Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil.

AIM: To estimate the nursing service costs using a top-down micro-costing approach and to compare it with a bottom-up micro-costing approach. BACKGROUND: Accurate data of nursing cost can contribute to reliable resource management. METHOD: We employed a retrospective cohort design in an adult intensive care unit in São Paulo. A total of 286 patient records were included. Micro-costing analysis was conducted in two stages: a top-down approach, whereby nursing costs were allocated to patients through apportionment, and a bottom-up approach, considering actual nursing care hours estimated by the Nursing Activities Score (NAS). RESULTS: The total mean cost by the top-down approach was US$1,640.4 ± 1,484.2/patient. The bottom-up approach based on a total mean NAS of 833 ± 776 points (equivalent to 200 ± 86 hr of nursing care) yielded a mean cost of US$1,487.2 ± 1,385.7/patient. In the 268 patients for whom the top-down approach estimated higher costs than the bottom-up approach, the total cost discrepancy was US$4,427.3, while for those costed higher based on NAS, the total discrepancy was US$436.9. The top-down methodology overestimated costs for patients requiring lower intensity of care, while it underestimated costs for patients requiring higher intensity of care (NAS >100). CONCLUSIONS: The top-down approach may yield higher estimated ICU costs compared with a NAS-based bottom-up approach. IMPLICATIONS FOR NURSING MANAGEMENT: These findings can contribute to an evidence-based approach to budgeting through reliable costing methods based on actual nursing workload, and to efficient resource allocation and cost management.

Liver X Receptor Activation Impairs Neutrophil Functions and Aggravates Sepsis.

BACKGROUND: Liver X receptors (LXRs) are nuclear receptors activated by oxidized lipids and were previously implicated in several metabolic development and inflammatory disorders. Although neutrophils express both LXR-α and LXR-ß, the consequences of their activation, particularly during sepsis, remain unknown. METHODS: We used the model of cecal ligation and puncture (CLP) to investigate the role of LXR activation during sepsis. RESULTS: In this study, we verified that LXR activation reduces neutrophil chemotactic and killing abilities in vitro. Mice treated with LXR agonists showed higher sepsis-induced mortality, which could be associated with reduced neutrophil infiltration at the infectious foci, increased bacteremia, systemic inflammatory response, and multiorgan failure. In contrast, septic mice treated with LXR antagonist showed increased number of neutrophils in the peritoneal cavity, reduced bacterial load, and multiorgan dysfunction. More important, neutrophils from septic patients showed increased ABCA1 messenger ribonucleic acid levels (a marker of LXR activation) and impaired chemotactic response toward CXCL8 compared with cells from healthy individuals. CONCLUSIONS: Therefore, our findings suggest that LXR activation impairs neutrophil functions, which might contribute to poor sepsis outcome.

Chlorhexidine-impregnated gel dressing compared with transparent polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients: A pilot randomised controlled trial.

BACKGROUND: In patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections. OBJECTIVES: The objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC. METHODS: One hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip. RESULTS: Of 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes. CONCLUSIONS: Our preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.

Bacteremia by Leuconostoc mesenteroides in an immunocompetent patient with chronic Chagas disease: a case report.

BACKGROUND: The Leuconostoc mesenteroides are members of the Streptococcae family and currently has been recognized as potential pathogens. This case describes a bacteremia caused by L. mesenteroides in an immunocompetent patient affected by Chagas disease. CASE PRESENTATION: A 67-year-old female patient with chagasic megaesophagus and megacolon was submitted to a Heller myotomy for achalasia in 2000 and endoscopic dilatation in 2015. Patient was admitted to the Nutrology Ward in May 2016 with protein-calorie malnutrition associated with achalasia and receiving enteral nutrition. In July 2016, the patient underwent a Serra-Doria surgery. In the third postoperative day she presented an important abdominal distension. She was submitted to a new surgical intervention, and then a terminal ileum perforation was detected, leading the surgeon to perform an enterectomy with side-to-side anastomosis. The next day after the surgery (4th postoperative day) the patient presented a decreased level of consciousness (Glasgow coma scale = 8), hypotension and hypoxemia. In two samples of blood cultures there was growth of Leuconostoc mesenteroides. Susceptibility pattern was evaluated by the diffusion disk method. The microorganism was susceptible to penicillin, ampicillin, chloramphenicol, erythromycin, and fluoroquinolones, but resistant to rifampin, tetracycline, vancomycin and teicoplanin. CONCLUSION: We concluded that infections caused by L. mesenteroides is serious and should be considered not only in settings of immunosuppression and prolonged antimicrobial use, but also in immunocompetent patients undergoing surgeries involving the gastrointestinal tract.

