{"id":514391,"date":"2024-07-10T16:31:01","date_gmt":"2024-07-10T19:31:01","guid":{"rendered":"https:\/\/revistapesquisa.fapesp.br\/?p=514391"},"modified":"2024-07-10T16:31:01","modified_gmt":"2024-07-10T19:31:01","slug":"antibiotic-resistant-bacteria-on-the-rise-in-brazilian-hospitals","status":"publish","type":"post","link":"https:\/\/revistapesquisa.fapesp.br\/en\/antibiotic-resistant-bacteria-on-the-rise-in-brazilian-hospitals\/","title":{"rendered":"Antibiotic-resistant bacteria on the rise in Brazilian hospitals"},"content":{"rendered":"

On November 6, Nazareno Scaccia put on a pair of gloves, tied a sterilized steel bucket to the end of a rope, then lowered it to the bottom of a sewer tunnel in central S\u00e3o Caetano, part of the S\u00e3o Paulo Metropolitan Area. He then hoisted it back up, full of slightly cloudy, yellowy-brown water with an unpleasant odor. He poured the liquid into a large plastic bottle and used a syringe attached to a filter to fill a small vial. \u201cWe do this to separate the microorganisms and prevent degradation of the chemical compounds present in the water,\u201d explained the Italian microbiologist, who is doing a postdoctoral fellowship at the University of S\u00e3o Paulo\u2019s School of Medicine (FM-USP). Some bacteria are capable of digesting the active ingredients of antibiotics, making it difficult to detect these compounds in water.<\/p>\n

Later that morning, Scaccia and biologists Miriam Lopes da Silva and Francisca Peternella traveled to eight other locations in the city to repeat the procedure. The water collected from taps, streams, common sewage, and hospital sewage was then taken to a laboratory at USP\u2019s School of Public Health (FSP) to test for the presence of antibiotic-resistant bacteria. The task was part of an international project<\/a>\u2014coordinated in Brazil by infectious disease specialist Anna Sara Levin from FM-USP\u2014that is studying whether more appropriate prescription and use of these medications could reduce the emergence and spread of microorganisms against which antibiotics no longer produce the desired effect.<\/p>\n

The spread of bacteria and other microorganisms resistant to almost all available antimicrobials is a global challenge. It has been a problem since antibiotics first came into use and it is progressing rapidly, keeping specialists up at night worrying about a threat to one of the greatest achievements of modern medicine: the ability to combat infections. Without effective antibiotics, it would be almost impossible to safely perform surgery, transplants, and chemotherapy. Common problems, such as a deep cut or a respiratory infection, would become life-threatening.<\/p>\n

\u201cFew interventions have increased human longevity as much as the treatment of drinking water and the development of vaccines and antibiotics,\u201d says Arnaldo Lopes Colombo, an expert in infectious diseases from the Federal University of S\u00e3o Paulo (UNIFESP) who heads the Paulista Institute of Antimicrobial Resistance, one of the Research, Innovation, and Dissemination Centers (RIDCs) funded by FAPESP. Some estimates suggest that the use of antibiotics to treat infections has increased the average human lifespan by about 20 years.<\/p>\n

Antibiotics are chemical compounds that kill or inhibit the growth of bacteria. They only act against these microorganisms\u2014they do not work against viruses, for example. Technically, the term is used to define compounds of natural origin (produced by fungi or other bacteria) that eliminate pathogenic bacteria. The term is more commonly used, however, to describe synthetic or semisynthetic molecules that exterminate these microorganisms. There are roughly 12 classes of antibiotics. Each acts at a different point in the structure or functioning of bacteria (see infographic on page 16<\/em>).<\/p>\n<\/div>

\n \n \n \n <\/picture>Alexandre Affonso\/Pesquisa FAPESP<\/span><\/div>
\n

When exposed to the appropriate concentration of antibiotics for a sufficient amount of time, bacteria are easily killed. If the dosage and duration of the treatment are lower than needed to kill them, some can survive and multiply, accumulating changes in their genetic material that allow them to escape the action of the drugs.<\/p>\n

Bacteria are everywhere: in water, soil, air, and on surfaces, including in our bodies. Due to the heavy use of antibiotics to treat human illness, to induce weight gain in livestock, and to protect animals from disease, bacteria are continually exposed to these drugs. This continuous contact leads to the selection of resistant strains.<\/p>\n

