O advento do uso de cateteres venosos centrais na prática médica trouxe muitos benefícios aos pacientes, porém está relacionado a um aumento na incidência de infecções por microrganismos multirresistentes. Além disso, freqüentemente ocorre colonização por bactérias produtoras de biofilme. Estes microrganismos se aderem ao material abiótico desses dispositivos intravenosos, ficando protegidos sob a matriz exopolissacarídica do biofilme. Isso faz com que sistema imunológico e antimicrobianos sejam incapazes de ter sua ação plena e, muitas vezes, não atingem os microrganismos mais internos. O motivo deste insucesso é porque muitos desses agentes biológicos e farmacológicos apresentam propriedades físico-químicas incompatíveis com a penetração nesta matriz. Com o objetivo de determinar quais antimicrobianos são mais adequados para uso quando o microrganismo é produtor de biofilme e quais as propriedades físico-químicas que estão diretamente relacionadas à penetração do antimicrobiano na matriz polissacarídica, utilizou-se método colorimétrico com cristal violeta em microplacas modificado para obtenção de concentração inibitória mínima em biofilme (MBIC) e método já padronizado para concentração inibitória mínima (MIC). Para isso foram testados 10 antimicrobianos em Staphylococcus spp.: rifampicina, azitromicina, claritromicina, eritromicina, levofloxacino, gentamicina, doxiciclina, cloranfenicol, clindamicina e vancomicina. Para Pseudomonas aeruginosa foram testados os mesmos, exceto rifampicina e vancomicina. A discrepância entre MIC e MBIC foi muito grande para vários fármacos, mostrando a necessidade de se avaliar estes parâmetros antes do início da farmacoterapia para uma escolha correta, especialmente em hospitais. Os fármacos que apresentaram melhores resultados foram a rifampicina e os macrolídeos, enquanto que os menos efetivos foram vancomicina e clindamicina. Isso foi atribuído ao perfil lipofílico, porém com alguma solubilidade em água das melhores moléculas. Em contra ponto, a elevada área polar, complexidade e massa molar foram características negativas para a penetração em biofilme, resultando numa ineficácia para essas moléculas. Além disso, também foi avaliado o tratamento de polímeros plásticos com EDTA, obtendo-se redução significativa da produção de biofilme nas placas tratadas com o agente químico. / The use of central venous catheters in medicine has brought benefits to the patients and represents a great advance in clinical practice, while on the other hand this device is related to an increase in the incidence of infections caused by multiresistant pathogens. Furthermore, frequently, the catheters get colonized by biofilm producing bacteria. These microorganisms adhere to the abiotic material of the catheters keeping themselves protected underneath the exopolysaccharide matrix of biofilm, this way the immune system and antimicrobials are incapable to fulfill their action and, many times, are unable to reach internal bacteria. This fact is explained by the fact that many of the biological and pharmacological agents have physical-chemical properties incompatible with the penetration into the matrix. Aiming to determine which antimicrobials are suitable for using when dealing with a biofilm producing microorganism and which physical-chemical properties are directly related to the agent penetration into the polysaccharide matrix, we used colorimetric method with crystal violet to obtain biofilm minimum inhibitory concentration (MBIC) and the already standardized method for minimum inhibitory concentration (MIC). To accomplish these 10 antimicrobials were tested in Staphylococcus spp.: rifampin, azithromycin, clarithromycin, erythromycin, levofloxacin, gentamicin, doxycycline, chloramphenicol, clindamycin and vancomycin. For Pseudomonas aeruginosa all antimicrobials except for rifampin and vancomycin were included. There was a great difference between MIC and MBIC for many drugs, showing the need to evaluate these parameters before beginning treatment. The drugs with better results were rifampin and macrolides, while the worse were vancomycin and clindamycin, which can be attributed to the lipophilic profile with some water solubility present in the molecules with better results. The characteristics associated with poor penetration into biofilm were high polar surface area, complexity e molecular weight. Furthermore, the previous treatment of the plastic polymers with EDTA was accessed resulting in statistically significant reduction of biofilm production.

