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1.
Cochrane Database Syst Rev ; 1: CD013326, 2021 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-33471367

RESUMO

BACKGROUND: Annually, infections contribute to approximately 25% of the 2.8 million neonatal deaths worldwide. Over 95% of sepsis-related neonatal deaths occur in low- and middle-income countries. Hand hygiene is an inexpensive and cost-effective method of preventing infection in neonates, making it an affordable and practicable intervention in low- and middle-income settings. Therefore, hand hygiene practices may hold strong prospects for reducing the occurrence of infection and infection-related neonatal death. OBJECTIVES: To determine the effectiveness of different hand hygiene agents for preventing neonatal infection in community and health facility settings. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5), in the Cochrane Library; MEDLINE via PubMed (1966 to 10 May 2019); Embase (1980 to 10 May 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 10 May 2019). We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were updated 1 June 2020. SELECTION CRITERIA: We included RCTs, cross-over trials, and quasi-RCTs that included pregnant women, mothers, other caregivers, and healthcare workers who received interventions within the community or in health facility settings DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and the GRADE approach to assess the certainty of evidence. Primary outcomes were incidence of (study author-defined) suspected infection within the first 28 days of life, bacteriologically confirmed infection within the first 28 days of life, all-cause mortality within the first seven days of life (early neonatal death), and all-cause mortality from the 8th to the 28th day of life (late neonatal death). MAIN RESULTS: Our review included five studies: one RCT, one quasi-RCT, and three cross-over trials with a total of more than 5450 neonates (two studies included all neonates but did not report the actual number of neonates involved). Four studies involved 279 nurses working in neonatal intensive care units and all neonates on admission. The fifth study did not clearly state how many nurses were included in the study. Studies examined the effectiveness of different hand hygiene practices for the incidence of (study author-defined) suspected infection within the first 28 days of life. Two studies were rated as low risk for selection bias, another two were rated as high risk, and one study was rated as unclear risk. One study was rated as low risk for allocation bias, and four were rated as high risk. Only one of the five studies was rated as low risk for performance bias. 4% chlorhexidine gluconate (CHG) compared to plain liquid soap We are uncertain whether plain soap is better than 4% chlorhexidine gluconate (CHG) for nurses' skin based on very low-certainty evidence (mean difference (MD) -1.75, 95% confidence interval (CI) -3.31 to -0.19; 16 participants, 1 study; very low-certainty evidence). We identified no studies that reported on other outcomes for this comparison. 4% chlorhexidine gluconate compared to triclosan 1% One study compared 1% w/v triclosan with 4% chlorhexidine gluconate and suggests that 1% w/v triclosan may reduce the incidence of suspected infection (risk ratio (RR) 1.04, 95% CI 0.19 to 5.60; 1916 participants, 1 study; very low-certainty evidence). There may be fewer cases of infection in the 1% w/v triclosan group compared to the 4% chlorhexidine gluconate group (RR 6.01, 95% CI 3.56 to 10.14; 1916 participants, 1 study; very low-certainty evidence); however, we are uncertain of the available evidence. We identified no study that reported on all-cause mortality, duration of hospital stay, and adverse events for this comparison. 2% CHG compared to alcohol hand sanitiser (61% alcohol and emollients) We are uncertain whether 2% chlorhexidine gluconate reduces the risk of all infection in neonates compared to 61% alcohol hand sanitiser with regards to the incidence of all bacteriologically confirmed infection within the first 28 days of life (RR 2.19, 95% CI 1.79 to 2.69; 2932 participants, 1 study; very low-certainty evidence) in the 2% chlorhexidine gluconate group, but the evidence is very uncertain.   The adverse outcome was reported as mean visual scoring on the skin. There may be little to no difference between the effects of 2% CHG on nurses' skin compared to alcohol hand sanitiser based on very low-certainty evidence (MD 0.80, 95% CI 0.01 to 1.59; 118 participants, 1 study; very low-certainty evidence). We identified no study that reported on all-cause mortality and other outcomes for this comparison. None of the included studies assessed all-cause mortality within the first seven days of life nor duration of hospital stay.  AUTHORS' CONCLUSIONS: We are uncertain as to the superiority of one hand hygiene agent over another because this review included very few studies with very serious study limitations.