Comparison between ultrasonography and computed tomography for measuring skeletal muscle mass in critically ill patients with different body mass index.

BACKGROUND & AIM: Among critical patients, there is an early onset of changes in both the quantity and quality of muscle mass. It is essential to find tools that promptly identify this muscle mass loss. The aim of this study was to compare the ultrasonography of the quadriceps femoris to the gold standard, thigh computed tomography (CT) for assessing the musculature of critically ill patients with different body mass index who have suffered traumatic brain injury. METHODS: This is a prospective validation study in an Intensive Care Unit (ICU) specialized in trauma care, located at a tertiary teaching hospital. Our study involved a convenience sample of patients. Sequential ultrasound and CT scans were performed at three distinct time intervals: upon admission, between 24 and 96 h' post-admission, and finally, between 96 and 168 h' post-admission. For all ultrasound measurements, we conducted simultaneous quadriceps CT measurements. The correlation between measurements obtained by ultrasound and computed tomography at three different times and in three BMI ranges was analyzed, in individuals with normal weight, overweight and obese. RESULTS: Results: We analyzed 252 images in 49 patients in time 1, 40 patients in time 2, and 37 in time 3 to compare the thickness quadriceps muscle using US and CT. Of these, 18 patients had a BMI ≤ 24.9 kg/m2 (normal weight), 18 patients from 25 to 29.9 kg/m2 (overweight), and 8 patients had a BMI ≥ 30 kg/m2 (obese). The mean age was 37 years, the majority (94%) were male and the main comorbidities were: hypertension 12%, diabetes 4% and 14% smoking. The results revealed minor discrepancies between measurements obtained through the two methods, these changes were not influenced by the body mass index, with these variations being practically insignificant in the context of clinical application. Thus, the correlation and concordance between the values obtained found a strong positive correlation with good limits of agreement. The Spearman's correlation coefficients obtained were r = 0.89, 0.91 and 0.88, p < 0.01 at T1, T2 and T3 respectively for normal weight, r = 0.91, 0.80 and 0.81, p < 0.01 at T1, T2 and T3 respectively for overweight and r = 0.89, 0.94 and 0.84, p < 0.01 at T1, T2 and T3 respectively for obesity. In addition to a positive correlation, we observed a high agreement between the methods. The Bland & Altman analysis at time 1 showed, respectively, the bias of 1.46, 2.03 and 0.76. At time 2, the bias was 0.42, 3.11 and 2.12. At time 3, the bias was 2.26, 3.38 and 2.11 mm. CONCLUSION: Our findings suggest that measure femoral quadriceps muscle thickness ultrasound-based exhibits a comparable performance to thigh CT. This conclusion stems from the excellent correlation and good agreement observed between ultrasound and CT, which is considered the gold standard for muscle assessment in critically ill patients. TRIAL REGISTRATION: This clinical trial is registered at REBEC https://ensaiosclinicos.gov.br/ identifier: RBR-2bzspnz. The protocol was approved, on July 30, 2019, by the Research Ethics Committee of the Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto - Trial Registration Number: 3,475,851.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit.

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

Effect of methylene blue on hemodynamic response in the early phase of septic shock: A case series.

RATIONALE: Methylene blue (MB) has been used to increase blood pressure in septic shock, acting on the activity of guanylate cyclase and nitric oxide synthase. PATIENCE CONCERNS: The aim of this study is to demonstrate the benefit of MB in early phase of septic shock.Diagnoses: We report 6 cases of patients with septic shock with up to 72 hours of evolution. INTERVENTIONS: We used MB after fluid replacement, use of norepinephrine and vasopressin. Patients received a loading dose of MB and maintenance for 48 hours. OUTCOMES: All patients presented a reduction in the dose of vasopressors and lactate levels soon after the administration of the loading dose of MB, an effect that was maintained with the maintenance dose for 48 hours. Interleukin 6 and interleukin 8 were elevated at the beginning of the septic condition, with a progressive and marked reduction after the beginning of MB infusion, demonstrating a role of MB in reducing the inflammatory activity. LESSONS: This case series suggests that MB used early in the treatment of septic shock may be useful in reducing vasopressor dose and lactate levels. Further studies are still required to further validate these findings.

