Rosineide Marques Ribas

Criptococose: estudo clínico-epidemiológico, laboratorial e das variedades do fungo em 96 pacientes

Ninety-six patients with cryptococcosis confirmed by clinical and laboratorial diagnosis were assessed in a prospective study in a University Hospital from March 1998 to November 2003; of these, 81.3% were HIV seropositive patients. Cryptococcus neoformans was isolated from different samples, of which the cerebrospinal fluid 74 (77%) was the most frequent. C. neoformans var neoformans was isolated in 89 cases, where as C. neoformans var gattii was isolated in 7. Cryptococcal meningoencephalitis was detected in 56.3% cases. It was the most frequent unique clinical manifestation and the fungus was detected in the bloodstream in 13.5% of the patients. Among the risk factors, AIDS (81.3%) was the most frequently associated with mycosis. Direct examination carried out on 121 samples revealed the microorganism in 98.3% of them, while the culture was positive for all samples. Most of the patients (59.4%) were treated with amphotericin B or with triazoles, however 72.9% of them ended in death, in particular those patients with positive tests for the HIV (62.5%). Nowadays, cryptococcosis has been frequently diagnosed in our region and represents one of the opportunistic diseases with the highest morbidity and mortality rates in patients with AIDS.

Pseudomonas aeruginosa bacteraemia: independent risk factors for mortality and impact of resistance on outcome.

The rates of multidrug-resistant, extensively drug-resistant and pandrug-resistant isolates amongst non-fermenting Gram-negative bacilli, particularly Pseudomonas aeruginosa, have risen worldwide. The clinical consequence of resistance and the impact of adverse treatment on the outcome of patients with P. aeruginosa bacteraemia remain unclear. To better understand the predictors of mortality, the clinical consequence of resistance and the impact of inappropriate therapy on patient outcomes, we analysed the first episode of P. aeruginosa bacteraemia in patients from a Brazilian tertiary-care hospital during the period from May 2009 to August 2011. Antimicrobial susceptibility testing was conducted; phenotypic detection of metallo-β-lactamase (MBL) and PCR of MBL genes were performed on carbapenem-resistant strains. Amongst the 120 P. aeruginosa isolates, 45.8 % were resistant to carbapenem and 36 strains were tested for MBL detection. A total of 30 % were phenotypically positive and, of these, 77.8 % expressed an MBL gene, bla(SPM-1) (57 %) and bla(VIM-type) (43 %). The resistance rates to ceftazidime, cefepime, piperacillin/tazobactam, carbapenem, fluoroquinolone and aminoglycoside were 55, 42.5, 35, 45.8, 44 and 44 %, respectively. Previous antibiotic use, length of a hospital stay ≥30 days prior to P. aeruginosa, haemodialysis, tracheostomy, pulmonary source of bacteraemia and Intensive Care Unit admission were common independent risk factors for antimicrobial resistance. Cefepime resistance, multidrug resistance and extensive drug resistance were independently associated with inappropriate therapy, which was an important predictor of mortality, being synergistic with the severity of the underlying disease.

Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance

INTRODUCTION This study aimed to determine the epidemiology of the three most common nosocomial infections (NI), namely, sepsis, pneumonia, and urinary tract infection (UTI), in a pediatric intensive care unit (PICU) in a developing country and to define the risk factors associated with NI. METHODS We performed a prospective study on the incidence of NI in a single PICU, between August 2009 and August 2010. Active surveillance by National Healthcare Safety Network (NHSN) was conducted in the unit and children with NI (cases) were compared with a group (matched controls) in a case-control fashion. RESULTS We analyzed 172 patients; 22.1% had NI, 71.1% of whom acquired it in the unit. The incidence densities of sepsis, pneumonia, and UTI per 1,000 patients/day were 17.9, 11.4, and 4.3, respectively. The most common agents in sepsis were Enterococcus faecalis and Escherichia coli (18% each); Staphylococcus epidermidis was isolated in 13% of cases. In pneumonias Staphylococcus aureus was the most common cause (3.2%), and in UTI the most frequent agents were yeasts (33.3%). The presence of NI was associated with a long period of hospitalization, use of invasive devices (central venous catheter, nasogastric tube), and use of antibiotics. The last two were independent factors for NI. CONCLUSIONS The incidence of NI acquired in this unit was high and was associated with extrinsic factors.

