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Eid R.C.,Intensive Care Unit | Domingues F.,Intensive Care Unit | Silva Barreto J.K.,Intensive Care Unit | Marra A.R.,Intensive Care Unit | And 4 more authors.
American Journal of Infection Control | Year: 2011

Background: Prevention of health care-associated infections is well described in critical care. However, surveillance in step-down unit (SDU) patients who need intermediate care with bilevel mechanical ventilation pressure through tracheotomy needs to be better understood. We evaluated the implementation of preventive measures in SDU over 2 different periods on device (bilevel mechanical ventilation)-associated pneumonia. Methods: A quasi-experimental, interrupted time series study was conducted in SDUs. Interventions were implemented to optimize the prevention of pneumonia associated with tracheostomy and evaluated in 2 phases. From January to October of 2007 (phase 1), some practices recommended by the Centers for Disease Control and Prevention were implemented, and the epidemiology unit carried out surveillance for pneumonia associated with tracheostomy. From November of 2007 to August of 2008 (phase 2) the same practices recommended by the Centers for Disease Control and Prevention were followed, but, in addition, the assessment of these processes as well as bedside interventions were initiated. Results: The mean incidence density of tracheostomy associated pneumonia per 1,000 tracheostomy-days in the SDUs was 6.0 in phase 1 and 0.7 in phase 2, P = .002. Conclusion: Reducing pneumonia associated with tracheostomy is a continuous multidisciplinary process that involves the measurement of multiple performance metrics. Copyright © 2011 by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. Source


Deliberato R.O.,Critical Care Unit | Marra A.R.,Critical Care Unit | Sanches P.R.,Critical Care Unit | Paes A.T.,Instituto Israelita Of Ensino E Pesquisa Iiep | And 3 more authors.
Diagnostic Microbiology and Infectious Disease | Year: 2013

Biomarkers such as procalcitonin (PCT) have been studied to guide duration of antibiotic therapy. We aimed to assess whether a decrease in PCT levels could be used to reduce the duration of antibiotic therapy in intensive care unit (ICU) patients with a proven infection without risking a worse outcome. We assessed 265 patients with suspected sepsis, severe sepsis, or septic shock in our ICU. Of those, we randomized 81 patients with a proven bacterial infection into 2 groups: an intervention group in which the duration of the antibiotic therapy was guided by a PCT protocol and a control group in which there was no PCT guidance. In the per-protocol analysis, the median antibiotic duration was 9 days in the PCT group (n = 20) versus 13 days in the non-PCT group (n = 31), P = 0.008. This study demonstrates that PCT can be a useful tool for limiting antimicrobial therapy in ICU patients with documented bacterial infection. © 2013 Elsevier Inc. Source


Shiramizo S.C.P.L.,Critical Care Unit | Marra A.R.,Critical Care Unit | Durao M.S.,Critical Care Unit | Paes A.T.,Instituto Israelita Of Ensino E Pesquisa Iiep | And 2 more authors.
PLoS ONE | Year: 2011

Background: The Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis (SS) and septic shock (SSh) have been recommended to reduce morbidity and mortality. Materials and Methods: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize SS and SSh shock patients' clinical outcomes were performed by applying sepsis bundles (6- and 24-hour) in May 2006. We compared bundle compliance and patient outcomes before (July 2005-April 2006) and after (May 2006-December 2009) implementation of the interventions. Results: A total of 564 SS and SSh patients were identified. Prior to the intervention, compliance with the 6 hour-sepsis resuscitation bundle was only 6%. After the intervention, compliance was as follows: 8.2% from May to December 2006, 9.3% in 2007, 21.1% in 2008 and 13.7% in 2009. For the 24 hour-management bundle, baseline compliance was 15.0%. After the intervention, compliance was 15.1% from May to December 2006, 21.4% in 2007, 27.8% in 2008 and 44.4% in 2009. The in-hospital mortality was 54.0% from July 2005 to April 2006, 41.1% from May to December 2006, 39.3% in 2007, 41.4% in 2008 and 16.2% in 2009. Conclusion: These results suggest reducing SS and SSh patient mortality is a complex process that involves multiple performance measures and interventions. © 2011 Shiramizo et al. Source


De Almeida S.M.,Intensive Care Unit | Marra A.R.,Intensive Care Unit | Wey S.B.,Federal University of Sao Paulo | Victor E.D.S.,Instituto Israelita Of Ensino E Pesquisa Iiep | And 2 more authors.
American Journal of Infection Control | Year: 2012

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. © 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved. Source


Yokota P.K.O.,Hospital Israelita Albert Einstein | Marra A.R.,Hospital Israelita Albert Einstein | Martino M.D.V.,Laboratory of Microbiology | Victor E.S.,Instituto Israelita Of Ensino E Pesquisa Iiep | And 3 more authors.
PLoS ONE | Year: 2014

Background: There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes.Material: This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock.Results: A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023).Conclusions: The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance. © 2014 Yokota et al. Source

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