L’acide mycophénolique (MPA) est un immunosuppresseur très prometteur dans le traitement des maladies auto-immunes (MAI) telles que le lupus érythémateux disséminé (LED) et les vascularites à ANCA, et disponible sous deux formes pharmaceutiques : le mycophénolate mofétil (MMF) et le mycophénolate sodique (EC-MPS). Les études menées chez les patients transplantés recommandent le dosage plasmatique et le suivi pharmacocinétique (PK) du MPA, dans un objectif d’optimisation thérapeutique. A ce jour, ce suivi est encore inexistant dans les MAI, et les données de corrélation concentrations-efficacité thérapeutique, sur lesquelles se base l’optimisation, demeurent toujours rares dans ce domaine. Les travaux présentés dans cette thèse s’inscrivent dans l’étude des corrélations PK/pharmacodynamie (PD) du MPA dans les MAI. Ces travaux ont permis de proposer des schémas et des outils d’optimisation des traitements à base de MPA pour ces patients. Pour cela, les concentrations plasmatiques du MPA et de son métabolite 7-O-glucuronide (MPAG) ont été déterminées pour 53 patients présentant de manifestations extra-rénales de MAI à l’aide d’une méthode de chromatographie couplée à la spectrométrie de masse. Les paramètres PK ont été estimés pour MMF et EC-MPS dans les deux groupes de MAI. D’après ces travaux, l’optimisation du MMF chez les patients atteints de MAI peut reposer sur le suivi de la concentration à 12 h (C12) en MPA. Un seuil de 3 mg/L est proposé afin de maintenir la rémission dans le LED, mais reste à définir dans les vascularites. Pour EC-MPS, une stratégie de prélèvements limités basée sur la mesure de la concentration maximale et la C12 est nécessaire pour estimer l’aire sous la courbe des concentrations entre 0 et 12 h du MPA. / Mycophenolic acid (MPA), the active form of both mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS), is an immunosuppressant increasingly used in the treatment of autoimmune diseases such as systemic lupus erythematosus (SLE) and ANCA-associated vasculitis. In transplant recipients, therapeutic drug monitoring (TDM) of MPA is widely used to prevent acute organ rejection. However, MPA TDM is currently not available in autoimmune diseases, as data on the pharmacokinetic (PK)/pharmacodynamic (PD) relationships are very sparse in this indication. Our aim was to study the possible PK/PD relationships of MPA in patients with non-renal manifestations of SLE or ANCA-associated vasculitis. An assay based on liquid chromatography coupled with mass spectrometry was applied to the PK study of MPA and its major glucuronide metabolite (MPAG) in 53 SLE and vasculitis patients receiving either MMF or EC-MPS. According to our results, in SLE patients with non-renal manifestations, TDM based on the measurement of MPA 12-h trough concentration (C12) would allow optimizing therapies with MMF. A 3-mg/L efficacy threshold could be proposed to prevent clinical flares under MMF maintenance therapy. For EC-MPS, a limited sampling strategy including MPA maximum concentration and C12 is necessary to estimate the area under the curve between 0 and 12-h of MPA.

Les cancers du poumon se placent au quatrième rang des cancers tous sexes confondus et constituent la première cause de mortalité par cancer pour l’homme et la troisième chez la femme. Le pronostic est sombre avec une survie relative globale estimée à 43% à 1 an et 14% à 5 ans. Les adénocarcinomes, les carcinomes épidermoïdes et les carcinomes à grandes cellules selon la classification OMS 2015 correspondent à 85% de ces cancers. Les adénocarcinomes pulmonaires ont été scindés en de multiples entités grâce aux progrès des techniques de biologie moléculaire ayant permis d’identifier différentes mutations (EGFR, RAS..) ou réarrangement chromosomique (EML4-ALK), à l’origine de ces tumeurs. Différentes thérapies ciblées ont pu ainsi être développées afin de contrecarrer ces anomalies tels que le crizotinib en cas de réarrangement EML4-Alk ou l’erlotinib en cas de mutation de l’EGFR. Chacun de ces sous-types tumoraux a une présentation clinique et une évolution qui lui est propre. Nous nous sommes particulièrement intéressés au réarrangement ALK, car la génération de néoépitopes dérivés de ce réarrangement pourrait induire une réponse immunitaire. Par ailleurs, il avait été montré dans des lymphomes qu’une translocation NPM-ALK induisait l’expression de PD-L1 via Stat 3. Or la liaison de PD-L1 à PD-1 exprimé par les lymphocytes T (LT) délivre un signal inhibiteur à ces cellules. Ce mécanisme d’échappement constitue une cible thérapeutique via des anticorps qui bloquent cette interaction. Le premier objectif de ce travail a consisté à caractériser la réponse immunitaire effectrice (LT-CD8) et les mécanismes régulant cette réponse (expression de PD-L1, de PD1, infiltration par des LT régulateurs, perte du CMH de classe 1) dans les adénocarcinomes du poumon avec un réarrangement ALK. Cette étude a été réalisée avec une nouvelle méthode de quantification des cellules immunes reposant sur une analyse multiparamétrique in situ fluorescente avec une analyse spectrale permettant de s’affranchir des problèmes de compensation de fluorescence. J’ai montré que les tumeurs du poumon avec un réarrangement ALK exprimaient plus fréquemment PD-L1 que les tumeurs non mutées ou présentant une mutation de l’EGFR. Si le nombre médian de lymphocytes T-CD8+, exprimant ou non PD1 ne différait pas entre les différents groupes, nous avons montré que les tumeurs ALK réarrangé présentaient, avec une fréquence plus grande, une expression de PD-L1 associée à un infiltrat LT-CD8+ total ou intratumoral ou CD8+PD1+ total ou intra-tumoral supérieurs à la médiane. Cette corrélation n’était pas retrouvée, ni dans les ADC EGFR muté ni dans les ADC non ALK, non EGFR, non KRAS. L’expression de PD-L1 associée à l’infiltration par les LT-CD8 exprimant PD-1 sont considérées comme des biomarqueurs de réponse à l’immunothérapie par des anti-PD-1/PDL-1. Cette caractérisation du microenvironnement des tumeurs du poumon avec un réarrangement ALK pourrait permettre de mieux comprendre le profil de réponse des patients à cette immunothérapie. La paroi alvéolaire du poumon est une surface muqueuse séparant l’organisme du monde extérieur. Or il est connu que la réponse immunitaire muqueuse n’est pas similaire à la réponse observée dans le sang aussi bien en termes de phénotype des cellules présentes dans ces deux compartiments que par le mode de génération et d’induction de ces cellules. Dans un premier travail de l’équipe nous avons montré que seule une vaccination par voie nasale (voie muqueuse) permettait le recrutement dans une tumeur de la sphère ORL ou du poumon, de LT anti-tumoraux et la régression de tumeurs muqueuses ORL et pulmonaires, contrairement à une vaccination par voie systémique (intramusculaire). Cette efficacité de la vaccination muqueuse était associée à l’induction de lymphocytes T résidents mémoires (Trm) dans les sites muqueux (poumon, ORL) caractérisés par l’expression des intégrines CD103 et CD49a. (...) / Lung cancer is the most common cause of cancer-related mortality worlwide and a therapeutic challenge. Approximately 5% to 6% of non-small cell lung carcinoma (NSCLC) have chromosomal rearrangements of the anaplastic lymphoma kinase (ALK) gene, which mainly involve the echinoderm microtubule–associated protein-like 4 (EML4) gene as a partner. Even if the ALK tyrosine kinase inhibitor (TKI), crizotinib, has been successfully developed in these patients, resistance invariably occurs leading to tumor relapse. The ALK rearranged protein is immunogenic, was shown to induce PD-L1 and highlight the potential of immunotherapy in this cancer. The first issue of our work was to set up an immunofluorescence multiplex platform to comprehensively analyse the tumor microenvironment of a retrospective cohort of 29 ALK positive ADC, compared to 27 EGFR mutated ADC and 25 