Fernanda Rodrigues

Nursing Workload as a Risk Factor for Healthcare Associated Infections in ICU: A Prospective Study

Introduction Nurse understaffing is frequently hypothesized as a potential risk factor for healthcare-associated infections (HAI). This study aimed to evaluate the role of nursing workload in the occurrence of HAI, using Nursing Activities Score (NAS). Methods This prospective cohort study enrolled all patients admitted to 3 Medical ICUs and one step-down unit during 3 months (2009). Patients were followed-up until HAI, discharge or death. Information was obtained from direct daily observation of medical and nursing rounds, chart review and monitoring of laboratory system. Nursing workload was determined using NAS. Non-compliance to the nurses’ patient care plans (NPC) was identified. Demographic data, clinical severity, invasive procedures, hospital interventions, and the occurrence of other adverse events were also recorded. Patients who developed HAI were compared with those who did not. Results 195 patients were included and 43 (22%) developed HAI: 16 pneumonia, 12 urinary-tract, 8 bloodstream, 2 surgical site, 2 other respiratory infections and 3 other. Average NAS and average proportion of non compliance with NPC were significantly higher in HAI patients. They were also more likely to suffer other adverse events. Only excessive nursing workload (OR: 11.41; p: 0.019) and severity of patient’s clinical condition (OR: 1.13; p: 0.015) remained as risk factors to HAI. Conclusions Excessive nursing workload was the main risk factor for HAI, when evaluated together with other invasive devices except mechanical ventilation. To our knowledge, this study is the first to evaluate prospectively the nursing workload as a potential risk factor for HAI, using NAS.

Streptococcus pneumoniae nasopharyngeal carriage in children attending day-care centers in the central region of Portugal, in the era of 7-valent pneumococcal conjugate vaccine.

The 7-valent pneumococcal conjugate vaccine became available in Portugal in 2001. Although not included in the national immunization program, vaccination coverage is high (over 60%). We studied for the first time the rates of nasopharyngeal (NP) carriage of pneumococci, antibiotic resistance patterns and serotypes among children attending day-care centers (DCCs) in Coimbra, a city in the Central Region of Portugal. Between January and February 2007, a cross-sectional study was conducted among children aged 6 months to 6 years attending eight DCCs. NP swabs were obtained from 507 children: 76.7% had received at least one dose of 7-valent pneumococcal conjugate vaccine and 64.3% were age-appropriately vaccinated. The global pneumococcal carriage rate was 61.3%. Colonization proportions varied with age and number of children attending each DCC. Serotyping revealed that 20.7% of the pneumococci were vaccine types (VTs), 70.8% were non-VTs, and 8.5% were nontypeable. Serotype 19F was the second most frequent serotype being detected in 10.5% of the samples. While global NP carriage was not associated with vaccination status, non-VTs were predominant among vaccinated children, who had significantly lower prevalence of VT. Of all isolates, 15.7% had penicillin minimum inhibitory concentrations that ranged between 0.12 and 2 microg/ml. The proportion of resistant strains was significantly higher among VT and unvaccinated children. In conclusion, the rates of vaccination and prevalence of pneumococcal NP were high. Rates of antimicrobial resistance were similar to those found in studies conducted in Oeiras and Lisbon. This study is a platform for future surveillance activities.

Case control study of rotavirus vaccine effectiveness in Portugal during 6 years of private market use.

Background: Although recommended by the vaccine committee of the Portuguese Paediatric Society, rotavirus vaccines have not been included in the routine immunization schedule. They have been available privately since 2006 with estimated coverage reaching approximately 30%. However, unlike other European countries using the vaccine, sentinel surveillance has detected fluctuations but no clear trends in the rate of gastrointestinal disease presentations. In this study, we set out to establish the real world effectiveness of rotavirus immunization in this low vaccine coverage setting. Methods: We carried out a test-negative case control study on a population of children attending a regional pediatric hospital, between 2006 and 2012, with symptoms of acute gastroenteritis and producing a stool sample for routine rotavirus testing. We calculated exposure odds ratio (ratio of odds of antecedent vaccination among cases compared with controls) to derive vaccine effectiveness ([1 − adjusted odds ratio]/100) against both hospital attendance and admission. Results: Vaccine effectiveness against attendance with rotavirus acute gastroenteritis was 83.7% (95% confidence interval: 73.9–89.8) and against hospital admission was 96.1% (95% confidence interval: 83.8–99.1). No significant difference between the 2 available vaccines was detected. Conclusion: Both rotavirus vaccines offer a high degree of individual protection in this population.