Essential role of CCR2 in neutrophil tissue infiltration and multiple organ dysfunction in sepsis.

RATIONALE: Sepsis is defined as a systemic inflammatory response to infection, which in its severe form is associated with multiple organ dysfunction syndrome (MODS). The precise mechanisms by which MODS develops remain unclear. Neutrophils have a pivotal role in the defense against infections; however, overwhelming activation of neutrophils is known to elicit tissue damage. OBJECTIVES: We investigated the role of the chemokine receptor CCR2 in driving neutrophil infiltration and eliciting tissue damage in remote organs during sepsis. METHODS: Sepsis was induced in wild-type mice treated with CCR2 antagonist (RS504393) or CCR2(-/-) mice by cecal ligation and puncture (CLP) model. Neutrophil infiltration into the organs was measured by myeloperoxidase activity and fluorescence-activated cell sorter. CCR2 expression and chemotaxis were determined in neutrophils stimulated with Toll-like receptor agonists or isolated from septic mice and patients. MEASUREMENTS AND MAIN RESULTS: CCR2 expression and responsiveness to its ligands was induced in circulating neutrophils during CLP-induced sepsis by a mechanism dependent on Toll-like receptor/nuclear factor-κB pathway. Genetic or pharmacologic inhibition of CCR2 protected mice from CLP-induced mortality. This protection was associated with lower infiltration of neutrophils into the lungs, heart, and kidneys and reduced serum biochemical indicators of organ injury and dysfunction. Importantly, neutrophils from septic patients express high levels of CCR2, and the severity of patient illness correlated positively with increasing neutrophil chemotaxis to CCR2 ligands. CONCLUSIONS: Collectively, these data identify CCR2 as a key receptor that drives the inappropriate infiltration of neutrophils into remote organs during sepsis. Therefore, CCR2 blockade is a novel potential therapeutic target for treatment of sepsis-induced MODS.

Effects of physical therapy with neuromuscular electrical stimulation in acute and late septic shock patients: A randomised crossover clinical trial.

BACKGROUND: Patients with sepsis and immobility in the intensive care unit are associated with muscle weakness, and early mobilisation can counteract it. However, during septic shock, mobilisation is often delayed due to the severity of the illness. Neuromuscular electrical stimulation (NMES) may be an alternative to mobilise these patients early. This study aims to identify whether NMES performed within the first 72 hours of septic shock diagnosis or later is safe from a metabolic perspective. METHODS: This is the analysis of two randomised controlled crossover studies. Patients with acute septic shock (within the first 72 hours of diagnosis) and sepsis and septic shock in the late phase (after 72 hours of diagnosis) were eligible. Patients were submitted in a random order to the intervention protocol (dorsal decubitus position with the lower limbs raised and NMES) and control (dorsal decubitus position with the lower limbs raised without NMES). The patients were allocated in group 1 (intervention and control) or group 2 (control and intervention) with a wash-out period of 4 to 6 hours. Metabolic variables were evaluated by indirect calorimetry. RESULTS: Sixteen patients were analysed in the acute septic shock study and 21 in the late sepsis/septic shock study. There were no significant differences between Oxygen Consumption (VO2) values in the acute phase of septic shock when the baseline period, intervention, and control protocols were compared (186.59 ± 46.10; 183.64 ± 41.39; 188.97 ± 44.88, p>0.05- expressed in mL/Kg/min). The same was observed when the VO2 values in the late phase were compared (224.22 ± 53.09; 226.20 ± 49.64; 226.79 ± 58.25, p>0.05). The other metabolic variables followed the same pattern, with no significant differences between the protocols. When metabolic variables were compared between acute to late phase, significant differences were observed (p<0.05). CONCLUSIONS: As metabolic rates in septic shock patients had no increase during NMES, either in the first 72 hours of diagnosis or later, NMES can be considered safe from a metabolic viewpoint, even despite the higher metabolic demand in the acute phase of shock. TRIAL REGISTRATION: NCT03193164; NCT03815994. Registered on June 5, 2017; November 13, 2018 (clinicaltrials.gov/).