wild type ADC. Mean number of total CD8+T cells expressing or not PD-1 and the ratio of CD8/regulatory T cells weren’t significantly different between the various subgroups. The percentage of tumor cells expressing PD-L1 were higher in the ALK positive ADC, than in the EGFR positive ADC or WT lung cancer. We found a significant correlation in ALK positive ADC between the number of total or intratumoral (intraT) CD8+ or PD-1+CD8+T and the expression of PD-L1 by tumor cells suggesting a possible role of adaptive immunity in the regulation of PD-L1 on these tumor cells. Furthermore, the percentage of patients displaying two criteria of clinical response (% PD-L1 on tumor cells and infiltration by intraT PD-1+CD8+ or CD8+T cells) was higher in the ALK positive ADC. According to our results, a subgroup of ALK rearranged lung ADC patients may represent good candidates to be treated by anti-PD-1/PD-L1 antibodies. The alveolar wall is a mucosal site in contact with the environment. Resident memory T cells (Trm) found most prominently at mucosal sites represent a new subset of long lived memory T cells that remain in tissue and do not recirculate. Due to their role in local immunity, strategies to elicit Trm after vaccination have been developed. We and others clearly showed that mucosal immunization were more efficient than the conventional systemic route (intramuscular, subcutaneous) to elicit Trm at the mucosal tumor site. Indeed, the mucosal route of immunization imprints T cells with a mucosal homing program defined by a profile of integrin and chemokine receptors promoting their homing to the site of initial activation. A correlation was observed between the ability to elicit these cells at the tumor site and the control of tumor growth. The second issue of this work was to characterize in a mouse model Trm after mucosal cancer vaccine administration and in human lung cancer. We first developed various original strategies (mucosal immunization, use of mucosal vector, modulation of TGF, parabiosis experiments) to elicit or inhibit Trm in a preclinical model of head and neck cancer. All these experiments converged to demonstrate that the induction of Trm are required for the control of tumor growth. In order to extrapolate this role of Trm in humans, we found that the number of Trm correlated with a better overall survival in lung cancer in multivariate analysis. The induction of Trm may represent a new surrogate biomarker for the efficacy of cancer vaccine.

O desenvolvimento industrial e urbano tem causado aumento mundial das emissões de poluentes atmosféricos. Nas áreas metropolitanas o problema da deterioração da qualidade do ar tem se constituído numa das mais graves ameaças à qualidade de vida dos seus habitantes e os veículos automotores contribuem diretamente com o aumento do material particulado (MP). Neste trabalho foram descritas as etapas metodológicas para validar a Tibouchina granulosa como biomonitor ambiental. Assim, foram abordados a caracterização das folhas, categorização do MP, protocolo de remoção de MP e determinação dos EGPs (Pd, Pt e Rh) na deposição seca das folhas. Para tanto foram realizadas quatro coletas anuais (2011-2014) de folhas, entre os meses de agosto e setembro, em pontos específicos. Os resultados da caracterização mostraram que as folhas permanecem residentes nos ramos por até 6 meses e ocorre o desenvolvimento duas novas folhas por nó a cada mês, indicando que o biomonitoramento pode ser realizado com distribuição temporal e espacial. Os caracteres anatômicos foliares mais relevantes são os tricomas, sendo caracterizados quatro tipos (glandular, adpresso-escabro, base ramificada e estrigoso) que adsorvem o MP. No protocolo de remoção da deposição seca, o número de MP variou de acordo com os diferentes reagentes analíticos utilizados, sendo os mais significativos o ALCONOX&reg e a água régia, que apresentaram valores de remoção na faixa de 99-98% e de 94-99%. As estimativas das incertezas analíticas dos EGPs apresentam valores de uCPt=5% (Pt), uCPd=12% (Pd) e uCRh=5% (Rh) e as incertezas de amostragem, os valores de 57% para o Pd, 24% para a Pt e 27% para o Rh. Portanto, a incerteza expandida foi da Pt U=48%, Pd U=86% e Rh U=9%, a incerteza do Rh apresentou valor mais baixo por ser o elemento minoritário. A elevada sensibilidade do método para determinação dos EGPs apresentou limite de detecção de 0,1 pg g-1 para o Pd, 1,3 pg g-1 para Pt e 0,3 pg g-1 para o Rh e acompanhada boa reprodutibilidade. As concentrações dos EGPs encontradas na deposição seca nos vários pontos de coletas indicaram a clara diferença de acúmulo destes elementos entre o ponto de referência e os locais impactados, sugerindo que a liberação dos EGPS pelos catalisadores veiculares pode ser considerada alta. A evidência da presença dos EGPs na deposição seca foi confirmada por meio da análise da distribuição, que mostrou claramente a similaridade com o material de referência certificado Used Auto Catalystc-2557. As distribuições espaciais dos EGPs foram semelhantes para a Coleta 2, indicando os hot points da RMSP. As concentrações do EGPs foram ordenadas em Pt>Pd>Rh e foram mais baixas no ponto de coleta para controle das amostragens em comparação com os outros locais amostrados. Pode ser concluído que as folhas de T. granulosa foram validadas como biomonitor passivo dos EGPs constituintes de catalisadores veiculares. / Industrial and urban development has caused worldwide increase in emissions air pollutants. In metropolitan areas, the problem of deterioration air quality has been one the most serious threats to quality life its inhabitants, motor vehicles contribute directly increase pollutants. This work describes the methodological steps to validate Tibouchina granulosa as environmental biomonitor, which involved the characterization the leaves, PM categorization, PM removal protocol and determination PGEs in dry deposition, for which four annual collections (2011-2014) were performed between August and September of each year. The of results leaf characters showed that leaves in the branches remain for up to 6 months and the development two new leaf occurs every month. The most relevant foliar characters anatomical are trichomes, being characterized five types. The highest particle concentrations adsorbed to stray trichomes and star-based trichomes. In dry deposition removal protocol, MP number varied according to different analytical reagents used, the most significant being ALCONOX&reg and aqua regia, which presented range removal values of 99-98% and 94-99%, respectively. The estimates analytical uncertainties PGEs show de uCPt=5% (Pt), uCPd=12% (Pd) e uCRh=5% (Rh) and sampling uncertainties values were 57% (Pd), 24% (Pt) and 27% (Rh). Therefore, the expanded uncertainty was Pt u=48%, Pd u=86% e Rh u=9%, in case Rh the uncertainties should be reevaluated by presenting minority values. The high sensitivity of the method for determination of PGEs showed a detection limit of 0.1 pg g-1 for Pd, 1.3 pg g-1 for Pt and 0.3 pg g-1 for Rh and good reproducibility of the results. The concentrations PGEs found in dry deposition in various collection points indicated the clear difference accumulation these elements between reference point and impacted sites, suggesting that release PGEs by the vehicle catalysts can be considered high. Confirming this evidence, through the ternary graphs, which clearly showed similar distributions in the environmental samples and equality with MRC (Used Auto Catalysts). The spatial distributions of Pt, Pd and Rh are similar for Collection 2. Concentrations of the PGEs were ordered in Pt>Pd>Rh and were lower at the collection points for control samplings compared to other sites sampled. In view of the above, it can be concluded that the leaves of T. granulosa can be used as environmental biomonitor of vehicular emissions of PGEs constituent of vehicular catalysts.

