Some pneumococcal serotypes are more frequently associated with relapses of acute exacerbations in COPD patients

Objectives: To analyze the role of the capsular type in pneumococci causing relapse and reinfection episodes of acute exacerbation in COPD patients. Methods: A total of 79 patients with 116 recurrent episodes of acute exacerbations caused by S. pneumoniae were included into this study (1995–2010). A relapse episode was considered when two consecutive episodes were caused by the same strain (identical serotype and genotype); otherwise it was considered reinfection. Antimicrobial susceptibility testing (microdilution), serotyping (PCR, Quellung) and molecular typing (PFGE/MLST) were performed. Results: Among 116 recurrent episodes, 81 (69.8%) were reinfections, caused by the acquisition of a new pneumococcus,and 35 (30.2%) were relapses, caused by a pre-existing strain. Four serotypes (9V, 19F, 15A and 11A) caused the majority (60.0%) of relapses. When serotypes causing relapses and reinfection were compared, only two serotypes were associatedwith relapses: 9V (OR 8.0; 95% CI, 1.34–85.59) and 19F (OR 16.1; 95% CI, 1.84–767.20). Pneumococci isolated from relapses were more resistant to antimicrobials than those isolated from the reinfection episodes: penicillin (74.3% vs. 34.6%, p,0.001), ciprofloxacin (25.7% vs. 9.9%, p,0.027), levofloxacin (22.9% vs. 7.4%, p = 0.029), and co-trimoxazole (54.3% vs. 25.9%, p,0.001). Conclusions: Although the acquisition of a new S. pneumoniae strain was the most frequent cause of recurrences, a third ofthe recurrent episodes were caused by a pre-existing strain. These relapse episodes were mainly caused by serotypes 9V and 19F, suggesting an important role for capsular type

Tannin-tolerant bacteria from crossbred Holstein x Zebu cows

The objective of this work was to isolate and characterize tannin-tolerant ruminal bacteria from crossbred Holstein x Zebu cows fed a chopped mixture of elephant grass (Pennisetum purpureum), young stems of "angico-vermelho" (Parapiptadenia rigida), and banana tree (Musa sp.) leaves. A total of 117 bacteria strains were isolated from enrichment cultures of rumen microflora in medium containing tannin extracts. Of these, 11 isolates were able to tolerate up to 3 g L-1 of tannins. Classical characterization procedures indicated that different morphological and physiological groups were represented. Restriction fragments profiles using Alu1 and Taq1 of 1,450 bp PCR products from the 16S rRNA gene grouped the 11 isolates into types I to VI. Sequencing of 16S rRNA PCR products was used for identification. From the 11 strains studied, seven were not identifiable by the methods used in this work, two were strains of Butyrivibrio fibrisolvens, and two of Streptococcus bovis.

Major variables influencing correct antibiotic prescription by primary care physicians in acute pharyngitis: a cross-sectional study

Objectives:To analyse which are the main variables that influence primary care professionals, in the prescription of antibiotics in patients with acute pharyngitis.To analyse which is the diagnosis pattern used by primary care professionals towards cutepharyngitis. To recognize the clinical and analytical criteria that primary care professionals use, to determine antibiotic treatment in acute pharyngitis.To identify the main clinical variables related with the prescription of antibiotics by primary care professionals, in acute pharyngitis treatment. Design: Cross-­‐sectional study Participants:165 primary care professionals from the Sanitary Region of Girona not attending paediatric patients and randomly selected from 29 ABS managed by two of the main health care providers: Insitut Català de la Salut (ICS) and Institut d’Assistència Sanitària (IAS) Main outcome measures: Each participant will fill out a questionnaire with personal and workplace questions, as well as about knowledge and attitude in front of the acute pharyngitis caused by group A streptococci. They will also answer 4 clinical questions about correct treatment and diagnosis of acute pharyngitis caused by group A streptococci

Bacterial variations on the methionine salvage pathway.

