Maristela Pinheiro Freire

Multiclonal Outbreak of Klebsiella pneumoniae Producing Extended-Spectrum β-Lactamase CTX-M-2 and Novel Variant CTX-M-59 in a Neonatal Intensive Care Unit in Brazil

ABSTRACT An outbreak of cephalosporin-resistant Klebsiella pneumoniae occurred in a neonatal intensive care unit in São Paulo, Brazil. Of the 10 pulsotypes identified during the outbreak and follow-up periods, nine produced CTX-M-2 or its new variant CTX-M-59 and one produced SHV-5. blaCTX-M-2/59 genes were located on closely related plasmids that were transferable.

Treatment of KPC-producing Enterobacteriaceae: suboptimal efficacy of polymyxins

Treatment of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae infections (KPC-EI) remains a challenge. Combined therapy has been proposed as the best choice, but there are no clear data showing which combination therapy is superior. Our aim was to evaluate the effectiveness of antimicrobial regimens for treating KPC-EI. This was a retrospective cohort study of KPC-EI nosocomial infections (based on CDC criteria) between October 2009 and June 2013 at three tertiary Brazilian hospitals. The primary outcomes were the 30-day mortality for all infections and the 30-day mortality for patients with bacteraemia. Risk factors for mortality were evaluated by comparing clinical variables of survivors and nonsurvivors. In this study, 118 patients were included, of whom 78 had bacteraemia. Catheter-related bloodstream infections were the most frequent (43%), followed by urinary tract infections (n = 27, 23%). Monotherapy was used in 57 patients and combined treatment in 61 patients. The most common therapeutic combination was polymyxin plus carbapenem 20 (33%). Multivariate analysis for all infections (n = 118) and for bacteremic infections (n = 78) revealed that renal failure at the end of treatment, use of polymyxin and older age were prognostic factors for mortality. In conclusion, polymyxins showed suboptimal efficacy and combination therapy was not superior to monotherapy.

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.

Surveillance Programme for Healthcare Associated Infections in the State of São Paulo, Brazil. Implementation and the first three years' results

Governmental programmes should be developed to collect and analyse data on healthcare associated infections (HAIs). This study describes the healthcare setting and both the implementation and preliminary results of the Programme for Surveillance of Healthcare Associated Infections in the State of São Paulo (PSHAISP), Brazil, from 2004 to 2006. Characterisation of the healthcare settings was carried out using a national database. The PSHAISP was implemented using components for acute care hospitals (ACH) or long term care facilities (LTCF). The components for surveillance in ACHs were surgical unit, intensive care unit and high risk nursery. The infections included in the surveillance were surgical site infection in clean surgery, pneumonia, urinary tract infection and device-associated bloodstream infections. Regarding the LTCF component, pneumonia, scabies and gastroenteritis in all inpatients were reported. In the first year of the programme there were 457 participating healthcare settings, representing 51.1% of the hospitals registered in the national database. Data obtained in this study are the initial results and have already been used for education in both surveillance and the prevention of HAI. The results of the PSHAISP show that it is feasible to collect data from a large number of hospitals. This will assist the State of São Paulo in assessing the impact of interventions and in resource allocation.

Surgical site infections in liver transplant recipients in the model for end-stage liver disease era: an analysis of the epidemiology, risk factors, and outcomes.

In recipients of liver transplantation (LT), surgical site infection (SSIs) are among the most common types of infection occurring in the first 60 days after LT. In 2007, the Model for End‐Stage Liver Disease (MELD) scoring system was adopted as the basis for prioritizing organ allocation. Patients with higher MELD scores are at higher risk for developing SSIs as well as other health care–associated infections. However, there have been no studies comparing the incidence of SSIs in the pre‐MELD era with the incidence in the period since its adoption. Therefore, the objectives of this study were to evaluate the incidence, etiology, epidemiology, and outcomes of post‐LT SSIs in those 2 periods and to identify risk factors for SSIs. We evaluated all patients who underwent LT over a 10‐year period (2002‐2011). SSI cases were identified through active surveillance. The primary outcome measure was an SSI during the first 60 days after LT. Risk factors were analyzed via logistic regression, and 60‐day survival rates were evaluated via Cox regression. We evaluated 543 patients who underwent LT 597 times. The SSI rates in the 2002‐2006 and 2007‐2011 periods were 30% and 24%, respectively (P = 0.21). We identified the following risk factors for SSIs: retransplantation, the transfusion of more than 2 U of blood during LT, dialysis, cold ischemia for >400 minutes, and a cytomegalovirus infection. The overall 60‐day survival rate was 79%. Risk factors for 60‐day mortality were retransplantation, dialysis, and a longer surgical time. The use of the MELD score modified the incidence and epidemiology of SSIs only during the first year after its adoption. Risks for SSIs were related more to intraoperative conditions and intercurrences after LT than to a patients status before LT. Liver Transpl 19:1011–1019, 2013.

