Brazilian University Hospital Research Articles

Diagnostic performance of the Xpert Carba-R™ assay directly from rectal swabs for active surveillance of carbapenemase-producing organisms in the largest Brazilian University Hospital

BackgroundThe global spread of carbapenemase-producing organisms (CPO) has been considered by international health authorities as a critical public health concern. Brazil has a high CPO prevalence according to distinct publications but many routine microbiology laboratories have only phenotypic resources to evaluate this epidemiological situation, which is time-consuming and detects only carbapenem-resistant isolates missing CPO susceptible expressing a slightly decreased susceptibility. New molecular platforms can detect CPO faster but a local evaluation is essential. AimTo evaluate the performance of CPO detection direct from rectal swabs with the Xpert Carba-R™ assay (Cepheid, Sunnyvale, CA) in the largest Brazilian University Hospital. MethodsA prospective diagnostic accuracy study of CPO was performed with the collection of rectal swabs from patients admitted into the Intensive Care Unit (ICU) and into the Emergency Department (ED) between April and July 2016. The Xpert Carba-R™ assay results were compared with carbapenem-resistant Enterobacterales (CRE) surveillance cultures plus in-house PCR carbapenemase detection (reference method). In case of discordant results between methods, additional tests were performed. The limit of detection (LoD) for the CRE culture and the Xpert Carba-R™ assay were performed with contrived isolates of known carbapenemases genes. ResultsA total of 921 clinical rectal swabs were analyzed being 21% (196/921) from the ICU and 79% (725/921) from the ED. Overall, the Xpert Carba-R™ assay detected 9.9% (91/921) of CPOs being 9.5% (87/921) positive only for blaKPC and 0.4% (4/921) positive only for blaNDM. The reference method detected 9.1% (84/921) CPO being 77 (8.4%) blaKPC, 5 blaVIM (0.5%) and 2 blaNDM (0.2%). No IMP or OXA-48 like gene was detected.Overall, twelve samples, 1.3% (10 blaKPC, 2 blaNDM) were Xpert Carba-R™ positive but negative by the reference method. Five isolates (0.5%) were positive for blaVIM only by in-house PCR and confirmed to be blaVIM-2 by DNA sequencing. The Kappa value, sensitivity, specificity, positive/negative predictive values and accuracy of the Xpert Carba-R™ assay were; 0.893 (95% confidence interval [CI], 0.842–0.944), 94% (86.7–98.0), 98.6% (97.5–99.3), 86.8% (78.1–93.0), 99.4% (98.6–99.8) and 98.2% (97.3–99.1), respectively. The LoD for blaKPC of the Xpert Carba-R™ assay and the CRE cultures were 101 CFU/swab. ConclusionThe Xpert Carba-R™ assay is an accurate test to detect CPO directly from the rectal swabs with significant lower turnaround time (TAT) when compared to the reference method (CRE culture plus in-house PCR). Xpert Carba-R™ may, therefore, be regarded as a good and fast epidemiological tool.

Understanding bereavement experiences of mothers facing the loss of newborn infants

Abstract Objective: to understand mothers' bereavement experiences regarding the loss of their newborn child in the Neonatal Intensive Care Unit of a Brazilian university hospital. Methods: the study was designed by the clinical-qualitative method to understand the meaning of the emerging relationships of health scenarios. Sample consisted of six mothers. The sufficiency of the sample was verified through the saturation of the data. The data collection instrument was a semistructured interview with script of open questions, the collected material was recorded and transcribed in full. Thematic analysis was performed by two independent authors. Results: feelings and perceptions of the grieving process gave rise to three categories: 1. Guilt and fantasy of bereavement related to the death and grief for their children; 2. Relationships and ambiguities - the relationship between internal concerns and perception of external relations; 3. Fear, disbelief, abandonment and loneliness - questions about perception of the external environment. Conclusions: mothers' bereavement experience is mainly permeated by loneliness and abandonment related to feelings of guilt for not being able to keep their children alive. The difficult and definitive separation in the postpartum period, caused by death, brings fantasies of reunion with their child. Women show the need to realize grief, especially by recognizing their baby's identity.

