The effect of a rapid molecular blood test on the use of antibiotics for nosocomial sepsis: a randomized clinical trial.

BACKGROUND: Appropriate use of antimicrobials is essential to improve outcomes in sepsis. The aim of this study was to determine whether the use of a rapid molecular blood test-SeptiFast (SF) reduces the antibiotic consumption through early de-escalation in patients with nosocomial sepsis compared with conventional blood cultures (BCs). METHODS: This was a prospective, randomized, superiority, controlled trial conducted at Sao Paulo Heart Institute in the period October 2012-May 2016. Adult patients admitted to the hospital for at least 48 h with a diagnosis of nosocomial sepsis underwent microorganism identification by both SF test and BCs. Patients randomized into the intervention group received antibiotic therapy adjustment according to the results of SF. Patients randomized into the control group received standard antibiotic adjustment according to the results of BCs. The primary endpoint was antimicrobial consumption during the first 14 days after randomization. RESULTS: A total of 200 patients were included (100 in each group). The intention to treat analysis found no significant differences in median antibiotic consumption. In the subgroup of patients with positive SF and blood cultures (19 and 25 respectively), we found a statistically significant reduction in the median antimicrobial consumption which was 1429 (1071-2000) days of therapy (DOT)/1000 patients-day in the intervention group and 1889 (1357-2563) DOT/1000 patients-day in the control group (p = 0.017), in the median time of antimicrobial de-escalation (8 versus 54 h-p < 0.001), in the duration of antimicrobial therapy (p = 0.039) and in anti-gram-positive antimicrobial costs (p = 0.002). Microorganism identification was possible in 24.5% of patients (45/184) by SF and 21.2% (39/184) by BC (p = 0.45). CONCLUSION: This randomized clinical trial showed that the use of a rapid molecular-based pathogen identification test does not reduce the median antibiotic consumption in nosocomial sepsis. However, in patients with positive microbiological tests, the use of SeptiFast reduced antimicrobial consumption through early de-escalation compared to conventional blood cultures. These results were driven by a reduction in the consumption of antimicrobials used for Gram-positive bacteria. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT01450358) on 12th October 2011.

Mycobacterium chelonae valve endocarditis resulting from contaminated biological prostheses.

OBJECTIVES: A rapid-growing mycobacteria biological prosthetic valve (BPV) endocarditis related to prosthetic manufacturing process is described in Brazil. METHODS: From 1999 to 2008, thirty-nine patients underwent BPV replacement due to culture-negative suspected endocarditis. All these cases had histological sections stained by Ziehl-Neelsen method. Clinical and microbiological data were reviewed in all acid-fast bacilli (AFB) positive cases. The 16S-23S internal transcribed sequence (ITS) was amplified using DNA extracted from paraffin-embedded samples, digested with restrictions enzymes and/or sequenced. RESULTS: Eighteen AFB positive BPV (18/39)(46%) were implanted in 13 patients and were from the same manufacturer. Four of them were implanted in other hospitals. Thirteen BPV were histologically proven endocarditis and five showed a colonization pattern. The examination of six non-implanted "sterile" BPV from this manufacturer resulted in 5 AFB positive. Mycobacterium chelonae was the AFB identified by ITS restriction analysis and sequencing. CONCLUSIONS: Rapid-growing mycobacteria infections must be suspected and Ziehl-Neelsen stain always performed on histology of either early or late BPV endocarditis, particularly when blood cultures are negative.

Guidelines on management of human infection with the novel virus influenza A (H1N1)--a report from the Hospital das Clínicas of the University of São Paulo.

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas "bundles" for the control of the pandemic novel influenza A (H1N1).

Epidemiology of human infection with the novel virus influenza A (H1N1) in the Hospital das Clínicas, São Paulo, Brazil--June-September 2009.

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3% of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC) is a reference center for H1N1 cases in São Paulo. During the winter of 2009, 472 patients in this hospital were diagnosed with H1N1 infection; of these, 210 were admitted, and 16 died. To control this pandemic and to provide adequate care for these patients, the Hospital das Clínicas implemented "bundles" including prevention strategies, an epidemiologic surveillance service, availability of fast diagnosis, antiviral treatment and training of staff. The purpose of this manuscript is to describe the epidemiologic features of novel human influenza A (H1N1) infection in the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the winter period of the 2009 pandemic.

Epidemiological aspects of pleural tuberculosis in the state of São Paulo, Brazil (1998-2005).

