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.

Território, Criminalidade e tráfico de drogas ilícitas em Montes Claros/MG

Urban violence, manifestly public and free, has changed the standard of sociability of townspeople. The city is an increasingly private space of hopes of reducing the risk of victimization, due to the fear of violence that separates and distances the classes in expectation of concealing this behavior. However, violence has many facets and, in one way or another, will always be present as a product of social friction. It is in the urban context and using drug trafficking as a backdrop that this work raises questions about the territorial violence in Montes Claros - MG. The objective was to analyze the dynamics of illicit drug trafficking from the concepts of territory, observing to what extent the appropriation of space contributes to the use of violence, especially in interpersonal disputes. Methodologically, it seeks from quantitative and qualitative techniques make the spatial distribution of criminal indicators, defining and creating hierarchy territories of violence in urban areas. From the qualitative approach seeks to organize and analyze data together to the Civil and Military Police, Brazilian Institute of Geography and Statistics -IBGE, João Pinheiro Foundation and the System of the Ministry of Health Mortality Information - SIM. The opportunity of miscegenation between the knowledge of the survey respondents and the official data has introduced qualitative part. The city of Montes Claros has been taken as an object of observation due to a set of conditions, which stood its medium size, your importance in the regional context and their socioeconomic disparities. The results point to the existence of multiple territoriality of violence involving the trafficking of illicit drugs in urban space. Territorial disputes by the traffickers have victimized people with socioeconomic characteristics and urban spatial origin similar. The dynamism of the established boundaries from the cohesion and / or rupture of the interests of those involved creates and destroys territories in the power struggle.