Internações por Condições Sensíveis à Atenção Primária de Menores de um ano, de 2008 a 2014, no estado de São Paulo, Brasil / Primary Health Care-Sensitive Hospitalizations in children under one year of age, from 2008 to 2014, in the State of São Paulo, Brazil

Resumo Este estudo teve o objetivo de descrever as causas e as tendências de Internações por Condições Sensíveis à Atenção Primária (ICSAP) em menores de um ano, entre 2008 e 2014, no estado de São Paulo, Brasil. Trata-se de um delineamento ecológico, baseado em dados secundários do Sistema de Informações Hospitalares. Classificaram-se as internações segundo o diagnóstico principal e a Lista Brasileira de ICSAP, considerando as seguintes faixas etárias: Neonatais precoce, Neonatal tardia e Pós-neonatal. Para a análise de tendência das internações foram ajustados modelos de regressão linear. Ocorreram 851.713 internações de Menores de um ano, sendo 22,6% por ICSAP. As principais reduções das frequências de internação foram: Pneumonias bacterianas (-7,10%) e Desvios nutricionais (-7,70) em Neonatal precoce. As elevações foram: Doenças relacionadas ao pré-natal e parto (+10,14%) e Doenças imunizáveis e condições evitáveis em Pós-neonatal (+14,13%), com destaque para coqueluche e sífilis congênita. Os resultados mostram uma deficiência no cuidado à saúde infantil na atenção primária no estado de São Paulo, enquanto que as tendências de internações estimadas podem auxiliar no planejamento de estratégias para diminuir os agravos e os gastos no setor terciário de atenção em saúde.

Abstract The scope of this article is to describe the trends of primary health care-sensitive (PHC) hospitalizations in children under one year of age between 2008 and 2014 in the State of São Paulo, Brazil. It is an ecological study with descriptive and analytical characteristics, based on secondary data from the national health information system. Hospitalizations were classified according to the Brazilian list of PHC hospitalizations considering the Early Neonatal, Late Neonatal and Post-Neonatal age groups. Linear regression models were adjusted for trend analysis of the 851,713 hospitalizations of children under one year of age analyzed, of which 22.6% were PHC-related. The main groups with decreases were: Bacterial pneumonia (-7.10%) and Nutritional disorders (-7.70%) in the Early neonatal phase. The main increases were: Disease related to prenatal/childbirth (+10.14%) and Immunosuppressive diseases and avoidable conditions in Post-neonatal (+14.13%) infants, among which pertussis and congenital syphilis were the main causes of hospitalization. The results showed a deficiency in the primary health care system for infants in the State of Sao Paulo. The estimated trends should be used for planning cost-effective strategies to prevent and control causes of hospitalization in children under one year of age.

Hospitalizations due to primary care-sensitive conditions among children under five years of age: cross-sectional study / Internações por condições sensíveis à atenção primária em crianças menores de cinco anos: estudo transversal

ABSTRACT CONTEXT AND OBJECTIVE: Hospitalizations due to primary care-sensitive conditions constitute an important indicator for monitoring the quality of primary healthcare. This study aimed to describe hospitalizations due to primary care-sensitive conditions found among children under five years of age (according to their age and sex), in two cities in Paraíba, Brazil. DESIGN AND SETTING: Cross-sectional study carried out in the municipalities of Cabedelo and Bayeux, in Paraíba, Brazil. METHODS: Data were collected from four public pediatric hospitals in Paraíba that receive children from these municipalities. Hospital admission authorizations were consulted to gather information on the children's profile and the characteristics of their hospitalizations. Differences in the causes of admissions and the respective lengths of hospital stay length were analyzed according to age group and sex. RESULTS: The proportion of hospital admissions due to primary care-sensitive conditions was 82.4%. The most frequent causes were: bacterial pneumonia (59.38%), infectious gastroenteritis and its complications (23.59%) and kidney and urinary tract infection (9.67%). Boys had higher frequency of hospitalizations due to primary care-sensitive conditions than girls. The median hospitalization due to primary care-sensitive conditions was found to be four days. The duration of hospital stays due to primary care-sensitive conditions was significantly longer than those due to conditions that were not sensitive to primary care. CONCLUSIONS: High rates of hospital admissions due to primary care-sensitive conditions were highlighted, especially among children of male sex, with long periods of hospitalization.

