RESUMO
Until 2015, polymyxin resistance was primarily attributed to chromosomal mutations. However, with the first report of mobile colistin resistance (mcr-1) in commensal Escherichia coli from food animals in China, the landscape has changed. To evaluate the presence of polymyxin resistance in Salmonella spp., a drop screening test for colistin and polymyxin B was carried out on 1156 isolates of non-human origin (animals, food, and the environment), received in Brazil, between 2016 and 2021. Subsequently, 210 isolates with resistant results in the drop test were subjected to the gold-standard test (broth microdilution) for both colistin and polymyxin B. Whole-genome sequencing (WGS) of 102 resistant isolates was performed for a comprehensive analysis of associated genes. Surprisingly, none of the isolates resistant to colistin in the drop test harbored any of the mcr variants (mcr-1 to mcr-10). WGS identified that the most common mutations were found in pmrA (n= 22; T89S) and pmrB (n = 24; M15T, G73S, V74I, I83A, A111V). Other resistance determinants were also detected, such as the aac(6')-Iaa gene in 72 isolates, while others carried beta-lactamase genes (blaTEM-1blaCTX-M-2, blaCMY-2). Additionally, genes associated with fluoroquinolone resistance (qnrB19, qnrS1, oqxA/B) were detected in 11 isolates. Colistin and polymyxin B resistance were identified among Salmonella from non-human sources, but not associated with the mcr genes. Furthermore, the already-described mutations associated with polymyxin resistance were detected in only a small number of isolates, underscoring the need to explore and characterize unknown genes that contribute to resistance.
RESUMO
OBJECTIVES: This study reports the genomic characterization of the multidrug resistant Salmonella Newport strain 195_20 recovered from the diarrheic faeces of a foal in Brazil and co-harbouring the mcr-9, blaCMY-2 and qnrB19 antibiotic resistance genes. METHODS: Bacterial isolate positive for mobile colistin resistance gene (mcr-9) was submitted to antimicrobial susceptibility testing by disk diffusion and broth microdilution for colistin and polymyxin B. The isolate was submitted to whole genome sequencing by Illumina technology and Nanopore Sequencing. Conjugation assays, plasmid sizes determined by S1-PFGE and plasmid content were investigated by hybrid assembly after MinIon long reads sequencing. RESULTS: Isolate 195_20 was identified as sequence type ST45, resistant to penicillin and cephalosporins (ampicillin, ceftazidime, ceftriaxone and cefotaxime), aminoglycosides (streptomycin and gentamicin), phenicol (chloramphenicol), quinolones and fluoroquinolones (nalidixic acid, ciprofloxacin, and pefloxacin), folate pathway antagonists (sulfonamides and trimethoprim-sulfamethoxazole), and tetracycline. A transferable IncHI2/IncHI2A plasmid sized ca. 262kb was found to carry the mcr-9 gene in a module consisting of IS903-mcr-9-wbuC-IS26. In addition, an 174kb IncC and a 48kb IncN plasmid were also identified in the 195_20 isolate, carrying blaCMY-2 and qnrB19, respectively. CONCLUSIONS: Not surprisingly, isolate 195_20 was susceptible to polymyxins, possibly due to absence of qseBC regulatory operon. Presence of mobile colistin resistance (mcr-9), third-generation cephalosporins (blaCMY-2) and quinolone (qnrB19) resistance determinants in zoonotic pathogens from animals in close contact with humans alerts for the possible route of transmission between these different reservoirs.
