Organismos Multirresistentes e Infeções Nosocomiais

Descrição Geral

Microorganismos multirresistentes (OMR)

• Considera-se multirresistência (resistência a múltiplos fármacos) quando um isolamento é resistente a pelo menos 1 fármaco em 3 ou mais MAIS Androgen Insensitivity Syndrome classes farmacológicas.
• Organismos:
  • Enterococos resistentes à vancomicina (VRE, pela sigla em inglês)
  • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess resistente à meticilina ( MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus, pela sigla em inglês)
  • Microorganismos produtores de beta-lactamase Beta-Lactamase Penicillins de espectro alargado ( ESBL ESBL Klebsiella, pela sigla em inglês)
  • Bacilos gram-negativos multirresistentes (MDRGNB, pela sigla em inglês) (sobretudo bacilos resistentes a carbapenemes e Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas aeruginosa difícil de tratar/resistente)

Infeção adquirida no hospital (IAH)

• Uma infeção nosocomial, cuja transmissão ocorre no hospital ou numa unidade de saúde
• Não está presente no momento da admissão.
• Tipos de IAH:
  • Pneumonias: ~ 24% das IAH
    • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia adquirida no hospital ( PAH PAH The glycine amide of 4-aminobenzoic acid. Its sodium salt is used as a diagnostic aid to measure effective renal plasma flow (ERPF) and excretory capacity. Glomerular Filtration)
    • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia associada ao ventilador (PAV)
  • Infeção do local cirúrgico (ILC): ~ 24% das IAH
  • Infeção hematogénica associada à linha central (CLABSI, pela sigla em inglês)
    • 10-15% das IAH
    • A IAH mais MAIS Androgen Insensitivity Syndrome letal
  • Infeção do trato urinário (ITU):
    • ~ 14% das IAH
    • A maioria devido a infeção urinária associada a cateter vesical (CAUTI, pela sigla em inglês)
  • Infeção por Clostridioides difficile (ICD): ~ 12% das IAH

Outras considerações

Excluindo a transmissão nosocomial de SARS-CoV-2 durante a pandemia, as IAH não bacterianas são menos comuns do que as IAH bacterianas.

• SARS-CoV-2:
  • Na primeira vaga pandémica de 2020, uma elevada proporção dos indivíduos hospitalizados ficou infetada (geralmente por outro doente)
  • A taxa de transmissão dependia do tipo de cuidado prestado (dados de 2020):
    • Hospitais de agudos ou gerais: 10-15%
    • Unidades de cuidados de longa duração (UCLD), incluindo hospitais de saúde mental: até 82% (47% das primeiras mortes por COVID-19 COVID-19 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that mainly affects the respiratory system but can also cause damage to other body systems (cardiovascular, gastrointestinal, renal, and central nervous systems). )
• Outras IAH víricas:
  • ~ 5% das IAH
  • Infeção cruzada:
    • Mais MAIS Androgen Insensitivity Syndrome comum em bebés e crianças
    • Também vistas em idosos, imunossuprimidos ou em indivíduos com cormobilidades
  • Exemplos:
    • Gripe (especialmente durante a epidemia)
    • Norovírus:
      • Altamente contagiosos
      • Correspondem a ~ 60% de todos os casos de gastroenterite aguda por agentes patogénicos conhecidos nos EUA
    • Vírus varicela zooster (menos comum devido à vacinação contra a varicela)
• Fungos:
  • Muitas vezes de esporos inalados (tornam-se aéreos quando as áreas poeirentas são perturbadas pela renovação)
  • ↑ risco de aspergilose pulmonar e disseminada em doentes imunossuprimidos, especialemente se neutropénicos
  • Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis auris: perigosa devido à elevada taxa de OMR
• IAH bacterianas especiais:
  • Mycobacteria Mycobacteria Mycobacterium is a genus of the family Mycobacteriaceae in the phylum Actinobacteria. Mycobacteria comprise more than 150 species of facultative intracellular bacilli that are mostly obligate aerobes. Mycobacteria are responsible for multiple human infections including serious diseases, such as tuberculosis (M. tuberculosis), leprosy (M. leprae), and M. avium complex infections. Mycobacterium:
    • M. tuberculosis Tuberculosis Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis a partir de doentes com tuberculose pulmonar
    • M. chimaera de unidades de aquecimento-arrefecimento contaminadas utilizadas em cirurgia cardíaca
  • Legionelose:
    • Frequentemente devido à contaminação de água potável, unidades de ar AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation condicionado, fontes de água, água não esterilizada em equipamento de terapia respiratória
    • Doentes imunossuprimidos são os mais MAIS Androgen Insensitivity Syndrome afetados