Introdução: A sepse é a maior causa de morbidade e mortalidade em pacientes queimados, uma vez que profundas alterações ocorrem na farmacocinética de agentes antimicrobianos prescritos para o controle das infecções. Além disso, pacientes queimados podem apresentar quadro de infecção por germes da comunidade, numa fase precoce de internação na UTI, e devem receber antimicrobianos que diferem daqueles indicados na sepse. Na vigência de infecção fúngica, o quadro se torna ainda mais grave para os pacientes queimados de prolongada internação e imunocomprometidos. Objetivo: Realizar o monitoramento plasmático de oito antimicrobianos largamente prescritos na UTI, a investigação da farmacocinética e a modelagem PK-PD para o ajuste do regime de dose e controle das infecções em pacientes queimados. Casuística: Investigaram-se 32 pacientes queimados internados na UTI/Unidade de Queimados - Divisão de Cirurgia Plástica do HC FMUSP, portadores de infecção recebendo pela via sistêmica sete antimicrobianos e um antifúngico. Métodos- Etapa Clinica: Os pacientes receberam os antimicrobianos geralmente em associação para o controle das infecções seguindo as recomendações da CCIH do hospital relativas ao regime de dose empírica inicial do controle de infecção na UTI de Queimados, na fase precoce e tardia da internação. Realizou-se o monitoramento plasmático do fluconazol, para a infecção fúngica, e dos sete antimicrobianos mais prescritos na UTI para os germes da comunidade e hospitalares (cefepime, ciprofloxacino, imipenem, oxacilina, piperacilina, sulfametoxazol e vancomicina) através das coletas de amostras sanguíneas de pico (termino da infusão) e vale (imediatamente antes da dose subseqüente). Complementarmente, a critério Clínico, foram colhidas amostras seriadas de sangue (pico, 1ª, 2ª, 4ª, 6ª e vale), totalizando seis coletas, para investigação da farmacocinética do agente que requereu ajuste de dose e individualização de terapia no paciente queimado. As coletas de sangue foram realizadas através de cateter venoso (2mL/coleta em tubos contendo EDTA sódico) pelo médico intensivista de plantão na UTI; o plasma foi obtido pela centrifugação para análise do fármaco de interesse ou então armazenado no congelador (-80o C) até o ensaio. Métodos - Etapa Analítica: Previamente à realização da Etapa Clínica, foi realizado no Laboratório o desenvolvimento, validação e otimização de método bioanalítico para quantificação dos oito antimicrobianos no plasma. Preferencialmente, as análises foram realizadas no dia da coleta de sangue do paciente, e o \"Laudo de Exame\" contendo os resultados foi expedido no mesmo dia ou na manhã do dia subseqüente possibilitando a intervenção precoce da Equipe Clínica e se necessária a substituição do regime empírico pela terapia individualizada dose ajustada. Métodos- Etapa estatística: A estatística propriamente dita foi realizada pelo tratamento estatístico com utilização do software GraphPad Instat 4.0., GraphPad Prism 4.0, pela utilização de testes paramétricos e não paramétricos. A modelagem farmacocinética foi realizada através da aplicação do software NonCompartmental Analysis, PK Solutions 2.0, aos pares de dados (C vs T) para cada antimicrobiano. Adicionalmente, aplicou-se o software GraphPad Prism 4.0 para a modelagem PK-PD, ferramenta importante na tomada de decisão relativa à alteração do regime empírico dos antimicrobianos. Resultados: Os pacientes queimados incluídos no protocolo eram adultos de ambos os sexos 23F/9M, 39,6 anos, 69,5 kg, 33,9% SCQ, e os agentes da queimadura foram para 27 pacientes/ térmico-fogo e para três pacientes/trauma elétrico; a lesão inalatória foi registrada em 11/32 pacientes. Foram realizados 303 seguimentos farmacoterapêuticos com a emissão de laudos de exame para os antimicrobianos prescritos aos pacientes nas fases precoce e tardia da internação. O ajuste de dose foi requerido para a vancomicina em 88% das solicitações de exame, cefepime (65%), sulfametozaxol (52%), fluconazol (74%) e imipenem (19%). Registrou-se alta variabilidade na farmacocinética para todos os antimicrobianos investigados. Adicionalmente, registrou-se alteração significativa dos parâmetros farmacocinéticos do imipenem, fluconazol, sulfametoxazol e vancomicina nos seguimentos de pacientes queimados com disfunção renal dialítica relativamente aqueles em que se registrou função renal preservada. A modelagem PK-PD para os diversos antimicrobianos se baseou nos parâmetros de predição de eficácia recomendados tais como o intervalo de tempo em que a concentração plasmática permaneceu acima da concentração inibitória mínima (%Δ T> CIM) para o cefepime, imipenem, oxacilina e piperacilina, ASCss0-24/CIM + Cssmax/CIM para o ciprofloxacino, ASCss0-24/CIM para o fluconazol e para a vancomicina e ASCss0-24/CIM +%Δ T> CIM para a sulfametoxazol. Conclusões: Registrou-se alta variabilidade na farmacocinética dos agentes investigados e a modelagem PK-PD justificou plenamente a substituição da terapia empírica inicial pela dose ajustada para a cobertura dos germes sensíveis, daqueles apresentando sensibilidade dose dependente ao antimicrobiano, além daqueles com alto CIM, pouco sensíveis as doses usuais. Finalmente, a modelagem PK-PD mostrou-se definitiva e ferramenta indispensável na manutenção desses agentes no arsenal terapêutico, garantindo terapia eficaz ao paciente queimado, evitando a emergência bacteriana e o desenvolvimento de resistência. / Introduction: Sepsis is a main cause of morbidity and mortality in burn patients, once pharmacokinetics of antimicrobials prescribed for the control of infections are significantly altered in those patients. In addition, burn patients in the ICU, initially can present infections by community microbial and must receive different antimicrobials than those prescribed for sepsis. On the other hand, burn immunocompromized patients with prolonged staying in the ICU, re-incidence of sepsis and fungal infection requires an effective antifungal agent that must be associated to the antimicrobials prescription. Objective: Therapeutic plasma monitoring of eight antimicrobials largely prescribed to burn patients from the ICU, Pharmacokinetic and PK-PD modeling for dose adjustment and for the control of infections. Study design: Thirty two burn inpatients with infections from the ICU Burns- Division of Plastic Surgery of Clinics Hospital Medical School University of Sao Paulo received systemically antimicrobials/ antifungal agents. Methods - Clinical Procedures: In general burn patients received several antimicrobial