A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting

Background Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. Methods A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. Results We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. Conclusion These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored

Impact of acute kidney injury exposure period among liver transplantation patients

Background: Acute kidney injury is a common complication of liver transplantation. in this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival.Methods: the study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study.Results: A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. the remaining 315 patients constituted the study population. in 207 procedures, the recipient was male (65%). the mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001).Conclusions: Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Universidade Federal de São Paulo, Div Nephrol, São Paulo, BrazilHosp Transplantes Euryclides de Jesus Zerbini, Liver Unit, São Paulo, BrazilHosp Israelita Albert Einstein, São Paulo, BrazilTufts Univ, New England Med Ctr, Div Nephrol, Medford, MA 02155 USAUniversidade Federal de São Paulo, Div Nephrol, São Paulo, BrazilWeb of Scienc

Implementation of an antibiotic prophylaxis protocol in an intensive care unit

Background: When properly employed, the prophylactic use of antimicrobials is associated with a reduction in surgical site infections (SSIs). We found that the appropriate use of antimicrobial prophylaxis was only 50.5% (53/105) among patients undergoing surgery in the adult intensive care unit of our hospital. in 2001, a protocol was designed to improve compliance with recommended practice.Methods: We used a prospective interventional study and a case control study carried out between 2001 and 2007, including follow-up and daily intervention to improve compliance with antimicrobial prophylaxis guidelines and to monitor antimicrobial consumption and SSI rates. Cases of noncompliance to the prophylaxis protocol (group I) were matched to controls (group II) with appropriate prophylaxis and compared with regards to type of surgery, operative duration, intraoperative antimicrobial use, type of antimicrobial used, length of hospital stay, severity of illness, comorbidities, invasive devices, possible adverse reactions, and death.Results: Compliance with antimicrobial prophylaxis metrics reached 85%; however, we were unable to detect a change in SSI rate or consumption and cost of antimicrobials. Inappropriate use was not associated with higher likelihood of death. There were no other significant differences between the 2 groups.Conclusion: Our intervention increased compliance with appropriate antimicrobial surgical prophylaxis with no negative impact on patient safety. Copyright (C) 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.Hosp Israelita Albert Einstein, Intens Care Unit, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilIIEP, Dept Stat, São Paulo, BrazilHosp Israelita Albert Einstein, Div Med Practice, São Paulo, BrazilVirginia Commonwealth Univ, Sch Med, Dept Internal Med, Richmond, VA USAUniversidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilWeb of Scienc

Identification of Clostridium difficile Asymptomatic Carriers in a Tertiary Care Hospital

Background. The diagnosis of Clostridium difficile infection (CDI) increases concern that asymptomatic carriers of toxigenic C. difficile may be diagnosed with CDI. Methods. A matched case control study was conducted in inpatients in a tertiary care center. The first 50 patients with diarrhea and a positive polymerase chain reaction (PCR) test beginning February 1, 2015, were identified as cases. Control patients were hospitalized patients receiving antibiotics, but with no diarrhea, housed in a room as close as possible to each case during the same admission time. A convenience sample of healthcare workers who cared for C. difficile infected patients was also tested. Results. We found two positive PCR results for C. difficile in controls (4.1%). None of these healthcare workers were positive for C. difficile by PCR. There was no difference between groups with respect to overall antibiotic use before the requested PCR for Clostridium difficile (p=0.359). The majority of cases had a high proportion of gastrointestinal disorders (71.4%) compared with control (8.2%), p<0.001. Patients with neoplasia had a higher chance of being identified as cases (p=0.041). Conclusions. PCR should not be the only diagnostic tool but should be complementary to other methods and to the medical history

Modulation of inflammatory response by selective inhibition of cyclooxygenase-1 and cyclooxygenase-2 in acute kidney injury

