Class of 2012 / Specific Aims: The primary aim of this study was to determine the time to appropriate therapy for all patients with candidemia and/or bacteriemia (due to either Enterococcus or Streptococcus species) during a one year period in relation to time of blood culture, time of Gram-stain result, time of PNA FISH species result, and time of final species determination result. The secondary and third aims were to compare the time to appropriate therapy based on clinician group that was notified of Gram-stain result and PNA FISH result and compare the time to appropriate therapy based on PNA FISH assay results reported during the day and night microbiology laboratory shifts. Methods: This Institutional Review Board approved project is a retrospective, chart review evaluation of the 24 hour/ 7 days a week use of PNA FISH assays with therapeutic interventions by infectious diseases pharmacists and physicians on patient outcome measures and time to appropriate therapy. All patients admitted to an academic medical center during a one year period (April 2010-March 2011) with either Enterococcus, Streptococcus, or Candida species isolated from blood were included. Main Results: A total of 168 subjects were identified with Candida species isolated from 31 subjects and Enterococcus/Streptococcus species isolated from blood in 137 subjects. Conclusions: While reporting conditions can affect interpretation and intervention rates, rapid species identification assays such as PNA FISH can be used by pharmacists to provide antimicrobial therapy recommendations based on the species identification and to decrease the time to appropriate antimicrobial therapy.

Yes / Background. Bacterial bloodstream infection (bBSI) is one of the leading causes of death in critically ill patients and accurate diagnosis is therefore crucial. We here report a 16S metagenomics approach for diagnosing and understanding bBSI. Methodology/Principal Findings. The proof-of-concept was delivered in 75 children (median age 15 months) with severe febrile illness in Burkina Faso. Standard blood culture and malaria testing were conducted at the time of hospital admission. 16S metagenomics testing was done retrospectively and in duplicate on the blood of all patients. Total DNA was extracted from the blood and the V3–V4 regions of the bacterial 16S rRNA genes were amplified by PCR and deep sequenced on an Illumina MiSeq sequencer. Paired reads were curated, taxonomically labeled, and filtered. Blood culture diagnosed bBSI in 12 patients, but this number increased to 22 patients when combining blood culture and 16S metagenomics results. In addition to superior sensitivity compared to standard blood culture, 16S metagenomics revealed important novel insights into the nature of bBSI. Patients with acute malaria or recovering from malaria had a 7-fold higher risk of presenting polymicrobial bloodstream infections compared to patients with no recent malaria diagnosis (p-value = 0.046). Malaria is known to affect epithelial gut function and may thus facilitate bacterial translocation from the intestinal lumen to the blood. Importantly, patients with such polymicrobial blood infections showed a 9-fold higher risk factor for not surviving their febrile illness (p-value = 0.030). Conclusions/Significance. Our data demonstrate that 16S metagenomics is a powerful approach for the diagnosis and understanding of bBSI. This proof-of-concept study also showed that appropriate control samples are crucial to detect background signals due to environmental contamination. / This work was supported by the Flemish Ministry of Sciences (EWI, SOFI project IDIS). / This paper has been subject to a correction. Please see Correction file above.