BACKGROUND: The thiomethyl group of S-adenosylmethionine is often recycled as methionine from methylthioadenosine. The corresponding pathway has been unravelled in Bacillus subtilis. However methylthioadenosine is subjected to alternative degradative pathways depending on the organism. RESULTS: This work uses genome in silico analysis to propose methionine salvage pathways for Klebsiella pneumoniae, Leptospira interrogans, Thermoanaerobacter tengcongensis and Xylella fastidiosa. Experiments performed with mutants of B. subtilis and Pseudomonas aeruginosa substantiate the hypotheses proposed. The enzymes that catalyze the reactions are recruited from a variety of origins. The first, ubiquitous, enzyme of the pathway, MtnA (methylthioribose-1-phosphate isomerase), belongs to a family of proteins related to eukaryotic intiation factor 2B alpha. mtnB codes for a methylthioribulose-1-phosphate dehydratase. Two reactions follow, that of an enolase and that of a phosphatase. While in B. subtilis this is performed by two distinct polypeptides, in the other organisms analyzed here an enolase-phosphatase yields 1,2-dihydroxy-3-keto-5-methylthiopentene. In the presence of dioxygen an aci-reductone dioxygenase yields the immediate precursor of methionine, ketomethylthiobutyrate. Under some conditions this enzyme produces carbon monoxide in B. subtilis, suggesting a route for a new gaseous mediator in bacteria. Ketomethylthiobutyrate is finally transaminated by an aminotransferase that exists usually as a broad specificity enzyme (often able to transaminate aromatic aminoacid keto-acid precursors or histidinol-phosphate). CONCLUSION: A functional methionine salvage pathway was experimentally demonstrated, for the first time, in P. aeruginosa. Apparently, methionine salvage pathways are frequent in Bacteria (and in Eukarya), with recruitment of different polypeptides to perform the needed reactions (an ancestor of a translation initiation factor and RuBisCO, as an enolase, in some Firmicutes). Many are highly dependent on the presence of oxygen, suggesting that the ecological niche may play an important role for the existence and/or metabolic steps of the pathway, even in phylogenetically related bacteria. Further work is needed to uncover the corresponding steps when dioxygen is scarce or absent (this is important to explore the presence of the pathway in Archaea). The thermophile T. tengcongensis, that thrives in the absence of oxygen, appears to possess the pathway. It will be an interesting link to uncover the missing reactions in anaerobic environments.

Impact of antibiotic resistance on chemotherapy for pneumococcal infections

Over the past three decades, penicillin-resistant pneumococci have emerged worldwide. In addition, penicillin-resistant strains have also decreased susceptibility to other β-lactams (including cephalosporins) and these strains are often resistant to other antibiotic groups, making the treatment options much more difficult. Nevertheless, the present in vitro definitions of resistance to penicillin and cephalosporins in pneumococci could not be appropriated for all types of pneumococcal infections. Thus, current levels of resistance to penicillin and cephalosporin seem to have little, if any, clinical relevance in nonmeningeal infections (e.g., pneumonia or bacteremia). On the contrary, numerous clinical failures have been reported in patients with pneumococcal meningitis caused by strains with MICs ≥ 0.12 μg/ml, and penicillin should never be used in pneumococcal meningitis except when the strain is known to be fully susceptible to this drug. Today, therapy for pneumococcal meningitis should mainly be selected on the basis of susceptibility to cephalosporins, and most patients may currently be treated with high-dose cefotaxime (±) vancomycin, depending on the levels of resistance in the patient's geographic area. In this review, we present a practical approach, based on current levels of antibiotic resistance, for treating the most prevalent pneumococcal infections. However, it should be emphasized that the most appropriate antibiotic therapy for infections caused by resistant pneumococci remains controversial, and comparative, randomized studies are urgently needed to clarify the best antibiotic therapy for these infections

Investigation phytochimique d'une brosse à dents africaine Zanthoxylum zanthoxyloides (Lam.) Zepernick et Timler (Syn. Fagara zanthoxiloides L.) (Rutaceae)