\u201cWe are seeing the emergence of bacteria for which there are no longer any effective medications,\u201d reports Brazilian infectious disease specialist Fernanda Lessa, head of the International Infection Control Branch at the USA\u2019s Centers for Disease Control and Prevention (CDC). She edited a special supplement on the subject that was published in the journal Clinical Infectious Diseases<\/em><\/a> in July 2023, stating: \u201cLuckily, infections caused by these microorganisms are still relatively rare in the community and are almost entirely limited to hospital settings.\u201d<\/p>\n

\"\"

Frank DeLeo\u2009\/\u2009NIAID<\/span><\/a> Electron microscope image of Staphylococcus aureus<\/em> (yellow<\/em>), which causes approximately 120,000 deaths per year as a result of hospital infections in the AmericasFrank DeLeo\u2009\/\u2009NIAID<\/span><\/p><\/div>\n

Even so, infections by multidrug-resistant bacteria\u2014also called superbugs\u2014can cause enormous damage. A survey led by epidemiologist Ramanan Laxminarayan of Princeton University, USA, estimated that there are 136 million hospital infections caused by these microorganisms worldwide every year. According to the results, published in the journal PLOS Medicine<\/em><\/a> in June 2023, China is by far the most affected nation, with 52 million cases. Brazil placed fifth, with four million cases.<\/p>\n

Worldwide, superbugs were directly responsible for 1.27 million deaths in 2019. If cases where the individual had another disease in addition to the infection are included, the number is 4.95 million, close to the total number of COVID-19 deaths recorded in the three-year pandemic and well above the combined annual deaths caused by malaria, AIDS, and tuberculosis.<\/p>\n

These figures were calculated by an international group of researchers, including Brazilians, based on data from 204 countries. Published in The Lancet <\/em><\/a>in 2022, the study found that almost 80% of deaths resulted from infections of the lower respiratory tract (bronchitis and pneumonia), the circulatory system, or the abdominal cavity.<\/p>\n

Six superbug species were responsible for at least 70% of deaths: Escherichia coli<\/em>, Staphylococcus aureus<\/em>, Klebsiella pneumoniae<\/em>, Streptococcus pneumoniae<\/em>, Acinetobacter baumannii<\/em>, and Pseudomonas aeruginosa<\/em>. All of them are on the list of priority pathogens for which new antibiotics are needed, published by the World Health Organization (WHO) in 2017.<\/p>\n<\/div>

\n \n \n \n <\/picture>Alexandre Affonso\/Pesquisa FAPESP<\/span><\/div>
\n

Home to 14% of the world’s population, the 35 countries in the Americas account for approximately 11% of deaths from antibiotic-resistant bacterial infections. In 2019, superbugs were directly responsible for 141,000 deaths and associated with 569,000 more, according to a study published in The Lancet Regional Health \u2013 Americas <\/em><\/a>in August 2023. Once again, the vast majority (80%) were caused by the six aforementioned pathogens. In absolute numbers, most cases occur in the most populous nations: the USA and Brazil. In the latter, there were 33,200 deaths (around 90 per day) directly caused by superbugs in 2019 and 138,000 more in which they played an indirect role. \u201cThe groups most likely to be affected are the very young and the elderly\u2014newborns aged less than one month and people aged over 65,\u201d says Eitan Berezin, a pediatrician from the Santa Casa School of Medicine in S\u00e3o Paulo and one of the authors of the paper (see graph below<\/em>).<\/p>\n

\u201cI suspect that today, the number of deaths in Brazil and worldwide would be even higher,\u201d said the CDC\u2019s Lessa in an interview in September. \u201cThese studies used data from 2019, but the use of antibiotics increased during the COVID-19 pandemic,\u201d she pointed out.<\/p>\n\n \n \n \n <\/picture>Alexandre Affonso\/Pesquisa FAPESP<\/span>\n

Two studies that she led, both published in Clinical Infectious Diseases<\/em> in July, supported this theory. In one, Lessa and colleagues analyzed drug dispensary records in six hospitals<\/a>\u2014two in Brazil, two in Chile, and two in Argentina\u2014from two periods: between March 2018 and February 2020, and in the first year of the pandemic. With the increase in hospital admissions following the emergence of the novel coronavirus, the use of antibiotics increased in all six hospitals (by up to 35%), something that was also observed in the USA. In Brazil, antibiotic prescriptions to treat respiratory infections at home have also increased. Between January 2019 and March 2020, 19.9 million courses of antibiotics were prescribed, while 27.5 million were prescribed in the first year of the pandemic, according to the second study<\/a>.<\/p>\n