The early days of pandemic (H1N1) 2009 virus infection in the central region of Portugal

BACKGROUNDnThe first case of pandemic (H1N1) 2009 virus infection was diagnosed in the central region of Portugal on June 16, 2009, in a woman infected in Canada.nnnMETHODSnThe aim of our study was, first to characterize the clinical and epidemiologic aspects of all the patients with clinical manifestations included in the definition of case for investigation with samples submitted to diagnosis of the pandemic (H1N1) 2009 virus infection, in the central region of Portugal; second to assess the precision of the case definition of case for investigation considered in the study according to the presence or the absence of fever at the moment of clinical observation. We reviewed the medical records of all the patients presenting with Influenza like-illness classified as case for investigation and the first cases of patients infected with the new pandemic (H1N1) 2009 virus, diagnosed in the central region of Portugal during the pandemic period between June and August, 2009, were analyzed. Real-time reverse-transcriptase polymerase-chain-reaction (RT-PCR) testing was used to confirm the pandemic (H1N1) 2009 virus infection. Data collection was performed on a standardized paper format in agreement with the General Health Directorate.nnnRESULTS AND DISCUSSIONnPandemic (H1N1) 2009 virus infection was confirmed in 255 patients. Overall, median age was 23 years and 42.7 % were included in the category of 20 to 29 years. Confirmed infection in patients with less than 2 years or greater than 50 years was a rare event. The first cases were imported from Europe, namely France, Spain and England. On a second phase, pandemic (H1N1) 2009 virus infection was acquired in the south of Portugal (Algarve), before de diagnosis of the first domestic case. The incidence rate for pandemic (H1N1) 2009 virus infection was 10.7 per 100,000 persons and was different according to the district. It was higher in the district of Coimbra and Guarda were the main roads connecting to Europe are. The median calculated incubation period for the for pandemic (H1N1) 2009 virus infection was 2 days. The length of the clinical manifestations until the patients look for medical observation had a median time of 2 days. All the cases were of mild to moderate severity. No deaths were observed.nnnCONCLUSIONSnThe early days of pandemic (H1N1) 2009 virus infection was mild in our region. Most affected patients were young adults, with the extreme categories ages of life being spared. Early detection and diagnosis, combined with stringent isolation and treatment procedures could have slowed the spread of the infection in our region.

Density Distribution of Pharyngeal Carriage of Meningococcus in Healthy Young Adults: New Approaches to Studying the Epidemiology of Colonization and Vaccine Indirect Effects.

Background: Improved understanding of Neisseria meningitidis (Nm) carriage biology and better methods for detection and quantification would facilitate studies of potential impact of new vaccines on colonization and transmission in adolescents. Methods: We performed plate cultures on 107 oropharyngeal swabs stored frozen in skim milk tryptone glucose glycerol (STGG) broth and previously positive for Nm. We compared quantitative polymerase chain reaction (qPCR) detection of Nm in 601 STGG-swabs with culture. Using qPCR (n = 87), a log-phase broth culture standard curve and semiquantitative plate cultures (n = 68), we measured density of carriage. We compared qPCR genogrouping of DNA extracts from STGG-swabs and from plate culture lawns (n = 110) with purified isolates (n = 80). Results: Swab storage resulted in only 10% loss of culture sensitivity. Direct sodC qPCR Nm detection yielded more positives (87/601, 14.5%) than culture (80/601, 13.3%). Most samples (57/110) positive by culture were also positive by qPCR and vice versa, but discrepancies (single positives) were frequent among low-density samples. sodC qPCR was positive in 79/80 isolates but in only 65 by ctrA qPCR. Density both by culture and qPCR varied across 4 orders of magnitude with the majority being low (<50 bacteria-gene copies/mL) and a minority being high (>1000). Genogrouping qPCRs yielded more positive results when performed on DNA extracts from lawn cultures. Conclusions: We provide the first description of the distribution of Nm carriage density. This could be important for understanding transmission dynamics and population-level effectiveness of adolescent vaccine programs. Storage of swabs frozen in STGG for batched laboratory analysis facilitates carriage studies and direct sodC qPCR for Nm combined with qPCR genogrouping of lawn culture extracts provides accurate, detailed description of colonization.

Pneumococcal Serotypes Colonise the Nasopharynx in Children at Different Densities

Prevalence of pneumococcal serotypes in carriage and disease has been described but absolute serotype colonisation densities have not been reported. 515 paediatric nasal swab DNA extracts were subjected to lytA qPCR and molecular serotyping by microarray. Absolute serotype densities were derived from total pneumococcal density (qPCR cycle threshold and standard curve) and relative abundance (microarray) and varied widely. Compared to all serotype densities observed, the strongest evidence of differences was seen for serotypes 21 and 35B (higher) and 3, 38 and non-typeables (lower) (p<0.05) with a similar hierarchy when only a single serotype carriage was assessed. There was no evidence of any overall density differences between children with single or multiple serotypes detected but serotypes with mid-range densities were more prevalent. The hierarchy of distinct pneumococcal serotype carriage densities described here for the first time, may help explain the dynamics of transmission between children.