Acute bacterial skin and skin structure infections (ABSSSI) are common infections within the local community, and they result in higher morbidity and health care costs. While risk factors for skin and soft tissue infections have been previously evaluated, risk factors associated with secondary bloodstream infections (BSI) has not been investigated, especially in an intercity patient population with limited health care resources. In this case control investigation, 392 patients consisting of 196 cases (ABSSSI + BSI) and 196 controls (ABSSSI) were investigated to determine risk for BSI. Both sociodemographic and underlying conditions were evaluated. According to bivariate analysis of cases and controls, individuals with ABSSSI + BSI were significantly older (p < 0.001), more often male (p = 0.008), and had a higher percentage of abnormal symptoms, such as elevated temperature, white blood cell count, and acute renal failure on hospital admission (p < 0.001). Individuals with ABSSSI + BSI also had a higher percentage of chronic renal failure (p = 0.002), diabetes (p = 0.005), congestive heart failure (p = 0.012), intravenous drug use (p =0.012), and a history of prior hospitalization (p < 0.001). Several of these factors remained statistically significant by logistic regression analysis, such as male gender aOR of 1.85, 95% CI 1.11-3.66; acute renal failure aOR 2.08, 95% CI 1.18-3.67; intravenous drug use aOR 4.38, 2.22-8.62; and prior hospitalization aOR 2.41, 95% CI 1.24-4.93. This study contributes to positive social change by identifying patient characteristics that are associated with ABSSSI-related BSI, thus providing health care providers the ability to improve patient outcomes in this underserved patient population.

Central line-associated bloodstream infection (CLABSI) at the local healthcare setting exceeded the benchmark of 0 CLABSI. The Infection Prevention and Control (IPC) department determined that a role as CLABSI nurse champion would address the problem; however, no comprehensive education on CLABSI prevention and maintenance was available at the site. The purpose of this project was to develop a CLABSI prevention and maintenance education module using Knowles's adult learning theory and the chain of infection model. The practice-focused question asked whether a CLABSI educational module would provide the necessary information to educate nurse champions on CLABSI prevention and maintenance. The education module was presented to 9 local experts, composed of the Infection Prevention and Control (IPC) director, doctor of medicine, microbiologist, biomedical technologists, IPC nurses, and 2 staff nurses, who evaluated the CLABSI education module. An 11-question Likert-scale questionnaire that included an option for recommendations for improvement was used by the expert panel to evaluate the module. Of the 11 questions, only 3 were scored as strongly agree or agree, indicating a need to modify the module to raise the education level of the content and to include the clinical standards, objectives, and dressing-change procedures. After modifications, the education module was scored again, and 100% met the criteria and the recommendations of the expert panel. The project has the potential to promote positive social change by increasing the knowledge of the CLABSI nurse champions and by reducing the risk of CLABSI at the site.

Background: Catheter-associated bloodstream infections have been extensively studied in Intensive Care Unit Patients. However, less is known about the effect these infections have on non-ICU patients. This study attempted to elucidate the nature of the problem effecting non-ICU patients through descriptive analysis. Methods: Data were collected for all non-ICU patients with Staphylococcus aureus (S. aureus) infections at Grady Memorial Hospital in 2006. Demographic and hospitalization information was collected. The hospital epidemiologist responsible for surveillance of infection control programs determined outcomes attributable to the S. aureus infections. Data were entered into an Excel spreadsheet and then imported into EpiInfo 2007. Results: There were 91 S. aureus bloodstream infections documented, 38 infections in non-ICU patients and 52 infections in ICU patients. The descriptive information we accumulated offered potentially important different points between patients with MSSA and MRSA. We found more MRSA infection than MSSA infection in both the non-ICU and ICU patients. Additionally, in both groups those with MRSA infection had a length of stay at least twice as long as patients with MSSA, longer time from admission to positive blood culture, and longer time from positive blood culture to discharge. The most common type of morbidity found was sepsis, which was also the most common morbidity found in those who died. Conclusions: Our hypothesis that non-ICU patients would have increased morbidity and mortality directly attributable to the CA-BSI with S. aureus was proven to be false. Although still an issue, the morbidity and mortality was not as different as we thought it would be. While our hypothesis was proven false, this research provides information that would be well served through further studies.

