Icaro Boszczowski

Impact of an Educational Intervention Implanted in a Neurological Intensive Care Unit on Rates of Infection Related to External Ventricular Drains

Background Studies on the implantation of care routines showed reduction on EVD catheter-related infections rates; however zero tolerance is difficult to be achieved. The objective of this study was to assess the impact of an educational intervention on the maximal reduction on rates of EVD-related infections. Methodology/Principal Findings The quasi-experimental (before-after intervention) study occurred in two phases: pre-intervention, from April 2007 to July 2008, and intervention, from August 2008 to July 2010. Patients were followed for 30 days after the removal of the EVD, and EVD-related infections were considered as only those with laboratorial confirmation in the CSF. Observations were made of the care of the EVD and compliance with Hygiene of the Hands (HH), a routine of care was drawn up, training was given, and intervention was made to reduce the time the EVD catheter remained in place. Results during the study, 178 patients were submitted to 194 procedures, corresponding to 1217 EVD catheters-day. Gram-negative agents were identified in 71.4% of the infections during the pre-intervention period and in 60% during the intervention period. During the study, EVD-related infection rates were reduced from 9.5% to 4.8% per patient, from 8.8% to 4.4% per procedure, and the incidence density dropped from 14.0 to 6.9 infections per 1000 catheters-day (p = 0.027). The mortality reduced 12% (from 42% to 30%). Conclusions/Significance During one year after the fourth intervention, no microbiologically identified infection was documented. In light of these results, educational intervention proved to be a useful tool in reducing these rates and showed also impact on mortality.

Outbreak of Extended Spectrum β-lactamase-producing klebsiella pneumoniae Infection in a Neonatal Intensive Care Unit Related to Onychomycosis in a Health Care Worker

Four cases of infection by extended spectrum β-lactamase-producing Klebsiella pneumoniae occurred in the neonatal intensive care unit. Isolation, empiric therapy change and education produced no effect. Newborn weekly colonization rates were 0–18.7%. One health care worker with onychomycosis was positive for extended spectrum β-lactamase-producing K. pneumoniae. Isolates were identical by molecular typing. Outbreak was controlled when the health care worker was excluded from the neonatal intensive care unit.

Characterization of epidemiological surveillance systems for healthcare-associated infections (HAI) in the world and challenges for Brazil

Surveillance systems for healthcare-associated infections (HAI) are essential for planning actions in prevention and control. Important models have been deployed in recent decades in different countries. This study aims to present the historical and operational characteristics of these systems and discuss the challenges for Brazil. Various models around the world have drawn on the experience of the United States, which pioneered this process. In Brazil, several initiatives have been launched, but the country still lacks a full national information system on HAI, thus indicating the need to promote action strategies, strengthen the role of States in communication between the Federal and local levels, pursue a national plan to organize surveillance teams with the necessary technological infrastructure, besides updating the relevant legislation for dealing with these challenges. Such measures are essential in the Brazilian context for the unified surveillance of HAI, aimed at healthcare safety and quality.A formacao de sistemas de vigilância de infeccoes relacionadas a assistencia a saude (IRAS) e medida essencial para o planejamento de acoes de prevencao e controle. No mundo, importantes modelos estao sendo implantados nas ultimas decadas. Este estudo busca apresentar os aspectos historicos e operacionais desses sistemas, discutindo os desafios para o Brasil. Os modelos internacionais se espelham no exemplo americano, pioneiro nesse processo. No Brasil, diversas iniciativas foram e estao sendo estabelecidas, entretanto, nao temos um pleno sistema nacional de informacao sobre IRAS, o que aponta a necessidade de reconhecer estrategias em vigencia, fortalecendo o Estado como elo de comunicacao; buscando um plano nacional para a formacao de equipes de vigilância com aparato tecnologico necessario, e discutindo a atualizacao das legislacoes que ja nao contemplam os desafios atuais de tais ocorrencias. Essas sao medidas essenciais no contexto brasileiro para a vigilância unificada de IRAS, almejando seguranca e qualidade nos cuidados em saude.

The Impact of Restricting Over-the-Counter Sales of Antimicrobial Drugs: Preliminary Analysis of National Data.

