Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results.

BACKGROUND: Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. METHODS: We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. RESULTS: We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. CONCLUSIONS: Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Treatment of chronic hepatitis C virus infection among Brazilian haemophiliacs.

Chronic hepatitis C virus (HCV) infection is now the most important cause of liver cirrhosis and hepatocellular carcinoma worldwide. HCV infection prevalence is high among haemophiliacs (39%-98%), who got infected when received inadequately or non-virus-inactivated large-pool clotting factors concentrates before 1992. Current treatment reduces the probability of developing advanced stages of liver disease. The objective of this study was to evaluate efficacy and safety of the treatment with interferon alpha (IFN) and ribavirin in haemophiliacs. From July 2000 to November 2002, 18 patients were treated with IFN, three million units thrice weekly combined with daily oral doses of 1,000 or 1,250 mg of ribavirin for a minimum of 48 weeks. Eleven patients (61%) showed end of treatment virological response, while nine [(50%): 95% CI: 27-73%] showed sustained virological response as defined by undetectable HCV-RNA six months after treatment. All those nine had persistently undetectable HCV-RNA two to four years post-treatment. There was no treatment interruption due to adverse events. Therefore, the rate of sustained virological response was 50%, with good tolerance.

Treatment of chronic hepatitis C virus infection among Brazilian haemophiliacs

Chronic hepatitis C virus (HCV) infection is now the most important cause of liver cirrhosis and hepatocellular carcinoma worldwide. HCV infection prevalence is high among haemophiliacs (39 percent-98 percent), who got infected when received inadequately or non-virus-inactivated large-pool clotting factors concentrates before 1992. Current treatment reduces the probability of developing advanced stages of liver disease. The objective of this study was to evaluate efficacy and safety of the treatment with interferon alpha (IFN) and ribavirin in haemophiliacs. From July 2000 to November 2002, 18 patients were treated with IFN, three million units thrice weekly combined with daily oral doses of 1,000 or 1,250 mg of ribavirin for a minimum of 48 weeks. Eleven patients (61 percent) showed end of treatment virological response, while nine [(50 percent): 95 percent CI: 27-73 percent] showed sustained virological response as defined by undetectable HCV-RNA six months after treatment. All those nine had persistently undetectable HCV-RNA two to four years post-treatment. There was no treatment interruption due to adverse events. Therefore, the rate of sustained virological response was 50 percent, with good tolerance.

Outcome predictors of 84 patients with hematologic malignancies and Fusarium infection.

BACKGROUND: Invasive infection by Fusarium sp. is associated with high mortality in patients with hematologic cancer. Yet to the authors' knowledge, little is known regarding predictors of adverse outcome. METHODS: The authors conducted a retrospective review of the records of patients with hematologic carcinoma and invasive fusariosis who were treated at one institution in the U.S. and at 11 centers in Brazil. RESULTS: The records of 84 patients were evaluated. Neutropenia was present in 83% and 33 patients had undergone stem cell transplantation. Only 18 patients (21%) were alive 90 days after the diagnosis of fusariosis. Multivariate predictors of poor outcome were persistent neutropenia (hazard ratio [HR] of 5.43; 95% confidence interval [95% CI], 2.64-11.11) and use of corticosteroids (HR of 2.18; 95% CI, 1.98-3.96). The actuarial survival rate of patients without any of these factors was 67% compared with 30% for patients who recovered from neutropenia but were receiving corticosteroids and 4% for patients with persistent neutropenia only. None of the patients with both risk factors survived (P<0.0001). CONCLUSIONS: Measures to reduce the duration of neutropenia, as well as the judicious use of corticosteroids, may reduce the high mortality rate of fusariosis in patients with hematologic cancer.

Epidemiologia e prevençäo da infecçäo no hospedeiro granulocitopênico / Epidemiology and prevention of infection diseases in lemopenic patients

A susceptibilidade à infecçäo aumenta dramaticamente quando a contagem periférica de neutrófilos cai abaixo de 500cels/mm3, e particularmente quando abaixo de 100cls/mm3. A rapidez da queda dos granulócitos e a duraçäo da aplasia estäo mais associados com os quadros infecciosos. Culturas de vigilância têm mostrado um valor limitado em predizer uma infecçäo invasiva em pacientes neutropênicos ou com câncer. O isolamento protetor simples em pacientes com granulocitopenia parece näo beneficiar a profilaxia das doenças infecciosas. O uso de descontaminaçäo digestiva seletiva, reduziu infecçöes do trato respiratório e septcemias bacterianas em crianças. O objetivo deste procedimento é eliminar microorganismos patogênicos potenciais, como Enterobacteriaceae, P. aeruginosa e Staphilococci. Os estudos mais recentes têm discutido o uso de Fator estimulador de colonias (CSF) associado a interferon-gama para prevençäo de infecçöes nesses pacientes