Moacyr Silva

Positive Deviance: A New Strategy for Improving Hand Hygiene Compliance

OBJECTIVE To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units. DESIGN A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene. SETTING Two 20-bed step-down units at a tertiary care private hospital. METHODS The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units. RESULTS During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01 ). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (p = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days. CONCLUSION A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Bloodstream infection after kidney transplantation: epidemiology, microbiology, associated risk factors, and outcome.

Background. Bloodstream infection (BSI) is associated with both relevant morbidity and mortality rates after kidney transplantation. Methods. From January 1, 2000 to January 31, 2006, all episodes of BSI were retrospectively assessed through the review of medical records in two tertiary teaching Hospitals in Sao Paulo, Brazil, where 3308 transplant procedures were performed during this period. Contaminants and polymicrobial infections were excluded. The main objectives of the study were to describe clinical and microbiologic aspects of BSI, as well as risk factors for both BSI and mortality from these infections in kidney transplant patients. Results. BSI was detected in 185 patients, with onset after a median of 235 days after transplantation; 62% occurred after 6 months. The primary source of infection was the urinary tract in 37.8%. The most prevalent pathogen overall was Escherichia coli (30.3%). Risk factors for early acquired BSI (first 6 months after transplantation) were acute rejection, ureteric stent placement, and receiving an organ from a deceased donor. For late BSI (after 6 months), associated risk factors were acute rejection, Charlson Comorbidity Score more than or equal to 3, and receiving an organ from a deceased donor. Risk factors related to 30-day mortality were Acute Physiology and Chronic Health Evaluation II Score more than or equal to 20, shock, and respiratory failure. Conclusions. BSI is most frequently a consequence of urinary tract infection, with a high prevalence of gram-negative bacilli. Severity of disease was the main determinant of 30-day mortality after BSI, and based on the knowledge of risk factors, some interventions are suggested for reducing the rate of BSI after transplantation.

The effect of limiting antimicrobial therapy duration on antimicrobial resistance in the critical care setting.

BACKGROUND Using antimicrobial agents for prolonged periods of time and/or in heavy densities is known to contribute to antimicrobial resistance. METHODS A quasiexperimental, before and after study to limit the duration of antimicrobial therapy to 14 days was conducted in a medical-surgical intensive care unit (ICU). An intervention to optimize antimicrobial therapy was performed when antimicrobial agents had been prescribed for more than 14 days. We then compared antimicrobial utilization using the defined daily dose (DDD) per 1000 patient-days, as well as resistance rates in selected organisms in the intervention phase to the previous 10-month period. RESULTS In the intervention phase, doctors approved to discontinue the antimicrobial therapy before 14 days in 89.8% (415/462) of the prescribed antibiotics in the ICU. Comparing the 2 time periods, we found a reduction in carbapenems (24.5% decrease), vancomycin (14.3% decrease), and cephalosporins (12.2% decrease) in the intervention phase. Imipenem resistance decreased in Acinetobacter baumannii from 88.5% to 20.0% (P <or= .001) and in Klebsiella pneumoniae from 54.5% to 10.7% (P = .01). CONCLUSION These results suggest that an intervention to reduce the duration of antimicrobial therapy contributed to more rational use of antimicrobial agents and to the reduction of bacterial resistance in the critical care setting.

Morbimortality of pandemic influenza A H1N1 infection in kidney transplant recipients requiring hospitalization: a comparative analysis with nonimmunocompromised patients.