OBJECTIVE: To analyze the epidemiological characteristics of and trends regarding the incidence of pleural TB. METHODS: This was a retrospective descriptive study of TB cases reported between 1998 and 2005 and compiled from the Epidemiological Surveillance Tuberculosis System (Epi-TB database). RESULTS: A total of 144,347 new cases of TB were reported during the period studied. Pulmonary TB was the predominant form (118,575 cases; 82.2%). Among the extrapulmonary forms (25,773 cases; 17.8%), pleural TB was the form most often reported (12,545 cases; 48.7%). For all forms, the incidence (per 100,000 population) decreased (from 49.7 in 1998 to 44.6 in 2005; R(2) = 0.898; p < 0.001), whereas the incidence of pleural TB remained stable (4.1 in 1998 and 3.8 in 2005; R(2) = 0.433; p = 0.076). The highest incidence of pleural TB was found among males (2:1) aged from 30 to 59 years. Of the 12,545 patients with pleural TB, 4,018 (32.0%) presented comorbidities: alcoholism (9.5%); HIV (8.0%); diabetes (3.3%); and mental illness (1.2%). The diagnosis was based on bacteriological (14.2%) and histological (30.2%) methods, as well as on unspecified methods (55.6%). CONCLUSIONS: Pleural TB was the predominant extrapulmonary form of TB in the state of São Paulo, with a stable incidence between 1998 and 2005, although there was a trend toward a decrease in the incidence of the pulmonary forms. The diagnosis of pleural TB was confirmed through histology and bacteriology in 44.4% of the cases.

Aspectos epidemiológicos da tuberculose pleural no estado de São Paulo (1998-2005) / Epidemiological aspects of pleural tuberculosis in the state of São Paulo, Brazil (1998-2005)

OBJETIVO: Analisar as características epidemiológicas e tendências quanto à incidência de TB pleural. MÉTODOS: Estudo descritivo, retrospectivo dos casos de TB reportados entre 1998 e 2005 e coletados do banco de dados do Sistema de Notificação de Tuberculose (Epi-TB) da Secretaria de Saúde do Estado de São Paulo. RESULTADOS: Foram notificados 144.347 casos novos de TB durante o período estudado. A forma pulmonar foi predominante (118.575 casos; 82,2 por cento). Das formas extrapulmonares (25.773 casos; 17,8 por cento), a pleural foi a mais referida (12.545 casos; 48,7 por cento). A incidência (por 100.000 habitantes) de todas as formas diminuiu, (49,7 em 1998 e 44,6 em 2005; R² = 0,898; p < 0,001), enquanto a incidência de TB pleural permaneceu estável (4,1 em 1998 e 3,8 em 2005; R² = 0,433; p = 0,076). A maior incidência de TB pleural ocorreu em pacientes do sexo masculino (2:1) entre 30 e 59 anos de idade. Dos 12.545 pacientes com TB pleural, 4.018 (32,0 por cento) apresentaram comorbidades: alcoolismo (9,5 por cento); HIV (8,0 por cento); diabetes (3,3 por cento); e doença mental (1,2 por cento). O diagnóstico referido fundamentou-se em métodos bacteriológicos (14,2 por cento) e histológicos (30,2 por cento), assim como outros não especificados (55,6 por cento). CONCLUSÕES: No estado de São Paulo, a TB pleural foi a forma extrapulmonar predominante, apresentando incidência estável no período entre 1998 e 2005, apesar da tendência de diminuição das formas pulmonares. A histologia e a bacteriologia definiram o diagnóstico em 44,4 por cento dos casos.

OBJECTIVE: To analyze the epidemiological characteristics of and trends regarding the incidence of pleural TB. METHODS: This was a retrospective descriptive study of TB cases reported between 1998 and 2005 and compiled from the Epidemiological Surveillance Tuberculosis System (Epi-TB database). RESULTS: A total of 144,347 new cases of TB were reported during the period studied. Pulmonary TB was the predominant form (118,575 cases; 82.2 percent). Among the extrapulmonary forms (25,773 cases; 17.8 percent), pleural TB was the form most often reported (12,545 cases; 48.7 percent). For all forms, the incidence (per 100,000 population) decreased (from 49.7 in 1998 to 44.6 in 2005; R² = 0.898; p < 0.001), whereas the incidence of pleural TB remained stable (4.1 in 1998 and 3.8 in 2005; R² = 0.433; p = 0.076). The highest incidence of pleural TB was found among males (2:1) aged from 30 to 59 years. Of the 12,545 patients with pleural TB, 4,018 (32.0 percent) presented comorbidities: alcoholism (9.5 percent); HIV (8.0 percent); diabetes (3.3 percent); and mental illness (1.2 percent). The diagnosis was based on bacteriological (14.2 percent) and histological (30.2 percent) methods, as well as on unspecified methods (55.6 percent). CONCLUSIONS: Pleural TB was the predominant extrapulmonary form of TB in the state of São Paulo, with a stable incidence between 1998 and 2005, although there was a trend toward a decrease in the incidence of the pulmonary forms. The diagnosis of pleural TB was confirmed through histology and bacteriology in 44.4 percent of the cases.