Assuntos
Infecções Bacterianas/prevenção & controle , Higiene das Mãos/métodos , Fatores Etários , Anti-Infecciosos Locais/administração & dosagem , Infecções Bacterianas/epidemiologia , Viés , Clorexidina/administração & dosagem , Clorexidina/análogos & derivados , Estudos Cross-Over , Higienizadores de Mão/administração & dosagem , Higienizadores de Mão/efeitos adversos , Humanos , Recém-Nascido , Enfermagem Neonatal/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Sabões/administração & dosagem , Triclosan/administração & dosagem
2.
Cient. dent. (Ed. impr.) ; 17(3): 183-190, sept.-dic. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-198600

RESUMO

OBJETIVO: El objetivo del presente estudio es comparar la eficacia, en términos de cicatrización oral y dolor postquirúrgico, en un grupo de pacientes tratados con una aplicación oral de ácido hialurónico al 1% junto con clorhexidina al 0,20% frente a pacientes tratados con placebo y un tercer grupo con CHX 0,20% + AH 0,20% + Pantenol. MÉTODO: El diseño del estudio es de un estudio analítico, experimental, aleatorizado, ciego, longitudinal prospectivo. Se randomizó una muestra de 45 pacientes, 15 en cada grupo de comparación, en los que se aplicaron postextracción dental unos geles de distinta composición en función del grupo objeto de estudio. En el grupo control se aplicó un gel de ácido hialurónico al 0,20%, clorhexidina al 0,20% y pantenol, en el grupo placebo se aplicó un gel de consistencia similar al anterior pero en ausencia de compuesto y en el grupo experimental se aplicó ácido hialurónico al 1% y clorhexidina al 0,20%. Las variables de eficacia fueron medidas a las 24h., 48h, 72h y 7 días. RESULTADOS: En relación al dolor postoperatorio no encontramos diferencias estadísticamente significativas en ninguno de los grupos analizados. En relación a la cicatrización el grupo en el que se aplicó ácido hialurónico 1% junto con clorhexidina 0,20% fue el que mejores resultados ofreció desde un punto de vista estadístico en las primeras 24-48h con respecto a los otros dos. CONCLUSIONES: En vista de los resultados obtenidos parece que las aplicaciones tópicas de ácido hialurónico al 1% junto con la clorhexidina al 0,20% influyen de manera positiva en cuanto a la cicatrización del tejido blando post extracción dental, sin embargo, no parece que tenga efectos beneficiosos en cuanto a los niveles de dolor oral post-intervención


OBJECTIVE: The objective of the present study is to compare the efficacy, in terms of oral healing and post-surgical pain, in a group of patients treated with an oral application of 1% hyaluronic acid (HA) together with 0.20% chlorhexidine (CHX), compared to patients treated with placebo and a third group treated with HA 0.20%, CHX 0.20% + Panthenol. METHOD: The study design is an analytical, experimental, randomized, blind, prospective longitudinal study. A sample of 45 patients was randomized and divided into 3 comparison groups of 15, with each group receiving a different composition gel after a dental extraction. The control group received a gel of 0.20% hyaluronic acid, 0.20% chlorhexidine; the placebo group was applied a gel of similar consistency to the previous but without active ingredients; and the experimental group received a gel with 1% hyaluronic acid and 0.20% chlorhexidine. Efficacy variables were measured at 24 hours, 48 hours, 72 hours and 7 days. RESULTS: For post-operative pain, we found no statistically significant differences in any of the groups analysed. For healing, the group receiving 1% hyaluronic acid and 0.20% chlorhexidine had the best results from a statistical point of view in the first 24-48 hours compared to the other two groups. CONCLUSIONS: The results obtained seemed to show that topical applications of 1% hyaluronic acid together with 0.20% chlorhexidine have a positive influence on the healing of soft tissue after dental extraction; however, it does not seem to have any beneficial effects in terms of post-operative oral pain


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Resultado do Tratamento , Ácido Hialurônico/administração & dosagem , Clorexidina/administração & dosagem , Extração Dentária , Projetos Piloto , Cicatrização/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Estudos Prospectivos , Estudos Longitudinais , Análise de Variância
3.
Exp Parasitol ; 218: 108008, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32979343

RESUMO

Acanthamoeba sp. is a free living amoeba that causes severe, painful and fatal infections, viz. Acanthamoeba keratitis and granulomatous amoebic encephalitis among humans. Antimicrobial chemotherapy used against Acanthamoeba is toxic to human cells and show side effects as well. Infections due to Acanthamoeba also pose challenges towards currently used antimicrobial treatment including resistance and transformation of trophozoites to resistant cyst forms that can lead to recurrence of infection. Therapeutic agents targeting central nervous system infections caused by Acanthamoeba should be able to cross blood-brain barrier. Nanoparticles based drug delivery put forth an effective therapeutic method to overcome the limitations of currently used antimicrobial chemotherapy. In recent years, various researchers investigated the effectiveness of nanoparticles conjugated drug and/or naturally occurring plant compounds against both trophozoites and cyst form of Acanthamoeba. In the current review, a reasonable effort has been made to provide a comprehensive overview of various nanoparticles tested for their efficacy against Acanthamoeba. This review summarizes the noteworthy details of research performed to elucidate the effect of nanoparticles conjugated drugs against Acanthamoeba.