Abstract P4-02-14: Impact of ACOSOG Z0011 trial at University Hospital in Brazil

Abstract Background: The American College of Surgeons Oncology Group (ACOSOG) Z0011 trialwas a milestone in the surgical treatment of the axilla. Its results have made significant contributions in reducing the extent of breast surgery. In Brazil, this new approach was questioned, since the survival of the disease remains lower in the developing countries due to the difficulty in the early diagnosis, delay in the treatment and diagnosis in more advanced stages. Objective: To evaluate the overall survival and locoregional recurrence in patients with sentinel lymph node (SLN) metastatic from breast cancer with or without complete axillary lymph node dissection (ALND) treated at our institution. Methods: This retrospective cohort study evaluated patients with primary invasive breast cancer and clinically negative axilla who underwent lumpectomy and sentinel lymph node dissection (SLND) at the São Paulo Hospital, from February 2008 to December 2018. Patients with metastatic SLN were treated with SLND (group 1) or ALND (group 2). Group 1 was composed by the patients who met the inclusion criteria of ACOSOG Z0011 trial. Group 2 was composed by patients treated previous to the publication or by patients that had exclusion criteria according ACOSOG Z0011 trial. Overall survival was defined as the time relapsed from the date of surgery to death from any cause. Locoregional recurrence was determined by the presence of disease in the breast or ipsilateral lymph nodes in the axilla, supraclavicular, infraclavicular or internal mammary. Survival was analyzed with Kaplan-Meier method and comparison among groups with log-rank. Cox proportional-hazards model were applied. Statistical analysis was performed in SPSS version 20.0 and STATA12, with p value <0.05 considered significant. Results: A total of 415 patients were included in this study, 23.3% (97 patients) were identified as metastatic SLN, 56 patients were treated with SLND only (group 1) and 41 patients with ALND (group 2). The groups were homogeneous in relation to the variables: age group (50 years versus 51 years and over) (p = 0.279), race (p = 0.120), level of education (p = 0.142), pathological diagnosis (p = 0.210), histological grade (p = 0.983), hormonal receptors (p = 0.708), HER2 status (p = 0.695), pT (p = 0.334). Average age was 58.3 years (group 1) and 56.3 years (group 2), p = 0.456; and average tumor size was 1.8 cm (group 1) and 2.2 cm (group 2), p = 0.048. In group 1, the average number of resected lymph nodes was 2.7 and 91% of the cases only 1 lymph node was positive. In group 2, the average number of positive lymph nodes was 3.5 and only 17% had additional axillary disease. The SLND presented 35.7% micrometastasis compared to 2.4% in ALND (p <0.001) and a lower number of capsular extravasation (8.9%), in contrast to 41.5% in the ALND group (p <0.001). In addition, ALND group also had greater axillary involvement as evidenced by axillary pathological staging, with N1 (73.2%), N2 (19.5%), N3 (4.9%) and SLND group with N1 (62.5%) and no cases N2 or N3 (p <0.001). The average survival time, estimated using the Kaplan-Meier model, was 9.18 years (95% CI: 8.47-9.90). There was no difference in overall survival between patients who underwent SLND alone or ALND. The 5-year survival was 80.1% in the SLND and 87.5% in the ALND (p = 0.376). The locoregional recurrence was a rare event, average time of 5 years was 1.8% SLND and 7.7% ALND (p = 0.196). Only 4 locoregional recurrences were described and all occurred within 18 months of follow-up. Conclusions: Overall survival and locoregional recurrence in patients with metastatic axillary sentinel lymph node treated with SLND alone did not differ from those who underwent ALND, corroborating ACOSOG Z0011 data. The omission of axillary lymph node dissection and the implementation of this practice in our service benefits the patients treated with less aggressive surgeries and, potentially, produces lower morbidity. Citation Format: Afonso CelsoPinto Nazário, Simone Elias, Gil Facina, Vanessa Monteiro Sanvido. Impact of ACOSOG Z0011 trial at University Hospital in Brazil [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-02-14.