AbstractTo describe the nationwide impact of a restrictive law on over-the-counter sales of antimicrobial drugs, implemented in Brazil in November 2010.Approximately 75% of the population receives healthcare from the public health system and receives free-of-charge medication if prescribed. Total sales in private pharmacies as compared with other channels of sales of oral antibiotics were evaluated in this observational study before and after the law (2008–2012). Defined daily dose per 1000 inhabitants per day (DDD/TID) was used as standard unit.In private pharmacies the effect of the restrictive law was statistically significant (P < 0.001) with an estimated decrease in DDD/TID of 1.87 (s.e. =  0.18). In addition, the trend of DDD/TID before the restrictive law was greater than after the intervention (P < 0.001). Before November 2010, the slope for the trend line was estimated as 0.08 (s.e. = 0.01) whereas after the law, the estimated slope was 0.03 (s.e. = 0.01). As for the nonprivate channels, no difference in sales was observed (P = 0.643). The impact in the South and Southeast (more developed) regions was higher than in the North, Northeast, and Mid-West. The state capitals had a 19% decrease, compared with 0.8% increase in the rest of the states.Before the law, the sales of antimicrobial drugs were steadily increasing. From November 2010, with the restrictive law, there was an abrupt drop in sales followed by an increase albeit at a significantly lower rate. The impact was higher in regions with better socio-economic status.

Polymyxin use as a risk factor for colonization or infection with polymyxin-resistant Acinetobacter baumannii after liver transplantation.

Acinetobacter baumannii is a leading agent of healthcare‐associated infection. The objective of this study was to evaluate cases of colonization or infection with polymyxin‐resistant A. baumannii (PRAB) in liver transplant recipients and to identify the risk factors for the acquisition of PRAB.

Socioeconomic Determinants of Antibiotic Consumption in the State of Sao Paulo, Brazil: The Effect of Restricting Over-The-Counter Sales

Background Improper antibiotic use is one of the main drivers of bacterial resistance to antibiotics, increasing infectious diseases morbidity and mortality and raising costs of healthcare. The level of antibiotic consumption has been shown to vary according to socioeconomic determinants (SED) such as income and access to education. In many Latin American countries, antibiotics could be easily purchased without a medical prescription in private pharmacies before enforcement of restrictions on over-the-counter (OTC) sales in recent years. Brazil issued a law abolishing OTC sales in October 2010. This study seeks to find SED of antibiotic consumption in the Brazilian state of São Paulo (SSP) and to estimate the impact of the 2010 law. Methods Data on all oral antibiotic sales having occurred in the private sector in SSP from 2008 to 2012 were pooled into the 645 municipalities of SSP. Linear regression was performed to estimate consumption levels that would have occurred in 2011 and 2012 if no law regulating OTC sales had been issued in 2010. These values were compared to actual observed levels, estimating the effect of this law. Linear regression was performed to find association of antibiotic consumption levels and of a greater effect of the law with municipality level data on SED obtained from a nationwide census. Results Oral antibiotic consumption in SSP rose from 8.44 defined daily doses per 1,000 inhabitants per day (DID) in 2008 to 9.95 in 2010, and fell to 8.06 DID in 2012. Determinants of a higher consumption were higher human development index, percentage of urban population, density of private health establishments, life expectancy and percentage of females; lower illiteracy levels and lower percentage of population between 5 and 15 years old. A higher percentage of females was associated with a stronger effect of the law. Conclusions SSP had similar antibiotic consumption levels as the whole country of Brazil, and they were effectively reduced by the policy.

Carbapenem-resistant Enterobacteriaceae in patients admitted to the emergency department: prevalence, risk factors, and acquisition rate

BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) have been reported worldwide and are associated with high mortality rates. Intestinal colonization acts as a reservoir and fosters exchange of resistance mechanisms. AIM To investigate the prevalence of patients harbouring CRE on hospital admission, risk factors associated, and the acquisition rate within the emergency department (ED). METHODS This was a cross-sectional survey with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain reaction (PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE. FINDINGS Forty-six patients were colonized; all positive PCR were Klebsiella pneumoniae carbapenemase. The acquisition rate was 18%. Previous exposure to healthcare in the last year, liver disease, and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community. CONCLUSION Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Multisite evaluation of environmental cleanliness of high-touch surfaces in intensive care unit patient rooms

HighlightsLarge variations of environmental cleanliness of high‐touch surfaces after discharge cleaning and disinfection are identified in ICU patient rooms in Brazil, Canada, the Netherlands and the US.Major differences exist in used cleaning and disinfection protocols, detergents and disinfectants.Monitoring of staff cleaning compliance using rapid methods such as reflective surface markers or adenosine triphosphate with ongoing staff feedback can ensure optimal cleaning and disinfection of high touch surfaces.The total aerobic count on high‐touch surfaces provided limited value for routine cleanliness monitoring and should be used selectively during outbreaks. &NA; The efficacy of discharge cleaning and disinfection of high‐touch surfaces of intensive care unit patient rooms in Brazil, Canada, the Netherlands, and the United States was evaluated and the effect of an educational intervention was determined. Significant site‐to‐site differences in cleaning regimens and baseline cleanliness levels were observed using ATP levels, colony‐forming units, and reflective surface marker removal percent pass rates. An educational intervention that includes rapid feedback of the ATP measurements could significantly improve the quality of the cleaning and disinfection regimens.