Introdução: Enterococcus faecium resistente à vancomicina (EFRV) surgiu como um importante patógeno multirresistente e de etiologia potencialmente letal nas infecções associadas aos cuidados de saúde em todo o mundo. Objetivo: O objetivo deste estudo de coorte retrospectivo foi avaliar os fatores associados à mortalidade em pacientes com bacteremia causadas por EFRV em um grande hospital de referência terciária no sul do Brasil. Métodos: Foram avaliados todos os casos documentados de bacteremia identificados entre maio de 2010 e julho de 2012. Regressão de Cox foi realizada para determinar se as características relacionadas ao hospedeiro ou o tratamento antimicrobiano estavam associadas com a mortalidade por qualquer causa em 30 dias. No total, 35 pacientes documentados com bacteremia por EFRV foram identificados durante o período de estudo. Resultados: A mediana do escore APACHE-II da população do estudo foi 26 (IQR 10). A mortalidade global em 30 dias foi de 65,7%%. Todos isolados de EFRV eram sensíveis à linezolida, daptomicina e quinopristina - dalfopristina. A linezolida foi o único agente antimicrobiano com atividade in vitro contra EFRV que foi administrada à coorte. Após a análise multivariada, o tratamento com linezolida (HR 0,08, 95% CI, 0,02-0,27) e a presença de insuficiência renal aguda no início da bacteremia (HR 4,01, 95% CI, 1,62-9,94) foram associadas de forma independente com o desfecho principal. Conclusão: Apresentação com insuficiência renal aguda e ausência de tratamento com um antibiótico eficaz representa um risco de mortalidade em pacientes com bacteremia por EFRV. / Background: Vancomycin-resistant Enterococcus faecium (VREF) has emerged as a relevant multidrug-resistant pathogen and potentially lethal etiology of health care-associated infections worldwide. Objective: The objective of this retrospective cohort study was to assess factors associated with mortality in patients with VREF bacteremia in a major tertiary referral hospital in southern Brazil. Methods: All documented cases of bacteremia identified between May 2010 and July 2012 were evaluated. Cox regression was performed to determine whether the characteristics related to the host or antimicrobial treatment were associated with the all-cause 30-day mortality. In total, 35 patients with documented VREF bacteremia were identified during the study period. Results: The median APACHE-II score of the study population was 26 (IQR 10). The overall 30-day mortality was 65.7%. All VREF isolates were sensitive to linezolid, daptomycin and quinopristin-dalfopristin. Linezolid was the only antimicrobial agent with in vitro activity against VREF that was administered to the cohort. After multivariate analysis, linezolid treatment (HR, 0.08; 95%CI, 0.02 – 0.27) and presence of acute kidney injury at the onset of bacteremia (HR, 4.01; 95%CI, 1.62 – 9.94) were independently associated with the main outcome. Conclusion: Presentation with acute kidney injury and lack of treatment with an effective antibiotic poses risk for mortality in patients with VREF bacteremia.

O tratamento de infecções por Staphylococcus aureus tem sido problemático devido ao surgimento de cepas resistentes a múltiplios antibióticos. O antibiótico de escolha para o tratamento de infecções por S. aureus resistente a oxacilina é o glicopeptídeo vancomicina. Desde o primeiro isolamento de cepas com sensibilidade reduzida a vancomicina (VISA) em 1997, tem havido crescente preocupação com a disseminação da resistência a este antibiótico. Os mecanismos moleculares que levam à resistência de baixo nível a vancomicina ainda não foram elucidados. A detecção deste fenótipo na rotina de laboratório clínico é laboriosa, pois as técnicas disponíveis são de difícil execução e interpretação. Até agora, não há relato de transmissão horizontal de infecção por VISA, e todas as cepas com este fenótipo foram isoladas de pacientes que faziam o uso prolongado de vancomicina. Uma deficiência no locus regulador de genes acessórios (agr) foi postulado como fator de risco para a aquisição do fenótipo VISA por uma cepa sensível a este antibiótico. Para este estudo, foram selecionadas 47 cepas de S. aureus, com sensibilidades variadas a vancomicina, inclusive 5 cepas VISA isoladas no Brasil. Determinou-se nas cepas as concentrações inibitórias mínimas de vancomicina e oxacilina, a atividade hemolítica em ágar sangue de carneiro e de coelho, a capacidade de aderir ao poliestireno e o polimorfismo do locus agr. Determinou-se a integridade do locus agr por PCR-RFLP e sequenciamento de bases em 13 cepas representativas das 47 estudadas. A integridade do locus regulador acessório sarA também foi avaliada por sequenciamento de bases nestas 13 cepas. Foram escolhidas 18 cepas sensíveis a vancomicina com variadas características fenotípicas e estas foram submetidas à indução de resistência a vancomicina através da passagem seriada em concentrações crescentes deste antibiótico. A taxa de mutação que leva à capacidade de crescimento em 6 