agents as recommended by the Control of Hospital Infection Committee as empirical dose at the beginning of therapy and also afterwards in the ICU. The control of infections by community microbials or yet by hospital microbials, and also for fungal infection, was performed by drug plasma monitoring of cefepime, ciprofloxacin, imipenem, oxacillin, piperacillin, sulphamethoxazole, vancomycin and fluconazole after blood sample collection at the peak and at the trough. Complementary, usually by clinical criteria, six blood sample collections were performed at time dose interval (end of drug infusion, 1st, 2nd, 4th, 6th and at the trough) for pharmacokinetic purposes, dose adjustment and individualization of drug therapy for burn patients. Blood sample collection was done by the physician from the ICU by venous catheter (2mL/each into blood collection tubes sodium EDTA); plasma obtained by centrifugation of blood tubes were analyzed in the same day or in a deep freezer to storage (-80o C) until assay. Methods - Analytical Procedures: Previously to the clinical study, in the Laboratory School of Pharmaceutical Sciences was performed the development, validation and optimization of bioanalytical methods for drug plasma monitoring of eight antimicrobial/antifungal agents by HPLC-UV. Drug measurements were performed on the day of blood collection and data were preferentially informed to the physician at the same day or at the early morning of the following day to facilitate the therapeutic intervention and changes on the morning prescription to guarantee drug efficacy. Methods Statistics Procedures: Descriptive statistics was performed by applying the software GraphPad Instat v 4.0., GraphPad Prism v.4.0 by parametric and non parametric tests. Pharmacokinetics was estimated by applying the software NonCompartmental Analysis, PK Solutions 2.0, to data (C vs T) for each antimicrobial agent. Additionally, the software GraphPad Prism v 4.0 was applied to PK-PD modeling, an important tool related to dilemma decision about changes on empirical dose of an antimicrobial agent and obviously helps the physician in the rationalization of drug therapy in severe burns. Results: Burn patients included in the protocol were of both genders 23F/9M, 39.6 yrs, 69.5 kg, 33.9% TBSA; agents of the accident were fire/ alcohol for 27 patients and electrical trauma for three patients; inhalation injury were described for 11/32 patients. Approximately 1500 drug plasma measurements for all antimicrobials prescribed to burn patients for the control of infection in the ICU were performed totalizing 303 follow up for pharmacokinetic purposes during the period in the ICU for 32 burn patients. Dose adjustment was required in 88% of vancomycin prescription, 65% for cefepime, 52% for sulphamethoxazole, 74% for fluconazole e 19% for imipenem. High pharmacokinetic variability was registered for all agents investigated. In addition, significant changes on pharmacokinetic parameters were described for imipenem, fluconazole, sulphamethoxazole and vancomycin for burn patients with dialytic renal dysfunction compared to those with renal function preserved. PK-PD modeling applied to antimicrobials investigated in the present study was based on predictive parameters recommended like time interval to maintain drug plasma concentration higher than the minimum effective concentration (%Δ T> MIC) for cefepime and also for imipenem, oxacillin and piperacillin; AUCss0-24/MIC plus Cssmax/MIC for ciprofloxacin, AUCss0-24/MIC for fluconazole and vancomycin, and finally, AUCss0-24/MIC plus %Δ T> MIC for sulphamethoxazole. Conclusions: High pharmacokinetic variability was obtained for all investigated agents. PK-PD modeling applied could justify definitively the antimicrobial therapy dose adjustment instead the empirical dose regimen. Then, drug efficacy was guaranteed against susceptible microbial, spreading to susceptible to antimicrobial dose dependent and also those presenting high value for MIC related to microbial resistance to empiric dose regimen. In conclusion, it was demonstrated that PK-PD modeling of antimicrobials with basis on predictive drug efficacy parameter is definitively an important tool to preserve and safeguard these agents for the control of severe infection in burn patients, to avoid the bacterial emergency and microbial resistance.

Suite à une transplantation, les patients présentent un affaiblissement de leur système immunitaire laissant ainsi place libre aux infections opportunistes et principalement au CMV. L’implication de ce virus dans l’accélération de la mise en place du rejet chronique du greffon reste controversée et largement incomprise. Nos objectifs ont été d’une part de déterminer l’impact de l’infection à CMV du donneur sur la survie du greffon rénal et d’autre part d’identifier certains facteurs liés à la réponse immunitaire de l’hôte pouvant moduler ce risque. Selon nos résultats, l’infection à CMV du donneur est un facteur de risque indépendant de la perte des greffons rénaux, d’autant plus si le receveur est aussi infecté. Le SNP PD-1.3 est un facteur de risque génétique fort de la perte du greffon rénal associé au CMV du donneur et ce résultat est confirmé grâce à une cohorte de validation de patients transplantés pulmonaires. Ce travail suggère un lien fort entre ce SNP et l’épuisement de la réponse immunitaire anti-CMV et met en avant l’importance de la physiopathologie liée au CMV sur l’association clinique observée. / Following a solid organ transplant, and to prevent the risk of rejection, patients take immunosuppressive treatments that weaken their immune system and promote tumors and infections, including cytomegalovirus (CMV). This virus is the cause of clinical infectious syndromes but also many "indirect" effects which are not yet clearly understood. Our objectives were firstly to determine the impact of the CMV donor infection on the renal graft survival and secondly to identify factors related to the immune response of the host which can modulate the risk. We showed that the CMV donor is an independent risk factor for kidney graft loss, especially if the recipient is infected. The SNP PD-1.3 is a strong genetic risk factor for renal graft loss associated with CMV donor and this result is confirmed by a validation cohort of lung transplant patients. This work suggests a strong link between this SNP and the exhaustion of the immune response specific anti -CMV and highlights the importance of the pathophysiology associated with CMV on the observed clinical association.

