A nationwide survey of Antimicrobial Stewardship in Pediatric Intensive Care Unit: implementation notes from the Brazilian underground.

A multicenter diagnostic study was conducted to investigate the implementation of an Antimicrobial Stewardship Program in Brazilian Pediatric Intensive Care Units. The analysis unveiled the main implementation impediments of the Antimicrobial Stewardship Program such as the lack of professionals and resources available to the program.

Assessment of the ABC2-SPH risk score to predict invasive mechanical ventilation in COVID-19 patients and comparison to other scores.

Background: Predicting the need for invasive mechanical ventilation (IMV) is important for the allocation of human and technological resources, improvement of surveillance, and use of effective therapeutic measures. This study aimed (i) to assess whether the ABC2-SPH score is able to predict the receipt of IMV in COVID-19 patients; (ii) to compare its performance with other existing scores; (iii) to perform score recalibration, and to assess whether recalibration improved prediction. Methods: Retrospective observational cohort, which included adult laboratory-confirmed COVID-19 patients admitted in 32 hospitals, from 14 Brazilian cities. This study was conducted in two stages: (i) for the assessment of the ABC2-SPH score and comparison with other available scores, patients hospitalized from July 31, 2020, to March 31, 2022, were included; (ii) for ABC2-SPH score recalibration and also comparison with other existing scores, patients admitted from January 1, 2021, to March 31, 2022, were enrolled. For both steps, the area under the receiving operator characteristic score (AUROC) was calculated for all scores, while a calibration plot was assessed only for the ABC2-SPH score. Comparisons between ABC2-SPH and the other scores followed the Delong Test recommendations. Logistic recalibration methods were used to improve results and adapt to the studied sample. Results: Overall, 9,350 patients were included in the study, the median age was 58.5 (IQR 47.0-69.0) years old, and 45.4% were women. Of those, 33.5% were admitted to the ICU, 25.2% received IMV, and 17.8% died. The ABC2-SPH score showed a significantly greater discriminatory capacity, than the CURB-65, STSS, and SUM scores, with potentialized results when we consider only patients younger than 80 years old (AUROC 0.714 [95% CI 0.698-0.731]). Thus, after the ABC2-SPH score recalibration, we observed improvements in calibration (slope = 1.135, intercept = 0.242) and overall performance (Brier score = 0.127). Conclusion: The ABC2-SPHr risk score demonstrated a good performance to predict the need for mechanical ventilation in COVID-19 hospitalized patients under 80 years of age.

Temporal validation of the MMCD score to predict kidney replacement therapy and in-hospital mortality in COVID-19 patients.

BACKGROUND: Acute kidney injury has been described as a common complication in patients hospitalized with COVID-19, which may lead to the need for kidney replacement therapy (KRT) in its most severe forms. Our group developed and validated the MMCD score in Brazilian COVID-19 patients to predict KRT, which showed excellent performance using data from 2020. This study aimed to validate the MMCD score in a large cohort of patients hospitalized with COVID-19 in a different pandemic phase and assess its performance to predict in-hospital mortality. METHODS: This study is part of the "Brazilian COVID-19 Registry", a retrospective observational cohort of consecutive patients hospitalized for laboratory-confirmed COVID-19 in 25 Brazilian hospitals between March 2021 and August 2022. The primary outcome was KRT during hospitalization and the secondary was in-hospital mortality. We also searched literature for other prediction models for KRT, to assess the results in our database. Performance was assessed using area under the receiving operator characteristic curve (AUROC) and the Brier score. RESULTS: A total of 9422 patients were included, 53.8% were men, with a median age of 59 (IQR 48-70) years old. The incidence of KRT was 8.8% and in-hospital mortality was 18.1%. The MMCD score had excellent discrimination and overall performance to predict KRT (AUROC: 0.916 [95% CI 0.909-0.924]; Brier score = 0.057). Despite the excellent discrimination and overall performance (AUROC: 0.922 [95% CI 0.914-0.929]; Brier score = 0.100), the calibration was not satisfactory concerning in-hospital mortality. A random forest model was applied in the database, with inferior performance to predict KRT requirement (AUROC: 0.71 [95% CI 0.69-0.73]). CONCLUSION: The MMCD score is not appropriate for in-hospital mortality but demonstrates an excellent predictive ability to predict KRT in COVID-19 patients. The instrument is low cost, objective, fast and accurate, and can contribute to supporting clinical decisions in the efficient allocation of assistance resources in patients with COVID-19.