Assuntos
Acanthamoeba/efeitos dos fármacos , Amebicidas/administração & dosagem , Nanopartículas/administração & dosagem , Acanthamoeba/crescimento & desenvolvimento , Ceratite por Acanthamoeba/tratamento farmacológico , Ceratite por Acanthamoeba/parasitologia , Amebíase/tratamento farmacológico , Amebíase/mortalidade , Amebíase/parasitologia , Amebicidas/farmacologia , Amebicidas/uso terapêutico , Biguanidas/administração & dosagem , Biguanidas/farmacologia , Biguanidas/uso terapêutico , Infecções Protozoárias do Sistema Nervoso Central/tratamento farmacológico , Infecções Protozoárias do Sistema Nervoso Central/mortalidade , Infecções Protozoárias do Sistema Nervoso Central/parasitologia , Clorexidina/administração & dosagem , Clorexidina/farmacologia , Clorexidina/uso terapêutico , Sistemas de Liberação de Medicamentos , Imunocompetência , Hospedeiro Imunocomprometido , Encefalite Infecciosa/tratamento farmacológico , Encefalite Infecciosa/mortalidade , Encefalite Infecciosa/parasitologia , Nanopartículas/classificação , Nanopartículas/uso terapêutico , Trofozoítos/efeitos dos fármacos
4.
Medicine (Baltimore) ; 99(39): e22218, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32991414

RESUMO

BACKGROUND: Chlorhexidine and silver sulfadiazine coated central venous catheters (CSS-CVC) may cause loss of antimicrobial efficacy due to friction between the CVC surface and sheer stress caused by the blood flow. Therefore, the aim of this study was to investigate the antibacterial efficacy of CSS-CVC at various flow rates using a bloodstream model. METHODS: Each CVC was subjected to various flow rates (0.5, 1, 2, and 4 L/min) and wear-out times (0, 24, 48, 72, 96, and 120 hours), and the optical density (OD) 600 after a Staphylococcus aureus incubation test was used to determine the antibacterial effect of CSS-CVC. RESULTS: In the 0.5 L/min group, there was no significant change in the OD600 value up to 120 hours compared with the baseline OD600 value for CSS-CVC (P > .467). However, the OD600 values of CSS-CVC in the 1 L/min (P < .001) and 2 L/min (P < .001) groups were significantly reduced up to 72 hours, while that in the 4 L/min (p < 0.001) group decreased rapidly up to 48 hours. CONCLUSION: This study suggests that there is a doubt whether sufficient antibacterial function can be maintained with prolonged duration of catheter placement.


Assuntos
Anti-Infecciosos Locais/farmacologia , Velocidade do Fluxo Sanguíneo , Cateterismo Venoso Central/instrumentação , Clorexidina/farmacologia , Sulfadiazina de Prata/farmacologia , Antibacterianos/farmacologia , Anti-Infecciosos Locais/administração & dosagem , Infecções Relacionadas a Cateter/prevenção & controle , Cateteres Venosos Centrais/normas , Clorexidina/administração & dosagem , Humanos , Modelos Biológicos , Projetos Piloto , Sulfadiazina de Prata/administração & dosagem
6.
Am J Obstet Gynecol ; 223(1): 113.e1-113.e11, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32407786

RESUMO

BACKGROUND: Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora. OBJECTIVE: To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo. STUDY DESIGN: In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery. RESULTS: From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis. CONCLUSION: Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Cesárea , Clorexidina/análogos & derivados , Procedimentos Cirúrgicos Eletivos , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Tópica , Adulto , Clorexidina/administração & dosagem , Método Duplo-Cego , Feminino , Humanos , Gravidez , Medição de Risco , Infecção da Ferida Cirúrgica/epidemiologia
7.
PLoS One ; 15(4): e0232062, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32330165

RESUMO

INTRODUCTION: Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers' perceptions of the intervention. MATERIALS AND METHODS: This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs. RESULTS: We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences. CONCLUSION: Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Clorexidina/análogos & derivados , Infecção Hospitalar/prevenção & controle , Adulto , Banhos/métodos , Clorexidina/administração & dosagem , Clorexidina/uso terapêutico , Cuidados Críticos/métodos , Infecção Hospitalar/epidemiologia , Feminino , Hospitais Comunitários , Humanos , Unidades de Terapia Intensiva , Masculino
8.
Cochrane Database Syst Rev ; 4: CD007892, 2020 04 26.
Artigo em Inglês | MEDLINE | ID: mdl-32335895

RESUMO

BACKGROUND: Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane Review first published in 2010 and subsequently updated in 2012, twice in 2014, in 2017 and 2018. OBJECTIVES: To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-RCTs assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-RCTs were eligible for inclusion, but we did not identify any. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze. DATA COLLECTION AND ANALYSIS: At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies. MAIN RESULTS: We included 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes. AUTHORS' CONCLUSIONS: Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Cesárea/efeitos adversos , Desinfecção/métodos , Endometrite/prevenção & controle , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intravaginal , Compostos de Benzalcônio/administração & dosagem , Clorexidina/administração & dosagem , Feminino , Febre/prevenção & controle , Humanos , Povidona-Iodo/administração & dosagem , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
Pak J Pharm Sci ; 33(1(Special)): 441-444, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32173641

