Diss. (sammanfattning) Stockholm : Karolinska institutet, 2002. / Härtill 4 uppsatser.

Lic.-avh. (sammanfattning) Stockholm : Karolinska institutet, 2009.

Orientador: Carlos Magno Castelo Branco Fortaleza / Resumo: Microrganismos multidroga-resistentes (MDR) tem se disseminado em hospitais, e apresentam potencial de transmissão em serviços não hospitares e saúde e mesmo na comunidade. Partindo deste princípio, desenvolvemos um estudo de metodologia mista de base individual e ecológica. O estudo foi conduzido no Hospital Estadual Bauru e distribuiu-se, resumidamente, em três etapas: (i) identificação de preditores para infecções por MDR com origem na comunidade (Community-onset [CO]-MDR); (ii) georreferenciamento e estudo da proximidade de domicílios de sujeitos com CO-MDR e outros que receberam alta hospitalar enquanto carreados de agente MDR (Retornando à Comunidade, RC) a serviços de saúde de complexidades diversas. No primeiro estudo, de delineamento caso-controle, identificamos internação prévia (com mais de seis meses de antecedência do diagnóstico) e doença pulmonar como fatores de risco para CO-MDR. Esses fatores apresentaram diferenças entre Gram-positivos e Gram-negativos. Já no segundo estudo, foi possível constatar a proximidade de domicílios de sujeitos dos grupos CO e RC com serviços de saúde, fossem eles Unidades Básicas (UBS), hospitais ou ambulatórios de especialidade. Em geral, quando comparados ao Methicillin-resistant Staphylococcus aureus (MRSA), outros agentes apresentavam maior dispersão em torno dos serviços de saúde. Os dados sugerem, ainda que indiretamente, a possibilidade de transmissão de microrganismos multidrogra-resistentes em espaços comunitários ou de as... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Multidrug-resistant microorganisms (MDR) have spread in hospitals, and have a potential for transmission in non-hospital healthcare settings and even in the community. This study was conducted in Bauru State Hospital and was distributed in three stages: (i) identification of predictors for community-onset MDR infections (CO-MDR); (ii) georeferencing and study of the proximity of CO-MDR and others who are discharged while harboring MDR (Returning to the Community, RC) to health services of diverse complexities.In the first case-control study, we identified previous hospitalization (with more than six months of the diagnosis) and pulmonary disease as risk factors for CO-MDR. These factors showed differences between Gram-positive and Gram-negative pathogens. In the second study, it was possible to verify the proximity of households of CO and RC subjects to health services, whether they were Basic Units (BHU), hospitals or specialty outpatient clinics. In general, when compared to Methicillin-resistant Staphylococcus aureus (MRSA), other agents were more dispersed around health services. The data suggest, albeit indirectly, the possibility of transmission of multidrug-resistant microorganisms in community or non-hospital care spaces. / Mestre

Decentralisation of the multidrug resistant tuberculosis (MDR TB) programme to primary health care (PHC) facilities in the Nelson Mandela Metropolitan was implemented in order to improve the effectiveness of MDR TB services. This study explored the knowledge gaps of nurses at PHC facilities as regards MDR TB. A quantitative, cross-sectional descriptive study was conducted; data was collected using a structured questionnaire. Non-probability sampling was applied in this study. A convenient sampling technique was used and 25 of the 42 facilities were selected. Thirty-two respondents completed the questionnaire with a response rate of 64%. Descriptive statistics were used to describe the data. Only 38% of the nurses had been trained on MDR TB. Overall scores were high with a mean knowledge score of 61%. However there were knowledge gaps regarding side effects of MDR TB medication. This study revealed gaps in knowledge of certain areas of MDR TB management / Health Studies / M.A. (Public Health)

