Carlos Emílio Levy

Isolation in Brazil of nosocomial Staphylococcus aureus with reduced susceptibility to vancomycin

OBJECTIVE To evaluate the possible presence of vancomycin-resistant Staphylococcus aureus (VRSA) in a Brazilian hospital. DESIGN Epidemiological and laboratory investigation of nosocomial VRSA. METHODS 140 methicillin-resistant S aureus strains isolated between November 1998 and October 1999 were screened for susceptibility to vancomycin. The screening was carried out by using brain-heart infusion agar (BHIA) supplemented with 4, 6, and 8 microg/mL of vancomycin. The minimum inhibitory concentration (MIC) determination was carried out as standardized by the National Committee for Clinical Laboratory Standards using the broth macrodilution, agar-plate dilution, and E-test methods. PATIENTS Hospitalized patients exposed to vancomycin. RESULTS 5 of the 140 isolates had a vancomycin MIC of 8 microg/mL by broth macrodilution, agar plate dilution, and E-test methods. Four VRSA strains were isolated from patients in a burn unit who had been treated with vancomycin for more than 30 days, and one from an orthopedic unit patient who had received vancomycin treatment for 7 days. Pulsed-field gel electrophoresis characterized four of the VRSA strains as belonging to the Brazilian endemic clone. All five strains were negative for vanA, vanB, and vanC genes by polymerase chain reaction. Transmission electron microscopy of the five strains revealed significantly thickened cell walls. One patient died due to infection caused by the VRSA strain. CONCLUSIONS This is the first report of isolation of VRSA in Brazil and the first report of isolation of multiple VRSA strains from one facility over a relatively short period of time. This alerts us to the possibility that VRSA may be capable of nosocomial transfer if adequate hospital infection control measures are not taken.

BTEX biodegradation by bacteria from effluents of petroleum refinery

Groundwater contamination with benzene, toluene, ethylbenzene and xylene (BTEX) has been increasing, thus requiring an urgent development of methodologies that are able to remove or minimize the damages these compounds can cause to the environment. The biodegradation process using microorganisms has been regarded as an efficient technology to treat places contaminated with hydrocarbons, since they are able to biotransform and/or biodegrade target pollutants. To prove the efficiency of this process, besides chemical analysis, the use of biological assessments has been indicated. This work identified and selected BTEX-biodegrading microorganisms present in effluents from petroleum refinery, and evaluated the efficiency of microorganism biodegradation process for reducing genotoxic and mutagenic BTEX damage through two test-systems: Allium cepa and hepatoma tissue culture (HTC) cells. Five different non-biodegraded BTEX concentrations were evaluated in relation to biodegraded concentrations. The biodegradation process was performed in a BOD Trak Apparatus (HACH) for 20 days, using microorganisms pre-selected through enrichment. Although the biodegradation usually occurs by a consortium of different microorganisms, the consortium in this study was composed exclusively of five bacteria species and the bacteria Pseudomonas putida was held responsible for the BTEX biodegradation. The chemical analyses showed that BTEX was reduced in the biodegraded concentrations. The results obtained with genotoxicity assays, carried out with both A. cepa and HTC cells, showed that the biodegradation process was able to decrease the genotoxic damages of BTEX. By mutagenic tests, we observed a decrease in damage only to the A. cepa organism. Although no decrease in mutagenicity was observed for HTC cells, no increase of this effect after the biodegradation process was observed either. The application of pre-selected bacteria in biodegradation processes can represent a reliable and effective tool in the treatment of water contaminated with BTEX mixture. Therefore, the raw petroleum refinery effluent might be a source of hydrocarbon-biodegrading microorganisms.

Characterization of the Brazilian endemic clone of methicillin-resistant Staphylococcus aureus (MRSA) from hospitals throughout Brazil

The objective of this study was to characterize patterns of the Brazilian endemic clone of methicillin-resistant Staphylococcus aureus (MRSA) from hospitals throughout Brazil. We studied 83 MRSA strains isolated from patients hospitalized in 27 public and private hospitals in 19 cities located in 14 Brazilian states from September, 1995, to June, 1997. The MRSA strains were typed using antibiograms, bacteriophage typing and pulsed field gel electrophoresis (PFGE). The analysis of genomic DNA by PFGE showed that 65 isolates presented the same PFGE pattern. This pattern was present in all of the hospitals studied indicating the presence of an endemic MRSA clone widely disseminated throughout Brazilian hospitals (BEC). All isolates belonging to the BEC proved to be resistant to ciprofloxacin, erythromycin, lincomycin, trimethoprim-sulphamethoxazole, and tetracycline. Variable susceptibility to these drugs was found only in isolates belonging to clones other than the BEC. The results show that, among MRSA, the BEC is common in Brazil. The best method for mapping changes in the frequency of this clone among MRSA is pulsed field gel electrophoresis. Use of molecular mapping is an important tool for monitoring the spread of potentially dangerous microbes.

