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- In Vitro Activity of Ceftolozane-Tazobactam Against Enterobacterales and Pseudomonas Aeruginosa Causing Urinary, Intra-Abdominal and Lower Respiratory Tract Infections in Intensive Care Units in Portugal: The STEP Multicenter StudyPublication . García-Fernández, S; García-Castillo, M; Melo-Cristino, J; Pinto, M; Gonçalves, E; Alves, V; Vieira, AR; Ramalheira, E; Sancho, L, et al.; STEP Multicenter StudyThe STEP surveillance study was designed to increase knowledge about distribution of multidrug-resistant (MDR) Enterobacterales and Pseudomonas aeruginosa in Portugal, focusing on the intensive care unit (ICU). Antimicrobial susceptibility of common agents was also evaluated and compared with that of one of the latest therapeutic introductions, ceftolozane-tazobactam (C/T). Clinical isolates of Enterobacterales (n=426) and P. aeruginosa (n=396) from patients admitted in Portuguese ICUs were included. Activity of C/T and comparators was investigated using standard broth microdilution. Isolates were recovered from urinary tract (UTI, 36.9%), intra-abdominal (IAI, 24.2%) and lower respiratory tract (LRTI, 38.9%) infections. In P. aeruginosa, overall distribution of MDR/extremely-drug resistant (XDR)/pan-drug resistant (PDR) isolates accounted for 21.2%, 23.2% and 0.8%, respectively. C/T was the most potent agent tested against P. aeruginosa and MDR/XDR/PDR phenotypes. In Escherichia coli, extended-spectrum beta-lactamases (ESBL) and carbapenemase (CP) phenotypes accounted for 16.6% and 1.7%, respectively, whereas in Klebsiella spp., ESBL and CP-phenotypes represented 28.5% and 17.9%, respectively. Overall, susceptibility of C/T against Enterobacterales was 86.9%. C/T was the least affected agent in E. coli (99.4% susceptibility), whereas its activity was moderate in Klebsiella spp. (71.5%) and Enterobacter spp. (70.4%), due in part to a high rate of ESBL and CP-phenotypes. In Enterobacterales, blaKPC was the most prevalent CP gene (63.0%), followed by blaOXA-48 (33.3%) and blaVIM (3.7%). These microbiological results reinforce C/T as a therapeutic option in ICU patients with UTI, IAI or LRTI due to P. aeruginosa or Enterobacterales isolates, but not for CP producers.
- Regulatory T Cells Show Dynamic Behavior During Late Pregnancy, Delivery, and the Postpartum PeriodPublication . Lima, J; Martins, C; Nunes, G; Sousa, MJ, et al.Regulatory T cells (Tregs) are critical immunomodulators during early pregnancy by preventing maternal T-cell activation against fetal cells. However, how populations of maternal Tregs vary during and after pregnancy in humans is still unclear. Therefore, we investigated Treg subsets in the peripheral blood of pregnant women from late pregnancy through the postpartum period. To accomplish this, the following circulating Treg subsets were analyzed in 43 healthy pregnant women and 35 nonpregnant women by flow cytometry during the third trimester, on the day of delivery, and postpartum: CD4DimCD25Hi, CD4+CD25HiFoxp3+, and CD4+CD25HiCD127-/dim. Additionally, the expression levels of the transcription factor Foxp3 in CD4DimCD25Hi Treg were analyzed. We have found that CD4DimCD25Hi Treg subset significantly decreased in the pregnant women on the day of delivery relative to the third trimester ( P < .05), and that all Treg subsets significantly increased postpartum compared to the third trimester and the day of delivery ( P < .05). Moreover, the Foxp3 expression ratios within the CD4DimCD25Hi Treg subset decreased during pregnancy and until delivery compared to those measured in the nonpregnant women and significantly increased postpartum compared to the third trimester and the day of delivery ( P < .05). Thus, despite their established role in offering immunoprotection to the fetus in early pregnancy, the number of circulating Tregs also varies from late pregnancy to the postpartum period. Our results offer an explanation for the possible effects of pregnancy on the clinical outcomes of some autoimmune diseases during the postpartum period.
- Urachal Adenocarcinoma: A Case Report with Key Imaging Findings and Radiologic-Pathologic Correlation.Publication . Schmitt, W; Baptista, M; Ferreira, M; Gomes, A; Gernano, AUrachal pathologies are rare and can mimic numerous abdominal and pelvic diseases. Differential diagnosis of urachal anomalies can be narrowed down by proper assessment of lesion location, morphology, imaging findings, patient demographics, and clinical history. We report a case of a 60-year-old male, with a history of unintentional weight loss without associated symptoms, who was diagnosed with locally invasive urachal adenocarcinoma. With this article, we pretend to emphasize urachal adenocarcinoma clinical features along with its key imaging findings with radiologic-pathologic correlation.
