Pan-American Guidelines for the treatment of SARS-CoV-2/COVID-19: a joint evidence-based guideline of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API).

BACKGROUND: Since the beginning of the COVID-19 pandemic, therapeutic options for treating COVID-19 have been investigated at different stages of clinical manifestations. Considering the particular impact of COVID-19 in the Americas, this document aims to present recommendations for the pharmacological treatment of COVID-19 specific to this population. METHODS: Fifteen experts, members of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API) make up the panel responsible for developing this guideline. Questions were formulated regarding prophylaxis and treatment of COVID-19 in outpatient and inpatient settings. The outcomes considered in decision-making were mortality, hospitalisation, need for mechanical ventilation, symptomatic COVID-19 episodes, and adverse events. In addition, a systematic review of randomised controlled trials was conducted. The quality of evidence assessment and guideline development process followed the GRADE system. RESULTS: Nine technologies were evaluated, and ten recommendations were made, including the use of tixagevimab + cilgavimab in the prophylaxis of COVID-19, tixagevimab + cilgavimab, molnupiravir, nirmatrelvir + ritonavir, and remdesivir in the treatment of outpatients, and remdesivir, baricitinib, and tocilizumab in the treatment of hospitalised patients with severe COVID-19. The use of hydroxychloroquine or chloroquine and ivermectin was discouraged. CONCLUSION: This guideline provides recommendations for treating patients in the Americas following the principles of evidence-based medicine. The recommendations present a set of drugs that have proven effective in the prophylaxis and treatment of COVID-19, emphasising the strong recommendation for the use of nirmatrelvir/ritonavir in outpatients as the lack of benefit from the use of hydroxychloroquine and ivermectin.

MOBILITY RESTRICTIONS FOR THE CONTROL OF COVID-19 EPIDEMIC

Objective: To determine whether the SEIR model, associated to mobility changes parameters, can determine the likelihood of establishing control over an epidemic in a city, state or country. Study design and setting: The critical step in the prediction of COVID-19 by a SEIR model are the values of the basic reproduction number (R0) and the infectious period, in days. R0 and the infectious periods were calculated by mathematical constrained optimization, and used to determine the numerically minimum SEIR model errors in a country, based on COVID-19 data until April 11th. The Community Mobility Reports from Google Maps (<https://www.google.com/covid19/mobility>) provided mobility changes on April 5th compared to the baseline (Jan 3th to Feb 6th). The data was used to measure the non-pharmacological intervention adherence. The impact of each mobility component was calculated by logistic regression models. COVID-19 control was defined by SEIR model R0<1.0 in a country. Results: The ECDC has registered 1,653,204 COVID-19 worldwide on April 11th. Sixteen countries presented 78% of all cases. Of the six Google Maps mobility parameters, the "Stay at home" parameter was the strongest one to control COVID-19 in a country: an increase of 50% in mobility trends for places of residence has a 99% chance of outbreak control. Conclusions: Residential mobility restriction presented itself as the most effective measure. The SEIR model associated with mobility parameters proved to be a useful tool in determining the chance of COVID-19 outbreak control.

Avaliação das práticas de higienização das mãos em três unidades de terapia intensiva / Evaluation of hand hygiene practices in three intensive care units / Evaluación de lãs prácticas de higienización de las manos em la unidades de terapia intensiva

Justificativa e Objetivos: Higienização das Mãos (HM) é uma medida simples e eficaz no combate às Infecções Relacionadas à Assistência à Saúde (IRAS). Apesar do esforço feito pelos profissionais do Serviço de Controle de Infecção Hospitalar (SCIH), o cumprimento das práticas ainda permanece baixo, geralmente inferior a 50%. Por esse motivo, este estudo objetivou avaliar as práticas de HM em três Unidades de Terapia Intensiva de um hospital privado de Belo Horizonte, MG, Brasil. Método: Estudo transversal, descritivo de natureza quantitativa, realizado em três UTIs de um hospital privado de Belo Horizonte, MG, Brasil. No período de julho/2016 a julho/2017 foram avaliados todos os documentos de HM do hospital de estudo, totalizando 1.100 observações in loco realizadas pelos enfermeiros do SCIH. Para análise dos dados adotou-se estatística descritiva e regressão linear utilizando o coeficiente de correlação de Pearson. Resultados: A taxa de adesão à HM variou entre 27,3 e 88,2%, com média de 47% (±16,8). O consumo de preparação alcoólica e sabonete líquido obtiveram, respectivamente, uma média de 32 e 47 ml/paciente-dia. Houve correlação positiva entre o consumo de preparação alcoólica e a taxa de adesão (r2=0,49, p=0,01). Conclusão: Os profissionais de saúde ainda necessitam de sensibilização acerca da importância da higiene de mãos para redução das IRAS.(AU)