Oropharyngeal Carriage of Meningococcus in Portugal by Group and Clonal Complex 6 Years After Adolescent Vaccine Campaign.

Portugal introduced (2+1) conjugate Meningococcal group C vaccine in 2006 with high coverage catch up to 18 years and has given only 1 dose at 1 year since 2012. Among 601 student oropharyngeal swabs, meningococcal carriage rate was 13.3% (A-0%, B-5.3%, C-0.3%, W-0.2%, X-0.2% and Y-1.7%). C and W strains were of potentially disease-causing clonal complexes (cc) but not the hyperinvasive cc11.

Os dias iniciais da infecção pelo vírus da gripe pandémica (H1N1) 2009 na região centro de Portugal

Resumo Introducao O primeiro caso de infeccao pelo virus da gripe pandemica (H1N1) 2009 foi diagnosticado na regiao centro de Portugal no dia 16 de Junho de 2009, numa mulher infectada no Canada. Metodos O nosso estudo tem por objectivos, em primeiro lugar caracterizar os aspectos clinicos e epidemiologicos de todos os doentes que tiveram manifestacoes clinicas incluidas na definicao de caso para investigacao com amostras submetidas para diagnostico da infeccao pelo virus da gripe pandemica (H1N1) 2009; em segundo lugar, avaliar a precisao da definicao de caso para investigacao de acordo com a presenca ou ausencia de febre no momento da observacao clinica. Efectuamos a revisao dos registos medicos de todos os doentes classificados como caso para investigacao e analisaram-se os primeiros casos de doentes infectados com o novo virus da gripe pandemica (H1N1) 2009, diagnosticados na regiao centro de Portugal durante o periodo pandemico compreendido entre Junho e Agosto de 2009. Foi utilizado o metodo da reaccao em cadeia da polimerase de retrotranscripcao em tempo real para confirmacao da infeccao pelo virus da gripe pandemica (H1N1) 2009. A colheita de dados foi efectuada de forma padronizada em suporte de papel de acordo com as normas da Direccao Geral de Saude. Resultados e discussao A infeccao pelo virus da gripe pandemica (H1N1) 2009 foi confirmada laboratorialmente em 255 casos. A idade media foi de 23 anos e 42,7 % foram incluidos na categoria dos 20 aos 29 anos. A infeccao em doentes com menos de 2 anos ou mais de 50 anos foi um acontecimiento raro. Os primeiros casos foram importados da Europa: Franca, Espanha e Inglaterra. Numa segunda fase, a infeccao foi adquirida no sul de Portugal (Algarve). A taxa de incidencia de infeccao pelo virus da gripe pandemica (H1N1) 2009 foi de 10,7 por 100 000 pessoas e foi diferente consoante o distrito. Foi mais elevado no distrito de Coimbra e da Guarda onde estao as principais estradas de ligacao com a Europa. O periodo de incubacao calculado para a infeccao pelo virus da gripe pandemica (H1N1) 2009 foi de 2 dias. A duracao das manifestacoes clinicas ate os doentes procurarem observacao medica teve um valor mediano de 2 dias. Todos os casos foram de gravidade ligeira a moderada, sem casos de morte. Conclusoes Os dias iniciais da infeccao pelo virus da gripe pandemica (H1N1) 2009 foram caracterizados na nossa regiao por casos de doenca com gravidade ligeira a moderada. Os mais afectados foram os jovens adultos, com as idades extremas da vida poupadas. O diagnostico precoce, o isolamento estrito e o tratamento podem ter diminuido a disseminacao da infeccao.