RESUMO CONTEXTO E OBJETIVO: As internações por condições sensíveis à atenção primária constituem importante indicador para o monitoramento da qualidade da atenção primária à saúde. O presente estudo objetivou descrever as internações por condições sensíveis à atenção primária em crianças menores de cinco anos (por idade e sexo) em duas cidades da Paraíba. TIPO DE ESTUDO E LOCAL: Estudo transversal realizado nos municípios de Cabedelo e Bayeux, ­Paraíba, Brasil. MÉTODOS: Coletaram-se os dados nos quatro hospitais públicos pediátricos da Paraíba que internam crianças residentes nos municípios estudados. A partir das autorizações de internação hospitalar, colheram-se informações relativas ao perfil da criança e características das internações. Analisaram-se as diferenças nas causas de internações e respectivos tempos de hospitalização segundo faixa etária e sexo. RESULTADOS: A proporção de internação por condição sensível à atenção primária foi de 82,4%. As causas mais frequentes foram: pneumonias bacterianas (59,38%), gastroenterites infecciosas e suas complicações (23,59%) e infecção do rim e trato urinário (9,67%). Meninos apresentaram maior frequência de internações por condições sensíveis à atenção primária do que meninas. Verificou-se mediana de quatro dias de hospitalização para as condições sensíveis à atenção primária. O tempo de hospitalização por condição sensível à atenção primária foi significantemente maior do que o tempo da condição não sensível à atenção primária. CONCLUSÕES: Ressaltam-se altas taxas de internações por condições sensíveis à atenção primária, principalmente em crianças do sexo masculino, com longos períodos de hospitalização.

Risk factors for the development of postoperative pneumonia after cardiac surgery / Factores de riesgo para desarrollar neumonía postquirúrgica en pacientes operados de cirugía cardiaca

Abstract Objective Identify risk factors that determine pneumonia development in patients who have undergone cardiac surgery. Methods Prospective study of a single cohort in a postoperative intensive care unit at a tertiary care center, encompassing all patients undergoing cardiac surgery from January to July 2014. Results 31 postoperative pneumonia cases were enrolled out of 211 patients (14.6%). The following independent risk factors were identified: hypertension (OR: 3.94, p = 0.01), chronic renal failure (OR: 13.67, p = 0.02), reintubation (OR: 22.29, p = 0.001) and extubation after 6 h (OR: 15.81, p = 0.005). Conclusions Main determinants for pneumonia after surgery were hypertension, chronic renal failure, extubation after 6 h and reintubation.

Resumen Objetivo Identificar los factores de riesgo para desarrollar neumonía en el periodo postquirúrgico de pacientes sometidos a cirugía cardiaca. Método Estudio de cohorte prospectiva que incluye pacientes > 18 años sometidos a cirugía cardiaca de enero a julio de 2014, en el Instituto Nacional de Cardiología Ignacio Chávez, México D.F. Se considera un valor de p < 0.05 como significativo. Resultados De un total de 211 pacientes operados, se diagnosticaron 31 casos de neumonía postquirúrgica (14.6%). Se identificaron los siguientes factores de riesgo independientes para desarrollar neumonía: la hipertensión arterial sistémica (OR: 3.94, p = 0.01), el antecedente de insuficiencia renal crónica (OR: 13.67, p = 0.02). La reintubación (OR: 22.29, p = 0.001) y permanecer intubado por más de 6 horas (OR: 15.81, p = 0.005). Conclusiones Los principales factores de riesgo independientes para desarrollar neumonía en el periodo postquirúrgico son la preexistencia de hipertensión arterial sistémica o insuficiencia renal crónica, la reintubación y permanecer intubado durante más de 6 h.