Background and Objectives: Hand Hygiene (HH) is a simple and effective measure in the fight against Healthcare-associated Infections (HAIs). Despite the effort made by professionals of the Infection Control Service, compliance with practices remains low, generally below 50%. For this reason, this study aimed to evaluate HH practices in three Intensive Care Units of a private hospital in Belo Horizonte, MG, Brazil. Methods: Cross-sectional, descriptive study performed in three ICUs of a private hospital in Belo Horizonte, MG, Brazil. From July 2016 to July 2017, all HH documents of the study hospital were evaluated, totaling 1,100 observations in loco performed by the nurses of the Infection Control Service. Data analysis was performed using descriptive statistics and linear regression using the Pearson correlation coefficient. Results: The rate of adhesion ranged from 27.3 to 88.2%, with an average of 47% (±16.8). Consumption of alcohol preparation and liquid soap obtained, respectively, an average of 32 and 47 ml/patient-day. Pearson's coefficient showed a positive correlation between alcohol consumption and adhesion rate (r=0.49, p=0.01). Conclusion: Healthcare workers still need to be aware of the importance of HH for reducing HAIs.(AU)

Justificación y objetivos: La Higienización de las Manos (HM) es una medida simple y eficaz en el combate a las Infecciones Relacionadas a la Asistencia Sanitaria (IRAS). A pesar del esfuerzo realizado por los profesionales del Servicio de Control de Infección Hospitalaria, el cumplimiento de las prácticas sigue siendo bajo, generalmente inferior al 50%. Por este motivo, este estudio objetivó evaluar las prácticas de HM en tres Unidades de Terapia Intensiva de un hospital privado de Belo Horizonte, MG, Brasil. Método: Estudio transversal, descriptivo de naturaleza cuantitativa, realizado en tres UTIs de un hospital privado de Belo Horizonte, MG, Brasil. En el período de julio/2016 a julio/2017 se evaluaron todos los documentos de HM del hospital de estudio, totalizando 1.100 observaciones in loco realizadas por los enfermeros del Servicio de Control de Infección. Para el análisis de los datos se adoptó estadística descriptiva y regresión lineal utilizando el coeficiente de correlación de Pearson. Resultados: La tasa de adhesión las prácticas de HM varió entre el 27,3 y el 88,2%, con una media del 47% (±16,8). El consumo de preparación alcohólica y jabón líquido obtuvieron, respectivamente, una media de 32 y 47 ml / paciente-día. Se observó una correlación positiva entre el consumo de alcohol y la tasa de adhesión (r2=0,49, p=0,01). Conclusiones: Los profesionales de la salud todavía necesitan sensibilización acerca de la importancia de la HM para reducir las IRAS.(AU)

Estimativa da incidência de pneumonia associada à ventilação mecânica (PAV) / Estimated incidence of ventilator-associated pneumonia (VAP)

A PAV é definida como aquela que ocorre 48 horas depois que um paciente é intubado e recebe ventilação mecânica (VM) e representa uma infecção grave e frequente nas Unidades de Terapia Intensiva (UTIs) em todo o mundo. Objetivo: estimar a incidência de PAV entre as populações de risco e descrever os fatores relacionados à PAV em pacientes sob VM por ≥48 horas e ≤7 dias. Método: este foi um estudo epidemiológico, prospectivo e observacional numa população de pacientes adultos que recebem VM em três UTIs brasileiras. Resultados: de um total de 100 pacientes triados, 92 foram incluídos neste estudo que ocorreu entre 13 de maio de 2011 a 8 de novembro de 2011. Os pacientes foram seguidos por um período médio de 14,6 dias. A média de idade foi 69,5 anos, com mediana de 74,5 anos. Quarenta e quatro pacientes (47,8%) eram do sexo masculino. O diagnóstico de PAV foi feito em 30 pacientes (32,6%). Os seguintes fatores foram encontrados entre pacientes com PAV: antibioticoterapia nos últimos 90 dias antes do recrutamento, hospitalização atual ≥5 dias antes do recrutamento, altas taxas de resistência antimicrobiana na comunidade ou no hospital, hospitalização prévia ≥2 dias nos últimos três meses antes do recrutamento e procedimento dialítico crônico nos últimos 30 dias antes do recrutamento. Conclusão: apesar das medidas de prevenção, foi observada uma incidência de 5,2 casos/1.000 pacientes-dia. Os fatores relacionados à PAV neste estudo estão em conformidade com a literatura internaciona