RESUMO

The objective of this study is to observe and analyze the efficacy of calcium hydroxide and chlorhexidine in pulp revascularization after trauma in young permanent teeth. A total of 120 patients who were treated in our hospital for pulp revascularization after trauma in young permanent teeth were enrolled as research objects in the study. The patients were treated with calcium hydroxide and chlorhexidine and the overall treatment efficiency was statistically observed. The improvement in various indicators before and after treatment was observed, including pain symptom score, gum swelling symptom score, tooth looseness score. The overall treatment efficiency was recorded. The results showed that there were 70 cases of significant effective treatment, 42 cases of effective treatment, and 8 cases of ineffective treatment, respectively, with overall treatment efficiency of 93.33%. Compared with the pain score, gum swelling score and teeth looseness score before treatment, these indicators showed a significant improvement after treatment, p<0.05. The application of calcium hydroxide and chlorhexidine during pulp revascularization after trauma in young permanent teeth can significantly improve the therapeutic effect and achieve higher therapeutic efficiency, demonstrating huge application value.


Assuntos
Hidróxido de Cálcio/administração & dosagem , Clorexidina/administração & dosagem , Necrose da Polpa Dentária/terapia , Polpa Dentária/irrigação sanguínea , Traumatismos Dentários/complicações , Criança , Feminino , Humanos , Masculino , Neovascularização Fisiológica
10.
J Surg Res ; 250: 161-171, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32065967

RESUMO

BACKGROUND: This secondary analysis compared antimicrobial utilization among surgical intensive care unit patients randomized to every other day chlorhexidine bathing (chlorhexidine) versus daily soap and water bathing (soap-and-water) using data from the CHlorhexidine Gluconate BATHing trial. MATERIALS AND METHODS: Antimicrobial utilization was quantified using defined daily dose (DDD)/100 patient-days and agent-days/100 patient-days for systemic antimicrobials. Antivirals (except oseltamivir), antiparasitics, and prophylaxis agents were excluded. The 2018 anatomic therapeutic chemical/DDD index was used to calculate DDD. Agent-days were calculated as the sum of calendar days where antimicrobials were administered. Patient-days were defined as time patients were at risk for health care-acquired infections plus up to 14 d. Primary analyses were conducted using linear regression adjusted for baseline Acute Physiology and Chronic Health Evaluation II scores. RESULTS: Of 325 CHlorhexidine Gluconate BATHing trial patients, 312 (157 in soap-and-water and 155 in chlorhexidine) were included. The median (interquartile range) of total antimicrobial DDD/100 patient-days was 135.4 (75.2-231.8) for soap-and-water and 129.9 (49.2-215.3) for chlorhexidine. The median (interquartile range) of total antimicrobial agent-days/100 patient-days was 155.6 (83.3-243.2) for soap-and-water and 146.7 (66.7-217.4) for chlorhexidine. After adjusting for Acute Physiology and Chronic Health Evaluation II scores, chlorhexidine bathing was associated with a nonsignificant reduction in total antimicrobial DDD/100 patient-days (-3.9; 95% confidence interval, -33.9 to 26.1; P = 0.80) and total antimicrobial agent-days/100 patient-days (-10.3; 95% confidence interval, -34.7 to 14.1; P = 0.41). CONCLUSIONS: Compared with daily soap and water bathing, every other day chlorhexidine bathing did not significantly reduce total antimicrobial utilization in surgical intensive care unit patients.


Assuntos
Antibacterianos/uso terapêutico , Anti-Infecciosos Locais/administração & dosagem , Banhos/métodos , Cuidados Críticos/métodos , Infecção Hospitalar/prevenção & controle , Uso de Medicamentos/estatística & dados numéricos , Adulto , Idoso , Clorexidina/administração & dosagem , Clorexidina/análogos & derivados , Cuidados Críticos/estatística & dados numéricos , Infecção Hospitalar/tratamento farmacológico , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sabões/administração & dosagem
11.
JAMA Ophthalmol ; 138(4): 382-386, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32105297

