A Febre Reumática, complicação tardia de uma infecção de orofaringe causada pelo Streptococcus pyogenes (estreptococo -hemolítico do grupo A de Lancefield), tem como conseqüência a Cardiopatia Reumática, explicada pelo mimetismo molecular entre proteínas cardíacas humanas e a associação de proteínas e carboidratos da membrana do S. pyogenes. A profilaxia secundária com a PGB 1.200.000 UI IM propõe-se a evitar novos surtos, sendo administrada em intervalos de vinte e um dias nos países com alto índice de estreptococcia. A lesão valvar predispõe à Endocardite Infecciosa, que resulta de bacteriemias causadas por focos infecciosos de origem bucal em cerca de 40% dos casos. Os Streptococcus Viridans constituem o grupo mais comumente encontrado nas Endocardites Infecciosas, em especial os Streptococcus sanguinis e Streptococcus oralis. O efeito do uso crônico da PGB não foi estudado com especificidade para essa microbiota. Assim, foi avaliada, qualitativa e quantitativamente, a microbiota bucal de 100 pacientes, aos 7 e 21 dias, após profilaxia secundária para a Febre Reumática com a PGB 1.200.000 UI IM e comparada com a de 100 pacientes portadores de doença arterial coronariana sem antecedentes de Febre Reumática. As espécies avaliadas foram divididas em S. sanguinis, S. oralis e outras espécies de Streptococcus Viridans Foram coletadas amostras de saliva pela mastigação de goma de parafina e transportadas em meio VMGA II S. As culturas foram semeadas em ágar Columbia CNA com 5% de sangue desfibrinado puro de carneiro com acréscimo de penicilina G. e incubadas a 35ºC em estufa de CO2 por 72 horas. As colônias sugestivas de Streptococcus foram submetidas a testes bioquímicos para confirmação de gênero e espécie. A concentração inibitória mínima foi determinada pelo método Etest e interpretada segundo os padrões do Clinical and Laboratory Standards Institute. Não houve diferença quanto à presença do S. sanguinis nos grupos estudados (P=0,40). O S. oralis prevaleceu aos 7 dias de PGB em relação ao grupo controle (P=0,01). Quanto à identificação de outras espécies, houve maior número de cepas nos pacientes do grupo controle quando comparados aos do grupo de estudo aos 7 e 21 dias de PGB (P<0,001). Os números de UFC/ml de S. sanguinis, S. oralis e de outras espécies foram comparados entre os grupos e não houve diferença entre eles (P=0,96; P=0,60 e P=0,77; respectivamente). Quanto às CIM do S. sanguinis e do S. oralis, não houve diferença entre os grupos (P=0,79 e P=0,13; respectivamente). Todos os testes estatísticos foram realizados em um nível de significância de 5%. Concluiu-se que o S. oralis prevaleceu aos 7 dias de PGB 1.200.000 UI IM; os Streptococcus Viridans de outras espécies prevaleceram no grupo controle; o número de UFC/mL de saliva não diferiu nos grupos estudados, a susceptibilidade dos S. sanguinis e S. oralis à penicilina G não foi alterada pela ação da PGB 1.200.000 UI IM a cada 21 dias e, por fim, a PGB não provocou reações de hipersensibilidade em nenhum paciente do estudo / Rheumatic fever is the result of a Streptococcus pyogenes (group A -hemolytic Streptococcus) infection of the upper respiratory tract. Rheumatic heart disease is a rheumatic fever consequence and is elucidated by the molecular mimicry between human cardiac proteins and group A streptococcal proteins and carbohydrates association. The secondary prophylaxis with 1,200,000 U BPG every three weeks is used for prevention of recurrent rheumatic fever in developing countries. Valvar defects are a risk for infective endocarditis which is resulted of bacteriemia caused for oral infectious focuses in 40% of cases. Viridans streptococci are the predominant group recovered in infective endocarditis, specially Streptococcus sanguinis and Streptococcus oralis. The effect of chronic BPG wasnt studied with specificity to these pathogens yet. Therefore, the oral microbiota was evaluated, qualitatively and quantitatively, at 7 and 21 days after secondary prophylaxis with BPG to rheumatic fever (study group), in a hundred patients and in comparison to another hundred patients with coronary heart disease who never acquired rheumatic fever (control group). The species evaluated were divided in S. sanguinis, S. oralis and another Streptococcus species. It was collected samples of chewing-stimulated saliva (1ml) and transported in VMGA II S medium. The samples were cultured in pure and with penicillin G 5% sheep blood Columbia ágar (CNA), incubated for 72 hours in an atmosphere containing 5% CO2 at 35ºC. The strains that were suggestive to Streptococcus were identified by biochemical tests to confirm bacteria species and genus. Minimal inhibitory concentration was determined by Etest method and interpreted in accordance to Clinical and Laboratory Standards Institute. The results showed that there was no difference in S. sanguinis presence in all groups (P=0.40). S. oralis prevailed in 7 days BPG group in comparison to control group (P=0.01). The control group showed the highest number of others species in comparison to 7 and 21 days BPG (P<0.001). CFU/ml numbers of S. sanguinis, S. oralis and other species strains were compared in 7 and 21 days BPG to control group and there was no difference among themselves (P=0.96, P=0.60 and P=0.77; respectively). There was no difference in S. sanguinis and S. oralis MICs among the study and control groups (P=0.79 and P=0.13). All statistic tests were done at 5% significance level. It was concluded that S. oralis prevailed in 7 days BPG group in comparison to control group; other species of Viridans streptococci prevailed in control group. The number of CFU/mL did not differ in both studied groups; the penicillin susceptibility of S. sanguinis and S. oralis did not change by BPG every three weeks and, by the end, it was not observed hypersensitivity reactions to penicillin in neither of the patients of this study