Guidelines on management of human infection with the novel virus influenza A (H1N1): a report from the Hospital das Clínicas of the University of São Paulo

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas "bundles" for the control of the pandemic novel influenza A (H1N1).

Epidemiology of human infection with the novel virus influenza A (H1H1) in the Hospital das Clínicas, São Paulo, Brazil - june-september 2009

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3 percent of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC) is a reference center for H1N1 cases in São Paulo. During the winter of 2009, 472 patients in this hospital were diagnosed with H1N1 infection; of these, 210 were admitted, and 16 died. To control this pandemic and to provide adequate care for these patients, the Hospital das Clínicas implemented "bundles" including prevention strategies, an epidemiologic surveillance service, availability of fast diagnosis, antiviral treatment and training of staff. The purpose of this manuscript is to describe the epidemiologic features of novel human influenza A (H1N1) infection in the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the winter period of the 2009 pandemic.

Uso prático de um índice de risco de complicações após cirurgia cardíaca / Practical use of a risk assessment model for complications after cardiac surgery

FUNDAMENTO: Identificar os fatores de risco para complicações pós-operatórias do paciente cardiopata com indicação cirúrgica que podem influenciar na decisão sobre a conduta terapêutica. OBJETIVO: Descrever a experiência de um hospital de Cardiologia na validação e uso prático de um escore de risco pré-operatório. MÉTODOS: Para validação do escore escolhido (Tuman), avaliaram-se consecutiva e prospectivamente 300 pacientes adultos antes da cirurgia cardíaca eletiva com o uso de circulação extracorpórea (CEC). Pacientes com escore de 0 a 5 foram considerados de baixo risco; de 6 a 9 como risco moderado; e maior que 10, como alto risco para complicações cardíacas, infecciosas, neurológicas, pulmonares e renais, além de óbito. RESULTADOS: A classificação de Tuman mostrou relação estatisticamente significante com ocorrência de complicações infecciosas (p=0,010), com outras complicações pós-operatórias (p=0,034) e com evolução para óbito (p<0,001). Infecção pulmonar foi a mais freqüente dentre as complicações infecciosas (15,3 por cento), Os pacientes infectados tiveram maior tempo de permanência na UTI (p=0,001) e internação mais prolongada (p=0,001). Após o uso rotineiro, uma nova avaliação de 154 pacientes operados em 2005 confirmou a validade desse escore na identificação daqueles com maior risco de infecções pós-operatórias. CONCLUSÃO: Escolheu-se o escore de Tuman por envolver variáveis de fácil obtenção, por classificar no mesmo sistema as cirurgias mais freqüentemente realizadas e prever risco de complicações pós-operatórias, além da mortalidade. Seu uso continuado nesse hospital permitiu identificar o grupo de pacientes com maior risco de complicações, especialmente as infecciosas, mas não foi preciso na predição do risco individual.

BACKGROUND: The identification of risk factors for postoperative complications in cardiac patients with surgical indication may influence the therapeutic decision. OBJECTIVE: To describe the experience of a Cardiology hospital in the validation and practical use of a preoperative risk score. METHODS:To validate TUMAN's score, chosen by considering morbidity and mortality, 300 adult patients were prospectively evaluated before elective cardiac surgery with the use of extracorporeal circulation (ECC). Patients with a score of zero to five were considered as being low risk; from six to nine, as moderate risk and a score higher than 10 as high risk for cardiac, infectious, neurological, pulmonary and renal complications, as well as death. RESULTS: The TUMAN classification showed a statistically significant association with the occurrence of infectious complications (p = 0.010), with the other postoperative complications (p = 0.034) and death (p <0.001). Pulmonary infection was the most frequent infectious complication (15.3 percent) and Infected patients had a longer ICU stay duration (p = 0.001) and more prolonged hospitalization (p = 0001). After routine use, a new review of 154 patients operated in 2005, confirmed the validity of this score in the identification of those with the highest risk of postoperative infections. CONCLUSION: TUMAN's score was chosen as it uses variables that can be promptly obtained, classifies in the same system the most frequently performed surgeries and predicts risk of postoperative complications, in addition to mortality. Its continued use in this hospital has been able to identify the group of patients with increased risk of complications, especially infectious ones, although it was not useful in the prediction of individual risk.