Evaluación de predictores clínicos de bacteriemia en adultos hospitalizados por neumonía adquirida en la comunidad / Evaluation of clinical predictors of bacteremia in adults hospitalized for community-acquired pneumonia

OBJETIVO: Identificar elementos clínicos sencillos que hagan posible determinar adecuadamente los casos con mayor probabilidad de presentar aislamientos bacterianos en los hemocultivos. MÉTODOS: Estudio de casos y controles con pacientes internados por neumonía adquirida en la comunidad entre 1998 y 2009, definiéndose como casos a los pacientes que presentaron hemocultivos positivos y como controles a aquellos con hemocultivos negativos. Se registraron variables demográficas y clínicas y se las sometió a un análisis bivariado. Las que presentaron diferencias estadísticamente significativas entre los grupos fueron introducidas en un modelo de regresión logística para definir predictores independientes y generar un modelo de predicción clínica. RESULTADOS: De los 322 pacientes estudiados, 15,2 por ciento tuvo hemocultivos positivos. Diez variables mostraron diferencias significativas, pero solo tres (temperatura <38°C, sodio <135 mEq/L y puntaje CURB-65) fueron seleccionadas para el análisis multivariado. El modelo desarrollado mostró escasa capacidad para predecir el resultado de los hemocultivos (R² = 0,176; Hosmer-Lemeshow: P = 0,338). CONCLUSIONES: Los datos obtenidos en esta serie no evidenciaron elementos clínicos con capacidad suficiente para predecir el resultado de los hemocultivos.

OBJECTIVE: Identify simple clinical elements that can be used to adequately determine the cases with the highest probability of presenting bacterial isolates in blood cultures. METHODS: Case-control study with patients hospitalized for community-acquired pneumonia from 1998-2009. Patients with positive blood cultures were defined as cases, and patients with negative blood cultures were defined as controls. The demographic and clinical variables were recorded and a bivariate analysis was conducted. The variables with statistically significant differences between the groups were introduced in a logistic regression model in order to define the independent predictors and generate a clinical prediction model. RESULTS: A total of 15.2 percent of the 322 patients studied had positive blood cultures. Ten variables showed significant differences, but only three variables (temperature <38°C, sodium <135 mEq/L and CURB-65 score) were selected for the multivariate analysis. The model developed showed limited capacity to predict the result of the blood cultures (R² = 0.176; Hosmer-Lemeshow: P = 0.338). CONCLUSIONS: The data obtained in this series did not demonstrate clinical elements with sufficient capacity to predict the result of the blood cultures.

Perfil clínico, epidemiológico e etiológico de pacientes com pneumonia adquirida na comunidade internados em um hospital geral da microrregião de Sumaré, SP / Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia at a general hospital in the Sumaré microregion of Brazil

