SURTO DE INFECÇÃO DE CORRENTE SANGUÍNEA RELACIONADO A HEPARINA POR ENTEROBACTER CLOACAE MULTIRRESISTENTE EM PACIENTES DIALÍTICOS INTERNADOS EM HOSPITAL TERCIÁRIO

Introdução/objetivo: Surtos de infecções relacionadas à hemodiálise podem ser comuns e associados a alta letalidade, frequentemente em decorrência de falha no tratamento da água ou nos processos assistenciais, desde a manipulação dos cateteres até a infusão de insumos utilizados no procedimento. Esse trabalho tem como objetivo relatar um surto de infecção de corrente sanguínea por Enterobacter cloclae multirresistente, relacionados a heparina contaminada, utilizada durante hemodiálise. Método: Estudo retrospectivo descritivo de uma série de casos de infecção de corrente sanguínea associada a hemodiálise em pacientes hospitalizados em hospital terciário em Sobral, Ceará. Resultado: Em agosto de 2023, o Serviço de Controle de Infecção hospitalar (SCIH) de um hospital terciário identificou 04 resultados de hemoculturas de pacientes com E. cloacae Multidroga-Resistente (MDR) em curto espaço de tempo (fora do padrão habitual de isolamento). Foram revisados então todos os casos ocorridos até então, quando foram identificados 33 pacientes em hemodiálise no leito, realizada por serviço terceirizado, e com resultado semelhante em hemocultura, em 2 meses. Alguns pacientes tinham hemoculturas positivas mesmo após dias de tratamento. Os desfechos foram alta (n=17/33; 56%) ou óbito (n=14/33; 44%). Dentre as fragilidades encontradas pelo Serviço de Controle de Infecção do hospital, juntamente com a equipe técnica da Vigilância Sanitária Estadual, estavam o manuseio, acondicionamento e administração de heparina. A análise microbiológica de frascos de heparina (n=4) de diferentes lotes, preparadas por manipulação pela empresa terceirizada, também evidenciou E. cloacae MDR. Cepas isoladas de sangue (n=19) e da heparina (n=2) foram submetidas a Eletroforese em Gel de campo Pulsado (PGFE), e todas se mostraram com mesmo padrão clonal. Todos os isolados eram portadores do gene blaKPC. Foram intensificadas medidas de prevenção pelo hospital e pelos órgãos reguladores e providenciada a substituição da troca do fornecedor de heparina, com resolução do surto. Conclusão: Surtos relacionados à hemodiálise podem ser de elevada letalidade, especialmente se causados por microrganismos multirresistentes. Heparina multidose aumenta o risco de surtos por fonte comum em hemodiálise. Nesse relato, o preparo, o fracionamento e o uso inadequados de heparina geraram uma fonte comum para um surto de infecção de corrente sanguínea por E. cloacae de difícil tratamento, com frequente desfecho letal

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Precision measurement of the structure of the CMS inner tracking system using nuclear interactions

The structure of the CMS inner tracking system has been studied using nuclear interactions of hadrons striking its material. Data from proton-proton collisions at a center-of-mass energy of 13 TeV recorded in 2015 at the LHC are used to reconstruct millions of secondary vertices from these nuclear interactions. Precise positions of the beam pipe and the inner tracking system elements, such as the pixel detector support tube, and barrel pixel detector inner shield and support rails, are determined using these vertices. These measurements are important for detector simulations, detector upgrades, and to identify any changes in the positions of inactive elements

Precision measurement of the structure of the CMS inner tracking system using nuclear interactions

The structure of the CMS inner tracking system has been studied using nuclear interactions of hadrons striking its material. Data from proton-proton collisions at a center-of-mass energy of 13 TeV recorded in 2015 at the LHC are used to reconstruct millions of secondary vertices from these nuclear interactions. Precise positions of the beam pipe and the inner tracking system elements, such as the pixel detector support tube, and barrel pixel detector inner shield and support rails, are determined using these vertices. These measurements are important for detector simulations, detector upgrades, and to identify any changes in the positions of inactive elements

Description and performance of track and primary-vertex reconstruction with the CMS tracker

A description is provided of the software algorithms developed for the CMS tracker both for reconstructing charged-particle trajectories in proton-proton interactions and for using the resulting tracks to estimate the positions of the LHC luminous region and individual primary-interaction vertices. Despite the very hostile environment at the LHC, the performance obtained with these algorithms is found to be excellent. For tbar t events under typical 2011 pileup conditions, the average track-reconstruction efficiency for promptly-produced charged particles with transverse momenta of p(T) > 0.9GeV is 94% for pseudorapidities of |η| < 0.9 and 85% for 0.9 < |η| < 2.5. The inefficiency is caused mainly by hadrons that undergo nuclear interactions in the tracker material. For isolated muons, the corresponding efficiencies are essentially 100%. For isolated muons of p(T) = 100GeV emitted at |η| < 1.4, the resolutions are approximately 2.8% in p(T), and respectively, 10μm and 30μm in the transverse and longitudinal impact parameters. The position resolution achieved for reconstructed primary vertices that correspond to interesting pp collisions is 10–12μm in each of the three spatial dimensions. The tracking and vertexing software is fast and flexible, and easily adaptable to other functions, such as fast tracking for the trigger, or dedicated tracking for electrons that takes into account bremsstrahlung

Strategies and performance of the CMS silicon tracker alignment during LHC Run 2

The strategies for and the performance of the CMS silicon tracking system alignment during the 2015–2018 data-taking period of the LHC are described. The alignment procedures during and after data taking are explained. Alignment scenarios are also derived for use in the simulation of the detector response. Systematic effects, related to intrinsic symmetries of the alignment task or to external constraints, are discussed and illustrated for different scenarios