Myocardial Injury and Prognosis in Hospitalized COVID-19 Patients in Brazil: Results From The Brazilian COVID-19 Registry. / Lesão Miocárdica e Prognóstico em Pacientes Hospitalizados com COVID-19 no Brasil: Resultados do Registro Nacional de COVID-19.

BACKGROUND: Cardiovascular complications of COVID-19 are important aspects of the disease's pathogenesis and prognosis. Evidence on the prognostic role of troponin and myocardial injury in Latin American hospitalized COVID-19 patients is still scarce. OBJECTIVES: To evaluate myocardial injury as independent predictor of in-hospital mortality and invasive mechanical ventilation support in hospitalized patients, from the Brazilian COVID-19 Registry. METHODS: This cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals of 17 cities, March-September 2020. Primary outcomes included in-hospital mortality and invasive mechanical ventilation support. Models for the primary outcomes were estimated by Poisson regression with robust variance, with statistical significance of p<0.05. RESULTS: Of 2,925 patients (median age of 60 years [48-71], 57.1% men), 27.3% presented myocardial injury. The proportion of patients with comorbidities was higher among patients with cardiac injury (median 2 [1-2] vs. 1 [0-2]). Patients with myocardial injury had higher median levels of brain natriuretic peptide, lactate dehydrogenase, creatine phosphokinase, N-terminal pro-brain natriuretic peptide, and C-reactive protein than patients without myocardial injury. As independent predictors, C-reactive protein and platelet counts were related to the risk of death, and neutrophils and platelet counts were related to the risk of invasive mechanical ventilation support. Patients with high troponin levels presented a higher risk of death (RR 2.03, 95% CI 1.60-2.58) and invasive mechanical ventilation support (RR 1.87, 95% CI 1.57-2.23), when compared to those with normal troponin levels. CONCLUSION: Cardiac injury was an independent predictor of in-hospital mortality and the need for invasive mechanical ventilation support in hospitalized COVID-19 patients.

FUNDAMENTO: As complicações cardiovasculares da COVID-19 são aspectos importantes da patogênese e do prognóstico da doença. Evidências do papel prognóstico da troponina e da lesão miocárdica em pacientes hospitalizados com COVID-19 na América Latina são ainda escassos. OBJETIVOS: Avaliar a lesão miocárdica como preditor independente de mortalidade hospitalar e suporte ventilatório mecânico em pacientes hospitalizados, do registro brasileiro de COVID-19. MÉTODOS: Este estudo coorte é um subestudo do registro brasileiro de COVID-19, conduzido em 31 hospitais brasileiros de 17 cidades, de março a setembro de 2020. Os desfechos primários incluíram mortalidade hospitalar e suporte ventilatório mecânico invasivo. Os modelos para os desfechos primários foram estimados por regressão de Poisson com variância robusta, com significância estatística de p<0,05. RESULTADOS: Dos 2925 pacientes [idade mediana de 60 anos (48-71), 57,1%], 27,3% apresentaram lesão miocárdica. A proporção de pacientes com comorbidades foi maior nos pacientes com lesão miocárdica [mediana 2 (1-2) vs. 1 (0-20)]. Os pacientes com lesão miocárdica apresentaram maiores valores medianos de peptídeo natriurético cerebral, lactato desidrogenase, creatina fosfoquinase, N-terminal do pró-peptídeo natriurético tipo B e proteína C reativa em comparação a pacientes sem lesão miocárdica. Como fatores independentes, proteína C reativa e contagem de plaquetas foram relacionados com o risco de morte, e neutrófilos e contagem de plaquetas foram relacionados ao risco de suporte ventilatório mecânico invasivo. Os pacientes com níveis elevados de troponina apresentaram um maior risco de morte (RR 2,03, IC95% 1,60-2,58) e suporte ventilatório mecânico (RR 1,87;IC95% 1,57-2,23), em comparação àqueles com níveis de troponina normais. CONCLUSÃO: Lesão cardíaca foi um preditor independente de mortalidade hospitalar e necessidade de suporte ventilatório mecânico em pacientes hospitalizados com COVID-19.

