Erratum: Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study - CORRIGENDUM.

[This corrects the article DOI: 10.1017/ash.2023.136.].

Sepsis-induced mitochondrial dysfunction: A narrative review.

Sepsis represents a deranged and exaggerated systemic inflammatory response to infection and is associated with vascular and metabolic abnormalities that trigger systemic organic dysfunction. Mitochondrial function has been shown to be severely impaired during the early phase of critical illness, with a reduction in biogenesis, increased generation of reactive oxygen species and a decrease in adenosine triphosphate synthesis of up to 50%. Mitochondrial dysfunction can be assessed using mitochondrial DNA concentration and respirometry assays, particularly in peripheral mononuclear cells. Isolation of monocytes and lymphocytes seems to be the most promising strategy for measuring mitochondrial activity in clinical settings because of the ease of collection, sample processing, and clinical relevance of the association between metabolic alterations and deficient immune responses in mononuclear cells. Studies have reported alterations in these variables in patients with sepsis compared with healthy controls and non-septic patients. However, few studies have explored the association between mitochondrial dysfunction in immune mononuclear cells and unfavorable clinical outcomes. An improvement in mitochondrial parameters in sepsis could theoretically serve as a biomarker of clinical recovery and response to oxygen and vasopressor therapies as well as reveal unexplored pathophysiological mechanistic targets. These features highlight the need for further studies on mitochondrial metabolism in immune cells as a feasible tool to evaluate patients in intensive care settings. The evaluation of mitochondrial metabolism is a promising tool for the evaluation and management of critically ill patients, especially those with sepsis. In this article, we explore the pathophysiological aspects, main methods of measurement, and the main studies in this field.

A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital.

Objectives: We carried out this work with the aim of assessing the effectiveness of a set of interventions over time for the administration of antibiotics. Design: Prospective observational study. Setting: Patients admitted to the emergency room and ICU of the hospital where the study was conducted are evaluated daily for some sociodemographic and clinical variables. Among them are some quality indicators, such as the time between the diagnosis of sepsis or septic shock until the start of the infusion of antibiotics. This indicator reflects several aspects related to a set of assistance measures (adequacy of antibiotic dispensation, rapid response team (RRT), sepsis care quality improvement program, antimicrobial management program, improvements in emergency department assistance). Patients or participants: Patients with sepsis or septic shock were admitted to the ICU of a university and public hospital in southern Brazil. Main variables of interest: The time between the diagnosis of sepsis or septic shock and the beginning of the infusion of antibiotics. Results: Between 2013 and 2018, 1676 patients were evaluated. The mean time for antibiotic infusion decreased from 6.1 ± 8.6 hours to 1.7 ± 2.9 hours (p < 0.001). The percentage of patients who received antibiotics in the first hour increased from 20.7 to 59.0% (p < 0.001). Conclusion: In this study, we demonstrated that a set of actions adopted in a large tertiary hospital was associated with decreased time to start antibiotic therapy in septic patients. How to cite this article: Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, et al. A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023;27(7):465-469.

Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study.

Objective: Data are scarce regarding hospital infection control committees and compliance with infection prevention and control (IPC) recommendations in Brazil, a country of continental dimensions. We assessed the main characteristics of infection control committees (ICCs) on healthcare-associated infections (HAIs) in Brazilian hospitals. Methods: This cross-sectional study was conducted in ICCs of public and private hospitals distributed across all Brazilian regions. Data were collected directly from the ICC staff by completing an online questionnaire and during on-site visits through face-to-face interviews. Results: In total, 53 Brazilian hospitals were evaluated from October 2019 to December 2020. All hospitals had implemented the IPC core components in their programs. All centers had protocols for the prevention and control of ventilator-associated pneumonia as well as bloodstream, surgical site, and catheter-associated urinary tract infections. Most hospitals (80%) had no budget specifically allocated to the IPC program; 34% of the laundry staff had received specific IPC training; and only 7.5% of hospitals reported occupational infections in healthcare workers. Conclusions: In this sample, most ICCs complied with the minimum requirements for IPC programs. The main limitation regarding ICCs was the lack of financial support. The findings of this survey support the development of strategic plans to improve IPCs in Brazilian hospitals.

Prolonged SARS-CoV-2 Infection and Intra-Patient Viral Evolution in an Immunodeficient Child.

