Prospective cohort study of incidence and risk factors for catheter-associated urinary tract infections in 145 intensive care units of 9 Latin American countries: INICC findings.

PURPOSE: Identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in Latin American Countries. METHODS: From 01/01/2014 to 02/10/2022, we conducted a prospective cohort study in 145 ICUs of 67 hospitals in 35 cities in nine Latin American countries: Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama, and Peru. To estimate CAUTI incidence, we used the number of UC-days as the denominator, and the number of CAUTIs as numerator. To estimate CAUTI RFs, we analyzed the following 10 variables using multiple logistic regression: gender, age, length of stay (LOS) before CAUTI acquisition, UC-days before CAUTI acquisition, UC-device utilization (DU) ratio, UC-type, hospitalizationtype, ICU type, facility ownership, and time period. RESULTS: 31,631 patients, hospitalized for 214,669 patient-days, acquired 305 CAUTIs. The pooled CAUTI rate per 1000 UC-days was 2.58, for those using suprapubic catheters, it was 2.99, and for those with indwelling catheters, it was 2.21. The following variables were independently associated with CAUTI: age, rising risk 1% yearly (aOR = 1.01; 95% CI 1.01-1.02; p < 0.0001 female gender (aOR = 1.28; 95% CI 1.01-1.61; p = 0.04), LOS before CAUTI acquisition, rising risk 7% daily (aOR = 1.07; 95% CI 1.06-1.08; p < 0.0001, UC/DU ratio (aOR = 1.14; 95% CI 1.08-1.21; p < 0.0001, public facilities (aOR = 2.89; 95% CI 1.75-4.49; p < 0.0001. The periods 2014-2016 and 2017-2019 had significantly higher risks than the period 2020-2022. Suprapubic catheters showed similar risks as indwelling catheters. CONCLUSION: The following CAUTI RFs are unlikely to change: age, gender, hospitalization type, and facility ownership. Based on these findings, it is suggested to focus on reducing LOS, UC/DU ratio, and implementing evidence-based CAUTI prevention recommendations.

Distance learning in antimicrobial stewardship: innovation in medical education.

BACKGROUND: This study aimed to analyse the impact that web-based distance learning has on knowledge gain in medical students, as well as student perceptions of the methodology. METHODS: This was an educational intervention study conducted at a tertiary teaching hospital in the city of São Paulo, Brazil. From 2008 to 2014, we offered a free web-based distance learning course, covering antimicrobial use and microbial resistance, to fifth-year medical students. The course encompassed 100 h of activities, with five theoretical modules, exercises and simulations, within a virtual learning environment. The students were tutored in their online activities, and some classes were conducted in real time for live discussions. In addition, students underwent face-to-face assessments of their knowledge of the topic before and after the course. Statistical analysis was performed and the means of the overall scores were obtained, as were the respective 95% confidence intervals (CIs). The means were compared by two-tailed paired t-tests and by the paired Wilcoxon test. RESULTS: Of 814 eligible medical students, 606 (74.45%) completed the entire course during the study period. The mean score for knowledge of the topic was significantly higher on the final assessment than on the initial assessment (p <  0.001). We found that dedication (in hours) was directly proportional to the level of participation, as reflected in the mean final score (p = 0.009) and in the proportion of students who passed (p = 0.028). All of the participants considered their knowledge adequate or insufficient before the course, stating that it is quite important or important to address the topic during medical education. Although dedication levels were low, 70.5% stated that they had learned "quite a lot" or "more than expected" about the topic and would dedicate more time to it if they could. CONCLUSIONS: The use of a virtual learning environment can promote teaching and learning in the infectious diseases field, specifically for antimicrobial stewardship, increasing knowledge significantly, and should be considered for inclusion in the final stages of medical education.

Dissemination of Multidrug-Resistant Proteus mirabilis Clones Carrying a Novel Integron-Borne blaIMP-1 in a Tertiary Hospital.

This study aimed to characterize multidrug-resistant Proteus mirabilis clones carrying a novel class 1 integron-borne blaIMP-1 In1359 was inserted into a large conjugative plasmid that also carried blaCTX-M-2 The production of carbapenemases in Enterobacteriaceae that are intrinsically resistant to polymyxins and tigecycline is very worrisome, representing a serious challenge to clinicians and infection control teams.