Coming and going to a surgical center, the evaluation of risks in transport of patients in a university hospital in Brazil

The patient’s in-hospital transport is an activity that must be performed with safety and quality and involves considerable risks, especially for surgical patients. The objective of this study was to evaluate the adequacy or not of transport of surgical patients from inpatient units to surgical centers and vice-versa. The transport and patient profile, the nursing workload, the professionals and conditions involved were assessed for each patient (or transport), and subsequently the transports were evaluated as inadequate (some non-conformity) or adequate. The transport was inadequate in 39.3% of the evaluations. The most common non-conformities were the lack of knowledge of the transport at the patient’s destination, incorrect documents, patient alone during the route, and absence of health professional during transport (when necessary). In this institution and in the period evaluated, the transport was mainly run by porter. Patients in rout to inpatient units have higher frequency of inadequate transport, mainly because of lack of communication with the destination unit. The increase in workload, evaluated by the Santos Score, also increased the risk of having inappropriate transport (OR = 1.21, CI95%: 1.08-1.16), and when the patients were grouped in minimal care versus non-minimal care, the latter also showed higher risk of inadequate transport. When the transports were evaluated separately by route, patients going to surgical centers had a higher risk when the Santos Score increased (OR = 1.168, CI95%: 1.07-1.27), and patients going to inpatient units had a lower risk when the Santos Score increased (OR = 0.605, CI95%: 0.46-0.80). In the last case, patients with a high workload were also accompanied by health professionals. The presence of a health professional when the patient was going to an inpatient unit also decreased the risk of inadequate transport (OR = 0.011, CI95%: 0.002-0.070). The patient returning to their origin unit showed more transport non-conformities. Perhaps the reason is the discredit attributed to risk in these patients once the surgical problem was solved. Thus, it is a fact that the patient nursing workload and the route of the transport were effective in predicting the risk of inadequate transport, being of great potential for practical use.

Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial

BackgroundProtective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS.MethodsWe conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis.ResultsWe randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835).ConclusionsIt was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation.Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258

Nontuberculous mycobacterial infections in a Brazilian pediatric population: a seven-year survey

ABSTRACTThe aim of this study was to describe the frequency of nontuberculous mycobacteria (NTM) isolation and their related outcomes among pediatric patients of a Brazilian university hospital from 2012 to 2019. NTM were identified in different clinical samples by microbiological culture and molecular-based methods. NTM were isolated from 14 patients, out of whom four (27%) were infected and were treated accordingly. Two were infected with Mycobacterium avium complex (MAC), two with M. abscessus complex (MABSC) and one with M. intracellulare. Two patients had cystic fibrosis-related lung disease and improved after successful NTM eradication. One patient was HIV-positive and died. One patient had severe combined immunodeficiency (SCID)-related pneumonia and is currently being followed-up. We conclude that NTM frequency in our center was low among pediatric patients. Whether this is inherent to Brazilian patients, due to the broad coverage of the Bacille Calmette-Guérin (BCG) vaccine in Brazil, or a result of underdiagnosis remains to be elucidated.

Early prediction of ICU readmissions using classification algorithms

Context:Determining which patients are ready for discharge from an Intensive Care Unit (ICU) presents a huge challenge, as ICU readmissions are associated with several negative outcomes such as increased mortality, length of stay, and cost compared to those patients who are not readmitted during their hospital stay. For these reasons, enhancing risk stratification in order to identify patients at high risk of clinical deterioration might benefit and improve the outcomes of critically ill hospitalized patients. Existing work on predicting ICU readmissions relies on information available at the time of discharge, however, in order to be more useful and to prevent complications, predictions need to be made earlier. Goals:In this work, we investigate the hypothesis that the basal characteristics and information collected at the time of the patient’s admission can enable accurate predictions of ICU readmission. Materials and Methods:We analyzed an anonymized dataset of 11,805 adult patients from three ICUs in a Brazilian university hospital. After excluding 1879 patients who died during their first ICU admission, our final dataset contained 9,926 patients. Of these, 658 patients (6.6%) had been readmitted to the ICU. The original dataset had 185 attributes, including demographics, length of stay prior to ICU admission, comorbidities, severity indexes, interventions, organ support care during ICU stay and laboratory results. The problem of predicting ICU readmissions was modeled as a binary classification task. We tested eight classification algorithms (including Bayesian algorithms, decision trees, rule-based, and ensemble methods) over different sets of attributes and evaluated their results based on six metrics. Results:Predictions made solely based on the attributes collected at the admission are highly accurate. Their quality in terms of prediction is no different from predictions made using the complete set of attributes for our dataset and for a subset of attributes selected by a feature selection method. Furthermore, our AUROC score of 0.91 (95% CI [0.89,0.92]) is higher than existing results published in the literature for other datasets. Discussion and Conclusion:The results confirm our hypothesis. Our findings suggest that early markers can be used to anticipate patients at high risk of clinical deterioration after ICU discharge.

