COVID-19 in the Perioperative Period of Cardiovascular Surgery: the Brazilian Experience.

INTRODUCTION: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. METHODS: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. RESULTS: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. CONCLUSION: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

Surveillance programs for detection and characterization of emergent pathogens and antimicrobial resistance: results from the Division of Infectious Diseases, UNIFESP.

Several epidemiological changes have occurred in the pattern of nosocomial and community acquired infectious diseases during the past 25 years. Social and demographic changes possibly related to this phenomenon include a rapid population growth, the increase in urban migration and movement across international borders by tourists and immigrants, alterations in the habitats of animals and arthropods that transmit disease, as well as the raise of patients with impaired host defense abilities. Continuous surveillance programs of emergent pathogens and antimicrobial resistance are warranted for detecting in real time new pathogens, as well as to characterize molecular mechanisms of resistance. In order to become more effective, surveillance programs of emergent pathogens should be organized as a multicenter laboratory network connected to the main public and private infection control centers. Microbiological data should be integrated to guide therapy, adapting therapy to local ecology and resistance patterns. This paper presents an overview of data generated by the Division of Infectious Diseases, Federal University of São Paulo, along with its participation in different surveillance programs of nosocomial and community acquired infectious diseases.

Molecular characterization of vancomycin-resistant Enterococci strains eight years apart from its first isolation in São Paulo, Brazil.

E. faecium was the first reported VRE species, carrying the vanA gene in Brazil. In spite of this, vancomycin-resistant E. faecalis has become the predominant species in Brazilian hospitals. The aim of this study was to evaluate the genetic relatedness of VREs isolated in a Brazilian teaching hospital eight years apart from its first isolation. We analyzed 38 VRE strains obtained from 81 surveillance cultures of patients admitted to the four largest intensive care units in Hospital São Paulo in February, 2006. Presence of the vanA gene was assayed by PCR and PFGE analysis was used for molecular characterization. All VRE strains carried the vanA gene. Two distinct clonal groups were observed among vancomycin-resistant E. faecalis. Vancomycin-resistant E. faecium belonged to five distinct clones were demonstrated by molecular typing. All of these clones were different from the first vancomycin-resistant enterococci clone isolated eight years ago in our hospital.

Assessment of healthcare professionals' adherence to hand hygiene after alcohol-based hand rub introduction at an intensive care unit in São Paulo, Brazil.

We analyzed the impact of introducing an alcohol-based hand gel and an educational program on hand hygiene adherence among healthcare workers in an intensive care unit. Adherence to hand hygiene was significantly higher after the intervention for the night shift work period (P=.001), among nursing assistants (P=.001), among nurses (P=.007) on weekend days (P=.016), and for invasive procedures (P=.012).

Control of multi-resistant bacteria and ventilator-associated pneumonia: is it possible with changes in antibiotics?

Potent antimicrobial agents have been developed as a response to the development of antibiotic-resistant bacteria, which especially affect patients with prolonged hospitalization in Intensive Care Units (ICU) and who had been previously treated with antimicrobials, especially third-generation cephalosporins. This study was to determine how changes in the empirical treatment of infections in ICU patients affect the incidence of Gram-negative bacteria species and their susceptibility to antimicrobials, and examine the impact of these changes on nosocomial infections. A prospective interventional study was performed in a university hospital during two periods: 1) First period (September 1999 to February 2000); and 2) Second period (August 2000 to December 2000); empirical treatment was changed from ceftriaxone and/or ceftazidime in the first period to piperacillin/tazobactam in the second. ICU epidemiological and infection control rates, as well as bacterial isolates from upper airways were analyzed. Ceftazidime consumption dropped from 34.83 to 0.85 DDD/1000 patients per day (p=0.004). Piperacillin/tazobactam was originally not available; its consumption reached 157.07 DDD/1000 patients per day in the second period (p=0.0002). Eighty-seven patients and 66 patients were evaluated for upper airway colonization in the first and second periods, respectively. There was a significant decrease in the incidence of K. pneumoniae (p=0.004) and P. mirabilis (p=0.036), restoration of K. pneumoniae susceptibility to cephalosporins (p<0.0001) and reduction of ventilator-associated pneumonia rates (p<0.0001). However, there was an increase in P. aeruginosa incidence (p=0.005) and increases in ceftazidime (p=0.003) and meropenem (p<0.0001) susceptibilities. Changing antimicrobial selective pressure on multi-resistant Gram-negative bacteria helps control ventilator-associated pneumonia and decreases antimicrobial resistance.