Even before the emergence of the novel coronavirus, there were already signs that consumption of antibiotics was growing around the world. Princeton’s Laxminarayan and colleagues tracked antibiotic sales in 76 countries between 2000 and 2015 and identified two trends. The first was a 65% increase in the quantity consumed, from 21.1 billion daily doses to 34.8 billion, according to a 2018 paper in the journal PNAS<\/em><\/a>. The second was that the proportion of people using this type of medication grew by almost 40%: from 11.3 daily doses per 1,000 inhabitants in 2000 to 15.7 per 1,000 in 2015. The increase was driven largely by economic improvement in and low- and middle-income countries. Despite the rise, it is estimated that globally, six million people die every year due to lack of access to antibiotics.<\/p>\n

The combination of the increased use of these drugs\u2014especially during the pandemic\u2014and overcrowding in hospitals appears to have facilitated the spread of genes that allow bacteria to escape the action of the drugs.<\/p>\n

In Brazil, this trend was observed by infectious disease specialist Carlos Kiffer of UNIFESP and colleagues from the Pontifical Catholic University of Paran\u00e1 (PUC-PR) and the Oswaldo Cruz Foundation (FIOCRUZ). The team analyzed genetic data from more than 80,000 bacterial samples collected in hospitals across the country between 2017 and 2022. They found that during the pandemic, there was a significant increase (from 4 to 21 percentage points) in the frequency of genes that give eight species of bacteria resistance to carbapenems, antibiotics considered the last resort in treating serious hospital infections. Klebsiella pneumoniae<\/em>, Escherichia coli<\/em> and Acinetobacter baumannii<\/em> were among the microorganisms affected, according to the results, published in Clinical Infectious Diseases <\/em><\/a>in July. \u201cThere was evidence that some of these genes were becoming more common in the country. We helped determine the scale of the problem,\u201d says Kiffer.<\/p>\n

For Anna Levin, an infectious disease specialist from USP and head of the monitoring project mentioned at the beginning of this report, hospital infections caused by antibiotic-resistant bacteria reflect the quality of care. \u201cWhen the system is at its limit, with too many patients and not enough health professionals to care for them, infection rates increase,\u201d says the researcher, who chairs the infection control committee at USP\u2019s Hospital das Cl\u00ednicas, the largest health complex in Brazil. During the pandemic, Levin’s group managed to control the spread of infections caused by multidrug-resistant bacteria in the hospital’s emergency room by testing patients for the pathogens and isolating anyone who was infected, treating them separately.<\/p>\n

Although antibiotic resistance has long been a problem, the world has only recently started paying attention to it, primarily because of two documents: a 2014 WHO report that showed the global nature of the phenomenon and a study by economist James O’Neill, carried out for the UK government, that made catastrophic projections for 2050. If nothing is done, antibiotic-resistant infections are expected to cause 10 million deaths per year by the middle of the century, resulting in economic losses of up to US$100 trillion.<\/p>\n

The 2016 edition of Brock Biology of Microorganisms<\/em>, a book often used as a reference in health courses, reports that at least 10,000 tons of antibiotics are produced globally per year for use in human and animal healthcare. One consequence is that these products, even when used correctly, contaminate the environment, leading to the emergence of resistant bacteria. \u201cIn Brazil, there is no rule that hospital sewage must be treated to eliminate bacteria from the urine and feces of patients or the hospital environment. We do not have a good surveillance system for monitoring the frequency of resistant microorganisms in hospitals and their spread in the community and the environment,\u201d says Ana Gales, an infectious disease specialist from UNIFESP who studies the subject.<\/p>\n

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L\u00e9o Ramos Chaves\u2009\/ Pesquisa Fapesp <\/span><\/a> Collection of sewage water from S\u00e3o Caetano to test for the presence of antibiotic-resistant bacteria (above<\/em>) and preparation for filtrationL\u00e9o Ramos Chaves\u2009\/ Pesquisa Fapesp <\/span><\/p><\/div>\n