µg/mL de vancomicina foi avaliada em 8 cepas através de ensaios de flutuação. Não observou-se correlação entre a aquisição de resistência a vancomicina com as atividades hemolíticas ou capacidade de adesão das cepas. A maioria das cepas (82,9%) apresentou-se como pertencente ao grupo polimórfico agr I, inclusive as cepas VISA. Duas cepas não conseguiram ser induzidas à resistência a vancomicina. O tempo levado para a aquisição de resistência não se correlacionou com nenhuma característica fenotípica ou genotípica de um grupo de cepas. A taxa de mutação que leva à capacidade de crescimento em 6µg/mL de vancomicina apresentou-se maior para uma cepa pertencente ao clone endêmico brasileiro (CEB) cujo locus agr pertence ao grupo I e não apresentou variação de acordo com funcionalidade ou tipo do locus agr. Apenas uma das cepas VISA apresentou uma mutação no locus agr que o torna disfuncional. Os loci agr das outras cepas estudadas apresentaram-se íntegros. O locus sarA das cepas estudadas apresentou-se íntegro e com polimorfismos funcionais agrupados de acordo com a linhagem clonal das cepas. Pôde-se concluir que a integridade funcional do locus agr não é uma condição sine qua non para a aquisição de resistência de baixo nível a vancomicina por parte de uma cepa sensível a este antibiótico. O grupo polimórfico agr II não tem maior predisposição à aquisição de resistência de baixo nível a vancomicina, como havia sido sugerido por alguns trabalhos disponíveis na literatura. / The treatment of staphylococcal infections has lately been a strenuous undertaking due to the resistance of Staphylococcus aureus to multiple antibiotics. The antimicrobial drug of choice for the treatment of methicillin resistant S. aureus (MRSA) is the glycopeptide vancomycin. Since the first isolation of S. aureus with reduced susceptibility to vancomycin (VISA) in 1997, there has been growing concern as to the dissemination of this resistance phenotype among isolates of this species. The molecular mechanisms that result in low level resistance to vancomycin have not yet been completely elucidated. The correct detection of this phenotype in the clinical laboratory is tricky, for the techniques available for this purpose are hard to execute and interpret. Until now, lateral transmission (dissemination) of VISA has not been reported and all strains bearing this phenotype have been isolated from patients who had been making prolonged use of vancomycin. A deficiency in the accessory gene regulator (agr) has been proposed as a risk factor for the acquisition of a VISA phenotype by a susceptible strain. For this study, 47 nosocomial VISA strains, that had been isolated in another study, were used. These strains were isolated from multiple geographical regions of Brazil, and included 5 VISA strains. The minimal inhibitory concentrations (MIC) of vancomycin and oxacillin, as well as haemolysis in sheep and rabbit agar, adhesion to polystyrene and agr polymorphism were determined in all of these strains. The integrity of the agr locus was determined by PCR-RFLP and by nucleotide sequencing in a sample of 13 strains chosen to be representative of the 47 strains studied. The integrity of the Staphylococcal accessory regulator sarA was also determined by nucleotide sequencing in these 13 strains. Another representative sample of 18 strains that were susceptible to vancomycin were submitted to induction of resistance to vancomycin by serial passage in increasing concentrations of this drug. The mutation rate of a mutation that leads to the ability of growing in a concentration of 6 µg/mL of vancomycin was determined for 8 strains by fluctuation assays. There was no correlation between the acquisition of resistance to vancomycin with either haemolysis or adhesion to polystyrene. Most strains (82.9%) bore a group I agr polymorphism, including all of the VISA strains. Two strains could not be induced to resistance. The time taken for each strain to acquire resistance to vancomycin did not correlate with any phenotypic or genotypic characteristic pertaining to a group of strains. The rate of mutation that leads to the ability of growing in 6µg/mL of vancomycin proved to be higher for a strain belonging to the Brazilian Endemic Clone (BEC) bearing an agr group I polymorphism, and did not vary according to presence or type of agr locus. Only one of the VISA strains presented a mutation in the agr locus that renders it disfunctional. The agr loci of the other strains studied presented themselves to be intact. The sarA loci of the strains evaluated were intact however presented functional polymorphisms that were groups according to the clonal lineage of the strains. It can thus be concluded that the functional integrity of the agr locus is not a sine qua non condition for the acquisition of low level resistance to vancomycin by a susceptible strain. Bearing of an agr group II polymorphism does not predispose a strain to acquire resistance to vancomycin, as has been previously suggested in literature.