abstract: The emergence of invasive non-Typhoidal Salmonella (iNTS) infections belonging to sequence type (ST) 313 are associated with severe bacteremia and high mortality in sub-Saharan Africa. Distinct features of ST313 strains include resistance to multiple antibiotics, extensive genomic degradation, and atypical clinical diagnosis including bloodstream infections, respiratory symptoms, and fever. Herein, I report the use of dynamic bioreactor technology to profile the impact of physiological fluid shear levels on the pathogenesis-related responses of ST313 pathovar, 5579. I show that culture of 5579 under these conditions induces profoundly different pathogenesis-related phenotypes than those normally observed when cultures are grown conventionally. Surprisingly, in response to physiological fluid shear, 5579 exhibited positive swimming motility, which was unexpected, since this strain was initially thought to be non-motile. Moreover, fluid shear altered the resistance of 5579 to acid, oxidative and bile stress, as well as its ability to colonize human colonic epithelial cells. This work leverages from and advances studies over the past 16 years in the Nickerson lab, which are at the forefront of bacterial mechanosensation and further demonstrates that bacterial pathogens are “hardwired” to respond to the force of fluid shear in ways that are not observed during conventional culture, and stresses the importance of mimicking the dynamic physical force microenvironment when studying host-pathogen interactions. The results from this study lay the foundation for future work to determine the underlying mechanisms operative in 5579 that are responsible for these phenotypic observations. / Dissertation/Thesis / Masters Thesis Biology 2016

Orientador: Antonio Carlos Paes / Resumo: A tuberculose causada por Mycobacterium bovis (bTB) é uma zoonose de distribuição mundial com ampla gama de hospedeiros. Nos países onde a bTB é prevalente, 10 a 20% dos casos de tuberculose humana são causados por M. bovis. São escassos em todo o mundo estudos que investigam a resistência à isoniazida (INH) e rifampicina (RMP) em linhagens de M. bovis de origem bovina, reservatórios silvestres, e em casos humanos de tuberculose. Foi investigada a diversidade genotípica de 67 linhagens de M. bovis isoladas de bovinos de abatedouro, obtidas de 100 linfonodos com lesão caseosa, pelas técnicas de Spoligotyping e MIRU-VNTR, bem como foi determinado o perfil fenotípico de resistência à INH e RMP pela técnica de REMA, e pesquisadas possíveis bases genéticas para resistência aos antimicrobianos. Dentre os isolados, 11 (16%) foram classificados como MDR-TB, 8 (12%) resistentes à INH e 2 (3%) resistentes à RMP. A pesquisa pelo GenoType MTBDRplus ver. 2.0 não acusou a presença de mutações em nenhum dos isolados fenotipicamente resistentes. Foram identificados 16 spoligotipos entre as linhagens. A subfamília BOV_1 predominou com 52 (77,6%) isolados, com os SIT 481, 482, 594, 665, 691, 698, 1021, 1667, 1852, 2141 e dois isolados sem shared type. A BOV_2 foi identificada em 8 (11,9%) isolados, com o SIT 683. Os SIT 982, 1851 e 1853 foram agrupados na família BOV. Dois isolados não foram classificados em família ou subfamília. A análise de MIRU-VNTR com painel de 12 MIRUs, identificou 31 i... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Tuberculosis caused by Mycobacterium bovis (bTB) is a zoonosis of worldwide distribution with broad host range. In countries where bTB is prevalent, 10-20% of the human cases of tuberculosis are caused by M. bovis. All over the world there are few studies investigating the resistance to isoniazid (INH) and rifampicin (RMP) in M. bovis strains from cattle, wild reservoirs, and human cases of tuberculosis. The genotypic diversity of 67 M. bovis strains obtained out of 100 lymph nodes with caseous lesions from slaughtered animals was investigated by Spoligotyping and MIRU-VNTR techniques, as well as the assessment of their phenotypic profile of resistance to INH and RMP by REMA method and the search of possible genetic basis for antimicrobial resistance. Among the obtained isolates, 11 (16%) were classified as MDR-TB, 8 (12%) INH-resistant and 2 (3%) RMP-resistant. The use of GenoType MTBDRplus ver. 2.0 did not pointed the presence of genetic mutations in any of the phenotypically resistant isolates. Sixteen different spoligotype patterns were identified. The BOV_1 subfamily predominated with 52 (77.6%) isolates, with SITs 481, 482, 594, 665, 691, 698, 1021, 1667, 1852, 2141 and two isolates without a given SIT. BOV_2 was identified in 8 (11.9%) isolates, within SIT 683. The SITs 982, 1851 and 1853 were grouped in BOV family. Two isolates were not classified in family or subfamily. The MIRU-VNTR analysis using the 12 classical MIRUs, identified a cluster of 31 isolates belonging... (Complete abstract click electronic access below) / Doutor