Microorganismos da cavidade oral têm sido admitidos como causadores de doenças sistêmicas com reconhecido mecanismo de disseminação via corrente sangüínea. Diferentes fatores, incluindo a presença da doença periodontal, têm influência no risco de bacteremia oral, podendo ocasionar endocardite infecciosa por Streptococcus viridans. Sendo assim, a manutenção da saúde bucal adquire elevado grau de importância em gestantes portadoras de doença valvar reumática, em que o risco de endocardite infecciosa é eminente. A escassez científica fez deste tema o objetivo deste estudo: investigar a condição clínica periodontal de gestantes portadoras de cardiopatia valvar, identificando agentes periodontopatógenos nas amostras coletadas de saliva, sulco/bolsa periodontal, Para tanto, foram estudadas 52 gestantes cardiopatas (GC) e 70 gestantes não-cardiopatas (GNC). A condição periodontal foi avaliada empregando-se profundidade clínica de sondagem (PCS), nível clínico de inserção (NCI), linha esmalte cemento/margem gengival (LEC/MG), índice de sangramento (IS) e índice de placa bacteriana (IP). As seguintes médias foram obtidas para os parâmetros periodontais avaliados: PCS: 1.52 (GC) e 1.45 (GNC); NCI: 1.13 (GC) e 1.02 (GNC); LEC/MG: 0.41 (GC) e 0.40 (GNC); IS: 7.34 (GC) e 6.27 (GNC) e IP: 12.19 (GC) e 13.48 (GNC). Não houve diferença entre os grupos para o NCI (p= 0,612). A presença da Porphyromonas gingivalis na saliva foi maior (p= 0,007) no GNC, porém não houve diferença nas amostras de sulco/bolsa periodontal. / Microorganisms of the oral cavity are known to cause systemic diseases, spread through sanguine current. Different factors, including the presence of periodontal disease, influencing the risk of oral bacteremia could cause infectious endocarditis for Streptococcus viridans. Nevertheless, the maintenance of the oral health is extremely important in pregnant women with rheumatic valvar disease, in which the risk of infectious endocarditis is eminent. The aim of this study was to investigate the clinical periodontal condition of pregnant women with valvar disease and to identify the presence of Porphyromonas gingivalis in saliva and subgingival samples. For these purposes, we studied 52 pregnant with valvar disease (GC) and 70 healthy pregnant women (GNC). The following periodontal parameters were evaluated: probing depth (PCS), clinical attachment level (NCI), gingival margin location (LEC/MG), bleeding on probing (IS) and plaque index (IP). The following mean periodontal parameters were obtained: PCS: 1.52 (GC) e 1.45 (GNC); NCI: 1.13 (GC) e 1.02 (GNC); LEC/MG: 0.41 (GC) e 0.40 (GNC); IS: 7.34 (GC) e 6.27 (GNC) e IP: 12.19 (GC) e 13.48 (GNC). There was no statistical difference for NCI among the groups. There was no difference between periodontal clinical conditions in pregnant women with valvar disease and healthy pregnant women. The presence of the Porphyromonas gingivalis in saliva samples of healthy pregnant women is statistically higher than in pregnant woman with valvar disease; however, there was no difference in periodontal samples

Einleitung: Die Implantation kryokonservierter allogener Aortenklappen stellt heutzutage eine effektive operative Technik dar, um in schweren Fällen einer floriden Aortenklappenendokarditis exzellente postoperative Ergebnisse zu erzielen. Diese Studie demonstriert die Langzeitergebnisse im Deutschen Herzzentrum Berlin über einen Zeitraum von 17 Jahren. Material und Methoden: Zwischen dem 1.Januar 1987 und 31.Dezember 2003 wurden bei 203 Patienten mit florider Aortenklappenendokarditis kryokonservierte Aortenklappenallografts implantiert (in subkoronarer Implantationstechnik n=107 und durch totalen Aortenwurzelersatz n=96). Das mittlere Alter der Patienten betrug 51,3 Jahre (2-82 Jahre). Darunter waren 42 Frauen und 161 Männer. 161 Patienten zeigten präoperativ eine anuläre Aortenwurzelabszeßbildung. Ergebnisse: Die 30-Tage-Mortalität (mit Anulusabszeß) betrug insgesamt 21,1% (23,6%): bei nativer Aortenklappenendokarditis 14,9% (17,5%) und bei Prothesen-endokarditis 29,2% (29,6%). Nach 17 Jahren waren 70,4+3,6% und 78,6+6,3% (p=0,24) der Patienten mit und ohne präoperativem Anulusabszeß am Leben. Bei 12 Patienten mit Anulusabszeß trat eine Allograft-Re-Infektion auf, die aktualisierte Freiheit von Reinfektion betrug 91,6+2,4% nach 17 Jahren. Insgesamt wurden 37 Patienten reoperiert, die aktualisierte Freiheit von Reoperation betrug 75,0+3,7% nach 17 Jahren. Die aktualisierte Freiheit von Explantation der Allografts wegen Strukturalteration betrug bei den Patienten mit Anulusabszeß nach 17 Jahren 96,0+2,0%. Thrombembolische Ereignisse traten nicht auf. Die Univarianzanalyse identifizierte die Allograft-Re-Infektion (p=0,0001) und zu klein bemessene Allografts (p=0,001) als Risikofaktoren für eine Reoperation sowohl bei nativer als auch Prothesenendokarditis. Schlußfolgerung: Aortenklappenallografts zeigen bei florider Aortenklappenendokarditis mit Anulusabszeß exzellente Langzeitresultate. Die 30-Tage–Mortalität wird hinsichtlich der Schwere der Erkrankung akzeptiert und Re-Infektionen sind selten. Zu klein bemessene Allografts und Re-Infektionen sind Risikofaktoren für Reoperationen. / Objective: Cryopreserved aortic valve homografts have become an accepted valve substitute in acute aortic valve endocarditis, but long-term studies of valve function are largely unavailable. This survey represents our observations over a period of 17 years. Material and methods: Between February 9, 1987 and October 30, 2003, 203 patients with infective aortic valve endocarditis underwent allograft replacement of the aortic valve (free-hand subcoronary technique, n=107 and root replacement, n=96). The patients’ age ranged between 2 and 82 years with a mean age of 51.3 years. The survey included 42 females and 161 males. 161 had infected aortic root with ring abscesses. Results: The hospital mortality of patients with native and prosthetic endocarditis complicated by periannular abscess was 14.9% (17.5%) and 29.2 % (29.6%) respectively making an overall hospital mortality of 21.2% (23.6%). 17 years patient survival in patients with and without periannular abscess was 70.4+3.6% and 78.6+6.3% (p=0,24) respectively. There were 12 events of recurrent endocarditis in patients with periannular abscess, giving an actuarial freedom of 91.6+2.4% at 17 years. Reoperation was performed in 37 patients for a variety of reasons, and overall freedom from reoperation was 75.0+3.7% at 17 years. Freedom from explantation for structural valve deterioration was 96.0+2.0% at 17 years for patients with periannular abcess. No thrombembolic event was evident. Univariable analysis identified recurrent endocarditis (p=0.0001) and undersized allograft (p=0.001) as risk factors for reoperation for both native and prosthetic aortic valve endocarditis. No risk factors for hospital mortality were found. Conclusion: Aortic allograft offers an excellent long-term clinical result in patients with infective aortic valve endocarditis with associated periannular abscess. Operative mortality is acceptable based on the severity of aortic pathology, with low evidence of recurrent endocarditis and no thrombembolic events. Undersized allograft and recurrent infection are risk factors for reoperation.