A Bayesian-derived 24-hour area under the concentration-time curve over minimum inhibitory concentration from broth microdilution (AUC24h/MICBMD) ratio of 400 to 600 is recommended as the new monitoring parameter for vancomycin to optimize efficacy and minimize nephrotoxicity. The AUC24h threshold of 600 mg*h/L for nephrotoxicity was extrapolated from studies that assessed the general population. It is unclear if this upper threshold is consistent or varies when used in special populations such as critically ill patients, obese patients, patients with preexisting renal disease, and patients on concomitant nephrotoxins.The purpose of this study is to investigate the generalizability of the proposed vancomycin AUC24h threshold of 600 mg*h/L for nephrotoxicity. The objective is to determine the optimal Bayesian-derived AUC24h threshold to minimize vancomycin-associated nephrotoxicity in special populations such as critically ill patients, obese patients, patients with preexisting renal disease, and patients on concomitant loop diuretics, ACEIs, ARBs, NSAIDs, aminoglycosides, piperacillin-tazobactam, and IV contrast dyes. The study design is a single-center, retrospective cohort study. For each patient, nephrotoxicity was assessed and the Bayesian-derived AUC24h was estimated. Using classification and regression tree (CART) analysis, the AUC24h threshold for nephrotoxicity was determined for each special population that had at least ten nephrotoxic patients. The predictive performances (e.g., positive predictive value [PPV], negative predictive value [NPV], sensitivity, specificity, and area under the receiver operating characteristic [ROC] curve) of each CART-derived threshold were then compared to the guideline threshold’s predictive performances. PPV and sensitivity were given greater weight when comparing the thresholds. Of the 336 patients, 29 (8.6%) nephrotoxic patients were observed after initiating vancomycin. Among the special populations of interest, critically ill patients, obese patients, patients with preexisting renal disease, and patients on concomitant loop diuretics included at least ten nephrotoxic patients and thus were further analyzed to determine the CART-derived AUC24h thresholds. The CART-derived AUC24h thresholds were 544 mg*h/L for critically ill patients (n=116), 586 mg*h/L for obese patients (n=111), 539 mg*h/L for patients with preexisting renal disease (n=54), and 543 mg*h/L for patients on concomitant loop diuretics (n=126). Compared to the guideline threshold of 600 mg*h/L, the CART-derived thresholds for critically ill patients, patients with preexisting renal disease, and patients on concomitant loop diuretics had comparable PPVs but significantly higher sensitivities. On the other hand, the CART-derived threshold for obese patients did not have a significantly different PPV, NPV, sensitivity, specificity, and area under the ROC curve. For critically ill patients, patients with preexisting renal disease, and patients on concomitant loop diuretics, a lower vancomycin AUC24h threshold for nephrotoxicity such as 544 mg*h/L, 539 mg*h/L, and 543 mg*h/L, respectively, may be considered to minimize the risk of nephrotoxicity. On the other hand, this study supports the continued use of the guideline threshold of 600 mg*h/L to minimize the risk of nephrotoxicity in obese patients.

Les infections dues aux bactéries gram-négatif multi résistantes en particulier la résistance aux carbapénèmes, représentent un problème majeur de santé publique. La hausse des taux de résistance à ces antibiotiques a conduit à la réutilisation de la colistine, comme alternative thérapeutique de dernier recours. Notre travail de thèse s'est concentré sur l'étude épidémiologique de la résistance aux antibiotiques d’isolats cliniques au Liban. Nos travaux se sont scindés en 4 chapitres, avec trois objectifs principaux; (i) l'étude des bactéries résistantes aux carbapénèmes, (ii) l'élucidation des mécanismes moléculaires de la résistance à la colistine (iii) l'émergence de bactéries à Gram-positif résistantes à la vancomycine. Initialement, une revue de la littérature sur l'épidémiologie et les facteurs de risque associés à l'infection bactérienne au cours de conflits armés et catastrophes naturelles en Asie et au Moyen Orient a été rédigée. Dans le deuxième chapitre nous avons cherché à voir l'effet du changement de traitement de la combinaison colistine-carbapénème à la colistine en monothérapie sur la résistance d’A. baumannii, en plus de la détection du blaVIM-2 codé par plasmide. Dans le troisième chapitre, nous avons détecté la propagation de bactéries gram-négatif résistantes à la colistine en raison de la mutation des (pmrA /pmrB, phoP/phoQ), ou mgrB. Enfin, nous détectons l'émergence du gène vanA d'E. faecium. Il serait nécessaire de mettre en place des enquêtes de surveillance de l’usage des antibiotiques pour éviter la propagation de souches résistantes à ces antibiotiques au Liban. / Infections due to multidrug-resistant gram-negative bacteria especially the resistance to carbapenems, have become a major public health problem. This increase in resistance to antibiotics has led to the resuscitation of colistin, as a last-resort treatment option. Our PhD work focused on the epidemiological study of the antibiotic