Ziel dieser Arbeit war, die Rastertunnelmikroskopie, die bereits zur Aufklärung von einfachen Reaktionsmechanismen eingesetzt wurde, für em kompliziertere Reaktionen anzuwenden. Die Oxidation von CO auf Pd(111) und auf einem RuO2-Film auf Ru(0001) wurde untersucht. Strukturelle Analysen ergeben mikroskopische Verteilungen der Adsorbate in den Überstrukturen von O und CO auf Pd(111) und RuO2. Dynamische und quantitative Analysen der Reaktionen liefern die Kinetik und die Mechanismen der Reaktionen direkt auf der mikroskopischen Ebene. O-Atome auf Pd(111) sind bei mittleren Bedeckungsgraden (0.10< theta mathrm O 135 K beweglich. Die Aktivierungsenergie der Diffusion (E * mathrm diff ) beträgt 0.54 pm 0.08 eV, der präexponentielle Faktor der Sprünge Gamma mathrm o beträgt 10 16 pm 3 s -1. Bei niedrigen Bedeckungen (theta mathrm CO sim 0) sind die CO-Moleküle auf Pd(111) schon bei T mathrm sample = 60 K sehr beweglich. Wenn man einen präexponentiellen Faktor von Gamma mathrm o = 10 13 s -1 annimmt, ergibt sich für E * mathrm diff von CO ein Wert von 0.15 eV. Adsorbiert CO auf der (2 times2) -O-Überstruktur bei T mathrm sample > 130 K, kommt es mit steigendem Bedeckungsgrad von CO zu Phasenübergängen, zunächst in eine ( sqrt 3 times Sqrt 3 ) R30 circ -O-Struktur, dann in eine (2 times1)-Struktur. Während der Phasenübergänge nimmt die Mobilität der O-Atome zu, was sich in einer Abnahme der E* mathrm diff um 10 bis 20 % (unter der Annahme von Gamma mathrm o = 10 16 s -1) im Vergleich zu einer CO-freien Oberfläche niederschlägt. Am Ende der Phasenübergänge entstehen aus einer fast völlig ungeordneten (O+CO)-Phase viele kleine (2 times1)-Inseln, die sich zu grösseren Inseln zusammenlegen. Die (2 times1)-Inseln sind bereits bei T mathrm sample = 136 K sehr reaktiv. Die quantitative Analyse der Abreaktion der (2 times1)-Inseln ergibt, dass die Reaktionsrate proportional zur Inselfläche und nicht zur Randlänge ist. Die Reaktionsordnung bezüglich theta mathrm(2 times1) ist sim 1. Unter der Annahme eines Vorfaktors k mathrm o von 10 13 s -1 wurde für diese Reaktion ein E* mathrm reac von 0.41 eV abgeschätzt. Für eine CO-Adsorption auf der (2 times2)-O-Überstruktur bei T mathrm sample < 130 K kommt es nicht zu einem Phasenübergang, sondern CO adsorbiert auf der (2 times2)-O-Struktur. Der RuO2-Film wurde bei Temperaturen zwischen 650 und 900 K auf der Ru(0001)-Probe aufgewachsen. Die Morphologie des Oxidfilms hängt stark von der Temperatur der Probe während des Wachstums Tprep ab. Bei Tprep sim 650 K ist die Morphologie überwiegend kinetisch bestimmt. Mit steigendener Temperatur bis Tprep = 900 K werden thermodynamische Effekte immer wichtiger. Die Dicke der Oxidschicht hängt nicht von Tprep ab und beträgt 7 AA bis 15 AA, was 2 bis 5 (Ru-O)-Monolagen entspricht. Die thermodynamische Stabilität der Morphologie ergibt sich aus Experimenten, in denen die Oxidschicht durch Heizen auf verschiedene Temperaturen partiell verdampft wurde. Der Film dampft nicht lageweise ab, sondern es entstehen Löcher in der ansonsten unverdampften Oxidschicht. Die Löcher haben eine charakteristische Form. Sie bilden Parallelogramme oder Rechtecke mit einer langen Achse in [001]-Richtung. Die Oberflächenenergie gamma 001 der einen Flanke der Löcher ist 2 bis 5 mal grösser als gamma bar110 der anderen Flanke. Beim Verdampfen des Films verbleiben die freigesetzten Ru-Atome des Oxids auf dem Substrat. Sie bilden dort eine komplizierte Morphologie von hexagonalen und runden Inseln. Die mikroskopischen Beobachtungen der chemischen Prozesse auf dem Film bestätigen die auf den makroskopischen Untersuchungen basierenden Modelle. Ein neuer Befund ist, dass die CO-Moleküle bei Raumtemperatur auf den Rulf -Reihen stabil adsorbieren, sobald die Ruzf -Reihen vollständig mit CO bedeckt sind. Der maximale Bedeckungsgrad theta mathrm CO1f ist 0.5, die COlf-Moleküle bilden lokal geordnete (2times1)-, c(2times2)- und (1times1)-Überstrukturen. Allerdings kommt es bei theta mathrm CO1f sim 0.5 zu einer langsamen Desorption. Wenn man ein k mathrm o von 10 16 s -1 annimmt, lässt sich ein E * mathrm des von 1.00 eV abschätzen. Unter der Annahme von Gamma mathrm o und k mathrm o von 10 13 s -1 lassen sich E* mathrm diff -Werte für O und CO zwischen 0.89 und 0.93 eV abschätzen, und für die Reaktion zwischen COlf und Olf ein Wert von E* mathrm reac sim 0.87 eV. Die Reaktionen zwischen Ozf und COlf, zwischen Olf und COzf sowie zwischen Olf und COlf verlaufen überwiegend statistisch. Manchmal wird eine leicht bevorzugte Reaktion quer zu den Rulf - und Ruzf -Reihen beobachtet. Unter steady-state-Bedingungen kann CO bei genügend grossem Partialdruck auf der Oberfläche adsorbieren. Unter steady-state-Bedingungen werden die gleichen COlf-Überstrukturen beobachtet wie in einer CO-Atmosphäre oder bei der Titration mit CO. Bei massiver Dosierung der Oxidoberfläche mit Oz und CO (sim 100 L) werden weisse Flecken beobachtet, die COlf ähnlich sind. Allerdings reagieren diese weder mit Oz noch mit CO, was auf einen anderen chemischen Zustand der RuO2-Oberfläche als den sauberen Zustand hinweist. / Scanning Tunneling Microscopy has already been established as a tool for the investigation of simple reaction mechanisms. The aim of this thesis was to apply this technique to study emmore complicated reactions. The oxidation of CO on Pd(111) and on a RuO2 film grown on Ru(0001) was investigated. Structural analyses of the O, CO and (CO+O) adlayers on Pd(111) and on RuO2 reveal the microscopic distributions of the adsorbates on the surfaces. Dynamic and quantitative analyses of the reactions yield the reaction kinetics and the reaction mechanisms in a direct way at the microscopic level. O atoms on Pd(111) at intermediate coverages (0.10

INTRODUÇÃO - OBJETIVO: A vancomicina é um glicopeptídeo de primeira escolha largamente prescrito aos pacientes críticos no tratamento de infecções graves causadas por patógenos nosocomiais Gram-positivos susceptíveis. Os pacientes grandes queimados são considerados pacientes críticos pelas condições metabólicas e importantes alterações fisiopatológicas decorrentes do choque séptico que modificam a farmacocinética da vancomicina. Destaca-se, entretanto que nos pacientes críticos queimados pediátricos essa alteração ocorre em diferente proporção quando comparada aquela reportada para pacientes adultos. Assim sendo, a efetividade desse antimicrobiano é um desafio para a equipe clínica da terapia intensiva, uma vez que a dose empírica nesses pacientes tem fornecido concentrações inferiores às recomendadas, resultando em falha terapêutica pela falta de cobertura do antimicrobiano contra patógenos susceptíveis, CIM &#8805;1mg/L. O objetivo foi realizar o monitoramento das concentrações plasmáticas de vancomicina seguido da abordagem farmacocinética-farmacodinâmica (PK/PD) a fim de se avaliar a efetividade do regime empírico recomendado ao paciente crítico pediátrico e se realizar o ajuste de dose para erradicação dos patógenos. CASUÍSTICA E MÉTODOS: Incluíram-se 20 pacientes (14M/6F), função renal normal com média de idade 5,95 (4,5-7,4) anos, peso 25,2 (20,5-30)kg, superfície de área queimada total 31,1(25-37)%. Os acidentes foram causados pelo fogo/ combustão por álcool; registrou-se lesão inalatória (12/20) e uso de drogas vasoativas e ventilação mecânica em 13/20 pacientes. Os exames de rotina laboratorial foram realizados diariamente; antes do início da terapia antimicrobiana, colheram-se amostras de sangue no D0 para cultura e realização do teste de susceptibilidade. Os pacientes foram investigados em diferentes seguimentos durante o choque séptico; o regime de dose empírica recomendada pelo CCIH foi prescrito e 3-4 amostras seriadas de sangue (1,5 mL/cada) foram coletadas do CVC no intervalo de dose após a dose diária empírica recomendada e após a individualização da terapia medicamentosa. A quantificação de vancomicina plasmática foi realizada através da cromatografia líquida. Na modelagem PK utilizou-se o programa PK Solutions Noncompartmental Data Analysis versão 2.0. Na abordagem PK/PD e no tratamento estatístico aplicou-se o programa GraphPad Prisma v.5.0. Empregou-se a razão da área sob a curva (ASCss0-24) e concentração inibitória mínima superior a 400 (ASCss0-24/CIM&#62;400) como índice preditivo de efetividade recomendada para o antimicrobiano. Aplicou-se estatística paramétrica com relação aos dados demográficos e laboratoriais, e estatística não paramétrica com relação à