Roseli Calil

Healthcare-associated infections among neonates in Brazil

OBJECTIVE To describe the epidemiology of healthcare-associated infections (HAIs) among neonates. DESIGN Prospective surveillance of HAIs was conducted during 2 years. Infections beginning within 48 hours of birth were defined as HAIs of maternal origin. Death occurring during an active episode of HAI was considered related to HAI. SETTING Seven neonatal units located in three Brazilian cities. PATIENTS All admitted neonates were included and observed until discharge. RESULTS Twenty-two percent of 4,878 neonates had at least one HAI. The overall incidence density was 24.9 per 1,000 patient-days, and 28.1% of all HAIs were maternally acquired. HAI rates ranged from 12.3% in the group with a birth weight (BW) of more than 2,500 g to 51.9% in the group with a BW of 1,000 g or less. The main HAIs were bloodstream infection (BSI) and pneumonia. Coagulase-negative staphylococci, Enterobacter species, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens. Forty percent of all deaths were related to HAI. Central venous catheter (CVC)-associated BSIs per 1,000 CVC-days ranged from 17.3 (BW, 1,501 to 2,500 g; device utilization [DU], 0.11) to 34.9 (BW, < or = 1,000 g; DU, 34.92). Ventilator-associated pneumonia per 1,000 ventilator-days ranged from 7.0 (BW, < or = 1,000 g; DU, 0.34) to 9.2 (BW, 1,001 to 1,500 g; DU, 0.14). CONCLUSIONS The high proportion of HAIs of maternal origin highlights perinatal care issues in Brazil and the need to improve the diagnosis of neonatal HAIs. The very low BW group and device-associated infections should be priorities for prevention strategies in this population.

Accuracy of white blood cell count, C-reactive protein, interleukin-6 and tumor necrosis factor alpha for diagnosing late neonatal sepsis

OBJECTIVE To evaluate the diagnostic value for late neonatal sepsis of white blood cell count (WBC) and assays for C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha), in isolation and in conjunction. METHODS This was a diagnostic test validation study. Chemiluminescence was used to assay CRP, IL-6 and TNF-alpha at the time of clinical suspicion and again after 24 and 48 hours, whereas the WBC was performed only once, at the time of suspicion. Patients were classified into three groups based on clinical progress and culture results: confirmed sepsis (CS), probable sepsis (PS), and not infected (NI). Statistical analysis was performed using the Wilcoxon and chi-square tests and Friedman analysis of variance; cutoffs were defined by plotting receiver operator characteristic curves. RESULTS The total study sample comprised 82 children, 42 of whom were classed as CS, 16 as PS and 24 as NI. At all three test times, the medians for CRP and IL-6 were significantly more elevated in the CS and PS groups, while the medians for TNF-alpha were abnormal only in the CS group. The CRP test had elevated indices of diagnostic utility at all three test times, better accuracy than the WBC and similar accuracy to the first IL-6 and TNF-alpha assays. There was no statistical difference between the cytokines, nor between them and the WBC. Combining tests did not increase diagnostic power, with the exception of the combination of WBC with CRP2 and when the sequential CRP assays were combined. CONCLUSIONS Both CRP and WBC were useful for the diagnosis of late neonatal sepsis and comparable with IL-6 and TNF-alpha. Accuracy increased when CRP and WBC were combined and when sequential CRP assay results were used.

Acurácia diagnóstica do leucograma, proteína C-reativa, interleucina-6 e fator de necrose tumoral-alfa na sepse neonatal tardia

