RESUMO
BACKGROUND: Many gaps in the burden of resistant pathogens exist in endemic areas of low- and middle-income economies, especially those endemic for carbapenem resistance. The aim of this study is to evaluate risk factors for carbapenem-resistance, to estimate the association between carbapenem-resistance and all-cause 30-day mortality and to examine whether mortality is mediated by inappropriate therapy. METHODS: A case-control and a cohort study were conducted in one tertiary-care hospital in Medellín, Colombia from 2014 to 2015. Phenotypic and genotypic characterization of isolates was performed. In the case-control study, cases were defined as patients infected with carbapenem-resistant K. pneumoniae (CRKP) and controls as patients infected with carbapenem-susceptible K. pneumoniae (CSKP). A risk factor analysis was conducted using logistic regression models. In the cohort study, the exposed group was defined as patients infected with CRKP and the non-exposed group as patients infected with CSKP. A survival analysis using an accelerated failure time model with a lognormal distribution was performed to estimate the association between carbapenem resistance and all-cause 30-day-mortality and to examine whether mortality is mediated by inappropriate therapy. RESULTS: A total of 338 patients were enrolled; 49 were infected with CRKP and 289 with CSKP. Among CRKP isolates CG258 (n = 29), ST25 (n = 5) and ST307 (n = 4) were detected. Of importance, every day of meropenem (OR 1.18, 95%CI 1.10-1.28) and cefepime (OR 1.22, 95%CI 1.03-1.49) use increase the risk of carbapenem resistance. Additional risk factors were previous use of ciprofloxacin (OR 2.37, 95%CI 1.00-5.35) and urinary catheter (OR 2.60, 95%CI 1.25-5.37). Furthermore, a significant lower survival time was estimated for patients infected with CRKP compared to CSKP (Relative Times 0.44, 95%CI 0.24-0.82). The strength of association was reduced when appropriate therapy was included in the model (RT = 0.81 95%CI 0.48-1.37). CONCLUSION: Short antibiotic courses had the potential to reduce the selection and transmission of CRKP. A high burden in mortality occurred in patients infected with CRKP in a KPC endemic setting and CRKP leads to increased mortality via inappropriate antibiotic treatment. Furthermore, dissemination of recognized hypervirulent clones could add to the list of challenges for antibiotic resistance control.
Assuntos
Antibacterianos/uso terapêutico , Enterobacteriáceas Resistentes a Carbapenêmicos , Doenças Endêmicas , Infecções por Klebsiella/tratamento farmacológico , Infecções por Klebsiella/mortalidade , Klebsiella pneumoniae/genética , Meropeném/uso terapêutico , Idoso , Antibacterianos/efeitos adversos , Estudos de Casos e Controles , Cefepima/efeitos adversos , Cefepima/uso terapêutico , Ciprofloxacina/efeitos adversos , Ciprofloxacina/uso terapêutico , Colômbia , Farmacorresistência Bacteriana Múltipla , Feminino , Genótipo , Humanos , Estimativa de Kaplan-Meier , Klebsiella pneumoniae/isolamento & purificação , Modelos Logísticos , Masculino , Meropeném/efeitos adversos , Pessoa de Meia-Idade , Fenótipo , Estudos Prospectivos , Fatores de Risco , Análise de Sobrevida , Cateteres Urinários/efeitos adversosRESUMO
OBJECTIVE: The purpose of this study was to understand through a quantitative assessment, the views of HPV and HPV vaccination among parents of sons from a FQHC in PR. METHODS: A self-administered questionnaire was given to a convenience sample of 200 parents of sons 9-17 years old. RESULTS: Nearly 30% of the parents reported that their sons had initiated the HPV vaccine regimen. Health care provider recommendation was significantly associated with vaccine initiation. Among parents of unvaccinated sons, the main reason for not getting the HPV vaccine was they did not know that boys were allowed to get the vaccine. CONCLUSIONS: Future efforts should focus on multilevel interventions aimed to increase knowledge as well as other modified behavioral determinants in parents of young males about HPV and the vaccine. Capacity building efforts should be targeted also to increase health providers' education and communication skills to promote HPV vaccination effectively.