Résumé: Dans le but de rechercher de nouveaux composés naturels à intérêt thérapeutique, les extraits dichlorométhanique et méthanolique de Zanthoxylum zanthoxyloides (Lam.) Zepernick et Timler (Syn. Fagara zanthoxyloides L.) (Rutaceae), une brosse à dents africaine ont été soumis à un criblage chimique et biologique. Un dépistage des activités: antifongiques contre le champignon phytopathogène Cladosporium cucumerinum et la levure commensale responsable de mycoses chez l'homme Candida albicans, antibactérienne contre la bactérie opportuniste Bacillus subtilis, larvicide contre le moustique vecteur de la fièvre jaune Aedes aegypti et molluscicide contre Biomphalaria glabrata, un escargot impliqué dans la transmission de la schistosomiase urinaire a été réalisé. Les propriétés antiradicalaires et inhibitrices de l'acétylcholinestérase de ces extraits ont aussi été dépistées. Sur la base des résultats obtenus lors de ce screening, l'investigation phytochimique de ces extraits a été entreprise. Elle a abouti à l'isolement de 14 composés, actifs pour la majorité contre Cladosporium cucumerinum et Bacillus subtilis, dont la structure a été établie au moyen de méthodes spectroscopiques (UV, MS, IR, 1H- et 13C-NMR). Des méthodes chimiques (hydrolyse, acétylation) ont été requises pour la confirmation de structures. L'extrait dichlorométhanique a fourni un nouveau composé, un dérivé du phényléthane, ainsi que dix composés connus, dont trois dérivés du phénylpropane, un lignane, un alcaloïde de la famille des benzophénanthridines, un triterpène, deux amides phénoliques et deux amides oléfmiques. L'extrait méthanolique a fourni un nouveau composé avec une fonction endoperoxyde, qui avait montré une activité inhibitrice modérée de l'acétylcholinestérase, ainsi que l'hespéridine et un dérivé de la chélérythrine. Par ailleurs, l'analyse LC/UV/APC1-MS de cet extrait a permis de détecter on-une sept produits connus. Parmi ces composés, se trouvent l'acide divanilloylquinique, la chélérythrine et quatre de ses dérivés: norchélérythrin.e, 6-(2-oxybutyl) dihydrochélérythrine, 6-hydroxy-dihydrochélérythrine et avicine, ainsi qu'une amide phénolique, l'amottianamide. La présence de ces dérivés de la chélérythrine a été mise en évidence dans deux autres espèces du même genre lors d'une étude LC/UV/APCI-MS comparative. Les activités fongicides contre Cladosporium cucumerinum et Candida albicans et bactéricides contre Bacillus subtilis et Streptococcus mutans ATCC 25175, mises en évidence sur plaque CCM et par les tests de dilution dans l'agar de ces composés, permettent de justifier l'utilisation de Zanthoxylum zanthoxyloides (Lam.) Zepemick et Timler comme brosse à dents africaine. Les techniques couplées de pointe utilisées dans cette étude ont montré leur apport inestimable dans le domaine de la recherche phytochimique et les applications futures dans le domaine de déréplication d'extraits bruts. Abstract: With the aim of discovering new natural therapeutics, the dichloromethane and methanol extracts of the African toothbrush tree Zanthoxylum zanthoxyloides (Lam.) Zepernick et Timler (Syn. Fagara zanthoxyloides L.) (Rutaceae), were submitted to biological and chemical assays. The former included: the antifimgal activities of the extracts against the phytopathogenic fungus Cladosporium cucumerinum, the commensal yeast which causes human mycoses Candida albicans, the bactericidal activity against the opportunistic bacteria Bacillus subtilis, the larvicidal activity against the yellow fever-transmitting mosquito Aedes aegypti and the molluscicidal effect on the snail Biomphalaria glabrata involved in the transmission of urinary schistosomiasis. The antiradical and acetylcholinesterase-inhibiting properties of these extracts were also investigated. On the basis of these results, a phytochemical investigation of the dichloromethane and methanol extracts of Zanthoxylum zanthoxyloides was undertaken. Their fractionation led to the isolation of 14 compounds, the majority of which were active against Cladosporium cucumerinum and Bacillus subtilis, whose structures were elucidated by spectroscopic techniques (UV, MS, IR, 1H- and 13C-NMR). Chemical methods (hydrolysis, acetylation) were performed to confirm the structures. The dichloromethane extract yielded a new phenylethane derivative, together with ten known compounds: three phenylpropane derivatives, a lignan, a benzophenanthridine alkaloid, a triterpene and four phenolic and olefinic amides. The methanol extract yielded a new compound with an endoperoxide moiety, which showed moderate acetylcholinesterase-inhibiting activity, together with hesperidin and a chelerythrine derivative. Seven more compounds were detected on-line by LC/UV/APCI-MS. Among the compounds detected were divanilloylquinic acid, chelerythrine and four chelerythrine derivatives: norchelerythrine, 6-(2-oxybuty1)-dihydrochelerythrine, 6-hydroxy dihydrochelerythrine and avicine, together with the phenolic amide amottianamide. Most of the chelerythrine derivatives were also found in two other Zanthoxylum species following LC/UV/APCI-MS analysis. The antifungal activities against Cladosporium cucumerinum and Candida albicans and antibacterial activities against Bacillus subtilis and Streptococcus mutans ATCC 25175, may explain the utilization in traditional medicine of the roots of this plant as a toothbrush. The advanced hyphenated techniques used in this study showed their inestimable contribution to the field of phytochemical research and applications in the field of dereplication of crude extracts.