Assuntos
Colistina , Proteínas de Escherichia coli , Animais , Cavalos , Humanos , Escherichia coli/genética , Proteínas de Escherichia coli/genética , Antibacterianos/farmacologia , Genômica , Salmonella/genética , Fezes , CefalosporinasRESUMO
This study analyzes the genomic findings of the first report of Salmonella isolate carrying the blaCTX-M-55 gene, recovered from a bacteremic patient from Brazil. A bacterial isolate positive for the blaCTX-M-55 gene was submitted to antimicrobial susceptibility testing by disk diffusion and epsilometric test. Whole genome sequencing was performed using Illumina technology. Conjugation assay was performed; plasmid sizes determined by S1-PFGE and plasmid content were investigated by hybrid assembly after MinION long reads sequencing. Isolate 288_18 was identified as sequence type ST13, resistant to ampicillin, cefotaxime, ceftazidime, cefepime, ceftriaxone, and aztreonam. A transferable IncFII plasmid sized approximately 67 kb was found to carry the blaTEM-1 and blaCTX-M-55 in a module consisting of IS26-blaTEM-1B-WbuC-blaCTX-M-55-IS26. In addition, an 117 kb IncI1plasmid was also identified in the 288_18 isolate, but without additional resistance genes. To the best of our knowledge, this is the first report of blaCTX-M-55 in Salmonella isolated from human infection in Brazil. The occurrence of blaCTX-M-55 in the IncFII epidemic plasmid in a relevant clinical human isolate of Salmonella Agona underscores the urgent need for enhanced and effective continuous surveillance for controlling its dissemination.
Assuntos
Antibacterianos , Escherichia coli , Humanos , Antibacterianos/farmacologia , beta-Lactamases/genética , Brasil/epidemiologia , Escherichia coli/genética , Testes de Sensibilidade Microbiana , Plasmídeos/genética , Salmonella/genética , Análise de Sequência , Proteínas de Bactérias/genéticaRESUMO
A resistência antimicrobiana está se tornando um grande desafio para saúde pública devido ao aumento da resistência aos beta-lactâmicos em geral. Os isolados de Salmonella spp. e Escherichia coli são os mais frequentes agentes causadores de doenças de transmissão hídrica e alimentar, mas também podem causar doenças invasivas graves, principalmente em imunodeprimidos, idosos e crianças. Ambos os patógenos vêm apresentando perfis de resistência as principais classes de antibióticos, nestes casos é necessária a busca de uma nova opção terapêutica, como por exemplo, as polimixinas. Em 2015, surgiu o primeiro relato da resistência às polimixinas mediado pelo gene mcr (mobile colistin resistance), que se disseminou por diversos continentes e ocasionou uma grande preocupação global em saúde pública. O objetivo deste trabalho foi identificar e caracterizar os mecanismos que medeiam à resistência à polimixinas em cepas de Salmonella spp. e E. coli Patogênica extraintestinal (ExPEC). Foi realizado a triagem pelo teste da gota e teste da CIM frente a colistina e polimixina B no total de 1026 isolados de Salmonella enterica e 159 isolados de ExPEC. Nos isolados resistentes foi verificado a presença de mutações nos genes (pmrA/B, phoP/Q) associados à resistência às polimixinas, e através da PCR foi feita a identificação dos genes de resistência plasmidial (mcr). Das 124 cepas de Salmonella resistentes a colistina e polimixina B, apenas um isolado foi positivo para o gene mcr-1, e este gene foi detectado em um plasmídeo do grupo IncX4. A cepa 2018.466 foi caracterizada como S. Choleraesuis proveniente de sangue de origem humana. Foram identificados 44 isolados de Salmonella spp. apresentando mutações em pmrA e pmrB. Dos 56 isolados de ExPEC resistentes a colistina, 21 isolados apresentaram o gene mcr-1. Este gene foi detectado em plasmídeos do grupo IncX4 (n=17) e em plasmídeos do grupo IncF (n=4). Cinco isolados de E.coli não apresentaram mutações nos genes estudados,sendo que três eram positivos para o gene mcr-1, enquanto as demais cepas apresentaram mutações em pmrA/B e phoP/Q. A tipagem pela PFGE foi realizada nos isolados de E.coli positivos para o gene mcr-1, com o objetivo de verificar a diversidade genética encontrada entre elas. Foram identificados 18 perfis genéticos, sem um clone principal...(AU)
