Influência dos fatores clínicos e microbiológicos na evolução das peritonites por Bacilos Gram-negativos não fermentadores em diálise peritoneal
Carregando...
Arquivos
Data
2018-02-26
Autores
Santos, Ana Cláudia Moro Lima dos
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Peritonite por bacilos Gram-negativos não fermentadores (BGNNF) é complicação importante da diálise peritoneal (DP), com curso clínico grave e elevada taxa de falência do método. Fatores associados à virulência, resistência antimicrobiana, formação de biofilme, entre outros, têm sido relatados, mas o limitado conjunto de evidências não permite concluir sobre os fatores responsáveis pelo pior curso clínico dessas infecções. O objetivo deste trabalho foi avaliar a influência das características microbiológicas, das condições clínicas do paciente e do tratamento na evolução de peritonites por BGNNF, ocorridas num único centro, em período de 18 anos. A sensibilidade in vitro aos antimicrobianos, produção de biofilme, além da análise do perfil clonal das bactérias pela técnica de eletroforese em gel de campo pulsado foram realizadas em todos os isolados bacterianos. Foram pesquisados genotipicamente, em isolados de Pseudomonas aeruginosa, a presença de marcadores de virulência (alginato, exoenzima S, fosfolipases C, exotoxina A, protesase alcalina, elastase e ramnolipídeos). Associações entre as características microbiológicas do paciente e tratamento com a taxa de resolução da peritonite foram estudadas. A espécie mais frequente foi Pseudomonas aeruginosa (45,59%), seguida por isolados do complexo Acinetobacter baumannii (17,65%). O estudo dos fatores de virulência da Pseudomonas aeruginosa revelou a presença de fatores de virulência em 100% dos casos, exceto exoenzima S (58,33%) e fosfolipase C não hemolítica (87,5%). Houve elevada proporção de BGNNF resistentes aos antimicrobianos testados, em particular à amicacina (36,73%) e à ciprofloxacina (44,9%), sendo que a sensibilidade aos betalactâmicos esteve acima de 70%. Observou-se elevada proporção de isolados produtores de biofilme (73,08%). Os resultados da tipagem por PFGE revelaram um perfil policlonal para a maioria dos isolados, entretanto para isolados do complexo Acinetobacter baumannii a análise revelou um cluster, entre 2000-2008, com perfil de multiresistência aos antimicrobianos, sugerindo fonte hospitalar. A evolução dos episódios mostrou reduzida taxa de cura (35,29%). A sensibilidade à amicacina e cefepime, se associaram de modo independente à maior chance de cura, enquanto a presença concomitante de infecção do óstio de saída do cateter de DP foi preditor independente de não resolução do episódio. Não se observaram associações entre fatores de virulência, produção de biofilme e características do paciente e tratamento com o desfecho dos episódios. Em conclusão, peritonites em DP, por BGNNF, são infecções com reduzida taxa de cura; a resistência bacteriana é fator associado à menor chance de resolução e peritonite por bactérias do gênero Acinetobacter spp. podem representar infecção grave, potencialmente de origem hospitalar, o que deve fazer redobrar os cuidados quanto ao seu manejo clínico.
