Multi-state survey of healthcare-associated infections in acute care hospitals in Brazil.

BACKGROUND: Healthcare-associated infections (HCAIs) challenge public health in developing countries such as Brazil, which harbour social inequalities and variations in the complexity of healthcare and regional development. AIM: To describe the prevalence of HCAIs in hospitals in a sample of hospitals in Brazil. METHODS: A prevalence survey conducted in 2011-13 enrolled 152 hospitals from the five macro-regions in Brazil. Hospitals were classified as large (≥200 beds), medium (50-199 beds) or small sized (<50 beds). Settings were randomly selected from a governmental database, except for 11 reference university hospitals. All patients with >48 h of admission to the study hospitals at the time of the survey were included. Trained epidemiologist nurses visited each hospital and collected data on HCAIs, subjects' demographics, and invasive procedures. Univariate and multivariate techniques were used for data analysis. FINDINGS: The overall HCAI prevalence was 10.8%. Most frequent infection sites were pneumonia (3.6%) and bloodstream infections (2.8%). Surgical site infections were found in 1.5% of the whole sample, but in 9.8% of subjects who underwent surgical procedures. The overall prevalence was greater for reference (12.6%) and large hospitals (13.5%), whereas medium- and small-sized hospitals presented rates of 7.7% and 5.5%, respectively. Only minor differences were noticed among hospitals from different macro-regions. Patients in intensive care units, using invasive devices or at extremes of age were at greater risk for HCAIs. CONCLUSION: Prevalence rates were high in all geographic regions and hospital sizes. HCAIs must be a priority in the public health agenda of developing countries.

Post-surgical mediastinitis due to carbapenem-resistant Enterobacteriaceae: Clinical, epidemiological and survival characteristics.

Invasive infections due to carbapenem-resistant Enterobacteriaceae (CRE), including polymyxin-resistant (PR-CRE) strains, are being increasingly reported. However, there is a lack of clinical data for several life-threatening infections. Here we describe a cohort of patients with post-surgical mediastinitis due to CRE, including PR-CRE. This study was a retrospective cohort design at a single cardiology centre. Patients with mediastinitis due to CRE were identified and were investigated for clinically relevant variables. Infecting isolates were studied using molecular techniques. Patients infected with polymyxin-susceptible CRE (PS-CRE) strains were compared with those infected with PR-CRE strains. In total, 33 patients with CRE mediastinitis were studied, including 15 patients (45%) with PR-CRE. The majority (61%) were previously colonised. All infecting isolates carried blaKPC genes. Baseline characteristics of patients with PR-CRE mediastinitis were comparable with those with PS-CRE mediastinitis. Of the patients studied, 70% received at least one agent considered active in vitro and most patients received at least three concomitant antibiotics. Carbapenem plus polymyxin B was the most common antibiotic combination (73%). Over 90% of patients underwent surgical debridement. Overall, in-hospital mortality was 33% and tended to be higher in patients infected with PR-CRE (17% vs. 53%; P=0.06). In conclusion, mediastinitis due to CRE, including PR-CRE, can become a significant challenge in centres with CRE and a high cardiac surgery volume. Despite complex antibiotic treatments and aggressive surgical procedures, these patients have a high mortality, particularly those infected with PR-CRE.

Post-surgical mediastinitis due to carbapenem-resistantEnterobacteriaceae: Clinical, epidemiological and survivalcharacteristics

Invasive infections due to carbapenem-resistant Enterobacteriaceae (CRE),including polymyxin-resistant(PR-CRE) strains, are being increasingly reported. However, there is a lack of clinical data for several life threatening infections. Here we describe a cohort of patients with post-surgical mediastinitis due to CRE,including PR-CRE. This study was a retrospective cohort design at a single cardiology centre. Patients with mediastinitis due to CRE were identified and were investigated for clinically relevant variables. Infecting isolates were studied using molecular techniques. Patients infected with polymyxin-susceptible CRE(PS-CRE) strains were compared with those infected with PR-CRE strains. In total, 33 patients with CRE mediastinitis were studied, including 15 patients (45%) with PR-CRE. The majority (61%) were previously colonised. All infecting isolates carriedblaKPC genes. Baseline characteristics of patients with PR-CRE mediastinitis were comparable with those with PS-CRE mediastinitis. Of the patients studied, 70% received atleast one agent considered active in vitro and most patients received at least three concomitant antibiotics. Carbapenem plus polymyxin B was the most common antibiotic combination (73%). Over 90% of patients underwent surgical debridement. Overall, in-hospital mortality was 33% and tended to be higherin patients infected with PR-CRE (17% vs. 53%; P = 0.06). In conclusion, mediastinitis due to CRE, includingPR-CRE, can become a significant challenge in centres with CRE and a high cardiac surgery volume. Despite complex antibiotic treatments and aggressive surgical procedures, these patients have a highmortality, particularly those infected with PR-CRE...

