Fabiano Marcio Nagel

Hand hygiene, and not ertapenem use, contributed to reduction of carbapenem-resistant Pseudomonas aeruginosa rates.

OBJECTIVE To evaluate the impact of ertapenem use in Pseudomonas aeruginosa carbapenem resistance, taking into account the volume of antimicrobial consumption, the consumption by the entire hospital of alcohol-based antiseptic hand rub, and the density rate of invasive practices. DESIGN Before-and-after trial. SETTING A tertiary care university hospital in southern Brazil. METHODS Ertapenem was first added to the hospital formulary in June 2006, and it was excluded in February 2009. We evaluated Pseudomonas aeruginosa resistance rates through 3 study periods: period 1, before ertapenem use (17 months); period 2, during ertapenem use (33 months); and period 3, after exclusion of ertapenem (15 months). RESULTS After introduction of ertapenem, there was a significant decrease in median consumption of imipenem or meropenem, from 2.6 to 2.2 defined daily doses (DDDs) per 100 patient-days (level change from 0.04 to -1.08; P < .01), and an increase in the use of these medications after ertapenem exclusion, from 2.2 to 3.3 DDDs per 100 patient-days (level change from -0.14 to 0.91; P < .01), by segmented regression analysis. There was no difference in the incidence density of carbapenem-resistant P. aeruginosa infection related to ertapenem use throughout the study periods. However, by multiple regression analysis, the reduction in the rate of carbapenem-resistant P. aeruginosa infection correlated significantly with the increase in the volume of alcohol used as hand sanitizer, which was from 660.7 mL per 100 patient-days in period 1 to 2,955.1 mL per 100 patient-days in period 3 (P = .04). Ertapenem use did not impact the rate of carbapenem-resistant P. aeruginosa infection. CONCLUSIONS Use of alcohol-based hand gel, rather than ertapenem, was associated with a reduction in the rates of carbapenem-resistant P. aeruginosa infection. Measures to reduce resistance must include factors other than just antimicrobial stewardship programs alone.

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation

BACKGROUND Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital. METHODS In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period. RESULTS During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year. CONCLUSION One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staffs workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Amino Acid Metabolism in Rat Hippocampus During the Period of Brain Growth Spurt

We studied protein synthesis, lipid synthesis and CO2 production by oxidation of glycine, alanine and leucine by slices of rat hippocampus during the period of brain growth spurt. The metabolism of the three amino acids decreased with the age of the animals, A major reduction was observed in protein synthesis, which was 4 times higher at 7 days of age than at 21 days of age for all amino acids studied. Glycine oxidation to CO2 was twice as high as alanine oxidation and ten times higher than leucine oxidation. The major pathway of leucine utilization was incorporation into proteins. Glycine was the amino acid that had the highest metabolic rate.

Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: parte II. Ventilação mecânica, controle endócrino metabólico e aspectos hematológicos e infecciosos

The role of intensive care specialists in the maintenance of deceased potential donors is not restricted to hemodynamics. Appropriate endocrine-metabolic management is fundamental to maintaining energy support and hydroelectrolytic control, which cooperate for hemodynamic stability. Hematological changes are also important, especially considering the issues caused by inappropriate transfusions. In addition, this article discusses the role of appropriate protective ventilation to prevent inflammatory responses and to provide more transplantable lungs. Finally, judicious assessment of infections and antibiotic therapy is discussed

Vancomycin minimal inhibitory concentration from broth microdilution and Etest in respiratory tract samples of patients with ventilation-associated pneumonia

additive effect on quinolone susceptibility.7 Though Qnr proteins and Aac(60)-Ib-cr only induce low level quinolone resistance, they are known to facilitate selection of resistancemutations in the presence of concentrations of quinolone antibiotics.8 We describe an isolate of K. pneumoniae isolate carrying three plasmid-mediated quinolone-resistant genes (qnrB, qnrS and aac (60)-Ib-cr variant) together with a novel variant of gyrA gene that has not been reported previously. These mechanisms were likely to have contributed individually to the high level ciprofloxacin and levofloxacin resistance.