Epidemiologia

• Percentagem de IAH nas hospitalizações:
  • 3,2% nos Estados Unidos
  • 6,5% na União Europeia/Espaço Económico Europeu
  • 15% de todos os indivíduos hospitalizados em todo o mundo, com maiores proporções em países pobres em recursos (da OMS)
• Tendência das IAH (nos EUA):
  • Aumento da probabilidade de ser causada por organismos resistentes aos antibióticos
  • 687.000 IAH comunicadas em hospitais de cuidados agudos em 2015, com 72.000 mortes associadas
  • A incidência diminuiu desde 2009, mas aumentou relativamente em 2020 (relacionado com a pandemia da COVID-19 COVID-19 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that mainly affects the respiratory system but can also cause damage to other body systems (cardiovascular, gastrointestinal, renal, and central nervous systems). )
  • 25-50% das IAH devem-se a dispositivos invasivos, mas a percentagem está a diminuir.
  • 75% das ITU estão associadas ao uso de catéteres vesicais e até 25% dos indivíduos hospitalizados são algaliados.
• Tendência dos OMR:
  • ≥ 30% das prescrições ambulatórias de antibióticos nos EUA são desnecessárias, levando ao aumento dos OMR.
  • MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus:
    • Entre 1995 e 2001, as infeções hematogénicas hospitalares por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus nos Estados Unidos aumentaram de 22% para 57%.
    • Com as medidas de prevenção de infeção, as taxas de infeção diminuíram anualmente em 17% entre 2005 e 2012.
  • VRE:
    • No início dos anos 90: representaram cerca de 15% dos isolamentos de enterococos
    • No início dos anos 2000: representava aproximadamente 29% dos isolamentos de enterococos
• As bactérias gram-negativas resistentes às fluoroquinolonas, ESBLs, carbapenemes e aminoglicosídeos aumentaram significativamente nas últimas 2 décadas.

Staphylococcus Aureus Resistente à Meticilina (MRSA)

MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus

• MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus é um grupo de Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess resistente a antibióticos beta-lactâmicos, incluindo cefalosporinas:
  • Concentração inibitória mínima de oxacilina ≥ 4 μg/mL
  • Infeção por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus associada à comunidade (CA-MRSA, pela sigla em inglês): infeção por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus sem associação com os cuidados de saúde
  • Infeção por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus associada aos cuidados de saúde (HA-MRSA, pela sigla em inglês):
    • Infeção por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus > 48 horas após internamento; OU
    • Infeção por MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus fora do hospital, dentro de 12 meses de exposição aos cuidados de saúde (por exemplo, cirurgia, hospitalização, diálise)
• Mecanismo de resistência:
  • A resistência ao MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus ocorre devida à presença de um gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics mec (necessário na resistência à meticilina).
  • O gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics tem um componente mecA, que gera a proteína de ligação à penicilina 2a (PBP2a):
    • A PBP2a (enzimas peptidase Peptidase Tubular System na membrana bacteriana) diminui a afinidade da ligação do microorganismo aos antibióticos beta-lactâmicos.
    • A deteção do gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics mec e PBP2a é a forma mais MAIS Androgen Insensitivity Syndrome precisa de determinar a resistência à meticilina.
• Fatores de risco:
  • Fatores de risco associados aos cuidados de saúde:
    • Hospitalização recente
    • Residência em instituição de longa permanência
    • Cirurgia recente
    • Hemodiálise
  • Fatores de risco adicionais:
    • Infeção por VIH
    • Utilização de drogas injetáveis
    • Uso prévio de antibiótico e/ou prescrição inapropriada de antibióticos
  • Fatores associados a surtos de MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus:
    • Prisão
    • Serviço militar
    • Partilha de equipamentos desportivos
    • Partilha de agulhas, lâminas ou outros objetos pontiagudos

Infeções e antibióticos

• Infeções comuns:
  • Infeções da pele e dos tecidos moles Moles Primary Skin Lesions:
    • Celulite
    • Fasceíte necrotizante
    • Úlcera do pé diabético
  • Infeções ósseas e articulares:
    • Osteomielite da coluna
    • Osteomielite dos ossos longos das extremidades superiores e inferiores
    • Artrite sética de articulações nativas e protésicas
  • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Bacteriemia
  • Endocardite
• Opções de antibióticos:
  • Oral:
    • Trimetoprim, sulfametoxazol
    • Tetraciclinas: doxiciclina, minociclina
    • Clindamicina
    • Oxazolidinonas: linezolida, tedizolida
    • Delafloxacina
  • Parenteral:
    • Vancomicina
    • Daptomicina
    • Dalbavancina
    • Oritavancina
    • Telavancina
    • Ceftarolina
    • Oxazolidinonas: linezolida, tedizolida
    • Delafloxacina

Prevenção

• Higienização das mãos e precauções de contacto (por exemplo, aventais, luvas)
• Algumas instituições de saúde recorrem à vigilância ativa de indivíduos de alto risco:
  • Rastreio com culturas das narinas, orofaringe ou períneo para identificar indivíduos colonizados por bactérias resistentes a antibióticos
  • As intervenções podem incluir descolonização, isolamento de contacto ou limpeza abrangente.
• O regime de descolonização pode variar, dependendo das circunstâncias (por exemplo, pós-alta, pré-cirurgia), mas pode incluir:
  • Banho de clorexidina
  • Tratamento nasal com mupirocina
• Limpeza ambiental
• Programas de gestão de utilização de antibióticos (ou seja, evitar a utilização excessiva de antibióticos)