Lesão Miocárdica e Prognóstico em Pacientes Hospitalizados com COVID-19 no Brasil: Resultados do Registro Nacional de COVID-19 / Myocardial Injury and Prognosis in Hospitalized COVID-19 Patients in Brazil: Results From The Brazilian COVID-19 Registry

Resumo Fundamento As complicações cardiovasculares da COVID-19 são aspectos importantes da patogênese e do prognóstico da doença. Evidências do papel prognóstico da troponina e da lesão miocárdica em pacientes hospitalizados com COVID-19 na América Latina são ainda escassos. Objetivos Avaliar a lesão miocárdica como preditor independente de mortalidade hospitalar e suporte ventilatório mecânico em pacientes hospitalizados, do registro brasileiro de COVID-19. Métodos Este estudo coorte é um subestudo do registro brasileiro de COVID-19, conduzido em 31 hospitais brasileiros de 17 cidades, de março a setembro de 2020. Os desfechos primários incluíram mortalidade hospitalar e suporte ventilatório mecânico invasivo. Os modelos para os desfechos primários foram estimados por regressão de Poisson com variância robusta, com significância estatística de p<0,05. Resultados Dos 2925 pacientes [idade mediana de 60 anos (48-71), 57,1%], 27,3% apresentaram lesão miocárdica. A proporção de pacientes com comorbidades foi maior nos pacientes com lesão miocárdica [mediana 2 (1-2) vs. 1 (0-20)]. Os pacientes com lesão miocárdica apresentaram maiores valores medianos de peptídeo natriurético cerebral, lactato desidrogenase, creatina fosfoquinase, N-terminal do pró-peptídeo natriurético tipo B e proteína C reativa em comparação a pacientes sem lesão miocárdica. Como fatores independentes, proteína C reativa e contagem de plaquetas foram relacionados com o risco de morte, e neutrófilos e contagem de plaquetas foram relacionados ao risco de suporte ventilatório mecânico invasivo. Os pacientes com níveis elevados de troponina apresentaram um maior risco de morte (RR 2,03, IC95% 1,60-2,58) e suporte ventilatório mecânico (RR 1,87;IC95% 1,57-2,23), em comparação àqueles com níveis de troponina normais. Conclusão Lesão cardíaca foi um preditor independente de mortalidade hospitalar e necessidade de suporte ventilatório mecânico em pacientes hospitalizados com COVID-19.

Abstract Background Cardiovascular complications of COVID-19 are important aspects of the disease's pathogenesis and prognosis. Evidence on the prognostic role of troponin and myocardial injury in Latin American hospitalized COVID-19 patients is still scarce. Objectives To evaluate myocardial injury as independent predictor of in-hospital mortality and invasive mechanical ventilation support in hospitalized patients, from the Brazilian COVID-19 Registry. Methods This cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals of 17 cities, March-September 2020. Primary outcomes included in-hospital mortality and invasive mechanical ventilation support. Models for the primary outcomes were estimated by Poisson regression with robust variance, with statistical significance of p<0.05. Results Of 2,925 patients (median age of 60 years [48-71], 57.1% men), 27.3% presented myocardial injury. The proportion of patients with comorbidities was higher among patients with cardiac injury (median 2 [1-2] vs. 1 [0-2]). Patients with myocardial injury had higher median levels of brain natriuretic peptide, lactate dehydrogenase, creatine phosphokinase, N-terminal pro-brain natriuretic peptide, and C-reactive protein than patients without myocardial injury. As independent predictors, C-reactive protein and platelet counts were related to the risk of death, and neutrophils and platelet counts were related to the risk of invasive mechanical ventilation support. Patients with high troponin levels presented a higher risk of death (RR 2.03, 95% CI 1.60-2.58) and invasive mechanical ventilation support (RR 1.87, 95% CI 1.57-2.23), when compared to those with normal troponin levels. Conclusion Cardiac injury was an independent predictor of in-hospital mortality and the need for invasive mechanical ventilation support in hospitalized COVID-19 patients.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry.