La maladie rénale peut se manifester avec différents types de pathologies buccales pouvant augmenter les risques de bactériémie. Bien que l’endocardite infectieuse soit une condition rare chez les patients atteints de maladie rénale, elle peut toutefois être retrouvée suite à des infections nosocomiales. Dans le passé, une antibiothérapie prophylactique était prescrite aux patients hémodialysés pour les protéger de l’endocardite infectieuse et de l’infection de l’accès d’hémodialyse. Aujourd’hui, cette recommandation est révolue. Afin de contrer les risques de bactériémie transitoire, une attention particulière doit être apportée aux soins d’hygiène orale à la maison. Le but de l’étude est d’évaluer l’efficacité de deux méthodes d’enseignement d’hygiène orale chez les patients atteints de maladie rénale. Objectifs de recherche Les trois objectifs de recherche sont a) d’évaluer les connaissances des parents de patients atteints de maladies rénales sur l’endocardite infectieuse et le lien avec la santé buccodentaire; b) d’évaluer la perception des parents par rapport à la santé buccodentaire de leur enfant et leurs habitudes d’hygiène orale; et c) de comparer l’influence de deux méthodes d’hygiène orale sur l’indice de plaque chez les enfants atteints de maladies rénales. Hypothèses Les deux hypothèses de recherche sont que a) les parents d’enfants atteints de maladies rénales connaissent et adhèrent aux recommandations émises par l’American Heart Association; et que b) l’amélioration de l’indice de plaque chez les patients atteints de maladies rénales est plus grande pour le groupe recevant des instructions par le matériel audiovisuel par rapport à ceux qui les reçoivent par le néphrologue. Méthodologie Suite à l’obtention d’un certificat d’éthique à la recherche du Centre Hospitalier Universitaire Sainte-Justine, 37 des 38 sujets recrutés âgés entre 6 et 16 ans (19 filles et 18 garçons) ont participé à cette étude transversale. Suite à la signature d’un consentement éclairé, les sujets sont assignés par randomisation à l’un des deux groupes d’instructions d’hygiène orale, soit celui sans instructions spécifiques (groupe 1) ou par matériel audiovisuel (groupe 2). Un questionnaire portant sur les connaissances des parents en rapport avec la santé buccodentaire est remis aux parents. Un indice de plaque initial est noté avant l’application des instructions d’hygiène orale reçues. Un indice de plaque final mis en évidence à l’aide de pastilles révélatrices est documenté avec des photographies intra-orales et mesuré par deux observateurs, testés pour la fiabilité intra et inter-observateurs. Résultats Les analyses statistiques ne démontrent aucune différence significative entre les deux groupes d’instructions d’hygiène orale. Les variables à l’étude (âge, sexe, suivi dentaire, fréquence des soins à la maison, connaissances et motivation) ne montrent aucune influence significative sur la qualité de l’hygiène orale des sujets. Seul l’indice de plaque initial est inversement relié à la perception des parents face à la santé buccodentaire de leur enfant : plus le relevé de plaque est bas, plus la santé buccodentaire est perçue comme bonne. Conclusion Selon les résultats de notre étude, il n’existe pas de différence statistiquement significative entre les deux méthodes d’instructions d’hygiène orale. Néanmoins, les deux techniques permettent de diminuer significativement l’indice de plaque chez les enfants atteints de maladies rénales et de conscientiser cette population à l’importance du maintien d’une bonne santé buccodentaire. / Renal diseases are known to cause oral changes that can increase the risk of developping a bacteraemia. Even if infective endocarditis is a rare condition in patients with renal disease, it is associated with nosocomial infections. In the past, antimicrobial therapy was recommended for haemodialysis patients to prevent infective endocarditis and indwelling venous catheter-related infections. The administration of prophylactic antibiotics is no longer supported, given the lack of evidence concerning this approach. To prevent patients from developing a transitory bacteraemia, home oral care has to be improved. The goal of this study is to assess the efficacy of two oral health instruction methods in children with renal disease. Objectives The objectives of this study are to assess the knowledge on infective endocarditis and its link to the oral health of parents with children who present with renal disease; to evaluate the perception of parents in relation with their child’s oral health and their dental behaviour and finally to compare the impact of the oral health instruction methods on the plaque index of children with renal disease. Hypothesis The two hypotheses of this study are a) parents of children suffering from renal diseases know and respect the guidelines published by the American Heart Association and b) that the improvement of the plaque index is better in the group who receives oral health instructions from the audio-visual material compared to the one receiving instructions from the nephrologist. Methods An ethic’s certification was obtained from the Centre Hospitalier Universitaire Sainte-Justine for children. Of the 38 recruited patients, 37 patients (19 girls, 18 boys) ranging in age from 6 to 16 years participated in this transversal study. Consent was obtained prior to randomised assignment to either oral hygiene delivered by means of an audio-visual aid (groupe 1) or by a nephrologist (group 2). A questionnaire investigating parental knowledge on renal disease linked with oral health was administered. An initial plaque index was taken before applying oral health instructions. A final plaque index using disclosing tablets was measured by two observers tested for intra and inter-reliability through intra-oral pictures. Results The statistical analyses do not show any significant differences between the two oral health instruction groups. No significant relation was found between oral health status and age, gender, dental follow up, frequency of home dental hygiene and motivation. The only significant relationship found was as parents perception of their child’s oral health increases, the initial plaque index decreases. Conclusion The results indicate that even if there is no statistically significant difference between the two methods of oral health instruction, both techniques are capable of reducing the plaque index of children suffering from renal disease.