Resurgence of Serotype 19F Carriage in Preschool Children in Portugal in the Context of Continuing Moderate Conjugate Pneumococcal Vaccine Uptake

TO THE EDITOR—Reduction to near extinction of pneumococcal (Streptococcus pneumoniae [Sp]) vaccine serotype nasal colonization has been reported over a period of around 5–7 years of pneumococcal conjugate vaccine (PCV) use [1, 2]. PCVs have been used in private practice in Portugal since 2001. They are not included in the universal national immunization program. After licensure of the 7-valent vaccine (PCV7, Wyeth), estimated coverage, based on sales information, increased from 32% in 2002 to 65% in 2005 and 79% in 2007, then fell slightly to 75% in 2008 (oral communication, Pfizer). In April 2009, the 10-valent vaccine (PCV10, GSK) became available and some infants received it. In January 2010, the 13-valent vaccine (PCV13, Pfizer) replaced PCV7 and is the vaccine that has been used almost exclusively since then (estimated coverage in 2010 and 2011 was approximately 65%; oral communication, Pfizer). Both schedules (2 + 1 and 3 + 1) have been used. Previously, we reported carriage rates by serotype in cross-sectional studies performed annually in preschool children attending day care centers (DCCs) in Coimbra, a city in the central region of Portugal, between 2007 and 2009 [3, 4]. Among the children studied, the proportion who had received at least 1 dose of PCV7 vaccine showed a significant upward trend over the 3 years (76.5%, 82.4%, and 84%) [4]. The proportion of PCV7 serotypes (by Quellung reaction) showed a significant downward trend over time, apart from 19F, which persisted, detected in 4.1% of all children studied in 2009 [4]. Studies from other countries suggest that 19F is slower to disappear than other PCV types [5, 6]. In February–March 2010 we swabbed the nasopharynges of 586 children attending the same urban DCCs in Coimbra. The study was approved by the Ethics Committee of Centro Hospitalar de Coimbra. Parents or guardians provided written informed consent for their child to participate. The mean age was 41.5 months (standard deviation, 18.1; range, 6.3–74.5); 326 (56%) children were male, and 507 (86.5%) had received at least 1 dose of PCV7 or PCV10 Among those aged ≥18 months, 78 (15.2%) and 338 (65.6%) had completed either a full 2 + 1 or 3 + 1 schedule, respectively. Nasopharyngeal swabs were inoculated into skim-milk tryptone glucose glycerol broth and stored at −80°C prior to culture. Standard microbiological techniques for the isolation and identification of Sp were used as described previously [7]. The Sp carriage rate was 58.5% (343/586). Molecular serotyping was undertaken, using a microarray-based method to determine cps gene content from genomic DNA hybridization, capable of detecting multiple serotypes in a single sample [8]. Excluding nontypeable (NT) signals (n = 7 NT only, n = 76 NT with other serotypes), which, using this methodology can include non-Sp streptococci, 73 children (12.5%) carried >1 Sp serotype. A total of 11.3% had PCV7/10 vaccine serotypes: 19F, 8.9% (52); 7F, 2.2% (13, including 2 with 19F); 1, 5, and 18C (1 each). Serotype 19F was more commonly detected than any other serotype. There was sole colonization by 19F in 34 children (5.8%) and by 19F with other serotype(s) in 18 (3.1%), among whom in 11 (1.9%) 19F was both the predominant serotype and represented >50% of the bacterial DNA detected in the sample (Figure 1). Accordingly, 45 children (7.7%) carried 19F as the only or the predominant serotype, a clear rise. Twenty cases of invasive disease due to 19F were reported to the national surveil-

Comparison between diagnosis and treatment of community-acquired pneumonia in children in various medical centres across Europe with the United States, United Kingdom and the World Health Organization guidelines

BackgroundThe aim of this study was to review the current status and usage of guidelines in the diagnosis and treatment of community-acquired pneumonia (CAP) in European countries and to compare to established guidelines in the United States (US), United Kingdom (UK), and the World Health Organization (WHO).MethodsA questionnaire was developed and distributed by the Community-Acquired Pneumonia Paediatric Research Initiative (CAP-PRI) working group and distributed to medical centres across Europe.ResultsOut of 19 European centres, 6 (31.6 %) used WHO guidelines (3 in combination with other guidelines), 5 (26.3 %) used national guidelines, and 5 (26.3 %) used local guidelines. Chest radiograph and complete blood count were the most common diagnostic examinations, while evaluation of clinical symptoms and laboratory tests varied significantly. Tachypnoea and chest recession were considered criteria for diagnosis in all three guidelines. In US and UK guidelines blood cultures, atypical bacterial and viral detection tests were recommended. In European centres in outpatient settings, amoxicillin was used in 16 (84 %) centers, clarithromycin in 9 (37 %) centers and azithromycin in 7 (47 %) centers, whereas in hospital settings antibiotic treatment varied widely. Amoxicillin is recommended as the first drug of choice for outpatient treatment in all guidelines.ConclusionsAlthough local variations in clinical criteria, laboratory tests, and antibiotic resistance rates may necessitate some differences in standard empirical antibiotic regimens, there is considerable scope for standardisation across European centres for the diagnosis and treatment of CAP.