dose, concentração plasmática, área sob a curva, constantes farmacocinéticas e efetividade do antimicrobiano. Aplicaram-se nesse estudo os testes paramétricos (ANOVA e Teste T de Student) e não paramétricos (Wilcoxon e Mann Whitney) no programa GraphPad Prisma v.5.0., e o nível de alfa igual ou inferior a 0,05 (P&#60;0,05) foi considerado na significância estatística. RESULTADOS: A dose empírica de vancomicina foi 50 (44-51) mg/kg dia, mediana (quartis, IQ25-75) mostrou que o alvo foi atingido para 85% (17/20) dos pacientes apenas contra cepas sensíveis (CIM&&#8804;1mg/L), ficando desta forma todos os pacientes desprotegidos contra cepas CIM &#62;1mg/L (CIM: 2-4 mg/L). Então, registrou-se alteração de conduta médica relativa à prescrição com aumento da dose diária de vancomicina 94 (85-104) mg/Kg. Esse aumento se mostrou significativo com relação a dose inicial empírica, p&#60;0,05. Após nova estabilização pela terapia dose ajustada, e coletas de sangue no platô, o alvo PK/PD foi alcançado para todos os pacientes, contra patógenos CIM 1mg/L. Entretanto, apenas 5/20 pacientes alcançaram o alvo PK/PD contra cepas susceptíveis CIM: 2mg/L, sendo que nenhum paciente se mostrou coberto contra cepas CIM 4mg/L. CONCLUSÃO: O regime empírico de dose recomendado para a vancomicina não se mostrou efetivo contra os patógenos sensíveis isolados. Concluindo, o controle terapêutico, estudo da farmacocinética e abordagem PK/PD realizado em tempo real possibilitou a alteração precoce de prescrição da vancomicina nos pacientes pediátricos grandes queimados de forma a otimizar a terapia antimicrobiana e o controle das infecções causadas por patógenos hospitalares susceptíveis (CIM &#8805;1mg/L). / INTRODUCTION- OBJECTIVE: Vancomycin is a first choice glycopeptide largely prescribed to critically ill adult or pediatric patients under therapy of severe infections caused by gram-positive susceptible nosocomial strains. Burn patients have metabolic conditions that change the pharmacokinetics of vancomycin in the treatment of severe infections. Pediatric patients are even more complicated because pharmacokinetic changes are quite different compared to adults, then effective vancomycin dose regimen is a challenge to clinic staff, once the initial dose recommended cannot reach the target against MIC &#8805; 1 mg/L strains. Then therapeutic fail with impact on desired outcome. Therefore the rational of study was to apply therapeutic drug plasma monitoring (TDM) in order to identify the pharmacokinetic changes that occur in paediatric burns through PK/PD approach to perform in a real time the dose adjustment required. METHODS - CASUISTRY: Twenty septic burn pediatric patients was investigated after the admission in the Intensive Care Unit of Burns (ICBU) Plastic Surgery Division of HCFMUSP. Vancomycin empiric dose regimen recommended was prescribed 500mg every 6 hours, and patients received one hour drug infusion. Blood sampling was performed after drug infusion at time dose interval (1.5 mL/tube, sodium EDTA): 2nd or 3rd h, 4th, and before the next dose. Vancomycin was quantified by liquid chromatography (LC). Pharmacokinetics was investigated on the basis on one compartment open model by Noncompartmental Data Analysis PK Solutions v 2.0, software. PK/PD approach was based on the ratio of area under the plasma concentration - time curve (AUCss0-24) and the minimum inhibitory concentration (MIC) performed by GraphPad Prism v 5.0 software. The predictive index of drug effectiveness recommended was ASCss0-24/CIM&#62;400. Statistics also was performed through by GraphPad Prism v 5.0 software by application of parametric tests to demographic data and also to laboratorial data (ANOVA, Student T test). Nonparametric statistics was applied related to dose, drug plasma measurements and AUC, kinetic data, data related to drug effectiveness (Mann Whitney). Statistical significant difference was considered, alpha lower than 0,05 (P&#60;0,05). RESULTS -CONCLUSION: It was shown that the therapeutic target was reached to 85% (17/20) patients with the empiric daily dose of vancomycin (44-51) mg/kg, median (quartiles, IQ25-75) only for susceptible strains (MIC&#8804;1mg/L). Then, changes of the prescription occurred in a real time and the daily dose was increased to 94 (85-104) mg/kg, p&#60;0.05. New blood sampling was done at the steady state for TDM, PK and PK/PD approach and the target was reached for all patients MIC 1 mg/L strains; while the target was reached only 5/20 patients against MIC: 2mg/L susceptible strains, and none patient reached the target against MIC 4mg/L strains. It was shown that the drug effectiveness wasn\'t guaranteed by the vancomycin dose regimen recommended for the treatment of sepsis caused by nosocomial MIC&#8805;1mg/L strains. In conclusion, TDM, pharmacokinetic study and PK/PD approach must be considered important tools do change vancomycin prescription in a real time in order to optimize the antimicrobial treatment of septic shock caused by nosocomial pathogens.

[pt] O presente trabalho teve por objetivo mapear a logística na gestão do portfólio de projetos de pesquisa, desenvolvimento e inovação tecnológica do Programa regulado de P e D da ANEEL. Desenvolvido no contexto regulatório e empresarial, avalia em que medida a realização desses projetos resultam em benefícios econômicos para concessionária. O trabalho examinou (i) gargalos que dificultam a apropriação dos resultados dos projetos de P e D pela própria concessionária e (ii) os aspectos motivacionais induzidos pela introdução de políticas públicas de incentivo ao setor. Esse foi o caso da Lei 9991/2000 que cria condições favoráveis à sustentabilidade corporativa e à introdução de inovações no mercado das concessionárias distribuidoras de energia elétrica pela aplicação de um percentual da sua receita operacional líquida no desenvolvimento de projetos de P e D. Os resultados da pesquisa confirmam uma tendência de crescimento dos montantes anuais de investimento no Programa e uma determinação de concentrar recursos num número menor de projetos direcionados às linhas de pesquisa de maior relevância da concessionária. A maioria dos projetos foi desenvolvida por universidades, com ou sem parceria com outras instituições, por um valor médio mais baixo do que o praticado pelas demais instituições executoras. Já as indústrias não tomam a iniciativa de propor projetos de P e D, provavelmente por não disporem de laboratórios próprios. Como medida para evitar a pulverização dos recursos de pesquisa observou-se uma preocupação do gestor em concentrar recursos em iniciativas de centros de pesquisa comprometidos com a solução de temas relevantes que têm afligindo o setor. / [en] The present study aimed to map the logistics management of the portfolio of R, D and I (research, technological development and innovation) projects developed under the ANEEL regulated Program. Developed under the regulatory and business environment, it assesses the extent to which the realization of these projects results in economic benefits to the energy concessionaire. The study examined (i) bottlenecks that hinder the appropriation of the results achieved by the R, D and I projects contracted by the concessionaire and (ii) the motivational aspects induced by the introduction of public policies to incite the sector. This was the case of the 9991/2000-Act that created favourable conditions for corporate sustainability and the introduction of innovations in the market of electric energy operated by distribution concessionaires as it defines that a percentage of the net operating revenues must be applied in the development of R, D and I projects. The results of the survey carried out confirm a growing trend of the annual investment in the program and a determination to concentrate resources on fewer projects targeted to areas of research most relevant to the concessionaire. Most projects were developed by universities, with or without partnership with other institutions, for an average of investments lower than that charged by other executing agencies. The reason why industries do not take the initiative to propose R and D projects may be explained by the fact that they do not have their own laboratories. As a measure to avoid spraying of research resources there was a concern of the manager to concentrate resources on initiatives of research centres committed to the solution of important issues that have afflicted the sector.