Comparison of ultrasound with computed tomography to measure skeletal muscle mass in critically ill patients: A prospective study protocol.

INTRODUCTION: Therapy and nutritional status directly interfere in the clinical evolution of critically ill patients, in reducing morbidity and mortality, by maintaining the functional integrity of the gastrointestinal tract, decreasing the catabolic response, besides contributing to the reduction of hospitalization time resulting in less treatment cost. Critical patients and trauma victims suffer early changes in the quantity and quality of muscle mass. Tools to identify the groups most susceptible to these complications are necessary so that interventions can minimize the deleterious effects of malnutrition in critically ill patients. METHODS AND ANALYSIS: The aim of the present study is to measure muscle mass loss by measuring the thickness of the rectus femoris muscle by bedside ultrasound in critically ill patients admitted to the Intensive Care Unit (ICU) of a university hospital. Information will be collected regarding the length of hospital and ICU stay, the reason for admission, anthropometric data at admission and during hospitalization, energy needs, nutritional therapy used, and fasting time. This is a prospective, observational study that will be carried out in a single center in an ICU of a tertiary university hospital. The study population will undergo 3 tomographic images and 3 ultrasounds of the rectus femoris of each patient at different times. We propose, unprecedentedly, performing a validation study of ultrasound with the gold standard Computed tomography to evaluate the musculature of critically ill patients victims of traumatic brain injury. The results got will texto be fundamental for the development of new fields of investigation and certainly contribute to the discovery of a new approach to treat sarcopenia in critically ill patients. The Research Ethics Committee approved the study and all patients included will sign an informed consent form. (Clinical Record: RBR-2bzspnz).

Assessment of physicians' knowledge about brain death and organ donation and associated factors.

Precocity and assertiveness when diagnosing brain death are essential for identifying potential donors. To assess the knowledge of physicians about brain death and organ donation, cross-sectional web-based survey was carried out with physicians from different specialties. The knowledge about brain death and organ donation was assessed by a questionnaire with 12 multiple-choice or multiple-answer questions (possible range from 0 to 12). The nonparametric Mann-Whitney and Kruskal-Wallis tests were performed to verify the association between the physicians' knowledge and others variables. The project was approved by the Research Ethics Committee of the Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, under number 4.022.657, and all patients agreed to participate and provided free prior-informed consent. Three hundred sixty physicians were included in this study, most of them have postgraduate (55%) and 59.2% were intensive care physicians. The median of responses was 5 (obtained range from 0 to 10). The participants were classified in 2 groups: with satisfactory knowledge (scores above 5) or without satisfactory knowledge (scores equal/below 5). There was better performance among participants who: completed graduation between 6 and 10 years (P < .012); were intensive care physicians (P < .002); had participated in training courses (P < .001); and those who had worked in intensive care unit (ICU) from 6 to 10 years (P < .023); had performed over 10 brain death protocols (P < .001), and felt safe to talk to family members about brain death (P < .001). The results showed that the participants had low knowledge about diagnosis of brain death and organ donation protocols despite the majority working in ICUs. Be an intensive care physician, had large time experience in ICU, and had performed brain death protocols were associated with unsatisfactory knowledge concerning the subject.

Effect of methylene blue on hemodynamic and metabolic response in septic shock patients.