Practical use of a risk assessment model for complications after cardiac surgery.

BACKGROUND: The identification of risk factors for postoperative complications in cardiac patients with surgical indication may influence the therapeutic decision. OBJECTIVE: To describe the experience of a Cardiology hospital in the validation and practical use of a preoperative risk score. METHODS: To validate TUMAN's score, chosen by considering morbidity and mortality, 300 adult patients were prospectively evaluated before elective cardiac surgery with the use of extracorporeal circulation (ECC). Patients with a score of zero to five were considered as being low risk; from six to nine, as moderate risk and a score higher than 10 as high risk for cardiac, infectious, neurological, pulmonary and renal complications, as well as death. RESULTS: The TUMAN classification showed a statistically significant association with the occurrence of infectious complications (p = 0.010), with the other postoperative complications (p = 0.034) and death (p <0.001). Pulmonary infection was the most frequent infectious complication (15.3%) and Infected patients had a longer ICU stay duration (p = 0.001) and more prolonged hospitalization (p = 0001). After routine use, a new review of 154 patients operated in 2005, confirmed the validity of this score in the identification of those with the highest risk of postoperative infections. CONCLUSION: TUMAN's score was chosen as it uses variables that can be promptly obtained, classifies in the same system the most frequently performed surgeries and predicts risk of postoperative complications, in addition to mortality. Its continued use in this hospital has been able to identify the group of patients with increased risk of complications, especially infectious ones, although it was not useful in the prediction of individual risk.

Infective endocarditis due to Bartonella spp. and Coxiella burnetii: experience at a cardiology hospital in Sao Paulo, Brazil.

Bartonella spp. and Coxiella burnetii are recognized as causative agents of blood culture-negative endocarditis (BCNE) in humans and there are no studies of their occurrences in Brazil. The purpose of this study is to investigate Bartonella spp. and C. burnetii as a causative agent of culture-negative endocarditis patients at a cardiology hospital in São Paulo, Brazil. From January 2004 to December 2004 patients with a diagnosis of endocarditis at our Institute were identified and recorded prospectively. They were considered to have possible or definite endocarditis according to the modified Duke criteria. Those with blood culture-negative were tested serologically using the indirect immunofluorescent assay (IFA) for Bartonella henselae, B. quintana, and C. burnetii. IFA-IgG titers >800 for Bartonella spp. and C. burnetii were considered positive. A total of 61 patients with endocarditis diagnosis were evaluated, 17 (27%) were culture-negative. Two have had IgG titer greater than 800 (>/=3,200) against Bartonella spp. and one against C. burnetii (phase I and II>/=6,400). Those with Bartonella-induced endocarditis had a fatal disease. Necropsy showed calcifications and extensive destruction of the valve tissue, which is diffusely infiltrated with mononuclear inflammatory cells predominantly by foamy macrophages. The patient with C. burnetii endocarditis received specific antibiotic therapy. Reports of infective endocartitis due to Bartonella spp. and C. burnetii in Brazil reveal the importance of investigating the infectious agents in culture-negative endocarditis.

Clustering of Enterococcus faecalis infections in a cardiology hospital neonatal intensive care unit.

Early identification of an outbreak is one of the main advantages of routine epidemiological surveillance. Enterococcus spp. used to be regarded as microorganisms of low pathogenicity, because they are part of the normal microbial flora of the gastrointestinal and genitourinary tract. Recently, they have emerged as important pathogenic agents, sometimes causing infections with high mortality rates. We studied a clustering of primary bloodstream infections caused by Enterococcus faecalis in a cardiology hospital neonatal intensive care unit (NICU). Four cases of primary bloodstream infection by E. faecalis were detected from April 15 to May 13, 2004, during active infection surveillance. The isolates were sensitive to glycopeptides. Some aspects of the management of these patients, including the date of insertion and placement of a central venous catheter, prescription of a specific medication, contiguity of beds, personnel attending the patients, and occurrence of diarrhea were analyzed to look for factors that might affect the spread of the microorganisms. Measures taken to hamper the spread included contact precautions throughout the unit, cleansing and disinfection of equipment and surfaces, bathing children with 2% chlorhexidine-gluconate-containing soap, professional reeducation, and reinforcement of all measures to prevent infections. We suggest that there is a need to re-evaluate preventive infection measures and to review the strategies aimed at decreasing the nosocomial infection rate in the NICU.