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-03-16T21:40:17Z No. of bitstreams: 2 Tese - Lara Stefânia Netto de Oliveira Leão Vasconcelos - 2013.pdf: 3438615 bytes, checksum: 0860846b3615244c0123e230f0e5c789 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-03-16T21:41:52Z (GMT) No. of bitstreams: 2 Tese - Lara Stefânia Netto de Oliveira Leão Vasconcelos - 2013.pdf: 3438615 bytes, checksum: 0860846b3615244c0123e230f0e5c789 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-03-16T21:41:52Z (GMT). No. of bitstreams: 2 Tese - Lara Stefânia Netto de Oliveira Leão Vasconcelos - 2013.pdf: 3438615 bytes, checksum: 0860846b3615244c0123e230f0e5c789 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-03-28 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / The health care environment presents numerous risks making it anharmful place, propitious to colonization and development of infections. Inserted in this scenario are the healthcare workers which are vulnerable to the carrier condition. and the oral cavity represents an important site of colonization. This study aimed to characterize the phenotype of Enterobacteriaceae isolated from the oral cavity of healthcare workers from an oncologic reference hospital in the central area of Brazil. We also aimed to detect co-colonization by Staphylococcus and Pseudomonas, as well as describe the profile socio-demographic, professional, disease/infection and behavioral of individuals colonized by Enterobacteriaceae. It was a descriptive cross-sectional epidemiological study conducted from May/2009 to November/2010 and saliva was collected a from each subjected. A total of 294 individuals participated in the research, being 149 healthcare members and 145 from the support team. The microbiological procedures were performed according to recommended techniques and data collection obtained by a questionnaire and analyzed through descriptive statistics. Among the participants, 55 (18.7%) were colonized by Enterobacteriaceae in the oral cavity. Were isolated 64 bacteria, including species potentially pathogenic. The most prevalent specie was gergoviae Enterobacter (17.2%). The highest rates of resistance were observed to β-lactams and 48.4% of isolates were considered multiresistant. The Extended Spectrum β-lactamases (ESBL) production was negative for the Enterobacteriaceae and none Klebsiella pneumoniae produced Carbapenemase (KPC). However, among the 43 CESP isolates group (Citrobacter, Enterobacter, Serratia, Providencia), 51.2% produced AmpC β- lactamase by induction and 48.8% were hiper producers. Staphylococcus and Pseudomonas were detected in the saliva of 56.4% individuals. The majory of the healthcare workers colonized by Enterobacteriaceae was men over 40 years. The nursing technician was the professional category most colonized (52.7%), followed by the cleaning staff (23.6%). The cleaning and hygiene sector (23.6%) and nursing stations (18.2%) represented the largest number of workers colonized. Some professionals (27.3%) had second job in another health service, while 41.8% remained in the institution around 40 hours or more a week. Some infection was reported among carriers, as tonsillitis, sinusitis and pharyngitis, being the first the most frequent (52.7%). Enterobacteriaceae carriage (18.2%) reported the use of personal protective equipment (PPE) as unnecessary to their s activity, 7.3% did not use the mask as precautionary measure, 23.6% realized sporadically the exchange of mask and 1.8 % never changed. The use of oral antiseptics was observed in 29.1% of the workers, the recent use of antimicrobials in 16.4% and