ASSESSMENT OF THE USE OF TRANEXAMIC ACID AFTER TOTAL KNEE ARTHROPLASTY.

ABSTRACTObjective: To evaluate the profile of blood loss and blood transfusions after the introduction of Tranexamic acid (TXA) in a tertiary university hospital in Brazil.Methods: 173 patients were retrospectively divided into two groups: the ones who received TXA and the control group. Hemoglobin levels (Hb), drain output, transfusion rates, and thromboembolic events were measured.Results: Among the patients included in this study, 82 cases received TXA. Blood transfusion occurred in 3 cases of the TXA group (3.7%), and in 27 control group cases (29.7%; p < 0.001). The average Hb decrease was 2.7 g/dl (± 1.39) and the median drain output was 270 mL in the TXA group. In the control group, the values were 3.41 g/dl (± 1.34; p < 0.001) and 460 mL (p < 0.001), respectively. Thromboembolic events occurred in 2 TXA group cases (2.4%) and in 3 control group cases (3.3%; p > 0.999).Conclusion: TXA was effective in reducing blood transfusion rates, Hb decrease, and drain output on the 1st postoperative day without increasing thromboembolic events. Level of evidence III, Retrospective comparative study.

Cost-effectiveness analysis is a mandatory strategy for health systems: evidence from a study involving therapies for hepatitis C.

Cost-effectiveness analysis is essential in health decision making. Several countries use it as synthesis of evidence to incorporate health technologies. The protease inhibitors (PI) boceprevir (BOC) and telaprevir (TVR) are indicated for chronic hepatitis C treatment and were incorporated in guidelines worldwide. Pre-marketing clinical trials showed higher sustained virological response rates in relation to previous therapies, but the incorporation of PIs generated a significant financial impact. The aim of this study was to discuss the relevance of cost-effectiveness analysis through a study that involved the inclusion of PIs in a clinical protocol. The analysis was part of a real-life study that included patients infected with hepatitis C virus genotype 1 treated in a tertiary university hospital in Brazil. Triple therapies (TT) with ribavirin (RBV), peginterferon α-2a (Peg-INF α-2a) and BOC or TVR were compared to dual therapy with RBV and Peg-INF α-2a. Sensitivity analysis of the cost-effectiveness ratio indicated an 88.2% chance of TTs presenting a higher cost per cure. The incremental cost-effectiveness ratios (ICER) exceeded the Brazilian gross domestic product (GDP) per capita by three times in all proposed scenarios. The sensitivity of ICER showed an 88.4% chance of TT not being cost-effective. The impact of PI incorporation was negative and the conduct about this could have been different if a previous cost-effectiveness analysis had been conducted.

Impact of a safety and quality improvement program on the safety climate among ICU professionals in a Brazilian university hospital

Introduction: The assessment of patient safety culture plays a key role in promoting safe care, aiming at areas that need improvement, and thus help guide actions and attitudes towards better overall performance. Objectives/Aims: To evaluate the impact of the implementation of a safety and quality improvement program and safety culture among intensive care professionals. Methods: Prospective study, multifaceted intervention: using strategies such as stimulation to report adverse events, dissemination of clinical and quality results, implementation of action plans, training, in addition to the stimulation of family members participation. The safety culture was measured anonymously with an electronic version of the Safety Attitudes Questionnaire (SAQ) (7 domains / 36 questions / with responses Likert scale) previously and 9 months after implementation. Fully / partially agreeing responses were interpreted as positive; the amount of positive answers of each question determined the performance of the respective domain, expressed as a percentage of the maximum grade reached. Results expressed as median (25-75% percentile) used the Mann-Whitney test. Results: The SAQ of the professionals was answered (pre-intervention: 115, 56%, post-intervention: 123, 60%). The answers were predominantly from physicians (pre: 38%, post: 38%) and nurses (pre: 22%, post: 28%). There was a significant increase in the total SAQ score (pre-intervention: 59.0 (46.1 -78.5) after the intervention (72.7 (52.5-88.3), p = 0.001). (66.6 (50-66.6) x 66.6 (50 - 100) p = .001) and a safety climate (37.5 (12.5 - 75.0) x 62.5 (37.5-87.5) p = 0.002). Conclusion: The implementation of a safety and quality improvement program was associated with an improvement in the overall security climate, enhancing the safety and teamwork climate. These factors may be implicated in safer care.

