Clinical characteristics and outcomes of healthcare workers with COVID-19 pre- and postvaccination.

Vaccines are the most effective strategy to control the spread of coronavirus disease-2019 (COVID-19). Data on COVID-19 among healthcare workers (HCW) pre- and postvaccination are limited. This study aims to evaluate the clinical characteristics and outcomes of HCW with COVID-19 pre- and postvaccination. Retrospective cohort study. All HCWs with suspected COVID-19 were included. Demographic data, occupation, symptoms, work in COVID-19 area, and vaccination status were collected. There were 22 267 HCW visits for suspected COVID-19; 7879 (35.4%) tested positive, and 14 388 (64.6%) tested negative. Fever, cough, fatigue, and dyspnea were positive predictors of COVID-19, and sore throat, headache, coryza, work in a COVID-19 area, and COVID-19 vaccination were negative predictors. Of the total number of visits, 41.2% were from vaccinated HCW and 58.8% were from unvaccinated HCW. Among HCWs with COVID-19, 84 (1.1%) required hospitalization, 11 (0.1%) in an intensive care unit (ICU), with three (0.04%) deaths. Six hospitalizations occurred in vaccinated HCWs, being of short duration, with no need for ICU admission and no deaths. SARS-CoV-2 infection prevalence was high among HCW, and vaccinated HCW had fewer hospitalizations, need for ICU, and deaths. Therefore, vaccines may attenuate COVID-19 severity, and efforts must be concentrated to ensure adequate vaccination for HCW.

Surgical Site Infection Rates in Four Cities in Brazil: Findings of the International Nosocomial Infection Control Consortium.

BACKGROUND: There are no data on surgical site infection (SSI) rates stratified by surgical procedures (SPs) in Brazil, and our objective was to report such rates. METHODS: From January 2005 to December 2010 we conducted a surveillance study on SSIs in four hospital members of the International Nosocomial Infection Control Consortium (INICC) in four Brazilian cities. We applied the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network's (CDC-NHSN's) surveillance methods. Surgical procedures were classified into following types following International Classification of Diseases (ICD-9) criteria. RESULTS: We recorded 349 SSIs, associated to 61,863 SPs (0.6%; [CI], 0.5-0.6). SSI rates per type of SP were compared with INICC and CDC-NHSN reports, respectively: 2.9% for cardiac surgery (vs. 5.6%, p = 0.001 vs. 1.3%, p = 0.001); 0.4% for cesarean section (vs. 0.7%, p = 0.001 vs. 1.8%, p = 0.001); 5.4% for craniotomy (vs. 4.4% p = 0.447 vs. 2.6% p = 0.005) and 1.1% for vaginal hysterectomy (vs. 2.0% p = 0.102 vs. 0.9% p = 0.499.) CONCLUSIONS: Our SSI rates were greater in two of the four analyzed types of SPs compared with CDC-NHSN, but similar to most INICC rates. These findings on the epidemiology of SSI in Brazil will enable us to introduce targeted interventions for infection control.

Outcomes and Risk Factors Associated with Clostridium difficile Diarrhea in Hospitalized Adult Patients.

Background. The epidemiology of Clostridium difficile infection has changed over time. Therefore, it is essential to monitor the characteristics of patients at risk of infection and factors associated with poor prognosis. Objective. To evaluate factors associated with C. difficile infection and with poor prognosis in those with documented C. difficile colitis. Methods. A retrospective case-control study of 75 patients with documented C. difficile colitis and 75 controls with hospital-acquired diarrhea of other causes. Stepwise multiple logistic regression was used to identify factors associated with C. difficile infection among patients with hospital-acquired diarrhea. Results. Previous antibiotic treatment (odds ratio (OR), 13.3; 95% confidence interval (CI), 1.40-126.90), abdominal distension (OR, 3.85; 95% CI, 1.35-10.98), and fecal leukocytes (OR, 8.79; 95% CI, 1.41-54.61) are considered as predictors of C. difficile colitis; anorexia was negatively associated with C. difficile infection (OR, 0.15; 95% CI, 0.03-0.66). Enteral tube feeding was independently associated with a composite outcome that included in-hospital mortality, intensive care unit admission, and treatment failure (OR, 3.75; 95%CI, 1.24-11.29). Conclusions. Previous antibiotic use and presence of fecal leukocytes in patients with hospital-acquired diarrhea are associated with C. difficile colitis and enteral tube support with complications associated with C. difficile colitis.