RESUMO

Importance: Alcohol-based surgical scrub is recommended for presurgical antisepsis by leading health organizations. Despite this recommendation, water-based scrub techniques remain common practice at many institutions. Objective: To calculate the potential financial savings that a large, subspecialty ophthalmic surgical center can achieve with a conversion to waterless surgical hand preparation. Design, Setting, and Participants: A review of accounting records associated with the purchase of scrubbing materials and water company invoices was conducted to assess direct costs attributable to water consumption and scrub materials for brushless, alcohol-based surgical scrub and water-based presurgical scrub. The flow rate of scrub sinks to estimate water consumption per year was tested. Savings associated with operating room (OR) and personnel time were calculated based on the prescribed scrub times for waterless techniques vs traditional running-water techniques. The study was conducted from January 5 to March 1, 2019. Main Outcomes and Measures: The primary outcomes for this study were the quantity of water consumed by aqueous scrubbing procedures as well as the cost differences between alcohol-based surgical scrub and water-based scrub procedures per OR per year. Results: Scrub sinks consumed 15.9 L of water in a 2-minute period, projecting a savings of 61 631 L and $277 in water and sewer cost per operating room per year. Alcohol-based surgical scrub cost $1083 less than aqueous soap applied from wall-mounted soap dispensers and $271 less than preimpregnated scrub brushes per OR per year in supply costs. The decrease in scrub time from adopting waterless scrub technique could save between approximately $280 000 and $348 000 per OR per year. Conclusions and Relevance: Adopting waterless scrub techniques has the potential for economic savings attributable to water. Savings may be larger for surgical facilities performing more personnel-intensive procedures.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Antissepsia/métodos , Clorexidina/análogos & derivados , Etanol/administração & dosagem , Desinfecção das Mãos/economia , Desinfecção das Mãos/métodos , Procedimentos Cirúrgicos Oftalmológicos , Água , Anti-Infecciosos Locais/economia , Clorexidina/administração & dosagem , Clorexidina/economia , Desinfetantes , Etanol/economia , Feminino , Humanos , Masculino , Salas Cirúrgicas , Procedimentos Cirúrgicos Oftalmológicos/economia , Cuidados Pré-Operatórios
12.
Br J Nurs ; 29(2): S24-S26, 2020 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-31972108

RESUMO

PURPOSE: Preventing CLABSI events in the dialysis inpatient population represents significant challenges. Bacteremia associated with lines or grafts are common health-associated infections that lead to adverse patient outcomes. Dialysis patients represent a much higher infection risk due to health frequency needs, more frequent hospitalizations, multiple comorbidity issues, fistula functionality, and multiple attempts for line access leading to additional complications, costs, morbidity, and mortality. METHODS: An observational study was conducted including central line device days, CLABSI events, and possible confounding variables in admitted dialysis patients. All CLABSI data were identified according to the Centers for Disease Control and Prevention's National Healthcare Safety Network's definitions for CLABSIs. The intervention involved the removal of 70% alcohol swabs and alcohol hub disinfecting caps, then replacing with swabs containing 3.15% chlorhexidine gluconate/70% alcohol for central line hub disinfection and vascular graft access skin disinfection. RESULTS: The 5-year preintervention period (2008-2012) involved 7568 central line days, 11 CLABSI events, and a 1.45 per 1000 device day rate. The 6-month trial period involved 1559 central line days and no CLABSI events. The 5-year postimplementation period (2013-2017) involved 9787 central line days, 5 CLABSI events, and a 0.51 per 1000 device day rate. The postimplementation period represented a statistically significant (P value=0.0493) reduction with 65% fewer CLABSI events compared with the preimplementation period. LIMITATIONS: A limitation was variations in scrub time and dry time during central venous catheter hub access. While we were comparing 2 products, behavioral practices using these 2 products were possible influencers and represent a possible confounding variable. CONCLUSIONS: This study found that using alcohol with chlorhexidine gluconate prior to accessing central line hubs and vascular grafts allows for reduction in CLABSI events and sustains statistically significant lower CLABSI rates in the inpatient dialysis population. HIGHLIGHTS Using alcohol with chlorhexidine gluconate (CHG) before accessing central line hubs helps reduce central line-associated bloodstream infection (CLABSI) events Using alcohol with CHG before accessing vascular grafts helps reduce CLABSI events A statistically significant reduction (65%) in CLABSI events occurred after use. Statistically significant lower CLABSI rates are sustainable with use of alcohol with CHG.


Assuntos
Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/prevenção & controle , Desinfecção/métodos , Diálise Renal/enfermagem , Álcoois/administração & dosagem , Cateterismo Venoso Central/efeitos adversos , Clorexidina/administração & dosagem , Clorexidina/análogos & derivados , Humanos , Pesquisa em Avaliação de Enfermagem
13.
Turk Neurosurg ; 30(4): 550-556, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31736037

RESUMO

AIM: To determine the effect of using three concurrent measures (2% chlorhexidine gluconate +70% alcohol for skin cleaning, changing the dressing every 48 hours, and observing the operating room) for patients who had venriculoperitoneal shunt (VPS) implantations on the infection rate. MATERIAL AND METHODS: This was a prospective interventional study. Using infection prevention compliance control lists, patients who had a VPS implanted between November 2012 and November 2013 were compared to those who had a VPS implanted between October 2011 and October 2012. The data included information about the patients, follow-up, and infection prevention. These data were obtained for the pre-, peri-, and postoperative periods. RESULTS: Triple bundle prevention in the applied protocol significantly reduced the VPS infection rate in the study group compared to the control group (p < 0.005). CONCLUSION: These findings revealed the importance of creating a prevention protocol and following it regularly in a way for all surgery, operating room, and service teams fully comply to prevent VPS infections.