In recent years, a number of studies have provided evidence that the problem, which was thought to be predominantly hospital-based, is becoming more pronounced in the wider environment. A team led by biochemical pharmacist Eliana Stehling of USP\u2019s Ribeir\u00e3o Preto School of Pharmaceutical Sciences is monitoring the spread of multidrug-resistant bacteria in almost 50 towns in the north of S\u00e3o Paulo State. They have detected the microorganisms in soil samples from agricultural areas and in water from rivers, streams, and creeks. \u201cIn the environment, especially in water, these drugs can lead to the emergence of superbugs, accelerating the spread of antimicrobial resistance, since these microorganisms go on to exchange genetic material with each other,\u201d says Jo\u00e3o Pedro Furlan, a pharmacist who is part of the Ribeir\u00e3o Preto group.<\/p>\n

At USP\u2019s S\u00e3o Paulo campus, Chilean microbiologist Nilton Lincopan and his team have identified resistant bacteria in every place imaginable, including in the Tiet\u00ea and Pinheiros rivers that cross the capital and in turtles, penguins, whales, dolphins, and seabirds off the Brazilian coast. \u201cWe have recorded around 30 cases in the last four years,\u201d says the researcher.<\/p>\n

They were also found in dogs and cats treated at veterinary clinics and hospitals in the city, and in samples of fresh lettuce, arugula, and cabbage sold by the biggest commercial distributor in S\u00e3o Paulo. \u201cSome strains are resistant to acidic environments. This means that when someone eats a poorly washed vegetable, they can pass through the stomach and colonize the intestine,\u201d explains Lincopan.<\/p>\n

Drug resistance also occurs among fungi, although it is more difficult to measure due to a lack of data. In 2022, the WHO released the first list of fungal pathogens that require public health interventions as a priority. It included the yeast Candida auris<\/em>, of which there have been outbreaks in hospitals all over the world. \u201cInfections caused by multidrug-resistant fungi are less common, but can be more lethal than bacterial infections,\u201d says UNIFESP\u2019s Colombo, who has been studying the problem.<\/p>\n

Experts have recommended certain measures be taken. The simplest and most comprehensive, which should be adopted by everyone, are to practice good personal and food hygiene, and to vaccinate against microorganisms when possible, such as for the bacteria that cause pneumonia, tuberculosis, and meningitis. Another is to use medications optimally and rigorously. Doctors should prescribe antibiotics only for bacterial infections, with the help of testing, if possible, to determine which drug is most appropriate for each case, and antifungals for fungal infections. Patients should take the recommended dose for the indicated length of time, even if their condition improves sooner. Whenever possible, people should stay away from hospitals, and when unavoidable, they should spend as little time there as possible.<\/p>\n

