The impact of healthcare-associated infection on mortality: failure in clinical recognition is related with inadequate antibiotic therapy

Purpose To understand if clinicians can tell apart patients with healthcare-associated infections (HCAI) from those with community-acquired infections (CAI) and to determine the impact of HCAI in the adequacy of initial antibiotic therapy and hospital mortality. Methods One-year prospective cohort study including all consecutive infected patients admitted to a large university tertiary care hospital. Results A total of 1035 patients were included in this study. There were 718 patients admitted from the community: 225 (31%) with HCAI and 493 (69%) with CAI. Total microbiologic documentation rate of infection was 68% (n = 703): 56% in CAI, 73% in HCAI and 83% in hospital-acquired infections (HAI). Antibiotic therapy was inadequate in 27% of patients with HCAI vs. 14% of patients with CAI (p<0.001). Among patients with HCAI, 47% received antibiotic therapy in accordance with international recommendations for treatment of CAI. Antibiotic therapy was inadequate in 36% of patients with HCAI whose treatment followed international recommendations for CAI vs. 19% in the group of HCAI patients whose treatment did not follow these guidelines (p = 0.014). Variables independently associated with inadequate antibiotic therapy were: decreased functional capacity (adjusted OR = 2.24), HCAI (adjusted OR = 2.09) and HAI (adjusted OR = 2.24). Variables independently associated with higher hospital mortality were: age (adjusted OR = 1.05, per year), severe sepsis (adjusted OR = 1.92), septic shock (adjusted OR = 8.13) and inadequate antibiotic therapy (adjusted OR = 1.99). Conclusions HCAI was associated with an increased rate of inadequate antibiotic therapy but not with a significant increase in hospital mortality. Clinicians need to be aware of healthcare-associated infections among the group of infected patients arriving from the community since the existing guidelines regarding antibiotic therapy do not apply to this group and they will otherwise receive inadequate antibiotic therapy which will have a negative impact on hospital outcome.Funding: Supported by an unrestricted grant from ASSUCIP (Associação de Apoio à Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António, Porto, Portugal). Teresa Cardoso is partially funded by a PhD research grant from the Teaching and Research Department (Departamento de Formação, Ensino e Investigação) of Oporto Hospital Centre (reference number 069/07(051-DEFI/084-CES)). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Differences in compliance with Surviving Sepsis Campaign recommendations according to hospital entrance time: day versus night

Introduction Higher compliance with Surviving Sepsis Campaign (SSC) recommendations has been associated with lower mortality. The authors evaluate differences in compliance with SSC 6-hour bundle according to hospital entrance time (day versus night) and its impact on hospital mortality. Methods Prospective cohort study of all patients with community-acquired severe sepsis admitted to the intensive care unit of a large university tertiary care hospital, over 3.5 years with a follow-up until hospital discharge. Time to compliance with each recommendation of the SSC 6-hour bundle was calculated according to hospital entrance period: day (08:30 to 20:30) versus night (20:30 to 08:30). For the same periods, clinical staff composition and the number of patients attending the emergency department (ED) was also recorded. Results In this period 300 consecutive patients were included. Compliance rate was (night vs. day): serum lactate measurement 57% vs. 49% (P = 0.171), blood cultures drawn 59% vs. 37% (P 8 mmHg 45% vs. 29% (P = 0.021), and central venous oxygen saturation (SvcO2) >70%, 7% vs. 2% (P = 0.082); fluids were administered in all patients with hypotension in both periods and vasopressors were administered in patients with hypotension not responsive to fluids in 100% vs. 99%. Time to get specific actions done was also different (night vs. day): serum lactate measurement (4.5 vs. 7 h, P = 0.018), blood cultures drawn (4 vs. 8 h, P < 0.001), antibiotic administration (5 vs. 8 h, P < 0.001), central venous pressure (8 vs. 11 h, P = 0.01), and SvcO2 monitoring (2.5 vs. 11 h, P = 0.222). The composition of the nursing team was the same around the clock; the medical team was reduced at night with a higher proportion of less differentiated doctors. The number of patients attending the Emergency Department was lower overnight. Hospital mortality rate was 34% in patients entering in the night period vs. 40% in those entering during the day (P = 0.281). Conclusion Compliance with SSC recommendations was higher at night. A possible explanation might be the increased nurse to patient ratio in that period. Adjustment of the clinical team composition to the patients' demand is needed to increase compliance and improve prognosis

Predisposition, Insult/Infection, Response and Organ Dysfunction (PIRO): A Pilot Clinical Staging System for Hospital Mortality in Patients with Infection