INTRODUCTION: Septic shock is a lethal disease responsible for a large proportion of deaths in the Intensive Care Unit (ICU), even with therapy centered on fluid resuscitation, use of vasopressors and empirical antibiotic therapy applied within the first hour of diagnosis. Considering the multifactorial pathophysiology of septic shock and the mechanism of action of vasopressors, some patients may not respond adequately, which can lead to the maintenance of vasodilatation, hypotension and increased morbidity, and mortality. This protocol aims to verify whether the use of methylene blue in septic patients with an early diagnosis can contribute to an earlier resolution of a shock compared to standard treatment. METHODS AND ANALYSIS: This is a study protocol for a single-center randomized clinical trial design in an ICU of a tertiary university hospital. In this study, we intend to include 64 patients aged between 18 and 80 years with a diagnosis of septic shock, of any etiology, with up to 72 hours of evolution after volume restoration, using norepinephrine at a dose ≥0.2 µg/kg/min and vasopressin at a dose of 0.04 IU/min. After the initial approach, we will randomize patients into two groups, standard care, and standard care plus methylene blue. The sample size was calculated in order to show 30% differences in septic shock resolution between groups. The Research Ethics Committee approved the study, and all patients included will sign an informed consent form (Clinical registration: RBR-96584w4).

Performance of microvesicles as biomarkers of clinical outcome in sepsis and trauma: A pilot study.

Sepsis remains one of the main causes of death in intensive care unit (ICU) worldwide, despite all technological and scientific advances. Microvesicles (MV) have become promising biomarkers for quick and accurate monitoring of several illnesses. The aim of this pilot study was to characterize and evaluate the performance of MV as biomarker of clinical outcome in septic and trauma patients. For this purpose, 39 subjects, both genders, aging from 18 to 85 years were included in three groups referred as Sepsis, Trauma and Healthy Control. Kinetic analysis of MV was carried out at four consecutive time points: admission (baseline)/T1, 24 h/T2, 72 h/T3 and outcome/T4 of discharge or death. At admission, an overall increase in total MV (Annexin V+) was observed in Sepsis.MV CD14+ (monocytes) was a putative biomarker to identify trauma patients, while MV CD3+ (T-cells) and CD41+ (platelets) were qualified to discriminated Trauma from Sepsis. Sepsis (Death) presented an increase in MV Annexin V+, CD45+, CD16+, CD14+, and CD41+ in comparison to Sepsis (Discharge). Moreover, Trauma (Death) presented an increase of MV CD3+ and CD235+ as compared to Trauma (Discharge). Analysing the ROC curve of specific MV evaluated according to performance, an accuracy of 100% was found to segregate the outcome in sepsis, and 95% in trauma. Our findings suggest that MV might be useful as a potential role in discriminating outcome in patients with sepsis/septic shock and trauma with high accuracy. However, further studies with a larger number of participants will be necessary to validate our findings.

Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: A quasi-experimental study.

BACKGROUND: We aimed to evaluate the impact of providing dental care to critically ill patients on their risk of death and ventilator-associated pneumonia (VAP). METHODS: A quasi-experimental study was conducted in 2 intensive care units (ICU) from 2016 to 2019. The intervention consisted of implementing routine dental care, focusing on oral hygiene and periodontal treatment, at least 3 times a week, for patients admitted to the study units. In the pre-intervention period, routine oral hygiene was provided by the ICU nursing staff. The primary and secondary study outcomes were mortality, evaluated at the end of the ICU stay, and VAP incidence density, respectively. Data were analyzed using the ARIMA (autoregressive integrated moving average) time series model in R software. RESULTS: During the intervention period, 5,147 dental procedures were performed among 355 patients. The time series showed that ICU mortality was 36.11%, 32.71%, and 32.30% within the 3 years before the intervention, and 28.71% during the intervention period (P = .015). VAP incidence density did not significantly change during the study period (P = .716). CONCLUSION: A dental care intervention focused on oral hygiene and periodontal treatment regularly provided by dentists to critically ill patients may decrease their risk of dying in the ICU. Randomized clinical trials should be performed to confirm these findings. TRIAL REGISTRATION: WHO-affiliated Brazilian Clinical Trials Registry. RBR-4jmz36. Registered 7 October 2018, before first patient enrollment.

Dissemination of blaKPC-2 by the spread of Klebsiella pneumoniae clonal complex 258 clones (ST258, ST11, ST437) and plasmids (IncFII, IncN, IncL/M) among Enterobacteriaceae species in Brazil.