Antimicrobial resistance is becoming a major public health challenge due to increasing resistance to beta-lactams in general. Salmonella spp. and Escherichia coli are the most frequent causative agents of diseases transmitted by water and food, but they can also cause serious invasive diseases, especially in immunosuppressed individuals, the elderly and children. Both pathogens have shown resistance profiles to the main classes of antibiotics, in these cases it is necessary to search for a new therapeutic option, such as polymyxins. In 2015, the first report of resistance to polymyxins mediated by the mcr gene (mobile colistin resistance) appeared, which spread across several continents and caused a major global concern in public health. The objective of this work was to identify and characterize the mechanisms that mediate resistance to polymyxins in strains of Salmonella spp. and extraintestinal pathogenic E. coli (ExPEC). Screening by drop test and MIC test against colistin and polymyxin B was performed on a total of 1026 Salmonella enterica isolates and 159 ExPEC isolates. In the resistant isolates, the presence of mutations in the genes (pmrA/B, phoP/Q) associated with resistance to polymyxins was verified, and through PCR the plasmid resistance genes (mcr) were identified. Of the 124 Salmonella strains resistant to colistin and polymyxin B, only one isolate was positive for the mcr-1 gene, and this gene was detected in a plasmid from the IncX4 group. Strain 2018.466 was characterized as S. Choleraesuis from blood of human origin. Forty-four Salmonella spp. showing mutations in pmrA and pmrB. Of the 56 colistin-resistant ExPEC isolates, 21 isolates harbored the mcr-1 gene. This gene was detected in plasmids from the IncX4 group (n=17) and in plasmids from the IncF group (n=4). Five E.coli isolates did not show mutations in the genes studied, three of which were positive for the mcr-1 gene, while the other strains showed mutations in pmrA/B and phoP/Q. Typing by PFGE was performed on E.coli isolates positive for the mcr-1 gene, with the objective of verifying the genetic diversity found among them. Eighteen genetic profiles were identified, without a main clone...(AU)
Assuntos
Infecções por Salmonella , Polimixinas , Infecções por Escherichia coli/epidemiologia , Doenças Transmitidas pela Água , Escherichia coli Extraintestinal Patogênica , AntibacterianosRESUMO
This study analyzes the genomic findings of the first report of Salmonella isolate carrying the blaCTX-M-55 gene, recovered from a bacteremic patient from Brazil. A bacterial isolate positive for the blaCTX-M-55 gene was submitted to antimicrobial susceptibility testing by disk diffusion and epsilometric test. Whole genome sequencing was performed using Illumina technology. Conjugation assay was performed; plasmid sizes determined by S1-PFGE and plasmid content were investigated by hybrid assembly after MinION long reads sequencing. Isolate 288_18 was identified as sequence type ST13, resistant to ampicillin, cefotaxime, ceftazidime, cefepime, ceftriaxone, and aztreonam. A transferable IncFII plasmid sized approximately 67 kb was found to carry the blaTEM-1 and blaCTX-M-55 in a module consisting of IS26-blaTEM-1B-WbuC-blaCTX-M-55-IS26. In addition, an 117 kb IncI1plasmid was also identified in the 288_18 isolate, but without additional resistance genes. To the best of our knowledge, this is the first report of blaCTX-M-55 in Salmonella isolated from human infection in Brazil. The occurrence of blaCTX-M-55 in the IncFII epidemic plasmid in a relevant clinical human isolate of Salmonella Agona underscores the urgent need for enhanced and effective continuous surveillance for controlling its dissemination.
Assuntos
Ceftazidima , Análise de Sequência , Sequenciamento Completo do Genoma , AmpicilinaRESUMO
A multi-drug resistant, CTX-M-65 producing Salmonella Infantis was identified from a patient in Brazil. Whole genome sequencing followed by hybrid assembly (short and long reads) indicated the presence of blaCTX-M-65 in a pESI-like megaplasmid in this ST32 isolate and phylogenetic analysis showed high similarity with IncFIB S. Infantis isolates from food and poultry in the USA.