Prevalence of atrial fibrillation, oral anticoagulation prescription and associated factors in Brazilian older adults

INTRODUCTION: Atrial fibrillation increases five times the risk of stroke. Anticoagulation reduces the incidence of cerebrovascular events. However, many patients do not receive thromboprophylaxis. OBJECTIVES: To estimate the prevalence of atrial fibrillation in the elderly at a Brazilian university hospital and the proportion of anticoagulation prescription. Secondary objectives were to identify the therapeutic options, the main reasons for non-prescription and the factors associated with ineffectiveness or lack of treatment. METHOD: cross-sectional study with a consecutive sample of 1,630 outpatients selected at Hospital de Clínicas de Porto Alegre between April and June of 2017. Atrial fibrillation was identified in 220 (13.50%) individuals. Medical records from 145 patients were accessed, followed by a telephone interview. The association between variables and outcomes was checked using the Mann-Whitney’s U Test and the binary logistic regression. RESULTS: The prevalence of atrial fibrillation was 13.50%. Anticoagulation therapy was prescribed in 77.93% of cases. In 76.11% of patients, warfarin was the chosen drug. There was a tendency towards no prescription in patients with previous bleeding (RR = 2.32; 95%CI 0.95 – 5.64; p = 0.06) and falls (RR = 2.02; 95%CI 0.82 – 5.03; p = 0.08). We found an association between reduced functional capacity (Barthel’s Activities of Daily Living Score &lt; 80) and higher rate of anticoagulation in therapeutic aim (RR = 0.22; 95%CI 0.06 – 0.87; p = 0.04). CONCLUSION: The prevalence of atrial fibrillation in this population was 13.50% and in 77.93% of cases anticoagulant were prescribed. Functional impairment was associated with a higher rate of anticoagulation in therapeutic aim.

Two variants of the Nutritional Risk in the Critically Ill Score as predictors of mortality in Intensive Care Unit patients at a Brazilian University Hospital

ABSTRACT Objective To evaluate the agreement between the modified version of the Nutritional Risk in the Critically Ill Score (without Interleukin-6) and a variant composed of C-Reactive Protein as well as its capacity to predict mortality. Methods A prospective cohort study was carried out with 315 patients in an Intensive Care Unit of a university hospital from October 2017 to April 2018. The agreement between the instruments was evaluated using the Kappa test. The predictive capacity for estimating mortality was assessed with the Receiver Operating Characteristic curve. Results The critical patients involved in the study had a mean age of 60.8±16.3 years and 53.5% were female. Most patients had C-Reactive Protein levels ?10mg/dL (n=263, 83.5%) and their admission in the Intensive Care Unit was medical (n=219, 69.5%). The prevalence of mortality was observed in 41.0% of the evaluated patients. The proportions at high nutritional risk according to Nutritional Risk in the Critically Ill without Interleukin-6 and with C-Reactive Protein were 57.5% and 55.6%, respectively. The tools showed strong and significant agreement(Kappa=0.935; p=0.020) and satisfactory performances in predicting mortality (area under the curve 0.695 [0.636-0.754] and 0.699 [0.640-0.758]). Conclusion Both versions of the Nutritional Risk in the Critically Ill tool show a satisfactory agreement and performance as predictors of mortality in critically ill patients. Further analysis of this variant and the association between nutrition adequacy and mortality is needed.

