Appraising epidemiology data and antimicrobial resistance of urinary tract infections in critically ill adult patients: a 7-year retrospective study in a referral Brazilian hospital

ABSTRACT BACKGROUND: Urinary tract infections (UTI) are highly preventable and have significant clinical and financial impact on the patient and the health care system. OBJECTIVE: To investigate UTIs in critically ill adult patients and the relationship of antimicrobial consumption and multidrug-resistant isolate. DESIGN AND SETTING: A cohort study performed in a Brazilian tertiary-care university hospital in the city of Uberlandia (MG), located at the Federal University of Uberlandia, southeast region of the country. METHODS: We analyzed a cohort of 363 patients with first episode of UTIs from the adult intensive care unit (ICU), from January 2012 to December 2018. The daily doses of antimicrobial administered were calculated. RESULTS: The incidence rate of UTI was 7.2/1000 patient days, with 3.5/1000 patient-days of bacteriuria, and 2.1/1000 patient-days of candiduria. Of 373 microorganisms identified, 69 (18.4%) were Gram-positive cocci, 190 (50.9%) Gram-negative bacilli, and 114 yeasts (30.7%). Escherichia coli and Candida spp. were the most common. Patients with candiduria had higher comorbidity score (Charlson Comorbidity Index ≥ 3), longer length of stay (P = 0.0066), higher mortality (P = < 0.0001) severe sepsis, septic shock, and were immunocompromised when compared with patients with bacteriuria. We observed correlation between antibiotics consumption and multidrug-resistant (MDR) microorganisms. CONCLUSION: The UTIs incidence was high and was mainly caused by Gram-negative bacteria that were resistant to common antibiotics. We observed increase in the consumption of broad-spectrum antibiotics in ICU correlating with MDR microorganisms. In general, ICU-acquired candiduria may be associated with critical illness and poor prognosis.

Late onset sepsis in newborn babies: epidemiology and effect of a bundle to prevent central line associated bloodstream infections in the neonatal intensive care unit

Aim: We assessed late onset sepsis (LOS) rates of neonates in a neonatal intensive care unit (NICU) before and after implementing an evidence-based bundle to prevent these infections in a country with poor resources. Methods: We evaluate trends of LOS between October 2010 and August 2012 in a large tertiary hospital in Brazil. We designed a protocol based of CDC guidelines for insertion of maintenance of central venous catheter targeted to reduction of bloodstream infections. During this period two major events occurred: a great increase of LOS rates in January months and relocation of the unit to a provisory place. Additionally we evaluated the risk factors and etiology of these infections. Results: A total of 112 (20.3%) cases defined as LOS were found. The overall incidence rate of LOS in the study was 16.1/1000 patient/days and 23.0/1000 CVC-days. Our monthly rates data of LOS/1000 patient-day reveal fluctuations over the studied period, with incidence rates of these infections in staff vacation period (January 2011 and 2012) significantly higher (59.6/1000 patients-days) than compared with the other months rates (16.6/1000 patients-days) (IRR = 3.59; p < 0.001). As opposite, the incidence rates of LOS during relocation period was lower (10.3/1000 patients-days) when compared with baseline period 26.7/1000 patients-days (IRR = 2.59; p = 0.007). After the intervention period, these rates decreased in the post intervention period, when compared with preintervention 14.7/1000 patients-days and 23.4/1000 patients-days, respectively (IRR = 1.59; p = 0.04). Conclusion: Through simple infection control measures, LOS can be successfully controlled especially in NICUs of limited resources countries such as ours. .

Genotypic study documents divergence in the pathogenesis of bloodstream infection related central venous catheters in neonates