Saliva as a potential tool for cystic fibrosis diagnosis

BackgroundSaliva and sweat are modified by cystic fibrosis (CF). In both cases the chloride and sodium ion concentrations for healthy subjects and CF patients differ, this representing a possible alternative tool for CF diagnosis. In this context, the aim of this study was to compare the concentrations of these ions in saliva samples taken from CF patients and healthy subjects.MethodsA case–control study was carried out at a university CF center, in which the saliva samples were analyzed on an ABL 835 Radiometer® to determine the ion concentration.ResultsFor the CF patients (n = 80) the values for the biochemical parameters of chloride, potassium and sodium ion concentration were higher (p < 0.009) and the volume and pH of the saliva were lower than in the case of healthy subjects (p < 0.009). For the healthy subjects group (n = 84) versus CF patients, according to the ROC curve, the values for sodium were: cutoff: 13.5 mmol/L, sensitivity: 73.4%, specificity: 70.6%; and for chloride: cutoff: 20 mmol/L, sensitivity: 68.1%, specificity: 72.9%.ConclusionsThe chloride and sodium concentrations in the saliva samples were higher for CF patients in comparison with healthy subjects. Thus, saliva as a tool for CF diagnosis can be considered a new challenge, and a population study including patients in all age classes needs to be performed, in different countries over the world, to extend the database to include a broad spectrum of information in order to identify normal ion concentration ranges for CF patients according to age, genotype and environment.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2614233148750145

Application of micronucleus test and comet assay to evaluate BTEX biodegradation

The BTEX (benzene, toluene, ethylbenzene and xylene) mixture is an environmental pollutant that has a high potential to contaminate water resources, especially groundwater. The bioremediation process by microorganisms has often been used as a tool for removing BTEX from contaminated sites. The application of biological assays is useful in evaluating the efficiency of bioremediation processes, besides identifying the toxicity of the original contaminants. It also allows identifying the effects of possible metabolites formed during the biodegradation process on test organisms. In this study, we evaluated the genotoxic and mutagenic potential of five different BTEX concentrations in rat hepatoma tissue culture (HTC) cells, using comet and micronucleus assays, before and after biodegradation. A mutagenic effect was observed for the highest concentration tested and for its respective non-biodegraded concentration. Genotoxicity was significant for all non-biodegraded concentrations and not significant for the biodegraded ones. According to our results, we can state that BTEX is mutagenic at concentrations close to its water solubility, and genotoxic even at lower concentrations, differing from some described results reported for the mixture components, when tested individually. Our results suggest a synergistic effect for the mixture and that the biodegradation process is a safe and efficient methodology to be applied at BTEX-contaminated sites.

Serum antibodies to Pseudomonas aeruginosa in cystic fibrosis as a diagnostic tool: A systematic review

BACKGROUND A systematic literature review of the last 40 years on the research of serum antibodies to Pseudomonas aeruginosa in cystic fibrosis and its utility as a diagnostic tool. METHODS Research papers in English, Portuguese, and Spanish were accessed through electronic databases (PubMed, Medline, LILACS, and SciELO). RESULTS 26 studies were assessed. ELISA technique was the most commonly used technique to detect serum P. aeruginosa antibodies. The most consistent results were those in which the response against the antigen St-Ag:1-17 was evaluated. The accuracy levels of the ELISA technique remain controversial, but most studies showed a good correlation between antibody titers and microbiological culture. CONCLUSIONS The detection of serum antibodies to P. aeruginosa shows capacity for early detection of this pathogen and potential utility and viability of incorporation in the diagnostic routine of patients with cystic fibrosis.