VAP is a pneumonia that occurs 48 hours after patient intubation and receiving mechanical ventilation (MV), and it represents a severe and common infection in intensive care units (ICUs) around the world. Objective: to estimate the incidence of VAP among the population at risk and to describe the factors associated with VAP in patients on MV for ≥48 hours and ≤7 days. Method: this was an epidemiological, prospective and observational study in adults receiving MV in 3 ICUs in Brazil. Results: out of a total of 100 patients screened, 92 were included in this study that occurred between 13 May and 8 November 2011. Patients were monitored for a mean period of 14.6 days. The mean age was 69.5, with a median of 74.5. Forty-four patients (47.8 %) were male. VAP was diagnosed in 30 patients (32.6 %). The following factors were found among the patients with VAP: antibiotic therapy in the last 90 days prior to recruitment, current hospitalization ≥5 days before recruitment, high rates of antimicrobial resistance in the community or in the hospital, previous hospitalization ≥2 days in the last 3 months before the recruitment and chronic dialysis procedure in the 30 days before recruitment. Conclusion: despite preventive measures, an incidence of 5.2 cases/1000 patient-days was observed. Factors associated with VAP in this study are in accordance with the international literature

Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction.

UNLABELLED: The applicability of the risk index for surgical site infection of the National Nosocomial Infection Surveillance (NNIS) has been evaluated for its performance in different surgeries. In some procedures, it is necessary to include other variables to predict. OBJECTIVE: to evaluate the applicability of the NNIS index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8236 patients who had been submitted to orthopaedic surgery. Statistical analysis was performed using multivariate logistic regression to fit the model. The incidence of infection was 1.41%. Prediction models were evaluated and compared to the NNIS index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the NNIS models in the prediction of infection.

Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction / Infecção de sítio cirúrgico em pacientes submetidos a cirurgias ortopédicas: o índice de risco NNIS e predição de risco / Infección de sitio quirúrgico en pacientes sometidos a cirugías ortopédicas: el índice de riesgo NNIS y la predicción de riesgo

The applicability of the risk index for surgical site infection of the National Nosocomial Infection Surveillance (NNIS) has been evaluated for its performance in different surgeries. In some procedures, it is necessary to include other variables to predict. Objective: to evaluate the applicability of the NNIS index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8236 patients who had been submitted to orthopaedic surgery. Statistical analysis was performed using multivariate logistic regression to fit the model. The incidence of infection was 1.41 percent. Prediction models were evaluated and compared to the NNIS index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the NNIS models in the prediction of infection.

A aplicabilidade do Índice de Risco de Infecção Cirúrgica do National Nosocomial Infection Surveillance-NNIS tem sido avaliada quanto ao seu desempenho em diferentes cirurgias. Em alguns procedimentos, é necessária a inclusão de outras variáveis de predição. O objetivo deste estudo foi avaliar a aplicabilidade do Índice NNIS para a predição da Infecção de Sítio Cirúrgico em cirurgias ortopédicas e propor um índice alternativo. Realizou-se estudo de coorte histórica em 8.236 pacientes submetidos a cirurgias ortopédicas. Utilizou-se modelo logístico multivariado para ajuste do modelo. A incidência de infecção foi de 1,41 por cento. Modelos de predição foram avaliados e comparados ao Índice NNIS. O modelo proposto foi aquele que apresentou maior acúracia em classificar pacientes com e sem infecção. O Índice NNIS não foi considerado bom preditor de infecção, apesar de ter estratificado moderadamente os pacientes cirúrgicos ortopédicos em pelo menos três dos quatro escores. O modelo alternativo foi superior ao modelo NNIS na predição de infecção.