Atividade antioxidante e antimicrobiana de extratos de atemoia (Annona cherimola Mill. x A. squamosa L.)

O objetivo deste trabalho foi quantificar os teores de fenóis e flavonoides totais, bem como avaliar as atividades antioxidante e antimicrobiana de extratos obtidos dos talos e folhas de atemoia (A. cherimola Mill. x A. squamosa L.), que pertence à família Annonaceae. A atividade antioxidante foi avaliada pelos métodos de sequestro dos radicais 2,2-difenil-1-picrilhidrazil (DPPH) e 2,2'-azinobis-3-etilbenzotiazolina-6-ácido sulfônico (ABTS), bem como pelo método da cooxidação do β-caroteno/ácido linoleico. A avaliação da atividade antimicrobiana dos extratos foi analisada contra 10 cepas de bactérias. Os resultados da atividade antioxidante dos extratos mostraram que o extrato etanólico dos talos (EEt) foi o antioxidante mais efetivo (IC50 = 10,44 ± 1,25 µg/mL) no método do sequestro do DPPH, bem como no sequestro do radical ABTS (24,81 ± 0,49%). O extrato hexânico das folhas apresentou o melhor percentual de atividade antioxidante no ensaio do β-caroteno/ácido linoleico (41,12 ± 4,35%). Os extratos etanólico dos talos e metanólico das folhas mostraram-se ativos contra cepas de Bacillus cereus, Klebsiella pneumoniae, Staphylococcus aureus resistente à meticilina (MRSA), Staphylococcus aureus e Staphylococcus epidermidis.

CSF lactate for accurate diagnosis of community-acquired bacterial meningitis.

CSF lactate measurement is recommended when nosocomial meningitis is suspected, but its value in community-acquired bacterial meningitis is controversial. We evaluated the diagnostic performance of lactate and other CSF parameters in a prospective cohort of adult patients with acute meningitis. Diagnostic accuracy of lactate and other CSF parameters in patients with microbiologically documented episodes was assessed by receiver operating characteristic (ROC) curves. The cut-offs with the best diagnostic performance were determined. Forty-five of 61 patients (74%) had a documented bacterial (n = 18; S. pneumoniae, 11; N. meningitidis, 5; other, 2) or viral (n = 27 enterovirus, 21; VZV, 3; other, 3) etiology. CSF parameters were significantly different in bacterial vs. viral meningitis, respectively (p < 0.001 for all comparisons): white cell count (median 1333 vs. 143/mm(3)), proteins (median 4115 vs. 829 mg/l), CSF/blood glucose ratio (median 0.1 vs. 0.52), lactate (median 13 vs. 2.3 mmol/l). ROC curve analysis showed that CSF lactate had the highest accuracy for discriminating bacterial from viral meningitis, with a cutoff set at 3.5 mmol/l providing 100% sensitivity, specificity, PPV, NPV, and efficiency. CSF lactate had the best accuracy for discriminating bacterial from viral meningitis and should be included in the initial diagnostic workup of this condition.

The High Prevalence and Diversity of Chlamydiales DNA within Ixodes ricinus Ticks Suggest a Role for Ticks as Reservoirs and Vectors of Chlamydia-Related Bacteria.