self-medication in 27.3%. Among the colonized persons was observed lack of knowledge about multiresistant microorganisms. The prevalence Enterobacteriaceae carriage is considered high and the resistance is a problem especially due to multidrug resistance and production of β-lactamase AmpC observed. The results of this research contribute with important subsidies to the programs for nosocomial infections prevention and control of, since knowledge of carrier status reduces the risk of transmission of microorganisms. / O ambiente da assistência à saúde apresenta inúmeros riscos que o torna um local insalubre, propício à colonização e ao desenvolvimento de infecções. Inseridos neste cenário estão os trabalhadores dos serviços de saúde, os quais são vulneráveis à condição de portador. A cavidade bucal representa assim um importante sítio de colonização. Este estudo buscou caracterizar o fenótipo de Enterobacteriaceae isoladas da cavidade bucal de trabalhadores de um hospital oncológico referência no Centro-Oeste brasileiro. Também fizeram parte dos objetivos desta pesquisa detectar co-colonização por Staphylococcus e Pseudomonas, bem como descrever o perfil sócio-demográfico, profissional, doença/infecção e comportamental dos indivíduos colonizados por Enterobacteriaceae. Estudo epidemiológico transversal do tipo descritivo realizado de maio/2009 a novembro/2010. Participaram 294 trabalhadores, sendo 149 membros da equipe de saúde e 145 da equipe de apoio. Os procedimentos microbiológicos foram realizados segundo técnicas padronizadas e a coleta de dados realizada por meio da aplicação de um formulário. Foi coletada uma amostra de saliva de cada sujeito Os dados foram analisados por meio de estatística descritiva. Dentre os participantes, 55 (18,7%) estavam colonizados por Enterobacteriaceae na cavidade bucal. Foram isoladas 64 bactérias, incluindo espécies potencialmente patogênicas. A espécie mais prevalente foi Enterobacter gergoviae (17,2%). As maiores taxas de resistências foram observadas para os β-lactâmicos e 48,4% dos isolados foram considerados multirresistentes. Para as enterobactérias pesquisadas, a produção de β-lactamase de Espectro Ampliado (ESBL) e Klebsiella pneumoniae Carbapenemase (KPC) foi negativa. Porém, dentre os 43 isolados do grupo CESP (Citrobacter, Enterobacter, Serratia, Providencia), 51,2% foram considerados produtores de β-lactamase AmpC por indução e 48,8% mutantes hiperprodutores. Staphylococcus e Pseudomonas estavam presentes na saliva de 56,4% dos sujeitos colonizados por Enterobacteriaceae. O maior número de portadores foi constituído por homens acima de 40 anos. Entre os técnicos de enfermagem, 52,7% estavam colonizados, seguidos dos auxiliares de limpeza (23,6%). O setor de higienização e limpeza (23,6%) e os postos de enfermagem (18,2%) contemplaram o maior número de trabalhadores colonizados. Alguns trabalhadores (27,3%) possuíam segundo emprego em outro serviço de saúde, enquanto que 41,8% permaneciam na instituição 40 horas ou mais na semana. Quadros frequentes de infecção foram relatados entre os portadores, como amigdalites, sinusites e faringites, sendo o primeiro o mais frequente (52,7%). Alguns portadores de Enterobacteriaceae (18,2%) relataram o uso de EPI como desnecessário à sua atividade, 7,3% não faziam o uso de máscara como medida de precaução, 23,6% realizavam a troca de máscara esporadicamente e 1,8% nunca trocava. O uso de antissépticos bucais foi observado em 29,1% dos trabalhadores, o uso recente de antimicrobianos em 16,4% e a prática da automedicação em 27,3%. A desinformação sobre micro-organismos multirresistentes foi comum entre os colonizados. A prevalência de portadores de Enterobacteriaceae foi elevada e o fenótipo de resistência dos isolados preocupante, especialmente pela multirresistência e produção de β-lactamases AmpC. As variáveis avaliadas revelaram realidades relevantes para o contexto da assistência à saúde e para a saúde do trabalhador. Os resultados desta pesquisa contribuíram com subsídios importantes para os programas de prevenção e controle das infecções nosocomiais, pois o conhecimento do estado portador reduz os riscos de transmissão de micro-organismos.

