PROGRAMA DE PÓS-GRADUAÇÃO EM VIGILÂNCIA SANITÁRIA INSTITUTO NACIONAL DE CONTROLE DE QUALIDADE EM SAÚDE

The outbreaks caused by rapidly growing mycobacteria (RGM) after invasive medical procedures, occurred in different regions of the country, resulted in the emergence of many questions related to the characteristics of microorganisms associated with these events, the procedures used in equipment disinfection and, mainly, the effectiveness of the products used, considered safe for this application up to now. Mycobacterium massiliense, among others RGM, has been isolated as etiologic agent of localized and systemic infections, and a single clone (BRA100) is prevalent in the whole country. The non-evidence of RGM transmission through human contact has led to the proposition that the infection can occur from environmental sources, reinforcing the suspicion of inadequate disinfection of medical articles. The aim of this study was to evaluate the RGM susceptibility by Confirmative in vitro Test for Determining Mycobactericidal Activity of Disinfectants, from Association of Official Analytical Chemists, to glutaraldehyde, peracetic acid and orthophtalaldehyde-based disinfectants. Five M. massiliense clinical strains belonging to the clone BRA100, and the reference strains M. bovis BCG Moreau, M. abscessus ATCC 19977, M. chelonae ATCC 35752, M. fortuitum ATCC 6841, M. massiliense INCQS 00594 were evaluated. For glutaraldehyde-based disinfectants, it was observed that none of them was effective for M. bovis BCG Moreau, the only reference strain recommended by AOAC in the effectiveness examination assay of this kind of product. M. chelonae was killed by the three tested disinfectants, while M. fortuitum was killed only by two of them. The three disinfectants were ineffective for M. abscessus and M. massiliense. The peracetic acid-based disinfectants showed effectiveness for all mycobacteria used (absence of growth), although M. massiliense isolates had presented a reduced susceptibility to peracetic acid B. Orthophtalaldehyde-based product was effective to M. bovis BCG Moreau and M. chelonae, and all the others mycobacteria studied were tolerant to this disinfectant. The high tolerance of M. massiliense isolates to glutaraldehyde was a determinant factor for the recent mandatory inclusion of the strain referent to this bacterial species in mycobactericidal activity evaluation assay for effectiveness verification of products in order to register them on Agencia Nacional de Vigilância Sanitaria. In order to reduce the nosocomial infections and, consequently, to promote human health, it is suggested that the use of glutaraldehyde-based products must be suspended for whatever purpose, in relation to high level disinfection, since all M. massiliense isolates from outbreaks and belonging to the prevalent clone in the country were tolerant to this disinfectant. Key-words: Rapidly growing mycobacteria; high level disinfection; biocide resistance; Mycobacterium massiliense. LISTA DE ILUSTRACOES Figura 1 Estrutura da parede celular de micobacterias 15 Figura 2 Infeccao por Micobacterias de Crescimento Rapido apos lipoaspiracao 18 Figura 3 Esquema da transferencia dos cilindros entre os tubos utilizados no Metodo Confirmatorio para Avaliacao da Atividade Micobactericida, da “Association of Official Analytical Chemists” – AOAC, conforme descrito no Procedimento Operacional Padronizado – POP INCQS n° 65.3210. 004 44 Figura 4 Atividade micobactericida do Glutaraldeido A frente aos microorganismos empregados no estudo 58 Figura 5 Atividade micobactericida do Glutaraldeido A1 frente aos microorganismos empregados no estudo 59 Figura 6 Atividade micobactericida do Glutaraldeido B frente aos microorganismos empregados no estudo 60 Figura 7 Atividade micobactericida do OPA frente aos micro-organismos empregados no estudo 70 LISTA DE TABELAS Tabela 1 Casos de infeccoes por Micobacterias de Crescimento Rapido nos estados brasileiros 22 Tabela 2 Dados sobre cinco cepas de Mycobacterium massiliense 35 Tabela 3 Dados sobre a analise do teor dos produtos estudados 36 Tabela 4 Avaliacao da qualidade dos desinfetantes utilizando Mycobacterium bovis cepa BCG Moreau 51 Tabela 4A Repeticao dos ensaios de avaliacao da qualidade dos produtos a base de Glutaraldeido e OPA, utilizando Mycobacterium bovis cepa BCG Moreau 52 Tabela 5 Avaliacao da qualidade dos desinfetantes utilizando Mycobacterium massiliense INCQS no00594 53 Tabela 6 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Glutaraldeido A 55 Tabela 7 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Glutaraldeido A1 56 Tabela 8 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Glutaraldeido B 57 Tabela 9 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Acido peracetico A 62 Tabela 10 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Acido peracetico A1 63 Tabela 11 Avaliacao da suscetibilidade de micobacterias frente ao produto denominado Acido peracetico B 64 Tabela 11A Repeticao dos ensaios da avaliacao da suscetibilidade de micobacterias frente ao produto denominado Acido peracetico B 65 Tabela 12 Avaliacao da suscetibilidade de micobacterias frente ao Ortoftalaldeido 67 Tabela 12A Repeticao dos ensaios da avaliacao da suscetibilidade de micobacterias frente ao Ortoftalaldeido 68 Tabela 12B Repeticao dos ensaios da avaliacao da suscetibilidade da cepa de Mycobacterium massiliense CRM 0019 e de Mycobacterium abscessus ATCC 19977 frente ao Ortoftalaldeido 69 LISTA DE ABREVIATURAS, SIMBOLOS E SIGLAS