L'endocardite infectieuse (EI) est une complication rare mais gravissime de la bactériémie à Staphylococcus aureus. Bien que certains facteurs de risque liés à l'hôte aient été décrits, l'implication de facteurs bactériens dans la survenue de l'EI est encore inconnue. Ces travaux de thèse ont visé à chercher tout élément bactérien associé à l'EI. Les facteurs phénotypiques décrits ou supposés comme potentiellement impliqués dans l'EI ont été testés. En parallèle, les profils génotypiques des souches obtenus par puces ADN ont été analysés par différents outils statistiques. L'analyse statistique univariée n'a montré aucune différence significative entre souches d'EI et souches de bactériémie, suggérant un processus complexe et multifactoriel. En effet, l'analyse discriminante en composante principale appliquée sur les données de puces ADN a permis de mettre en évidence une distinction entre les deux groupes de souches, confirmée sur une collection indépendante de souches. De plus, une fonction linéaire simplifiée, basée sur seulement 8 marqueurs génétiques, a permis d'obtenir des performances similaires, sur la collection de souches initiale ainsi que la collection indépendante de validation. En dernier lieu, les souches d'EI et de bactériémie ont été comparées à partir de séquences du génome complet (n = 40 (20 EI, 20 bactériémies)). L'analyse statistique par analyse discriminante en composante principale réalisée sur ces données génomiques confirme une distinction possible entre les deux groupes de souches. Au total, ces travaux de thèse apportent la preuve de concept que les facteurs bactériens sont impliqués dans la survenue de l'EI au cours de bactériémie à S. aureus / Infective endocarditis (IE) is a severe condition complicating 10-25% of Staphylococcus aureus bacteremia. Although host-related IE risk factors have been identified, the involvement of bacterial features in IE complication is still unclear. This PhD work aimed to characterize strictly defined IE and bacteremia isolates and searched for discriminant features. Phenotypic traits previously reported or hypothesized to be involved in staphylococcal IE pathogenesis were tested. In parallel, the genotypic profiles of all isolates, obtained by microarray, were analyzed. No significant difference was observed between IE and bacteremia strains, regarding either phenotypic or genotypic univariate analyses, suggesting a multifactorial process. However, the discriminant analysis of principal components (DAPC), applied on microarray data, segregated IE and bacteremia isolates. The performance of this model was confirmed with an independent collection of IE and bacteremia isolates. Finally, a simple linear discriminant function based on a subset of 8 genetic markers retained valuable performance both in study collection and in the independent validation collection. At last, IE and bacteremia isolates were compared based on whole genome sequence data from a subset of 40 isolates. When applied to this dataset, DAPC confirmed a possible segregation between the two groups of isolates. All in all, this PhD work provides the proof of concept that bacterial characteristics may contribute to the occurrence of IE in patients with S. aureus bacteremia

Microorganismos da cavidade oral têm sido admitidos como causadores de doenças sistêmicas com reconhecido mecanismo de disseminação via corrente sangüínea. Diferentes fatores, incluindo a presença da doença periodontal, têm influência no risco de bacteremia oral, podendo ocasionar endocardite infecciosa por Streptococcus viridans. Sendo assim, a manutenção da saúde bucal adquire elevado grau de importância em gestantes portadoras de doença valvar reumática, em que o risco de endocardite infecciosa é eminente. A escassez científica fez deste tema o objetivo deste estudo: investigar a condição clínica periodontal de gestantes portadoras de cardiopatia valvar, identificando agentes periodontopatógenos nas amostras coletadas de saliva, sulco/bolsa periodontal, Para tanto, foram estudadas 52 gestantes cardiopatas (GC) e 70 gestantes não-cardiopatas (GNC). A condição periodontal foi avaliada empregando-se profundidade clínica de sondagem (PCS), nível clínico de inserção (NCI), linha esmalte cemento/margem gengival (LEC/MG), índice de sangramento (IS) e índice de placa bacteriana (IP). As seguintes médias foram obtidas para os parâmetros periodontais avaliados: PCS: 1.52 (GC) e 1.45 (GNC); NCI: 1.13 (GC) e 1.02 (GNC); LEC/MG: 0.41 (GC) e 0.40 (GNC); IS: 7.34 (GC) e 6.27 (GNC) e IP: 12.19 (GC) e 13.48 (GNC). Não houve diferença entre os grupos para o NCI (p= 0,612). A presença da Porphyromonas gingivalis na saliva foi maior (p= 0,007) no GNC, porém não houve diferença nas amostras de sulco/bolsa periodontal. / Microorganisms of the oral cavity are known to cause systemic diseases, spread through sanguine current. Different factors, including the presence of periodontal disease, influencing the risk of oral bacteremia could cause infectious endocarditis for Streptococcus viridans. Nevertheless, the maintenance of the oral health is extremely important in pregnant women with rheumatic valvar disease, in which the risk of infectious endocarditis is eminent. The aim of this study was to investigate the clinical periodontal condition of pregnant women with valvar disease and to identify the presence of Porphyromonas gingivalis in saliva and subgingival samples. For these purposes, we studied 52 pregnant with valvar disease (GC) and 70 healthy pregnant women (GNC). The following periodontal parameters were evaluated: probing depth (PCS), clinical attachment level (NCI), gingival margin location (LEC/MG), bleeding on probing (IS) and plaque index (IP). The following mean periodontal parameters were obtained: PCS: 1.52 (GC) e 1.45 (GNC); NCI: 1.13 (GC) e 1.02 (GNC); LEC/MG: 0.41 (GC) e 0.40 (GNC); IS: 7.34 (GC) e 6.27 (GNC) e IP: 12.19 (GC) e 13.48 (GNC). There was no statistical difference for NCI among the groups. There was no difference between periodontal clinical conditions in pregnant women with valvar disease and healthy pregnant women. The presence of the Porphyromonas gingivalis in saliva samples of healthy pregnant women is statistically higher than in pregnant woman with valvar disease; however, there was no difference in periodontal samples