Relationship between nasal colonization and ventilator-associated pneumonia and the role of the environment in transmission of Staphylococcus aureus in intensive care units

BACKGROUND This study assessed the relationship between nasal colonization and ventilator-associated pneumonia (VAP) by Staphylococcus aureus, as well the role of the environment in the transmission of this organism. METHODS We performed a cohort study of patients with VAP caused by methicillin-resistant S aureus (MRSA) or methicillin-sensitive S aureus during 2 years in an adult intensive care unit (ICU). All patients had nasal swab specimens obtained at admission and during the ICU stay. Clinical samples also were collected for analysis, as were samples from the hands of health care professionals and the environment, and were typed using pulsed-field gel electrophoresis. RESULTS S aureus VAP represented 12.5% of the cases, and statistical analysis identified colonization as a risk factor for the development of this infection. MRSA was isolated from the environment and hands, indicating the existence of a secondary reservoir. Molecular typing revealed a polyclonal profile; however, clone J was the most frequent (45.5%) among isolates of MRSA tested, with a greater profile of resistance than the other isolates. There was strong evidence suggesting transmission of MRSA to patients from the environment. CONCLUSION Nasal colonization for S aureus is a risk factor for development of VAP.

Risk factors for vancomycin-resistant enterococci colonisation in critically ill patients

Vancomycin-resistant enterococci (VRE) are important hospital pathogens and have become increasingly common in patients admitted to the intensive care unit (ICU). To determine the incidence and the risk factors associated with VRE colonisation among ICU patients, active surveillance cultures for VRE faecal carriages were carried out in patients admitted to the ICU of the University Hospital of Uberlândia, Minas Gerais, Brazil. Risk factors were assessed using a case-control study. Seventy-seven patients (23.1%) were found to be colonised with vanC VRE and only one patient (0.3%) was colonised with vanA VRE. Independent risk factors for VRE colonisation included nephropathy [odds ratio (OR) = 13.6, p < 0.001], prior antibiotic use (OR = 5.5, p < 0.03) and carbapenem use (OR = 17.3, p < 0.001). Our results showed a higher frequency (23.1%) of Enterococcus gallinarum and Enterococcus casseliflavus, species that are intrinsically resistant to low levels of vancomycin (vanC), without an associated infection, associated with prior antibiotic use, carbapenem use and nephropathy as comorbidity. This study is the first to demonstrate the risk factors associated with vanC VRE colonisation in ICU hospitalised patients. Although vanA and vanB enterococci are of great importance, the epidemiology of vanC VRE needs to be better understood. Even though the clinical relevance of vanC VRE is uncertain, these species are opportunistic pathogens and vanC VRE-colonised patients are a potential epidemiologic reservoir of resistance genes.

Comparing hospital infections in the elderly versus younger adults: an experience in a Brazilian University Hospital.

The elderly population will grow rapidly over the next 25 years, however there is little information about hospital infections in this group of patients in Brazil. We examined the prevalence of nosocomial and community infections in elderly ((3) 65 years) patients and their relationship with intrinsic and extrinsic risk factors in a Brazilian University Hospital. A total of 155 hospitalized elderly patients were evaluated, and clinical and demographic information about each patient was obtained from hospital records. The rates of nosocomial and community infections were 16.1% and 25.6%, respectively. When the elderly group with and without nosocomial infections was analyzed, practically all the risk factors considered (use of antibiotics, invasive devices, surgery and time of hospitalization) were significantly more associated with the patients with hospital infection. All patients with nosocomial infections were taking antibiotics and most of them (56.0%) were being treated with two or more antibiotics; the length of hospitalization was double (p=0.007) compared to patients who had not acquired hospital infection. The most frequent sites of nosocomial and community infections were surgical (56.0%) and the skin (37.1%), and most of the patients (47.5%) were in the surgical clinic wards. In conclusion, the elderly patients were more likely to develop a nosocomial infection (16.1% prevalence). Surgical infection accounted for the majority (56.0%) of the nosocomial infections, in contrast with North American studies that indicate urinary tract infections to be the commonest.