Drug induced liver damage in a universitary hospital

&lt;strong&gt;Background:&lt;/strong&gt; Drug Induced Liver Injury (DILI) is responsible for wide spectrum of liver injury. Clinically, these events are presented in various forms and for reaching a different diagnosis other injury causes must be excluded. &lt;strong&gt;Aim:&lt;/strong&gt; Identify and characterize cases of hepatotoxicity induced by drugs, herbal and dietary supplements in University Hospital in Brazil. &lt;strong&gt;Material and Methods: &lt;/strong&gt;Observational and retrospective study. Was collected in records of University Hospital, between August 2009 at August 2014. The causality of the drug reactions suspected were evaluated Council for International Organizations of Medical Sciences (CIOMS). &lt;strong&gt;Results:&lt;/strong&gt; We selected 30 suspected cases, 50% was female and average was 39 years. The therapeutic classes most common was: anti-infectives; antineoplastic agents; central nervous system drugs, anabolic steroid and herbal and dietary supplements (HDS). Cholestatic or mixed injury was observed in 73% these cases; 60% were highly probable, according to CIOMS. &lt;strong&gt;Conclusion:&lt;/strong&gt; DILI is caused by a wide variety of drugs, dietary supplements and dietary supplements. Anti-infectives and chemotherapy were responsible for much of the response

1211. Microbiologic Evaluation of Mobile Phones and Hands of Healthcare Professionals in Two Intensive Care Units in a Brazilian University Hospital

BackgroundHealthcare-associated infections (HAIs) are a worldwide concern because of their high morbidity, mortality, and associated costs. Mobile phones (MP) are an important work tool in the healthcare setting, but they can be a reservoir of nosocomial pathogens if not carefully cleaned and cause re-contamination of the healthcare professional’s (HCP) hands. We aimed to evaluate bacterial colonization of HCP’s hands and their respective MPs.MethodsA cross-sectional study was performed in two Intensive Care Units (ICUs), an internal medicine and a burn unit, of a Brazilian tertiary university hospital. These units were chosen because of their different hand hygiene (HH) compliance. We assessed HH and MP handling practices by an electronic inquiry and collected samples from the dominant hand (DH) by the sterile bag technique and of MPs by moistened sterile swab. MALDI-TOF was used for bacterial identification and Dilution Agar (DA) was used to screen Gram-negative bacteria (GNB) susceptibility to carbapenems and colistin.ResultsForty-seven HCPs were evaluated; of whom, 30% were medical residents, 19% nurses, 17% nurse-technicians, 17% physiotherapists, 13% cleaning staff, and 4% radiology technicians.Overall, 85% of HCPs reported use of MP at work, 26% had never cleaned it, and 34% reported optimal HH compliance practices. All of them believed that MPs can have HAIs agents. DH culture showed 94% of colonization and the most common Gram-positive bacteria (GPB) and GNB were S. epidermidis (n = 17∕44) and A. baumannii complex (n = 11∕44), respectively. MP were colonized in 89% of the cases and the most common GPB and GNB were S. epidermidis (n = 16∕42) and Pseudomonas spp (n = 9∕42), respectively. Overall, in the screening 38% of GNB were resistant to meropenem and 22% to colistin. A. baumannii was the most common meropenem (n = 4) and colistin (n = 2) resistant GNB. In the two units, 32% of HCPs had the same microorganism species isolated in the MP and in the DH (Table 1).ConclusionThere was a high rate of bacterial colonization on the MP and DH of HCPs and some of these bacteria were carbapenem or colistin resistant. A policy for MP handling in the healthcare setting should be implemented in order to avoid cross-contamination between the MP and the hand of HCPs. Disclosures All authors: No reported disclosures.