A Febre Reumática, complicação tardia de uma infecção de orofaringe causada pelo Streptococcus pyogenes (estreptococo -hemolítico do grupo A de Lancefield), tem como conseqüência a Cardiopatia Reumática, explicada pelo mimetismo molecular entre proteínas cardíacas humanas e a associação de proteínas e carboidratos da membrana do S. pyogenes. A profilaxia secundária com a PGB 1.200.000 UI IM propõe-se a evitar novos surtos, sendo administrada em intervalos de vinte e um dias nos países com alto índice de estreptococcia. A lesão valvar predispõe à Endocardite Infecciosa, que resulta de bacteriemias causadas por focos infecciosos de origem bucal em cerca de 40% dos casos. Os Streptococcus Viridans constituem o grupo mais comumente encontrado nas Endocardites Infecciosas, em especial os Streptococcus sanguinis e Streptococcus oralis. O efeito do uso crônico da PGB não foi estudado com especificidade para essa microbiota. Assim, foi avaliada, qualitativa e quantitativamente, a microbiota bucal de 100 pacientes, aos 7 e 21 dias, após profilaxia secundária para a Febre Reumática com a PGB 1.200.000 UI IM e comparada com a de 100 pacientes portadores de doença arterial coronariana sem antecedentes de Febre Reumática. As espécies avaliadas foram divididas em S. sanguinis, S. oralis e outras espécies de Streptococcus Viridans Foram coletadas amostras de saliva pela mastigação de goma de parafina e transportadas em meio VMGA II S. As culturas foram semeadas em ágar Columbia CNA com 5% de sangue desfibrinado puro de carneiro com acréscimo de penicilina G. e incubadas a 35ºC em estufa de CO2 por 72 horas. As colônias sugestivas de Streptococcus foram submetidas a testes bioquímicos para confirmação de gênero e espécie. A concentração inibitória mínima foi determinada pelo método Etest e interpretada segundo os padrões do Clinical and Laboratory Standards Institute. Não houve diferença quanto à presença do S. sanguinis nos grupos estudados (P=0,40). O S. oralis prevaleceu aos 7 dias de PGB em relação ao grupo controle (P=0,01). Quanto à identificação de outras espécies, houve maior número de cepas nos pacientes do grupo controle quando comparados aos do grupo de estudo aos 7 e 21 dias de PGB (P<0,001). Os números de UFC/ml de S. sanguinis, S. oralis e de outras espécies foram comparados entre os grupos e não houve diferença entre eles (P=0,96; P=0,60 e P=0,77; respectivamente). Quanto às CIM do S. sanguinis e do S. oralis, não houve diferença entre os grupos (P=0,79 e P=0,13; respectivamente). Todos os testes estatísticos foram realizados em um nível de significância de 5%. Concluiu-se que o S. oralis prevaleceu aos 7 dias de PGB 1.200.000 UI IM; os Streptococcus Viridans de outras espécies prevaleceram no grupo controle; o número de UFC/mL de saliva não diferiu nos grupos estudados, a susceptibilidade dos S. sanguinis e S. oralis à penicilina G não foi alterada pela ação da PGB 1.200.000 UI IM a cada 21 dias e, por fim, a PGB não provocou reações de hipersensibilidade em nenhum paciente do estudo / Rheumatic fever is the result of a Streptococcus pyogenes (group A -hemolytic Streptococcus) infection of the upper respiratory tract. Rheumatic heart disease is a rheumatic fever consequence and is elucidated by the molecular mimicry between human cardiac proteins and group A streptococcal proteins and carbohydrates association. The secondary prophylaxis with 1,200,000 U BPG every three weeks is used for prevention of recurrent rheumatic fever in developing countries. Valvar defects are a risk for infective endocarditis which is resulted of bacteriemia caused for oral infectious focuses in 40% of cases. Viridans streptococci are the predominant group recovered in infective endocarditis, specially Streptococcus sanguinis and Streptococcus oralis. The effect of chronic BPG wasnt studied with specificity to these pathogens yet. Therefore, the oral microbiota was evaluated, qualitatively and quantitatively, at 7 and 21 days after secondary prophylaxis with BPG to rheumatic fever (study group), in a hundred patients and in comparison to another hundred patients with coronary heart disease who never acquired rheumatic fever (control group). The species evaluated were divided in S. sanguinis, S. oralis and another Streptococcus species. It was collected samples of chewing-stimulated saliva (1ml) and transported in VMGA II S medium. The samples were cultured in pure and with penicillin G 5% sheep blood Columbia ágar (CNA), incubated for 72 hours in an atmosphere containing 5% CO2 at 35ºC. The strains that were suggestive to Streptococcus were identified by biochemical tests to confirm bacteria species and genus. Minimal inhibitory concentration was determined by Etest method and interpreted in accordance to Clinical and Laboratory Standards Institute. The results showed that there was no difference in S. sanguinis presence in all groups (P=0.40). S. oralis prevailed in 7 days BPG group in comparison to control group (P=0.01). The control group showed the highest number of others species in comparison to 7 and 21 days BPG (P<0.001). CFU/ml numbers of S. sanguinis, S. oralis and other species strains were compared in 7 and 21 days BPG to control group and there was no difference among themselves (P=0.96, P=0.60 and P=0.77; respectively). There was no difference in S. sanguinis and S. oralis MICs among the study and control groups (P=0.79 and P=0.13). All statistic tests were done at 5% significance level. It was concluded that S. oralis prevailed in 7 days BPG group in comparison to control group; other species of Viridans streptococci prevailed in control group. The number of CFU/mL did not differ in both studied groups; the penicillin susceptibility of S. sanguinis and S. oralis did not change by BPG every three weeks and, by the end, it was not observed hypersensitivity reactions to penicillin in neither of the patients of this study