Des nanoparticules à base d’oxyde de titane ont été synthétisées par pyrolyse laser en vue de leur application dans le domaine de la photocatalyse. Le travail montre la souplesse de la méthode pour la synthèse de TiO2 et M-TiO2 (M= Pd, Fe, Cu, Si, N) à partir de tetraisopropoxyde de titane. Des sels organiques des métaux, de SiH4 et d’NH3 ont été utilisés pour introduire des atomes de Fe, Cu, Pd, Si et N dans des nanoparticules de TiO2. Les nanoparticules ont été analysées par microscopie électronique de transmission (MET), diffraction de rayons X (DRX), surface spécifique (SBET), spectroscopie des photoélectrons X (XPS), spectrométrie d’émission à torche plasma (ICP/OES). Leurs propriétés optiques ont été évaluées par spectroscopie de réflexion diffuse (DRS). L’activité photocatalytique des nanoparticules synthétisées a été évaluée dans la dégradation du bleu de méthylène, de l’acide formique et du phénol, sous d’irradiation UV et/ou UV-Visible. Les résultats ont été comparés à ceux obtenus dans les mêmes conditions avec le produit commercial Degussa P25 de chez Evonik.Les analyses montrent que les échantillons sont composés de nanoparticules sphériques avec une distribution de taille comprise entre 5 et 20 nm, la phase cristallographique majoritaire est le TiO2 anatase. Les surfaces développées en analyse BET sont importantes, autour de 80 m2/g (170 pour N-TiO2), comparées au produit commercial Degussa P25. Les analyses chimiques montrent que les atomes de Fe, Cu, Pd, Si et N sont efficacement introduits dans les nanoparticules de TiO2 avec des rendements MPoudre/MPrécurseur au moins égaux à 48%.Les échantillons de TiO2, Pd-TiO2 et Cu-TiO2 montrent une meilleure activité que TiO2 Degussa P25 vis-à-vis de la décomposition d’acide formique sous irradiation UV-Vis tandis que Fe-TiO2, Si-TiO2 et N-TiO2 sont moins actifs. L’effet de la concentration et de l’état d’oxydation du Pd dans le TiO2 a alors été étudié plus spécifiquement. L’addition de Pd sous la forme PdO diminue l’activité vis-à-vis de la décomposition de l’acide formique et du bleu de méthylène. Par contre l’addition de Pd sous la forme métallique améliore l’activité vis-à-vis de la dégradation du bleu de méthylène, d’acide formique et du phénol. Cette activité est toujours aussi importante après quatre cycles de photocatalyse.Nous avons également évalué l’activité des oxynitrures de titane et de N-TiO2 vis-à-vis de la dégradation de l’acide formique et de la décoloration du bleu de méthylène sous irradiation visible. Les oxynitrures présentent des activités faibles, qui semblent être améliorées par l’addition de palladium. L’échantillon N-TiO2 montre quant à lui des excellentes propriétés photocatalytiques vis-à-vis de la dégradation de l’acide formique sous irradiation visible tout en gardant une très bonne efficacité sous l’UV. / Titanium based oxides nanoparticles were synthesized by laser pyrolysis and were tested as possible as photocatalysts. Using the laser pyrolysis method, this work shows that TiO2 and M-TiO2 (M = Pd, Fe, Cu, Si, N) can be easily synthesized in one step from titanium tetra isopropoxideprecursor mixed with organic salts of metals, SiH4 or NH3 to introduce atoms of Fe, Cu, Pd, Si and N in TiO2 nanoparticles. Nanoparticles were characterized by transmission electron microscopy (TEM), X-ray diffraction (XRD), Brunauer-Emmett-Teller specific surface (SBET), X-photoelectron spectroscopy (XPS), and inductively coupled plasma spectroscopy (ICP/EOS). Their optical properties were measured by diffuse reflection spectroscopy (DRX). Photocatalytic activity of nanoparticles was evaluated using the degradation of methylene blue, formic acid and phenol tests under UV (360 nm) and/or UV-Visible(290-780nm) or pure visible radiation (455 nm). Results were compared to those of TiO2 Degussa P25 (from Evonik) obtained under same conditions.The nanoparticles are of spherical shape with a size distribution from 5 to 10 nanometers, there are mostly in anatase crystallographic phase. The specific surfaces area is always around 80 m2/g (170 m2/g for N-TiO2), indicating smaller size than TiO2 Degussa P25. Chemical analysis indicate that Fe, Cu, Pd, Si and N atoms are efficiently introduced into TiO2 powders. The mass ration MPowder/MPrecursor yield is always higher than 48%.Using the formic acid degradation test, TiO2, Pd-TiO2 and Cu-TiO2 were more active than TiO2 Degussa P25 test under UV-Vis radiation while Fe-TiO2, Si-TiO2 and N-TiO2 were less actives. Therefore, the influence of Pd amount/oxidation state upon the photocatalytic properties of Pd-TiO2 nanoparticles was studied in more details. Pd-TiO2 activity to degrade methylene blue, formic acid and phenol was improved in presence of metallic palladium. This activity is still important after 4 tests cycles.The activity of Titanium Oxynitride (exhibiting large shift of the optical gap towards the visible region) and N-doped TiO2 nanoparticles was also studied in formic acid and methylene blue degradation test under visible radiation. Oxynitrides exhibit low activity, which appears to be improved by the addition of palladium. This low activity could be related to the presence of an amorphous phase in the sample. N-TiO2 samples were active in formic acid degradation under visible radiation while keeping a very good efficiency in the UV.