resistance of clinical isolates in Lebanon. This thesis is divided into 5 chapters with three main objectives; (1) the investigation of carbapenem-resistant bacteria in Lebanese hospitals. (2) the Elucidation of the molecular mechanisms of colistin-resistant bacteria in Lebanese patients, and (3) the emergence of vancomycin-resistant gram-positive bacteria in Lebanon. At the start of this thesis, we have prepared a literature review on the epidemiology and the risk factors associated with bacterial infection in conflict wounded and natural disaster in Asia and the Middle East. The second chapter aimed to see the effect of the shift of treatment from colistin-carbapenem combination to colistin monotherapy on the prevalence and resistance of A. baumannii, in addition to the detection of the plasmid-encoded blaVIM-2 gene. In the third chapter, we have detected the spread of colistin-resistant gram-negative bacteria due to mutation of the two-component systems (pmrA /pmrB, phoP/phoQ), or mgrB. We detect the emergence of vanA of Enterococcus faecium resistant to vancomycin. This observation confirms that colistin resistance in Gram-negative bacteria is indeed increasing. In conclusion, it appears necessary and urgent to set up surveys to monitor the use of antibiotics to prevent the spread of resistant strains in Lebanon.

<p>Pathogenic bacteria present a critical threat to modern medicine. Therapeutic strategies to target and eliminate resilient bacteria are not advancing at the same rate as the emergence of bacterial resistance. An associated urgent concern regarding antibiotic resistance is the existence and proliferation of intracellular bacteria, which find refuge from bactericidal mechanisms by hiding within mammalian cells. Therefore, many once-successful antibiotics become ineffective through the development of resistance, or through failure to reach intracellular locations in therapeutic concentration. To overcome these challenges, the covalent combination of a conventional antibiotic with an antibiotic, cell-penetrating peptide was explored to develop dual-action antibiotic conjugates. </p> <p>Herein, we utilized a strategy in conjugating the antibiotics by a cleavable linkage to cationic amphiphilic polyproline helices (CAPHs) to improve vancomycin and linezolid antibiotics. This approach enables the conjugate to penetrate cells and deliver two potent monomeric antimicrobial drugs. The vancomycin-CAPH conjugate, <b>VanP14S</b>, showed enhanced mammalian cell uptake compared to vancomycin, a poor mammalian cell-penetrating agent; and <b>VanP14S</b> was capable of cleaving and releasing two antibiotics under mimicked physiological conditions. Enhanced antibacterial activity was observed against a spectrum of Gram-positive and Gram-negative pathogens, including drug-resistant strains. Further investigation revealed that this conjugate’s bactericidal activity was not entirely the result of significant membrane perturbation such as a lytic mode of action. Mammalian cell toxicity and red blood cell lysis were insignificant at relevant bactericidal concentrations below 20 µM. The current results suggest an enhanced binding to the peptidoglycan of bacteria, the target of vancomycin, although more work is needed to justify this claim. Preliminary results on <b>VanP14GAPS</b>, a conjugate with a more rigid CAPH, convey similar activity to <b>VanP14S; </b>however,<b> </b>moderate increases in red blood cell lysis and cytotoxicity were observed. </p> <p>Regarding the <b>LnzP14</b> conjugate, preliminary data reveal that the conjugate has Gram-negative activity against <i>Escherichia coli</i>, whereas linezolid is ineffective in killing Gram-negative bacteria. This conjugate showed significant enhancement in cellular uptake compared to the CAPH, and the release of linezolid and CAPH in physiological conditions was confirmed. Overall, arming a conventional antibiotic with an antimicrobial, cell-penetrating peptide appears to be a powerful strategy in providing novel antibiotic conjugates with the propensity to overcome the limitations in treating challenging pathogens.</p>

No / We describe a series of experiments designed to investigate the conformational transition that highly-branched polymers with ligands undergo when interacting with bacteria, a process that may provide a new sensing mechanism for bacterial detection. Fluorescent highly-branched poly(N-isopropyl acrylamide)s (HB-PNIPAM) were prepared by sequential self-condensing radical copolymerizations, using anthrylmethyl methacrylate (AMMA) and fluorescein-O-acrylate (FA) as fluorescent comonomers and 4-vinylbenzyl pyrrole carbodithioate as a branch forming monomer. Differences in reactivity necessitated to first copolymerize AMMA then react with FA in a separate sequential monomer feed step. Modifications of the chain ends produced vancomycin-functional derivatives (HB-PNIPAM-Van). The AMMA and FA labels allow probing of the conformational behaviour of the polymers in solution via Forster resonance energy transfer experiments. It was shown that interaction of this polymer's end groups with Staphylococcus aureus induced a macromolecular collapse. The data thus provide conclusive evidence for a conformational transition that is driven by binding to a bacterium.

