Brazilian experience in EU-CORE: daptomycin registry and treatment of serious Gram-positive infections

OBJECTIVES: To collect data about non-controlled prescribing use of daptomycin and its impact among Brazilian patients with serious Gram positive bacterial infection, as well as the efficacy and safety outcomes. MATERIALS AND METHODS: This is a multi-center, retrospective, non-interventional registry (August 01, 2009 to June 30, 2011) to collect data on 120 patients (44 patients in the first year and 76 patients in the second year) who had received at least one dose of commercial daptomycin in Brazil for the treatment of serious Gram-positive bacterial infection. RESULTS: Right-sided endocarditis (15.8%), complicated skin and soft tissue infections (cSSTI)wound (15.0%) and bacteremia-catheter-related (14.2%) were the most frequent primary infections; lung (21.7%) was the most common site for infection. Daptomycin was used empirically in 76 (63.3%) patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the most common suspected pathogen (86.1%). 82.5% of the cultures were obtained prior to or shortly after initiation of daptomycin therapy. Staphylococcus spp. - coagulase negative, MRSA, and methicillin-susceptible S. aureus were the most frequently identified pathogens (23.8%, 23.8% and 12.5%, respectively). The most common daptomycin dose administered for bacteremia and cSSTI was 6 mg/kg (30.6%) and 4 mg/kg (51.7%), respectively. The median duration of inpatient daptomycin therapy was 14 days. Most patients (57.1%) did not receive daptomycin while in intensive care unit. Carbapenem (22.5%) was the most commonly used antibiotic concomitantly. The patients showed clinical improvement after two days (median) following the start of daptomycin therapy. The clinical success rate was 80.8% and the overall rate of treatment failure was 10.8%. The main reasons for daptomycin discontinuation were successful end of therapy (75.8%), switched therapy (11.7%), and treatment failure (4.2%). Daptomycin demonstrated a favorable safety and tolerability profile regardless of treatment duration. CONCLUSIONS: Daptomycin had a relevant role in the treatment of Gram-positive infections in the clinical practice setting in Brazil.

Infecção ou colonização por micro-organismos resistentes: identificação de preditores / Infection or colonization with resistant microorganisms: identification of predictors

OBJETIVO: Identificar os fatores preditores de infecção ou colonização por micro-organismos resistentes. MÉTODOS: Foi realizado estudo quantitativo de coorte prospectivo. Foram realizadas a análise descritiva, para conhecimento da população do estudo, e a análise discriminante, para identificação dos fatores preditores. RESULTADOS: Foram incluídos 85 pacientes com infecções por micro-organismos resistentes: Pseudomonas aeruginosas resistente aos carbapenêmicos (24,7%), Acinetobacter resistente aos carbapenêmicos (21,2%), Staphylococcus aureus resistente à meticilina (25,9%), Enterococcus spp. resistente à vancomicina (17,6%) e Klebsiella pneumoniae resistente aos carbapenêmicos (10,6%). A análise discriminante identificou transferências de outros hospitais e internação na Unidade de Terapia Intensiva como fatores preditores para ocorrência de infecção pelos grupos S. aureus resistente à meticilina, Acinetobacter resistente aos carbapenêmicos e K. pneumoniae resistente aos carbapenêmicos. Nenhuma das variáveis estudadas foi discriminante para Enterococcus spp. resistente à vancomicina e P. aeruginosas resistente aos carbapenêmico. CONCLUSÃO: Os fatores preditores encontrados foram: internação na UTI e a transferências de outros hospitais.

OBJECTIVE: Identifying predictors of infection or colonization with resistant microorganisms. METHODS: A quantitative study of prospective cohort was carried out. A descriptive analysis was performed in order to know the population of the study and a discriminant analysis was performed to identify the predictors. RESULTS: In this study were included 85 patients with infections caused by resistant microorganisms: carbapenem-resistant Pseudomonas aeruginosas (24.7%); carbapenem-resistant Acinetobacter (21.2%); methicillin-resistant Staphylococcus aureus (25.9%), vancomycin-resistant Enterococcus spp (17.6%) and carbapenem-resistant Klebsiella pneumonia (10.6%). The discriminant analysis identified transfers from other hospitals and hospitalization in intensive care unit as predictors for the occurrence of infections by the following groups: S. aureus resistant to methicillin, Acinetobacter resistant to carbapenems and K. pneumoniae resistant to carbapenems. None of the studied variables was discriminant for vancomycin-resistant Enterococcus spp. and carbapenem-resistant P. aeruginosas.