Pseudomonas aeruginosa multirresistente: um problema endêmico no Brasil

Global reports have documented the endemicity of multidrug-resistant (MDR) Pseudomonas aeruginosa associated with high levels of morbidity/mortality. In Brazil, outbreaks of MDR P. aeruginosa have been related to clonal dissemination. Currently, therapeutic options for the treatment of these infections are restricted to carbapenemic antibiotics (i.e., imipenem [IPM]). Thus, carbapenem resistance is a public health issue, since carbapenems are considered the last resort to nosocomial infections caused by MDR Gram-negative bacteria. In Brazil, the main mechanisms associated with MDR P. aeruginosa phenotypes are metallo-betalactamase (MBL) production (SPM-1 enzyme), presence of 16S rRNA methylase RmtD, loss of OprD porin, and overexpression of efflux pumps, which may explain the high level of carbapenem and aminoglycoside resistance. Accordingly, the emergence and dissemination of MDR strains is worrisome. Finally, based on national reports published by different groups of investigators, it is deduced that the convergence of multiple mechanisms of P. aeruginosa resistance has played a major role in the selection of endemic MDR clones widespread in Brazil.

Pseudomonas aeruginosa infection in patients with cystic fibrosis: scientific evidence regarding clinical impact, diagnosis, and treatment

Evidence-based techniques have been increasingly used in the creation of clinical guidelines and the development of recommendations for medical practice. The use of levels of evidence allows the reader to identify the quality of scientific information that supports the recommendations made by experts. The objective of this review was to address current concepts related to the clinical impact, diagnosis, and treatment of Pseudomonas aeruginosa infections in patients with cystic fibrosis. For the preparation of this review, the authors defined a group of questions that would be answered in accordance with the principles of PICO–an acronym based on questions regarding the Patients of interest, Intervention being studied, Comparison of the intervention, and Outcome of interest. For each question, a structured review of the literature was performed using the Medline database in order to identify the studies with the methodological design most appropriate to answering the question. The questions were designed so that each of the authors could write a response. A first draft was prepared and discussed by the group. Recommendations were then made on the basis of the level of scientific evidence, in accordance with the classification system devised by the Oxford Centre for Evidence-Based Medicine, as well as the level of agreement among the members of the group.

Laryngoscope blades and handles as sources of cross-infection: an integrative review.

The lack of standardization of efficient procedures to clean and disinfect laryngoscope blades and handles, which may be important sources of infection during their clinical use, has been reported previously, revealing contamination with blood, body fluids and micro-organisms. This paper aimed to evaluate the evidence available in the literature regarding the risk of laryngoscope blades and handles as a source of patient contamination. An integrative review of the literature was performed using databases such as Medline, LILACS, SciELO, Cochrane Library, BDENF and PubMed, and keywords in Medical Subject Headings (MeSH). The sample comprised 20 articles published between 1994 and 2012. The studies demonstrated risk of cross-infection and no consensus in current guidelines regarding cleaning and disinfection of this equipment. It was concluded that there are important gaps to be filled and urgent investigations required in order to facilitate standardization of efficient procedures to clean and disinfect laryngoscope blades and handles, and in turn to reduce the potential risk to which the patient and/or health team is exposed.

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital

INTRODUCTION Vancomycin-resistant enterococci (VRE) can colonize or cause infections in high-risk patients and contaminate the environment. Our objective was to describe the epidemiological investigation of an outbreak of VRE, the interventions made, and their impact on its control. METHODS We conducted a retrospective, descriptive, non-comparative study by reviewing the charts of patients with a VRE-positive culture in the University Hospital of Campinas State University, comprising 380 beds, 40 of which were in intensive care units (ICUs), who were admitted from February 2008-January 2009. Interventions were divided into educational activity, reviewing the workflow processes, engineering measures, and administrative procedures. RESULTS There were 150 patients, 139 (92.7%) colonized and 11 (7.3%) infected. Seventy-three percent were cared for in non-ICUs (p = 0.028). Infection was more frequent in patients with a central-line (p = 0.043), mechanical ventilation (p = 0.013), urinary catheter (p = 0.049), or surgical drain (p = 0.049). Vancomycin, metronidazole, ciprofloxacin, and third-generation cephalosporin were previously used by 47 (31.3%), 31 (20.7%), 24 (16%), and 24 (16%) patients, respectively. Death was more frequent in infected (73%) than in colonized (17%) patients (p < 0.001). After the interventions, the attack rate fell from 1.49 to 0.33 (p < 0.001). CONCLUSIONS Classical risk factors for VRE colonization or infection, e.g., being cared for in an ICU and previous use of vancomycin, were not found in this study. The conjunction of an educational program, strict adhesion to contact precautions, and reinforcement of environmental cleaning were able to prevent the dissemination of VRE.