Healthcare worker adherence to follow-up after occupational exposure to blood and body fluids at a teaching hospital in Brazil.

Healthcare workers (HCWs) are at a high risk for exposure to pathogens in the workplace. The objective of this study was to evaluate HCW adherence to follow-up after occupational exposure to blood and body fluids at a tertiary care university hospital in the city of São Paulo, Brazil. Data were collected from 2102 occupational exposures to blood and body fluids reports, obtained from the Infection Control Division of the Universidade Federal de São Paulo/Escola Paulista de Medicina/Hospital São Paulo, in São Paulo, Brazil, occurring between January of 2005 and December of 2011. To evaluate adherence to post-exposure follow-up among the affected HCWs, we took into consideration follow-up visits for serological testing. For HCWs exposed to materials from source patients infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV), as well as from source patients of unknown serological status, follow-up serological testing was scheduled for 3 and 6 months after the accident. For those exposed to materials from source patients co-infected with HIV and HCV, follow-up evaluations were scheduled for 3, 6, and 12 months after the accident. During the study period, there were 2056 accidental exposures for which data regarding the serology of the source patient were available. Follow-up evaluation of the affected HCW was recommended in 612 (29.8%) of those incidents. After the implementation of a post-exposure protocol involving telephone calls and official letters mailed to the affected HCW, adherence to follow-up increased significantly, from 30.5 to 54.0% (P = 0.028). Adherence was correlated positively with being female (P = 0.009), with the source of the exposure being known (P = 0.026), with the source patient being HIV positive (P = 0.029), and with the HCW having no history of such accidents (P = 0.047). Adherence to the recommended serological testing was better at the evaluation scheduled for 3 months after the exposure (the initial evaluation) than at those scheduled for 6 and 12 months after the exposure (P = 0.004). During the study period, there was one confirmed case of HCW seroconversion to HCV positivity. The establishment of a protocol that involves the immediate supervisor of the affected HCWs, in the formal summoning of those HCWs is necessary in order to increase the rate of adherence to post-exposure follow-up.

Incidence and risk factors for catheter-associated urinary tract infection in 623 intensive care units throughout 37 Asian, African, Eastern European, Latin American, and Middle Eastern nations: A multinational prospective research of INICC.

OBJECTIVE: To identify urinary catheter (UC)-associated urinary tract infection (CAUTI) incidence and risk factors. DESIGN: A prospective cohort study. SETTING: The study was conducted across 623 ICUs of 224 hospitals in 114 cities in 37 African, Asian, Eastern European, Latin American, and Middle Eastern countries. PARTICIPANTS: The study included 169,036 patients, hospitalized for 1,166,593 patient days. METHODS: Data collection took place from January 1, 2014, to February 12, 2022. We identified CAUTI rates per 1,000 UC days and UC device utilization (DU) ratios stratified by country, by ICU type, by facility ownership type, by World Bank country classification by income level, and by UC type. To estimate CAUTI risk factors, we analyzed 11 variables using multiple logistic regression. RESULTS: Participant patients acquired 2,010 CAUTIs. The pooled CAUTI rate was 2.83 per 1,000 UC days. The highest CAUTI rate was associated with the use of suprapubic catheters (3.93 CAUTIs per 1,000 UC days); with patients hospitalized in Eastern Europe (14.03) and in Asia (6.28); with patients hospitalized in trauma (7.97), neurologic (6.28), and neurosurgical ICUs (4.95); with patients hospitalized in lower-middle-income countries (3.05); and with patients in public hospitals (5.89).The following variables were independently associated with CAUTI: Age (adjusted odds ratio [aOR], 1.01; P < .0001), female sex (aOR, 1.39; P < .0001), length of stay (LOS) before CAUTI-acquisition (aOR, 1.05; P < .0001), UC DU ratio (aOR, 1.09; P < .0001), public facilities (aOR, 2.24; P < .0001), and neurologic ICUs (aOR, 11.49; P < .0001). CONCLUSIONS: CAUTI rates are higher in patients with suprapubic catheters, in middle-income countries, in public hospitals, in trauma and neurologic ICUs, and in Eastern European and Asian facilities.Based on findings regarding risk factors for CAUTI, focus on reducing LOS and UC utilization is warranted, as well as implementing evidence-based CAUTI-prevention recommendations.