La aplicabilidad del Índice de Riesgo de Infección Quirúrgica del National Nosocomial Infection Surveillance-NNIS ha sido evaluada en cuanto a su desempeño en diferentes cirugías. En algunos procedimientos es necesaria la inclusión de otras variables de predicción. El objetivo de este estudio fue evaluar la aplicabilidad del Índice NNIS para la predicción de la Infección de Sitio Quirúrgico en cirugías ortopédicas y proponer un índice alternativo. Se realizó un estudio de cohorte histórica en 8.236 pacientes sometidos a cirugías ortopédicas. Se utilizó el modelo logístico multivariado para ajustar el modelo. La incidencia de infección fue 1,41 por ciento. Modelos de predicción fueron evaluados y comparados al Índice NNIS. El modelo propuesto fue aquel que presentó mayor precisión en clasificar pacientes con y sin infección. El Índice NNIS no fue considerado un buen factor de predicción de la infección, a pesar de haber estratificado moderadamente a los pacientes quirúrgicos ortopédicos en por el menos tres de los cuatro puntajes. El modelo alternativo fue superior al modelo NNIS en la predicción de infección.

Nosocomial infections in brazilian pediatric patients: using a decision tree to identify high mortality groups

Nosocomial infections (NI) are frequent events with potentially lethal outcomes. We identified predictive factors for mortality related to NI and developed an algorithm for predicting that risk in order to improve hospital epidemiology and healthcare quality programs. We made a prospective cohort NI surveillance of all acute-care patients according to the National Nosocomial Infections Surveillance System guidelines since 1992, applying the Centers for Disease Control and Prevention 1988 definitions adapted to a Brazilian pediatric hospital. Thirty-eight deaths considered to be related to NI were analyzed as the outcome variable for 754 patients with NI, whose survival time was taken into consideration. The predictive factors for mortality related to NI (p < 0.05 in the Cox regression model) were: invasive procedures and use of two or more antibiotics. The mean survival time was significantly shorter (p < 0.05 with the Kaplan-Meier method) for patients who suffered invasive procedures and for those who received two or more antibiotics. Applying a tree-structured survival analysis (TSSA), two groups with high mortality rates were identified: one group with time from admission to the first NI less than 11 days, received two or more antibiotics and suffered invasive procedures; the other group had the first NI between 12 and 22 days after admission and was subjected to invasive procedures. The possible modifiable factors to prevent mortality involve invasive devices and antibiotics. The TSSA approach is helpful to identify combinations of predictors and to guide protective actions to be taken in continuous-quality-improvement programs.

Nosocomial infections in Brazilian pediatric patients: using a decision tree to identify high mortality groups.

Nosocomial infections (NI) are frequent events with potentially lethal outcomes. We identified predictive factors for mortality related to NI and developed an algorithm for predicting that risk in order to improve hospital epidemiology and healthcare quality programs. We made a prospective cohort NI surveillance of all acute-care patients according to the National Nosocomial Infections Surveillance System guidelines since 1992, applying the Centers for Disease Control and Prevention 1988 definitions adapted to a Brazilian pediatric hospital. Thirty-eight deaths considered to be related to NI were analyzed as the outcome variable for 754 patients with NI, whose survival time was taken into consideration. The predictive factors for mortality related to NI (p < 0.05 in the Cox regression model) were: invasive procedures and use of two or more antibiotics. The mean survival time was significantly shorter (p < 0.05 with the Kaplan-Meier method) for patients who suffered invasive procedures and for those who received two or more antibiotics. Applying a tree-structured survival analysis (TSSA), two groups with high mortality rates were identified: one group with time from admission to the first NI less than 11 days, received two or more antibiotics and suffered invasive procedures; the other group had the first NI between 12 and 22 days after admission and was subjected to invasive procedures. The possible modifiable factors to prevent mortality involve invasive devices and antibiotics. The TSSA approach is helpful to identify combinations of predictors and to guide protective actions to be taken in continuous-quality-improvement programs.

Aspergilose do sistema nervoso central após transplante hepático. Relato de caso / Cerebral aspergillosis in a liver transplanted patient. Case report

Introdução: O acometimento do sistema nervoso central pelo Aspergillus é muito grave e com alto índice de mortalidade. Relato de caso: Descrevemos o caso de uma paciente transplantada hepática em uso de imunossupressores que evoluiu com piora clínica. Tomografia computadorizada e ressonância magnética revelaram múltiplas lesões cerebrais. Em decorrência de má condição clínica da paciente, optou-se pelo tratamento conservador e em três dias ela evoluiu para óbito. Estudo anatomopatológico constatou quadro compatível com aspergilose. Discussão: Em pacientes imunossuprimidos, a suspeita precoce da infecção central fúngica é essencial para tentar evitar uma evolução catastrófica como no caso relatado.

