Antibiotic stewardship and nosocomial infection prevention in critically ill patients: a quality improvement program.

OBJECTIVE: The objective of this study was to evaluate the impact of the implementation of a bundle of interventions through a "Program for Antibiotic Management and Nosocomial Infection Prevention" in the intensive care unit on antibiotic and devices use and healthcare-associated infections. METHODS: This was a quasi-experimental study of consecutive series of cases in periods before and after the establishment of protocols and checklists for the use of antibiotics as well as other measures to prevent healthcare-associated infection as part of a quality improvement program. Antimicrobial consumption was assessed by the defined daily dose. RESULTS: A total of 1,056 and 1,323 admissions in the pre-intervention and post-intervention phases, respectively, were evaluated. The defined daily dose per 100 patient-day decreased from 89±8 to 77±11 (p=0.100), with a decrease in carbapenems, glycopeptides, polymyxins, penicillins, and cephalosporins. The rates of ventilator and central venous catheter use decreased from 52.8 to 44.1% and from 76 to 70%, respectively. The rates of healthcare-associated infection decreased from 19.2 to 15.5%. CONCLUSION: Quality improvement actions focused primarily on antimicrobial management and prevention of healthcare-associated infection are feasible and have the potential to decrease antibiotic use and healthcare-associated infection rates.

Antibiotic stewardship and nosocomial infection prevention in critically ill patients: a quality improvement program

SUMMARY OBJECTIVE: The objective of this study was to evaluate the impact of the implementation of a bundle of interventions through a "Program for Antibiotic Management and Nosocomial Infection Prevention" in the intensive care unit on antibiotic and devices use and healthcare-associated infections. METHODS: This was a quasi-experimental study of consecutive series of cases in periods before and after the establishment of protocols and checklists for the use of antibiotics as well as other measures to prevent healthcare-associated infection as part of a quality improvement program. Antimicrobial consumption was assessed by the defined daily dose. RESULTS: A total of 1,056 and 1,323 admissions in the pre-intervention and post-intervention phases, respectively, were evaluated. The defined daily dose per 100 patient-day decreased from 89±8 to 77±11 (p=0.100), with a decrease in carbapenems, glycopeptides, polymyxins, penicillins, and cephalosporins. The rates of ventilator and central venous catheter use decreased from 52.8 to 44.1% and from 76 to 70%, respectively. The rates of healthcare-associated infection decreased from 19.2 to 15.5%. CONCLUSION: Quality improvement actions focused primarily on antimicrobial management and prevention of healthcare-associated infection are feasible and have the potential to decrease antibiotic use and healthcare-associated infection rates.

Lesão miocárdica e complicações cardiovasculares na COVID-19: estudo de coorte em pacientes graves e críticos / Myocardial injury and cardiovascular complications in COVID-19: a cohort study in severe and critical patients

RESUMO Objetivo: Caracterizar a lesão miocárdica e as complicações cardiovasculares e seus preditores em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. Métodos: Este foi um estudo de coorte observacional em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. A lesão miocárdica foi definida como níveis sanguíneos de troponina cardíaca acima do limite de referência superior ao percentil 99. Os eventos cardiovasculares considerados foram combinação de trombose venosa profunda, embolia pulmonar, acidente vascular cerebral, infarto do miocárdio, isquemia aguda de membros, isquemia mesentérica, insuficiência cardíaca e arritmia cardíaca. Regressão logística univariada e multivariada ou modelos de risco proporcional de Cox foram utilizados para determinar os preditores de lesão miocárdica. Resultados: Foram admitidos à unidade de terapia intensiva 567 pacientes graves e críticos com COVID-19, dos quais 273 (48,1%) apresentavam lesão miocárdica. Dos 374 pacientes críticos com COVID-19, 86,1% tinham lesão miocárdica, além de apresentarem mais disfunção orgânica e maior mortalidade aos 28 dias (56,6% versus 27,1%; p < 0,001). Foram preditores de lesão miocárdica idade avançada, hipertensão arterial e uso de imunomoduladores. Complicações cardiovasculares ocorreram em 19,9% dos pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva, e a maioria dos eventos deu-se em pacientes com lesão miocárdica (28,2% versus 12,2%; p < 0,001). A ocorrência de evento cardiovascular precoce durante internação em unidade de terapia intensiva estava associada à maior mortalidade aos 28 dias em comparação com eventos tardios ou inexistentes (57,1% versus 34,0% versus 41,8%; p = 0,01). Conclusão: Pacientes com formas graves e críticas de COVID-19 admitidos à unidade de terapia intensiva foram comumente diagnosticados com lesão miocárdica e complicações cardiovasculares, e ambas estavam associadas à maior mortalidade nesses pacientes.