The assessment of infection control in dental practices in the municipality of São Paulo

OBJECTIVE: The goal of this study was to evaluate the infection control measures actually implemented by dental surgeons during dental practice, as patients and professionals are exposed to high biological risk in dental care environments. METHOD: 614 questionnaires (90.69 percent) were answered by professionals registered in updating or in post-graduate courses in the Municipality of São Paulo. RESULTS: Out of surveyed professionals 30.62 percent admitted that surface protection barriers were not used, whereas 34.17 percent were using non ideal or outdated pre-disinfection practices. The autoclave was used by 69.38 percent of participants, although 33.80 percent were not monitoring control of the sterilization cycles. Chemical and biological indicators were not used simultaneously by 83.21 percent of respondents and were not employed on a daily or weekly basis by at least 81.75 percent. Dubious methods of sterilization were cited by 44.77 percent. Occupational accidents caused by cutting and piercing objects were reported by 47.88 percent; however, the biologic risk was underestimated by 74.15 percent of the professionals who suffered the accidents. Irritant solutions were used as an antiseptic agent by 18.55 percent. CONCLUSIONS: Infection control measures reported by dental surgeons during their practices are deficient. It is necessary to educate, raise awareness of professionals, and promote constant updating courses on procedures which aim at improving safety of dental care.

Vancomycin use in a hospital with high prevalence of Methicillin-Resistant Staphylococcus aureus: comparison with Hospital Infection Control Practices Advisory Committe Guidelines (HICPAC)

This study evaluates vancomycin prescribing patterns in a tertiary-care hospital, with high prevalence of methicillin-resistant Staphylococcus aureus, comparing with the guidelines proposed by the Hospital Infection Control Practices Advisory Committee. The study was conducted in a 930-bed tertiary-care hospital, during 40 days (March 10 to April 30, 2003). Data were collected of all patients given vancomycin, using a standardized chart-extraction form designed. Inappropriate use was subdivided in five categories: empiric therapy without risk factors; continued empiric use for presumed infections in patients whose cultures were negative for beta-lactam-resistant Gram-positive microorganisms; treatment of infections caused by beta-lactam-sensitive Gram-positive microorganisms, without allergy history to beta-lactam antimicrobials; treatment in response to a single blood culture positive for coagulase-negative staphylococcus, if other blood cultures taken during the same time frame were negative; systemic or local prophylaxis for infection or colonization of indwelling central or peripheral intravascular catheters. Of 132 orders, 126 (95.4 percent) were considered to have been appropriate. Of these 126 prescriptions, 31 (24.6 percent) were administered for treatment of proven Gram-positive infections (78.1 percent of those were MRSA), 1 (0.8 percent) for beta-lactam allergy and 95 (75.4 percent) for empiric treatment of suspected Gram-positive infections. The majority of the patients (88.6 percent) have used antimicrobial recently (3 months). The mean pre-treatment hospitalization period was 14±15 days. Of the 132 treatments, 105 (79.5 percent) were nosocomial infections. In the institution analyzed, the vancomycin use was considered conscientious. Reduction in use of glycopeptide may be obtained by adaptations the CDC criteria, or by improvement of diagnostic criteria.

Infecção da ferida cirúrgica em pacientes submetidos à cirurgia digestória / Surgical site infection in patients submitted to the digestory surgery

A infecção da ferida cirúrgica (IFC) tem sido apontada como um dos mais importantes tipo de infecção. Objetivos: este estudo buscou desenvolver um índice preditor de risco para IFC em pacientes submetidos à cirurgia digestória, comparar sua capacidade preditora com o índice de risco do National Nosocomial Infection Surveillance (NNIS); determinar a incidência da IFC intra-hospitalar e pós-alta. Métodos: tratou-se de um estudo prospectivo, realizado em dois hospitais gerais de São Paulo, no período de agosto de 2001 a março de 2002. Resultados: 609 pacientes foram submetidos a cirurgia e acompanhados durante a internação e após alta. Foram notificadas 149 IFC, obteve-se uma incidência global de 24,5% IFC, sendo 33 (22,1%) durante a internação e 116 (77,9%) após alta. Por análise multivariada construiu-se o modelo alternativo como as seguintes variáveis ( p na regressão logística <0,20): obesidade, risco cirurgia, duração ajustada, cirurgia laparoscópica e potencial de contaminação. Na validação do índice de risco, NNIS, verificou-se que o mesmo mostrou-se pouco preditor à ocorrência da IFC, na amostra estudada, curva ROC [(0,652); 0,627; IC95% 0,575 - 0,678]; modelo alternativo [(0,895); 0,753; IC95% 0,708 - 0,799]. Conclusão: a presença de obesidade, o potencial de contaminação a duração da cirurgia ajustada e o risco cirurgia incrementam significativamente o risco da IFC. Acredita-se que tais resultados possam contribuir para subsidiar uma análise crítica e reflexiva em relação ao sistema de vigilância epidemiológica adotada pelos profissionais do controle de infecção, aprimorando a vigilância atualmente realizada para o paciente cirúrgico , atentando para parâmetros que até o momento não utilizados.