Pediatric mortality due to nosocomial infection: a critical approach.

Nosocomial infection is a frequent event with potentially lethal consequences. We reviewed the literature on the predictive factors for mortality related to nosocomial infection in pediatric medicine. Electronic searches in English, Spanish and Portuguese of the PubMed/MEDLINE, LILACS and Cochrane Collaboration Databases was performed, focusing on studies that had been published from 1996 to 2006. The key words were: nosocomial infection and mortality and pediatrics/neonate/ newborn/child/infant/adolescent. The risk factors found to be associated with mortality were: nosocomial infection itself, leukemia, lymphopenia, neutropenia, corticosteroid therapy, multiple organ failure, previous antimicrobial therapy, catheter use duration, candidemia, cancer, bacteremia, age over 60, invasive procedures, mechanical ventilation, transport out of the pediatric intensive care unit, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Burkholderia cepacia infections, acute physiology and chronic health evaluation (APACHE) II scores over 15. Among these factors, the only one that can be minimized is inadequate antimicrobial treatment, which has proven to be an important contributor to hospital mortality in critically-ill patients. There is room for further prognosis research on this matter to determine local differences. Such research requires appropriate epidemiological design and statistical analysis so that pediatric death due to nosocomial infection can be reduced and health care quality improved in pediatric hospitals.

Pediatric mortality due to nosocomial infection: a critical approach

Nosocomial infection is a frequent event with potentially lethal consequences. We reviewed the literature on the predictive factors for mortality related to nosocomial infection in pediatric medicine. Electronic searches in English, Spanish and Portuguese of the PubMed/MEDLINE, LILACS and Cochrane Collaboration Databases was performed, focusing on studies that had been published from 1996 to 2006. The key words were: nosocomial infection and mortality and pediatrics/neonate/ newborn/child/infant/adolescent. The risk factors found to be associated with mortality were: nosocomial infection itself, leukemia, lymphopenia, neutropenia, corticosteroid therapy, multiple organ failure, previous antimicrobial therapy, catheter use duration, candidemia, cancer, bacteremia, age over 60, invasive procedures, mechanical ventilation, transport out of the pediatric intensive care unit, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Burkholderia cepacia infections, acute physiology and chronic health evaluation (APACHE) II scores over 15. Among these factors, the only one that can be minimized is inadequate antimicrobial treatment, which has proven to be an important contributor to hospital mortality in critically-ill patients. There is room for further prognosis research on this matter to determine local differences. Such research requires appropriate epidemiological design and statistical analysis so that pediatric death due to nosocomial infection can be reduced and health care quality improved in pediatric hospitals.

Applicability of the national nosocomial infections surveillance system risk index for the prediction of surgical site infections: a review.

This review outlines the evolution of risk rates of surgical site infection adopted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance (NNIS) system, and evaluates their advantages and limitations. The types of surgical procedures for which the NNIS index has proven to be an efficient system for the classification of patients are presented. The necessity of adapting the NNIS index to take into account specific characteristics associated with hospitals and practices in various regions and countries is stressed. The requirement for further testing and development of the rate concerning specific procedures, particularly those involving orthopaedic surgery, is discussed.

Applicability of the national nosocomial infections surveillance system risk index for the prediction of surgical site infections: a review

This review outlines the evolution of risk rates of surgical site infection adopted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance (NNIS) system, and evaluates their advantages and limitations. The types of surgical procedures for which the NNIS index has proven to be an efficient system for the classification of patients are presented. The necessity of adapting the NNIS index to take into account specific characteristics associated with hospitals and practices in various regions and countries is stressed. The requirement for further testing and development of the rate concerning specific procedures, particularly those involving orthopaedic surgery, is discussed.

Are there regional variations in the diagnosis, surveillance, and control of methicillin-resistant Staphylococcus aureus?