The Chlamydiales order is composed of nine families of strictly intracellular bacteria. Among them, Chlamydia trachomatis, C. pneumoniae, and C. psittaci are established human pathogens, whereas Waddlia chondrophila and Parachlamydia acanthamoebae have emerged as new pathogens in humans. However, despite their medical importance, their biodiversity and ecology remain to be studied. Even if arthropods and, particularly, ticks are well known to be vectors of numerous infectious agents such as viruses and bacteria, virtually nothing is known about ticks and chlamydia. This study investigated the prevalence of Chlamydiae in ticks. Specifically, 62,889 Ixodes ricinus ticks, consolidated into 8,534 pools, were sampled in 172 collection sites throughout Switzerland and were investigated using pan-Chlamydiales quantitative PCR (qPCR) for the presence of Chlamydiales DNA. Among the pools, 543 (6.4%) gave positive results and the estimated prevalence in individual ticks was 0.89%. Among those pools with positive results, we obtained 16S rRNA sequences for 359 samples, allowing classification of Chlamydiales DNA at the family level. A high level of biodiversity was observed, since six of the nine families belonging to the Chlamydiales order were detected. Those most common were Parachlamydiaceae (33.1%) and Rhabdochlamydiaceae (29.2%). "Unclassified Chlamydiales" (31.8%) were also often detected. Thanks to the huge amount of Chlamydiales DNA recovered from ticks, this report opens up new perspectives on further work focusing on whole-genome sequencing to increase our knowledge about Chlamydiales biodiversity. This report of an epidemiological study also demonstrates the presence of Chlamydia-related bacteria within Ixodes ricinus ticks and suggests a role for ticks in the transmission of and as a reservoir for these emerging pathogenic Chlamydia-related bacteria.

High quality draft genomes of the Mycoplasma mycoides subsp. mycoides challenge strains Afadé and B237.

Members of the Mycoplasma mycoides cluster' represent important livestock pathogens worldwide. Mycoplasma mycoides subsp. mycoides is the etiologic agent of contagious bovine pleuropneumonia (CBPP), which is still endemic in many parts of Africa. We report the genome sequences and annotation of two frequently used challenge strains of Mycoplasma mycoides subsp. mycoides, Afadé and B237. The information provided will enable downstream 'omics' applications such as proteomics, transcriptomics and reverse vaccinology approaches. Despite the absence of Mycoplasma pneumoniae like cyto-adhesion encoding genes, the two strains showed the presence of protrusions. This phenotype is likely encoded by another set of genes.

Approches diagnostiques des bactéries intracellulaires et des germes fastidieux [Diagnostic approach of intracellular bacteria and fastidious microorganisms].

Obligate or facultative intracellular bacteria are fastidious organisms that do not or poorly grow on conventional culture media. Some of them may be the cause of frequent and potentially severe infections, such as tuberculosis (Myco- bacterium tuberculosis), community-acquired respiratory infections (Legionella spp., Mycoplasma pneumoniae, Chlamydia pneumoniae) or blood culture-negative endocarditis (Coxiella burnetii, Bartonella spp., Tropheryma whipplei). The objective of this paper is to provide a comprehensive summary of the available and recommended diagnostic tests for the detection of these fastidious organisms in clinical practice.

High expression levels of macrophage migration inhibitory factor sustain the innate immune responses of neonates.

The vulnerability to infection of newborns is associated with a limited ability to mount efficient immune responses. High concentrations of adenosine and prostaglandins in the fetal and neonatal circulation hamper the antimicrobial responses of newborn immune cells. However, the existence of mechanisms counterbalancing neonatal immunosuppression has not been investigated. Remarkably, circulating levels of macrophage migration inhibitory factor (MIF), a proinflammatory immunoregulatory cytokine expressed constitutively, were 10-fold higher in newborns than in children and adults. Newborn monocytes expressed high levels of MIF and released MIF upon stimulation with Escherichia coli and group B Streptococcus, the leading pathogens of early-onset neonatal sepsis. Inhibition of MIF activity or MIF expression reduced microbial product-induced phosphorylation of p38 and ERK1/2 mitogen-activated protein kinases and secretion of cytokines. Recombinant MIF used at newborn, but not adult, concentrations counterregulated adenosine and prostaglandin E2-mediated inhibition of ERK1/2 activation and TNF production in newborn monocytes exposed to E. coli. In agreement with the concept that once infection is established high levels of MIF are detrimental to the host, treatment with a small molecule inhibitor of MIF reduced systemic inflammatory response, bacterial proliferation, and mortality of septic newborn mice. Altogether, these data provide a mechanistic explanation for how newborns may cope with an immunosuppressive environment to maintain a certain threshold of innate defenses. However, the same defense mechanisms may be at the expense of the host in conditions of severe infection, suggesting that MIF could represent a potential attractive target for immune-modulating adjunctive therapies for neonatal sepsis.