Accuracy of tracheal aspirate gram stain in predicting Staphylococcus aureus infection in ventilator-associated pneumonia.

BACKGROUND: The Gram stain can be used to direct initial empiric antimicrobial therapy when complete culture is not available. This rapid test could prevent the initiation of inappropriate therapy and adverse outcomes. However, several studies have attempted to determine the value of the Gram stain in the diagnosis and therapy of bacterial infection in different populations of patients with ventilator-associated pneumonia (VAP) with conflicting results. The objective of this study is to evaluate the accuracy of the Gram stain in predicting the existence of Staphylococcus aureus infections from cultures of patients suspected of having VAP. METHODS: This prospective single-center open cohort study enrolled 399 patients from December 2005 to December 2010. Patients suspected of having VAP by ATS IDSA criteria were included. Respiratory secretion samples were collected by tracheal aspirate (TA) for standard bacterioscopic analysis by Gram stain and culture. RESULTS: Respiratory secretion samples collected by tracheal aspirates of 392 patients were analyzed by Gram stain and culture. When Gram-positive cocci were arranged in clusters, the sensitivity was 68.4%, specificity 97.8%, positive predictive value 88.1% and negative predictive value 92.8% for predicting the presence of Staphylococcus aureus in culture (p < 0.001). CONCLUSIONS: A tracheal aspirate Gram stain can be used to rule out the presence of Staphylococcus aureus in patients with a clinical diagnosis of VAP with a 92.8% Negative Predictive Value. Therefore, 7.2% of patients with Staphylococcus aureus would not be protected by an empiric treatment that limits antimicrobial coverage to Staphylococcus aureus only when Gram positive cocci in clusters are identified.

Viral epidemiology of respiratory infections among children at a tertiary hospital in Southern Brazil.

INTRODUCTION: This study reports the pediatric epidemiology of respiratory syncytial virus (RSV), influenza (IF), parainfluenza (PIV), and adenovirus (ADV) at Hospital de Clínicas de Porto Alegre. METHODS: Cases of infection, hospitalizations in intensive care units (ICUs), nosocomial infections, and lethality rates were collected from 2007 to 2010. RESULTS: RSV accounted for most nosocomial infections. Intensive care units admission rates for ADV and RSV infections were highest in 2007 and 2010. During 2008-2009, H1N1 and ADV had the highest ICU admission rates. ADV had the highest fatality rate during 2007-2009. CONCLUSIONS: Each virus exhibited distinct behavior, causing hospitalization, outbreaks, or lethality.

Evaluation of respiratory syncytial virus group A and B genotypes among nosocomial and community-acquired pediatric infections in Southern Brazil.

BACKGROUND: Respiratory syncytial virus (RSV) is the main cause of lower respiratory tract illness in children worldwide. Molecular analyses show two distinct RSV groups (A and B) that comprise different genotypes. This variability contributes to the capacity of RSV to cause yearly outbreaks. These RSV genotypes circulate within the community and within hospital wards. RSV is currently the leading cause of nosocomial respiratory tract infections in pediatric populations. The aim of this study was to evaluate the G protein gene diversity of RSV amplicons. METHODS: Nasopharyngeal aspirate samples were collected from children with nosocomial or community-acquired infections. Sixty-three RSV samples (21 nosocomial and 42 community-acquired) were evaluated and classified as RSV-A or RSV-B by real-time PCR. Sequencing of the second variable region of the G protein gene was performed to establish RSV phylogenetics. RESULTS: We observed co-circulation of RSV-A and RSV-B, with RSV-A as the predominant group. All nosocomial and community-acquired RSV-A samples were from the same phylogenetic group, comprising the NA1 genotype, and all RSV-B samples (nosocomial and community-acquired) were of the BA4 genotype. Therefore, in both RSV groups (nosocomial and community-acquired), the isolates belonged to only one genotype in circulation. CONCLUSIONS: This is the first study to describe circulation of the NA1 RSV genotype in Brazil. Furthermore, this study showed that the BA4 genotype remains in circulation. Deciphering worldwide RSV genetic variability will aid vaccine design and development.