Assuntos
Farmacorresistência Bacteriana Múltipla , Salmonella enterica , Antibacterianos/farmacologia , Brasil , Genômica , Humanos , Filogenia , Plasmídeos , Salmonella enterica/efeitos dos fármacos , Salmonella enterica/genética , beta-Lactamases/genéticaRESUMO
BACKGROUND: Uropathogenic Escherichia coli (UPEC) are frequent pathogens worldwide, impacting on the morbidity and economic costs associated with antimicrobial treatment. OBJECTIVES: We report two novel mutations associated with polymyxin-B resistance in an UPEC isolate collected in 2019. METHODS: Isolate was submitted to antimicrobial susceptibility testing including broth microdilution for polymyxin B. Whole genome was sequenced and analyzed. RESULTS: Polymyxin-B total inhibition occurred at 16 mg/L (resistant). UPEC isolate was assigned to the phylogroup D, serotype O117:H4, and Sequence Type 69. mcr genes were not detected, but two novel mutations in the pmrA/basS (A80S) and pmrB/basR (D149N) genes were identified. CONCLUSIONS: The occurrence of non-mcr polymyxin resistance in E. coli from extraintestinal infections underscores the need of a continuous surveillance of this evolving pathogen.
Assuntos
Proteínas de Bactérias/genética , Farmacorresistência Bacteriana Múltipla/genética , Fatores de Transcrição/genética , Escherichia coli Uropatogênica/genética , Antibacterianos/farmacologia , Humanos , Mutação , Filogenia , Polimixina B/farmacologia , Infecções Urinárias/microbiologia , Infecções Urinárias/patologia , Escherichia coli Uropatogênica/classificação , Escherichia coli Uropatogênica/efeitos dos fármacos , Escherichia coli Uropatogênica/isolamento & purificaçãoRESUMO
Dissemination of carbapenem-resistant Acinetobacter baumannii (CRAB) is mainly driven by the spread of clonal lineages. High frequencies of CRAB are reported in South America, and clonal complexes CC1, CC15, CC79 and CC25 are predominant. A total of 79 non-redundant CRAB recovered from 26 Brazilian hospitals were selected for antimicrobial susceptibility testing by microdilution and whole-genome sequencing (WGS). Multilocus sequence typing (MLST), acquired antimicrobial resistance genes and phylogeny based on high-quality SNPs were extracted from WGS data. XDR (86.1%), MDR (12.7%) and one PDR isolate from CC15 (1.3%) were identified. Colistin resistance was more frequent in CC25 isolates (P < 0.01). Prevalence of CC79 (n = 22; 27.8%) CC1 (n = 21; 26.6%), CC15 (n = 21; 26.6%) and CC25 (n = 12; 15.2%) was observed. Regarding carbapenem-hydrolysing class D ß-lactamases (CHDLs), blaOXA-23 was frequently detected in CC1, CC15 and CC25 isolates, whereas blaOXA-72 was the most frequent CHDL in CC79 isolates [n = 12/22 (54.5%); P < 0.01]. High-quality SNP analysis correlated well with sequence type and revealed that CRAB clones are highly conversed and present some clone-specific resistance determinants. This study provides essential information to understand the antimicrobial resistance patterns of CRAB in Brazilian hospitals, where hyperendemic XDR-CRAB clones are disseminated. Phenotypic and genomic analysis of CRAB recovered from Brazilian hospitals revealed the predominance of XDR phenotype in the majority of international clonal complex CC79, CC1, CC15 and CC25. Dissemination of specific CRAB lineages in Brazil is suggested to be driven by their resistance determinants under antimicrobial selective pressure.
