BACKGROUND Acinetobacter baumannii outbreaks have been associated with pandemic International Clones (ICs), but the virulence factors involved with their pathogenicity are sparsely understood. Pigment production has been linked with bacterial pathogenicity, however, this phenotype is rarely observed in A. baumannii. OBJECTIVES This study aimed to characterise the reddish-brown pigment produced by A. baumannii strains, and to determine its biosynthetic pathway by genomic approaches. METHODS Pigment characterisation and antimicrobial susceptibility were conducted by phenotypic tests. The clonal relationship was obtained by pulsed field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST). The genome of an A. baumannii was obtained for characterisation of genes involved with pigment production. FINDINGS The pyomelanin was the pigment produced by A. baumannii. Strains were extensively drug resistant and belonged to the IC-5/ST79. The pyomelanin biosynthetic pathway was determined and presented a particular architecture concerning the peripheral (tyrB, phhB and hpd) and central (hmgB, hmgC and hmgR) metabolic pathway genes. The identification of a distant HmgA homologue, probably without dioxygenase activity, could explain pyomelanin production. Virulence determinants involved with adherence (csuA/BABCDE and a T5bSS-carrying genomic island), and iron uptake (basABCDEFGHIJ, bauABCDEF and barAB) were characterised. MAIN CONCLUSION There is a biosynthetic pathway compatible with the pyomelanin production observed in persistent A. baumannii IC-5 strains.

BACKGROUND Acinetobacter baumannii is a leading cause of nosocomial infections. This species is characterised by the presence of pandemic lineages (International Clones) that present a broad antimicrobial resistance profile. OBJECTIVE To perform the molecular epidemiology of carbapenem-resistant A. baumannii from a clinical setting in the Amazon Basin, and to characterise their antimicrobial resistance determinants. METHODS The genetic relationship of carbapenem-resistant A. baumannii were assessed by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Class A, B and D β-lactamase genes were screened by polymerase chain reaction (PCR) and sequencing. The antimicrobial susceptibility profile was obtained by Disc-diffusion method and minimum inhibitory concentration (MIC) determination. FINDINGS All carbapenem-resistant A. baumannii strains belonged to three international clones, IC-1, IC-5 and IC-6, the latter recently reported by the first time in Brazil. The major determinant of carbapenem resistance in IC-1 and IC-5 strains was bla OXA-23, associated with ISAba1 and ISAba3, respectively, while IC-6 harboured the bla OXA-72. CONCLUSIONS The A. baumannii epidemiology in Brazilian Amazon Region was unknown. It was demonstrated that A. baumannii XDR international clones were responsible for nosocomial infections in Boa Vista during 2016-2018, revealing that the epidemiological scenario of A. baumannii infections in Amazon Region resembles those from the cosmopolitan regions worldwide.

Resumo Em países em desenvolvimento, a pneumonia é a principal causa de adoecimento e morte na infância, principalmente em grupos vulneráveis. O objetivo deste estudo foi analisar os fatores associados à pneumonia em crianças Yanomami internadas por condições sensíveis à atenção primária (ICSAP). As internações foram divididas em dois grupos: i) pneumonias e ii) demais causas, de acordo com a lista brasileira de ICSAP. Foram estimadas taxas ajustadas de ICSAP e utilizou-se a regressão logística não condicional para analisar fatores associados. Mais de 90% dos registros foram considerados ICSAP. A taxa padronizada de ICSAP foi 18,6/1.000. As chances de internação por pneumonia foram 2,7 (IC: 1,3-5,4) vezes maiores em crianças de 0,1 a 5,9 meses; 1,9 (IC: 1,1-3,3) vezes maiores nas crianças que tiveram a duração da hospitalização variando de 8 a 14 dias; e 3,0 (IC: 1,2-7,5) vezes maiores nas crianças com diagnóstico secundário de desnutrição. O excesso de internações evitáveis é um forte indício da baixa qualidade das ações em terras indígenas e do limitado acesso à atenção primária, contrariando o modelo assistencial proposto pelo subsistema de saúde indígena no Brasil que, em tese, deveria privilegiar tecnologias assistenciais ancoradas na atenção primária.

Abstract In developing countries, pneumonia is the leading cause of sickness and mortality in childhood, especially among vulnerable groups. The scope of this study was to analyze the factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care Sensitive Conditions (ACSC). Hospital admissions were divided into two groups: i) pneumonia; and ii) other causes, according to the Brazilian ACSC list. Adjusted hospitalization rates were estimated and unconditional logistic regression was used to analyze factors associated with pneumonia. Over 90% of the registered cases were considered ACSC. The adjusted rate of ACSC was 18.6/1000. The odds ratio of hospitalization for pneumonia was 2.7 (CI: 1.3-5.4) times higher in children aged between 0.1 and 5.9 months; 1.9 (CI: 1.1-3.3) times higher in children who were hospitalized for 8-14 days; and three (CI: 1.2-7.5) times higher in children with a secondary diagnosis of malnutrition. The excess of avoidable hospitalizations is a clear indication of the low quality of care and limited accessibility to primary health care in indigenous territories, which is contrary to the assistance model proposed by the indigenous healthcare subsystem in Brazil, which should in theory focus on welfare technologies based on primary health care.

Resumo Em países em desenvolvimento, a pneumonia é a principal causa de adoecimento e morte na infância, principalmente em grupos vulneráveis. O objetivo deste estudo foi analisar os fatores associados à pneumonia em crianças Yanomami internadas por condições sensíveis à atenção primária (ICSAP). As internações foram divididas em dois grupos: i) pneumonias e ii) demais causas, de acordo com a lista brasileira de ICSAP. Foram estimadas taxas ajustadas de ICSAP e utilizou-se a regressão logística não condicional para analisar fatores associados. Mais de 90% dos registros foram considerados ICSAP. A taxa padronizada de ICSAP foi 18,6/1.000. As chances de internação por pneumonia foram 2,7 (IC: 1,3-5,4) vezes maiores em crianças de 0,1 a 5,9 meses; 1,9 (IC: 1,1-3,3) vezes maiores nas crianças que tiveram a duração da hospitalização variando de 8 a 14 dias; e 3,0 (IC: 1,2-7,5) vezes maiores nas crianças com diagnóstico secundário de desnutrição. O excesso de internações evitáveis é um forte indício da baixa qualidade das ações em terras indígenas e do limitado acesso à atenção primária, contrariando o modelo assistencial proposto pelo subsistema de saúde indígena no Brasil que, em tese, deveria privilegiar tecnologias assistenciais ancoradas na atenção primária.

Abstract In developing countries, pneumonia is the leading cause of sickness and mortality in childhood, especially among vulnerable groups. The scope of this study was to analyze the factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care Sensitive Conditions (ACSC). Hospital admissions were divided into two groups: i) pneumonia; and ii) other causes, according to the Brazilian ACSC list. Adjusted hospitalization rates were estimated and unconditional logistic regression was used to analyze factors associated with pneumonia. Over 90% of the registered cases were considered ACSC. The adjusted rate of ACSC was 18.6/1000. The odds ratio of hospitalization for pneumonia was 2.7 (CI: 1.3-5.4) times higher in children aged between 0.1 and 5.9 months; 1.9 (CI: 1.1-3.3) times higher in children who were hospitalized for 8-14 days; and three (CI: 1.2-7.5) times higher in children with a secondary diagnosis of malnutrition. The excess of avoidable hospitalizations is a clear indication of the low quality of care and limited accessibility to primary health care in indigenous territories, which is contrary to the assistance model proposed by the indigenous healthcare subsystem in Brazil, which should in theory focus on welfare technologies based on primary health care.