Purpose To develop a clinical staging system based on the PIRO concept (Predisposition, Infection, Response and Organ dysfunction) for hospitalized patients with infection. Methods One year prospective cohort study of all hospitalized patients with infection (n = 1035), admitted into a large tertiary care, university hospital. Variables associated with hospital mortality were selected using logistic regressions. Based on the regression coefficients, a score for each PIRO component was developed and a classification tree was used to stratify patients into four stages of increased risk of hospital mortality. The final clinical staging system was then validated using an independent cohort (n = 186). Results Factors significantly associated with hospital mortality were • for Predisposition: age, sex, previous antibiotic therapy, chronic hepatic disease, chronic hematologic disease, cancer, atherosclerosis and a Karnofsky index50%. Finally, this new clinical staging system was studied in a validation cohort, which provided similar results (0%, 9%, 31% and 67%, in each stage, respectively). Conclusions Based on the PIRO concept, a new clinical staging system was developed for hospitalized patients with infection, allowing stratification into four stages of increased mortality, using the different scores obtained in Predisposition, Response, Infection and Organ dysfunction. The proposed system will likely help to define inclusion criteria in clinical trials as well as tailoring individual management plans for patients with infectionThis research was supported by an unrestricted grant from ASSUCIP - Associação de Apoio à Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António, Porto, Portugal (Intensive Care Unit Support Association). Teresa Cardoso is funded by a PhD research grant from the Teaching and Research Department (Departamento de Formação, Ensino e Investigação) of Oporto Hospital Centre. Teixeira-Pinto is funded by a clinical research grant from the Science and Technology Foundation (PIC/IC/83312/2007). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Seleção do coqueiro anão verde para produção de polpa.

bitstream/item/90698/1/cot-62-2.pdfISSN 1678-1937

Self-efficacy, mental models and team adaptation: a first approach on football and futsal refereeing

Objective: Within the football and futsal refereeing context, even though referees work within teams, there is very little research considering the implications of team dynamics. In response, this study starts to address this gap in the literature by investigating the moderating effect of mental models on the relationship between self-efficacy beliefs and perceptions of team adaptation within the exciting context of professional and national football and futsal refereeing. Design: We obtained online questionnaires from 339 active football and futsal referees within the National and Professional league at two distinct points (April and May) within the football season. Results: Self-efficacy beliefs were positively associated with perceptions of team adaptation (only for football referees). Mental models were positively associated with team adaptation. Likewise, the moderation between mental models and self-efficacy beliefs was positively associated with perceptions of team adaptation (only for futsal referees). However, such an effect was only significant at the futsal referees’ level. Conclusion: This study emphasises the importance of mental models for team adaptation and the importance of self-efficacy beliefs in predicting perceptions of team adaptation. We hope that this study represents the first step in a greater appreciation of the salience of team dynamics and their impact on football and futsal referees’ performance and that future research can build upon our work.info:eu-repo/semantics/publishedVersio

Classification of healthcare-associated infection: a systematic review 10 years after the first proposal

BACKGROUND: Ten years after the first proposal, a consensus definition of healthcare-associated infection (HCAI) has not been reached, preventing the development of specific treatment recommendations. A systematic review of all definitions of HCAI used in clinical studies is made. METHODS: The search strategy focused on an HCAI definition. MEDLINE, SCOPUS and ISI Web of Knowledge were searched for articles published from earliest achievable data until November 2012. Abstracts from scientific meetings were searched for relevant abstracts along with a manual search of references from reports, earlier reviews and retrieved studies. RESULTS: The search retrieved 49,405 references: 15,311 were duplicates and 33,828 were excluded based on title and abstract. Of the remaining 266, 43 met the inclusion criteria. The definition more frequently used was the initial proposed in 2002--in infection present at hospital admission or within 48 hours of admission in patients that fulfilled any of the following criteria: received intravenous therapy at home, wound care or specialized nursing care in the previous 30 days; attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the previous 30 days; were hospitalized in an acute care hospital for ≥2 days in the previous 90 days, resided in a nursing home or long-term care facility. Additional criteria founded in other studies were: immunosuppression, active or metastatic cancer, previous radiation therapy, transfer from another care facility, elderly or physically disabled persons who need healthcare, previous submission to invasive procedures, surgery performed in the last 180 days, family member with a multi-drug resistant microorganism and recent treatment with antibiotics. CONCLUSIONS: Based on the evidence gathered we conclude that the definition initially proposed is widely accepted. In a future revision, recent invasive procedures, hospitalization in the last year or previous antibiotic treatment should be considered for inclusion in the definition. The role of immunosuppression in the definition of HCAI still requires ongoing discussion.This research was supported by an ASSUCIP (Associação de Apoio à Unidade de Cuidados Intensivos Polivalente - ICU, Hospital de Santo António, Porto, Portugal) grant. Dr. Cardoso is partially funded by a PhD research grant from the Teaching and Research Department (Departamento de Formação, Ensino e Investigação) of Oporto Hospital Centre. The funding organization had no role in the design or conduct of the study; the collection, analysis or interpretation of the data; or the preparation, review or approval of the manuscript, nor in the decision to submit the manuscript for publication