Yes / Corneal ulcers, a leading cause of blindness in the developing world are treated inappropriately without prior microbiology assessment because of issues related to availability or cost of accessing these services. In this work we aimed to develop a device for identifying the presence of Gram-positive or Gram-negative bacteria or fungi that can be used by someone without the need for a microbiology laboratory. Working with branched poly (N-isopropyl acrylamide) (PNIPAM) tagged with Vancomycin, Polymyxin B, or Amphotericin B to bind Gram-positive bacteria, Gram-negative bacteria and fungi respectively, grafted onto a single hydrogel we demonstrated specific binding of the organisms. The limit of detection of the microbes by these polymers was between 10 and 4 organisms per high power field (100X) for bacteria and fungi binding polymers respectively. Using ex vivo and animal cornea infection models infected with bacteria, fungi or both we than demonstrated that the triple functionalised hydrogel could pick up all 3 organisms after being in place for 30 min. To confirm the presence of bacteria and fungi we used conventional microbiology techniques and fluorescently labelled ligands or dyes. While we need to develop an easy-to-use either a colorimetric or an imaging system to detect the fluorescent signals, this study presents for the first time a simple to use hydrogel system, which can be applied to infected eyes and specifically binds different classes of infecting agents within a short space of time. Ultimately this diagnostic system will not require trained microbiologists for its use and will be used at the point-of-care. / We gratefully acknowledge support for this research by the Well- come Trust which provided funding for Shivshetty, Swift and Pinnock (Grant 0998800/B/12/Z).

Introdução: Enterococcus resistente à vancomicina (VRE do inglês Vancomycin Resistant Enterococcus) é uma importante causa de infecção relacionada a assistência à saúde com alta morbidade e mortalidade principalmente nos pacientes imunocomprometidos sendo a segunda causa mais comum de infecções hospitalares nessa população de pacientes em alguns centros. O uso prolongado da terapia antimicrobiana com vancomicina e outras drogas, são fatores de risco associados com a disseminação desse patógeno. Além disso, espécies de enterococos podem apresentar fatores de virulência tais como: substância de agregação (asa1), gelatinase (gelE), citolisina (cylA), proteína de superfície enterococo (esp) e hidrolase glicosil (hylefm). Entretanto, o papel da virulência na colonização e infecção por VRE é controverso. Objetivos: Avaliar o perfil clonal, virulência e resistência de 86 isolados de VRE (80 E. faecium e 06 E. faecalis) de infecção e colonização de 76 pacientes com doenças hematológicas e/ou submetidos a transplante de Medula Óssea (TMO) internados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) no período de 10 anos (2005-2014). Material e Métodos: Foram realizadas concentração inibitória mínima para: vancomicina, teicoplanina, linezolida, gentamicina e estreptomicina em alta concentração (HLAR); Avaliação da clonalidade por eletroforese em campo pulsado (PFGE); Detecção dos mecanismos de resistência (vanA e vanB) e de virulência (esp, asa1, gelE, cylA e hylefm) pela técnica de PCR e sequenciamento total do genoma de dezoito isolados selecionados de acordo com a clonalidade. Foi criado um banco de dados no programa Epiinfo (CDC) com variáveis clinicas e demográficas dos pacientes. A proporção de isolados de colonização portadores de genes de virulência foi comparada com os isolados de infecção assim como a proporção de isolados de infecção portadores de genes de virulência que evoluíram para óbito. O valor de p < 0,005 foi considerado significativo. Resultados: Trinta e quatro pacientes eram colonizados e 42 infectados por VRE (28 eram infecção de corrente sanguínea), 48 pacientes eram transplantados dos quais 32 eram alogênicos. A mortalidade em 14 dias foi de 21.0% e durante a hospitalização de 53.9%. Todos os isolados foram resistentes à vancomicina e 87,3% à teicoplanina. Resistência a gentamicina e estreptomicina em alta concentração (HLAR) foi observada em 08 e 59 isolados respectivamente. Um isolado apresentou resistência a linezolida identificado pela primeira vez na unidade. O gene vanA foi detectado em todos os isolados. Quanto aos genes de virulência, 96,5% de isolados foram positivos para o gene esp e 69,8% para os genes gelE e asa1. Isolados de infecção de E. faecium carrearam mais genes de virulência: esp (100%), gelE (80,0%) e asa1 (75,5%) e o gene gelE foi significativamente