Secular trends in Klebsiella pneumoniae isolated in a tertiary-care hospital: increasing prevalence and accelerated decline in antimicrobial susceptibility

Abstract: INTRODUCTION Klebsiella pneumoniae has become an increasingly important etiologic agent of nosocomial infections in recent years. This is mainly due to the expression of virulence factors and development of resistance to several antimicrobial drugs. METHODS This retrospective study examines data obtained from the microbiology laboratory of a Brazilian tertiary-care hospital. To assess temporal trends in prevalence and antimicrobial susceptibility, K. pneumoniae isolates were analyzed from 2000 to 2013. The relative frequencies of K. pneumoniae isolation were calculated among all Gram-negative bacilli isolated in each period analyzed. Susceptibility tests were performed using automated systems. RESULTS: From 2000-2006, K. pneumonia isolates comprised 10.7% of isolated Gram-negative bacilli (455/4260). From 2007-2013, this percentage was 18.1% (965/5331). Strictly considering isolates from bloodstream infections, the relative annual prevalence of K. pneumoniae increased from 14-17% to 27-32% during the same periods. A progressive decrease in K. pneumoniae susceptibility to all antimicrobial agents assessed was detected. Partial resistance was also observed to antimicrobial drugs that have been used more recently, such as colistin and tigecycline. CONCLUSIONS Our study indicates that K. pneumoniae has become a major pathogen among hospitalized patients and confirms its recent trend of increasing antimicrobial resistance.

Pilot study with a glutamine-supplemented enteral formula in critically ill infants

Seriously ill infants often display protein-calorie malnutrition due to the metabolic demands of sepsis and respiratory failure. Glutamine has been classified as a conditionally essential amino acid, with special usefulness in critical patients. Immunomodulation, gut protection, and prevention of protein depletion are mentioned among its positive effects in such circumstances. With the intent of evaluating the tolerance and clinical impact of a glutamine supplement in seriously ill infants, a prospective randomized study was done with nine patients. Anthropometric and biochemical determinations were made, and length of stay in the intensive care unit (ICU), in the hospital, and under artificial ventilation, and septic morbidity and mortality were tabulated. Infants in the treatment group (n=5) were enterally administered 0.3 g/kg of glutamine, whereas controls received 0.3 g/kg of casein during a standard period of five days. Septic complications occurred in 75% of the controls (3/4) versus 20% of the glutamine-treated group (1/5, p<=0.10), and two patients in the control group died of bacterial infections (50% vs. 0%, p<=0.10). Days in the ICU, in the hospital, and with ventilation numerically favored glutamine therapy, although without statistical significance. The supplements were usually well tolerated, and no patient required discontinuation of the program. The conclusion was that glutamine supplementation was safe and tended to be associated with less infectious morbidity and mortality in this high-risk population.

Orifice diseases project - experience of the "Hospital das Clínicas" University of São Paulo Medical Center in day-hospital of anorectal disease

The treatment of malignant or benign colorectal pathologies that require more complex management are priorities in tertiary hospitals such as "Hospital das Clínicas" University of São Paulo Medical Center (HCFMUSP). Therefore, benign, uncomplicated orifice conditions are relegated to second place. The number of patients with hemorrhoids, perianal fistulas, fissures, condylomas and pilonidal cysts who seek treatment at the HFMUSP is very great, resulting in over-crowding in the outpatient clinics and a long waiting list for recommended surgical treatment (at times over 18 months). The authors describe the experience of the HCFMUSP over an eight-day period with day-hospital surgery in which 140 patients underwent surgery. Data was prospectively taken on the patients undergoing surgery for benign orifice pathologies including age, sex, diagnosis, surgery performed, immediate and late postoperative complications, and follow-up. 140 patients operated on over eight days were studied. 68 were males (48.75%) with ages ranging from 25 to 62 (mean 35.2 yrs.). Hemorrhoids was the most frequent condition encountered (82 hemorrhoidectomies, 58.6%), followed by perineal fistula (28 fistula repairs, 20.0%). The most common complication was headache secondary to rachianesthesia occurring in 9 patients (6.4%). One patient (0.7%) developed bleeding immediately PO that required reoperation. Mean follow-up was 104 days. Day-surgery characterized by quality care and low morbidity is feasible in tertiary public hospitals, permitting surgery for benign orifice pathologies on many patients within a short period of time.