Enterococos Resistentes à Vancomicina (VRE)

VRE

• Os microorganismos do género Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus são resistentes à vancomicina (a maioria dos isolados são Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus faecium)
• Concentração inibitória mínima (resistente à vancomicina): ≥ 32 μg/mL
• Mecanismo de resistência:
  • A vancomicina liga-se ao terminal D-alanil-D-alanina (D-Ala-D-Ala) dos precursores da parede celular bacteriana → interrupção na síntese da parede celular bacteriana
  • A resistência ocorre devido à modificação do sítio de ligação D-Ala-D-Ala na biossíntese de um peptidoglicano:
    • O terminal D-Ala é substituído por D-lactato → perda de ligação de hidrogénio, facilitando a ligação de alta afinidade da vancomicina ao alvo
    • Codificado por vários conjuntos de genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure de resistência à vancomicina (ou seja, vanA, vanB, vanC, vanD e vanE )
• Fatores de risco:
  • Terapêutica antimicrobiana prévia (sobretudo cefalosporinas e vancomicina)
  • Internamento com > 72 horas (sobretudo permanência na UCI)
  • Doença renal terminal (DRT) com necessidade de diálise
  • Recetores de transplante
  • Uso de inibidor da bomba de protões
  • Dispositivos invasivos
  • Superfícies ou equipamentos contaminados (por exemplo, termómetros, grades de cama)
  • Residência em instituições de longa permanência

Infeções e antibióticos

• Infeções comuns:
  • Bacteriemia
  • Endocardite
  • ITU
• Opções de antibióticos:
  • Linezolida
  • Daptomicina
  • Tigeciclina
  • Oritavancina
  • Teicoplanina
  • Telavancina

Prevenção

• Higienização das mãos e precauções de contacto
• Banho de clorexidina (benefício mais MAIS Androgen Insensitivity Syndrome reconhecido nos internamentos na UCI)
• Culturas de vigilância para VRE em indivíduos de alto risco:
  • Amostras obtidas de zaragatoas retais e perirretais, amostras de fezes, áreas de rutura da pele e feridas drenantes
  • Os profissionais de saúde podem transmitir a infeção para outros indivíduos: São instituídas medidas de contacto e isolamento apropriado em indivíduos com culturas positivas.
• Limpeza ambiental

Bactérias que Produzem Beta-Lactamases de Espectro Alargado (ESBL)

ESBL ESBL Klebsiella

• Beta-lactamases ou enzimas expressas em microorganismos resistentes a penicilinas, cefalosporinas e aztreonam Aztreonam The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam (um monobactam)
• As beta-lactamases abrem o anel beta-lactâmico, levando à desativação do antibiótico.
• Presentes mais MAIS Androgen Insensitivity Syndrome frequentemente em microorganismos gram-negativos, predominantemente em:
  • Klebsiella pneumoniae Klebsiella Pneumoniae Gram-negative, non-motile, capsulated, gas-producing rods found widely in nature and associated with urinary and respiratory infections in humans. Aminoglycosides
  • Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella oxytoca
  • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli
  • Proteus mirabilis Proteus mirabilis A species of gram-negative, facultatively anaerobic, rod-shaped bacteria that is frequently isolated from clinical specimens. Its most common site of infection is the urinary tract. Proteus
• Mecanismo de resistência:
  • A produção da enzima beta-lactamase Beta-Lactamase Penicillins leva à resistência da maioria dos antibióticos beta-lactâmicos.
  • Existem vários tipos de ESBLs:
    • Beta-lactamases TEM: As substituições de aminoácidos produzem enzimas que hidrolisam penicilinas e cefalosporinas de espectro estreito.
    • Beta-lactamases SHV: substituições de aminoácidos
    • Beta-lactamases CTX-M: surgem da aquisição de plasmídeos de genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure de beta-lactamases
• Fatores de risco:
  • Hospitalização
  • Residência em instituição de longa permanência
  • Hemodiálise
  • Presença de cateter intravascular
  • Terapêutica antibiótica recente
  • Corticoterapia
  • Presença de sonda de alimentação percutânea

Infeções e antibióticos

• Infeções comuns:
  • Bacteriemia
  • ITU
  • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
• Opções de antibióticos:
  • Carbapenemes:
    • Imipenem Imipenem Semisynthetic thienamycin that has a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to beta-lactamases. Clinical studies have demonstrated high efficacy in the treatment of infections of various body systems. Its effectiveness is enhanced when it is administered in combination with cilastatin, a renal dipeptidase inhibitor. Carbapenems and Aztreonam
    • Meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam
    • Doripenem Doripenem A carbapenem derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of infections such as hospital-acquired pneumonia, and complicated intra-abdominal or urinary-tract infections, including pyelonephritis. Carbapenems and Aztreonam
    • Ertapenem Ertapenem A carbapenem derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of gram-positive and gram-negative bacterial infections including intra-abdominal infections, acute gynecological infections, complicated urinary tract infections, skin infections, and respiratory tract infections. It is also used to prevent infection in colorectal surgery. Carbapenems and Aztreonam
  • Combinação de cefalosporinas com inibidores da beta-lactamase Beta-Lactamase Penicillins:
    • Ceftolozane-tazobactam
    • Ceftazidima-avibactam
  • Aminoglicosídeos
  • Piperacilina-tazobactam (nas ITUs isoladas)
  • Fosfomicina e nitrofurantoína (na cistite simples)