A space-time model for carbapenemase-producing Klebsiella pneumoniae (KPC) cluster quantification in a high-complexity hospital.

A retrospective space-time permutation model with non-Euclidean distance criteria was applied within a high-complexity hospital setting to quantitatively explore cluster patterns of 273 patients infected with or colonized by carbapenemase-producing Klebsiella pneumoniae during 4 years. Results were compared to standard nosocomial active-surveillance methods. Two clusters were identified in the period, suggesting that space-time strategies for cluster quantification within confined environments may be useful.

Pharmacodynamic comparison of linezolid, teicoplanin and vancomycin against clinical isolates of Staphylococcus aureus and coagulase-negative staphylococci collected from hospitals in Brazil.

Pharmacodynamic exposures, measured as the ratio of steady-state total drug area under the curve to MIC (AUC/MIC), were modelled using a 5000-patient Monte-Carlo simulation against 119 non-duplicate clinical isolates of Staphylococcus aureus and 82 coagulase-negative staphylococci (CNS) collected from hospitals in Brazil between 2003 and 2005. Pharmacodynamic targets included an AUC/MIC >82.9 for linezolid and >345 for teicoplanin and vancomycin, as well as a free drug AUC/MIC >180 for vancomycin. The cumulative fractions of response (CFRs) against all S. aureus isolates were 96.0%, 30.1%, 71.6%, 48.0% and 65.1% for linezolid 600 mg every 12 h, teicoplanin 400 mg every 24 h and 800 mg every 24 h, and vancomycin 1000 mg every 12 h and every 8 h, respectively. Using a free drug target for vancomycin improved the CFR to 94.6% for the high-dose regimen, but did not substantially alter results for the lower dose. CFRs against all CNS isolates were 97.8%, 13.4%, 34.6%, 10.9% and 31.3%, respectively, for the same antibiotic regimens. The CFR was reduced for all compounds among the methicillin-resistant isolates, except for linezolid against methicillin-resistant CNS. Sensitivity analyses did not alter the final order of pharmacodynamic potency against these isolates. Although higher doses of vancomycin and teicoplanin increased the CFR, the likelihood of achieving bactericidal targets was still lower than with linezolid. The results for the high-dose vancomycin regimen were highly dependent on the pharmacodynamic target utilised. These data suggest that linezolid has a greater probability of attaining its requisite pharmacodynamic target than teicoplanin and vancomycin against these staphylococci.

Antimicrobial susceptibility to levofloxacin and other antibacterial agents among common respiratory pathogens-a Brazilian perspective from the GLOBAL Surveillance Initiative 2001-2002.

The GLOBAL (Global Landscape On Bactericidal Activity of Levofloxacin) Surveillance programme monitored antimicrobial susceptibility patterns of the key respiratory tract pathogens Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis collected in Brazil during 1997-1998, 1999-2000 and 2001-2002. Penicillin and azithromycin resistance among S. pneumoniae strains increased from 1997-1998, reaching 7.9% and 9.5%, respectively, in 2001-2002. Although decreasing by 4.9% since the previous study, trimethoprim-sulphamethoxazole resistance remained high at 33.7%. Concurrent resistance to penicillin, azithromycin and trimethoprim-sulphamethoxazole was seen in 2.9% of the S. pneumoniae isolates collected. Levofloxacin remained extremely active against S. pneumoniae, with 0.3% resistance reported in 1997-1998 and 0% resistance in 1999-2000 and 2001-2002. beta-Lactamase production in H. influenzae was > 10% in all three studies, with correspondingly high rates of ampicillin resistance. Trimethoprim-sulphamethoxazole was the least active agent tested against H. influenzae, with resistance rates of > 40% recorded in all three studies. All H. influenzae isolates were susceptible to cefuroxime, ceftriaxone, azithromycin and levofloxacin. Of the M. catarrhalis isolates, 98.0% in 1997-1998, 98.0% in 1999-2000 and 81.8% in 2001-2002 were beta-lactamase-positive. The continued high prevalence of antimicrobial resistance in Brazil underscores the importance of current surveillance initiatives. Levofloxacin, a fluoroquinolone prescribed widely for respiratory tract infections, continued to show potent activity against key respiratory pathogens.