High-touch surfaces disinfection compliance in a COVID-19 intensive care unit.

Environmental cleaning and disinfection are fundamental health care-associated infection prevention measures. This study aimed to evaluate the disinfection compliance of high-touch surfaces in a COVID-19-only intensive care unit, using a fluorescent marker. It was divided into 3 phases, baseline assessment, educational feedback, and post feedback. Disinfection compliance improved significantly from the first to the third phase, 14.3% to 51.4% (P < .001), respectively.

Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC).

Objective: Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs. Design: Prospective cohort study. Setting: This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries. Participants: The study included patients admitted to ICUs across 24 years. Results: In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21-9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34-7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17-1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15-1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22-5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78-3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79-3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51-0.77; P < .0001). Conclusions: Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

The impact of healthcare-associated infections on mortality in ICU: A prospective study in Asia, Africa, Eastern Europe, Latin America, and the Middle East.

BACKGROUND: The International Nosocomial Infection Control Consortium has found a high ICU mortality rate. Our aim was to identify all-cause mortality risk factors in ICU-patients. METHODS: Multinational, multicenter, prospective cohort study at 786 ICUs of 312 hospitals in 147 cities in 37 Latin American, Asian, African, Middle Eastern, and European countries. RESULTS: Between 07/01/1998 and 02/12/2022, 300,827 patients, followed during 2,167,397 patient-days, acquired 21,371 HAIs. Following mortality risk factors were identified in multiple logistic regression: Central line-associated bloodstream infection (aOR:1.84; P<.0001); ventilator-associated pneumonia (aOR:1.48; P<.0001); catheter-associated urinary tract infection (aOR:1.18;P<.0001); medical hospitalization (aOR:1.81; P<.0001); length of stay (LOS), risk rises 1% per day (aOR:1.01; P<.0001); female gender (aOR:1.09; P<.0001); age (aOR:1.012; P<.0001); central line-days, risk rises 2% per day (aOR:1.02; P<.0001); and mechanical ventilator (MV)-utilization ratio (aOR:10.46; P<.0001). Coronary ICU showed the lowest risk for mortality (aOR: 0.34;P<.0001). CONCLUSION: Some identified risk factors are unlikely to change, such as country income-level, facility ownership, hospitalization type, gender, and age. Some can be modified; Central line-associated bloodstream infection, ventilator-associated pneumonia, catheter-associated urinary tract infection, LOS, and MV-utilization. So, to lower the risk of death in ICUs, we recommend focusing on strategies to shorten the LOS, reduce MV-utilization, and use evidence-based recommendations to prevent HAIs.

Multinational prospective study of incidence and risk factors for central-line-associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years.

OBJECTIVE: To identify central-line (CL)-associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs). DESIGN: From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms. SETTING: The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries. PATIENTS: In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs. METHODS: For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs). RESULTS: The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03-1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03-1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03-1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23-1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31-4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22-3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09-2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11-6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57-3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81-3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71-3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96-2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02-2.18; P = .04). CONCLUSIONS: The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; and implementing evidence-based CLABSI prevention recommendations.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections in ICUs of 8 Latin American countries.