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation.

BACKGROUND: Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital. METHODS: In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period. RESULTS: During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year. CONCLUSION: One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staff's workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Community-acquired pneumonia at the Hospital de Clínicas de Porto Alegre: evaluation of a care protocol.

To assess the adequacy of medical prescriptions for community-acquired pneumonia at the emergency department of the Hospital de Clínicas de Porto Alegre, we conducted a prospective cohort study, from January through April 2011. All patients with suspected pneumonia were selected from the first prescription of antimicrobials held in the emergency room. Patients with a description of pneumonia, community-acquired pneumonia, respiratory infection, or other issues related to community-acquired pneumonia were selected for review. Two-hundred and fifteen patients were studied. Adherence to the hospital care protocol was: 11.2% for the initial recommended tests (chest X-ray and collection of sputum sample), 34.4% for blood cultures, and 92.1% for the antimicrobial choice. Sixty percent of the prescriptions consisted of a combination of drugs, and the association of beta-lactam and macrolide was the most common. The Hospital Infection Control Committee evaluated patients' prescriptions within a median time of 23.5h (IQR 25-75%, 8-24). Negative evaluations accounted for 10% of prescriptions (n=59). Fourteen percent of the patients died during hospitalization. In the multivariate analysis, Pneumonia Severity Index Score and use of ampicillin+sulbactam alone were independently related to in-hospital mortality. There was a high adherence to the hospital's CAP protocol, in relation to antimicrobial choice. Severity score and use of ampicillin+sulbactam alone were independently associated to in-hospital death.

Antimicrobial stewardship through telemedicine in a community hospital in Southern Brazil.

We developed an antimicrobial stewardship programme, based on telemedicine, for a remote community hospital in southern Brazil. Expertise in infectious diseases was provided from a 250-bed tertiary hospital for cardiology patients located 575 km away. At the community hospital, antimicrobial prescriptions were completed via a secure web site. A written reply was sent back to the prescriber by email and SMS text message. During a 4-month study period there were 81 prescriptions for 76 patients. Most antimicrobial prescriptions (67%) were for respiratory infections. Ampicillin was prescribed in 44% of cases (n = 56), gentamicin in 18% of cases (n = 23) and azithromycin in 18% of cases (n = 23). Two infectious diseases specialists independently reviewed each antimicrobial prescription. A total of 41 prescriptions (55%) were considered inappropriate. The median time to obtain a second opinion via the web site was 22 min (interquartile range 12-55). Overall compliance with the recommendations of the infectious diseases specialist was 100% (81 out of 81 requests). Telemedicine appears to have a useful potential role in antimicrobial stewardship programmes.

Microbiologic isolates and risk factors associated with antimicrobial resistance in patients admitted to the intensive care unit in a tertiary care hospital.

This study reviewed the clinical and microbiologic data for patients admitted to the intensive care unit with hospital-acquired infections. In the multivariate analysis, AIDS and previous antibiotic use were associated with the emergence of multiresistant bacteria. Hematologic diseases, length of stay, number of days on central venous catheter, antimicrobial use, and presence of multiresistant bacteria were associated with death. The previous use of antibiotics and the length of the hospital stay contribute to the development of infections caused by multiresistant gram-negative bacteria.

The impact of serum vancomycin levels and minimum inhibitory concentrations of methicillin-resistant Staphylococcus aureus on mortality in patients with nosocomial pneumonia.