Pressure sores among malnourished necropsied adults - preliminary data

Pressure sores are common among bedridden, elderly, or malnourished patients, and may occur in terminal ill patients because of impaired mobility, fecal or urinary incontinence, and decreased healing capacity. The aim of this study was to compare frequency of pressure sores between malnourished and non-malnourished necropsied adults. METHOD: All (n = 201) adults (age ³ 18 years) autopsied between 1986 and 1996 at the Teaching Hospital of Triangulo Mineiro Medical School (Uberaba) were eligible for the study. Gender, race, weight, height and main diagnoses were recorded. Ninety-six cases were excluded because of probable body water retention (congestive heart failure, hepatic insufficiency, nephrotic syndrome) or pressure sores secondary to peripheral vascular ischemia. Body mass index (BMI) was used to define malnourished (BMI < 18.5 kg/m²) and non-malnourished (BMI > 18.5kg/m²) groups. RESULTS: Except for weight (42.5kg; range: 28-57 vs. 60; 36-134.5kg) and BMI (16.9; range: 12.4-18.5 vs. 22.7; range: 18.5-54.6kg/m²), respectively, there were no statistical differences among 43 malnourished and 62 non-malnourished cases in relation to age (54.9 ± 20.4 vs. 52.9 ± 17.9 years), percentage of white persons (74.4 vs. 64.5%), male gender (76.7 vs. 69.3%) and main diagnoses. Five malnourished (11.6%) and 7 (11.5%) non-malnourished cases had pressure sores (p=0.89). CONCLUSION: Pressure sores were equally common findings in necropsied persons with protein-energy malnutrition, as assessed by body mass index.

The effects of glutamine-supplemented diet on the intestinal mucosa of the malnourished growing rat

Glutamine is the most abundant amino acid in the blood and plays a key role in the response of the small intestine to systemic injuries. Mucosal atrophy is an important phenomenon that occurs in some types of clinical injury, such as states of severe undernutrition. Glutamine has been shown to exert powerful trophic effects on the gastrointestinal mucosa after small bowel resection or transplant, radiation injury, surgical trauma, ischemic injury and administration of cytotoxic drugs. Since no study has been performed on the malnourished animal, we examined whether glutamine exerts a trophic effect on the intestinal mucosa of the malnourished growing rat. Thirty-five growing female rats (aged 21 days) were divided into 4 groups: control - chow diet; malnutrition diet; malnutrition+chow diet; and malnutrition+glutamine-enriched chow diet (2%). For the first 15 days of the experiment, animals in the test groups received a malnutrition diet, which was a lactose-enriched diet designed to induce diarrhea and malnutrition. For the next 15 days, these animals received either the lactose-enriched diet, a regular chow diet or a glutamine-enriched chow diet. After 30 days, the animals were weighed, sacrificed, and a section of the jejunum was taken and prepared for histological examination. All the animals had similar weights on day 1 of experiment, and feeding with the lactose-enriched diet promoted a significant decrease in body weight in comparison to the control group. Feeding with both experimental chow-based diets promoted significant body weight gains, although the glutamine-enriched diet was more effective. RESULTS: The morphological and morphometric analyses demonstrated that small intestinal villous height was significantly decreased in the malnourished group, and this change was partially corrected by the two types of chow-based diet. Crypt depth was significantly increased by malnutrition, and this parameter was partially corrected by the two types of chow-based diet. The glutamine-enriched diet resulted in the greatest reduction of crypt depth, and this reduction was also statistically significant when compared with control animals. CONCLUSIONS: Enteral glutamine has some positive effects on body weight gain and trophism of the jejunal mucosa in the malnourished growing rat.