BACKGROUND: With the progression of the Coronavirus disease pandemic, the number of mutations in the viral genome has increased, showing the adaptive evolution of severe acute respiratory syndrome coronavirus 2 in humans and intensification in transmissibility. Long-term infections also allow the development of viral diversity. In this study, we report the case of a child with severe combined immu presenting a prolonged severe acute respiratory syndrome coronavirus 2 infection. We aimed to analyze 3 naso-oropharyngeal swab samples collected between August and December 2021 to describe the amino acid changes present in the sequence reads that may have a role in the emergence of new viral variants. METHODS: The whole genome from clinical samples was sequenced through high throughput sequencing and analyzed using a workflow to map reads and then find variations/single-nucleotide polymorphisms. In addition, the samples were isolated in cell culture, and a plaque forming units assay was performed, which indicates the presence of viable viral particles. RESULTS: The results obtained showed that the virus present in all samples is infectious. Also, there were 20 common mutations among the 3 sequence reads, found in the ORF1ab and ORF10 proteins. As well, a considerable number of uncommon mutations were found. CONCLUSIONS: In conclusion, we emphasize that genomic surveillance can be a useful tool to assess possible evolution signals in long-term patients.

IMPACTO-MR: um estudo brasileiro de plataforma nacional para avaliar infecções e multirresistência em unidades de terapia intensiva / IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

RESUMO Objetivo: Descrever o IMPACTO-MR, um estudo brasileiro de plataforma nacional em unidades de terapia intensiva focado no impacto das infecções por bactérias multirresistentes relacionadas à assistência à saúde. Métodos: Descrevemos a plataforma IMPACTO-MR, seu desenvolvimento, critérios para seleção das unidades de terapia intensiva, caracterização da coleta de dados, objetivos e projetos de pesquisa futuros a serem realizados na plataforma. Resultados: Os dados principais foram coletados por meio do Epimed Monitor System® e consistiram em dados demográficos, dados de comorbidades, estado funcional, escores clínicos, diagnóstico de internação e diagnósticos secundários, dados laboratoriais, clínicos e microbiológicos e suporte de órgãos durante a internação na unidade de terapia intensiva, entre outros. De outubro de 2019 a dezembro de 2020, 33.983 pacientes de 51 unidades de terapia intensiva foram incluídos no banco de dados principal. Conclusão: A plataforma IMPACTO-MR é um banco de dados clínico brasileiro de unidades de terapia intensiva focado na pesquisa do impacto das infecções por bactérias multirresistentes relacionadas à assistência à saúde. Essa plataforma fornece dados para o desenvolvimento e pesquisa de unidades de terapia intensiva individuais e ensaios clínicos observacionais e prospectivos multicêntricos.

ABSTRACT Objective: To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. Methods: We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. Results: The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. Conclusion: The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

Antimicrobial stewardship: The influence of behavioral nudging on renal-function-based appropriateness of dosing.

Failure to adjust doses may contribute to adverse events. We evaluated the effectiveness of providing the estimated glomerular filtration rate on appropriateness of dosing for antimicrobials. The approach increased appropriateness of dosing from 33.9% to 41.4% (P < .001). Nudging prescription behavior can boost strategies for adequate antimicrobial prescription.

High Prevalence of Multidrug Resistant Bacteria in Cirrhotic Patients with Spontaneous Bacterial Peritonitis: Is It Time to Change the Standard Antimicrobial Approach?

Introduction: Spontaneous bacterial peritonitis (SBP) has a deleterious clinical impact in end-stage liver disease, and multidrug resistance has increased, raising concern about effectiveness of traditional antibiotic regimens. Patients and Methods: Single-center retrospective study of ascitic fluid infections in cirrhotic patients. Results: We analyzed medical records related to 2129 culture-positive ascitic fluid and found 183 samples from cirrhotic patients. There were 113 monobacterial SBP cases from 97 cirrhotic patients; 57% of patients were male; hepatitis C and alcohol were the main etiologies for cirrhosis. Multidrug resistant bacteria were isolated in 46.9% of SBP samples, and third-generation cephalosporin and quinolone resistant reached 38.9% and 25.7% of SBP cases. Conclusion: SBP due to multidrug resistant bacteria is a growing problem, and one should consider reported resistance profiles for the decision-making process of empirical first-line treatment prescription.

Antimicrobial stewardship through telemedicine and its impact on multi-drug resistance.