CHILD DEATHS FROM CONGENITAL MALFORMATION OCCURRED IN A NORTHEASTERN CAPITAL FROM 1996 TO 2016

Objective: to analyze the relationship between knowledge and the adequacy of nursing annotations and their determinants. Method: An exploratory, descriptive and quantitative approach, carried out in the Medical Clinic and in the Adult Intensive Care Unit of a Brazilian university hospital. A total of 114 professionals and 41 medical records were included. Results: The professionals had a high mean score of knowledge and a low mean score of adequacy and there was no correlation between them (rs = -0,122; p &gt; 0.05). The knowledge score was higher for professionals graduated in Nursing. The mean score of adequacy was higher for the professional category nurse if packed in Medical Clinic and with the professional that was dissatisfied with the training. Conclusion: there is no relationship between the professional's knowledge about nursing notes and the adequacy of the notes, which leads to serious ethical, legal and patient safety issues.Descritores: Anormalidades congênitas; Recém-nascidos; Mortalidade infantil; Enfermagem neonatal.

Incidence of infections caused by carbapenem-resistant Acinetobacter baumannii

Carbapenem-resistant Acinetobacter baumannii (CR-Ab) has become a worrying health care problem, mainly in developing countries, such as Brazil. The objective was to investigate the prevalence and prognostic factors for CR-Ab infections at a Brazilian university hospital and examine the impact of inappropriate antimicrobial therapy on patient outcome. A retrospective study on hospitalized patients with CR-Ab infections was carried out from January 2013 to December 2017. An epidemiologic analysis was carried out to determine the frequency of infections, the epidemiologic indicators by year, the risk factors for 30-day mortality, and the impact of inappropriate therapy. A total of 489 patients were included in the study. A rate of 0.7 per 1,000 patient-day CR-Ab infections was observed, mostly in the lungs (54.7%), and predominantly in the adult intensive care unit. The occurrence of infections by CR-Ab per 1,000 patient-days in November 2014 exceeded the established control limit, confirming an outbreak. The prevalence of CR-Ab increased in the investigated hospital, passing to an endemic pathogen with a direct impact on mortality and the control of these strains.

Neonatal Near Miss among Newborns of Women with Type 1 Diabetes Mellitus.

Objective To investigate the frequency of neonatal near miss (NNM) and associate it with maternal morbidity in newborns of women with type 1 diabetes mellitus (T1DM). Methods This was a cross-sectional retrospective study from a secondary analysis of data retrieved from medical records of pregnant women with T1DM cared at a Brazilian university hospital between 2005 and 2015. Maternal near miss (MNM) and potentially life-threatening conditions (PTLC) were classified according to the World Health Organization criteria. NNM was classified according to the Pan American Health Organization Neonatal Near Miss Working Group criteria. Association of maternal morbidity with NNM was assessed using chi-square test. Results There were 122 newborns (NB) among 137 T1DM pregnancies. Thirty-seven NB presented NNM—incidence of 303 NNM per 1000 live births (37/122). NNM was associated with MNM (P < 0.001, OR (95% CI): 17.15 (1.85–159.12)). PLTC did not increase the odds of NNM (P=0.07; OR (95% CI): 2.1281 (0.92–4.91)). Seven newborns died, six of them from pregnancies without severe maternal morbidity. 71% of the neonatal death (5/7) occurred in malformed neonates. Conclusion MNM was associated with NNM among women with T1DM, and PLTC, paradoxically, did not increase NNM.

The nursing workload assessed through the Nursing Activities Score as a predictor for the occurrence of ventilator-associated pneumonia in an adult intensive care unit

Objective: Evaluate the relation of nursing workload, evaluated by the Nursing Activities Score (NAS), with the occurrence of Ventilator-associated Pneumonia (VAP) in an Intensive Care Unit (ICU) and the impact of VAP on hospitalization costs.Methods: Retrospective cohort study in Adult ICU of a high complexity Brazilian university hospital. The profile, outcomes, costs, and daily NAS from patients were collected. We also proposed some workload indicators based on NAS daily evaluation.Results: The study included 195 patients, 27.17% diagnosed with VAP. VAP was more prevalent in patients diagnosed with trauma on admission. The total costs of care were higher for VAP patients. In all multivariate models tested were predictive for VAP: the patient's intubation that occurs in days prior of the ICU admission day (higher risk if occurs in days prior the ICU admission day) and ventilation time prior ICU (higher risk if higher time). We found others predictors, but these were dependent on the model tested. Additional risk predictors were tracheostomy, propofol use, neuromuscular blocker use and the higher NAS from admission. The protective factors found were the percentage of adequacy of the assignment based in NAS that measure if the workload measured by the NAS was offered and the increment in NAS during the ventilation time.Conclusions: The offering of an adequate nursing work scale (adequate number of professionals for the care), as a function of the nursing workload measured by the NAS, could be effective in the reduction of VAP, hospital stay time and hospital costs.