Prevenção

• Precauções de contacto
• Restrições de antibióticos (fármacos beta-lactâmicos)
• Limpeza ambiental

Bacilos Gram-Negativos Multirresistentes (BGNMR)

BGNMR

• As bactérias gram-negativas resistentes a vários antibióticos incluem:
  • Acinetobacter Acinetobacter Multidrug-resistant Organisms and Nosocomial Infections baumannii: 67% resistente aos carbapenemes
  • Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections spp: 37% resistente a cefalosporinas de 3ª ou 4ª geração
  • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli:
    • 42% resistente a fluoroquinolonas
    • 19% resistente a cefalosporinas de 3ª ou 4ª geração
    • 2% resistente a carbapenemes
  • Klebsiella pneumoniae Klebsiella Pneumoniae Gram-negative, non-motile, capsulated, gas-producing rods found widely in nature and associated with urinary and respiratory infections in humans. Aminoglycosides:
    • 29% resistente a cefalosporinas de 3ª ou 4ª geração
    • 13% resistente a carbapenemes
  • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas:
    • 31% resistente a fluoroquinolonas
    • 26% resistente a cefalosporinas de 3ª ou 4ª geração
    • 26% resistente a carbapenemes
• Mecanismos de resistência:
  • As bactérias gram-negativas possuem resistência inata (não apresentam resposta à vancomicina devido à incapacidade do fármaco de penetrar na membrana externa).
  • Alguns produzem beta-lactamases.
  • Formação de biofilme (reduz a difusão do agente antimicrobiano)
  • Genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure de resistência (podem ser transferidos entre bactérias por meio de vetores (por exemplo, plasmídeos, transposões)):
    • Produzem enzimas inativadoras de antibióticos, como carbapenemases, levando à resistência a carbapenemes
    • Alguns regulam negativamente a proteína da membrana externa OprD (uma porina específica de carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam), diminuindo a difusão do antibiótico.
    • São criadas bombas de efluxo de fármacos, que expulsam agentes antimicrobianos.
    • A transferência de um gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics 16S rRNA rRNA The most abundant form of RNA. Together with proteins, it forms the ribosomes, playing a structural role and also a role in ribosomal binding of mRNA and tRNAs. Individual chains are conventionally designated by their sedimentation coefficients. In eukaryotes, four large chains exist, synthesized in the nucleolus and constituting about 50% of the ribosome. RNA Types and Structure metilase de Actinomycetes para Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas confere resistência a aminoglicosídeos
• Os fatores de risco incluem:
  • Permanência na UCI
  • Hemodiálise crónica
  • Recetores de transplante
  • Uso frequente de certos antibióticos (por exemplo, cefalosporinas de largo espectro, aminoglicosídeos, carbapenemes, fluoroquinolonas)
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
  • Insuficiência hepática
  • Doença pulmonar
  • Albumina < 3 g/dL
  • VIH

Enterobactérias Resistentes a Carbapenemes (CRE)

• Microorganismos:
  • São resistentes a ≥ 1 antibiótico da classe carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam
  • Produzem uma enzima carbapenemase (as carbapenemases da Klebsiella pneumoniae Klebsiella Pneumoniae Gram-negative, non-motile, capsulated, gas-producing rods found widely in nature and associated with urinary and respiratory infections in humans. Aminoglycosides são as mais MAIS Androgen Insensitivity Syndrome comuns nos Estados Unidos)
• Infeções comuns:
  • PAV
  • Bacteriemia
  • Abcessos intra-abdominais
  • ITUs (por exemplo, cistite, pielonefrite)
• Opções de antibióticos:
  • O tratamento é limitado, sobretudo em infeções graves (por exemplo, bacteriemia).
  • Estão frequentemente presentes genes Genes A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. DNA Types and Structure de resistência a outros antibióticos.
  • Nas infeções resistentes a ertapenem Ertapenem A carbapenem derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of gram-positive and gram-negative bacterial infections including intra-abdominal infections, acute gynecological infections, complicated urinary tract infections, skin infections, and respiratory tract infections. It is also used to prevent infection in colorectal surgery. Carbapenems and Aztreonam, mas suscetíveis a meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam:
    • Pode ser utilizada infusão prolongada de meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam.
    • Se o teste de carbapenemase for positivo, deve ser evitado o uso de um meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam (mesmo que a suscetibilidade seja positiva).
  • Na cistite não complicada:
    • Ciprofloxacina, levofloxacina
    • Trimetoprim-sulfametoxazol
    • Nitrofurantoína
    • Aminoglicosídeo em dose única
  • ITUs complicadas e infeções fora do trato urinário:
    • Ceftazidima-avibactam
    • Meropenem-vaborbactam
    • Imipenem-cilastatina-relibactam
    • Cefiderocol Cefiderocol Multidrug-resistant Organisms and Nosocomial Infections

Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas resistente de difícil tratamento

• Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas não suscetível aos seguintes:
  • Piperacilina-tazobactam
  • Ceftazidima, cefepima
  • Aztreonam Aztreonam The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam
  • Meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam, imipenem-cilastatina
  • Ciprofloxacina, levofloxacina
• Infeções:
  • VAP
  • ITU
  • Infeção associada a dispositivo (por exemplo, cateter)
  • Feridas ou queimaduras
• Opções de antibióticos:
  • Ceftolozane-tazobactam
  • Ceftazidima-avibactam
  • Imipenem-cilastatina-relibactam
  • Cefiderocol Cefiderocol Multidrug-resistant Organisms and Nosocomial Infections

Prevenção

• Higienização das mãos
• Precauções de isolamento
• Programas de gestão de utilização de antibióticos
• Limpeza ambiental

Infeções Hematogénicas Associadas a Cateter Venoso Central (IHACVC)

IHACVC

• Infeção associada à colocação ou uso prolongado de um dispositivo intravascular – geralmente um cateter venoso central
• Fatores de risco:
  • Fatores do hospedeiro:
    • Doença crónica
    • Transplante de medula óssea
    • Deficiência imunológica (especialmente neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia)
    • Desnutrição
    • Administração de nutrição parentérica total
    • Infeções anteriores da corrente sanguínea
    • Extremos de idade
    • Perda da integridade da pele (por exemplo, queimaduras)
  • Fatores relacionados com o cateter:
    • Localização do cateter (por exemplo, o cateter subclávio apresenta menos risco)
    • Duração do cateterismo
    • Tipo de cateter (por exemplo, os cateteres não tunelizados apresentam um maior risco de infeção)
    • Condições de inserção
    • Cuidados com o local do cateter
    • Habilidade do operador que realiza a inserção
• Fontes de infeção:
  • Colonização da pele
  • Contaminação intraluminal
  • Disseminação hematogénica
  • Contaminação da infusão
• Microorganismos mais MAIS Androgen Insensitivity Syndrome comuns:
  • Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus coagulase-negativos ( CoNS CoNS Staphylococcus, pela sigla em inglês)
  • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
  • Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus
  • Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis spp.
  • Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella spp.
  • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli
  • Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections spp.
  • Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas spp.

Antibióticos e tratamento

• Terapêutica empírica:
  • Microorganismos gram-positivos: vancomicina
  • Bacilos gram-negativos se não houver instabilidade hemodinâmica, neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia ou queimaduras: ceftriaxone Ceftriaxone A broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears. Cephalosporins
  • Bacilos gram-negativos se houver instabilidade hemodinâmica, neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia ou queimaduras graves (uso de agentes antipseudomonas):
    • Ceftazidima, cefepima
    • Piperacilina-tazobactam
    • Imipenem Imipenem Semisynthetic thienamycin that has a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to beta-lactamases. Clinical studies have demonstrated high efficacy in the treatment of infections of various body systems. Its effectiveness is enhanced when it is administered in combination with cilastatin, a renal dipeptidase inhibitor. Carbapenems and Aztreonam, meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam
• Terapêutica dirigida a Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus:
  • Suscetível à meticilina:
    • Nafcilina
    • Oxacilina
    • Cefazolina
    • Flucloxacilina
  • Resistente à meticilina:
    • Vancomicina
    • Daptomicina
• Terapêutica dirigida a Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus:
  • Suscetível à ampicilina: ampicilina
  • Resistente à ampicilina, sensível à vancomicina: vancomicina
  • Resistente à ampicilina, resistente à vancomicina: daptomicina, linezolida
• Enterobacteriaceae Enterobacteriaceae A family of gram-negative, facultatively anaerobic, rod-shaped bacteria that do not form endospores. Its organisms are distributed worldwide with some being saprophytes and others being plant and animal parasites. Many species are of considerable economic importance due to their pathogenic effects on agriculture and livestock. Cephalosporins (por exemplo, Escherichiacoli, Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella spp., Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections spp.):
  • ESBL ESBL Klebsiella negativo:
    • Ceftriaxone Ceftriaxone A broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears. Cephalosporins
    • Ciprofloxacina
  • ESBL ESBL Klebsiella positivo:
    • Imipenem Imipenem Semisynthetic thienamycin that has a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to beta-lactamases. Clinical studies have demonstrated high efficacy in the treatment of infections of various body systems. Its effectiveness is enhanced when it is administered in combination with cilastatin, a renal dipeptidase inhibitor. Carbapenems and Aztreonam
    • Meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam
    • Ertapenem Ertapenem A carbapenem derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of gram-positive and gram-negative bacterial infections including intra-abdominal infections, acute gynecological infections, complicated urinary tract infections, skin infections, and respiratory tract infections. It is also used to prevent infection in colorectal surgery. Carbapenems and Aztreonam
    • Ciprofloxacina
• Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas spp.:
  • Antibioterapia preferencial:
    • Ceftazidima
    • Cefepima
    • Piperacilina-tazobactam
  • Alternativa:
    • Imipenem Imipenem Semisynthetic thienamycin that has a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to beta-lactamases. Clinical studies have demonstrated high efficacy in the treatment of infections of various body systems. Its effectiveness is enhanced when it is administered in combination with cilastatin, a renal dipeptidase inhibitor. Carbapenems and Aztreonam
    • Meropenem Meropenem A thienamycin derivative antibacterial agent that is more stable to renal dehydropeptidase I than imipenem, but does not need to be given with an enzyme inhibitor such as cilastatin. It is used in the treatment of bacterial infections, including infections in immunocompromised patients. Carbapenems and Aztreonam
    • Ciprofloxacina
• Tratamento de infeções associadas a cateter:
  • O cateter deve ser removido nos seguintes casos:
    • Instabilidade hemodinâmica
    • Sépsis
    • Coágulo sanguíneo ou tromboflebite supurativa
    • Endocardite
    • Infeção do trajeto do cateter venoso central subcutâneo tunelizado ou infeção do reservatório do cateter venoso central
    • A bacteriemia persiste mesmo após 72 horas de antibioterapia adequada.
    • Microorganismos identificados: Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus, Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas, MDRGNB ou Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis spp.
  • O cateter deve ser mantido nos seguintes casos:
    • Infeção não complicada por CoNS CoNS Staphylococcus
    • Infeção que não envolve material ortopédico nem um implante endovascular
    • Terapêutica de bloqueio com antibióticos (instilação de antibióticos no lúmen) com administração de antibioterapia sistémica