- Categorização TIRADS (Thyroid Imaging Reporting and Data System) e Bethesda de Nódulos da Tiróide: Experiência InstitucionalPublication . Germano, A; Schmitt, W; Ribeiro, C; Simões, H; Gasparinho, G; Ferreira, M; Gomes, AIntrodução: As categorizações TIRADS (thyroid imaging reporting and data system) e Bethesda atribuem riscos de malignidade e propõem recomendações a seguir visando uniformizar a interpretação desses exames pelos radiologistas e anatomopatologistas e triar eficazmente nódulos da tiróide para cirurgia ou seguimento. O objectivo do estudo foi avaliar o risco de malignidade das categorias diagnósticas TIRADS e Bethesda nos nódulos da tiróide puncionados na nossa Instituição. Material e Métodos: Foi efectuado um estudo transversal, descritivo e analítico, com avaliação retrospectiva dos dados. Incluíram-se 906 nódulos da tiróide de 842 doentes consecutivos, puncionados entre 01/01/2012 e 31/12/2014. Obteve-se confirmação histológica em 173 nódulos (19,1%). Os diagnósticos citológicos foram categorizados pelo sistema Bethesda. Foram estratificados 743 nódulos nas categorias TIRADS. Estimou-se o risco de malignidade das diferentes categorias TIRADS e Bethesda. Resultados: A percentagem de nódulos malignos entre os operados foi de 26,7 em 2012, 36,9 em 2013 e 55,2 em 2014. Nos estratos TIRADS 2, 3, 4a, 4b e 5 incluíram-se respectivamente 25; 354; 298; 49 e 17 nódulos. Obteve-se uma diferença estatisticamente significativa entre os riscos de malignidade dos nódulos pouco suspeitos (2, 3 e 4a – 5%) e muito suspeitos (4b e 5 – 48,5%), p < 0,001. As percentagens de nódulos nas categorias Bethesda I;II, III, IV, V e VI foram de 9,8; 73,1; 6,1; 5; 3,3 e 28, com riscos de malignidade respectivos de 2 a 15 %; 1 a 8%; 13 a 35%; 24 a 33%; 57 a 77% e 84 a 100%. Obteve-se uma diferença estatisticamente significativa entre os riscos de malignidade dos nódulos não cirúrgicos (I, II e III – 2 a 14%) e cirúrgicos (IV a VI – 49 a 65%), p < 0,001. Conclusão: Na classificação TIRADS, houve prevalência institucional superior à esperada de nódulos malignos na categoria dos provavelmente benignos e inferior à esperada de nódulos malignos nas categorias de elevada suspeição. Na classificação de Bethesda, houve prevalência institucional superior à esperada de nódulos malignos nas categorias benigno/indeterminado. Estas duas técnicas têm sido benéficas na triagem pré-cirúrgica dos pacientes com nódulos da tiróide, facto demonstrado por aumento progressivo da percentagem de nódulos malignos entre os tumores operados de 2012 a 2014.
- Genetic Background and Expression of the New qepA4 Gene Variant Recovered in Clinical TEM-1- and CMY-2-Producing Escherichia coli.Publication . Manageiro, V; Félix, D; Jones-Dias, D; Sampaio, D; Vieira, L; Sancho, L; Ferreira, E; Caniça, MA new QepA4 variant was detected in an O86:H28 ST156-fimH38 Escherichia coli, showing a multidrug-resistance phenotype. PAβN inhibition of qepA4-harboring transconjugant resulted in increase of nalidixic acid accumulation. The qepA4 and catA1 genes were clustered in a 26.0-kp contig matching an IncF-type plasmid, and containing a Tn21-type transposon with multiple mobile genetic elements. This QepA variant is worrisome because these determinants might facilitate the selection of higher-level resistance mutants, playing a role in the development of resistance, and/or confer higher-level resistance to fluoroquinolones in association with chromosomal mutations.
