Risk of acute kidney injury and cost-effectiveness analysis comparing vancomycin and linezolid for the treatment of pediatric patients infected with Gram-positive bacteria / Risco de lesão renal aguda e custo-efetividade comparando vancomicina e linezolida para o tratamento de pacientes pediátricos infectados por bactérias Gram-positivas

Objective: This study aimed to compare the occurrence of acute kidney injury (AKI) in pediatric patients who used vancomycin (VAN) or linezolid (LNZ) to treat Gram-positive coccus (GPC) infections and to assess which treatment (VAN or LNZ) is the most cost-effective considering a pediatric hospital perspective. Methods: A retrospective cohort was performed to evaluate the occurrence of nephrotoxicity in pediatric patients without previous AKI, with GPC infections that used LNZ, or VAN monitored by serum VAN levels. Initially, descriptive analysis and Fisher and chisquare test were performed for this comparison. Then, a cost-effectiveness analysis was conducted through a decision tree model. The outcomes of interest were the rate of AKI related to the drug and the rate of admission to the intensive care unit (ICU) and cure. Results: In patients without previous acute kidney injury (AKI), 20% developed nephrotoxicity associated with VAN versus 9.6% in the LNZ group (p = 0.241). As there was no difference in nephrotoxicity between VAN andlinezolid (LNZ), vancomycin (VAN) monitored by serum VAN levels can optimize and rationalize the treatment. The nephrotoxicity risk criterion should not guide the prescription for LNZ. Furthermore, the average global cost of treatment with VAN was approximately R$ 43,000, while for LNZ, it was R$ 71,000. Conclusion: VAN was considered dominant (lower cost and greater effectiveness) over LNZ for treating patients with GPC infection.

Objetivo: Este estudo objetivou comparar a ocorrência de lesão renal aguda (LRA) em pacientes pediátricos que usaram vancomicina (VAN) ou linezolida (LNZ) para tratar infecções por cocos Gram-positivos (CGP) e avaliar qual tratamento (VAN ou LNZ) é o mais custo-efetivo considerando a perspectiva de um hospital pediátrico. Métodos: Foi realizada uma coorte retrospectiva para avaliar a ocorrência de nefrotoxicidade em pacientes pediátricos sem LRA prévia, com infecções por CGP que utilizaram LNZ ou VAN, combinada com vancocinemia. Para essa comparação, inicialmente foram realizados análise descritiva e testes de Fisher e qui-quadrado. Em seguida, foi realizada uma análise de custo-efetividade por meio de um modelo de árvore de decisão. Os desfechos de interesse foram a taxa de LRA relacionada ao medicamento e a taxa de internação em unidade de terapia intensiva e cura. Resultados: Nos pacientes sem LRA prévia, 20% deles desenvolveram nefrotoxicidade associada à VAN versus 9,6% no grupo LNZ (p = 0,241). Como não houve diferença na nefrotoxicidade entre VAN e LNZ, a VAN combinada com a vancocinemia pode otimizar e racionalizar o tratamento, e a prescrição de LNZ não deve ser guiada pelo critério de risco de nefrotoxicidade. Além disso, o custo médio global do tratamento com VAN foi de aproximadamente R$ 43.000, enquanto para LNZ foi de R$ 71.000. Conclusão: Assim, a VAN foi considerada dominante (menor custo e maior eficácia) sobre a LNZ para o tratamento de pacientes com infecção por CGP.

From disease to noninvasive intracranial monitoring / Da doença ao monitoramento intracraniano não invasivo

ABSTRACT Professor Sérgio Mascarenhas was a Brazilian researcher with a vast legacy. His work paved the way for new research possibilities by consolidating the use of innovation and transdisciplinary science. In Medicine, he proposed changes to what had previously been well-accepted concepts, and his contributions have influenced medical practices. Although many authors consider intracranial pressure (ICP) as an unrivaled variable for monitoring and diagnosis of many diseases, its clinical applicability is still the subject of debate in the literature because of the difficulty in standardizing protocols. Mascarenhas's research and the creation of a device for noninvasive monitoring of intracranial compliance are discussed and are shown to have led to the creation of Brain4care, a start-up, and a new perspective on the debate on ICP monitoring.

RESUMO O professor Sérgio Mascarenhas foi um pesquisador com vasto legado. Seu trabalho abriu caminho para novas possibilidades de pesquisa, consolidando o uso da inovação e da ciência transdisciplinar. Na Medicina, ele propôs mudanças no que antes eram conceitos bem-aceitos, e suas contribuições influenciaram a prática médica. Embora muitos autores considerem a pressão intracraniana (PIC) uma variável incomparável para o monitoramento e o diagnóstico de uma série de doenças, sua aplicabilidade clínica ainda é motivo de debate na literatura pela dificuldade de padronização de protocolos. A pesquisa do Professor Mascarenhas e a criação de um dispositivo para o monitoramento não invasivo da complacência intracraniana levaram à criação do Brain4care, uma start-up, e a uma nova perspectiva sobre o debate do monitoramento da PIC.

PRAT tool: a harmonization of antimicrobial stewardship program interventions

Objective: The Antimicrobial Stewardship Program (ASP) in hospitals aims to promote the rational use of antimicrobials, providing better results to patients (increasing effectiveness and decreasing the risk of adverse events), hospital epidemiology (impact on levels of microbial resistance), and enable cost-effectiveness studies. Therefore, a tool (called PRAT­ antimicrobial therapy-related problem) is suggested in this paper. This unvalidated tool is the initial step towards organizing the antimicrobial therapy-related interventions to improve the use of this drug class, mainly by suggesting a harmonized registry process of ASP interventions. Methods: Therefore, this work presents the PRAT tool, developed based on the 10 years' experience of ASP at Pequeno Príncipe Hospital, inspired by the classification for drug-related problems of the Pharmaceutical Care Network Europe and according to a collaborative work using the Delphi technique. Results: This tool allows the identification and exact description of the antimicrobial therapy-related problem in 17 domains and 67 subcategories. Based on this identification, it suggests how to classify this problem (effectiveness, safety and need/indication) and what interventions can be conducted. Conclusion: This tool has the potential to establish a profile of antimicrobial-related problems, allowing prioritization to be visualized through the most (and least) interventions made in a given period, and might be useful in improving the quality of care through settings, by means of targeted educational interventions. Furthermore, if there is a harmonization of terminology for the classification of antimicrobial therapy-related problems, other hospitals can adopt it, and so the tool can improve research and comparison between institutions (benchmarking).