OBJECTIVE: To assess the way healthcare facilities (HCFs) diagnose, survey, and control methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Questionnaire. SETTING: Ninety HCFs in 30 countries. RESULTS: Evaluation of susceptibility testing methods showed that 8 laboratories (9%) used oxacillin disks with antimicrobial content different from the one recommended, 12 (13%) did not determine MRSA susceptibility to vancomycin, and 4 (4.5%) reported instances of isolation of vancomycin-resistant S. aureus but neither confirmed this resistance nor alerted public health authorities. A MRSA control program was reported by 55 (61.1%) of the HCFs. The following isolation precautions were routinely used: hospitalization in a private room (34.4%), wearing of gloves (62.2%), wearing of gowns (44.4%), hand washing by healthcare workers (53.3%), use of an isolation sign on the patient's door (43%), or all four. When the characteristics of HCFs with low incidence rates (< 0.4 per 1,000 patient-days) were compared with those of HCFs with high incidence rates (> or = 0.4 per 1,000 patient-days), having a higher mean number of beds per infection control nurse was the only factor significantly associated with HCFs with high incidence rates (834 vs 318 beds; P = .02). CONCLUSION: Our results emphasize the urgent need to strengthen the microbiologic and epidemiologic capacities of HCFs worldwide to prevent MRSA transmission and to prepare them to address the possible emergence of vancomycin-resistant S. aureus.

Predictive factors of in-hospital mortality and of severe perioperative complications in myocardial revascularization surgery.

OBJECTIVE: To investigate preoperative predictive factors of severe perioperative intercurrent events and in-hospital mortality in coronary artery bypass graft (CABG) surgery and to develop specific models of risk prediction for these events, mainly those that can undergo changes in the preoperative period. METHODS: We prospectively studied 453 patients who had undergone CABG. Factors independently associated with the events of interest were determined with multiple logistic regression and Cox proportional hazards regression model. RESULTS: The mortality rate was 11.3% (51/453), and 21.2% of the patients had 1 or more perioperative intercurrent events. In the final model, the following variables remained associated with the risk of intercurrent events: age > or = 70 years, female sex, hospitalization via SUS (Sistema nico de Sa de - the Brazilian public health system), cardiogenic shock, ischemia, and dependence on dialysis. Using multiple logistic regression for in-hospital mortality, the following variables participated in the model of risk prediction: age > or = 70 years, female sex, hospitalization via SUS, diabetes, renal dysfunction, and cardiogenic shock. According to the Cox regression model for death within the 7 days following surgery, the following variables remained associated with mortality: age > or = 70 years, female sex, cardiogenic shock, and hospitalization via SUS. CONCLUSION: The aspects linked to the structure of the Brazilian health system, such as factors of great impact on the results obtained, indicate that the events investigated also depend on factors that do not relate to the patient's intrinsic condition.

Fatores preditores da mortalidade hospitalar e de complicaçöes per-operatórias graves em cirurgia de revascularizaçäo do miocárdio / Predictive factors of in-hospital mortality and of severe perioperative complications in myocardial revascularization surgery

OBJECTIVE: To investigate preoperative predictive factors of severe perioperative intercurrent events and in-hospital mortality in coronary artery bypass graft (CABG) surgery and to develop specific models of risk prediction for these events, mainly those that can undergo changes in the preoperative period. METHODS: We prospectively studied 453 patients who had undergone CABG. Factors independently associated with the events of interest were determined with multiple logistic regression and Cox proportional hazards regression model. RESULTS: The mortality rate was 11.3 percent (51/453), and 21.2 percent of the patients had 1 or more perioperative intercurrent events. In the final model, the following variables remained associated with the risk of intercurrent events: age 70 years, female sex, hospitalization via SUS (Sistema Unico de Saúde - the Brazilian public health system), cardiogenic shock, ischemia, and dependence on dialysis. Using multiple logistic regression for in-hospital mortality, the following variables participated in the model of risk prediction: age 70 years, female sex, hospitalization via SUS, diabetes, renal dysfunction, and cardiogenic shock. According to the Cox regression model for death within the 7 days following surgery, the following variables remained associated with mortality: age 70 years, female sex, cardiogenic shock, and hospitalization via SUS. CONCLUSION: The aspects linked to the structure of the Brazilian health system, such as factors of great impact on the results obtained, indicate that the events investigated also depend on factors that do not relate to the patient's intrinsic condition

Improving water quality can reduce pyrogenic reactions associated with reuse of cardiac catheters.