OBJETIVO: Avaliar o valor do leucograma, proteina C-reativa (PCR), interleucina-6 (IL-6) e do fator de necrose tumoral-alfa (TNF-α), isoladamente e em conjunto, na deteccao da sepse neonatal tardia. METODOS: Estudo de validacao diagnostica. A PCR, IL-6 e TNF-α foram dosados por quimioluminescencia a suspeita clinica, 24 e 48 horas depois, e o leucograma unicamente a suspeita. De acordo com evolucao clinica e resultados de culturas, tres grupos foram definidos: sepse comprovada (SC), sepse provavel (SP) e nao infectados (NI). Os testes estatisticos utilizados foram os de Wilcoxon, qui-quadrado e analise de variância de Friedman e os limites de corte foram obtidos pela construcao da curva ROC. RESULTADOS: Estudaram-se 82 criancas, sendo 42 no grupo SC, 16 no SP e 24 NI. Nos tres momentos, as medianas da PCR e da IL-6 mostraram-se significativamente mais elevadas nos grupos SC e SP, e as do TNF-α alteraram-se apenas no grupo SC. Os indices diagnosticos da PCR foram elevados nos tres momentos e com acuracia superior a do leucograma e semelhante a da IL-6 e a do TNF-α em suas primeiras medidas. Entre as citocinas, nao houve diferenca estatistica entre elas, nem em relacao ao leucograma. A associacao dos testes nao aumentou a capacidade diagnostica, exceto na combinacao entre leucograma e PCR2 e na dosagem seriada de PCR. CONCLUSOES: A PCR e o leucograma mostram-se uteis no diagnostico de sepse neonatal tardia e comparaveis a IL-6 e ao TNF-α. A acuracia aumentou com a associacao PCR-leucograma e a dosagem seriada da PCR.

Incidence and risk factors of accidental extubation in a neonatal intensive care unit

OBJECTIVE To determine the incidence and risk factors of accidental extubation (AE) in a tertiary neonatal intensive care unit. METHODS A prospective cohort study was conducted to determine AE incidence density per 100 patient-days, during a 23-month period, in 222 newborns receiving assisted ventilation (AV). Logistic regression analysis was used to determine risk factors for AE. The presence of a cyclical pattern in extubation rates, according to the variables of interest, was investigated by Cosinor analysis. RESULTS The mean AE rate was 5.34/100 patient-days ventilated. AE-associated predictive variables were: subsequent use of the oral and nasal routes during AV [relative risk (RR) = 4.73; 95% confidence interval (95%CI) 1.92-11.60], AV duration (per day, RR = 1.03; 95%CI 1.02-1.04), and number of patient-days ventilated (RR = 1.01; 95%CI 1.01-1.02). According to the adjusted multiple regression analysis, total AV time was the only independent predictor of AE in this sample (RR = 1.02; 95%CI 1.01-1.03). AV time of 10.5 days showed an accuracy of 0.79 (95%CI 0.71-0.87) for the occurrence of AE. Cosinor analysis showed significant periodicity in overall AE rate and in the number of patient-days ventilated. There was a significant correlation between the number of patient-days ventilated and AE frequency. CONCLUSION Mean AE density was 5.34/100 patient-days ventilated. AV duration was the only independent predictor of AE. The best accuracy for AE occurrence was achieved at 10.5 days of AV duration.

Incidencia e fatores de risco para a extubação acidental em uma unidade de terapia intensiva neonatal

Objetivo: Determinar a incidencia, os fatores de risco para a extubacao acidental (EA) e a presenca de periodicidade nas taxas de EA em uma unidade de terapia intensiva neonatal de nivel terciario. Metodos: Estudo de coorte prospectivo para determinar a densidade de incidencia de extubacao acidental por 100 pacientes-dia durante o periodo de 23 meses, em 222 RN em assistencia ventilatoria (AV). Foram estudados os fatores de risco para a EA, por intermedio da analise de regressao logistica. A presenca de periodicidade nas taxas de extubacao, segundo as variaveis de interesse, foi investigada pela analise de Cosinor. Resultado: A media da taxa de extubacao acidental foi de 5,34/100 pacientes-dia ventilados. As variaveis preditoras que se associaram a extubacao acidental foram o uso subsequente da via oral e nasal durante a assistencia ventilatoria (RR=4,73; IC95% 1,92-11,60), duracao da assistencia ventilatoria (a cada dia RR=1,03; IC95% 1,02-1,04) e o numero de pacientes-dia/ventilados (RR=1,01; IC95% 1,01-1,02). Pela regressao multipla ajustada o tempo total de AV foi o unico preditor independente para a extubacao acidental nesta amostra (RR=1,02; IC95% 1,01-1,03). O tempo de AV de 10,5 dias apresentou acuracia de 0,79 (IC 95%-0,71-0,87) para a ocorrencia de EA. A analise de Cosinor demonstrou periodicidade significativa na taxa geral de EA e no numero de pacientes-dia ventilados. Houve correlacao significativa entre numero de pacientes-dia e a frequencia de EA. Conclusao: O unico preditor independente para EA foi a duracao da AV. A melhor acuracia para a ocorrencia de EA foi obtida aos 10,5 dias de duracao da AV Abstract