Background. Clinical and epidemiological data of pandemic influenza A H1N1 infection in solid-organ transplant recipients have been described, but scarce data compare these outcomes with nonimmunocompromised patients. Methods. We retrospectively reviewed and compared the clinical presentation, morbidity, and mortality of all kidney transplant (KT) and nonimmunocompromised (non-KT) patients admitted for at least 12 hr with a diagnosis of pandemic influenza A H1N1 infection in a single hospital complex during the 2009 pandemic. Results. There were 22 patients in the KT group (29.3%) and 53 in the non-KT group (70.7%). The prevalence of diabetes was higher in KT group (27.3% vs. 5.7%) while chronic pulmonary disease was more frequent in non-KT group (34% vs. 9.1%). Clinical and radiological presentations and duration of disease were similar between the two groups. The incidence of acute renal failure was higher among KT patients (40.9% vs. 17%). No differences in the rate of intensive care unit admission (22.7% vs. 22.6%) or hospital mortality (9.1% vs. 7.5%) were observed. For the overall population, poor outcome, defined as intensive care unit admission or death, was associated with in-hospital acquisition (relative risk [RR]=42.6 [95% confidence interval {95% CI } 2.2–831.9], P=0.003), symptom onset more than 48 hr (RR=12.17 [95% CI 1.3–117.2], P=0.007), and acute renal failure (RR=11.8 [95% CI 2.9–48.8], P<0.001). Among KT recipients, in-hospital acquisition was the only covariate associate with poor outcome (RR=30.0 [95% CI 2.1–421.1], P=0.004). Conclusions. No significant differences in morbidity and mortality were observed comparing KT and non-KT patients infected with pandemic H1N1 influenza A virus.

Secular trends in the epidemiology of Clostridium difficile infection (CDI): relationship with alcohol gel and antimicrobial usage in a hospital

BACKGROUND Clostridium difficile-associated diarrhea (CDAD) has shown increasing incidence, morbidity, and mortality in recent years. We assessed the number of CDAD tests requested, CDAD positivity rates, the use of alcohol-based hand rubs, and antimicrobial utilization. METHODS We collected information on every adult patient (>18 years) who developed diarrhea and had a positive stool test for C. difficile toxin from June 2005 to December 2009 at a tertiary care hospital. A time-series analysis was performed using monthly data on the incidence of C. difficile infection (CDI) (i.e., cases of infection per 1000 patient-days), as well as the consumption of alcohol-based hand rubs (in liters/1000-patient days) and antibiotics (in defined daily doses per 1000 patient-days). RESULTS The mean number of annual requests for C. difficile tests was 1031, and the rates per 1000 patient-days for each year from 2005 to 2009 were 0.30, 0.46, 0.39, 0.31, and 0.40 overall in the hospital, and 0.18, 0.10, 0.53, 0.38, and 0.37 in the intensive care unit (ICU). The use of alcohol-based hand rubs per 1000 patient-days increased from 37.4 to 73.0, and from 41.5 to 129.4 in the hospital and in the ICU, respectively. CONCLUSIONS The incidence of CDI in the hospital and ICU remained low, despite the increased use of alcohol-based hand rubs and antimicrobials.

Simulated Moving Bed Reactor

The simulated moving bed reactor (SMBR), an important chromatographic reactor, is addressed in this chapter. The SMBR mathematical model, considering external and internal mass-transfer resistances and variable velocity due to change of liquid composition, is shown. An analytical solution for linear SMBR in the presence of mass-transfer resistances, based on the steady-state equivalent true moving bed reactor analogy, is also presented. This solution allows a fast evaluation of the linear SMBR performance for different conditions. The required steps to implement an SMBR-based process, fundamental data acquisition and validation, are highlighted using the green solvent ethyl lactate as a case study. The performance of this reactor for acetals production is also discussed. For all the studied compounds, the SMBR exhibits high conversion and high productivity at moderate temperatures, but also a significant desorbent consumption, which might be reduced by using new materials with lower water affinity.

Contact precautions in the intensive care unit setting: 12 years of surveillance

The utilization of isolation precautions has increased in tertiary care hospitals due to the increase in colonization with multidrug-resistant organisms over time. We assessed the frequency of multidrug-resistant microorganisms responsible for implementation of contact precautions in the ICU of a tertiary care hospital over a 12-year period.