OBJETIVO: Analisar aspectos clínicos, etiológicos e epidemiológicos das pneumonias adquiridas na comunidade (PAC) em indivíduos internados. MÉTODOS: Foram estudados prospectivamente 66 pacientes com PAC maiores de 14 anos no Hospital Estadual Sumaré, localizado na cidade de Sumaré (SP), entre outubro de 2005 e setembro de 2007. Coletamos dados sobre história clínica, exame clínico, escore pneumonia severity index (PSI) e exames laboratoriais (hemocultura, bacterioscopia/cultura de escarro, sorologias para Chlamydophila pneumoniae, Mycoplasma pneumoniae e Legionella pneumophila, além de antígenos urinários de Legionella sp. e Streptococcus pneumoniae). RESULTADOS: A idade média dos pacientes foi de 53 anos, a maioria tinha baixa escolaridade, e 55,7 por cento apresentavam pelo menos uma comorbidade no momento da internação. O percentual de idosos vacinados contra influenza entre os internados foi significativamente menor que os da comunidade dos municípios da microrregião de Sumaré (52,6 por cento vs. > 70 por cento). A febre foi menos frequente entre os idosos (p < 0,05). A evolução clínica se associou com o escore PSI, mas não com a idade. A etiologia foi confirmada em 31 (50,8 por cento) dos casos, sendo 21 (34,4 por cento) devido a S. pneumoniae, detectado principalmente pelo antígeno urinário; seguido de C. pneumoniae, em 5 (8,2 por cento). Receberam alta hospitalar por cura 80,3 por cento dos pacientes. A taxa de letalidade foi de 4,9 por cento. CONCLUSÕES: O conhecimento do perfil etiológico de PAC no âmbito regional favorece a escolha adequada da terapia empírica, que é particularmente relevante em pacientes idosos e naqueles com comorbidades. A falta da vacinação contra influenza em idosos é um fator de risco de internação por PAC.

OBJECTIVE: To analyze the clinical, etiological, and epidemiological aspects of community-acquired pneumonia (CAP) in hospitalized individuals. METHODS: We prospectively studied 66 patients (> 14 years of age) with CAP admitted to the Hospital Estadual Sumaré, located in the Sumaré microregion of Brazil, between October of 2005 and September of 2007. We collected data related to clinical history, physical examination, pneumonia severity index (PSI) scores, and laboratory tests (blood culture; sputum smear microscopy and culture; serology for Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila; and detection of Legionella sp. and Streptococcus pneumoniae antigens in urine). RESULTS: The mean age of patients was 53 years. Most had a low level of education, and 55.7 percent presented with at least one comorbidity at the time of hospitalization. The proportion of elderly people vaccinated against influenza was significantly lower among the inpatients than in the general population of the Sumaré microregion (52.6 percent vs. > 70 percent). Fever was less common among the elderly patients (p < 0.05). The clinical evolution was associated with the PSI scores but not with age. The etiology was confirmed in 31 cases (50.8 percent) and was attributed to S. pneumoniae, principally detected by the urinary antigen test, in 21 (34.4 percent), followed by C. pneumoniae, in 5 (8.2 percent). The mortality rate was 4.9 percent, and 80.3 percent of the patients were classified as cured at discharge. CONCLUSIONS: The knowledge of the etiologic profile of CAP at the regional level favors the appropriate choice of empirical treatment, which is particularly relevant in elderly patients and in those with comorbidities. The lack of influenza vaccination in elderly patients is a risk factor for hospitalization due to CAP.

Risk factors for Hospital-Acquired Pneumonia in nonventilated adults

Although most recent publications focus on Ventilator-associated Pneumonia, Non-Ventilator-associated Hospital-acquired pneumonia (NVHAP) is still worrisome. We studied risk factors for NVHAP among patients admitted to a small teaching hospital. Sixty-six NVHAP case patients and 66 controls admitted to the hospital from November 2005 through November 2006 were enrolled in a case-control study. Variables under investigation included: demographic characteristics, comorbidities, procedures, invasive devices and use of medications (Sedatives, Antacids, Steroids and Antimicrobials). Univariate and multivariable analysis (hierarchical models of logistic regression) were performed. The incidence of NVHAP in our hospital was 0.68 percent (1.02 per 1,000 patients-day). Results from multivariable analysis identified risk factors for NVHAP: age (Odds Ratio[OR]=1.03, 95 percent Confidence Interval[CI]=1.01-1.05, p=0.002), use of Antacids (OR=5.29, 95 percentCI=1.89-4.79, p=0.001) and Central Nervous System disease (OR=3.13, 95 percentCI=1.24-7.93, p=0.02). Although our findings are coherent with previous reports, the association of Antacids with NVHAP recalls a controversial issue in the physiopathology of Hospital-Acquired Pneumonia, with possible implications for preventive strategies.