This work explored the role of inhibition of cyclooxygenases (COXs) in modulating the inflammatory response triggered by acute kidney injury.C57Bl/6 mice were used.Animals were treated or not with indomethacin (IMT) prior to injury (days -1 and 0).Animals were subjected to 45 min of renal pedicle occlusion and sacrificed at 24 h after reperfusion. Serum creatinine and blood urea nitrogen, reactive oxygen species (ROS), kidney myeloperoxidase (MPO) activity, and prostaglandin E2 (PGE(2)) levels were analyzed. Tumor necrosis factor (TNF)-alpha, t-bet, interleukin (IL)-10, IL-1 beta, heme oxygenase (HO)-1, and prostaglandin E synthase (PGES) messenger RNA (mRNA) were studied. Cytokines were quantified in serum.IMT-treated animals presented better renal function with less acute tubular necrosis and reduced ROS and MPO production. Moreover, the treatment was associated with lower expression of TNF-alpha, PGE(2), PGES, and t-bet and upregulation of HO-1 and IL-10. This profile was mirrored in serum, where inhibition of COXs significantly decreased interferon (IFN)-gamma, TNF-alpha, and IL-12 p70 and upregulated IL-10.COXs seem to play an important role in renal ischemia and reperfusion injury, involving the secretion of pro-inflammatory cytokines, activation of neutrophils, and ROS production. Inhibition of COX pathway is intrinsically involved with cytoprotection.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Univ São Paulo, Inst Biomed Sci, Dept Immunol, Transplantat Immunobiol Lab, BR-05508900 São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, Expt & Clin Immunol Lab, São Paulo, BrazilUniv Fed Juiz de Fora, Div Nephrol, Juiz de Fora, MG, BrazilUniversidade Federal de São Paulo, Dept Biol Sci, São Paulo, BrazilHosp Israelita Albert Einstein, Inst Ensino & Pesquisa, São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, Expt & Clin Immunol Lab, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Biol Sci, São Paulo, BrazilFAPESP: 04/08311-4FAPESP: 07/07139-3 e 06/03982-5Web of Scienc

Successful prevention of ventilator-associated pneumonia in an intensive care setting

Background: Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings.Objective: Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU).Methods: A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P 1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions.Results: the incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P = .05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%. Conclusion: These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.Hosp Israelita Albert Einstein, Intens Care Unit, São Paulo, BrazilHosp Israelita Albert Einstein, Infect Control Units, São Paulo, BrazilIIEP, São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, EPM, São Paulo, BrazilVirginia Commonwealth Univ, Sch Med, Dept Internal Med, Richmond, VA USAUniversidade Federal de São Paulo, Div Nephrol, EPM, São Paulo, BrazilWeb of Scienc

Low estimated glomerular filtration rate and chronic kidney failure following liver transplant: A retrospective cohort study

Background: Patients undergoing orthotropic liver transplant (LTx) often present with chronic kidney disease (CKD). Identification of patients who will progress to end-stage renal disease (ESRD) might allow not only the implementation of kidney protective measures but also simultaneous kidney transplant.Study Design: Retrospective cohort study in adults who underwent LTx at a single center. ESRD, death, and composite of ESRD or death were studied outcomes.Results: 331 patients, who underwent LTx, were followed up for 2.6 +/- 1.4 years; 31(10%) developed ESRD, 6 (2%) underwent kidney transplant after LTx and 25 (8%) remained on chronic hemodialysis. Patients with preoperative eGFR lesser than 60 ml/min per 1.73 m(2) had a 4-fold increased risk of developing ESRD after adjustment for sex, diabetes mellitus, APACHE II score, use of nephrotoxic drugs, and severe liver graft failure (HR = 3.95, 95% CI 1,73, 9.01; p = 0.001). Other independent risk factors for ESRD were preoperative diabetes mellitus and post-operative severe liver graft dysfunction.Conclusion: These findings emphasize low eGFR prior to LTx as a predictor for ESRD or death. the consideration for kidney after liver transplant as a treatment modality should be taken into account for those who develop chronic kidney failure after LTx.Albert Einstein Israelita Hosp HIAE, Learning & Res Inst, Transplantat Program, São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, São Paulo, BrazilEuryclides Jesus Zerbini Transplant Hosp Sao Paul, Liver Unit, São Paulo, BrazilTufts Univ, Sch Med, St Elizabeths Med Ctr, Brighton, MA USAUniversidade Federal de São Paulo, Div Nephrol, São Paulo, BrazilWeb of Scienc