- Impact of Labor on Peripheral Blood Maternal T-Cell Subsets and on Regulatory T and B CellsPublication . Lima, J; Martins, C; Nunes, G; Sousa, MJ; Branco, J; Borrego, LLabor is thought to positively influence immune system development in the offspring, but studies investigating the impact of different modes of delivery on maternal immune system cells are scarce. Therefore, the aim of this study was to investigate the effect of labor on maternal peripheral blood T-cell subsets and on the recently described regulatory T and B cells. METHODS: Cross-sectional study comparing the absolute counts and percentages of peripheral blood T-cell subsets (maturation and activation profiles) and regulatory T and B cells between healthy pregnant women who delivered their newborns via elective cesarean (no labor; n = 14) and those who had a spontaneous vaginal delivery (after labor; n = 18). The cells were characterized using flow cytometry. RESULTS: We found that compared to the women who had elective cesareans, those who had spontaneous vaginal deliveries had significantly ( P < .05) lower absolute counts of B cells (median [cells/μL]: 146 [interquartile range, IQR = 49] vs 192 [IQR = 65]) and natural killer-like T (NKT-like) cells (median [cells/μL]: 154 [IQR = 125] vs 224 [IQR = 117]) in the peripheral blood. No further significant differences, particularly in regulatory T and B cells, were identified between the study groups. CONCLUSION: Labor does not seem to have a major impact on maternal peripheral blood T-cell subsets or regulatory T and B cells.
- Serotype 3 Remains the Leading Cause of Invasive Pneumococcal Disease in Adults in Portugal (2012-2014) Despite Continued Reductions in Other 13-Valent Conjugate Vaccine SerotypesPublication . Horácio, A; Silva-Costa, C; Lopes, J; Ramirez, M; Melo-Cristino, J; Portuguese Group for the Study of Streptococcal InfectionsSince 2010 the 13-valent pneumococcal conjugate vaccine (PCV13) replaced the 7-valent vaccine (PCV7) as the leading pneumococcal vaccine used in children through the private sector. Although, neither of the PCVs were used significantly in adults, changes in adult invasive pneumococcal disease (IPD) were expected due to herd protection. We characterized n = 1163 isolates recovered from IPD in adults in 2012-2014 with the goal of documenting possible changes in serotype prevalence and antimicrobial resistance. Among the 54 different serotypes detected, the most frequent, accounting for half of all IPD, were serotypes: 3 (14%), 8 (11%), 19A (7%), 22F (7%), 14 (6%), and 7F (5%). The proportion of IPD caused by PCV7 serotypes remained stable during the study period (14%), but was smaller than in the previous period (19% in 2009-2011, p = 0.003). The proportion of IPD caused by PCV13 serotypes decreased from 51% in 2012 to 38% in 2014 (p < 0.001), mainly due to decreases in serotypes 7F and 19A. However, PCV13 serotype 3 remained relatively stable and the most frequent cause of adult IPD. Non-PCV13 serotypes continued the increase initiated in the late post-PCV7 period, with serotypes 8 and 22F being the most important emerging serotypes. Serotype 15A increased in 2012-2014 (0.7% to 3.5%, p = 0.011) and was strongly associated with antimicrobial resistance. However, the decreases in resistant isolates among serotypes 14 and 19A led to an overall decrease in penicillin non-susceptibility (from 17 to 13%, p = 0.174) and erythromycin resistance (from 19 to 13%, p = 0.034). Introduction of PCV13 in the NIP for children, as well as its availability for adults may further alter the serotypes causing IPD in adults in Portugal and lead to changes in the proportion of resistant isolates.
- Characterization of B cells in healthy pregnant women from late pregnancy to post-partum: a prospective observational studyPublication . Lima, J; Martins, C; Leandro, MJ; Nunes, G; Sousa, MJ; Branco, J; Borrego, LMBACKGROUND: B cells play a role in pregnancy due to their humoral and regulatory activities. To our knowledge, different maturational stages (from transitional to memory) of circulating B cell subsets have not yet been characterized (cell quantification and phenotype identification) in healthy pregnant women. Thus, the objective of our study was to characterize these subsets (as well as regulatory B cells) from late pregnancy to post-partum and to compare them with the circulating B cells of non-pregnant women. METHODS: In all of the enrolled women, flow cytometry was used to characterize the circulating B cell subsets according to the expression of IgD and CD38 (Bm1-Bm5 classification system). Regulatory B cells were characterized based on the expression of surface antigens (CD24, CD27, and CD38) and the production of IL-10 after lipopolysaccharide stimulation. RESULTS: Compared to the absolute counts of B cells in the non-pregnant women (n = 35), those in the pregnant women (n = 43) were significantly lower (p < 0.05) during the 3rd trimester of pregnancy and on delivery day (immediately after delivery). The percentages of these cells on delivery day and at post-partum were significantly lower than those in the non-pregnant women. In general, the absolute counts and percentages of the majority of the B cell subsets were significantly lower in the 3rd trimester of pregnancy and on delivery day than in the non-pregnant women. However, these counts and percentages did not differ significantly between the post-partum and the non-pregnant women. The most notable exceptions to the above were the percentages of naïve B cells (which were significantly higher in the 3rd trimester and on delivery day than in the non-pregnant women) and of CD24(hi)CD38(hi) regulatory B cells (which were significantly higher in the post-partum than in the non-pregnant women). CONCLUSION: According to our study, the peripheral B cell compartment undergoes quantitative changes during normal late pregnancy and post-partum. Such findings may allow us to better understand immunomodulation during human pregnancy and provide evidence that could aid in the development of new strategies to diagnose and treat pregnancy-associated disturbances. Our findings could also be useful for studies of the mechanisms of maternal responses to vaccination and infection.