OBJECTIVE: To investigate the pathogenesis of bloodstream infection by Staphylococcus epidermidis, using the molecular epidemiology, in high-risk neonates. METHODS: We conducted a prospective study of a cohort of neonates with bloodstream infection using central venous catheters for more than 24 h. "National Healthcare Safety Network" surveillance was conducted. Genotyping was performed by DNA fingerprinting and mecA genes and icaAD were detected by multiplex-PCR. RESULTS: From April 2006 to April 2008, the incidence of bloodstream infection and central venous catheter-associated bloodstream infection was 15.1 and 13.0/1000 catheter days, respectively, with S. epidermidis accounting for 42.9% of episodes. Molecular analysis was used to document the similarity among six isolates of bloodstream infection by S. epidermidis from cases with positive blood and central venous catheter tip cultures. Fifty percent of neonates had bloodstream infection not identified as definite or probable central venous catheter-related bloodstream infection. Only one case was considered as definite central venous catheter-related bloodstream infection and was extraluminally acquired; the remaining were considered probable central venous catheter-related bloodstream infections, with one probable extraluminally and another probable intraluminally acquired bloodstream infection. Additionally, among mecA+ and icaAD+ samples, one clone (A) was predominant (80%). A polyclonal profile was found among sensitive samples that were not carriers of the icaAD gene. CONCLUSIONS: The majority of infections caused by S. epidermidis in neonates had an unknown origin, although 33.3% appeared to have been acquired intraluminally and extraluminally. We observed a polyclonal profile between sensitive samples and a prevalent clone (A) between resistant samples. .

Sepse neonatal precoce em unidade de terapia intensiva neonatal de um hospital universitário terciário / Early-onset sepsis in a neonatal intensive care unit at a tertiary referral university hospital

Objetivo: Avaliar a incidência de sepse neonatal precoce, fatores de risco e evolução em hospital universitário brasileiro. Métodos: No período de janeiro de 2010 a janeiro de 2011 foi realizada vigilância de sepse precoce na Unidade de Terapia Intensiva Neonatal do Hospital das Clínicas de Uberlândia. A sepse precoce foi definida nas primeiras 48 horas de vida, segundo critérios clínicos (febre, hipotermia, apneia, bradicardia), laboratoriais (escore hematológico) e/ou microbiológicos (hemocultura), associados a fatores de risco maternos. Para análise dos fatores de risco foi realizado estudo retrospectivo do tipo caso-controle. Realizaram-se análises estatísticas univariada e multivariada pelo programa BioEstat 5.0. A investigação foi aprovada pela Comissão de Ética da Universidade. Resultados: Foram internados 396 neonatos, com a detecção de 34 casos (8,5%) de sepse precoce; este índice representou um terço (31,4%) dos episódios de sepse, associada a alta mortalidade (44,1%). O diagnóstico foi baseado em critérios clínicos (94,1%), com a identificação de apenas um caso devido ao Streptococcus agalactiae. Adicionalmente, a colonização das gestantes era desconhecida em 61,7%. Pela análise univariada o valor de Apgar menor que 7 no 5º minuto (P=0,02) foi um fator de risco para sepse precoce e o número de consultas pré-natais maior ou igual a 7 (P=0,01), fator de proteção, enquanto na análise multivariada apenas o maior número de consultas no pré-natal (P=0,04) foi significativo. Conclusão: São necessários novos estudos para melhor conhecimento epidemiológico da sepse precoce, além de medidas de prevenção e controle desta infecção, considerando sua associação com uma alta mortalidade...

Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil / Redução de infecções de corrente sanguínea associadas ao cateter, após procedimentos em neonatos admitidos em uma unidade de teapia intensiva de um hospital universitário no Brasil

INTRODUCTION: Catheter-associated bloodstream infection (CA-BSI) is the most common nosocomial infection in neonatal intensive care units. There is evidence that care bundles to reduce CA-BSI are effective in the adult literature. The aim of this study was to reduce CA-BSI in a Brazilian neonatal intensive care unit by means of a care bundle including few strategies or procedures of prevention and control of these infections. METHODS: An intervention designed to reduce CA-BSI with five evidence-based procedures was conducted. RESULTS: A total of sixty-seven (26.7 percent) CA-BSIs were observed. There were 46 (32 percent) episodes of culture-proven sepsis in group preintervention (24.1 per 1,000 catheter days [CVC days]). Neonates in the group after implementation of the intervention had 21 (19.6 percent) episodes of CA-BSI (14.9 per 1,000 CVC days). The incidence of CA-BSI decreased significantly after the intervention from the group preintervention and postintervention (32 percent to 19.6 percent, 24.1 per 1,000 CVC days to 14.9 per 1,000 CVC days, p=0.04). In the multiple logistic regression analysis, the use of more than 3 antibiotics and length of stay >8 days were independent risk factors for BSI. CONCLUSIONS: A stepwise introduction of evidence-based intervention and intensive and continuous education of all healthcare workers are effective in reducing CA-BSI.