Assuntos
Contaminação de Equipamentos/prevenção & controle , Hidrocefalia/cirurgia , Controle de Infecções/métodos , Derivação Ventriculoperitoneal/métodos , Adolescente , Criança , Pré-Escolar , Clorexidina/administração & dosagem , Clorexidina/análogos & derivados , Feminino , Humanos , Hidrocefalia/diagnóstico , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Fatores de Risco , Derivação Ventriculoperitoneal/efeitos adversos
14.
Adv Neonatal Care ; 20(1): 38-47, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31567183

RESUMO

BACKGROUND: Central-line-associated bloodstream infection (CLABSI) contributes to significant morbidity and mortality in the neonatal intensive care unit (NICU). Disinfection of skin is part of bundled cares aimed at prevention of CLABSI. While considered an essential component of insertion and maintenance bundles, the optimal solution to disinfect neonatal skin remains controversial. PURPOSE: The purpose of this project was to survey neonatal nurse practitioners and nursing leaders across NICUs regarding the current use of chlorhexidine gluconate (CHG) in term and preterm infants. METHODS: This descriptive study involved the collection of survey data to determine NICU practices related to the use of CHG in their infant population. The sample was composed of nursing directors of NICUs and neonatal nurse practitioners who completed an electronic survey via a provided link. FINDINGS/RESULTS: Chlorhexidine was reported to be used in 53 (82.81%) of the NICUs and was the primary agent used to prepare the skin for central vascular catheter insertion (53.23%) followed by povidone-iodine (45.16%), and 70% isopropyl alcohol (1.61%). Gestational age or birth weight restrictions for CHG use were reported in 43 (82.69%) NICUs. Trends in the data demonstrated nursing's role in using CHG in the NICU. Adverse events reported from CHG included burns, redness, dermatitis, and other irritations. Concerns included risk of absorption, burns, skin irritation, lack of evidence, and overall safety. IMPLICATIONS FOR PRACTICE: Systematic monitoring by nurse leaders is needed to identify evidence related to skin disinfection and CHG in neonates. Targeted education for nursing staff related to directed to developmental maturation of the skin, safe use of CHG, review of best evidence, rationale for usage of CHG, and potential iatrogenic effects is recommended. IMPLICATIONS FOR RESEARCH: Research is needed to evaluate the impact of educational offerings and surveillance for adverse events on CLABSI rates.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Anti-Infecciosos Locais/normas , Infecções Relacionadas a Cateter/prevenção & controle , Clorexidina/administração & dosagem , Clorexidina/normas , Desinfecção/normas , Unidades de Terapia Intensiva Neonatal/normas , Desinfecção/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Masculino , Inquéritos e Questionários , Estados Unidos
15.
Infect Control Hosp Epidemiol ; 41(1): 98-101, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31619301

RESUMO

Cutaneous antisepsis with chlorhexidine or povidone-iodine, usually with alcohol, has been extensively studied. This review of published studies reveals that sequential use of povidone-iodine and chlorhexidine leads to a greater reduction in the bioburden of aerobic and anaerobic bacteria on the skin, lower risk of intravascular catheter colonization, and lower risk of surgical site infection compared to use of either agent alone. As such, sequential use of cutaneous antiseptic agents may further reduce risk of surgical site infections, as well as infections associated with insertion of transdermal devices such as nephrostomy tubes, left-ventricular assistance devices, and intravascular catheters.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Carga Bacteriana , Clorexidina/administração & dosagem , Povidona-Iodo/administração & dosagem , Pele/microbiologia , Administração Cutânea , Álcoois/administração & dosagem , Bactérias Aeróbias , Bactérias Anaeróbias , Infecções Relacionadas a Cateter/prevenção & controle , Humanos , Infecção da Ferida Cirúrgica/prevenção & controle
16.
J Infect Chemother ; 26(2): 188-193, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31495567