BACKGROUND: Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors in Latin-America. METHODS: From January 1, 2014 to February 10, 2022, we conducted a multinational multicenter prospective cohort study in 58 ICUs of 34 hospitals in 21 cities in 8 Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama). We applied multiple-logistic regression. Outcomes are shown as adjusted-odds ratios (aOR). RESULTS: About 29,385 patients were hospitalized during 92,956 days, acquired 400 CLABSIs, and pooled CLABSI rate was 4.30 CLABSIs per 1,000 CL-days. We analyzed following 10 variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization (DU) ratio, CL-type, tracheostomy use, hospitalization type, intensive care unit (ICU) type, and facility ownership, Following variables were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 3% daily (aOR=1.03;95%CI=1.02-1.04; P < .0001); number of CL-days before CLABSI acquisition, rising risk 4% per CL-day (aOR=1.04;95%CI=1.03-1.05; P < .0001); publicly-owned facility (aOR=2.33;95%CI=1.79-3.02; P < .0001). ICU with highest risk was medical-surgical (aOR=2.61;95%CI=1.41-4.81; P < .0001). CL with the highest risk were femoral (aOR=2.71;95%CI=1.61-4.55; P < .0001), and internal-jugular (aOR=2.62;95%CI=1.82-3.79; P < .0001). PICC (aOR=1.25;95%CI=0.63-2.51; P = .52) was not associated with CLABSI risk. CONCLUSIONS: Based on these findings it is suggested to focus on reducing LOS, CL-days, using PICC instead of femoral or internal-jugular; and implementing evidence-based CLABSI prevention recommendations.

COVID-19 and isolation: Risks and implications in the scenario of new variants.

With the emergence of new variants of SARS-CoV-2, questions about transmissibility, vaccine efficacy, and impact on mortality are important to support decision-making in public health measures. Modifications related to transmissibility combined with the fact that much of the population has already been partially exposed to infection and/or vaccination, have stimulated recommendations to reduce the isolation period for COVID-19. However, these new guidelines have raised questions about their effectiveness in reducing contamination and minimizing impact in work environments. Therefore, a collaborative task force was developed to review the subject in a non-systematic manner, answering questions about SARS-CoV-2 variants, COVID-19 vaccines, isolation/quarantine periods, testing to end the isolation period, and the use of masks as mitigation procedures. Overall, COVID-19 vaccines are effective in preventing severe illness and death but are less effective in preventing infection in the case of the Omicron variant. Any strategy that is adopted to reduce the isolation period should take into consideration the epidemiological situation of the geographical region, individual clinical characteristics, and mask for source control. The use of tests for isolation withdrawal should be evaluated with caution, due to results depending on various conditions and may not be reliable.

Multinational Prospective Cohort Study of Mortality Risk Factors in 198 ICUs of 12 Latin American Countries over 24 Years: The Effects of Healthcare-Associated Infections.

BACKGROUND: The International Nosocomial Infection Control Consortium (INICC) has found a high ICU mortality rate in Latin America. METHODS: A prospective cohort study in 198 ICUs of 96 hospitals in 46 cities in 12 Latin American countries to identify mortality risk factors (RF), and data were analyzed using multiple logistic regression. RESULTS: Between 07/01/1998 and 02/12/2022, 71,685 patients, followed during 652,167 patient-days, acquired 4700 HAIs, and 10,890 died. We prospectively collected data of 16 variables. Following 11 independent mortality RFs were identified in multiple logistic regression: ventilator-associated pneumonia (VAP) acquisition (adjusted odds ratio [aOR] = 1.17; 95% CI: 1.06-1.30; p < 0.0001); catheter-associated urinary tract infection (CAUTI) acquisition (aOR = 1.34; 95% CI: 1.15-1.56; p < 0.0001); older age, rising risk 2% yearly (aOR = 1.02; 95% CI: 1.01-1.02; p < 0.0001); longer indwelling central line(CL)-days, rising risk 3% daily (aOR = 1.03; 95% CI: 1.02-1.03; p < 0.0001); longer indwelling urinary catheter(UC)-days, rising risk 1% daily (aOR = 1.01; 95% CI: 1.01-1.26; p < 0.0001); higher mechanical ventilation (MV) (aOR = 6.47; 95% CI: 5.96-7.03; p < 0.0001) and urinary catheter-utilization ratio (aOR = 1.19; 95% CI: 1.11-1.27; p < 0.0001); lower-middle level income country (aOR = 2.94; 95% CI: 2.10-4.12; p < 0.0001); private (aOR = 1.50; 95% CI: 1.27-1.77; p < 0.0001) or public hospital (aOR = 1.47; 95% CI: 1.24-1.74; p < 0.0001) compared with university hospitals; medical hospitalization instead of surgical (aOR = 1.67; 95% CI: 1.59-1.75; p < 0.0001); neurologic ICU (aOR = 4.48; 95% CI: 2.68-7.50; p < 0.0001); adult oncology ICU (aOR = 3.48; 95% CI: 2.14-5.65; p < 0.0001); and others. CONCLUSION: Some of the identified mortality RFs are unlikely to change, such as the income level of the country, facility ownership, hospitalization type, ICU type, and age. But some of the mortality RFs we found can be changed, and efforts should be made to reduce CL-days, UC-days, MV-utilization ratio, UC-utilization ratio, and lower VAPs and CAUTI rates.