Assuntos
Acinetobacter baumannii/efeitos dos fármacos , Acinetobacter baumannii/genética , Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Farmacorresistência Bacteriana Múltipla/genética , Polimixinas/farmacologia , Acinetobacter baumannii/isolamento & purificação , Proteínas de Bactérias/genética , Brasil , Genoma Bacteriano/genética , Hospitais , Humanos , Testes de Sensibilidade Microbiana , Epidemiologia Molecular , Tipagem de Sequências Multilocus , Filogenia , Polimorfismo de Nucleotídeo Único/genética , Sequenciamento Completo do Genoma , beta-Lactamases/genéticaAssuntos
Infecções por Acinetobacter , Acinetobacter baumannii , Bacteriemia , Infecção Hospitalar , Transplante de Células-Tronco Hematopoéticas , Infecções por Acinetobacter/tratamento farmacológico , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Brasil , Infecção Hospitalar/tratamento farmacológico , Farmacorresistência Bacteriana Múltipla , Humanos , Testes de Sensibilidade MicrobianaAssuntos
Bacteriemia , Salmonelose Animal , Salmonella enterica , Animais , Colistina/farmacologia , Humanos , Salmonella/genéticaRESUMO
Acinetobacter baumannii is the main species of the Acinetobacter genus; however, non-baumannii Acinetobacter (NBA) species causing infections have been described for the past years, as well as antimicrobial resistance. In this study, we describe the occurrence of two multidrug-resistant (MDR) IMP-1-producing Acinetobacter bereziniae isolates recovered from bloodstream infections in different patients but in the same intensive care unit among 134 carbapenem-resistant Acinetobacter screened. Antimicrobial susceptibility testing revealed resistance to carbapenems, extended spectrum, and antipseudomonad cephalosporins, amikacin, and trimethoprim-sulfamethoxazole. Both A. bereziniae isolates shared the same ApaI-pulsed-field gel electrophoresis (PFGE) pattern. Whole-genome sequencing of both isolates revealed that blaIMP-1 was embedded into an In86 Class I integron carrying also sul1, aac(6')-31, and aadA genes. A new sequence type (ST1309 Pasteur) was deposited. The virulence genes lpxC and ompA, seen in A. baumannii, were detected in the A. bereziniae strains. Recognition of A. bereziniae causing invasive MDR infection underscores the role of NBA species as human pathogens especially in at-risk patients.
Assuntos
Acinetobacter/genética , Acinetobacter/isolamento & purificação , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Farmacorresistência Bacteriana Múltipla/genética , Sepse/microbiologia , beta-Lactamases/genética , Acinetobacter/efeitos dos fármacos , Infecções por Acinetobacter/tratamento farmacológico , Infecções por Acinetobacter/microbiologia , Antibacterianos/farmacologia , Brasil , Carbapenêmicos/farmacologia , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/microbiologia , Genômica/métodos , Humanos , Integrons/genética , Testes de Sensibilidade Microbiana/métodos , Sepse/tratamento farmacológico , Centros de Atenção TerciáriaRESUMO
O objetivo deste estudo foi analisar a qualidade microbiológica de suco de laranja in natura em Presidente Prudente (SP) e estabelecimentos comerciais. Foi avaliada a qualidade higiêncio-sanitária do ambiente de trabalho mediante um check-list e a qualidade do suco de laranja por contagem em placa. Os resultados foram submetidos à análise de variância (ANOVA) para dados não paramétricos (Kruskal-Wallis) com p <0,05. A maioria dos estabelecimentos apresentou boas práticas de higiene adequadas. Não foi confirmada a presença de coliformes termotolerantes. Para os demais parâmetros microbiológicos foram observadas altas contaminações em algumas amostras de suco. As bactérias ácido-láticas (BAL's) apresentaram contagem entre 3,15 (dp=0,21) a 5,68 (dp=0,01) log UFC/mL, e sua avaliação inibitória foram satisfatórias, uma vez que conseguiram inibir Escherichia coli (15 a 27 mm) e Listeria monocytogenes (23 a 27 mm). A adoção de medidas de boas práticas de higiene, além da educação continuada dos manipuladores de alimentos, promove a redução da contaminação.