Projects
\n1.<\/strong> S\u00e3o Paulo Institute of Antimicrobial Resistance (Aries Project) (n\u00ba 21\/10599-3<\/a>); Grant Mechanism<\/strong> Research, Innovation, and Dissemination Centers (RIDC); Principal Investigator<\/strong> Arnaldo Lopes Colombo (UNIFESP); Investment<\/strong> R$15,021,964.28.
\n2.<\/strong> International multidisciplinary network to characterize microbiological aspects and the natural history of Invasive Fungal Infections (IFI) by species of the genus Candida<\/em> (n\u00ba 17\/02203-7<\/a>); Grant Mechanism<\/strong> Thematic Project; Principal Investigator<\/strong> Arnaldo Lopes Colombo (UNIFESP); Investment<\/strong> R$1,328,821.49.
\n3.<\/strong> Screening and early isolation of patients colonized by carbapenem-resistant enterobacteriaceae admitted to the emergency department (n\u00ba 18\/06016-0<\/a>); Grant Mechanism<\/strong> Regular Research Grant; Principal Investigator<\/strong> Icaro Boszoczowski (FM-USP); Investment<\/strong> R$114,610.59.
\n4.<\/strong> Resistome, plasmidome, and virulome of Enterobacterales isolated from the environment carrying mcr-like genes (n\u00ba 21\/01655-7<\/a>); Grant Mechanism<\/strong> Regular Research Grant; Principal Investigator<\/strong> Eliana Guedes Stehling (USP-RP); Investment<\/strong> R$199,956.01.
\n5.<\/strong> Study of the resistance, virulence, and epidemiological profile of Escherichia coli<\/em> isolated from the environment (n\u00ba 18\/01890-3); Grant Mechanism<\/strong> Doctoral Fellowship; Supervisor<\/strong> Eliana Guedes Stehling (USP-RP); Beneficiary<\/strong> Jo\u00e3o Pedro Rueda Furlan; Investment<\/strong> R$150,141.19.
\n6.<\/strong> One Health Brazilian Resistance (OneBR): Integrated genomic base for surveillance, diagnosis, and treatment of antimicrobial resistance at the human-environment-animal interface in Brazil (n\u00ba 20\/08224-9<\/a>); Grant Mechanism<\/strong> Regular Research Grant; Principle Investigator<\/strong> Nilton Erbet Lincopan Huenuman (USP); Investment<\/strong> R$241,806.62.
\n7.<\/strong> Viruloma and pathogenicity of priority bacterial strains resistant to carbapenems and polymyxins in One Health (n\u00ba 19\/15578-4<\/a>); Grant Mechanism<\/strong> Doctoral Fellowship; Supervisor<\/strong> Nilton Erbet Lincopan Huenuman (USP); Beneficiary<\/strong> Fernanda Ribeiro dos Santos Esposito; Investment<\/strong> R$190,601.93.
\n8.<\/strong> Pan-resistome of Klebsiella pneumoniae<\/em> and Escherichia coli<\/em> beta-lactamase producers (KPC-2, CTX-M-8, CTX-M-15) endemic in Brazil (n\u00ba 16\/08593-9<\/a>); Grant Mechanism<\/strong> Regular Research Grant; Principal Investigator<\/strong> Nilton Erbet Lincopan Huenuman (USP); Investment<\/strong> R$214,075.41.
\n9.<\/strong> Comparative analysis of the Klebsiella pneumoniae<\/em> XDR resistome (NDM-1\/KPC-2), part of the endemic high-risk clonal complex (CC) CC258 (n\u00ba 15\/21325-0<\/a>); Grant Mechanism<\/strong> Doctoral Fellowship; Supervisor<\/strong> Nilton Erbet Lincopan Huenuman (USP); Beneficiary<\/strong> Louise Teixeira Cerdeira; Investment<\/strong> R$131,634.25.<\/p>\n