Enterococos são ubíquos no ambiente e fazem parte da microbiota do trato gastrintestinal de humanos e animais. A importância dessas bactérias tem sido associada com infecções hospitalares e resistência a múltiplas drogas, principalmente à vancomicina. O objetivo do presente estudo foi realizar a caracterização molecular de cepas de Enterococcus spp. resistentes à vancomicina (VRE) isoladas a partir de amostras coletadas de pacientes hospitalizados, água superficial de rios urbanos e carne de frango comercializada no Brasil. A presença do gene vanA foi confirmada em 20 cepas multirresitentes isoladas durante 1997-2011. Dentre os isolados VRE, 12 cepas foram identificadas como E. faecium e oito como E. faecalis. Cepas de E. faecium isoladas de amostras clínicas e águas foram classificadas como clonalmente relacionadas pelo PFGE, com perfil virulência predominante (acm+, esp+). Adicionalmente, enquanto cepas de E. faecium isoladas dos rios pertenceram aos ST203, ST412 e ST478 (previamente caracterizados como endêmicos em hospitais brasileiros), novos STs foram identificados entre as cepas de E. faecalis (ST614, ST615 e ST616) e E. faecium (ST953 e ST954) isoladas de alimentos. Sequências completas do transposon Tn1546 das cepas clínicas VREfm 320/07 (ST478) e ambiental VREfm 11 (ST412) mostraram Tn1546-like element de ~12800 pb, com um ponto de mutação no gene vanA na posição 7.698 (substituição do nucleotídeo T pelo C) e uma no gene vanX na posição 8.234 (G pelo T). Além disso, uma deleção na extremidade esquerda do Tn1546, e as sequências IS1251 e IS1216E na região intergênica vanHS e vanYX, respectivamente, também foram detectados. A este respeito, a IS1216E na região intergênica vanXY constitui um conjunto de genes previamente relatado em cepas clínicas de VREfm no Brasil, denotando uma característica regional. IS1216E tem sido associada com os genes tcrB e aadE que conferem resistência ao cobre e aminoglicosídeos, em E. faecium e Streptococcus agalactiae, respectivamente. Portanto, essa IS pode contribuir para a rápida aquisição de resistência antimicrobiana entre as espécies de cocos Gram-positivos clinicamente importantes. Os tipos de Tn1546 indistiguíveis que foram identificados no atual estudo isolados de humano e ambientes aquáticos sugerem uma comum partilha de um pool de genes de resistência à vancomicina. / Enterococci are ubiquitous in the environment and in the intestinal tract of humans and animals. The importance of these bacteria has been associated with nosocomial infection and multiple resistance to antimicrobial agents, mainly vancomycin. The aim of the present study was to perform molecular characterization of vancomycin-resistant Enterococcus spp. strains (VRE) isolated from hospitalized patients, surface water of urban rivers and retail chicken meat in Brazil. The presence of the vanA gene was confirmed in 20 multidrug-resistant strains isolated in 1997-2011. Among these VRE isolates, (n = 12) were identified as E. faecium and (n = 8) as E. faecalis. E. faecium strains isolated from water and clinical samples were classified as clonally related by PFGE, the predominant virulence profile being (acm+, esp+). Additionally, while E. faecium strains isolated from rivers belonging to ST203, ST412 and ST478 (previously characterized as endemic in Brazilian hospitals), new STs were identified among strains of E. faecalis (ST614, ST615 and ST616) and E. faecium (ST953 and ST954) isolated from food. Complete sequences of transposon Tn1546 from VREfm clinical strain 320/07 (ST478) and environmental strain VREfm 11 (ST412) showed a Tn1546-like element of ~12800 bp, with T7698C vanA and G8234T vanX mutations. Moreover, deletion of the Tn1546 left extremity, and the IS1251 and IS1216E sequence inside the vanHS and vanYX intergenic region, respectively, were also detected. In this regard, the IS1216E sequence inside the vanXY intergenic region constitutes a gene array previously reported for Brazilian VREfm clinical strains alone, denoting a regional characteristic. IS1216E has been associated with tcrB and aadE genes, which confer resistance to copper and aminoglycosides, in E. faecium and Streptococcus agalactiae, respectively. Therefore, IS1216E should contribute to rapid acquisition of antimicrobial resistance among species of the clinically important Gram-positive cocci. On the other hand, Tn1546-like elements were identical among clinical and environmental VREfm isolates, suggesting sharing of a common vancomycin resistance gene pool.