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.

Hypothyroidism does not lead to worse prognosis in COVID-19: findings from the Brazilian COVID-19 registry.

BACKGROUND: It is not clear whether previous thyroid diseases influence the course and outcomes of COVID-19. METHODS: The study is a part of a multicentric cohort of patients with confirmed COVID-19 diagnosis from 37 hospitals. Matching for age, sex, number of comorbidities, and hospital was performed for the paired analysis. RESULTS: Of 7,762 patients with COVID-19, 526 had previously diagnosed hypothyroidism and 526 were matched controls. The median age was 70 years, and 68.3% were females. The prevalence of comorbidities was similar, except for coronary and chronic kidney diseases that were higher in the hypothyroidism group (p=0.015 and p=0.001). D-dimer levels were lower in patients with hypothyroid (p=0.037). In-hospital management was similar, but hospital length-of-stay (p=0.029) and mechanical ventilation requirement (p=0.006) were lower for patients with hypothyroidism. There was a trend of lower in-hospital mortality in patients with hypothyroidism (22.1% vs 27.0%; p=0.062). CONCLUSION: Patients with hypothyroidism had a lower requirement of mechanical ventilation and showed a trend of lower in-hospital mortality. Therefore, hypothyroidism does not seem to be associated with a worse prognosis.

Campos impregnados com iodo em cirurgia da coluna: impacto na infecção de sítio cirúrgico / Iodine-impregnated incision drapes in spine surgery: impact on surgical site infection / Paños quirúrgicos impregnados com yodo em cirugía de coluna: impacto en la infección del sitio quirúrgico

Objetivo: Avaliar o impacto de campos adesivos impregnados com iodo (CAII) na prevenção de infecção de sítio cirúrgico (ISC) de coluna vertebral. Método: Coorte retrospectiva que comparou desfecho de ISC em pacientes que utilizaram CAII com os que não usaram, de 2015 a 2019. Resultados: A frequência geral de ISC foi de 16,7%, com a taxa de ISC para os que utilizaram CAII de 40% e, entre os que não usaram, de 60%; p = 0,728; intervalo de confiança de 95% (IC95%) 0,19­3,11. A normotermia foi o único fator protetor independente para ISC (p = 0,043). O tratamento de complicações infecciosas acarretou o incremento de custo hospitalar de 83,6% a cada dia de atendimento. Os pacientes que utilizaram CAII tiveram 10 (± 4,9) dias a menos de permanência hospitalar. Conclusões: Os resultados sugerem que o uso de CAII não foi associado a menor risco de ISC. Esses dados podem ser úteis para o planejamento cirúrgico e a segurança do paciente.

Objective: To evaluate the impact of iodine-impregnated incision drapes (IIIDs) to prevent surgical site infection (SSI) in the spine. Method: Retrospective cohort study comparing SSI outcome in patients in which IIIDs were and were not used, from 2015 to 2019. Results: The overall frequency of SSI was 16.7%, with SSI rate among patients using and not using IIIDs of 40% and 60%, respectively; p = 0.728; 95% confidence interval (95%CI) 0.19­3.11. Normothermia was the only independent protective factor for SSI (p = 0.043). The treatment of infectious complications resulted in hospital costs increase of 83.6% each day of care. Patients who were treated with IIIDs stayed 10 days less (± 4.9) in hospital. Conclusions: The results suggest that the use of IIIDs was not associated with a lower risk of SSI. These data can be useful for surgical planning and patient safety.