Scientific articles<\/strong>
\nBALASUBRAMANIAN, R. et al<\/em>. Global incidence in hospital-associated infections resistant to antibiotics: An analysis of point prevalence surveys from 99 countries<\/a>. PLOS Medicine<\/strong>. June 13, 2023.
\nANTIMICROBIAL RESISTANCE COLLABORATORS. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis<\/a>. The Lancet<\/strong>. Jan. 19, 2022.
\nWHO. Prioritization of pathogens to guide discovery, research and development of new antibiotics for drug-resistant bacterial infections, including tuberculosis<\/a>. Sept. 4, 2017.
\nANTIMICROBIAL RESISTANCE COLLABORATORS. The burden of antimicrobial resistance in the Americas in 2019: A cross-country systematic analysis<\/a>. The Lancet Regional Health \u2012 Americas<\/strong>. Aug. 8, 2023.
\nPATEL, T. S. et al<\/em>. Trends in inpatient antibiotic use among adults hospitalized during the coronavirus disease 2019 pandemic in Argentina, Brazil, and Chile, 2018\u20132021<\/a>. Clinical Infectious Diseases<\/strong>. July 5, 2023.
\nSOLANKY, D. et al<\/em>. Prescribing of outpatient antibiotics commonly used for respiratory infections among adults before and during the coronavirus disease 2019 pandemic in Brazil.<\/a> Clinical Infectious Diseases<\/strong>. July 5, 2023.
\nKLEIN, E. Y. et al<\/em>. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015<\/a>. PNAS<\/strong>. Mar. 26, 2018.
\nKIFFER, C. R. V. et al<\/em>. A 7-Year Brazilian national perspective on plasmid-mediated carbapenem resistance in Enterobacterales, Pseudomonas aeruginosa<\/em>, and Acinetobacter baumannii<\/em> complex and the impact of the coronavirus disease 2019 pandemic on their occurrence<\/a>. Clinical Infectious Diseases<\/strong>. July 5, 2023.
\nFURLAN, J. P. R. et al<\/em>. Genetic plurality of blaKPC-2-harboring plasmids in high-risk clones of Klebsiella pneumoniae<\/em> of environmental origin<\/a>. Science of the Total Environment<\/strong>. July 10, 2023.
\nFURLAN, J. P. R. et al<\/em>. Early dissemination of novel NDM-1-producing Klebsiella pneumoniae <\/em>ST6326 to the environment<\/a>. Journal of Global Antimicrobial Resistance<\/strong>. Sept. 2023.
\nFURLAN, J. P. R. et al<\/em>. Detection of CTX-M-27-positive endophytic Escherichia coli <\/em>ST131 lineage C1\/H<\/em>30R subclade carrying bla<\/em>KPC-2 on an IncX3-IncU plasmid in a fresh vegetable<\/a>.<\/u> Journal of Global Antimicrobial Resistance<\/strong>. June 20, 2022.
\nFURLAN, J. P. R. & STEHLING, E. G. Multiple sequence types, virulence determinants and antimicrobial resistance genes in multidrug- and colistin-resistant Escherichia coli<\/em> from agricultural and non-agricultural soils<\/a>. Environmental Pollution<\/strong>. Nov. 1, 2021.
\nESPOSITO, F. et al<\/em>. Genomic analysis of carbapenem-resistant Pseudomonas<\/em> aeruginosa<\/em> isolated from urban rivers confirms spread of clone sequence type 277 carrying broad resistome and virulome beyond the hospital<\/a>.<\/u> Frontiers in Microbriology<\/strong>. Sept. 3, 2021.
\nLOPES, F. et al<\/em>. Endophytic lifestyle of global clones of extended-spectrum \u03b2-lactamase-producing priority pathogens in fresh vegetables: A trojan horse strategy favoring human colonization?<\/a> mSystems<\/strong>. Feb. 9, 2021.
\nDA SILVA, L. C. B. A. et al<\/em>. Human pandemic K27-ST392 CTX-M-15 extended-spectrum \u03b2-lactamase-positive Klebsiella pneumoniae<\/em>: A one health clone threatening companion animals<\/a>. One Health<\/strong>. July 3, 2022.
\nEWBANK, A. C. et al<\/em>. World Health Organization critical priority Escherichia coli <\/em>clone ST648 in magnificent frigatebird (Fregata magnificens<\/em>) of an uninhabited insular environment<\/a>. Frontiers in Microbiology<\/strong>. Aug. 11, 2022.
\nSANO, E. et al<\/em>. One health clones of multidrug-resistant Escherichia coli<\/em> carried by synanthropic animals in Brazil<\/a>.<\/u> One Health<\/strong>. Dec. 21, 2022.
\nMARTINS, W. M. B. S. et al<\/em>. SPM-1-producing Pseudomonas aeruginosa<\/em> ST277 clone recovered from microbiota of migratory birds.<\/a> Diagnostic Microbiology and Infectious Disease<\/strong>. Mar. 2018.
\nNARCISO, A. C. et al<\/em>. Healthcare-associated carbapenem-resistant OXA-72-producing Acinetobacter baumannii<\/em> of the clonal complex CC79 colonizing migratory and captive aquatic birds in a Brazilian zoo.<\/a> Science of the Total Environment<\/strong>. July 15, 2020.
\nNARCISO, A. C. et al<\/em>. Detection of OXA-58-producing Acinetobacter seifertii<\/em> recovered from a black-necked swan at a zoo lake.<\/a> Antimicrobial Agents and Chemotherapy<\/strong>. Nov. 22, 2017.
\nPIC\u00c3O, R. C. et al<\/em>. The route of antimicrobial resistance from the hospital effluent to the environment: Focus on the occurrence of KPC-producing Aeromonas<\/em> spp. and Enterobacteriaceae in sewage.<\/a> Diagnostic Microbiology and Infectious Disease<\/strong>. May 2013.
\nWHO<\/strong>. WHO fungal priority pathogens list to guide research, development and public health action<\/a>. Oct. 25, 2022.<\/p>\n","protected":false},"excerpt":{"rendered":"Microorganisms killed at least 33,000 people in the country in 2019","protected":false},"author":16,"featured_media":514416,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[156,159],"tags":[247,260],"coauthors":[105],"class_list":["post-514391","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cover","category-science","tag-medicine","tag-public-health","position_at_home-sumario"],"acf":[],"_links":{"self":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/514391","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/users\/16"}],"replies":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/comments?post=514391"}],"version-history":[{"count":5,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/514391\/revisions"}],"predecessor-version":[{"id":520762,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/514391\/revisions\/520762"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media\/514416"}],"wp:attachment":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media?parent=514391"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/categories?post=514391"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/tags?post=514391"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/coauthors?post=514391"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}