INTRODUÇÃO: As infecções de corrente sanguínea associadas ao cateter (ICS-AC) são as infecções hospitalares mais frequentes em unidades de terapia intensiva neonatais. O objetivo do nosso estudo foi reduzir as ICS-AC através de um pacote de medidas de cuidados incluindo algumas estratégias de controle e prevenção destas infecções. MÉTODOS: Foi realizada uma intervenção desenhada para reduzir as infecções de corrente sanguínea associadas ao cateter com cinco procedimentos de base. RESULTADOS: Um total de 67 (26,7 por cento) ICS-AC foi observado. Houve 46 (32 por cento) episódios de sepse com critério microbiológico (24,1 por 1.000 catater dias(CVC-dias). Os neonatos do grupo, após a implementação da intervenção, tiveram 21 (19,6 por cento) episódios de ICS-AC (14,9 por 1.000 CVC-dias). A incidência de ICS-AC reduziu significantemente entre os grupos pré-intervenção e pós-intervenção após a implementação das medidas (32 por cento para 19.6 por cento, 24.1 por 1.000 CVC-dias para 14.9 por 1.000 CVC-dias, p=0.04). Na análise de regressão logística múltipla, o uso de > três antibióticos e tempo de hospitalização > 8 dias foram fatores de risco independentes para ICS. CONCLUSÕES: A introdução de uma intervenção baseada em evidências e a educação intensiva e continuada de todos os profissionais de saúde são efetivas para a redução de ICS-AC.

Late onset sepsis and intestinal bacterial colonization in very low birth weight infants receiving long-term parenteral nutrition / Sepse de ataque tardio e colonização bacteriana intestinal em neonatos de muito baixo peso recebendo nutrição parenteral total

INTRODUCTION: The purpose of this study was to establish the late onset sepsis (LOS) rate of our service, characterize the intestinal microbiota and evaluate a possible association between gut flora and sepsis in surgical infants who were receiving parenteral nutrition (PN). METHODS: Surveillance cultures of the gut were taken at the start of PN and thereafter once a week. Specimens for blood culture were collected based on clinical criteria established by the medical staff. The central venous catheter (CVC) tip was removed under aseptic conditions. Standard laboratory methods were used to identify the microorganisms that grew on cultures of gut, blood and CVC tip. RESULTS: 74 very low birth weight infants were analyzed. All the infants were receiving PN and antibiotics when the gut culture was started. In total, 21 (28.4%) infants experienced 28 episodes of LOS with no identified source. Coagulase negative staphylococci were the most common bacteria identified, both in the intestine (74.2%) and blood (67.8%). All infections occurred in patients who received PN through a central venous catheter. Six infants experienced episodes of microbial translocation. CONCLUSIONS: In this study, LOS was the most frequent episode in neonates receiving parenteral nutrition who had been submitted to surgery; 28.6% of this infection was probably a gut-derived phenomenon and requires novel strategies for prevention.

INTRODUÇÃO: O objetivo deste estudo foi estabelecer a taxa de sepse de ataque tardio (LOS) do nosso serviço, caracterizar a microbiota intestinal e avaliar uma possível associação entre a flora intestinal e sepse em recém-nascidos cirúrgicos que estavam recebendo nutrição parenteral (NP). MÉTODOS: Culturas do intestino foram colhidas no início da nutrição parenteral e, posteriormente, uma vez por semana. As amostras para a cultura de sangue foram coletadas com base em critérios clínicos estabelecidos pela equipe médica. A ponta do cateter venoso central (CVC) foi removida sob condições assépticas. Métodos laboratoriais padrão foram usados para identificar os microrganismos que cresceram em culturas de sangue, do intestino, e da ponta do CVC. RESULTADOS: Foram analisados 74 recém-nascidos de muito baixo peso. Todas as crianças estavam recebendo nutrição parenteral e antibióticos quando a cultura do intestino foi iniciada. No total, 21 (28,4%) crianças apresentaram 28 episódios de sepse tardia sem fonte identificada. Os estafilococos coagulase negativo foram os mais comuns das bactérias identificadas, tanto no intestino (74,2%) como no sangue (67,8%). Todas as infecções ocorreram em pacientes que receberam nutrição parenteral através de um cateter venoso central. Seis crianças experimentaram episódios de translocação microbiana. CONCLUSÕES: Neste estudo LOS foi o episódio mais frequente em recém-nascidos recebendo nutrição parenteral e submetidos a cirurgia, 28,6% da infecção provavelmente foi um fenômeno derivado do intestino o que exige novas estratégias para a prevenção.