Objetivo: Evaluar el impacto de las paños quirúrgicos adhesivos impregnados de yodo (IIIDS) en la prevención de la infección del sitio quirúrgico (ISQ) de la columna. Método: Cohorte retrospectiva que comparó el resultado de ISQ en pacientes que usaron IIIDS con los que no lo hicieron, de 2015 a 2019. Resultados: La frecuencia general de ISQ fue del 16.7%, con una tasa de ISQ para los que usaron IIIDS del 40% y, entre los que no lo usaron, 60%; p = 0,728; Intervalo de confianza del 95% (IC 95%) 0,19­3,11. La normotermia fue el único factor protector independiente para la ISQ (p = 0,043). El tratamiento de las complicaciones infecciosas supuso un aumento de los costes hospitalarios del 83,6% por día de atención. Los pacientes que utilizaron IIIDS tuvieron 10 (± 4,9) días menos de estancia hospitalaria. Conclusiones: Los resultados sugieren que el uso de IIIDS no se asoció con un menor riesgo de ISQ. Estos datos pueden ser útiles para la planificación quirúrgica y la seguridad del paciente.

Adesão aos protocolos de atendimento para a não infecção de sítio cirúrgico de coluna / Adherence to care protocols for non-infection of the surgical site of the spine / Cumplimiento de los protocolos de atención para la no infección del sitio quirúrgico de la columna vertebral

Objetivo: avaliar a adesão aos protocolos de atendimento para a não infecção de sítio cirúrgico (NISC) de coluna e os fatores associados. Método: estudo transversal realizado por meio da revisão de 60 prontuários de pacientes submetidos à cirurgia de coluna de 2015 a 2019, seu desfecho de não infecção e as condições relacionadas. O estudo foi executado no primeiro semestre de 2020. Resultados: algumas variáveis relacionadas para NISC foram: profilaxia antimicrobiana de 30 a 60 min antes da cirurgia (RR= 0,97; p=0,026), normotermia (RR= 0,80; p=0,050), internação pós cirúrgica em Unidade de Terapia Intensiva (até 3 dias) (RR=2,00; p=0,040). A frequência de NISC foi de 83,3% (50/60) p= 0,728). Conclusão: apenas a normotermia foi fator associado a não infecção para NISC na regressão linear. Ressalta-se que a adesão aos processos de trabalho é primordial para a proteção das infecções, reduzir eventos adversos e garantir a segurança.

Objective: to evaluate adherence to treatment protocols for non-surgical site infection (NISC) of the spine and associated factors. Method: cross-sectional study conducted through the review of 60 medical records of patients undergoing spinal surgery from 2015 to 2019, its non-infection outcome and related conditions. The study was carried out in the first half of 2020. Results: some variables related to NISC were: antimicrobial prophylaxis from 30 to 60 min before surgery (RR= 0.97; p=0.026), normothermia (RR= 0.80; p =0.050), post-surgical hospitalization in the Intensive Care Unit (up to 3 days) (RR=2.00; p=0.040). The frequency of NISC was 83.3% (50/60) p= 0.728). Conclusion: only normothermia was a factor associated with non-infection for NISC in linear regression. It is noteworthy that adherence to work processes is essential to protect against infections, reduce adverse events and ensure safety.

Objetivo: Evaluar la adherencia a los protocolos de tratamiento de la infección del sitio no quirúrgico (NISC) de la columna y los factores asociados. Método: estudio transversal realizado mediante la revisión de 60 historias clínicas de pacientes sometidos a cirugía de columna entre 2015 y 2019, su desenlace no infeccioso y afecciones relacionadas. El estudio se realizó en el primer semestre de 2020. Resultados: Algunas variables relacionadas con NISC fueron: profilaxis antimicrobiana de 30 a 60 min antes de la cirugía (RR = 0,97; p = 0,026), normotermia (RR = 0,80; p = 0,050), internación posquirúrgica en la Unidad de Cuidados Intensivos (hasta 3 días) (RR = 2,00; p = 0,040). La frecuencia de NISC fue del 83,3% (50/60) p = 0,728). Conclusión: solo la normotermia fue un factor asociado a la no infección por NISC en regresión lineal. Es de destacar que la adherencia a los procesos de trabajo es fundamental para proteger contra infecciones, reducir los eventos adversos y garantizar la seguridad.