A abordagem do tema morte em cursos de enfermagem, do nível técnico à graduação

A morte constitui um dos maiores enigmas da existência humana, tendo demandado esforços para sua compreensão ao longo da história do pensamento ocidental. Considerada a mais universal das experiências, sendo que sua representação varia entre as culturas. Sabendo que a morte e o morrer são constitutivos da vida, certamente, carecem de maiores estudos no que se refere ao processo de formação do enfermeiro, uma vez que ele, em sua prática profissional, irá cuidar da pessoa na vida, na iminência de morte e na morte. A partir da experiência em enfermagem, da vivência de dificuldades apresentadas por diversos profissionais da saúde, em particular técnicos e enfermeiros, e de um trabalho de conclusão de curso de enfermagem sobre a temática, surgiu a necessidade de abordar como o tema morte se apresenta na formação do enfermeiro e do técnico de enfermagem. O presente estudo tem por objetivo realizar levantamentos bibliográficos em literaturas específicas, avaliando questões que envolvam abordagens relacionadas ao tema, buscando subsídios para construir um Curso de Extensão para graduandos em enfermagem. Para isso, está sendo feita a identificação de disciplinas que abordam o conceito de morte, nos cursos, além da pesquisa bibliográfica sobre o tema. Este trabalho justifica-se pela observação da falta de preparo psicológico dos profissionais de enfermagem, em vivenciar o processo da terminalidade. Considerando que um Curso de Extensão é um recurso a mais no processo ensino-aprendizado, e que pode abordar de maneira mais direta e específica o cuidado com o paciente terminal, julgamos ser pertinente sua proposta, que é parte de uma dissertação de mestrado em Ensino em Ciências da Saúde e do Meio Ambiente

Probing protein sequences as sources for encrypted antimicrobial peptides

Starting from the premise that a wealth of potentially biologically active peptides may lurk within proteins, we describe here a methodology to identify putative antimicrobial peptides encrypted in protein sequences. Candidate peptides were identified using a new screening procedure based on physicochemical criteria to reveal matching peptides within protein databases. Fifteen such peptides, along with a range of natural antimicrobial peptides, were examined using DSC and CD to characterize their interaction with phospholipid membranes. Principal component analysis of DSC data shows that the investigated peptides group according to their effects on the main phase transition of phospholipid vesicles, and that these effects correlate both to antimicrobial activity and to the changes in peptide secondary structure. Consequently, we have been able to identify novel antimicrobial peptides from larger proteins not hitherto associated with such activity, mimicking endogenous and/or exogenous microorganism enzymatic processing of parent proteins to smaller bioactive molecules. A biotechnological application for this methodology is explored. Soybean (Glycine max) plants, transformed to include a putative antimicrobial protein fragment encoded in its own genome were tested for tolerance against Phakopsora pachyrhizi, the causative agent of the Asian soybean rust. This procedure may represent an inventive alternative to the transgenic technology, since the genetic material to be used belongs to the host organism and not to exogenous sources

Drought impacts on children's respiratory health in the Brazilian Amazon.

notes: PMCID: PMC3893650types: Journal Article; Research Support, Non-U.S. Gov'tThis is an open access article that is freely available in ORE or from the publisher's web site. Please cite the published version.Drought conditions in Amazonia are associated with increased fire incidence, enhancing aerosol emissions with degradation in air quality. Quantifying the synergic influence of climate and human-driven environmental changes on human health is, therefore, critical for identifying climate change adaptation pathways for this vulnerable region. Here we show a significant increase (1.2%-267%) in hospitalisations for respiratory diseases in children under-five in municipalities highly exposed to drought. Aerosol was the primary driver of hospitalisations in drought affected municipalities during 2005, while human development conditions mitigated the impacts in 2010. Our results demonstrated that drought events deteriorated children's respiratory health particularly during 2005 when the drought was more geographically concentrated. This indicates that if governments act on curbing fire usage and effectively plan public health provision, as a climate change adaptation procedure, health quality would improve and public expenditure for treatment would decrease in the region during future drought events.Natural Environment Research Council (NERC)Economic and Social Research Council (ESRC