Nosocomial infections in a Brazilian neonatal intensive care unit: a 4-year surveillance study / Infecções hospitalares em uma unidade de terapia intensiva neonatal brasileira: vigilância de quatro anos

INTRODUCTION: Report the incidence of nosocomial infections, causative microorganisms, risk factors associated with and antimicrobial susceptibility pattern in the NICU of the Uberlândia University Hospital. METHODS: Data were collected through the National Healthcare Safety Network surveillance from January 2006 to December 2009. The patients were followed five times/week from their birth to their discharge or death. RESULTS: The study included 1,443 patients, 209 of these developed NIs, totaling 293 NI episodes, principally bloodstream infections (203; 69.3 percent) and conjunctivitis (52; 17.7 percent). Device-associated infection rates were as follows: 17.3 primary bloodstream infections per 1,000 central line-days and 3.2 pneumonias per 1000 ventilator-days. The mortality rate in neonates with NI was 11.9 percent. Mechanical ventilation, total parenteral nutrition, orogastric tube, previous antibiotic therapy, use of CVC and birth weight of 751-1,000g appeared to be associated with a significantly higher risk of NI (p < 0.05). In multiple logistic regression analysis for NI, mechanical ventilation and the use of CVC were independent risk factors (p < 0.05). Coagulase- negative Staphylococcus (CoNS) (36.5 percent) and Staphylococcus aureus (23.6 percent) were the most common etiologic agents isolated from cultures. The incidences of oxacillin-resistant CoNS and S. aureus were 81.8 percent and 25.3 percent, respectively. CONCLUSIONS: Frequent surveillance was very important to evaluate the association of these well-known risk factors with NIs and causative organisms, assisting in drawing the attention of health care professionals to this potent cause of morbidity.

INTRODUÇÃO: Relatar a incidência das infecções hospitalares, microrganismos causadores, fatores de risco associados e o padrão de susceptibilidade aos antimicrobianos na UTI neonatal do Hospital Universitário de Uberlândia. MÉTODOS: Realizou-se vigilância National Healthcare Safety Network de janeiro de 2006 a dezembro de 2009. Os pacientes foram acompanhados cinco vezes por semana desde o seu nascimento até a alta ou óbito. RESULTADOS: O estudo incluiu 1.443 pacientes dos quais 209 desenvolveram infecção hospitalar, totalizando 293 episódios de IHs, com destaque para as infecções de corrente sanguínea (203; 69,3 por cento) e conjuntivite (52; 17,7 por cento). As taxas de infecção associadas a dispositivos foram as seguintes: 17,3 infecções da corrente sanguínea primária por 1.000 CVC dia e 3,2 pneumonias por 1.000 ventiladores-dia. A taxa de mortalidade em recém-nascidos com infecções hospitalares foi de 11,9 por cento. A ventilação mecânica, nutrição parenteral total, sonda orogástrica, antibioticoterapia prévia, uso de CVC e peso de 751-1.000g pareceu estar associado com um risco significativamente maior de IH (p < 0,05). Na análise de regressão logística múltipla para IH, ventilação mecânica e uso de CVC foram fatores de risco independentes (p < 0,05). Staphylococcus coagulase-negativo (SCoN) (36,5 por cento) e Staphylococcus aureus (23,6 por cento) foram os agentes etiológicos mais comumente isolados. A incidência de SCoN e S. aureus resistente à oxacilina foram de 81,8 por cento e 25,3 por cento, respectivamente. CONCLUSÕES: Uma vigilância frequente foi importante para avaliar a associação de fatores de risco bem conhecidos com as IHs e etiologia com a finalidade de chamar a atenção dos profissionais de saúde para esta grande causa de morbidade.