Nosocomial bloodstream infections in Brazilian hospitals: analysis of 2,563 cases from a prospective nationwide surveillance study.

Nosocomial bloodstream infections (nBSIs) are an important cause of morbidity and mortality. Data from a nationwide, concurrent surveillance study, Brazilian SCOPE (Surveillance and Control of Pathogens of Epidemiological Importance), were used to examine the epidemiology and microbiology of nBSIs at 16 Brazilian hospitals. In our study 2,563 patients with nBSIs were included from 12 June 2007 to 31 March 2010. Ninety-five percent of BSIs were monomicrobial. Gram-negative organisms caused 58.5% of these BSIs, Gram-positive organisms caused 35.4%, and fungi caused 6.1%. The most common pathogens (monomicrobial) were Staphylococcus aureus (14.0%), coagulase-negative staphylococci (CoNS) (12.6%), Klebsiella spp. (12.0%), and Acinetobacter spp. (11.4%). The crude mortality was 40.0%. Forty-nine percent of nBSIs occurred in the intensive-care unit (ICU). The most frequent underlying conditions were malignancy, in 622 patients (24.3%). Among the potential factors predisposing patients to BSI, central venous catheters were the most frequent (70.3%). Methicillin resistance was detected in 157 S. aureus isolates (43.7%). Of the Klebsiella sp. isolates, 54.9% were resistant to third-generation cephalosporins. Of the Acinetobacter spp. and Pseudomonas aeruginosa isolates, 55.9% and 36.8%, respectively, were resistant to imipenem. In our multicenter study, we found high crude mortality and a high proportion of nBSIs due to antibiotic-resistant organisms.

Hospital-Acquired SARS-CoV-2 infection among patients admitted to a university hospital.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a public health emergency, as it is a highly contagious disease, health services had to adapt to the high demand for hospitalizations in order to contain hospital outbreaks. We aimed to identify the impact of nosocomial transmission of severe acute respiratory coronavirus virus 2 among inpatients at a university hospital in São Paulo, Brazil. Among 455 inpatients diagnosed with coronavirus disease 2019 in March-May, 2020, nosocomial infection was implicated in 42 (9.2%), of whom 23 (54.7%) died. becoming routine, especially when community transmission occur with high levels of incidence. It was possible to observe with this study that the nosocomial transmission by SARS-CoV-2 was present even with these measures instituted, and some of the damages caused by these infections are intangible.

Baseline factors associated with death in a COVID-19 hospital cohort, Sao Paulo, 2020.

This study aimed to verify socio-demographic and baseline clinical factors associated with death in a hospital cohort of patients with COVID-19. A retrospective cohort study was conducted between February and December 2020 in a university hospital in the city of São Paulo, using Hospital Epidemiology Center data. RT-PCR-positive patients were selected to compose the sample (n = 1,034). At the end of the study, 362 (32%) patients died. In this cohort, age equal to or greater than sixty years (HR = 1.49) and liver disease (HR = 1.81) were independent risk factors for death from COVID-19 associated with higher in-hospital mortality.

Impact of In-Hospital infection with SARS-CoV-2 among Inpatients at a university hospital.