Current paper analyzes the microbiological quality of in natura orange juice in Presidente Prudente, Brazil, and in commercial establishments. Hygiene and sanitary conditions of work environment was investigated through a check-list and the quality of orange juice was analyzed by plate counts for ANOVA results for non-parameter data (Kruskal-Wallis) at p<0.05. Most commercial establishments had good hygiene practice and thermo-tolerant coliforms were not extant. There were, however, high contaminations in several juice samples. Acid-lactic bacteria had counts between 3.15(dp=0.21) and 5.68(dp=0.01) log CFU/mL. Inhibitory evaluation was satisfactory since their impaired Escherichia coli (15 - 27 mm) and Listeria monocytogenes (23 - 27mm). Good practice in hygiene and continued education by food handlers cause a reduction of contamination.
RESUMO
Dissemination of carbapenem-resistant Acinetobacter baumannii (CRAB) is mainly driven by the spread of clonal lineages. High frequencies of CRAB are reported in South America, and clonal complexes CC1, CC15, CC79 and CC25 are predominant. A total of 79 non-redundant CRAB recovered from 26 Brazilian hospitals were selected to perform antimicrobial susceptibility test (AST) by microdilution and whole genome sequencing (WGS). MLST, acquired resistance genes and phylogeny based on high-quality SNPs were extracted from WGS. XDR (86.1%), MDR (12.7%) and one PDR isolate from CC15 (1.3%) were identified. Colistin resistance was more frequently on CC25 isolates (p<0.01). Prevalence of CC79 (n=22; 27.8%) CC1 (n=21; 26.6%), CC15 (n=21; 26.6%), and CC25 (n=12; 15.2%) was observed. Regarding the carbapenem-hydrolyzing class D β-lactamases (CHDL), blaOXA-23 gene was frequently detected in CC1, CC15, and CC25 isolates, but blaOXA-72 gene was the most frequent CHDL in CC79 isolates (n=12/22, 54.5%; p<0.01). High-quality SNPs analysis correlated well with the ST, and revealed that CRAB clones are highly conversed and present some clone-specific resistance determinants. This study provides essential information to understand the antimicrobial resistance patterns of CRAB in Brazilian hospitals, where hyperendemic XDR CRAB clones are disseminated. Phenotypic and genomic analysis of CRAB recovered from 26 Brazilian hospitals revealed the prevalence of XDR phenotype in the majority of international clonal complex CC79, CC1, CC15 and CC25. Dissemination of specific CRAB lineages in Brazil is suggested to be driven by their resistance determinants under antimicrobial selective pressure.
RESUMO
A difteria é uma doença aguda, toxi-infecciosa, imunoprevenível, de notificação compulsória e de distribuição mundial, sendo prevalente em locais com higienização inadequada e/ou baixa cobertura vacinal. Tem como agente etiológico o micro-organismo Corynebacterium diphtheriae (bacilo diftérico) e, em alguns casos, por C. ulcerans, bactéria relacionada às infecções de natureza zoonótica e responsável por provocar uma doença semelhante à difteria respiratória clássica, muitas vezes chamada de difteria zoonótica. Ambos podem produzir uma exotoxina responsável por causar toda a sintomatologia deste agravo. A doença em sua forma clássica é caracterizada pela formação de uma ou mais pseudomembranas de cor acinzentada principalmente nas tonsilas, orofaringe e nasofaringe, mas raramente, a difteria, pode se apresentar como lesões na pele, chamada de difteria cutânea. Além disso, pode resultar em diversas complicações, principalmente quando não tratada ou tratada de forma inadequada, como por exemplo, a obstrução das vias aéreas, miocardite...(AU)
Assuntos
Epidemiologia , Corynebacterium diphtheriae , DifteriaRESUMO
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.
Assuntos
Transtornos de Deglutição/sangue , Eletrólitos/sangue , Endoscopia/métodos , Nutrição Enteral/métodos , Gastrostomia/métodos , Neoplasias de Cabeça e Pescoço/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Cálcio/sangue , Transtornos de Deglutição/mortalidade , Transtornos de Deglutição/terapia , Endoscopia/mortalidade , Feminino , Gastrostomia/mortalidade , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Hiponatremia/epidemiologia , Magnésio/sangue , Masculino , Pessoa de Meia-Idade , Fósforo/sangue , Portugal/epidemiologia , Potássio/sangue , Prognóstico , Estudos Retrospectivos , Cloreto de Sódio/sangueRESUMO
ABSTRACT BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.