BACKGROUND: Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) infections; however, treatment failure is not uncommon, even when the minimum inhibitory concentration (MIC) of the MRSA strain is within the susceptible range for vancomycin. OBJECTIVE: To describe the relationship between molecular markers such as the mecA and agrII genes, serum vancomycin levels and vancomycin MICs, and the 30-day mortality rate of patients with nosocomial MRSA pneumonia in an intensive care unit (ICU). METHODS: The present study was a prospective cohort study including all patients with MRSA hospital-acquired pneumonia or ventilator-associated pneumonia who were admitted to the ICU of a tertiary care hospital between June 2009 and December 2011. The MIC for vancomycin was determined using the E-test and broth microdilution methods. Variables analyzed included age, sex, comorbid conditions, serum vancomycin trough concentration, the Acute Physiology and Chronic Health Evaluation II (APACHE) score and the presence of the agrII gene. The primary outcome was mortality at 30 days. RESULTS: Thirty-six (42.4%) patients died within 30 days of the index MRSA culture. A multiple regression analysis that included the variables of MIC (determined using the E-test or broth microdilution methods), APACHE II score, serum vancomycin level and the presence of agrII revealed that only the APACHE II score was related to the 30-day mortality rate (P=0.03). Seven patients (9.0%) with isolates exhibiting an MIC ≥1.5 µg/mL according to the E-test method died, and nine patients (11.6%) survived (P=0.76). Of the patients for whom MICs were determined using the broth microdilution method, 11 (14.1%) patients with MICs of 1.0 µg/mL died, and 16 (20.5%) survived (P=0.92). The median APACHE II score of survivors was 22.5, and the median score of nonsurvivors was 25.0 (P=0.03). The presence of the agrII gene was not related to the 30-day mortality rate. CONCLUSIONS: Patients with severe hospital-acquired pneumonia presented with MRSA isolates with low to intermediate vancomycin MICs in the ICU setting. At the Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil), the 30-day mortality rate was high, and was similar among patients with severe hospital-acquired pneumonia infected with MRSA isolates that exhibited MICs of ≤1.5 µg/mL determined using the E-test method and ≤1.0 µg/mL determined using the broth microdilution method in those who achieved optimal serum vancomycin levels. The APACHE II scores which provides an overall estimate of ICU mortality were independently associated with mortality in the present study, regardless of the MICs determined. Molecular markers, such as the agrII gene, were not associated with higher mortality in the present study.

HISTORIQUE: La vancomycine est le traitement de première intention des infections par le Staphylococcus aureus résistant à la méthicilline (SARM), mais les échecs thérapeutiques ne sont pas rares, même lorsque la concentration minimale inhibitrice (CMI) de la souche de SARM se situe dans la plage susceptible de vancomycine. OBJECTIF: Décrire le lien entre les marqueurs moléculaires comme les gènes mecA et agrII, le taux de vancomycine sérique et la CMI de vancomycine, et le taux de mortalité au bout de 30 jours des patients atteints d'une pneumonie à SARM d'origine nosocomiale à l'unité de soins intensifs (USI). MÉTHODOLOGIE: La présente étude prospective de cohorte incluait tous les patients ayant une pneumonie à SARM d'origine nosocomiale ou d'une pneumonie acquise sous ventilation mécanique qui ont été hospitalisés à l'USI d'un hôpital de soins tertiaires entre juin 2009 et décembre 2011. Les chercheurs ont déterminé la CMI de la vancomycine au moyen des méthodes d'E-test et de microdilution en bouillon. Les variables qu'ils ont analysées sont l'âge, le sexe, les états comorbides, la concentration minimale de vancomycine sérique, le score APACHE (évaluation de physiologie aiguë et de maladie chronique II) et la présence du gène agrII. La mortalité au bout de 30 jours était l'issue primaire. RÉSULTATS: Trente-six patients (42,4 %)sont décédés dans les 30 jours suivant la culture de référence du SARM. Une analyse de régression multiple qui incluait les variables de la CMI (déterminée au moyen des méthodes d'E-test ou de microdilution en bouillon, le score APACHE II, le taux de vancomycine sérique et la présence du gène f agrII a révélé que seul le score APACHE II était lié au taux de mortalité au bout de 30 jours (P=0,03). Sept patients (9,0 %) dont les isolats présentaient une CMI d'au moins 1,5 µg/mL d'après la méthode d'E-test sont décédés, et neuf patients (11,6 %) ont survécu (P=0,76). Chez les patients dont la CMI a été déterminée au moyen de la méthode de microdilution en bouillon, 11 (14,1 %) ayant une CMI de 1,0 µg/mL sont décédés et 16 (20,5 %) ont survécu (P=0,92). Les survivants avaient un score APACHE II médian de 22,5, et les non-survivants, de 25,0 (P=0,03). La présence du gène agrII n'était pas liée au taux de décès au bout de 30 jours. CONCLUSIONS: Les patients ayant une grave pneumonie d'origine nosocomiale présentaient des isolats de SARM à la CMI faible à intermédiaire à la vancomycine à l'USI. Au Hospital de Clínicas de Porto Alegre (Porto Alegre, Brésil), le taux de mortalité au bout de 30 jours était élevé, tout comme chez les patients atteints d'une grave pneumonie d'origine nosocomiale infectés par des isolats du SARM dont la CMI était égale ou inférieure à 1,5 µg/mL d'après par la méthode d'E-test (ou égale ou inférieure à 1,0 µg/mL d'après la méthode de microdilution en bouillon) qui ont atteint des taux optimaux de vancomycine sérique. Les scores APACHE II qui procurent une évaluation globale de la mortalité à l'USI s'associaient de manière indépendante avec la mortalité dans la présente étude, quelle que soit la CMI établie. De plus, les marqueurs moléculaires, tels que le gène agrII, n'étaient pas liés à un taux de mortalité plus élevé y.

