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

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

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

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

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

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