Reduction in the use of diagnostic tests in infants with risk factors for early-onset neonatal sepsis does not delay antibiotic treatment

BACKGROUND: Despite a low positive predictive value, diagnostic tests such as complete blood count (CBC) and C-reactive protein (CRP) are commonly used to evaluate whether infants with risk factors for early-onset neonatal sepsis (EOS) should be treated with antibiotics. STUDY DESIGN: We investigated the impact of imple- menting a protocol aiming at reducing the number of dia- gnostic tests in infants with risk factors for EOS in order to compare the diagnostic performance of repeated clinical examination with CBC and CRP measurement. The primary outcome was the time between birth and the first dose of antibiotics in infants treated for suspected EOS. RESULTS: Among the 11,503 infants born at 35 weeks during the study period, 222 were treated with antibiotics for suspected EOS. The proportion of infants receiving an- tibiotics for suspected EOS was 2.1% and 1.7% before and after the change of protocol (p = 0.09). Reduction of dia- gnostic tests was associated with earlier antibiotic treat- ment in infants treated for suspected EOS (hazard ratio 1.58; 95% confidence interval [CI] 1.20-2.07; p <0.001), and in infants with neonatal infection (hazard ratio 2.20; 95% CI 1.19-4.06; p = 0.01). There was no difference in the duration of hospital stay nor in the proportion of infants requiring respiratory or cardiovascular support before and after the change of protocol. CONCLUSION: Reduction of diagnostic tests such as CBC and CRP does not delay initiation of antibiotic treat- ment in infants with suspected EOS. The importance of clinical examination in infants with risk factors for EOS should be emphasised.

Some pneumococcal serotypes are more frequently associated with relapses of acute exacerbations in COPD patients

Objectives: To analyze the role of the capsular type in pneumococci causing relapse and reinfection episodes of acute exacerbation in COPD patients. Methods: A total of 79 patients with 116 recurrent episodes of acute exacerbations caused by S. pneumoniae were included into this study (1995–2010). A relapse episode was considered when two consecutive episodes were caused by the same strain (identical serotype and genotype); otherwise it was considered reinfection. Antimicrobial susceptibility testing (microdilution), serotyping (PCR, Quellung) and molecular typing (PFGE/MLST) were performed. Results: Among 116 recurrent episodes, 81 (69.8%) were reinfections, caused by the acquisition of a new pneumococcus,and 35 (30.2%) were relapses, caused by a pre-existing strain. Four serotypes (9V, 19F, 15A and 11A) caused the majority (60.0%) of relapses. When serotypes causing relapses and reinfection were compared, only two serotypes were associatedwith relapses: 9V (OR 8.0; 95% CI, 1.34–85.59) and 19F (OR 16.1; 95% CI, 1.84–767.20). Pneumococci isolated from relapses were more resistant to antimicrobials than those isolated from the reinfection episodes: penicillin (74.3% vs. 34.6%, p,0.001), ciprofloxacin (25.7% vs. 9.9%, p,0.027), levofloxacin (22.9% vs. 7.4%, p = 0.029), and co-trimoxazole (54.3% vs. 25.9%, p,0.001). Conclusions: Although the acquisition of a new S. pneumoniae strain was the most frequent cause of recurrences, a third ofthe recurrent episodes were caused by a pre-existing strain. These relapse episodes were mainly caused by serotypes 9V and 19F, suggesting an important role for capsular type

Prevención de la infección neonatal precoz por estreptococo del grupo B

El estreptococo del grupo B (EGB) constituye la principal causa de morbimortalidad neonatal y de morbilidad materna durante el embarazo y el posparto. Coloniza el aparato digestivo y el genitourinario en un 10-30% de las gestantes, con una tasa de transmisión vertical del 50%. De entre los recién nacidos colonizados, un 1-2% desarrollará una sepsis grave precoz. Se ha realizado una revisión bibliográfica con el objetivo de conocer las estrategias de prevención de la infección neonatal por EGB. Los resultados ponen de manifiesto que las recomendaciones para su prevención consisten en el cribado universal prenatal de colonización por EGB mediante cultivo vaginorrectal a las 35-37 semanas, y la administración de profilaxis antibiótica intraparto a todas las embarazadas portadoras.