OBJECTIVE: The objective of this study was to evaluate the incidence of nosocomial infection and the impact of cross-transmission of SARS-CoV-2 among inpatients at a tertiary care teaching hospital. METHODS: This was a retrospective cohort study involving inpatients admitted to a tertiary university hospital in the city of São Paulo, Brazil, between March 2020 and February 2021. Cases were identified on the basis of a positive reverse-transcription polymerase chain reaction result for SARS-CoV-2 and the review of electronic medical records. Nosocomial transmission was defined by applying the criteria established by the Brazilian National Health Regulatory Agency. RESULTS: We identified 2146 cases of SARS-CoV-2 infection, 185 (8.6%) of which were considered cases of nosocomial transmission. The mean age was 58.3 years. The incidence density was 1.78 cases per 1,000 patient-days on the general wards, being highest on the cardiac surgery ward, and only 0.16 per 1,000 patient-days on the COVID-19 wards. Of the 185 patients evaluated, 115 (62.2%) were men, 150 (81.1%) cases had at least one comorbidity, and 104 (56.2%) evolved to death. CONCLUSIONS: Despite the preventive measures taken, nosocomial transmission of SARS-CoV-2 occurred throughout our hospital. Such measures should be intensified when the incidence of community transmission peaks.

Acute kidney injury: Incidence, risk factors, and outcomes in severe COVID-19 patients.

BACKGROUND: COVID-19 is a multisystemic disorder that frequently causes acute kidney injury (AKI). However, the precise clinical and biochemical variables associated with AKI progression in patients with severe COVID-19 remain unclear. METHODS: We performed a retrospective study on 278 hospitalized patients who were admitted to the ward and intensive care unit (ICU) with COVID-19 between March 2020 and June 2020, at the University Hospital, São Paulo, Brazil. Patients aged ≥ 18 years with COVID-19 confirmed on RT-PCR were included. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. We evaluated the incidence of AKI, several clinical variables, medicines used, and outcomes in two sub-groups: COVID-19 patients with AKI (Cov-AKI), and COVID-19 patients without AKI (non-AKI). Univariate and multivariate analyses were performed. RESULTS: First, an elevated incidence of AKI (71.2%) was identified, distributed across different stages of the KDIGO criteria. We further observed higher levels of creatinine, C-reactive protein (CRP), leukocytes, neutrophils, monocytes, and neutrophil-to-lymphocyte ratio (NLR) in the Cov-AKI group than in the non-AKI group, at hospital admission. On univariate analysis, Cov-AKI was associated with older age (>62 years), hypertension, CRP, MCV, leucocytes, neutrophils, NLR, combined hydroxychloroquine and azithromycin treatment, use of mechanical ventilation, and vasoactive drugs. Multivariate analysis showed that hypertension and the use of vasoactive drugs were independently associated with a risk of higher AKI in COVID-19 patients. Finally, we preferentially found an altered erythrocyte and leukocyte cellular profile in the Cov-AKI group compared to the non-AKI group, at hospital discharge. CONCLUSIONS: In our study, the development of AKI in patients with severe COVID-19 was related to inflammatory blood markers and therapy with hydroxychloroquine/azithromycin, with vasopressor requirement and hypertension considered potential risk factors. Thus, attention to the protocol, hypertension, and some blood markers may help assist doctors with decision-making for the management of COVID-19 patients with AKI.

An eight-year multicenter study on short-term peripheral intravenous catheter-related bloodstream infection rates in 100 intensive care units of 9 countries in Latin America: Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama, and Venezuela. Findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND: Data on short-term peripheral intravenous catheter-related bloodstream infections per 1,000 peripheral venous catheter days (PIVCR BSIs per 1,000 PVC days) rates from Latin America are not available, so they have not been thoroughly studied. METHODS: International Nosocomial Infection Control Consortium (INICC) members conducted a prospective, surveillance study on PIVCR BSIs from January 2010 to March 2018 in 100 intensive care units (ICUs) among 41 hospitals, in 26 cities of 9 countries in Latin America (Argentina, Brazil, Colombia, Costa Rica, Dominican-Republic, Ecuador, Mexico, Panama, and Venezuela). The Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) definitions were applied, and INICC methodology and INICC Surveillance Online System software were used. RESULTS: In total, 10,120 ICU patients were followed for 40,078 bed days and 38,262 PVC days. In addition, 79 PIVCR BSIs were identified, with a rate of 2.06 per 1,000 PVC days (95% confidence interval [CI], 1.635-2.257). The average length of stay (ALOS) of patients without a PIVCR BSI was 3.95 days, and the ALOS was 5.29 days for patients with a PIVCR BSI. The crude extra ALOS was 1.34 days (RR, 1.33; 95% CI, 1.0975-1.6351; P = .040).The mortality rate in patients without PIVCR BSI was 3.67%, and this rate was 6.33% in patients with a PIVCR BSI. The crude extra mortality was 1.70 times higher. The microorganism profile showed 48.5% gram-positive bacteria (coagulase-negative Staphylococci 25.7%) and 48.5% gram-negative bacteria: Acinetobacter spp, Escherichia coli, and Klebsiella spp (8.5% each one), Pseudomonas aeruginosa (5.7%), and Candida spp (2.8%). The resistances of Pseudomonas aeruginosa were 0% to amikacin and 50% to meropenem. The resistance of Acinetobacter baumanii to amikacin was 0%, and the resistance of coagulase-negative Staphylococcus to oxacillin was 75%. CONCLUSIONS: Our PIVCR BSI rates were higher than rates from more economically developed countries and were similar to those of countries with limited resources.