Management of pregnancy in a University Hospital: a 6-year study

In order to evaluate the obstetric care in the Obstetric Clinic of the Gynaecology and Obstetrics Department of University of São Paulo, the authors present a survey of the management of pregnancy during the 6-year period from 1993 to 1998. The number of deliveries increased during the study by 45% over the 6 years. During this same period the number of fetal deaths was 526 (4.48%), but there was a significant decrease (p < 0.05) in the incidence of fetal death. However, there was no concomitant increase in the proportion of pregnant women with prenatal care that could explain this improvement. Incidence of premature labor also decreased considerably. The authors believe that the increment in the number of deliveries was due mainly to the increasing number of pregnant women referred to our service. The efforts made by the service towards decreasing the time of hospitalization of both newborns in the nursery and the mothers in the hospital made this possible. Despite the increasing number of deliveries, there was a significant improvement in the management of pregnancy during the period of study. This improvement may be a consequence of the standardization of a protocol of management of pregnancy based on the recent progress in scientific and technological knowledge.

Cost of drugs manufactured by the University Hospital - role of the Central Pharmacy

The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clinicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

Prevalence rates of infection in intensive care units of a tertiary teaching hospital

OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of São Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69%) received antimicrobials on the day of study, 72 (57%) for treatment, and 15 (12%) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8%), non- intensive care unit nosocomial infection in 24 (33.3%), and intensive care unit-acquired infection in 22 patients (30.6%). Eleven patients (15.3%) had no defined type. The most frequently reported infections were respiratory (58.5%). The most frequently isolated bacteria were Enterobacteriaceae (33.8%), Pseudomonas aeruginosa (26.4%), and Staphylococcus aureus (16.9%; [100% resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8%. Patients with infection had a mortality rate of 34.7%. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms). Factors such as nasogastric intubation, postoperative status, and age ³60 years were significantly associated with infection. This study documents the clinical impression that prevalence rates of intensive care unit-acquired infections are high and suggests that preventive measures are important for reducing the occurrence of infection in critically ill patients.

Adductor policis muscle: a new anthropometric parameter

PURPOSE: To measure the thickness of adductor pollicis muscle in healthy adults. This measurement will be used as a nutritional anthropometric parameter in further studies. SUBJECTS AND METHOD: Four hundred and twenty-one healthy adults were studied, 209 men and 212 women, with ages ranging from 18 to 87 years, living in Rio de Janeiro. The adductor pollicis muscle was also studied in the human anatomy lab as well as in normal healthy volunteers using CAT scans and nuclear magnetic resonance imaging to ensure that only the adductor pollicis was included in measurement of muscle thickness with a Lange caliper. To standardize the measurement, the methodology was detailed, with subjects sitting with the dominant hand dangling over the homolateral thigh and the elbow bent at approximately a 90° angle. The Lange caliper was applied at a pressure of 10 g/mm², pinching the adductor pollicis muscle at the vertex of an imaginary angle between the thumb and the index finger. The average of 3 consecutive measurements was considered to be the muscle thickness. RESULTS: This study provides the first estimates of adductor pollicis thickness in normal healthy subjects as an anthropometric parameter. The normal values in the dominant hand for men were 12.5 ± 2.8 mm (mean ± SD), median 12 mm, and for women were 10.5 ± 2.3 mm, median 10 mm.

Hypophosphatemia in critically ill children

The purpose of this paper is to review clinical studies on hypophosphatemia in pediatric intensive care unit patients with a view to verifying prevalence and risk factors associated with this disorder. We searched the computerized bibliographic databases Medline, Embase, Cochrane Library, and LILACS to identify eligible studies. Search terms included critically ill, pediatric intensive care, trauma, sepsis, infectious diseases, malnutrition, inflammatory response, surgery, starvation, respiratory failure, diuretic, steroid, antiacid therapy, mechanical ventilation. The search period covered those clinical trials published from January 1990 to January 2004. Studies concerning endocrinological disorders, genetic syndromes, rickets, renal diseases, anorexia nervosa, alcohol abuse, and prematurity were not included in this review. Out of 27 studies retrieved, only 8 involved pediatric patients, and most of these were case reports. One clinical trial and one retrospective study were identified. The prevalence of hypophosphatemia exceeded 50%. The commonly associated factors in most patients with hypophosphatemia were refeeding syndrome, malnutrition, sepsis, trauma, and diuretic and steroid therapy. Given the high prevalence, clinical manifestations, and multiple risk factors, the early identification of this disorder in critically ill children is crucial for adequate replacement therapy and also to avoid complications.