Magister Pharmaceuticae - MPharm / Many studies have reported low cure rates for multidrug-resistant tuberculosis (MDRTB) patients and MDR-TB patients co-infected with human immunodeficiency virus (HIV). However, little is known about the effect of HIV infection and antiretroviral therapy on the treatment outcomes of MDR-TB in South Africa. Therefore, the objectives of the study are: to find out whether HIV infection and interactions between ARVs and second line anti-TB drugs have an impact on the following MDR-TB treatment outcomes: cure rate and treatment failure at Brewelskloof Hospital. MDR-TB patients were treated for 18-24 months. The study was designed as a case-control retrospective study comparing MDR-TB treatment outcomes between HIV positive (cases) and HIV negative patients (controls). Patients were included in the study only if they complied with the following criteria: sensitivity to second line anti-TB drugs, MDR-TB infection, co-infection with HIV (for some of them), male and female patients, completion of treatment between 1 January 2006 and 31 December 2008. Any patients that presented with extreme drug-resistant tuberculosis (XDR-TB) were excluded from the study. Data were retrospectively collected from each patient’s medical records. There were a total of 336 patients of which 242 (72%) were MDR-TB patients and 94 (27.9%) MDRTB co-infected with HIV patients. Out of the 242 MDR-TB patients, 167 (69.2%) were males and 75 (30.7%) were females. Of the 94 patients with MDR-TB co-infected with HIV, 51 (54.2%) males and 43 (45.7%) females. Patients with multidrug-resistant tuberculosis co-infected with HIV who qualify for antiretroviral therapy were treated with stavudine, lamivudine and efavirenz while all MDR-TB patients were given kanamycin, ethionamide, ofloxacin, cycloserine and pyrazinamide. The cure rate of MDR-TB in HIV (+) patients and in HIV (-) patients is 34.5% and 30 % respectively. There is no significant difference between both artes (pvalue = 0.80). The MDR-TB cure rate in HIV (+) patients taking antiretroviral drugs and in HIV (+) patients without antiretroviral therapy is 35% and 33% respectively. The difference between both rates is not statistically significant. The study shows that 65 (28.0%) patients completed MDR-TB treatment but could not be classified as cured or failure, 29 (12.5%) patients failed, 76 (32.7%) defaulted, 18 (7.7%) were transferred out and 44 (18.9%) died. As far as treatment completed and defaulted is concerned, there is no significant statistical difference between HIV (+) and HIV (-) The number of patients who failed the MDR-TB treatment and who were transferred out is significantly higher in the HIV (-) group than in the HIV (+) group. Finally the number of MDR-TB patients who died is significantly higher in the HIV (+) group). The median (range) duration of antiretroviral therapy before starting anti-tuberculosis drugs is 10.5 (1-60) months. According to this study results, the MDR-TB treatment cure rate at Brewelkloof hospital is similar to the cure rate at the national level. The study also hows that HIV infection and antiretroviral drugs do not influence any influence on MDR-TB treatment outcomes. / South Africa

Magister Pharmaceuticae - MPharm / The aim of the study was to determine firstly, kanamycin plasma concentrations using liquid chromatography coupled with mass spectrometry (LC/MS); secondly, to investigate the PK parameters of kanamycin in patients infected with MDR-TB and in patients co-infected with MDR-TB and HIV; thirdly, to assess the influence of HIV infection and renal impairment on the PK of kanamycin and fourthly, to find out whether there is any interaction between antiretroviral drugs and kanamycin.