mais frequente entre isolados de infecção que de colonização (p=0,008). Infecções causadas por isolados de E. faecium positivos para o gene asa1 foram significantemente associadas com maior mortalidade (p < 0,05). Quinze diferentes Pulsed field type (PFT) foram observados entre os isolados de E. faecium e 06 entre os isolados de E. faecalis. Dezessete E. faecium foram sequenciados e diferentes sequencias tipo (ST) foram observadas (ST412, ST478, ST78 e ST896) já descritas em outros estudos no Brasil. O isolado resistente a linezolida apresentou mutação no domínio V do gene 23S rRNA com um perfil alélico diferente, caracterizando um novo ST (ST987) descrito pela primeira vez no Brasil. Todos os ST observados nos isolados de E. faecium pertencem ao complexo clonal 17, dos quais dois STs (ST963, ST792) foram descritos pela primeira vez no país. O isolado de E. faecalis sequenciado pertencia ao ST9 e ao complexo clonal 9 já descrito por outros autores. Conclusão: Nosso estudo observou que E. faecium foi predominante em nosso hospital e os ST circulantes pertenciam ao CC17. Os isolados de infecção foram mais virulentos que os isolados de colonização e o gene gelE foi significativamente mais frequente nos isolados de infecção. Infecções causadas por isolados de E. faecium positivos para o gene asa1 foram associadas com a alta mortalidade. Este achado pode ser útil para controlar a disseminação de E. faecium no ambiente hospitalar e em pacientes hematológicos / Introduction: Vancomycin Resistant Enterococcus (VRE) is a important cause of health care-associated infection with high morbidity and mortality, mainly in immunocompromised patients, being the second most common cause of hospital infections in this population of patients in some centers. Prolonged use of antimicrobial therapy with vancomycin and other drugs are risk factors associated with the spread of this pathogen. In addition, enterococcal species may present virulence factors such as: aggregation substance (asa1), gelatinase (gelE), cytolysin (cylA), enterococcal surface protein (esp) and glycosyl hydrolase (hylefm). However, the role of virulence on VRE colonization and infection is controversial. Objectives: To evaluate the clonal profile, virulence and resistance of 86 isolates of VRE (80 E. faecium and 06 E. faecalis) from infection and colonization of 76 patients with hematological diseases and / or submitted to bone marrow transplantation (BMT) at Hospital das Clinics of the Medical School of the University of São Paulo (HC-FMUSP) in the period of 10 years (2005-2014). Material and Methods: Minimum inhibitory concentration to vancomycin, teicoplanin, linezolid, gentamicin and streptomycin in high concentration (HLAR) was performed; Clonality of isolates by pulsed field electrophoresis (PFGE) was evaluated; Detection of resistance (vanA and vanB) and virulence (esp, asa1, gelE, cylA and hylefm) genes by PCR technique and whole genome sequencing of eighteen isolates selected based on clonality. Results: All isolates were resistant to vancomycin and 87.3% to teicoplanin. Resistance to gentamicin and streptomycin in high concentration (HLAR) was observed in 08 and 59 isolates respectively. One isolate presented resistance to linezolid observed for the first time in the unit. The vanA gene was detected in all isolates. Regarding virulence genes, 96.5% of isolates were positive for the esp gene and 69.8% for the gelE and asa1 genes. Isolates of E. faecium infection carried more virulence genes: esp (100%), gelE (80.0%) and asa1 (75.5%) and gelE gene was significantly more frequent among infection isolates than colonization (p = 0.008). Infections caused by E. faecium isolates carrying the asa1 gene were significantly associated with higher mortality (p < 0.05). Fifteen different Pulsed field type (PFT) were observed among the isolates of E. faecium and 06 among E. faecalis isolates. Seventeen E. faecium were sequenced and the following sequences type (ST) were observed (ST412, ST478, ST78 and ST896) all of them already described in Brazil. The linezolid-resistant isolate showed the 23S gene Vdomain mutation with a different allelic profile, characterizing a new ST (ST987) described for the first time in our study. All STs observed in E. faecium isolates belong to clonal complex 17. Two other STs (ST963, ST792) were identified for the first time in the country. The E. faecalis isolate belong to ST9 and clonal complex 9 already described by other authors in Brazil. Conclusion: Our study observed that E. faecium was predominant in our hospital and the circulating STs belonged to CC17 a virulent lineage. E. faecium infection isolates were more virulent than colonization isolates and harbored significantly more gelE gene. It appears that infections caused by E. faecium isolates carrying asa1 gene evolved more frequently to death. This finding may be useful to control the spread of E. faecium in the hospital environment and in haematological patients