- Sensibilidade das enterobacteriáceas produtoras de beta-lactamases de espectro alargado à fosfomicinaPublication . Brito, T; Portugal, C; Sancho, L; Carvalho, C; Grima, B; Alves, JDIntrodução: A emergência de enterobacteriáceas produtoras de beta-lactamases de espectro alargado (ESBL) nos últimos anos representa um problema de saúde pública, escasseando alternativas eficazes para o seu tratamento. Vários trabalhos internacionais têm demonstrado uma sensibilidade in vitro muito elevada destas bactérias à fosfomicina, havendo alguns que testaram a eficácia clínica do tratamento de cistites agudas não complicadas no subgrupo das Escherichia coli com resultados promissores. No Hospital Prof. Dr. Fernando Fonseca EPE (HFF) tem havido um aumento anual progressivo do isolamento destes patogéneos. Os autores pretenderam testar a sensibilidade das enterobacteriáceas produtoras de ESBL à fosfomicina no HFF e averiguar o eventual potencial terapêutico. Material e métodos: Estudo prospectivo, durante 6 meses, no qual foi testada a sensibilidade à fosfomicina das enterobacteriáceas produtoras de ESBL isoladas. Foi utilizado o equipamento VITEK 2® para identificação das estirpes. A susceptibilidade à fosfomicina foi determinada através do método de difusão de disco (Oxoid®). O tratamento estatístico foi realizado através do programa Microsoft Excel®. Resultados: Foram identificadas 150 enterobacteriáceas ESBL, das quais 52% corresponderam a Klebsiella pneumoniae e 44% a Escherichia coli. Cerca de 88% das Escherichia coli e 68% das Klebsiella pneumoniae apresentaram sensibilidade à fosfomicina. Conclusões: De acordo com os dados obtidos a nível internacional e no nosso hospital, os autores recomendam a utilização da fosfomicina para tratamento de cistites agudas não complicadas provocadas por Escherichia coli produtoras de ESBL, sugerindo, concomitantemente, a realização de trabalhos futuros de eficácia clínica para consubstanciar esta prática e recomendação.
- Determinants of the Sympatric Host-Pathogen Relationship in TuberculosisPublication . David, S; Mateus, AR; Duarte, EL; Albuquerque, J; Portugal, C; Sancho, L; Lavinha, J; Gonçalves G, GMajor contributions from pathogen genome analysis and host genetics have equated the possibility of Mycobacterium tuberculosis co-evolution with its human host leading to more stable sympatric host-pathogen relationships. However, the attribution to either sympatric or allopatric categories depends on the resolution or grain of genotypic characterization. We explored the influence on the sympatric host-pathogen relationship of clinical (HIV infection and multidrug-resistant tuberculosis [MDRTB]) and demographic (gender and age) factors in regards to the genotypic grain by using spacer oligonucleotide typing (spoligotyping) for classification of M. tuberculosis strains within the Euro-American lineage. We analyzed a total of 547 tuberculosis (TB) cases, from six year consecutive sampling in a setting with high TB-HIV coinfection (32.0%). Of these, 62.0% were caused by major circulating pathogen genotypes. The sympatric relationship was defined according to spoligotype in comparison to the international spoligotype database SpolDB4. While no significant association with Euro-American lineage was observed with any of the factors analyzed, increasing the resolution with spoligotyping evidenced a significant association of MDRTB with sympatric strains, regardless of the HIV status. Furthermore, distribution curves of the prevalence of sympatric and allopatric TB in relation to patients' age showed an accentuation of the relevance of the age of onset in the allopatric relationship, as reflected in the trimodal distribution. On the contrary, sympatric TB was characterized by the tendency towards a typical (standard) distribution curve. Our results suggest that within the Euro-American lineage a greater degree of genotyping fine-tuning is necessary in modeling the biological processes behind the host-pathogen interplay. Furthermore, prevalence distribution of sympatric TB to age was suggestive of host genetic determinisms driven by more common variants.
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