This article reports the spread of bla(KPC-2) in the Sao Paulo and Rio de Janeiro states, facilitated by globally spread K. pneumoniae clonal complex 258 (CC258) clones (ST258, ST11, and ST437) and a diversity of plasmids (IncFII, IncN, and IncL/M, two untypeable plasmids carrying Tn4401a or Tn4401b) successfully disseminated among species of the Enterobacteriaceae (Enterobacter cloacae, Serratia marcescens, and Citrobacter freundii). It also constitutes the first description of sequence type 258 (ST258) in Brazil, which was associated with a nosocomial hospital outbreak in Ribeirao Preto city.

Impact of replacing powdered gloves with powder-free gloves on hand-hygiene compliance among healthcare workers of an intensive care unit: a quasi-experimental study.

BACKGROUND/OBJECTIVE: After wearing powdered gloves, healthcare workers (HCW) are supposed to wash their hands instead of using alcohol-based hand-rub (ABHR). Washing hands takes longer than using ABHR, and the use of powdered gloves may be an obstacle to hand-hygiene compliance. This study aimed to evaluate the impact of replacing powdered gloves with powder-free gloves on hand-hygiene compliance among HCW of an intensive care unit (ICU). METHODS: A quasi-experimental study was conducted in a general ICU of a tertiary care university hospital in Brazil. From June 1st to July 15th, 2017, all HCW were provided with powdered latex gloves only for all clinical procedures. From July 15th to August 31st, 2017, HCW were provided with nitrile powder-free gloves only. Hand-hygiene compliance was assessed through direct observation, and evaluated according to the World Health Organization Hand Hygiene guidelines. We calculated that a sample size of 544 hand hygiene opportunities needed to be observed per period. Data analysis were performed using the STATA SE® version 14, and we compared the individual's percentage of compliance using the t test for paired data before and after the intervention. RESULTS: Overall, 40 HCW were assessed before and after the introduction of nitrile powder-free gloves, with 1114 and 1139 observations of hand hygiene opportunities, respectively. The proportion of compliance with hand hygiene was 55% (95% confidence interval [CI] 51-59%) using powdered latex gloves and 60% (95% CI 57-63%) using powder-free gloves. The difference in proportions between the two types of gloves was 5.1% (95% CI 2.5-7.6%, p < 0.001). CONCLUSION: Our data indicate that replacing powdered gloves with powder-free gloves positively influenced hand-hygiene compliance by HCW in an ICU setting.

Clinical investigation of intestinal fatty acid-binding protein (I-FABP) as a biomarker of SARS-CoV-2 infection.

OBJECTIVES: SARS-CoV-2 exhibits tropism for the gastrointestinal tract; however, lesions in enterocytes and their correlation with disease severity and patient prognosis are still unknown. METHODS: SARS-CoV-2 patients were enrolled in 5 medical centres in São Paulo, Brazil and their clinical characteristics and laboratory findings recorded. At admission, day 7 and day 14 of hospitalisation, plasma and urine samples were collected, and cytokine levels and intestinal fatty acid-binding protein (I-FABP) concentrations measured. RESULTS: COVID-19 patients displayed ≈48-, 74- and 125-fold increased urinary I-FABP levels at admission (n=283; P<0.001), day 7 (n=142; P<0.01) and day 14 (n=75; P<0.01) of hospitalisation. Critically ill patients and nonsurvivors showed higher I-FABP concentrations compared with patients with less severe illness. At admission, infected patients demonstrated enhanced production of plasma interferon (IFN)-γ and interleukin (IL)-6. The receiver operating characteristic curve suggested I-FABP as a biomarker for COVID-19 disease severity at admission (P<0.0001; Youden index=6.89; area under the curve=0.699). Patients with I-FABP ≥6.89 showed higher IL-6 and C-reactive protein levels (P<0.001) at admission and had a prolonged length of hospital stay. CONCLUSIONS: Our findings revealed damage to enterocytes in SARS-CoV-2 infection, which is associated with illness severity, poor prognosis and exacerbated inflammatory response.

Case Report: Fatal Viscerotropic Disease in a Young Woman Following Yellow Fever Vaccination.

Yellow fever is a viral hemorrhagic disease, and vaccination is the most effective way to minimize the impact of the disease. Serious adverse events after yellow fever vaccination are rare. We report the case of a young woman with an unusual presentation of yellow fever 17DD vaccine-associated acute viscerotropic disease, with severe hepatic impairment following a long incubation period. She died more than a month after yellow fever vaccination.