RESUMO

BACKGROUND: Bundled measures have been recommended to reduce the risk of central venous catheter (CVC)-related bloodstream infection. However, the importance of each procedure involved in CVC insertion/management for preventing catheter-related bloodstream infection (CRBSI) has not been thoroughly assessed. We aimed to analyze the effectiveness of maintenance antisepsis at the CVC insertion site in reducing the CRBSI risk through comparing the use of 0.05% chlorhexidine to 1% chlorhexidine. PATIENTS AND METHODS: In the South Miyagi Medical Center, Japan, 372 patients with a CVC who had undergone antisepsis maintenance using 0.05% chlorhexidine swabs 12 months prior to implementing 1% chlorhexidine swabs, and 344 patients at 12 months post-implementation of 1% chlorhexidine swabs, were followed prospectively for the development of CRBSI and signs of infection, and their data compared. RESULTS: Post-implementation of the 1% chlorhexidine swabs, the CRBSI rate decreased from 3.64/1000 catheter-days to 1.77/1000 catheter-days. The risk of CRBSI decreased to 0.465 (95% confidence interval [CI]: 0.216-1.001). Furthermore, the risk of CRBSI ≥20 days after CVC insertion decreased to 0.200 (95% CI: 0.049-0.867); however, we found no difference between 0.05% and 1% chlorhexidine use within 19 days of CVC insertion. The increased number of patients with insertion site tenderness after implementing 1% chlorhexidine indicated a possible adverse effect of chlorhexidine. CONCLUSION: Maintenance antisepsis with 1% chlorhexidine decreased the risk of developing CRBSI ≥20 days after CVC insertion, indicating the effectiveness of antisepsis with 1% chlorhexidine. Our data highlight the importance of maintenance antisepsis in reducing the rate of late-phase CRBSI.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Antissepsia/métodos , Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/métodos , Clorexidina/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/tratamento farmacológico , Infecções Relacionadas a Cateter/tratamento farmacológico , Cateterismo Venoso Central/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
17.
Acta Obstet Gynecol Scand ; 99(2): 231-239, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31539171

RESUMO

INTRODUCTION: Cesarean sections are the most common major operation worldwide. One in 10 women develops a surgical-site infection after cesarean section. The PREPS pilot trial was developed to assess the feasibility of a randomized controlled trial of vaginal cleansing with chlorhexidine before cesarean section, to reduce infectious morbidity. MATERIAL AND METHODS: A multi-center, open-label, parallel-group pilot randomized controlled trial across 4 UK maternity units. Women aged ≥16 years, undergoing elective or emergency cesarean section, ≥34 weeks of gestation, and able to give informed consent were eligible. Women were randomized 1:1 to chlorhexidine 0.05% or no cleansing and were followed up until 6 weeks after cesarean section. The feasibility of a larger randomized controlled trial was assessed by the pilot trial's recruitment, ability to use verbal consent in an emergency, adherence, follow-up and withdrawal rates. The main clinical outcome collected was Center for Disease Control and Prevention (CDC) classification of endometritis at 30 days. Trial registration number is ISRCTN33435996. RESULTS: A total of 320 women (128% of target) were randomized. Of these, 93% (95% CI 89%-95%) received their allocated intervention. Of the 88 women who had an emergency cesarean section, verbal consent was initially given by 32 (36%) women, with the remainder having sufficient time to give written consent. Endometritis (CDC definition) was collected from medical notes of 96% of women, 68% (95% CI 63%-73%) were followed up at both 14 and 30 days by telephone, and we were able to collect patient-reported outcomes. In the vaginal cleansing arm 2/152 (1.3%) women had endometritis compared with 1/155 (0.7%) in the no cleansing arm (RR 2.08, 95% CI 0.19-22.31). CONCLUSIONS: It is possible to perform a randomized controlled trial in women undergoing an elective or emergency cesarean section, using a verbal-followed-by-written consent process, while maintaining high adherence and retaining women in the trial.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Cesárea , Clorexidina/administração & dosagem , Endometriose/prevenção & controle , Sepse/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intravaginal , Adulto , Feminino , Humanos , Medidas de Resultados Relatados pelo Paciente , Projetos Piloto
18.
J Matern Fetal Neonatal Med ; 33(2): 272-276, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30021481

RESUMO

Introduction: The ideal antiseptic agent for skin preparation before elective cesarean section (CS) is not yet determined. The aim of the study was to assess the impact of skin preparation by chlorhexidine-alcohol compared with povidone-iodine before elective CS on the rate of surgical site infection (SSI).Materials and methods: This prospective observational study included a total of 1424 pregnant women at term who were candidates for the elective CS and were divided into two equal groups of 712 patients in each, group 1 (chlorhexidine-alcohol group) and group 2 (povidone-iodine group). Patients were followed up at 1 week and 1 month postoperative to determine the rate of SSI.Results: The rate of SSI was 3.7% (26 patients) in the chlorhexidine-alcohol group compared with 4.6% (33 patients) in the povidone-iodine group (odds ratio: 0.7798, 95% CI: 0.46-1.3, p = .35), nine patients in the chlorhexidine-alcohol group, and 10 patients in the povidone-iodine group required resuturing (odds ratio: 0.9, 95% CI: 0.36-2.2, p = .82). Four patients (0.56%) in the chlorhexidine-alcohol group and five patients (0.7%) in the povidone-iodine group developed endometritis (p = .74). The rate or readmission because of SSI was 2.7% (19 patients) in the chlorhexidine-alcohol group and 2.9% (21 patients) in the povidone-iodine group (p = .75).Conclusions: Skin preparation with either chlorhexidine-alcohol or povidone-iodine resulted in comparable rates of SSIs. Accordingly, both are suitable antiseptic agents for skin preparation before elective CS.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Cesárea/métodos , Clorexidina/administração & dosagem , Povidona-Iodo/administração & dosagem , Infecção da Ferida Cirúrgica/prevenção & controle , Cesárea/efeitos adversos , Feminino , Humanos , Gravidez , Cuidados Pré-Operatórios/métodos
19.
Trop Biomed ; 37(4): 1141-1145, 2020 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33612766