Durante os anos 90 um aumento dramático no isolamento de VRE foi reportado nos estados Unidos, principalmente em unidades de terapia intensiva, esta tendência continua até hoje. No Brasil o primeiro caso de VRE foi documentado em 1996 e desde então muitos casos têm sido descritos em todo país. Uma variedade de medidas tem sido usada para reduzir taxas de VRE, mas a melhor estratégia para o controle e prevenção deste patógeno ainda não está totalmente definida. O Objetivo deste estudo foi avaliar o impacto de um processo multidisciplinar para monitorar a adesão de profissionais às precauções padrão e de contato e o papel do meio ambiente e de equipamentos na transmissão de VRE. Este estudo consistiu de três períodos: um período basal, um período de intervenção e outro de pós-intervenção. O teste qui-quadrado foi usado para comparar os dados dos períodos pré e pós-intervenção e o teste de qui-quadrado para tendência linear foi usado para avaliar a distribuição de VRE e o uso de glicopeptídeos durante o período de estudo, o nível de p<0.05 foi significante. As amostars foram avaliadas pela técnica de PFGE. PCR para detecção do gene de resistência foi realizada para as amostras clínicas. E. faecium foi a espécie mais freqüente tendo sido responsável por 71% das culturas positivas. Foram documentadas 36 infecções e aquelas da corrente sangüínea foram as mais frequentes 17 (47%) A intervenção educacional foi realizada com 136 profissionais. Foram avaliadas 706 oportunidades de precauções padrão e de contato. A adesão às precauções padrão e de contato não aumentou comparando os períodos pré e pós-intervenção. Entretanto, a proporção de culturas ambientais e de equipamentos diminuiu significativamente comparando os períodos pré (23.2%) and pós-intervenção (2.4%) (p<0.001) e foram associadas a diminuição das Infecções por VRE por 1.000 pacientes-dia (p=0.004). O uso de vancomicina (DDD) não mudou significativamente ao longo do estudo (p=0.97) e o uso de teicoplanina aumentou principalmente nos últimos meses de 2007 (p<0.001). O mesmo clone de E. faecium foi encontrado em 90% das amostras. No presente estudo, redução da proporção de contaminação ambiental e de equipamentos esteve associada com diminuição das taxas de infecção por VRE. / During the 1990s a dramatic increase of VRE isolation was reported mostly in the Intensive Care Units (UCI) in the USA and the trend continues. In Brazil, the first VRE isolated occurred in 1996 and many cases have been described thereafter. A variety of measures have been used to reduce VRE rates, the optimal approach however to control and prevent this pathogen, is not well defined. The aim of this study was to evaluate the impact of a multidisciplinary process to monitor improve healthcare work (HCW) compliance with standard and contact precautions and the role of environment and equipments on the transmission of VRE. This study consisted of three period baseline, intervention and pos-intervention period. Chi-2 test was used to compared data pre and pos intervention and chi-2 test for linear trend was used to evaluate the distribution VRE and use of glycopeptides during the study period, the level of p<0.05 was significant. PFGE was performed. Detection of genes of resistance of VRE isolated from clinical samples was performed by PCR E. faecium was the most frequent species isolated being responsible for 71% of positives cultures. Thirty-six infection were documented, bloodstream infection 17 (47%) was the most frequent site. The educational intervention was given to 136 HCW. 706 opportunities were evaluated, the compliance with standard and contact precautions did not improve comparing pre and pos-intervention period. However, the proportion of environmental and equipments positive cultures decreased significantly comparing pre (23.2%) and pos-intervention (2.4%) period (p<0.001) and was associated with decrease of VRE infection per 1.000 pts-day (p=0.004). The use of vancomycin (DDD) did not change significantly over the study period (p=0.97) and the use of teicoplanin increased (p<0.001). Ninety percent of E. faecium belong to the same type. In the present study, reduction of proportion of positive environmental and equipments cultures was associated with decreased of rates of VRE infections.