Compliance with handwashing at two intensive care units in São Paulo.

Handwashing compliance was compared at two medical- surgical intensive care units (ICUs) of a teaching and a non-teaching hospital. The mean compliance was 22.2% and 42.6%, respectively. Respiratory therapists at the non-teaching hospital had the best handwashing compliance (52.6%). Nursing assistants at the teaching hospital had the worst compliance (11.5%). Nursing assistant was the only health-care worker category with a significant difference between the two ICUs (odds ratio = 6.0; 95% confidence interval = 3.83-9.43; p< 0.001).

Impact of an Automated Surveillance to Detect Surgical-Site Infections in Patients Undergoing Total Hip and Knee Arthroplasty in Brazil.

In this retrospective study, we compared automated surveillance with conventional surveillance to detect surgical site infection after primary total hip or knee arthroplasty. Automated surveillance demonstrated better efficacy than routine surveillance in SSI diagnosis, sensitivity, and predictive negative value in hip and knee arthroplasty. Infect Control Hosp Epidemiol 2016;37:991-993.

COVID-19 in the perioperative period of cardiovascular surgery: the brazilian experience

Abstract Introduction: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

Pediatric risk of mortality and hospital infection.

We studied the association of Pediatric Risk of Mortality scores with nosocomial infections among 341 critically ill patients admitted to a pediatric intensive care unit between June 1998 and December 2000. Through stepwise logistic regression analysis, the best predictors for nosocomial infections were device utilization ratio, antimicrobial therapy, and length of stay.

Severe nosocomial infections with imipenem-resistant Acinetobacter baumannii treated with ampicillin/sulbactam.

Forty consecutive patients with nosomial infections caused by multidrug-resistant Acinetobacter baumannii were treated with intravenous ampicillin/sulbactam. The infections were primary bloodstream (32.5%), pneumonia (30%), urinary tract (15%), peritonitis (7.5%), surgical site (7.5%), meningitis (5%) and sinusitis (2.5%). Most were severe infections with underlying conditions (median APACHE II score: 14.5) and 72.5% occurred in the ICU. Twenty-seven (67.5%) were improved/cured, seven (17.5%) were failures and six (15%) were considered to have an indeterminate outcome because patients died within the first 48 h of treatment. Two cases of meningitis were treated and did not respond. The median daily dose of ampicillin/sulbactam was 6 g/3 g and six patients received 12 g/6 g. No adverse effects were observed. This study indicates that ampicillin/sulbactam may be a good and safe therapeutic option to treat severe nosocomial infections caused by multi-drug resistant A. baumannii.

Nosocomial infection in a pediatric intensive care unit in a developing country.

OBJECTIVE: Determine the rate and outcome of nosocomial infection (NI) in pediatric intensive care unit patients in a developing country. DESIGN: Prospective cohort study using the Centers for Disease Control and Prevention definitions to diagnose nosocomial infection and NNISS (National Nosocomial Infection Surveillance System) methodology. SETTING: São Paulo Hospital - Universidade Federal de São Paulo - Brazil, a 700-bed teaching hospital with an 8-bed pediatric intensive care unit. PARTICIPANTS: All 515 children consecutively admitted to the pediatric intensive care unit from April 1996 to October 1997. RESULTS: The NI incidence was 18.3% and the mean infection rate per 1,000 patient days was 46.1; the ventilator-associated pneumonia rate was 18.7 per 1,000 ventilator days; the central line-associated bloodstream infection rate was 10.2 per 1,000 central line days; and the urinary tract catheter-associated infection rate was 1.8 per 1,000 catheter days. Pneumonia was the most common NI (31.6%), followed by bloodstream infections (17.3%), and surgical site infection (17.3%). Gram-negative bacterias were the most common pathogens identified in the NIs (54.8%), followed by Gram-positive bacterias (23.8%), and yeasts. CONCLUSION: Pneumonia was the most common type of NI. A high incidence of ventilator-associated pneumonia and central line-associated bloodstream infections was found, whereas the urinary tract catheter-associated infection rate was low. Gram-negative bacterias were the most common etiologic agents identified in the unit, and yeasts were frequently found. Pediatric patients have characteristics of their own, with major differences when compared to the adult population.