Correlation of enthesitis indices with disease activity and function in axial and peripheral spondyloarthritis: a cross-sectional study comparing MASES, SPARCC and LEI

BackgroundThe presence of enthesitis is associated with higher disease activity, more disability and incapacity to work and a poorer quality of life in spondyloarthritis (SpA). There is currently no consensus on which clinical score should be used to assess enthesitis in SpA. The objective of the present work was to compare the correlation of three enthesitis indices (MASES, SPARCC and LEI) with measures of disease activity and function in a heterogeneous population of patients with axial and peripheral SpA.MethodsA cross-sectional study was conducted in three Brazilian public university hospitals; patients fulfilling ASAS classification criteria for peripheral or axial SpA were recruited and measures of disease activity and function were collected and correlated to three enthesitis indices: MASES, SPARCC and LEI using Spearman’s Correlation index. ROC curves were used to determine if the the enthesitis indices were useful to discriminate patients with active disease from those with inactive disease.ResultsTwo hundred four patients were included, 71.1% (N = 145) fulfilled ASAS criteria for axial SpA and 28.9% (N = 59) for peripheral SpA. In axial SpA, MASES performed better than LEI (p = 0.018) and equal to SPARCC (p = 0.212) regarding correlation with disease activity (BASDAI) and function (BASFI). In peripheral SpA, only MASES had a weak but statistical significant correlation with DAS28-ESR (rs 0.310 p = 0.05) and MASES had better correlation with functional measures (HAQ) than SPARCC (p = 0.034).ConclusionIn this sample composed of SpA patients with high coexistence of axial and peripheral features, MASES showed statistical significant correlation with measures of disease activity and function in both axial and peripheral SpA.

Escherichia coli Bloodstream Infections in Patients at a University Hospital: Virulence Factors and Clinical Characteristics.

Extraintestinal pathogenic Escherichia coli (ExPEC) isolates are responsible for many bloodstream infections. The aim of this study was to characterize E. coli isolated from the bloodstreams of patients (n = 48) at the University Hospital in Brazil. Epidemiological data were obtained through the analysis of medical records and laboratory tests. By PCR analysis, we investigated the presence of virulence factors (VFs), pathogenicity islands (PAIs), extended-spectrum β-lactamase (ESBL), phylogenetic classifications (A, B1, B2, C, D, E, and F) and molecular genotype by enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR). The mortality analysis showed that 33.3% of the deaths were associated with bacteraemia due to E. coli infections; in addition, an age between 60 and 75 years (p < 0.001; OR = 6.3[2.1–18.9]) and bacteraemia with an abdominal origin (p = 0.02; OR = 5[1.2–20.5]) were risk factors for the severity of the infection. Additionally, the presence of the afa gene was associated with mortality due to E. coli bacteraemia (p = 0.027; OR = 11.4[1.5–85.7]). Immunosuppression (27.1%), intestinal diseases (25.0%) and diabetes (18.8%), were prevalent among patients, and most of the bacteraemia cases were secondary to urinary tract infections (50.0%). The serum resistance gene traT was present in 77.1% of isolates, group capsular 2 (kpsMT II) was present in 45.8% and the K5 capsule was present in 20.8% of isolates. The isolates also showed a high prevalence for the siderophore yersiniabactina (fyuA) (70.8%) and PAI IV536 (77.1%). Phylogenetic analysis showed that group B2 (45.8%) was the most prevalent, and was the phylogroup that had a higher prevalence of VFs and PAIs. However, in this study, a considerable number of isolated bacteria were classified as group B1 (18.8%) and as group E (14.6%). Eight (16.7%) isolates were resistant to third and fourth generation cephalosporin and group CTX-M-1 (CTX-M-15) was the most prevalent ESBL type. The molecular genotyping showed two clonal lineages and several isolates that were not related to each other. This study provides additional information on the epidemiological and molecular characteristics of E. coli bloodstream infections in Brazil.