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Infecções por Papillomavirus/psicologia , Vacinas contra Papillomavirus/administração & dosagem , Pais/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adolescente , Adulto , Criança , Estudos Transversais , Feminino , Humanos , Masculino , Infecções por Papillomavirus/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Porto Rico , Provedores de Redes de Segurança , Fatores SocioeconômicosRESUMO
Introducción: la producción de enzimas con actividad hidrolítica frente a carbapenémicos, denominadascarbapenemasas, es uno de los principales mecanismos de resistencia a carbapenémicos en Pseudomonas aeruginosa. El test de Hodge modificado es la prueba fenotípica más empleada para la detección de carbapenemasas; sin embargo, de acuerdo con el CLSI, este método sólo puede emplearse en Enterobacteriáceas ya que presenta limitaciones en Bacilos Gram negativos no fermentadorescomo Pseudomonas aeruginosa. Objetivo: evaluar la eficacia de variaciones del test de Hodge modificado para la detección de carbapenemasas en aislados de Pseudomonas aeruginosa. Materiales y métodos: se evaluó el desempeño del test 3D y tres variaciones del test de Hodge modificado, tomando como prueba de referencia la detección de los genes de las carbapenemasas KPC, VIM, IMP, NDM y OXA-48 mediante reacción en cadena de la polimerasa. Las variaciones consistieron en emplear: a) agar MacConkey en lugar de Mueller Hinton, b) Klebsiella pneumoniae ATCC 700603 como cepa indicadora sensible a carbapenémicos en lugar de Escherichia coli ATCC 29212 y c) las dos condiciones anteriores simultáneamente. Resultados: de los ensayos evaluados, la tercera variación, que empleó tanto agar MacConkey como la cepa indicadora de Klebsiella pneumoniaeATCC 700603, mostró los mejores valores de sensibilidad y especificidad para la detección de carbapenemasas en Pseudomonas aeruginosa (90,0% y 85,7%, respectivamente). Conclusiones: la implementación de las variaciones del test de Hodge modificado podría ser una alternativa económica y de fácil realización para la detección fenotípica de carbapenemasas en Pseudomonas aeruginosa en los laboratorios de Microbiología Clínica.
Introduction: one of the most important mechanisms of carbapenem resistance in Pseudomonas aeruginosa is the production of carbapenem-hydrolyzing enzymes known as carbapenemases. The modified Hodge test is the most frequently used phenotypic screening test for carbapenemases. Nevertheless,CLSI recommends using modified Hodge test only in members of Enterobacteriaceae, sincethe test has demonstrated limitations in other Gram-negative bacilli and non-glucose-fermenters as Pseudomonas aeruginosa. Objective: To evaluate the performance of 3D test and three variations of modified Hodge test to detect carbapenemases in Pseudomonas aeruginosa isolates. Materials and methods: The efficacy of 3D test and three variations in modified Hodge test were evaluated taking polymerase chain reaction for carbapenemases KPC, VIM, IMP, NDM and OXA-48 as the gold standard. Variations consisted in using a) MacConckey agar instead of Mueller Hinton, b) Klebsiellapneumoniae ATCC 700603 as indicator carbapenem-sensitive strain instead of Escherichia coli ATCC 29212 and c) last two conditions simultaneously. Results: Of the variations tested, the third assay using both MacConckey agar and Klebsiella pneumoniae ATCC 700603 showed the best sensitivity and specificity (90.0% and 85.7%, respectively). Conclusions: The implementation of variations in modified Hodge test could be a cheap and easy to perform alternative for phenotypic carbapenemase detection in Pseudomonas aeruginosa in Clinical Microbiology laboratories.