métodos analíticos para o doseamento da daptomicina injetável. A daptomicina é um antibiótico pertencente a uma nova classe de antimicrobianos, conhecidos como lipopeptídeos cíclicos. Foi aprovada para comercialização nos Estado Unidos em 2003 e no Brasil em 2009. Até o momento, não foram relatados métodos de quantificação para o fármaco em produtos farmacêuticos, tanto na literatura científica quanto em compêndios oficiais. Foram realizados métodos para a caracterização da matéria-prima como solubilidade, ponto de fusão, espectrofotometria no infravermelho (IV) e na região do ultravioleta (UV) e calorimetria exploratória diferencial (DSC), sendo que os mesmos permitiram a identificação do fármaco na matéria-prima. Os seguintes métodos para análise quantitativa da daptomicina injetável foram desenvolvidos e validados: cromatografia líquida de alta eficiência (CLAE), ensaio microbiológico (método turbidimétrico) e espectrofotometria na região do UV. Todos os métodos foram validados de acordo com as guias vigentes, frente aos parâmetros de especificidade, linearidade, precisão, exatidão e robustez, tendo sido atendidos os requisitos estabelecidos. Os teores médios de daptomicina na formulação em estudo, pelos métodos desenvolvidos (n=12/método) foram: 100,23 ± 0,59% (CLAE); 100,96 ± 2,58% (ensaio microbiológico) e 98,98 ± 1,35% (espectrofotometria no UV). Esses resultados foram comparados pelo teste de ANOVA, que indicou que os métodos de CLAE e microbiológico são intercambiáveis. Pelo estudo de degradação forçada verificou-se que a condição que induz à maior degradação do fármaco é o meio alcalino, sendo que a reação segue cinética de primeira ordem nas condições usadas. Constatou-se ainda que a amostra degradada da daptomicina não tem ação antimicrobiana. Pelas suas características, os métodos de CLAE e microbiológico podem sem usados no controle de qualidade de rotina e em estudos de estabilidade da formulação injetável de daptomicina.