Prevenção

• Lavagem das mãos
• Utilizar precauções máximas de barreira 
• Desinfeção da pele com clorexidina
• Evitar o local de inserção femoral
• Remoção do cateter quando deixa de haver indicação

Infeções do Trato Urinário Associadas a Cateter Vesical (CAUTI)

CAUTI

• Infeção urinária associada a cateter urinário (cateter de Foley)
• Diferenciação de acordo com a “Infectious Diseases Society of America”:
  • Bacteriúria sintomática (ITU):
    • Crescimento de cultura de ≥ 10³ unidades formadoras de colónias (UFC)/mL de bactérias uropatogénicas
    • Sinais e sintomas de ITU sem identificação de outra fonte
    • Os sintomas podem incluir febre, dor costovertebral ou no ângulo suprapúbico, alteração do estado de consciência e hipotensão.
    • Associada a cateterismo uretral ou suprapúbico permanente ou cateterização intermitente, atual ou nas últimas 48 horas
  • Bacteriúria assintomática:
    • Crescimento de cultura de ≥ 10⁵ UFC/mL de bactérias uropatogénicas
    • Indivíduo com cateterização uretral ou suprapúbica permanente, ou cateterização intermitente sem sintomas de ITU
• Fatores de risco:
  • Maior duração do cateterismo (risco de infeção do catéter vesical: ~ 3-7% por dia)
  • Sexo feminino
  • Idade avançada
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
  • Colonização bacteriana do saco de drenagem
  • Problemas de manutenção do cateter (i.e., erros na técnica estéril, não manutenção de um sistema de drenagem fechado)
• Patogénese:
  • Extraluminal ( mais MAIS Androgen Insensitivity Syndrome comum): As bactérias entram na bexiga ao longo do biofilme (forma-se em redor do cateter).
  • Intraluminal: drenagem incompleta (promove a estase urinária ou a infeção ascendente do saco de coleta de urina contaminada)
• Microorganismos comuns:
  • Escherichia coli
  • Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis spp.
  • Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus spp.
  • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas
  • Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella spp.

Tratamento

• Opções antimicrobianas:
  • Dependente dos resultados da cultura e da suscetibilidade
  • Não se recomenda antibioterapia na bacteriúria assintomática exceto em certos casos (por exemplo, gravidez, previsão de procedimento urológico)
  • Exige a consideração dos seguintes fatores:
    • Culturas de urina anteriores
    • Terapêutica antimicrobiana prévia
    • Exposição de profissionais de saúde
    • Prevalência de resistência antimicrobiana
    • Alergia a antibióticos
• O uso de cateteres permanentes deve ser minimizado:
  • O cateterismo intermitente apresenta menor risco de ITU.
  • Se for necessário um cateter permanente, a substituição está recomendada com o início da antibioterapia.
• Prevenção:
  • Evitar o cateterismo desnecessário.
  • Usar técnicas estéreis na colocação do cateter.
  • Remover o cateter assim que deixar de ser necessário.

