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Estudo caso-controle dos aspectos clínicos, fatores de risco e mortalidade associados a infecções nosocomiais por Klebsiella pneumoniae produtoras de carbapenemases do tipo KPC

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Abstract : The bacterial resistance to antimicrobials by Klebsiella pneumoniae Carbapenemase (KPC), especially in Klebsiella pneumoniae, is a serious problem to handling healthcare associated infections. Carbapenems, considered the ?last-line agents" to treat several infections by Gram-negative bacteria become ineffective against carbapenem-producing bacteria, and few effective antibiotics are currently available to treatment. To identify clinical aspects, risk factors and mortality associated to infections caused by KPC-producing K. pneumoniae (Kp-KPC), this matched case-control study was performed at the University Hospital of the Federal University of Santa Catarina (HU/UFSC) from January 2012 through December 2014. The bacterial identification and antimicrobial susceptibility testing were performed by automatized methodology (Vitek 2®/Biomerieux). Two phenotypic tests were performed in different moment to screening the isolates with carbapenems resistance. All isolates were confirmed by molecular methodology (Polimerase Chain Reaction - PCR). Were selected isolates from urine and blood culture of forty patients with Kp-KPC (case) and forty patients with non-KPC-producing K. pneumoniae (Kp-non-KPC). Data obtained included origin of patient at the time of hospital admission, risk factors such as length of stay before infection, Intensive Care Unit (ICU) stay prior to K. pneumoniae isolation, surgery, use of invasive devices, prior antibiotic therapy, empiric therapy and definitive treatment, as well as comorbidities and outcomes. Data were collected from medical charts. Most of transferred patients to HU/UFSC from others hospitals belonged to case group (P=0.010). This highlight the need of surveillance cultures to patients transferred to HU/UFSC. In this study, stayed in ICU, (Odds Ratio [OR], 3.115; Confidence Intervals [CI] 95%, 1.247-7.781; P=0.014), use of venous catheter (OR, 5.516; CI 95%, 1.109-27.429; P=0.023), use of urinary catheter (OR, 3.484; CI 95%, 1.246-9.747; P=0.015) and prior antimicrobial use (OR, 3.444; CI 95%, 1.310-9.058; P=0.011) were associated with Kp-KPC infections by univariable analysis. The analysis of the antibiotics or class of antibiotics most commonly used, showed significant difference to case group for the use of extended-spectrum cephalosporins (P=0.039). The analysis of empirical therapy showed that 71.4% of patients who did not use empiric antibiotic died. Amongpatients who used empirical therapy, mortality was higher for patients who received appropriate therapy (58.3% vs 37.5%). After antimicrobial susceptibility testing, mortality was higher for patients who received appropriate therapy (55% vs 50%). Furthermore, it was found that mortality of patients who received definitive associated therapy (70%) was higher than patients who used monotherapy (40%) (P=0.370). The mortality frequency was significant higher for case group (47.5% vs 25%, P=0.036). The increase number of isolates, both in clinical samples and surveillance cultures, alert to the need to improve the measures already adopted in order to control the spread of the microorganisms in HU/UFSC. Venous and urinary catheters were associated with Kp-KPC infections, so in long-stay hospitalizations, these devices should be reviewed regularly to check whether they are still needed. Kp-KPC is an emerging pathogen associated with significant mortality in HU/UFSC. The mortality frequency associated with limited therapeutic options, highlight the need of early detection, contact prevention measures and development of new drugs for the treatment of these infections.


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