Einleitung Streptococcus (S.) suis verursacht bei Schweinen unter anderem Meningitis, Arthritis, Serositis und Endokarditis und ist eine der größten Herausforderungen für die Schweineindustrie. Von 29 beschriebenen Serotypen sind die Serotypen 2, 7 und 9 unter invasiven Isolaten weltweit besonders prävalent, vor allem in Europa. Bis heute gibt es keinen zugelassenen Impfstoff zur Prävention von S. suis-Erkrankungen in Europa, daher ist im Feld die Anwendung stallspezifischer Impfstoffe verbreitet. Diese bieten jedoch höchstens homologen Schutz und ihre Wirkung kann durch prädisponierende Faktoren wie eine Infektion mit dem porcine reproductive and respiratory syndrome Virus (PRRSV) beeinträchtigt werden. Daher hat sich die Forschung auf Antigene fokussiert, die potentiell heterologen Schutz vermitteln. Zielstellung Ziele der Studie waren die Charakterisierung vernachlässigter invasiver S. suis Pathotypen der wichtigen Serotypen 7 und 9 und die Etablierung neuer Infektionsmodelle im Schwein. Des Weiteren sollte die immunogene und protektive Wirkung des Immunoglobulin (Ig) M-degradierenden Enzyms von S. suis, IdeSsuis, im Serotyp 9 Infektionsversuch untersucht werden. Material und Methoden In dieser Arbeit wurden in vitro Versuche und experimentelle Infektionen im Schwein durchgeführt. Dazu gehörte die Geno- und Phänotypisierung von 22 S. suis Serotyp 7 Stämmen und vier Serotyp 9 Stämmen. Die Genotypisierung erfolgte mittels multiplex (MP) Polymerase-Kettenreaktion (PCR), einer PCR zur Differenzierung verschiedener Genvarianten des muramidase-release protein (MRP) sowie mittels multilocus sequence typing (MLST). Zur Phänotypisierung der S. suis Stämme wurden bactericidal assays eingesetzt, die als Bakteriämiemodell fungierten. Auf diese Weise konnten die Empfänglichkeit gegenüber S. suis Stämmen sowie deren Virulenz beurteilt werden. Durch Zugabe von rekombinantem (r) IdeSsuis wurde die Rolle adaptiven IgMs in der Begrenzung der Bakteriämie untersucht. Anhand von Western Blot Analysen erfolgte die Untersuchung der Expression und Funktionalität von IdeSsuis sowie die Expression von MRP in S. suis Serotyp 7 Stämmen. Enzyme-linked immunosorbent assays (ELISA) kamen zum Einsatz, um die Entwicklung von IgM und IgG Spiegeln in Ferkeln im zeitlichen Verlauf und die IgG Spiegel nach rIdeSsuis Immunisierung zu messen. Durch rIdeSsuis Immunisierung induzierte Antigen-spezifische T-Helferzellen (Th-Zellen) wurden mithilfe der Durchflusszytometrie untersucht. Schließlich erfolgte die Durchführung zweier S. suis Serotyp 7 Etablierungsversuche mit je 18 bzw. 5 Ferkeln sowie zwei S. suis Serotyp 9 Impf- und Infektionsversuche mit je 18 Ferkeln. Sektionsproben wurden histologisch untersucht. In einem Fall wurde eine Endokarditis mittels fluorescence in situ hybridization (FISH) charakterisiert. Ergebnisse Die meisten untersuchten Serotyp 7 Stämme gehörten dem Sequenztyp (ST) 29 an, einem emerging pathotype in Europa. Trotz der engen phylogenetischen Verwandtschaft, war mrp in den Stämmen sehr variabel. Phänotypisch bildeten alle Stämme gleichermaßen eine kleine MRP Variante, MRPs. Für vier ausgewählte Serotyp 7 Stämme wurde die Expression von IdeSsuis gezeigt, jedoch mit Unterschieden in Größe und Funktionalität. Bactericidal assays dieser vier Stämme zeigten starke Proliferation im Blut von Absatzferkeln, aber Abtöten im Blut von Läuferschweinen aus zwei Herden mit unterschiedlichem S. suis Status. Dieses Überlebensmuster unterschied sich deutlich von dem eines Serotyp 9 Stammes. Durch Zugabe von rIdeSsuis, konnte gezeigt werden, dass das Abtöten der Serotyp 7 Stämme im Blut von Läuferschweinen des infizierten Bestandes IgM-vermittelt war. Unabhängig von der Herkunft entwickelten sich die IgM Spiegel in den Ferkeln im zeitlichen Verlauf fast synchron. Schließlich konnte die Virulenz eines Serotyp 7 Stammes in einem intravenösen Infektionsversuch mit 5 Ferkeln gezeigt werden. Alle Tiere entwickelten schwere Symptome einer S. suis Erkrankung. In einem Impf- und Infektionsversuch mit einem hoch virulenten Serotyp 9 Stamm wurde die immunogene und protektive Wirkung einer rIdeSsuis Immunisierung untersucht. Neun Ferkel wurden mit rIdeSsuis oder einem Placebo prime-boost-boost immunisiert und zwei Wochen später infiziert. Neunzig Prozent der Placebotiere entwickelten schwere Symptome einer S. suis Erkrankung und starben oder mussten aus Tierschutzgründen euthanasiert werden. Alle geimpften Tiere überlebten den Versuch, fielen jedoch mit Fieber und Lahmheiten auf. Es konnte also gezeigt werden, dass eine rIdeSsuis Immunisierung vor Mortalität, nicht aber Morbidität durch den Infektionsstamm schützt. Alle immunisierten Ferkel serokonvertierten und Antigen-spezifische Th-Zellen wurden nachgewiesen. Weder die IgG Antwort noch die Th-Zell Antwort wurde jedoch durch die Infektion verstärkt. In einem weiteren Impf- und Infektionsversuch mit einem anderen Serotyp 9 Stamm fiel ein Tier am 11. Tag nach der Infektion mit Zeichen einer akuten Leptomeningitis auf, nachdem es zuvor klinisch völlig unauffällig war. In der Sektion des Tieres wurde eine Endokarditis der Mitralklappe diagnostiziert, die mit Biofilm-Bildung assoziiert war, was mithilfe von Histologie und FISH gezeigt werden konnte. Zusätzlich wurde eine fibrinopurulente Leptomeningitis diagnostiziert. Das Ferkel hatte Antikörper gegen rIdeSsuis und tötete den Infektionsstamm ex vivo im Blut ab. Schlussfolgerungen In dieser Arbeit habe ich zwei wichtige S. suis Pathotypen charakterisiert: S. suis Serotyp 7 Stämme des ST29 und einen hoch virulenten Serotyp 9 Stamm vom ST94. Die Serotyp 7 Stämme stellten einen besonderen Pathotypen dar, bei dessen Bekämpfung IgM eine wichtige Rolle spielt. Bei einer Serotyp 9 Infektion konnten trotz des Abtötens der Bakterien im Blut und opsonisierender Antikörper Biofilmbildung und eine folgende akute Leptomeningitis nicht verhindert werden. Letztlich wurde Schutz vor einem hoch virulenten Serotyp 9 Stamm durch rIdeSsuis Immunisierung und damit zum ersten Mal für ein Antigen Protektion vor den wichtigen Serotypen 2 und 9 aufgezeigt. Dies ist ein