Active surveillance to determine the impact of methicillin resistance on mortality in patients with bacteremia and influences of the use of antibiotics on the development of MRSA infection

INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) is among the most important pathogens of nosocomial infections, mainly in intensive care units (ICUs), and accounts for 40-60% of all healthcare-associated S. aureus infections. We evaluated the incidence of nosocomial infection by S. aureus, identified the risk factors for MRSA infection, and evaluated the effect of resistance to methicillin on mortality in patients. METHODS We conducted MRSA surveillance at a university hospital in Brazil from January 1, 2010, to December 31, 2010, and performed a retrospective case-control matched study to evaluate the frequency of subsequent MRSA bacteremia and death among patients. We evaluated and compared the risk factors between patients with MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infection. RESULTS Sepsis was the most common cause of infection (17.7/1,000 patient-days), followed by surgical site (11.4/1,000 patient-days), pneumonia (4.1/1,000 patient-days), and urinary tract infection (2.4/1,000 patient-days). The significant risk factors were time of hospitalization, use of central vascular catheter (CVC), urinary catheter, nasogastric tube, parenteral nutrition, tracheostomy, mechanical ventilation, and previous antibiotic administration, the latter of which was the only independent risk factor for MRSA infection. Mortality was significantly higher in patients with MRSA. The number of antibiotics tested was not related to increases in the frequency of MRSA/1,000 patient-days. The incidence of mortality attributable to MRSA (bloodstream infection) BSI was 50%. CONCLUSIONS Surveillance results showed that the use of high levels of antibiotics was directly related to the development of MRSA infection, and the mortality attributable to MRSA in patients with bacteremia was significant.

Late onset sepsis in newborn babies: epidemiology and effect of a bundle to prevent central line associated bloodstream infections in the neonatal intensive care unit.

AIM We assessed late onset sepsis (LOS) rates of neonates in a neonatal intensive care unit (NICU) before and after implementing an evidence-based bundle to prevent these infections in a country with poor resources. METHODS We evaluate trends of LOS between October 2010 and August 2012 in a large tertiary hospital in Brazil. We designed a protocol based of CDC guidelines for insertion of maintenance of central venous catheter targeted to reduction of bloodstream infections. During this period two major events occurred: a great increase of LOS rates in January months and relocation of the unit to a provisory place. Additionally we evaluated the risk factors and etiology of these infections. RESULTS A total of 112 (20.3%) cases defined as LOS were found. The overall incidence rate of LOS in the study was 16.1/1000 patient/days and 23.0/1000 CVC-days. Our monthly rates data of LOS/1000 patient-day reveal fluctuations over the studied period, with incidence rates of these infections in staff vacation period (January 2011 and 2012) significantly higher (59.6/1000 patients-days) than compared with the other months rates (16.6/1000 patients-days) (IRR=3.59; p<0.001). As opposite, the incidence rates of LOS during relocation period was lower (10.3/1000 patients-days) when compared with baseline period 26.7/1000 patients-days (IRR=2.59; p=0.007). After the intervention period, these rates decreased in the post intervention period, when compared with preintervention 14.7/1000 patients-days and 23.4/1000 patients-days, respectively (IRR=1.59; p=0.04). CONCLUSION Through simple infection control measures, LOS can be successfully controlled especially in NICUs of limited resources countries such as ours.

Sepse, sepse grave e choque séptico: aspectos clínicos, epidemiológicos e prognóstico em pacientes de Unidade de Terapia Intensiva de um Hospital Universitário

INTRODUCTION: Sepsis is considered to be a severe disease with high mortality. The objective of this study was to determine the incidence and evolution of sepsis among critically ill patients. METHODS: Prospective surveillance of sepsis was performed in the adult intensive care unit, between April and December 2007. RESULTS: The patient frequency/day was 442. Seventy-five patients (18.6%) had sepsis and 72% of these cases were hospital-acquired. The rates of severe sepsis and septic shock per patient/day were 5.0 and 3.1, respectively. The total mortality was 34.6% and 61% of the cases had microbiological diagnoses. CONCLUSIONS: Sepsis presented with higher frequency than is usually described in the literature.

Nosocomial bloodstream infections: organisms, risk factors and resistant phenotypes in the Brazilian University Hospital.

Bacteremia is one of the most frequent and challenging hospital-acquired infection and it is associated with high attributable morbidity and mortality and additional use of healthcare resources. The objective of this work was to determine the frequencies of its occurrence, organisms and resistance phenotypes associated to nosocomial acquired bloodstream infections. A total number of 51 nosocomial bacteremia by Gram-negative and 99 by Gram-positive were evaluated and compared during a 15-month period. The risk factors associated with these bacteremias were analyzed and antibiotic use and surgery were associated with bacteremia by Gram-negative and > 2 invasive devices with Gram-positive. The resistance phenotypes ESBL (extended-spectrum beta-lactamases) (23.5%) and AmpC/others (17.6%) correspond to 41.2 % with predominance of E. agglomerans among AmpC (44.4%) and K. pneumoniae among ESBLs (38.5%). Among S. aureus bacteremia, approximately 40% were associated to MRSA (methicillin-resistant Staphylococcus aureus).