Peritonitis due to non-fermentative Gram-negative bacilli (NFGNB) is a serious complication of peritoneal dialysis (PD), with a severe clinical course and high technique failure rate. Factors as bacterial virulence, antimicrobial resistance, biofilm formation, among others, have been reported, but the limited amount of evidence does not allow to conclude on the factors responsible for the worst clinical course of these infections. The objective of this study was to evaluate the influence of the microbiological characteristics, patients conditions, and treatment on evolution of peritonitis episodes at a single center in an 18 - year period. In vitro susceptibility, biofilm production, and clonal profile analysis of bacteria by pulsed-field gel electrophoresis (PFGE) were performed in all isolates. The presence of virulence markers (alginate, exoenzyme S, phospholipases C, exotoxin A, alkaline protease, elastase, and ramnolipids) was genotyped in bacterial isolates of Pseudomonas aeruginosa. From the data referring to the patient and causal agent, associations between the microbiological, patient characteristics, and treatment on the resolution rate of peritonitis were analyzed. The most frequent species was Pseudomonas aeruginosa (45.59%), followed by Acinetobacter baumannii complex (17.65%). The study of the virulence factors of Pseudomonas aeruginosa revealed the presence of virulence factors in 100% of the cases, except for exonzyme S (58.33%) and hemolytic phospholipase C (87.5%). There was a high proportion of antimicrobial resistant, in particular to amikacin (36.73%) and ciprofloxacin (44.9%), with sensitivity to betalactam above 70%. A high (73.08%) proportion of biofilm producing isolates was observed. The results of the PFGE typing revealed a polyclonal profile for most of the isolates; however, for the Acinetobacter baumannii complex species the analysis revealed a cluster at interval from 2000 to 2008, with antimicrobial multi resistance profile, suggest that peritonitis by this agent had a hospital source. The evolution of the episodes showed a reduced resolution rate (35.29%). The susceptibility to amikacin and to cefepime were independently associated with a higher odds of resolution, while the concomitant presence of PD catheter exit site infection was an independent predictor of non-resolution. In conclusion, peritonitis due to NFGNB in PD are infections with reduced resolution rate; bacterial resistance is an independent predictor of lower odds of resolution. Peritonitis by Acinetobacter spp. can represent serious
Peritonitis due to non-fermentative Gram-negative bacilli (NFGNB) is a serious complication of peritoneal dialysis (PD), with a severe clinical course and high technique failure rate. Factors as bacterial virulence, antimicrobial resistance, biofilm formation, among others, have been reported, but the limited amount of evidence does not allow to conclude on the factors responsible for the worst clinical course of these infections. The objective of this study was to evaluate the influence of the microbiological characteristics, patients conditions, and treatment on evolution of peritonitis episodes at a single center in an 18 - year period. In vitro susceptibility, biofilm production, and clonal profile analysis of bacteria by pulsed-field gel electrophoresis (PFGE) were performed in all isolates. The presence of virulence markers (alginate, exoenzyme S, phospholipases C, exotoxin A, alkaline protease, elastase, and ramnolipids) was genotyped in bacterial isolates of Pseudomonas aeruginosa. From the data referring to the patient and causal agent, associations between the microbiological, patient characteristics, and treatment on the resolution rate of peritonitis were analyzed. The most frequent species was Pseudomonas aeruginosa (45.59%), followed by Acinetobacter baumannii complex (17.65%). The study of the virulence factors of Pseudomonas aeruginosa revealed the presence of virulence factors in 100% of the cases, except for exonzyme S (58.33%) and hemolytic phospholipase C (87.5%). There was a high proportion of antimicrobial resistant, in particular to amikacin (36.73%) and ciprofloxacin (44.9%), with sensitivity to betalactam above 70%. A high (73.08%) proportion of biofilm producing isolates was observed. The results of the PFGE typing revealed a polyclonal profile for most of the isolates; however, for the Acinetobacter baumannii complex species the analysis revealed a cluster at interval from 2000 to 2008, with antimicrobial multi resistance profile, suggest that peritonitis by this agent had a hospital source. The evolution of the episodes showed a reduced resolution rate (35.29%). The susceptibility to amikacin and to cefepime were independently associated with a higher odds of resolution, while the concomitant presence of PD catheter exit site infection was an independent predictor of non-resolution. In conclusion, peritonitis due to NFGNB in PD are infections with reduced resolution rate; bacterial resistance is an independent predictor of lower odds of resolution. Peritonitis by Acinetobacter spp. can represent serious
Descrição
Palavras-chave
Diálise peritoneal, Peritonite, Fatores de virulência, Resistência antimicrobiana, Pseudomonas aeruginosa, Acinetobacter baumannii, peritoneal dialysis, peritonitis, virulence factors, antimicorbial resistance