Use of intra-aortic balloon pump in cardiac surgery: analysis of 80 consecutive cases.

BACKGROUND: About 10% to 15% of patients undergoing cardiac surgery may develop low cardiac output syndrome in the perioperative period; of this total, 2% require mechanical support for adequate hemodynamic control. OBJECTIVE: To describe the mortality rates of patients who required the use of IABP in the perioperative or postoperative period of cardiac surgery, identifying preoperative variables associated with a worse outcome, as well as to describe the postoperative complications and medium-term survival. METHODS: Retrospective cohort study including 80 consecutive cases between January/2009 and September/ 2011. The patients had on average 62.9 ± 11.3 years and 58.8% were male; 81.3% were hypertensive, 50.0% had prior myocardial infarction and 38.8% has NYHA III/IV heart failure. The mainsurgery performed was isolated coronary artery bypass grafting (37.5%). RESULTS: Hospital mortality was 53.8% (IC 95%: 42.7-64.9), and cross-clamp time > 90 minutes was an independent predictor of mortality in multivariate analysis (OR 1.52 CI 95%: 1.04-2.22). 71.3% of patients (CI 95%: 61.2-81.4) had at least one additional complication in the perioperative period, with lower limb ischemia observed in 5.0% patients. One-year survival was 43.6%, with a plateau in survival rates after a sharp initial drop, related to hospital mortality. CONCLUSION: Patients who require IABP comprise a group of very high risk for morbidity and mortality. IABP use, however, enables the recovery of many patients from an evolution that would invariably be fatal, and patients discharged from hospital have a good medium-term survival.

Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study.

BACKGROUND: Antimicrobial stewardship programs (ASP) have been implemented to promote rational use of antimicrobial drugs. Multidisciplinary teams are needed to form effective committees. OBJECTIVE: Assess the impact of ASP, with and without the presence of a pharmacist, in a cardiology hospital in Brazil. METHODS: The program started with an infectious disease (ID) physician, and after 22 months, a pharmacist started to work in the ASP team. We present data related to: stage 1-before the program implementation; stage 2-with the ID physician; and stage 3 with the inclusion of a pharmacist. Analysis was made by segmented regression of time series. RESULTS: After the start of ASP there was a significant reduction of consumption of all antimicrobials. The pharmacist contributed to the significant reduction in consumption of fluoroquinolones, clindamycin and ampicillin/sulbactam and in increase in total cephalosporins use in stage 3. Adherence rate to the ASP team recommendations was 64.1%. There was a significant reduction of 69% in hospital antibiotics costs. CONCLUSION: A non-expensive ASP in a limited resource country resulted in reductions in antimicrobial consumption and costs. The multidisciplinary team contributed to maximize the impact of interventions.

Disseminated Histoplasma capsulatum and Cryptococcus neoformans co-infection in patients with AIDS.

Histoplasmosis and cryptococcosis are the most prevalent systemic mycoses in HIV-infected patients. The authors report a 20-year-old Brazilian HIV-positive woman with concomitant disseminated histoplasmosis and cryptococcosis. In addition, we review the reported cases described in the medical literature.