vielversprechendes Ergebnis hinsichtlich der Entwicklung eines Impfstoffes gegen S. suis. / Introduction Streptococcus (S.) suis causes meningitis, arthritis, serositis and endocarditis and is one of the biggest challenges for the swine industry. Of 29 described serotypes, the serotypes 2, 7 and 9 are highly prevalent amongst invasive S. suis isolates worldwide, especially in European countries. To date, no commercially produced vaccine is available in Europe for prevention of S. suis disease, thus the use of autogenous vaccines in the field is common. However, bacterins may at most confer homologous protection and their efficacy may be influenced by predisposing factors such as an infection with the porcine reproductive and respiratory syndrome virus (PRRSV). Research has therefore focused on subunit vaccines with the potential to elicit cross-protection against various serotypes. Aim of the study The objective of this study was to characterize neglected invasive S. suis pathotypes of the important serotypes 7 and 9 and to establish infection models in the main host of S. suis, the pig. A further aim was to investigate immunogenicities and protective efficacies of the immunoglobulin (Ig) M-degrading enzyme of S. suis, IdeSsuis, in a serotype 9 challenge experiment. Materials and methods In vitro experiments and experimental challenges in swine were conducted as part of this thesis. This included the geno- and phenotyping of 22 S. suis serotype 7 strains and four serotype 9 strains. Genotyping was conducted using a multiplex (MP) polymerase chain reaction (PCR), a PCR for differentiation of variants of the muramidase-released protein (MRP) gene and multilocus sequence typing (MLST). For phenotyping of the S. suis strains, bactericidal assays were carried out which served as a model for bacteraemia. This way, susceptibility to S. suis strains and virulence of different strains was assessed. Further, through addition of recombinant (r) IdeSsuis, the role of adaptive IgM in limiting bacteraemia was elucidated. Western blot analyses were conducted to investigate expression and functionality of IdeSsuis as well as expression of MRP in S. suis serotype 7 strains. Enzyme-linked immunosorbent assays (ELISA) were used to determine the development of IgM and IgG levels in piglets over time and to assess IgG levels following rIdeSsuis immunization. Antigen-reactive T-helper (h) cells induced by rIdeSsuis immunization were investigated using flow cytometry. Finally, two experiments to establish a serotype 7 infection model with 18 and 5 piglets each and two vaccination and challenge experiments using different S. suis serotype 9 strains (n=18 piglets/ experiment) were conducted. Samples of dissected animals were examined histologically. In one case, an endocarditis was analysed using fluorescence in situ hybridization (FISH). Results Most of the investigated serotype 7 strains belonged to sequence type (ST) 29 which was thus shown to be an emerging pathotype in Europe. Despite the close phylogenetic relation of the strains, mrp was highly variable. Phenotypically, all strains expressed a small variant of MRP, MRPs. Four selected serotype 7 strains were shown to express IdeSsuis with differences in size and functionality. Bactericidal assays of these four strains revealed high proliferation in blood of weaning piglets but killing in blood of growing piglets of two herds which differed in their S. suis infection status. This survival pattern was distinct from a serotype 9 strain. Addition of rIdeSsuis revealed that killing of the serotype 7 strains in blood of growing piglets of the infected herd was IgM-mediated. Independent of the originating herd, IgM levels of the piglets rose almost synchronous over time. Finally, the virulence of a serotype 7 strain was proven in an intravenous challenge experiment with five pigs which all developed severe clinical signs of S. suis disease. In a vaccination and challenge experiment using a highly virulent serotype 9 strain, immunogenicities and protective efficacies of rIdeSsuis immunization were investigated. Nine piglets were prime-boost-boost vaccinated with rIdeSsuis or placebo-treated and challenged two weeks later. Ninety per cent of the placebo-treated piglets developed severe clinical signs of S. suis disease and died or had to be euthanized due to animal welfare reasons. All vaccinated piglets survived the experiment, however elevated body temperatures and lameness were also noted in this group. Accordingly, rIdeSsuis vaccination protected from mortality but not morbidity caused by the challenge strain. Seroconversion of the immunized piglets and antigen-reactive Th cells were detected. Neither the IgG response nor the Th cell response was boosted through the challenge. In a further vaccination and challenge experiment with a different serotype 9 strain, one animal was clinically unobtrusive following infection and then developed an acute leptomeningitis on the 11th day post infection and had to be euthanized. Dissection of the animal revealed an endocarditis on the mitral valve which was proven to be associated with biofilm formation by histology and FISH. In addition, a fibrinosuppurative leptomeningitis was diagnosed. The piglet had specific antibodies against rIdeSsuis and mediated killing of the challenge strain in a bactericidal assay. Conclusions In this thesis, I characterized two important pathotypes: S. suis serotype 7 strains of ST29 and a highly virulent serotype 9 strain of ST94. The serotype 7 strains represent a distinct pathotype and IgM plays a significant role in their control. Following a serotype 9 infection, biofilm formation and a subsequent acute leptomeningitis could not be prevented despite blood bactericidal activity and opsonizing antibodies. Finally, protection against challenge with a highly virulent serotype 9 strain through rIdeSsuis immunization was demonstrated. Thereby, for the first time an antigen was shown to confer cross-protection against the important serotypes 2 and 9, which is highly encouraging regarding the development of a vaccine against S. suis.