Group B streptococcus maternal and neonatal colonization in preterm rupture of membranes and preterm labor

PURPOSE To identify the prevalence and risk factors of maternal colonization by group B streptococcus (GBS) in pregnant women with premature labor (PL) and/or premature membrane rupture (PMR). METHODS Two anal and two vaginal swabs were collected from 203 pregnant women with diagnosis of PL or PMR assisted at the practice along one year. Pregnant women with imminent labor at admission were excluded. One swab of each source was placed in a transfer milieu and sent for culture in blood-agar plates; the two remaining swabs were incubated for 24 hours in Todd-Hewitt milieu for further sowing in blood-agar plates. Risk factors were analyzed by the chi-square test, Students t-test (p-value set at 0.05 and 95% confidence interval) and logistic regression. The following variables were analyzed: age, race, parity and mother schooling; culture results by source and type of culture; admission diagnosis; gestational age at admission; asymptomatic bacteriuria; gestational age at delivery; type of delivery; neonatal GBS colonization rate and immediate neonatal condition. RESULTS Prevalence of maternal GBS colonization was 27.6% (56 cases). The colonization rates according to gestational complications were 30% for PMR, 25.2% for PL and 17.8% for PL + PMR. Univariate analysis has shown that the variables Caucasian race, low level of schooling and bacteriuria were associated with higher colonization rates. Multivariate analysis showed that the presence of urinary infection was the only variable associated with maternal colonization. The GBS detection rate was significantly higher with the use of a selective milieu and collection from both anal and vaginal sources. The neonatal colonization rate was 3.1%. Two cases of early sepsis by GBS occurred in the sample, with prevalence of 10.8 cases per one thousand live births and 50% mortality rate. CONCLUSION The studied sample showed high maternal colonization rates by Streptococcus agalactiae. To increase GBS detection rate, it is necessary to use a selective culture milieu and to combine anal-rectal and vaginal cultures. There was a high incidence of early neonatal sepsis.

Serum Metabolic Alterations upon Zika Infection

Zika virus (ZIKV) infection has recently emerged as a major concern worldwide due to its strong association with nervous system malformation (microcephaly) of fetuses in pregnant women infected by the virus. Signs and symptoms of ZIKV infection are often mistaken with other common viral infections. Since transmission may occur through biological fluids exchange and coitus, in addition to mosquito bite, this condition is an important infectious disease. Thus, understanding the mechanism of viral infection has become an important research focus, as well as providing potential targets for assertive clinical diagnosis and quality screening for hemoderivatives. Within this context, the present work analyzed blood plasma from 79 subjects, divided as a control group and a ZIKV-infected group. Samples underwent direct-infusion mass spectrometry and statistical analysis, where eight markers related to the pathophysiological process of ZIKV infection were elected and characterized. Among these, Angiotensin (1-7) and Angiotensin I were upregulated under infection, showing an attempt to induce autophagy of the infected cells. However, this finding is concerning about hypertensive individuals under treatment with inhibitors of the Renin-Angiotensin System (RAS), which could reduce this response against the virus and exacerbate the symptoms of the infection. Moreover, one of the most abundant glycosphingolipids in the nervous tissue, Ganglioside GM2, was also elected in the present study as an infection biomarker. Considered an important pathogen receptor at membranes outer layer, this finding represents the importance of gangliosides for ZIKV infection and its association with brain tropism. Furthermore, a series of phosphatidylinositols were also identified as biomarkers, implying a significant role of the PI3K-AKT-mTOR Pathway in this mechanism. Finally, these pathways may also be understood as potential targets to be considered in pharmacological intervention studies on ZIKV infection management.