Neumonía adquirida en la comunidad (NAC) y asociada al cuidado crónico de la salud (NACS) en 560 mayores de 65 años / Community-acquired pneumonia and associated chronic health care in 560 older than 65 year

Los mayores de 65 tienden a desarrollar neumonía. Evaluamos la epidemiología, el impacto de los factores de riesgo y las comorbilidades y el pronóstico de NAC y NACS en una cohorte de ancianos. Métodos. Se recolectaron prospectivamente datos en mayores de 65 años no-inmunosuprimidos, atendidos por NAC y NACS. Se definió neumonía por criterios clínicos y radiológicos; considerándose NAC en no internados durante los 15 días previos y NACS si además residían en alguna institución de cuidado crónico o geriátrico. Resultados. De 844 pacientes con NAC, 560 eran mayores de 65 (66.4%), y 100 (el 17.9% de ellos) eran NACS. Mediante análisis univariado se determinó que los portadores de NACS eran mayores, debieron internarse o se habían internado anteriormente por neumonía u otra razón más frecuentemente; también los pacientes con NACS presentaban más frecuentemente comorbilidad neurológica, conciencia alterada, aspiración, uso previo de antibióticos y clase V del PSI (p < 0.001 para todos estos). En análisis multivariado solo la edad mayor de 80 y la comorbilidad neurológica permanecieron más frecuentes en NACS. Los agentes más comunes fueron S. pneumoniae, M. pneumoniae, C. pneumoniae, L. pneumophila, P. aeruginosa, enterobacterias, S. aureus, H. influenzaey virus. No hubo diferencias en etiología entre NAC y NACS. La mortalidad a 30 días fue mayor en los pacientes con NACS (44.5 vs. 33.7%). Conclusión. En mayores de 65 la neumonía es más frecuente, más grave y su etiología es diferente respecto de los menores. La NACS presenta más gravedad y mayor mortalidad.

People older than 65 years are more susceptible to pneumonia. This paper presents an assessment of the impact of risk factors and co-morbidities and the prognosis of community-acquired pneumonia (CAP) and health care associated community-acquised pneumonia (HCAP) in the elderly. Methods. Prospective data collection in immuno-competent patients older than 65 years hospitalized for CAP or HCAP. Pneumonia was defined by radiographic and clinical criteria; CAP was considered in patients who were not hospitalized during the previous 15 days, while HCAP was diagnosed in those who developed pneumonia outside the hospital in a nursing home or long-term health care facility. Results. Out of 844 patients admitted with the diagnosis of pneumonia during 5 years, 560 were older than 65 (66.4%); 460 (54.6%) were classified as CAP and 100 (17.9%) as HCAP. In comparison with the CAP patients, patients with HCAP were older and had more often been admitted in the past for pneumonia or other reason, (p < 0.001). They also presented a higher frequency of neurologic co-morbidity, altered consciousness, aspiration, use of prior antibiotics and high risk pneumonia (risk class V of the Pneumonia Severity Index - PSI) (p < 0.001). In the multivariate analysis, age older than 80 and neurologic co-morbidity were more often significantly associated with HCAP. The more frequent identified microbial agents were S. pneumoniae, M. pneumoniae, C. pneumoniae, L.pneumophila, P. aeruginosa, enteric Gram - negative bacteria, S. aureus, H. influenzae and viruses. The etiology of CAP and HCAP was similar. Thirty - day mortality was higher in HCAP (44.5 vs. 33.7%). Conclusion. In patients older than 65, CAP is more frequent and severe, and the microbial etiology is different than in CAP of younger people. HCAP is even more severe and has higher mortality.