OBJECTIVE: To report the results of our preintervention investigation and subsequent 19-month three-phase intervention study designed to reduce pyrogenic reactions among patients undergoing cardiac catheterization using reprocessed catheters. DESIGN: A case-control study for the preintervention period and a prospective cohort study for the intervention period. SETTING: A 400-bed hospital in Belo Horizonte, Brazil. PARTICIPANTS: Any patient undergoing cardiac catheterization in the hospital. INTERVENTIONS: Three intervention phases were implemented to improve the quality of the water supplied to the cardiac catheter reprocessing laboratory. Standard operating procedures for reprocessing cardiac catheters were established and reprocessing staff were trained and educated. RESULTS: The rate of pyrogenic reactions decreased significantly during the intervention phases, from 12.8% (159 of 1,239) in phase 1 to 5.3% (38 of 712) in phase 2 to 0.5% (4 of 769) in phase 3 (chi-square test for linear trend, 97.5; P < .001). CONCLUSION: Improving water quality and using standard operating procedures for reprocessing catheters can prevent pyrogenic reactions in hospitalized patients.

Esforço conjunto para melhoria de qualidade em hospital público pediátrico brasileiro através do controle de infecçäo hospitalar / Joint effort to improve quality in a Brazilian pediatric public hospital through cross-infection control

Objetivo: Verificar o papel do laboratório de microbiologia no controle de infecçöes hospitalares ao longo do período de janeiro de 1993 a dezembro de 1996 no Centro Geral de Pediatria da Fundaçäo Hospitalar do Estado de Minas Gerais. Métodos: Seguimento de 101.139 pacientes-dia (11.147 saídas = altas - óbitos + transferências) das unidade de internaçäo e de tratamento intensivo através da metodologia do National Nosoco-Control (CDC) de Atlanta - EUA, através de seus componentes global (desde 1992) e de Unidade de Tratamento Intensivo (desde 1996), exercida através de busca-ativa e prospectiva de infecçöes hospitalares em todos os sítios, segundo critérios diagnósticos e definiçöes do CDC e Portaria 930 do Ministério da Saúde Brasileiro, de 1992. Resultados: Os cindo agentes etiológicos mais freqüentes (de um total de 139 isolados de infecçöes hospitalares) foram Klebsiella sp=24,5 por cento; S. aureus = 18 por cento; P. aeruginosa = 13,7 por cento; E. coli = 12,9 por cento; S. epidermidis = 12,2 por cento. A porcentagem de identificaçäo de patógenos isolados de sítios topográficos de infecçöes hospitalares aumentou de 6,2 por cento em 1993 para 13,3 por cento em 95 e 28,2 por cento em 96 (p < 0,001). A porcentagem de identificaçäo do germe aumentou de 7,5 por cento em 93 para 16,1 por cento em 95 e 33,8 por cento em 96 (p <0,001). O intervalo de tempo da coleta do material até o resultado microbiológico declinou de média de dez dias em 1993 para seis dias em 96 (p = 0,001). Conclusöes: A educaçäo continuada e a melhoria de comunicaçäo entre a comissäo de controle de infecçöes hospitalares, pediatras, cirurgiöes e membros do laboratório têm exercido um papel importante na determinaçäo do perfil etiológico das infecçöes hospitalares no Centro Geral de Pediatria. A necessidade de um esforço conjunto para se determinar a etiologia microbiológica dessas infecçöes está sendo cada vez mais incorporadas por todos. A metodologia NNIS para controle de infecçöes hospitalares aplicada a hospitais brasileiros traduz seu impacto também no laboratório de microbiologia

Prevalência de microorganismos isolados em mediastinites pós-cirurgia cardíaca / Prevalence of microorganisms isolated in mediastinitis pos-cardiac surgery

As infecçöes pós-cirurgia cardíaca se constituem em uma das complicaçöes que elevam as taxas de morbidade e mortalidade após estes procedimentos. As mediastinites, por sua vez, säo uma das mais graves intercorrências, determinando aumento significativo dos custos de internaçäo, além de promover, muitas vezes, limitaçäo na capacidade produtiva dos sobreviventes. O rigoroso controle de infecçöes pode determinar a prevençäo e/ou o diagnóstico precoce da afecçäo; a rapidez da instituiçäo da terapêutica indicada, pode minorar o sofrimento do paciente e os gastos com internaçäo hospitalar. No período de janeiro de 1989 a agosto de 1992, 1588 pacientes foram submetidos à cirurgia cardíaca em nossa instituiçäo, sendo 687 coronarianos, 609 valvulopatas, 292 congênitos. Ocorreram 33 casos de mediastinites, o que representa 2,1% do total. O microorganismo mais frequentemente isolado nas culturas foi o Staphylococcus aureus em 17 pacientes.