Factors associated with successful completion of outpatient parenteral antibiotic therapy in an area with a high prevalence of multidrug-resistant bacteria: 30-day hospital admission and mortality rates.

OBJECTIVES: To identify factors associated with hospital admission and mortality within the first 30 days after enrolment in an outpatient parenteral antimicrobial therapy (OPAT) program, also analysing adequacy of the treatment regimen and clinical outcomes. PATIENTS AND METHODS: This was a retrospective cohort study conducted between October 2016 and June 2017 in the state of São Paulo, Brazil. Variables related to hospital admission and mortality were subjected to bivariate analysis, and those with a P<0.05 were subjected to multivariate analysis as risk factors. RESULTS: We evaluated 276 patients, of whom 80.5% were ≥60 years of age and 69.9% had more than one comorbidity. Of the patients evaluated, 41.3% had pneumonia and 35.1% had a urinary tract infection. The most common etiological agent, isolated in 18 (31.6%) cases, was Klebsiella pneumoniae, and 13 (72,2%) strains were carbapenem resistant. The OPAT was in accordance with the culture results in 76.6% of the cases and with the institutional protocols in 76.4%. The majority (64.5%) of the patients were not admitted, and a cure or clinical improvement was achieved in 78.6%. Multivariate analysis showed that, within the first 30 days after enrolment, the absence of a physician office visit was a predictor of hospital admission (P<0.001) and mortality (P = 0.006). CONCLUSIONS: This study demonstrated the viability of OPAT in elderly patients with pulmonary or urinary tract infections in an area with a high prevalence of multidrug-resistant bacteria and that a post-discharge physician office visit is protective against hospital admission and mortality.

Polymyxin for treatment of ventilator-associated pneumonia in a setting of high carbapenem resistance.

OBJECTIVES: To analyse the use of polymyxins for the treatment of ventilator-associated pneumonia (VAP) at a teaching hospital where carbapenem-resistant gram-negative bacteria are endemic. PATIENTS AND METHODS: This was a historical cohort study of patients receiving polymyxins to treat VAP in ICUs at a public university hospital in southern Brazil between January 1, 2017 and January 31, 2018. RESULTS: During the study period, 179 cases of VAP were treated with polymyxins. Of the 179 patients, 158 (88.3%) were classified as having chronic critical illness. Death occurred in 145 cases (81.0%). Multivariate analysis showed that the factors independently associated with mortality were the presence of comorbidities (P<0.001) and the SOFA score of the day of polymyxin prescription (P<0.001). Being a burn patient was a protective factor for mortality (P<0.001). Analysis of the 14-day survival probability showed that mortality was higher among the patients who had sepsis or septic shock at the time of polymyxin prescription (P = 0.028 and P<0.001, respectively). Acinetobacter baumannii was identified as the etiological agent of VAP in 121 cases (67.6%). In our cohort, polymyxin consumption and the incidence density of VAP were quite high. CONCLUSIONS: In our study, comprised primarily of chronically critically ill patients, there was a high prevalence of VAP caused by multidrug-resistant bacteria, consistent with healthcare-associated infections in low- and middle-income countries. Presence of comorbidities and the SOFA score at the time of polymyxin prescription were predictors of mortality in this cohort. Despite aggressive antimicrobial treatment, mortality was high, stressing the need for antibiotic stewardship.