Double-dose hepatitis B vaccination in cirrhotic patients on a liver transplant waiting list

Development of immunity to hepatitis B virus in cirrhotic patients waiting for liver transplantation is highly desirable. Though a double-dose regimen is available, little is know about its effectiveness. We examined the efficacy of double-dose hepatitis B virus vaccination in cirrhotic patients waiting for liver transplantation. We studied 43 patients who were waiting for liver transplantation. They were vaccinated with three doses of 40 mg hepatitis B vaccine at 0, 1 and 6 months; the normal dose is 20 microg. Efficacy was measured based on seroconversion of anti-HBs. Global response to the primary vaccination scheme was 67.5% (29 patients). Forty-one per cent of responders had anti-HBs titers above 1,000 IU/mL. No factors were associated with response, based on multivariate analysis. The vaccination scheme of 40 microg at 0, 1 and 6 months was superior to conventional vaccination doses (20 microg) for cirrhotic patients on a waiting list for liver transplantation.

Liberal Versus Restrictive Transfusion Strategy in Critically Ill Oncologic Patients: The Transfusion Requirements in Critically Ill Oncologic Patients Randomized Controlled Trial*

Objective: To assess whether a restrictive strategy of RBC transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock. Design: Single center, randomized, double-blind controlled trial. Setting: Teaching hospital. Patients: Adult cancer patients with septic shock in the first 6 hours of ICU admission. Interventions: Patients were randomized to the liberal (hemoglobin threshold, < 9 g/dL) or to the restrictive strategy (hemoglobin threshold, < 7 g/dL) of RBC transfusion during ICU stay. Measurements and Main Results: Patients were randomized to the liberal (n = 149) or to the restrictive transfusion strategy (n = 151) group. Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0–3] vs 0 [0–2] unit; p < 0.001). At 28 days after randomization, mortality rate in the liberal group (primary endpoint of the study) was 45% (67 patients) versus 56% (84 patients) in the restrictive group (hazard ratio, 0.74; 95% CI, 0.53–1.04; p = 0.08) with no differences in ICU and hospital length of stay. At 90 days after randomization, mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95% CI, 0.53–0.97; p = 0.03). Conclusions: We observed a survival trend favoring a liberal transfusion strategy in patients with septic shock when compared with the restrictive strategy. These results went in the opposite direction of the a priori hypothesis and of other trials in the field and need to be confirmed.

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.

Health care-associated infections in hematology-oncology patients with neutropenia: A method of surveillance

We present a prospective method of surveillance of health care-associated infection in hematology-oncology inpatients with neutropenia. Incidence rates were calculated on the basis of the number of hospitalized patients, the duration of hospital stay (in days), the number of days of neutropenia, and (in cases of central line-associated blood stream infection) the number of central line-days. We detected 11.4 and 66.4 episodes of febrile neutropenia per 1,000 hospital-days and per 1,000 days of neutropenia, respectively. The incidence of central line-associated blood stream infection was 2.6 per 1,000 central line-days. Gram-negative bacteria were the most prevalent pathogens. Efforts should be made to monitor infection rates on hematology-oncology wards.

Risk factors for infectious and noninfectious complications of totally implantable venous catheters in cancer patients

OBJECTIVE The aim of this study was to investigate the risk factors for complications of totally implantable catheters in a referral cancer center. METHODS This was a retrospective study of prospectively collected data of all consecutive cancer patients undergoing port placement, with a primary outcome of interest of major complication and subanalysis of the types of complications. RESULTS We studied 1255 nonvalved implanted port catheters inserted in 1230 patients, for a combined total of 469,882 catheter-days of use. Venous puncture was ultrasound (US)-guided in 1049 cases (84%). Inadvertent arterial puncture occurred in 14 cases (1.1%) and was more frequent in procedures not guided by US (P = .045). Among the outpatients, 90 (9%) developed infection, and 75 (29%) of the hospitalized patients (P < .001) developed infections. Infection was diagnosed in 131 catheters (13%) implanted through the internal jugular vein (IJV), 23 catheters (14%) implanted in the subclavian vein (SCV), 1 catheter (5%) implanted in the external jugular vein, and 10 catheters (31%) implanted in the femoral vein (P = .044). In the multivariate analysis, only the hospitalization regimen maintained statistical significance, with hospitalization presenting as a risk factor for infection (P < .001). Regarding the introduction site, ambulatory patients in whom the femoral vein was the site of access had more infections than the others (28.6% vs 9.4% of the IJV, 4.8% of the SCV, and 4.8% of the external jugular vein; P = .019), which did not occur among the hospitalized patients (33.3% vs 26.5% of IJV and 39.5% of the SCV; P = .218). CONCLUSIONS Not using US is a risk factor for iatrogenic arterial puncture. Port implantation in hospitalized patients and the use of femoral access are risk factors for infection.