Hypertension in employees of a University General Hospital

PURPOSE: To find out the prevalence of hypertension in employees of the Hospital and relate it to social demographic variables. METHODS: Blood pressure measurement was performed with a mercury sphygmomanometer, using an appropriate cuff size for arm circumference, weight, and height in a population sample of 864 individuals out of the 9,905 employees of a University General Hospital stratified by gender, age, and job position. RESULTS: Hypertension prevalence was 26% (62% of these reported being aware of their hypertension and 38% were unaware but had systolic/diastolic blood pressures of >140 and/or >90 mm Hg at the moment of the measurement). Of those who were aware of having hypertension, 51% were found to be hypertensive at the moment of the measurement. The prevalence was found to be 17%, 23%, and 29% (P <.05) in physicians, nursing staff, and "others", respectively. The univariate analysis showed a significant odds ratio for the male gender, age >50 years, work unit being the Institute of Radiology and the Administration Building, educational level 10 years, and body mass index >30 kg/m². The multivariate logistic regression model revealed a statistically significant association of hypertension with the following variables: gender, age, skin color, family income, and body mass index. CONCLUSIONS: Hypertension prevalence was high, mainly in those who were not physicians or members of the nursing staff. High-risk groups (obese, non-white, men, low family income) should be better advised of prevention and early diagnosis of hypertension by means of special programs.

Pesquisa de Micobactérias Ambientais em água de torneira, luvas e soluções utilizadas em procedimentos cirúrgicos no Hospital Universitário Getúlio Vargas - Manaus/AM

Investigou-se por métodos bacteriológicos (cultivo) e moleculares (PCR - Restriction Enzyme Analysis, PRA), a presença de micobactérias ambientais em águas de torneira, soluções e luvas cirúrgicas, utilizadas nas etapas dos procedimentos cirúrgicos executados no centro cirúrgico do Hospital Universitário Getulio Vargas (HUGV), na cidade de Manaus-Amazonas/Brasil. Foram colhidas e analisadas 105 amostras sendo: 24 de águas (colhidas das 2 torneiras existentes no centro cirúrgico), 8 de solução de Povidine e 7 de solução de Clorhexidina, que servem para a higienização das mãos dos cirurgiões; 39 de luvas cirúrgicas (superfícies internas e externas); e 27 de soluções que foram efetivamente utilizadas durante o ato cirúrgico. Por método bacteriológico obteve-se 41 isolados micobacterianos apenas de águas das torneiras. Pelo PRA obteve-se a detecção de DNA micobacteriano somente na amostra de água que forneceu acima de 100 colônias de micobactérias por tubo semeado. Os isolados foram identificados como sendo Mycobacterium celatum perfil 2, M. gordonae perfil 3, M. gordonae perfil 6, M. intracellulare perfil 1, M. lentiflavum perfil 3 e M. mucogenicum perfil 1. O encontro de M. mucogenicum, espécie já incriminada em surtos pós-cirúrgicos, indica que devem ser efetuados procedimentos de limpeza e monitoramento em todos os pontos de distribuição de águas, visando à prevenção de surtos de micobacterioses nosocomiais induzidos pelo uso das águas nas diferentes atividades de manuseio ou higienização dos pacientes submetidos a procedimentos invasivos.