RESUMO

Coronavirus Disease 2019 (COVID-19) has infected more than 8 million people globally since its discovery in December 2019. For COVID-19 prevention, the World Health Organization recommended regular handwashing with soap, cough etiquette, mask wearing and social distancing. However, COVID-19 is rather difficult to contain because of its high transmissibility property. Gargling is effective for reducing infection in the respiratory tract. Most antiseptic gargles have antimicrobial properties against common respiratory pathogens. No published study on the effectiveness of antiseptic gargling among COVID-19 patients has been available to date. This article reviewed available literature on methods and solutions available for gargling and their effect on respiratory tract infections.


Assuntos
Anti-Infecciosos Locais/uso terapêutico , /prevenção & controle , Anti-Infecciosos Locais/administração & dosagem , Clorexidina/administração & dosagem , Clorexidina/uso terapêutico , Humanos , Povidona-Iodo/administração & dosagem , Povidona-Iodo/uso terapêutico
20.
Trials ; 20(1): 754, 2019 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-31856900

RESUMO

BACKGROUND: Current international guidelines recommend the use of a daily topical exit-site antimicrobial to prevent peritoneal dialysis (PD)-related infections. Although nonantibiotic-based therapies are appealing because they may limit antimicrobial resistance, no controlled trials have been conducted to compare topical antimicrobial agents with usual exit-site care for the prevention of PD-related infections among the Thai PD population. We propose a controlled three-arm trial to examine the efficacy and safety of a daily chlorhexidine gluconate-impregnated patch versus mupirocin ointment versus usual exit-site care with normal saline for the prevention of PD-related infections. METHODS/DESIGNS: This study is a randomized, double-blind, multicenter, active-controlled, clinical trial. Adult patients aged 18 years or older who have end-stage kidney disease and are undergoing PD will be enrolled at three PD Centers in Thailand. A total of 354 PD patients will be randomly assigned to either the 2% chlorhexidine gluconate-impregnated patch, mupirocin ointment, or usual exit-site care with normal saline dressing according to a computer-generated random allocation sequence. Participants will be followed until discontinuation of PD or completion of 24 months. The primary study outcomes are time to first PD-related infection (exit-site/tunnel infection or peritonitis) event and the overall difference in PD-related infection rates between study arms. Secondary study outcomes will include (i) the rate of infection-related catheter removal and PD technique failure, (ii) rate of nasal and exit-site Staphylococcus aureus colonization, (iii) healthcare costs, and (iv) skin reactions and adverse events. We plan to conduct a cost-utility analysis alongside the trial from the perspectives of patients and society. A Markov simulation model will be used to estimate the total cost and health outcome in terms of quality-adjusted life years (QALYs) over a 20-year time horizon. An incremental cost-effectiveness ratio in Thai Baht and U.S. dollars per QALYs gained will be illustrated. A series of probabilistic sensitivity analyses will be conducted to assess the robustness of the cost-utility analysis findings. DISCUSSION: The results from this study will provide new clinical and cost-effectiveness evidence to support the best strategy for the prevention of PD-related infections among the Thai PD population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02547103. Registered on September 11, 2015.


Assuntos
Antibacterianos/administração & dosagem , Anti-Infecciosos Locais/administração & dosagem , Infecções Relacionadas a Cateter/epidemiologia , Diálise Peritoneal/efeitos adversos , Peritonite/epidemiologia , Infecções Estafilocócicas/epidemiologia , Administração Tópica , Adulto , Idoso , Antibacterianos/economia , Anti-Infecciosos Locais/economia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateteres de Demora/efeitos adversos , Clorexidina/administração & dosagem , Clorexidina/análogos & derivados , Ensaios Clínicos Fase IV como Assunto , Análise Custo-Benefício , Método Duplo-Cego , Custos de Medicamentos , Feminino , Humanos , Incidência , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Mupirocina/administração & dosagem , Mucosa Nasal/microbiologia , Diálise Peritoneal/instrumentação , Peritonite/diagnóstico , Peritonite/microbiologia , Peritonite/prevenção & controle , Projetos Piloto , Ensaios Clínicos Controlados Aleatórios como Assunto , Solução Salina/administração & dosagem , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/prevenção & controle , Staphylococcus aureus/isolamento & purificação , Resultado do Tratamento
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