Evaluation of adenosine triphosphate test for cleaning assessment of gastroscopes and the effect on workload in a busy endoscopy center

HighlightsAdenosine triphosphate (ATP) test failed more than culture and protein tests.The inclusion of ATP testing after a single cleaning increased the length of time for the whole procedure (cleaning plus testing cleanliness) by 50%.First cleaning: 70.8% of gastroscopes failed the ATP test; 58.3% of gastroscopes had no microbial growth; and in 91.7% of gastroscopes the protein was undetectable.Second cleaning: 64.7% of gastroscopes still failed the ATP test. Two samples had bacterial growth, and none had protein detected.Poor correlation was found between ATP test and culture. Objective Using adenosine triphosphate (ATP) tests to assess manual cleaning of gastroscopes and to determine the associated workload in a busy endoscopy unit. Methods Patient‐used gastroscopes were sampled before and after cleaning to assess ATP levels, bioburden, and protein. Samples were collected by flushing 20 mL of sterile water through the biopsy port to the distal end. Time spent for reprocessing and performing the ATP test was recorded. Results Twenty‐four samples were collected from 10 gastroscopes. After manual cleaning, 14/24 (58.3%) samples had no microbial growth (mean, 21 colony‐forming units/cm2), and in 22/24 (91.7%) samples the protein was undetectable (mean, 0.04 &mgr;g/cm2). ATP test was above the cutoff (200 relative light units [RLU]) in 17/24 (70.8%) samples (mean, 498 RLU). After the second cleaning, 11/17 (64.7%) gastroscopes still failed the ATP test (mean, 321.2 RLU). The mean time spent to perform manual cleaning and ATP tests was 16 and 8 minutes, respectively. Hence, each test increased the length of time for cleaning plus testing cleanliness by 50%. Conclusion Further studies regarding the optimal cutoff for ATP tests are needed. ATP tests for cleaning monitoring are easy to perform and provide immediate feedback to the team. However, the increased workload needs to be considered.

Caracterização dos sistemas de vigilância epidemiológica das infecções relacionadas à assistência à saúde (IRAS) no mundo e desafios para o Brasil

Surveillance systems for healthcare-associated infections (HAI) are essential for planning actions in prevention and control. Important models have been deployed in recent decades in different countries. This study aims to present the historical and operational characteristics of these systems and discuss the challenges for Brazil. Various models around the world have drawn on the experience of the United States, which pioneered this process. In Brazil, several initiatives have been launched, but the country still lacks a full national information system on HAI, thus indicating the need to promote action strategies, strengthen the role of States in communication between the Federal and local levels, pursue a national plan to organize surveillance teams with the necessary technological infrastructure, besides updating the relevant legislation for dealing with these challenges. Such measures are essential in the Brazilian context for the unified surveillance of HAI, aimed at healthcare safety and quality.A formacao de sistemas de vigilância de infeccoes relacionadas a assistencia a saude (IRAS) e medida essencial para o planejamento de acoes de prevencao e controle. No mundo, importantes modelos estao sendo implantados nas ultimas decadas. Este estudo busca apresentar os aspectos historicos e operacionais desses sistemas, discutindo os desafios para o Brasil. Os modelos internacionais se espelham no exemplo americano, pioneiro nesse processo. No Brasil, diversas iniciativas foram e estao sendo estabelecidas, entretanto, nao temos um pleno sistema nacional de informacao sobre IRAS, o que aponta a necessidade de reconhecer estrategias em vigencia, fortalecendo o Estado como elo de comunicacao; buscando um plano nacional para a formacao de equipes de vigilância com aparato tecnologico necessario, e discutindo a atualizacao das legislacoes que ja nao contemplam os desafios atuais de tais ocorrencias. Essas sao medidas essenciais no contexto brasileiro para a vigilância unificada de IRAS, almejando seguranca e qualidade nos cuidados em saude.