Infecções por enterobacteriaceae resistente aos carbapenêmicos em hospital de ensino: epidemiologia e caracterização molecular

Introduction: The production of KPC (Klebsiella pneumoniae carbapenemase) has become an important mechanism of carbapenem-resistance among Enterobacteriaceae strains. In Brazil, KPC is already widespread and its incidence has increased significantly, reducing treatment options. The “perfect storm” combination of the absence of new drug developmentand the emergence of multidrug-resistant strains resulted in the need for the use of older drugs, with greater toxicity, such as polymyxins. Aims: To determine the occurrence of carbapenemase-producing strains in carbapenem-resistant Enterobacteriaceae isolated from patients with nosocomial infection/colonization during September/2014 to August/2015, to determine the risk factors associated with 30-day- mortality and the impact of inappropriate therapy. Materials and Methods: We performed a case control study to assess the risk factors (comorbidities, invasive procedures and inappropriate antimicrobial therapy) associated with 30-day-mortality, considering the first episode of infection in 111 patients. The resistance genes blaKPC, blaIMP, blaVIM and blaNDM-1 were detected by polymerase chain reaction technique. Molecular typing of the strains involved in the outbreak was performed by pulsed field gel electrophoresis technique. The polymyxin resistance was confirmed by the microdilution broth method. Results: 188 episodes of carbapenem-resistant Enterobacteriaceae infections/colonizations were detected; of these, 122 strains were recovered from the hospital laboratory. The presence of blaKPC gene were confirmed in the majority (74.59%) of these isolates. It was not found the presence of blaIMP , blaVIM and blaNDM-1 genes. K. pneumoniae was the most frequent microorganism (77,13%), primarily responsible for urinary tract infections (21,38%) and infections from patients of the Intensive Care Unit (ICU) (61,38%). Multivariate statistical analysis showed as predictors independently associated with mortality: dialysis and bloodstream infection. The Kaplan-Meier curve showed a lower probability of survival in the group of patients receiving antibiotic therapy inappropriately. Antimicrobial use in adult ICU varied during the study period, but positive correlation between increased incidence of strains and the consumption was not observed. In May and July 2015, the occurrence rates of carbapenem-resistant Enterobacteriaceae KPC-producing per 1000 patient-days were higher than the control limit established, confirming two outbreaks, the first caused by colistin-susceptible KPC-producing K. pneumoniae isolates, with a polyclonal profile and the second by a dominant clone of colistin-resistant (≥ 32 μg/mL) KPC-producing K. pneumoniae. The cross transmission between patients became clear by the temporal and spatial relationships observed in the second outbreak, since some patients occupied the same bed, showing problems in hand hygiene adherence among healthcare workers and inadequate terminal disinfection of environment. The outbreak was contained when the ICU was closed to new admissions. Conclusions: The study showed an endemicity of K. pneumoniae KPC-producing in adult ICU, progressing to an epidemic monoclonal expansion, resulted by a very high antibiotic consumption of carbapenems and polymyxins and facilitated by failures in control measures the unit.

Diagnóstico ambiental da área de influência do complexo sucroalcooleiro Usina Vale do São Simão Ltda

One of the most widespread renewable energy sources in Brazil is ethanol, from sugarcane, therefore, the sugar and alcohol sector is expanding, with positive impacts for the economy of the country. Sugar cane was introduced in Brazil as a crop during its colonization, for the production of sugar, and put the country in the global scenario. The expansion of this crop occurred in the seventies, to reduce the reliance in fossil energy sources and to stimulate the development of the agricultural activity. Thus, the federal government has promoted the sugar cane crop and the production of ethanol as a fuel. However, it is important to minimize possible impacts that the crop may cause to the environment. Sugar cane has expanded in the frontiers of the mesoregion of Triângulo Mineiro and Alto Paranaíba-MG, and, in this perspective, the agroindustrial complex known as Companhia Energética Vale do São Simão Ltda., with the Mill located in the county of Santa Vitória, Minas Gerais, was adopted to evaluate the environmental impacts caused by the sugarcane in the area of influence of the mill. The mill has a polygonal area corresponding to 53,525.20 hectares, and for its establishment a Study and Report of Environmental Impacts (EIA/RIMA) was presented, as required as an environment protection instrument by the Environment National Policy (Law nº 6.938/81), and detailed by the Resolution CONAMA nº 01/1986. These studies pointed that native vegetation fragments in the Area of Influence of the Mill, before its implantation, corresponded to approximately 20.7% of the area. Therefore, this study evaluated the impacts of the installation of Usina Vale do São Simão, between 2007 and 2012, determining its reflex on the environmental regularization of the farms, and the vegetation fragments existing in the area, in the recovery and recomposition of areas defined as Legal Reserve and Permanent Preservation. Previous studies of the area were analyzed, soil use and occupation was mapped for the years 2007 and 2012, and the areas of permanent preservation and native vegetation fragments were marked. In general, there was a decline in native vegetation coverage in the period, although it cannot be stated that such reduction was a direct effect of the milling activity. Therefore, the legal requirement of preserving such areas was not capable of bringing the positive effects of protection and recovery as demanded by the Law, highlighting that the current legislation was not enough to protect such areas.