Pneumonias Nosocomiais e Associadas à Ventilação (PAV)

Pneumonias no hospital

• Definições:
  • PAH PAH The glycine amide of 4-aminobenzoic acid. Its sodium salt is used as a diagnostic aid to measure effective renal plasma flow (ERPF) and excretory capacity. Glomerular Filtration ou pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia nosocomial: infeção pulmonar que surge ≥ 48 horas após a admissão e não incubada no momento da admissão
  • PAV: desenvolvimento de pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia ≥ 48 horas após intubação endotraqueal
• Fatores de risco:
  • Ventilação mecânica: A maioria das PAHs ocorre em indivíduos que não estão sob ventilação mecânica (mas os indivíduos sob ventilação mecânica apresentam maior risco de PAH PAH The glycine amide of 4-aminobenzoic acid. Its sodium salt is used as a diagnostic aid to measure effective renal plasma flow (ERPF) and excretory capacity. Glomerular Filtration).
  • Idade avançada
  • Doença pulmonar crónica
  • Alteração do estado de consciência
  • Aspiração
  • Cirurgia torácica ou abdominal superior
  • Agentes que aumentam o pH pH The quantitative measurement of the acidity or basicity of a solution. Acid-Base Balance gástrico
  • Exposição prévia a antibióticos (sobretudo antibióticos de largo espectro)
  • Reintubação ou intubação prolongada
  • Aumento do uso de opioides
  • Trauma
  • Paralisia
  • Múltiplas colocações e cirurgias de cateter venoso central
  • Uso de relaxantes musculares ou glucocorticoides
  • Presença de um monitor de pressão intracraniana
  • Desnutrição
  • Insuficiência renal crónica
  • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
  • Hospitalização anterior
• Microorganismos comuns:
  • Bacilos gram-negativos:
    • Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli
    • Klebsiella pneumoniae Klebsiella Pneumoniae Gram-negative, non-motile, capsulated, gas-producing rods found widely in nature and associated with urinary and respiratory infections in humans. Aminoglycosides
    • Enterobacter Enterobacter Multidrug-resistant Organisms and Nosocomial Infections spp.
    • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas
    • Acinetobacter Acinetobacter Multidrug-resistant Organisms and Nosocomial Infections spp.
• Bacilos gram-positivos:
  • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess (incluindo MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus)
  • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus spp

Tratamento

• Opções de antibioterapia:
  • Incluir cobertura para:
    • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
    • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas
    • Outros bacilos gram-negativos
  • Considerar agentes patogénicos locais e os riscos para OMR.
• Esquema:
  • Indivíduos sem risco para OMR e baixo risco para MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus: 1 agente contra Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas, outros BGN e Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess sensível à meticilina:
    • Piperacilina-tazobactam
    • Cefepima
    • Levofloxacina
  • Indivíduos em risco para OMR (incluindo MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus): 2 agentes contra Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas e outros BGN, e 1 agente com atividade contra MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus:
    • Piperacilina-tazobactam/cefepima/ceftazidima/ carbapenem Carbapenem The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam/ aztreonam Aztreonam The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam; E,
    • Um aminoglicosídeo (por exemplo, amicacina, gentamicina); E,
    • Vancomicina/linezolide/telavancina
• Prevenção:
  • Uso de ventilação não invasiva com pressão positiva sempre que possível (evitar intubação)
  • Protocolos de desmame
  • Minimizar a sedação
  • Facilitar o condicionamento físico e a mobilidade precoce
  • Prevenir a aspiração:
    • Elevação da cama
    • Drenagem de secreções subglóticas
  • Abordagem para ajudar a diminuir a PAV:
    • Probióticos
    • Cuidados de higiene oral (clorexidina)
    • Profilaxia de úlcera de stress
    • Tubos endotraqueais revestidos de prata

Infeção por Clostridioides difficile (ICD)

ICD

• Infeção causada pela bactéria formadora de esporos Clostridioides difficile
• Uma das infeções hospitalares mais MAIS Androgen Insensitivity Syndrome comuns
• Fatores de risco:
  • Uso de antibióticos
  • Idade avançada
  • Hospitalização
  • Doença grave concomitante
• Microbiologia e doença:
  • Clostridioides difficile:
    • Bacilo gram-positivo anaeróbio, formador de esporos e produtor de toxinas
    • Liberta 2 exotoxinas potentes que induzem colite e diarreia: enterotoxina A (diarreia) e toxina B (colite pseudomembranosa)
  • Colite pseudomembranosa (inflamação grave do revestimento do intestino):
    • Dor abdominal
    • Diarreia aquosa profusa (pode ocasionalmente ser sanguinolenta)
    • Leucocitose
    • Associada ao uso recente de antibióticos (por exemplo, clindamicina, fluoroquinolonas, cefalosporinas, penicilinas)

Tratamento

• Opções de antibioterapia:
  • Fidaxomicina oral
  • Vancomicina oral
  • Metronidazol
• ICD recorrente: Associar bezlotoxumab (anticorpo monoclonal).
• Descontinuar o antibiótico precipitante.
• Cuidados de suporte: Reposição de fluidos e eletrólitos.
• Outros:
  • Transplante de microbiota fecal (TMF):
    • As fezes processadas de um doador saudável são instiladas no trato intestinal.
    • A administração ocorre através de cápsulas orais, colonoscopia, enema de retenção ou tubo nasojejunal/nasoduodenal
  • Considerar cirurgia em caso de doença fulminante (hipotensão, choque, íleo ou megacólon).
• Prevenção:
  • Controlo da infeção:
    • Higienização das mãos
    • Utilizar água e sabão em vez de desinfetante para as mãos à base de álcool (os esporos de Clostridioides difficile são resistentes ao álcool).
  • Minimizar o uso de antibióticos.
  • Profilaxia oral com vancomicina em indivíduos de alto risco para ICD