RESUMO CONTEXTO: A gastrostomia endoscópica percutânea (PEG) é a via de eleição preferencial para a nutrição entérica de longa duração. A disfagia neurológica e as neoplasias cervico-faciais constituem as principais indicações para PEG por poderem conduzir a desnutrição energético-proteica e alterações hidroeletrolíticas, com potencial impacto negativo no equilíbrio metabólico. A síndrome de realimentação pode também estar associada a alterações hidroeletrolíticas graves em doentes alimentados por PEG e contribuir para um mau prognóstico. OBJETIVO: Avaliar as alterações das concentrações séricas dos principais eletrólitos e a eventual associação entre os valores séricos alterados e o prognóstico dos doentes gastrostomizados. Métodos - Estudo retrospetivo realizado em doentes seguidos na Consulta de Nutrição Artificial do Hospital Garcia de Orta, propostos e submetidos a PEG, de 2010 a 2016 e que faleceram sob nutrição por PEG. Consideraram-se os valores séricos dos iões em estudo avaliados imediatamente antes do procedimento endoscópico de gastrostomia, obtidos por consulta do processo clínico. A sobrevida, após a realização da PEG até à morte foi registrada em meses. RESULTADOS: Avaliaram-se 101 doentes. A sobrevida média pós-gastrostomia foi 6,55 meses. Destes, 59 apresentaram alterações de alguns iões no momento da realização da PEG. O sódio estava alterado em 31 (30,6%), magnésio em 20 (19,8%), cloro em 19 (18,8%), potássio em 14 (13,8%), cálcio em 10 (9,9%) e o fósforo em 9 (8,9%). Quando comparada a sobrevida dos doentes com valores de sódio baixo (<135 mmol/L) com a dos doentes com valores normais/elevados, esta foi 2,76 meses vs 7,80 meses, respectivamente (P=0,007). CONCLUSÃO: As alterações dos eletrólitos séricos nos doentes submetidos a PEG foram muito frequentes, com mais de metade dos doentes a apresentarem pelo menos uma alteração aquando da realização do procedimento. A alteração mais frequente foi a hiponatrémia, associando-se a pior prognóstico com sobrevida significativamente mais curta, refletindo provavelmente um grave compromisso metabólico sistêmico.
Assuntos
Gastrostomia/métodos , Transtornos de Deglutição/sangue , Nutrição Enteral/métodos , Eletrólitos/sangue , Endoscopia/métodos , Neoplasias de Cabeça e Pescoço/sangue , Fósforo/sangue , Portugal/epidemiologia , Potássio/sangue , Prognóstico , Gastrostomia/mortalidade , Cloreto de Sódio/sangue , Transtornos de Deglutição/mortalidade , Transtornos de Deglutição/terapia , Cálcio/sangue , Estudos Retrospectivos , Endoscopia/mortalidade , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/terapia , Hiponatremia/epidemiologia , Magnésio/sangue , Pessoa de Meia-IdadeRESUMO
BACKGROUND:: Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. OBJECTIVE:: In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. METHODS:: Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. RESULTS:: A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease ( P <0.001) and worst nutritional status defined by BMI ( P =0.002), mid upper arm circumference ( P <0.001), mid arm muscular circumference ( P <0.001), triceps skinfold ( P =0.07) and subjective global assessment ( P <0.001). A third presented deficient/low handgrip strength. Alcohol consumption ( P =0.03) and malnutrition detected by BMI ( P =0.03), mid upper arm circumference ( P =0.001), triceps skinfold ( P =0.06), mid arm muscular circumference ( P =0.02) and subjective global assessment ( P <0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality ( P <0.001). CONCLUSION:: Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.