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.

O ensino de arte pós-moderno na arte de Daniel Francisco de Souza

This thesis presents a research that links cultural history and visual culture in a sociobiographical approach. It gives a “political treatment” to the educational experience in the transition of art teaching from the modern to the postmodern. By taking into account my experiences as an educator and the poetic practice in Daniel Francisco de Souza’s visual art, I propose a dialogue with his art and a series of visual narratives this artist/student produced at the time of his education and recently. Such visual narratives were taken as research source and research subject. They were created in a rural setting in dialogue with formal art teaching in two phases: 1992–6, when Daniel Fran cisco attended elementary school in the rural area of Uberlândia, MG; and 2008–10, when he attended Visual Arts graduation at Federal University of Uberlândia city. I analyze historical processes related to art and teaching, from the early sixteenth century to the present times, to realize residues in students’ poetic experiences. I relate Brazilian educational public policies with experi- ences in that rural school. I try to show the extent to which our educational practices triggered experiences — from ones common to intense ones — and promoted forms of “emancipation-knowledge” or “regulation-knowledge” and how the “selective tradition” was and how art predetermined history images gave way to everyday visual references, pointing to the “broad field” of visual culture. I make an effort to show Daniel Francisco’s work as an adult by tak- ing it according to different approaches. In a poetic reading, first, I emphasixe the material and the symbolic in his art. In a second look, I approach his work through the intertwining experiences of three characters from different times and places that participated in the making of his art: the artist farmer, the artist teacher and the teacher researcher. I assume the existence of a mutual cultural incompleteness in these three characters; which means that parts of their “structures of feeling” built on the interrelationship among them are part of the artist’ work as a historical content decanted. Thirdly, I demonstrate how the artist sees his place as a key re ference to his poetic creation. His work does not reflect the rural bucolic as something untouched. In showing the difficulty in distinguishing the archaic residual, I identify emerging issues in his work. I conclude that the artist — Daniel Francisco — and the researcher — myself — present maverick features: both are scavengers; their productions approach the working with scraps in art and in the academy; even momentarily, they live in exile in the warmth of the borders or the edges, from where one sees the center clearly. In these spaces, when certain structures and normative codes enter into coalition, they fragment pre-established strategies and stimulate the creation of survival tactics.