INTRODUCTION: Telemedicine technologies are increasingly being incorporated into infectious disease practice. We aimed to demonstrate the impact of antimicrobial stewardship through telemedicine on bacterial resistance rates. METHODS: We conducted a quasi-experimental study in a 220-bed hospital in southern Brazil. An antimicrobial stewardship program incorporating the use of telemedicine was implemented. Resistance and antimicrobial consumption rates were determined and analysed using a segmented regression model. RESULTS: After the intervention, the rate of appropriate antimicrobial prescription increased from 51.4% at baseline to 81.4%. Significant reductions in the consumption of fluoroquinolones (level change, ß = -0.80; P < 0.01; trend change, ß = -0.01; P = 0.98), first-generation cephalosporins (level change, ß = -0.91; P < 0.01; trend change, ß = +0.01; P = 0.96), vancomycin (level change, ß = -0.47; P = 0.04; trend change, ß = +0.17; P = 0.66) and polymyxins (level change, ß = -0.15; P = 0.56; trend change, ß = -1.75; P < 0.01) were identified. There was an increase in the consumption of amoxicillin + clavulanate (level change, ß = +0.84; P < 0.01; trend change, ß = +0.14; P = 0.41) and cefuroxime (level change, ß = +0.21; P = 0.17; trend change, ß = +0.66; P = 0.02). A significant decrease in the rate of carbapenem-resistant Acinetobacter spp. isolation (level change, ß = +0.66; P = 0.01; trend change, ß = -1.26; P < 0.01) was observed. CONCLUSIONS: Telemedicine, which provides a tool for decision support and immediate access to experienced specialists, can promote better antibiotic selection and reductions in bacterial resistance.

Acinetobacter etiology respiratory tract infections associated with mechanical ventilation: what impacts on the prognosis? A retrospective cohort study.

INTRODUCTION: Acinetobacter species treatment often represents a challenge. The main objective of this study is identify predictors of ICU mortality in patients submitted to mechanical ventilation (MV). MATERIALS AND METHODS: Retrospective cohort study. Patients with MV > 48 h who developed a respiratory tract positive culture for Acinetobacter were included, and distinguished among colonized, ventilator-associated pneumonia (VAP) or ventilator-associated tracheobronchitis (VAT) patients. Primary outcome was ICU mortality. RESULTS: 153 patients were in MV and presented positive culture for Acinetobacter calcoaceticus-baumanii complex, 70 of them with VAP, 59 with VAT and 24 patients were colonized. The factors related to ICU mortality were VAP (OR 2.2, 95% CI 1.1-4.5) and shock at the time of diagnosis (OR 4.8, 95% CI 1.8-2.3). In multivariate analysis, only SOFA score at the time of diagnosis (OR 1.06, 95% CI 1.03-1.09) was related with ICU mortality. A paired-matched analysis was performed to assess effect of dual therapy on outcomes, and no effect was found in terms of clinical cure, ICU or hospital mortality or duration of antimicrobial therapy. CONCLUSIONS: Previous comorbidities and degree of associated organic injury seem to be more important factors in the prognosis than double antibiotic therapy in patients with Acinetobacter-related respiratory infection.

High-Flow Nasal Cannula in Critically Ill Subjects With or at Risk for Respiratory Failure: A Systematic Review and Meta-Analysis.

High-flow nasal cannula (HFNC) oxygen delivery has been gaining attention as an alternative means of respiratory support for critically ill patients, with recent studies suggesting equivalent outcomes when compared with other forms of oxygen therapy delivery. The main objective of this review was to extract current data about the efficacy of HFNC in critically ill subjects with or at risk for respiratory failure. We performed a systematic review of publications (from database inception to October 2015) that evaluated HFNC in critically ill subjects with or at risk for acute respiratory failure and performed a meta-analysis comparing HFNC with noninvasive ventilation (NIV) and with standard oxygen therapy regarding major outcomes: incidence of invasive mechanical ventilation and ICU mortality. A total of 9 studies were included. HFNC was not associated with a reduction in the incidence of invasive mechanical ventilation compared with NIV (odds ratio [OR] 0.83, 95% CI 0.57-1.20, P = .31) or standard oxygen therapy (OR 0.49, 95% CI 0.22-1.08, P = .17). Additionally, HFNC use did not reduce ICU mortality compared with NIV (OR 0.72, 95% CI 0.23-2.21, P = .56) or with standard oxygen therapy (OR 0.69, 95% CI 0.33-1.42, P = .29). There was a trend toward better oxygenation compared with conventional oxygen therapy but a worse gas exchange compared with NIV. At this moment, HFNC therapy seems not to be superior to conventional oxygen therapy or NIV in terms of invasive mechanical ventilation rate or ICU mortality in critical illness, but new studies are needed to determine whether HFNC is associated with any difference in major outcomes when compared with other techniques.