Does the change on gastrointestinal tract microbiome affects host?

During the past decade, studies on the composition of human microbiota and its relation to the host became one of the most explored subjects of the medical literature. The development of high-throughput molecular technologies allowed a deeper characterization of human microbiota and a better understanding of its relationship with health and disease. Changes in human habits including wide use of antimicrobials can result in dysregulation of host-microbiome homeostasis, with multiple consequences. The purpose of this review is to highlight the most important evidence in the literature of host-microbiome interactions and illustrate how these intriguing relations may lead to new treatment and prevention strategies.

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.

Preventing catheter-associated infections in the Pediatric Intensive Care Unit: impact of an educational program surveying policies for insertion and care of central venous catheters in a Brazilian teaching hospital.

OBJECTIVES: To determine the impact of an educational program on the prevention of central venous catheter-related infections in a Brazilian Pediatric Intensive Care Unit. PATIENTS AND METHODS: All patients admitted to the unit between February 2004 and May 2005 were included in the cohort study in a longitudinal assessment. An educational program was developed based on the Centers for Disease Control and Prevention recommendations for prevention of catheter-associated infections and was adapted to local conditions and resources after an initial observational phase. Incidence of catheter-associated infections was measured by means of on-site surveillance. RESULTS: One hundred eighteen nosocomial infections occurred in 253 patients (46.6 infections per 100 admissions) and in 2,954 patient-days (39.9 infections per 1,000 patient-days). The incidence-density of catheter infections was 31.1 episodes per 1.000 venous central catheter-days before interventions, and 16.5 episodes per 1,000 venous central catheter-days afterwards (relative risk 0.53 [95% CI 0.28-1.01]). Corresponding rates for exit-site catheter infections were 8.0 and 2.5 episodes per 1,000 venous central catheter-days [0.32 (0.07-1.49)], and the rates for bloodstream infections were 23.1 and 13.9 episodes per 1,000 venous central catheter-days, before and after interventions [0.61 (0.32-1.14)]. CONCLUSION: A prevention strategy targeted at the insertion and maintenance of vascular access can decrease rates of vascular-access infections in pediatric intensive care unit.

Perceptions and attitudes of the professional staff concerning infection surveillance and control programs in Brazilian hospitals.

BACKGROUND: Several countries have conducted studies to assess the status of their infection control programs (ICP) with the objective of improving quality of infection control practices. METHODS: To assess the perceptions and attitudes of the health care workers (HCW) concerning ICP in Brazilian hospitals, we conducted a cross-sectional survey using a self-administered online questionnaire during a Web-based course (WBC) on infection control (IC) and antimicrobial resistance (AR). RESULTS: Of 6256 Brazilian HCW registered for the WBC, 1998 were members of infection control committees (ICC) and answered the survey. Eight hundred six (40.4%) respondents said that an ICP was established for more than 10 years in their institutions. Most professionals reported that their hospitals perform microbiologic surveillance targeted at epidemiologically important multidrug-resistant organisms, but the majority underestimated the prevalence of AR. CONCLUSION: Our survey highlights important information about the perceptions and attitudes of ICC members that may be used to tailor key interventions for implementing effective ICP. It suggests, additionally, that, to achieve countrywide standardized IC mechanisms in a developing country, authorities should consider the social, cultural, and economical disparities between regions and identify specific regional needs to make available the resources required to minimize such disparities.

Does the change on gastrointestinal tract microbiome affects host?

During the past decade, studies on the composition of human microbiota and its relation to the host became one of the most explored subjects of the medical literature. The development of high-throughput molecular technologies allowed a deeper characterization of human microbiota and a better understanding of its relationship with health and disease. Changes in human habits including wide use of antimicrobials can result in dysregulation of host–microbiome homeostasis, with multiple consequences. The purpose of this review is to highlight the most important evidence in the literature of host–microbiome interactions and illustrate how these intriguing relations may lead to new treatment and prevention strategies.

