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.

Transposição didática da interação do laser com sistmas biológicos no ensino médio: uma proposta de guia didático para professores

In this dissertation was elaborated an interdisciplinary didactic sequence for the development of Physical concepts involved in the interaction of laser radiation with biological matter in order to make a relation between Physics and other fields of knowledge aiming to enlarge the contextualization of scientific knowledge. The objective was to develop an educational product which theme is “Laser’s Interaction with Biological Tissues”. In this work, basic physical concepts related to laser radiation were presented, its interaction with matter and applicability in the student's daily life, with emphasis on Public Health. The inclusion of the subject in schools was effected through didactic transposition as theoretical foundation and the three pedagogical moments as teaching support. The development of the project involved discussions of scientific knowledge applied in society’s daily life. In the product's design the didactic sequence was projected and the use of varied teaching resources has been proposed, such as videos, texts, experiments, simulators and de Software “Tracker”. The construction of paradidactic material was performed considering different stages of equal importance for a teacher's reflection process. The work prioritizes the alternative conceptions of student, transforming him in a direct agent of the construction of knowledge and this aspect is based on the profile of the Student's Material. Another important point is the evaluation's proposal, this was systematized to be done class after class through building texts, essay questions, presentation of papers, among others activities. The didactic sequence guides the introduction of relevant topics of the students and society’s daily life, the ideas are not closed and in many times the teacher make changes which deem relevant to the teaching for better development of their practice.