ABSTRACT Objective: To characterize myocardial injury and cardiovascular complications and their predictors in severe and critical COVID-19 patients admitted to the intensive care unit. Methods: This was an observational cohort study of severe and critical COVID-19 patients admitted to the intensive care unit. Myocardial injury was defined as blood levels of cardiac troponin above the 99th percentile upper reference limit. Cardiovascular events considered were the composite of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, heart failure and arrhythmia. Univariate and multivariate logistic regression or Cox proportional hazard models were used to determine predictors of myocardial injury. Results: Of 567 patients with severe and critical COVID-19 admitted to the intensive care unit, 273 (48.1%) had myocardial injury. Of the 374 patients with critical COVID-19, 86.1% had myocardial injury, and also showed more organ dysfunction and higher 28-day mortality (56.6% versus 27.1%, p < 0.001). Advanced age, arterial hypertension and immune modulator use were predictors of myocardial injury. Cardiovascular complications occurred in 19.9% of patients with severe and critical COVID-19 admitted to the intensive care unit, with most events occurring in patients with myocardial injury (28.2% versus 12.2%, p < 0.001). The occurrence of an early cardiovascular event during intensive care unit stay was associated with higher 28-day mortality compared with late or no events (57.1% versus 34% versus 41.8%, p = 0.01). Conclusion: Myocardial injury and cardiovascular complications were commonly found in patients with severe and critical forms of COVID-19 admitted to the intensive care unit, and both were associated with increased mortality in these patients.

Myocardial injury and cardiovascular complications in COVID-19: a cohort study in severe and critical patients. / Lesão miocárdica e complicações cardiovasculares na COVID-19: estudo de coorte em pacientes graves e críticos.

OBJECTIVE: To characterize myocardial injury and cardiovascular complications and their predictors in severe and critical COVID-19 patients admitted to the intensive care unit. METHODS: This was an observational cohort study of severe and critical COVID-19 patients admitted to the intensive care unit. Myocardial injury was defined as blood levels of cardiac troponin above the 99th percentile upper reference limit. Cardiovascular events considered were the composite of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, heart failure and arrhythmia. Univariate and multivariate logistic regression or Cox proportional hazard models were used to determine predictors of myocardial injury. RESULTS: Of 567 patients with severe and critical COVID-19 admitted to the intensive care unit, 273 (48.1%) had myocardial injury. Of the 374 patients with critical COVID-19, 86.1% had myocardial injury, and also showed more organ dysfunction and higher 28-day mortality (56.6% versus 27.1%, p < 0.001). Advanced age, arterial hypertension and immune modulator use were predictors of myocardial injury. Cardiovascular complications occurred in 19.9% of patients with severe and critical COVID-19 admitted to the intensive care unit, with most events occurring in patients with myocardial injury (28.2% versus 12.2%, p < 0.001). The occurrence of an early cardiovascular event during intensive care unit stay was associated with higher 28-day mortality compared with late or no events (57.1% versus 34% versus 41.8%, p = 0.01). CONCLUSION: Myocardial injury and cardiovascular complications were commonly found in patients with severe and critical forms of COVID-19 admitted to the intensive care unit, and both were associated with increased mortality in these patients.

OBJETIVO: Caracterizar a lesão miocárdica e as complicações cardiovasculares e seus preditores em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. MÉTODOS: Este foi um estudo de coorte observacional em pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva. A lesão miocárdica foi definida como níveis sanguíneos de troponina cardíaca acima do limite de referência superior ao percentil 99. Os eventos cardiovasculares considerados foram combinação de trombose venosa profunda, embolia pulmonar, acidente vascular cerebral, infarto do miocárdio, isquemia aguda de membros, isquemia mesentérica, insuficiência cardíaca e arritmia cardíaca. Regressão logística univariada e multivariada ou modelos de risco proporcional de Cox foram utilizados para determinar os preditores de lesão miocárdica. RESULTADOS: Foram admitidos à unidade de terapia intensiva 567 pacientes graves e críticos com COVID-19, dos quais 273 (48,1%) apresentavam lesão miocárdica. Dos 374 pacientes críticos com COVID-19, 86,1% tinham lesão miocárdica, além de apresentarem mais disfunção orgânica e maior mortalidade aos 28 dias (56,6% versus 27,1%; p < 0,001). Foram preditores de lesão miocárdica idade avançada, hipertensão arterial e uso de imunomoduladores. Complicações cardiovasculares ocorreram em 19,9% dos pacientes graves e críticos com COVID-19 admitidos à unidade de terapia intensiva, e a maioria dos eventos deu-se em pacientes com lesão miocárdica (28,2% versus 12,2%; p < 0,001). A ocorrência de evento cardiovascular precoce durante internação em unidade de terapia intensiva estava associada à maior mortalidade aos 28 dias em comparação com eventos tardios ou inexistentes (57,1% versus 34,0% versus 41,8%; p = 0,01). CONCLUSÃO: Pacientes com formas graves e críticas de COVID-19 admitidos à unidade de terapia intensiva foram comumente diagnosticados com lesão miocárdica e complicações cardiovasculares, e ambas estavam associadas à maior mortalidade nesses pacientes.