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.

Estudo fitoquímico e biológico das folhas de Banisteriopsis argyrophylla (A. Juss.) B. Gates (Malpighiaceae)

With the increasing fungi resistance compared with existing drugs on the market and the side effects reported by some compounds with antioxidant properties and enzymatic inhibitors, in particular against α-amylase and α-glucosidase, the discovery of new compounds with biological potential, becomes a need. In this context, natural products can be an important source for the discovery of new active molecular architectures. Then, this study aimed to evaluate the antioxidant activity, the enzymatic inhibitory activity of α-amylase and α-glucosidase, the antifungal and cytotoxic activities of ethanolic extract (EE) the leaves of Banisteriopsis argyrophylla (Malpighiaceae) and their fractions, obtained by liquid-liquid extraction using solvents of increasing polarity. The antioxidant activity was evaluated by the free radical DPPH scavenging method (2,2-diphenyl-1-picrylhydrazyl) and the ethyl acetate fractions (FAE) and n-butanol (FB) were the most active, confirmed by the peak current and the oxidation potential obtained by differential pulse voltammetry (DPV). The inhibitory activity of the α-amylase and α-glucosidase was analyzed considering the reactions between substrates α-(2-chloro-4-nitrophenyl)-β-1,4-galactopiranosilmaltoside (Gal-α-G2-CNP) and 4-nitrophenyl-α-D-glucopyranoside (p-NPG), respectively. Initially, it was found that the EE showed considerable activity against α-amylase (EC50 = 2.89±0.1 μg m L–1) compared to the acarbose used as positive control (EC50 = 0.08±0.1 μg mL–1) and that did not showed promising activity against the α-glucosidase. After this observation we evaluated the inhibitory activity of α-amylase fractions, with FAE (EC50 = 2.33±0.1 μg mL–1) and FB (EC50 = 2.57 ± 0.1 μg mL–1) showing the best inhibitions. The antifungal activity was evaluated against Candida species, and the FAE had better antifungal potential (MIC's between 93.75 and 11.72 μg mL–1) compared with amphotericin as positive standard (MIC = 1.00 and 2.00 μg L–1 for C. parapsilosis and C. krusei used as controls, respectively). The EE (CC50 = 360.00 ± 12 μg mL–1) and fractions (CC50's> 270.00 μg mL–1) were considerably less toxic to Vero cells than the cisplatin used as positive control (CC50 = 7.01 ± 0 6 μg mL–1). The FAE showed the best results for the activities studied, this fraction was submitted to ultra performance liquid chromatography coupled with mass spectrometry (UPLC-MS)), and the following flavonoids have been identified: (±)-catechin, quercetin-3-O-β-D-Glc/ quercetin-3-O-β-D-Gal, quercetin-3-O-β-L-Ara, quercetin-3-O-β-D-Xyl, quercetin-3-O-α-L-Rha, kaempferol-3-O-α-L-Rha, quercetin-3-O-(2''-galoil)-α-L-Rha, quercetin-3-O-(3''-galoil)-α-L-Rha and kaempferol-3-O-(3''-galoil)-α-L-Rha,. FAE was submitted to column chromatography using C18 phase, and (±)-catechin was isolated (FAE-A1, 73 mg) and three fractions consisting of a mixture of flavonoids were obtained (FAE-A2, FAE-A3 and FAE-A4). These compounds were identified by thin layer chromatography (TLC) and (–)-ESI-MS. The (±)-catechin fraction showed an MIC = 2.83 μg ml–1 in assay using C. glabrata, with amphotericin as positive control. The fractions FAE-A2, FAE-A3, FAE-A4, showed less antifungal potential in tested concentrations. The identified flavonoids are described in the literature, regarding their antioxidant capacity and (±)-catechin, quercetin-3-O-Rha and kaempferol-3-O-Rha are described as α-amylase inhibitors. Thus, B. argyrophylla is an important species that produces compounds with antioxidant potential that can be related to the traditional use as anti-inflammatory and also has antifungal compounds and inhibitors of α-amylase. Therefore, these leaves are promising resources for the production of new drugs.