Applicability of the surgical site infection risk index to patients undergoing cardiac, neurologic and orthopedic surgery

Introduction: The surgical site infection risk index (SSIRI) includes three risk factors for surgical site infection (SSI): potential for surgical contamination, duration of surgery, and patient's ASA score. A patient having a preoperative American Society of Anesthesiologists (ASA) score of III, IV or IV; a surgery classified as either contaminated or dirty-infected; an operation with duration of surgery more than T hours, where T depends on the surgical procedure being performed are considered in risk of SSI. The SSIRI can be used as a method of postoperative surveillance. The aim of this study is to analyze the applicability of the SSIRI to patients undergoing cardiac, neurologic and orthopedic surgery. Methods: A retrospective cohort study including patients undergoing cardiac, neurological and orthopedic surgeries considered major, from January to December 2014, evaluated through review of medical charts of patients admitted to a university hospital in southern Brazil. Values of p <0.05 were considered significant. Results: A total of 761 patients were included in the study; of these, 122 (16%) developed SSI. The SSIRI did not demonstrate statistical significance to distinguish the patients most likely to develop SSI between the four levels of the ASA score. Black and brown patients, patients who underwent intraoperative blood transfusion, and patients who underwent surgical reintervention were more susceptible to SSI. Conclusions: The SSIRI could not be used as a method of postoperative surveillance for patients in the present study. The other risk factors found may serve as a guide to articulate SSI prevention strategies and, thus, minimize chances of development of serious infections (AU)

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation.

BACKGROUND: Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital. METHODS: In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period. RESULTS: During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year. CONCLUSION: One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staff's workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Avaliação da limpeza terminal em uma unidade para pacientes portadores de microrganismos multirresistentes / Evaluation of terminal cleaning in an unit for patients with multidrugresistant organisms

INTRODUÇÃO: As infecções relacionadas à assistência à saúde são as complicações mais comuns a acometerem pacientes hospitalizados. O controle da disseminação de microrganismos de importância epidemiológica é um componente importante para a segurança do paciente.MÉTODOS: O estudo teve como objetivo avaliar a qualidade da limpeza terminalrealizada em leitos de uma unidade fechada para portadores de microrganismos multirresistentes. As limpezas foram avaliadas por meio de duas metodologias:inspeção visual por check list e detecção da presença de adenosina trifosfato(ATP). Foram avaliadas três superfícies próximas ao paciente: colchão, mesa de alimentação e mesa de cabeceira.RESULTADOS: Sessenta e seis leitos submetidos a limpeza terminal foram avaliados. Quinze leitos (23%) foram reprovados pela inspeção visual e 42 (66%)foram reprovados pela metodologia de detecção de ATP. As duas metodologias adotadas apresentaram baixa concordância nos resultados (kappa=0,235). As mesas de cabeceira e de alimentação apresentaram valores significantemente maiores de ATP quando comparadas aos colchões.CONCLUSÃO: As taxas de reprovação encontradas utilizando as duas metodologiasindicam que a prática hoje adotada na instituição pode ser aprimorada.

BACKGROUND: Health care acquired infections are the most common complicationsinvolving hospitalized patients. Controlling the spread of microorganisms of epidemiological importance is an essential component for patient safety.METHODS: This study aimed to evaluate the quality of terminal cleaning performed in a closed unit for patients with multidrug resistant organisms. Cleaning was evaluated using two methods: visual inspection (checklist) and adenosine triphosphate (ATP)bioluminescence assay. We evaluated three surfaces near the patient: mattress,feed table and bedside table.RESULTS: Sixty-six assessments were evaluated. Fifteen rooms (23%) were disapproved by visual inspection and 42 (66%) were disapproved by ATP detectionmethodology. The two methods used showed poor agreement of results (kappa =0.235). The bedside tables and feed tables showed significantly higher values ofATP when compared to mattresses.CONCLUSION: The cleaning failure rates found using the two different methodsindicate that the practice adopted in the institution can be improved.

Antimicrobial stewardship through telemedicine in a community hospital in Southern Brazil.

We developed an antimicrobial stewardship programme, based on telemedicine, for a remote community hospital in southern Brazil. Expertise in infectious diseases was provided from a 250-bed tertiary hospital for cardiology patients located 575 km away. At the community hospital, antimicrobial prescriptions were completed via a secure web site. A written reply was sent back to the prescriber by email and SMS text message. During a 4-month study period there were 81 prescriptions for 76 patients. Most antimicrobial prescriptions (67%) were for respiratory infections. Ampicillin was prescribed in 44% of cases (n = 56), gentamicin in 18% of cases (n = 23) and azithromycin in 18% of cases (n = 23). Two infectious diseases specialists independently reviewed each antimicrobial prescription. A total of 41 prescriptions (55%) were considered inappropriate. The median time to obtain a second opinion via the web site was 22 min (interquartile range 12-55). Overall compliance with the recommendations of the infectious diseases specialist was 100% (81 out of 81 requests). Telemedicine appears to have a useful potential role in antimicrobial stewardship programmes.