INTRODUÇÃO - OBJETIVO: A vancomicina é um glicopeptídeo de primeira escolha largamente prescrito aos pacientes críticos no tratamento de infecções graves causadas por patógenos nosocomiais Gram-positivos susceptíveis. Os pacientes grandes queimados são considerados pacientes críticos pelas condições metabólicas e importantes alterações fisiopatológicas decorrentes do choque séptico que modificam a farmacocinética da vancomicina. Destaca-se, entretanto que nos pacientes críticos queimados pediátricos essa alteração ocorre em diferente proporção quando comparada aquela reportada para pacientes adultos. Assim sendo, a efetividade desse antimicrobiano é um desafio para a equipe clínica da terapia intensiva, uma vez que a dose empírica nesses pacientes tem fornecido concentrações inferiores às recomendadas, resultando em falha terapêutica pela falta de cobertura do antimicrobiano contra patógenos susceptíveis, CIM &#8805;1mg/L. O objetivo foi realizar o monitoramento das concentrações plasmáticas de vancomicina seguido da abordagem farmacocinética-farmacodinâmica (PK/PD) a fim de se avaliar a efetividade do regime empírico recomendado ao paciente crítico pediátrico e se realizar o ajuste de dose para erradicação dos patógenos. CASUÍSTICA E MÉTODOS: Incluíram-se 20 pacientes (14M/6F), função renal normal com média de idade 5,95 (4,5-7,4) anos, peso 25,2 (20,5-30)kg, superfície de área queimada total 31,1(25-37)%. Os acidentes foram causados pelo fogo/ combustão por álcool; registrou-se lesão inalatória (12/20) e uso de drogas vasoativas e ventilação mecânica em 13/20 pacientes. Os exames de rotina laboratorial foram realizados diariamente; antes do início da terapia antimicrobiana, colheram-se amostras de sangue no D0 para cultura e realização do teste de susceptibilidade. Os pacientes foram investigados em diferentes seguimentos durante o choque séptico; o regime de dose empírica recomendada pelo CCIH foi prescrito e 3-4 amostras seriadas de sangue (1,5 mL/cada) foram coletadas do CVC no intervalo de dose após a dose diária empírica recomendada e após a individualização da terapia medicamentosa. A quantificação de vancomicina plasmática foi realizada através da cromatografia líquida. Na modelagem PK utilizou-se o programa PK Solutions Noncompartmental Data Analysis versão 2.0. Na abordagem PK/PD e no tratamento estatístico aplicou-se o programa GraphPad Prisma v.5.0. Empregou-se a razão da área sob a curva (ASCss0-24) e concentração inibitória mínima superior a 400 (ASCss0-24/CIM&#62;400) como índice preditivo de efetividade recomendada para o antimicrobiano. Aplicou-se estatística paramétrica com relação aos dados demográficos e laboratoriais, e estatística não paramétrica com relação à dose, concentração plasmática, área sob a curva, constantes farmacocinéticas e efetividade do antimicrobiano. Aplicaram-se nesse estudo os testes paramétricos (ANOVA e Teste T de Student) e não paramétricos (Wilcoxon e Mann Whitney) no programa GraphPad Prisma v.5.0., e o nível de alfa igual ou inferior a 0,05 (P&#60;0,05) foi considerado na significância estatística. RESULTADOS: A dose empírica de vancomicina foi 50 (44-51) mg/kg dia, mediana (quartis, IQ25-75) mostrou que o alvo foi atingido para 85% (17/20) dos pacientes apenas contra cepas sensíveis (CIM&&#8804;1mg/L), ficando desta forma todos os pacientes desprotegidos contra cepas CIM &#62;1mg/L (CIM: 2-4 mg/L). Então, registrou-se alteração de conduta médica relativa à prescrição com aumento da dose diária de vancomicina 94 (85-104) mg/Kg. Esse aumento se mostrou significativo com relação a dose inicial empírica, p&#60;0,05. Após nova estabilização pela terapia dose ajustada, e coletas de sangue no platô, o alvo PK/PD foi alcançado para todos os pacientes, contra patógenos CIM 1mg/L. Entretanto, apenas 5/20 pacientes alcançaram o alvo PK/PD contra cepas susceptíveis CIM: 2mg/L, sendo que nenhum paciente se mostrou coberto contra cepas CIM 4mg/L. CONCLUSÃO: O regime empírico de dose recomendado para a vancomicina não se mostrou efetivo contra os patógenos sensíveis isolados. Concluindo, o controle terapêutico, estudo da farmacocinética e abordagem PK/PD realizado em tempo real possibilitou a alteração precoce de prescrição da vancomicina nos pacientes pediátricos grandes queimados de forma a otimizar a terapia antimicrobiana e o controle das infecções causadas por patógenos hospitalares susceptíveis (CIM &#8805;1mg/L). / INTRODUCTION- OBJECTIVE: Vancomycin is a first choice glycopeptide largely prescribed to critically ill adult or pediatric patients under therapy of severe infections caused by gram-positive susceptible nosocomial strains. Burn patients have metabolic conditions that change the pharmacokinetics of vancomycin in the treatment of severe infections. Pediatric patients are even more complicated because pharmacokinetic changes are quite different compared to adults, then effective vancomycin dose regimen is a challenge to clinic staff, once the initial dose recommended cannot reach the target against MIC &#8805; 1 mg/L strains. Then therapeutic fail with impact on desired outcome. Therefore the rational of study was to apply therapeutic drug plasma monitoring (TDM) in order to identify the pharmacokinetic changes that occur in paediatric burns through PK/PD approach to perform in a real time the dose adjustment required. METHODS - CASUISTRY: Twenty septic burn pediatric patients was investigated after the admission in the Intensive Care Unit of Burns (ICBU) Plastic Surgery Division of HCFMUSP. Vancomycin empiric dose regimen recommended was prescribed 500mg every 6 hours, and patients received one hour drug infusion. Blood sampling was performed after drug infusion at time dose interval (1.5 mL/tube, sodium EDTA): 2nd or 3rd h, 4th, and before the next dose. Vancomycin was quantified by liquid chromatography (LC). Pharmacokinetics was investigated on the basis on one compartment open model by Noncompartmental Data Analysis PK Solutions v 2.0, software. PK/PD approach was based on the ratio of area under the plasma concentration - time curve (AUCss0-24) and the minimum inhibitory concentration (MIC) performed by GraphPad Prism v 5.0 software. The predictive index of drug effectiveness recommended was ASCss0-24/CIM&#62;400. Statistics also was performed through by GraphPad Prism v 5.0 software by application of parametric tests to demographic data and also to laboratorial data (ANOVA, Student T test). Nonparametric statistics was applied related to dose, drug plasma measurements and AUC, kinetic data, data related to drug effectiveness (Mann Whitney). Statistical significant difference was considered, alpha lower than 0,05 (P&#60;0,05). RESULTS -CONCLUSION: It was shown that the therapeutic target was reached to 85% (17/20) patients with the empiric daily dose of vancomycin (44-51) mg/kg, median (quartiles, IQ25-75) only for susceptible strains (MIC&#8804;1mg/L). Then, changes of the prescription occurred in a real time and the daily dose was increased to 94 (85-104) mg/kg, p&#60;0.05. New blood sampling was done at the steady state for TDM, PK and PK/PD approach and the target was reached for all patients MIC 1 mg/L strains; while the target was reached only 5/20 patients against MIC: 2mg/L susceptible strains, and none patient reached the target against MIC 4mg/L strains. It was shown that the drug effectiveness wasn\'t guaranteed by the vancomycin dose regimen recommended for the treatment of sepsis caused by nosocomial MIC&#8805;1mg/L strains. In conclusion, TDM, pharmacokinetic study and PK/PD approach must be considered important tools do change vancomycin prescription in a real time in order to optimize the antimicrobial treatment of septic shock caused by nosocomial pathogens.