O objetivo desse estudo foi avaliar os efeitos da administração prévia de antibiótico na incidência de complicações infecciosas em procedimentos de estimulação cardíaca artificial. Os pacientes foram selecionados em um estudo duplo-cego e randomizado (1:1). Grupo I Cefazolina (1,0g dose única) versus grupo II placebo. O comitê de segurança interrompeu o estudo após a inclusão de 649 pacientes devido à diferença entre os grupos (group I 314; grupo II 335 pacientes) em favor do uso de antibiótico: 2 infectados (0,63%) versus 11 infectados no grupo placebo (3,28%); p=0,016. Marcadores identificados por análise univariada: não uso de antibiótico; procedimentos de implantes (versus trocas); hematoma pós-operatório e duração do procedimento. O não uso de antibiótico e hematoma pós-operatório foram significantes em análise multivariada / The objective of this study was to evaluate the effects of the previous venous antibiotic administration in the incidence of infectious complications in cardiac stimulation surgical procedures. Patients were selected in a double blind, randomized (1:1) trial. Group I Cefazolin (1,0g one dose) versus group II placebo. The security committee interrupted the trial after inclusion of 649 patients due to differences between groups (group I 314; group II 335 patients) in favor of the antibiotic arm: 2 infected patients (0,63%) versus 11 infected patients in the placebo arm (3,28%); p=0,016. Markers identified by univariate analysis: non-use of preventive antibiotic; implant procedures (versus replacement); post-operative haematoma and procedure duration. The non-use of antibiotic and the post-operative haematoma were independent predictors of infection in multivariate analysis

Made available in DSpace on 2011-11-09T14:45:44Z (GMT). No. of bitstreams: 2 license.txt: 1648 bytes, checksum: e095249ac7cacefbfe39684dfe45e706 (MD5) 000239.pdf: 1746615 bytes, checksum: b1538d716409c5efb4a08da0bc08f73d (MD5) Previous issue date: 2008 / Fundação Oswaldo Cruz. Instituto Fernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil / Objetivo: avaliar a evolução clínica, morbidade e mortalidade de crianças e adolescentes portadores de cardiopatia reumática em acompanhamento ambulatorial num centro terciário. Material e Métodos: estudo descritivo observacional longitudinal de base hospitalar. Foi realizada análise de prontuários de pacientes com 3-18 anos, acompanhados por no mínimo 2 anos no ambulatório do Instituto Nacional de Cardiologia no Rio de Janeiro. O diagnóstico foi confirmado pelos critérios de Jones e/ou exame ecocardiográfico com lesão reumática típica mitral e/ou aórtica. Banco de dados foi elaborado com o programa ACCESS 2000, e a análise estatística realizada com o programa EPI-INFO 2000. Foi considerado significativo o valor de α- 0,05. Resultados:139 prontuários foram incluídos no estudo. A mediana da idade no início do seguimento foi de 11 anos, 52,6% eram do sexo feminino. Quanto à forma de apresentação clínica 45,3% estavam no primeiro surto, 14,4% em recidiva e 40,3% na fase crônica. A mediana de idade dos pacientes crônicos e em recidiva era superior aos pacientes do primeiro surto de febre reumática (p-0,0001). O tempo médio de seguimento foi de 9,9 anos (2-21 anos). A lesão valvar predominante foi a insuficiência mitral (82,7%), seguida da insuficiência aórtica (55,9%) e da insuficiência mitro-aórtica em 45,3% dos casos. Houve redução importante dos percentuais de lesões valvares graves - tanto mitrais como aórticas - ao final do seguimento.Recidivas foram evidenciadas em 32,3%. Pacientes com profilaxia irregular ou sem profilaxia apresentaram a média do número total de surtos (2,4 surtos por paciente) superior a do grupo em profilaxia regular (1,4 surtos por paciente), com diferença entre os grupos estatisticamente significante (p-0,0009).A mortalidade foi de 4,3% (n=6) Todos os pacientes que evoluíram para óbito eram portadores de próteses valvares. O abandono de tratamento foi de 10,8%, sendo que 1,4% desses pacienteseram portadores de próteses mecânicas (n-=2). Procedimentos intervencionistas foram realizados em 45,3% dos pacientes - valvuloplastia por cateter balão em 2,9% e cirurgia cardíaca valvar em 42,4%. Reoperação foi necessária em 8,6% (2ª cirurgia) e 2,8% (3ª cirurgia). O procedimento mais realizado foi o implante de prótese mecânica mitral (31,3%), seguido por prótese mecânica aórtica (20,9%) e plastia mitral (18,6%). A endocardite infecciosa foi evidenciada em 8,6%, sendo a endocardite de prótese em 3,6%, responsável por 50% da mortalidade desta amostra, com letalidade de 25%. Outrascausas de mortalidade incluíram estenose grave de prótese biológica (n=1), estenose grave de prótese mecânica (n=1) e trombose de prótese biológica (n=1). / Objective: to investigate the outcome, mortality and morbidity of children and adolescents with rheumatic heart disease followed up in an outpatient care unit of a terciarie center. Methods– descriptive longitudinal observational study of an hospitalar based population. Medical file of patients – 3 to18 years old - with rheumatic heart disease, followed-up for at least 2 years from in the outpatient care unit of the National Cardiology Institute (InstitutoNacional de Cardiologia) in Rio de Janeiro were reviewed. Diagnosis were confirmed through medical file register of the revised Jones criteria for rheumatic fever and/or Doppler echocardiographic report of typical chronic mitral or aortic lesions. Database program ACCESS 2000, statistical analysis was performed using EPI-INFO 2000 software, with significant αvalue 0,05. Results–139 medical files were reviewed. Median age at the first visit to the service was 11 years, 52,5% were female. At the first exam, 45,3% presented with acute rheumatic fever- first attack, 14,4% recurrence; while 40,3% had chronic valvular lesions. Median age of the chronic and recurrent group was greater than median age of the first attack group (p-0,0001). Mean follow-up time was 9,9 years (2 to 21 years). Mitral regurgitation was the most common valvular lesion (82,7%), followed by aortic regurgitation (55,9%) and combined mitral and aortic regurgitation (45,3%). There was a significant percent decrease in severe valvular lesions - both mitral and aortic – at the end of follow-up period. Recurrences were present in 32,3% of cases. There was a significant difference (p-0,0009) between the mean rate of the total number of attacks of patients under irregular or no prophylaxis (2,4 attacks / patient) compared with patients under regular prophylaxis (1,4 attacks / patient). Mortality rate were 4,3% (n=6). All these patients that died had prosthesis. 10,8% were lost of follow-up - 1,4% of these patients had mechanical prostheses (n=2). 45,4% underwent valve procedures: 2,9% balloon dilatation and 42,4% valve surgery. Reoperation wererequired by 8,6% (2 nd surgery) and rereoperation by 2,8% (3 rd surgery). The most common surgical procedure was mitral valve replacement with mechanical prosthesesimplantation (31,3%), followed by aortic valve replacement with mechanical prostheses implantation (20,9%) and mitral valve repair (18,6%). A total of 8,6% presented with endocarditis - 3,6% had prosthetic valve endocarditis, that accounted for 50% mortality of this group, and for a letality rate of 25%.Another causes of death included severe bioprosthesis stenosis (n=1), severe mechanical prosthesis stenosis (n=1) and bioprosthesis valve trombosis (n=1).