Infeção do Local Cirúrgico (ILC)

ILC

• Infeção da área de uma cirurgia recente
• Fatores de risco:
  • Tabagismo
  • Idade avançada
  • Doença vascular
  • Obesidade
  • Desnutrição
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Terapêutica imunossupressora
  • Presença de infeção recente ou antiga do local cirúrgico
  • Cirurgia recente
  • Hospitalização
  • Transfusão
  • Fatores locais da ferida:
    • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Proximidade de outros locais de feridas abertas ou contaminadas
    • Presença de infeções antigas
• Microbiologia e doença:
  • Microorganismos comuns:
    • Superfícies da pele e mucosas: bactérias gram-positivas (por exemplo, Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess, CoNS CoNS Staphylococcus).
    • As regiões inguinais podem ser contaminadas por bacilos gram-negativos e microorganismos anaeróbios.
  • As infeções podem ser:
    • Superficiais (por exemplo, com edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, calor Calor Inflammation, exsudado): caracterizadas por observação
    • Mais MAIS Androgen Insensitivity Syndrome profundas (por exemplo, com envolvimento da fáscia, músculo ou órgão): São necessários exames de imagem e exploração.

Tratamento

• Drenagem do fluido infetado
• Exploração e desbridamento, se necessário (sobretudo se presença de necrose dos tecidos)
• Terapêutica antibiótica:
  • Devem ser consideradas a extensão da infeção, comorbilidades e manifestações sistémicas.
  • Indicada nas infeções profundas (nem sempre necessária nas infeções superficiais).
  • Geralmente orientada com base na cultura e sensibilidades: A seleção empírica é baseada na coloração de Gram inicial, local da ferida e tipo.
  • Os microorganismos mais MAIS Androgen Insensitivity Syndrome comuns são:
    • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
    • CoNS CoNS Staphylococcus
    • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus spp.
    • Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus spp.
• Prevenção:
  • Paciente:
    • Cessação tabágica
    • Preparação intestinal antes da cirurgia do cólon
  • Controlo de infeção:
    • Higienização das mãos
    • Vestuário cirúrgico e dispositivos de barreira
    • Profilaxia antimicrobiana
    • Descolonização de Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
    • Aplicação de antisséticos na pele
    • Depilação: Evitar barbear com lâminas no local da cirurgia planeada.
  • Outras medidas perioperatórias:
    • Manter a normotermia.
    • Limitar o número de pessoas e a entrada no bloco operatório.
    • Utilizar câmaras de Fluxo Laminar 
    • Oxigénio suplementar
    • Minimizar a transfusão de glóbulos vermelhos.
    • Controlo glicémico
    • Aplicação tópica e local de antibióticos
    • Protetores de feridas intraoperatórios
  • Terapêutica profilática de feridas por pressão negativa

Relevância Clínica

• Infeções do trato urinário: largo espectro de doenças, desde a cistite simples (autolimitada) até à pielonefrite grave. As infeções mais MAIS Androgen Insensitivity Syndrome frequentemente causadas por Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli. A apresentação clínica inclui disúria, urgência e frequência miccional, dor suprapúbica e febre. A análise da urina e a urocultura estabelecem o diagnóstico. O tratamento envolve antibioterapia (por exemplo, trimetoprim-sulfametoxazol, nitrofurantoína, ceftriaxone Ceftriaxone A broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears. Cephalosporins). Podem ser necessários exames adicionais se não houver resposta à terapêutica.
• Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia: infeção do parênquima pulmonar mais MAIS Androgen Insensitivity Syndrome frequentemente causada por uma bactéria ou vírus. A pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia adquirida na comunidade (PAC) é responsável por 80% dos casos. Se a infeção for adquirida durante um internamento numa unidade de saúde, a infeção é denominada pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia associada aos cuidados de saúde (PACS). O diagnóstico é baseado na apresentação clínica de febre, tosse produtiva, dispneia, roncos inspiratórios e presença de consolidação na radiografia do tórax. A pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia atípica pode apresentar sintomas mais MAIS Androgen Insensitivity Syndrome ligeiros e exames de imagem com alterações menos significativas. O tratamento da PAC envolve habitualmente antibioterapia empírica, enquanto a pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia associada à ventilação requer terapêutica antibiótica dirigida.
• Sépsis: disfunção orgânica resultante de uma resposta sistémica desregulada do hospedeiro à infeção. A etiologia é sobretudo bacteriana, sendo a pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia a fonte mais MAIS Androgen Insensitivity Syndrome comum. Os doentes apresentam-se com febre, taquicardia, taquipneia, hipotensão e/ou alteração do estado de consciência. O diagnóstico de choque sético é estabelecido durante o tratamento, quando são necessários vasopressores para controlar a hipotensão. A sépsis e o choque sético são emergências médicas e a antibioterapia deve ser administrada dentro de 1 hora após o diagnóstico.