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.

Uma proposta de ensino de frações no 6º ano do ensino fundamental a partir da teoria histórico-cultural

This text presents developed in the Graduate Program in Science and Mathematics Education at the Federal University of Uberlândia, in which it was intended to answer the question: What are the pedagogical implications for the fractions concept learning for students of the 6th grade of elementary school that the teaching guide activities can provide? The objectives of this research were: a) analyze the possible pedagogical implications for the learning of the fraction's concept for students of the 6th grade of elementary school through guiding teaching activities; b) using the conceptual connections of the fraction to enable students to develop an abstract thought and c) investigate whether guiding teaching activities reflect on 'how to think' and 'how to do' of the student. Five teaching activities have been developed (MOURA, 2002) from the perspective of teaching guiding activity (TGA) and had as object of study the teaching of fractions for students in 6th year of elementary school. They have been prepared and proposed activities in which it was intended to investigate the use of history of mathematics as an aid in learning the conceptual fraction links (CARAÇA, 1951) by students. Such activities, for analysis, were organized into episodes and scenes (MOURA, 2004) and discussed how students deal with the measurement of whole quantity (all) and subunits (part); how they represent in verbal or written language. It is hoped that the research is set up as an important contribution to mathematics teaching area and may contribute to the initial and continuing training of mathematics teacher sand the formation of theoretical thinking of elementary school students.