Imipenem-resistant Pseudomonas aeruginosa infection at a medical-surgical intensive care unit: risk factors and mortality.

OBJECTIVES: The aim of this study was to evaluate the risk factors and attributable mortality associated with imipenem-resistant Pseudomonas aeruginosa (IRPA) infections in a medical-surgical intensive care unit (ICU). METHODS: A retrospective case-control study was carried out at a 16-bed medical-surgical ICU in a 780-bed, university-affiliated hospital. All patients admitted from January 1, 2003, to December 31, 2004, who had nosocomial infection caused by IRPA, were included in the study. RESULTS: Imipenem-resistant P. aeruginosa was recovered from 63 patients during the study period. One hundred eighty-two controls were matched with cases by period of admission, age, and time at risk. Urinary tract (34.9%) and respiratory tract (22.2%) were the main sources of IRPA isolation. In multivariate analysis, a previous stay in the ICU (odds ratio, 3.54; 95% confidence interval [CI], 1.29-9.73; P = .03) was the only independent risk factor for IRPA infection. The in-hospital mortality rate among case patients was 49% (31 of 63) compared with 33% (61 of 182) for control patients (odds ratio, 1.92; 95% CI, 1.07-3.44; P = .02). Thus, we had an attributable mortality of 16% (95% CI, 9.74%-22.3%; P = .03). CONCLUSIONS: Our study suggests that IRPA infections are strongly related to previous ICU stay, and that IRPA infections significantly increase mortality in those critical patients.

Impact of an education program on the incidence of central line-associated bloodstream infection in 2 medical-surgical intensive care units in Brazil.

An intervention study was undertaken to evaluate the impact of an education program on the incidence of central line-associated bloodstream infection (CLABSI) in 2 intensive care units. There was a nonsignificant reduction in the incidence of CLABSI (odds ratio, 0.46 [95% confidence interval, 0.21-1.02]; P=.04) despite a significant increase in knowledge of CLABSI prevention by the staff of both intensive care units after the education program.

Impact of a hospital-wide antimicrobial formulary intervention on the incidence of multidrug-resistant gram-negative bacteria.

We examined the impact of an antimicrobial formulary change, based on reduction in third-generation cephalosporin use, on resistant gram-negative pathogens in a tertiary hospital. No significant changes were demonstrated in their incidence per 1000 patient-days. Otherwise, there was a significant decrease in rate of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae (63.1% to 52.5%, P = .04) and third-generation cephalosporin-resistant Enterobacter species (31.4% to 25%, P = .04) between the 2 study periods. On the other hand, there was also a significant increase in rate of ampicillin-sulbactam-resistant Acinetobacter baumannii (8% to 47%, P = .01) after the implementation of the formulary intervention.

Preventing catheter-associated infections in the Pediatric Intensive Care Unit: impact of an educational program surveying policies for insertion and care of central venous catheters in a Brazilian teaching hospital

Objectives: To determine the impact of an educational program on the prevention of central venous catheter-related infections in a Brazilian Pediatric Intensive Care Unit. Patients and Methods: All patients admitted to the unit between February 2004 and May 2005 were included in the cohort study in a longitudinal assessment. An educational program was developed based on the Centers for Disease Control and Prevention recommendations for prevention of catheter-associated infections and was adapted to local conditions and resources after an initial observational phase. Incidence of catheter-associated infections was measured by means of on-site surveillance. Results: One hundred eighteen nosocomial infections occurred in 253 patients (46.6 infections per 100 admissions) and in 2,954 patient-days (39.9 infections per 1,000 patient-days). The incidence-density of catheter infections was 31.1 episodes per 1.000 venous central catheter-days before interventions, and 16.5 episodes per 1,000 venous central catheter-days afterwards (relative risk 0.53 [95 percent CI 0.28-1.01]). Corresponding rates for exit-site catheter infections were 8.0 and 2.5 episodes per 1,000 venous central catheter-days [0.32 (0.07-1.49)], and the rates for bloodstream infections were 23.1 and 13.9 episodes per 1,000 venous central catheter-days, before and after interventions [0.61 (0.32-1.14)]. Conclusion: A prevention strategy targeted at the insertion and maintenance of vascular access can decrease rates of vascular-access infections in pediatric intensive care unit.