Um modelo para o parecer psiquiátrico no hospital geral

OBJETIVO: Propor um modelo estruturado para a elaboração das respostas às solicitações de pareceres psiquiátricos no hospital geral e discutir seus aspectos fundamentais. MÉTODOS: Foi realizada uma pesquisa sistemática nas bases de dados PubMed/Medline e PsycINFO à procura de artigos que descrevessem modelos para a resposta aos pareceres psiquiátricos em hospitais gerais. Além disso, todos os artigos sobre psiquiatria de ligação publicados no Jornal Brasileiro de Psiquiatria (indexado no PsycINFO) nos últimos dez anos foram analisados para localizar as contribuições brasileiras ao tema. Foram selecionados artigos que descrevessem modelos estruturados para as respostas às solicitações de pareceres psiquiátricos em hospitais gerais. As informações contidas nesses artigos foram usadas na construção de uma proposta de ficha de parecer psiquiátrico. RESULTADOS: Apenas dois artigos preenchiam os critérios de seleção. Outros cinco artigos que descreviam problemas no processo de consultoria psiquiátrica forneceram informações sobre questões que deveriam ser abordadas nos pareceres. Os modelos de parecer descritos foram analisados, e um novo modelo foi desenvolvido. CONCLUSÃO: Os pareceres psiquiátricos são documentos que atendem às necessidades médicas e educacionais em um hospital geral. Um modelo estruturado de parecer evita a omissão de informações importantes, melhorando a comunicação entre os psiquiatras pareceristas e os outros médicos no hospital geral.

Validade e fidedignidade da Escala de Depressão Geriátrica na identificação de idosos deprimidos em um hospital geral

OBJETIVO: O objetivo deste estudo foi avaliar validade e fidedignidade da Escala de Depressão Geriátrica (EDG) nas versões de 30 e 15 itens na identificação de suspeitas de depressão em idosos nas enfermarias de clínica médica do Hospital Universitário Lauro Wanderley, em João Pessoa, Paraíba. MÉTODOS: Realizou-se um estudo observacional e transversal, com aplicação da EDG-30 e da EDG-15 por uma entrevistadora treinada, efetuando-se no mesmo dia exame mental dos pacientes por um psiquiatra de acordo com critérios da CID-10. A fidedignidade das duas versões da EDG foi avaliada por meio da técnica do teste-reteste e da equivalência interobservadores. RESULTADOS: A concordância entre a aplicação da EDG30 e o exame psiquiátrico foi significativa e moderada (kappa = 0,48; p = 0,04), enquanto a EDG-15 não apresentou concordância estatística (p = 0,62). A EDG-30 apresentou sensibilidade de 83% e especificidade de 57%, mas a EDG-15 apresentou sensibilidade de 50% e especificidade de 62%. Os escores da EDG-30 apresentaram correlação estatisticamente significativa entre si no teste-reteste e na equivalência entre observadores, porém a versão de 15 itens não foi fidedigna. CONCLUSÕES: Conclui-se que a EDG-30 é mais sensível e fidedigna que a EDG-15. Assim, a EDG-30 é útil para detectar como negativos os pacientes que realmente não apresentem depressão, porém são necessários estudos posteriores para adequação dos itens dessa escala à nossa clientela, a fim de aumentar sua especificidade e valor preditivo positivo.

Tempo médio de hospitalização e categorias diagnósticas em hospital psiquiátrico

OBJETIVO: Avaliar o tempo médio de hospitalização (TMH) e os diagnósticos dos pacientes. MÉTODOS: Fez-se um levantamento documental dos registros de 2.247 prontuários de pacientes internados de janeiro a dezembro de 2004 em um hospital psiquiátrico. Foram investigados TMH, idade, sexo, procedência e grupos diagnósticos. Usaram-se medidas de tendência central e de dispersão, testes t de Student, de Kruskal-Wallis ou análise da variância, qui-quadrado e de Pearson. Adotou-se o nível de significância de 5%. RESULTADOS: Eram procedentes de Campo Grande (MS) 59,8% dos pacientes, 65,5% eram do sexo masculino (p = 0,000) e 43,3% apresentavam diagnóstico de esquizofrenia; não houve diferença significativa na idade entre os dois sexos (p = 0,080). O TMH foi de 27,66 dias por paciente. Houve diferença significativa do TMH em função das características diagnósticas (p = 0,001) entre os três grupos de procedência (p = 0,045), ficando as cidades a mais de 200 km de Campo Grande com média maior de dias de hospitalização (29,1 dias). Também foram encontradas diferenças estatísticas na distribuição das categorias diagnósticas em função do número de hospitalizações (p = 0,000), na distribuição das principais categorias diagnósticas (p = 0,000) e também nas distribuições em relação à procedência (p = 0,000). CONCLUSÃO: O TMH está dentro da média recomendada pelo Ministério da Saúde brasileiro.