Definindo pneumonia associada à ventilação mecânica: um conceito em (des)construção

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) setting. It has variable prevalence rates, ranging from 6 to 50 cases per 100 admissions to the ICU.(1,2) Such variability comes mainly from two aspects: the presence of case-mix differences among the different units evaluated in the literature and the lack of accurate diagnostic criteria that allow for an accurate functional diagnosis, making subjectivity an important aspect of definitive diagnosis and treatment decisions.(3) Several studies show that the incidence of this infection increases with the length of time on mechanical ventilation and show a rate of infection of approximately 3% per day during the first five days of mechanical ventilation.(2,4) The development of nosocomial pneumonia in an intensive care setting, especially of VAP, has significant morbidity, prolonging the duration of mechanical ventilation as well as the length of stay in the ICU with all the costs associated with that extended stay.(4-6) Bedside VAP diagnosis takes into consideration a combination of clinical, radiological and laboratory findings. Microbiological data are used as an attempt to refine diagnostic accuracy given the low specificity of clinical criteria alone. These criteria include the following: presence of a new or progressive, persistent infiltrate OR consolidation OR cavitation; AND at least two of these criteria: fever (axillary temperature above 38°C), without any other etiology OR leukopenia (<4,000 cells/mm3) or leukocytosis (>12,000 cells/mm3) OR emergence of purulent secretions OR change in secretion characteristics OR increased secretions. Additional factors to consider include the presence of functional impairment, hypoxemia with worsening PO2/FiO2 (relative partial pressure of oxygen/ fraction of inspired oxygen), increased biomarkers, altered mental status or the appearance of severe sepsis/septic shock. Ventilator-associated pneumonia is considered to have microbiological confirmation if at least one of the following laboratory criteria is present: positive blood culture without any other apparent source of infection OR positive pleural fluid culture OR bronchoalveolar lavage culture ≥104 UFC/ mL or tracheal aspirate culture ≥106 UFC/mL OR histopathology exam with evidence of lung infection OR urinary antigen or culture for Legionella spp. OR other positive laboratory tests for respiratory pathogens (serology, direct visualization and culture). In the absence of any of these microbiological criteria, VAP is diagnosed clinically. Camila Hubner Dalmora1, Caroline Deutschendorf1, Fabiano Nagel2, Rodrigo Pires dos Santos1,Thiago Lisboa2,3Such variability comes mainly from two aspects: the presence of case-mix differences among the different units evaluated in the literature and the lack of accurate diagnostic criteria that allow for an accurate functional diagnosis, making subjectivity an important aspect of definitive diagnosis and treatment decisions.

Infecção por patógenos multi-resistentes na UTI: como escapar?

Infeccoes causadas por patogenos potencialmente resistentes sao um problema crescente e as unidades de cuidado intensivo (UTIs) constituem o carro-chefe na prevalencia deste tipo de infeccao no sistema hospitalar, seja pela complexidade dos pacientes criticos ou pelo alto consumo de antimicrobianos nestas unidades.(1,2) Mais de 70% dos pacientes criticamente doentes internados em UTIs receberao algum antimicrobiano durante seu periodo de permanencia.(1) Alem disso, as infeccoes tem um peso importante na morbi-mortalidade dentro das unidades, e a prevalencia de infeccoes causadas por patogenos cujo tratamento e cada vez mais complexo tem aumentado progressivamente ao longo dos ultimos anos.(1-3) Somado a isso existe o fato de os microorganismos multirresistentes, mesmo sendo um problema de âmbito mundial, apresentarem comportamento distinto quanto aos mecanismos de resistencia e padroes de sensibilidade nas diversas regioes do mundo, dificultando generalizacoes.(4) A emergencia de resistencia tem se tornado um desafio no sistema hospitalar nos ultimos anos.(2) A exposicao aos antimicrobianos e, consequentemente, seu uso inadequado, se constitui no principal fator associado ao risco de desenvolvimento de resistencia. Dentro deste cenario, os principais patogenos associados a infeccao nosocomial e que, ao mesmo tempo, representam os maiores riscos em relacao a padroes de resistencia que limitem nossas alternativas terapeuticas, foram agrupados em um acronimo e sao conhecidos como patogenos ESKAPE (Quadro 1).(2) Apesar de nao compartilharem os mesmos mecanismos de inducao de resistencia, todos tem em comum uma prevalencia que vem crescendo progressivamente em virtude da pressao seletiva exercida pelas politicas (ou ausencia delas) de uso de antimicrobianos, principalmente nas UTIs. Por outro lado, o desenvolvimento de novas drogas que pudessem ampliar nosso arsenal terapeutico, minimizando assim o impacto clinico do aumento da resistencia, e extremamente restrito, nao havendo neste momento drogas em desenvolvimento para a maioria dos patogenos incluidos no conceito ESKAPE, especialmente gram-negativos.(5)