Ventilator-associated pneumonia in an adult clinical-surgical intensive care unit of a Brazilian university hospital: incidence, risk factors, etiology, and antibiotic resistance

The objective of this study was to evaluate clinical characteristics, etiology, and resistance to antimicrobial agents, among patients with ventilator-associated pneumonia (VAP). A case study vs. patients control under mechanical ventilation and hospitalized into clinical-surgical adults ICU of HC-UFU was performed from March/2005 to March/2006. Patients under ventilation for over 48 h were included in the study including 84 with diagnosis of VAP, and 191 without VAP (control group). Laboratory diagnosis was carried out through quantitative microbiological evaluation of tracheal aspirate. The identification of pathogens was performed by classical microbiological tests, and the antibiotics sensitivity spectrum was determined through the CLSI technique. VAP incidence rate over 1,000 days of ventilation was 24.59. The mean (± SD) duration of mechanical ventilation prior to VAP diagnosis was 23.2 ± 17.2 days. By multivariate analysis the risk factors predisposing for VAP were: mechanical ventilation time and mechanical ventilation > seven days, tracheostomy and use of > three antibiotics. Mortality rate was high (32.1 percent) but lower than that of the control group (46.5 percent). Major pathogens were identified in most of patients (95.2 percent) and included: Pseudomonas aeruginosa (29 percent), Staphylococcus aureus (26 percent), Enterobacter/Klebsiella/Serratia (19 percent) and Acinetobacter spp. (18 percent), with expressive frequencies of P. aeruginosa (52 percent), S. aureus (65.4 percent) and Enterobacteriaceae (43.7 percent) resistant to imipenem, oxacillin and 3/4 generation cephalosporins, respectively. In conclusion, our observation showed VAPs caused by multiresistant microorganisms, the prescription of > three antibiotics, and mortality with unacceptably high rates. The practice of de-escalation therapy appears to be urgently needed in order to improve the situation.

Neumonía adquirida en la comunidad en el adulto hospitalizado. Cuadro clínico y factores pronósticos / Community-acquired pneumonia in hospitalized adult patients. Clinical presentation and prognostic factors

BACKGROUND: Community-acquired pneumonia (CAP) is a serious health problem in Chile. AIM: To study prognostic factors on admission and outcome of CAP, in immune competent adult patients, hospitalized in the Catholic University Clinical Hospital. PATIENTS AND METHODS: All adult patients admitted with a CAP in a period of 2 years were prospectively studied. Patients with immunodeficiency, solid tumors or receiving oral adrenal steroids were excluded from the study. RESULTS: In the study period, 463 patients (69 +/- 19 years, 55 per cent male) were evaluated. Ninety four percent were treated with 2nd or 3rd generation cephalosporins. Mean hospital length of stay was 10 days. Mortality during hospital stay was 8 per cent and in the ensuing 30 days, it was 12 per cent. Bacterial etiology was established in 25 per cent of cases. The most frequent pathogens isolated were Streptococcus pneumoniae (10.2 per cent), Haemophilus influenzae (3.7 per cent), Staphylococcus aureus (2.8 per cent) and Gram negative bacilli (5.2 per cent). Admission prognostic factors associated with hospital mortality were an age over 65 years, presence of comorbidity, chronic neurological and hepatic disease, suspicion of aspiration, duration of symptoms for less than 3 days, presence of dyspnea and altered mental status, absence of cough, fever and chills; low blood pressure, tachypnea, metabolic acidosis, hypoxemia, high blood urea nitrogen, hypernatremia, hyperkalemia, hyperphosphatemia, hypoalbuminemia, multilobar radiographic pulmonary infiltrates, bacteremia, high risk categories of the Fine Index (IV and V), and admission to Intermediate Care Unit or ICU. CONCLUSIONS: The features of community acquired pneumonia of these patients are similar to those reported abroad.

Pneumonias comunitárias / Community acquired pneumonias

São apresentadas as pneumonias mais comuns adquiridas na comunidade, com discussão dos aspectos diagnósticos, condutas terapêuticas e preventivas