Treatment of nosocomial pneumonia: an experience with meropenem.

This study aimed at evaluating the efficacy and safety of meropenem as first choice treatment for nosocomial pneumonia (NP) in intensive care units (ICU) in Hospital das Clínicas (HC) - University of São Paulo; a hospital with high incidence of antimicrobial resistance. Prospective, open, and non-comparative trial with meropenem were done in patients with ventilator-associated or aspiration NP in 2 ICUs at HC - University of São Paulo. Etiologic investigation was done through bronchoalveolar lavage and blood cultures prior to study entry. Twenty-five (25) critically ill patients with NP were enrolled (mean age 40 years). Ventilator-acquired pneumonia was responsible for 76% of cases and aspiration NP for 24%. Specific etiologic agents were identified and considered to be clinically and temporally responsible for NP in 11 (44%) patients. A. baumanii was responsible for 6 cases (55%), P. aeruginosa for 3 (27%), and S. aureus for 2 (18%). At completion of treatment, 19 patients (76%) showed either cure (48%) or improvement (28%) after use of meropenem therapy. Mortality was 12% at the end of therapy (8% after excluding 1 non-evaluable patient). After 4 to 6 weeks of follow-up, 12 (48%) patients had improved or been totally cured, and overall mortality was 24%. Clinical complications were observed in 11 patients (44%), with none of them definitely related to the study drug. Meropenem as monotherapy was effective and well-tolerated in most NP patients in our ICU. The low mortality rate in this study might have been due to first choice use of this drug. Controlled, drug comparative clinical trials are needed to support this preliminary observation.

Evaluation of the in vitro activity of 9 antimicrobials against bacterial strains isolated from patients in intensive care units in brazil: MYSTIC Antimicrobial Surveillance Program.

Multi-resistant bacterial strains are increasingly prevalent in hospital environments. Bacterial resistance is an important problem, especially for practitioners in intensive care units (ICUs) because of the selective pressure on the prevalent bacteria in these environments. The MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) study has been monitoring the performance of carbapenems and other antibiotics in different hospitals for at least 3 years. The in vitro activities of meropenem, imipenem, ceftazidime, cefepime, cefotaxime, ciprofloxacin, piperacilin/tazobactam, gentamicin, and tobramycin were compared against 452 recent clinical aerobic isolates. The isolates consisted of 19 species of Gram-negative bacteria (n=290) including K. pneumoniae (n=49), E. coli (n=48), A. baumannii (n=47), Enterobacter spp. (n=41), and P. aeruginosa (n=33) and 9 species of Gram-positive bacteria (n=162) including Staphylococcus aureus (n=63), Enterococcus faecalis (n=22), Streptococcus pneumoniae (n=22) and coagulase negative Staphylococci (n=21). All isolates were collected from ICU patients. Minimal inhibitory concentrations (MICs) were determined by Etest methodology, using standardized and controlled procedures. Meropenem and imipenem showed the lowest MIC(90) for all species tested. Gram-negative isolates showed the following overall resistance percentages to the other 7 drugs: tobramycin (43.1%), cefotaxime (38.6%), gentamicin (34.1%), ceftazidime (31.7%), ciprofloxacin (25.5%), piperacillin/tazobactam (26.9%), and cefepime (18.6%). Carbapenems were the most active drugs overall and only P. aeruginosa presented some degree of resistance (18.2%). We also evaluated the production of extended spectrum beta-lactamase (ESBL) among all Enterobacteriaceae members (n=176) by Etest/ESBL strip. ESBL production was detected in 51 strains (29.0%). Among them, Klebsiella pneumoniae was the most prevalent at 59.2%, followed by Enterobacter spp. (19.5%) and E. coli (14.6%). The high level of resistance against several antimicrobials and the alarming rate of ESBL production may restrict therapeutic choice to the carbapenems in this selected group of patients.

Re-evaluation of the basic procedures involved in the storage of measles vaccine in public health units of the municipality of Niterói, State of Rio de Janeiro, Brazil.

Four years after the first visit seventeen public health units were visited again and evaluated as to standards of storage recommended by the Brazilian Immunization Programme. In 100% of the units, refrigerators and proper inside location of vaccines in the refrigerator were adequately or regularly maintained and checked, respectively. However, when control of temperature was checked, only 64.7% presented adequate storage conditions. In 94.1% of the units, health workers complained of lack of immediate technical support in emergency situations. In 55.2% the titers vaccine samples of were under the minimal recommended potency. It is necessary that the factors concerning the cold chain be continually evaluated so that the quality of the vaccines that will be used is not affected.