Antibiotic prophylaxis in orthopedic surgeries: the results of an implemented protocol

Though the basic principles of antibiotic prophylaxis have been well established, there is still considerable incorrect usage, including how much is prescribed and especially in the duration of treatment, which is generally superior to what is indicated. The adequate use of these drugs contributes towards decreasing the time of internment of the patient, prevents surgical site infection (SSI), decreasing the development of resistant microorganisms, and towards reduced costs for the hospital pharmacy. A protocol for the use of antibiotic prophylaxis in the Orthopedics and Traumatology Service of the Hospital do Servidor Público Estadual de São Paulo was developed. The objectives of the study were to promote rational antibiotic surgical prophylaxis, through the implantation of a protocol for the use of these drugs in a surgical unit, with the direct contribution of a druggist in collaboration with the Infection Control Committee, to evaluate the adhesion of the health team to the protocol during three distinct periods (daily pre-protocol, early post-protocol and late post-protocol) and to define the consumption of antimicrobials used, measured as daily defined dose.

Análise de minimização de custos do uso de linezolida vs vancomicina em infecções de pele e partes moles por MRSA / Cost minimization analysis: use of linezolid vs vancomycin for MRSA skin and soft tissues infections

A linezolida é um antibiótico eficaz no tratamento de infecções de pele e de parte moles (IPPM) causadas por S. aureus resistente a meticilina (MRSA); além disso, seu uso pode antecipar a alta, reduzir os custos, minimizar as complicações decorrentes da internação e do uso da via intravenosa. Este estudo compara os tratamentos com linezolida e vancomicina para IPPM-MRSA

Análise da validade dos índices preditivos do risco de infecçäo de sítio cirúrgico e desenvolvimento de modelo de ajuste para avaliaçäo de cirurgias vasculares / Analysis of the validity the precourt appointed index of the risk of surgical-site infections and development of models of adjust for evaluation of vascular surgeries

Introduçao: A comparaçao dos índices de infecçao hospitalar depende de ajustes baseados na gravidade dos pacientes atendidos e dos tipos de procedimentos realizados. O método NNIS (National Nosocomial Infection Surveillance System), desenvolvido pelo CDC (Centers for Disease Control) ajusta a ocorrência de ISC (Infecçao de sítio cirúrgico) por três variáveis, a classificaçao ASA da gravidade da doença, a duraçao da operaçao e o potencial de contaminaçao da ferida operatória. O método NNIS foi avaliado em diversas situaçoes, mostrando-se de baixa acurácia em algumas situaçoes, como as cirurgias vasculares. O presente estudo tem como objetivo analisar a validade do método NNIÇ em cirurgias vasculares e desenvolver método específico de ajuste para estas operaçoes. Material e métodos: Foi realizado um coorte prospectivo no Serviço de Cirurgia Vascular do Hospital do Servidor Público Estadual de 1992 a 1996. Através de busca ativa, foram anotados o tipo de operaçao, o diagnóstico de infecçao e sete variáveis: o sexo, a idade, o tempo de intemaçao pré-operatório (TIP), a duraçao da operaçao, esta ajustada pelo ponto proposto como duraçao máxima para cada procedimento, a classificaçao ASA, o potencial de contaminaçao da ferida operatória e a classificaçao da lesao arterial subjacente (LAS), desenvolvida para este estudo. A amostra foi aleatoriamente dividida em dois grupos. No primeiro grupo foi realizada análise da validade no método NNIS, e também análise univariada, bivariada e multivariada para a construçao de modelo preditivo. Os dados referentes ao segundo grupo foram utilizados para análise da validade do método NNIS e dos índices desenvolvidos com a amostra anterior. Resultados: Nas 909 operaçoes do primeiro grupo, foram observadas 120 (l3,2 por cento ) ISC. A análise do modelo NNIS mostrou baixa correlaçao entre o índice e a ISC, tendo sido calculado coeficiente g de Goodman-Kruskal=O,O872. Foram desenvolvidos cinco modelos com extratificaçoes diferentes das variáveis. A duraçao ajustada da operaçao e a classificaçao da LAS se mostraram associadas à ISC em todos os modelos. No entanto o TIP somente se mostrou associado com a extratificaçao desta variável em dois cortes. A análise da validade de três dos cinco modelos e do modelo NNIS na amostra de teste (n=297) mostrou baixa acurácia para todos os métodos propostos. Discussao e conclusoes: Os métodos multivariados nao se mostraram apropriados para ajuste dos índices em ...(au)

Antibioticoprofilaxia em cirurgia. Noçöes gerais / Antibiotic prophylaxis in surgery. General ideas

Os autores discutem definiçäo, uso lógico e utilizaçäo racional de profilaxia antibiótica, enfatizando a necessidade de respaldo de tal uso na literatura médica; apresentam normatizaçäo de drogas e tempos de uso que correspondem a uma análise crítica dos trabalhos publicados, que mostram a utilidade da antibioticoprofilaxia segundo os vários procedimentos