Made available in DSpace on 2015-07-22T20:49:40Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-06-24 / Introdução: Apesar dos inúmeros avanços no entendimento da fisiopatologia das infecções da corrente sanguínea (ICS), a má evolução clínica e a manutenção da elevada mortalidade persistem nos pacientes com esta síndrome. O uso de terapêutica empírica de largo espectro, em virtude do desconhecimento da evolução e das características clínicas e microbiológicas dessas infecções em nossos hospitais agravam o surgimento da resistência microbiana e aumentam os custos relacionados sem, na maioria das vezes, diminuírem as taxas de morbidade e mortalidade dos pacientes acometidos pela doença. Objetivos: Observar a evolução clínica, os fatores predisponentes e a mortalidade atribuída em pacientes com hemoculturas positivas, durante 30 dias, em um hospital terciário, na cidade de Maceió. Metodologia: Foram incluídos no estudo 143 pacientes, admitidos no hospital sede da pesquisa, no período de outubro de 2005 a dezembro de 2006, que apresentaram pelo menos uma hemocultura positiva. Todas as variáveis foram aferidas sistematicamente no protocolo do estudo, até o trigésimo dia de evolução. Para se verificar a associação entre as variáveis qualitativas foi utilizado o teste de Qui-quadrado (SIEGEL). O nível de significância foi de 5%. O pacote estatístico utilizado foi o SPSS 15.0 for Windows. Resultados: Até o trigésimo dia de acompanhamento, 30,1% dos pacientes apresentaram apenas bacteremia e 69,9% evoluíram para sepse. Destes, 20,3% desenvolveram sepse grave e 10,5% evoluíram para choque séptico. A Taxa global de mortalidade no Hospital, durante o período da pesquisa foi de 3,7%, enquanto a mortalidade atribuída a esta patologia foi de 37,8%. Entre os pacientes que apresentaram quadro de bacteremia, sem repercussão clínica, sepse, sepse grave e choque séptico, estas taxas foram respectivamente 9,3%, 50%, 65,5% e 84,6% no trigésimo dia, após o diagnóstico. Os focos prevalentes nesta amostra foram secundários aos tratos: respiratório (32,2%), urinário (14%), e intra-abdominal (7,7%). 14% das ICS foram relacionadas ao cateter venosos central. Entre as especialidades que mais contribuíram para a casuística deste estudo estão a neurologia, cardiologia, clínica médica geral, oncologia, pediatria e neonatologia, correspondendo, respectivamente a 19,6%, 18,9%, 16,8%, 12,6%, 8,4% e 7,7%. A taxa de ocorrência de bacteremia/candidemia observada nas unidades de terapia intensiva (UTI) foi de 1,2%, contra 0,33% nas enfermarias. Nestas últimas, 55,12% evoluíram para sepse, enquanto na UTI este índice aumentou significativamente para 87,69% ( p<0,05). Entre as comorbidades, a diabetes melitus foi incidente em 26,6% dos casos, insuficiência renal crônica em 21,7%, neuropatia em 29,4% e a doença pulmonar obstrutiva crônica em 11,2%. Os principais agentes etiológicos isolados foram: Staphylococcus coagulase negativo (25,9%), Staphylococcus aureus (21%), Klebsiella pneumoniae (14%), Escherichia coli (9,1%) e Candida Spp. (8.4%). O principal microrganismo isolado nas hemoculturas dos pacientes que evoluíram para o óbito foi o S. aureus, presente em 24,1% dos casos. Observamos que 14% dos casos foram ICS de origem nosocomial. Conclusão: Os resultados apresentados condizem com os dados publicados na literatura, em relação à incidência, à evolução e a mortalidade atribuída aos distintos quadros das ICS e corroboram com a necessidade do estabelecimento das características desta doença, que poderão nortear as Instituições na adoção de medidas preventivas e terapêuticas eficazes. / Introduction: Despite the countless breakthroughs regarding the understanding of the pathophysiology of bloodstream infections (BSIs), poor response and persistently high mortality rates are the norm for these patients. In view of the poor knowledge as to the pathological outcome and clinical and microbiological features of these infections within our hospitals, the use of empirical broad-spectrum therapeutics contributes to the emergence of anti-microbial resistance and to higher related costs, without a concomitant reduction in morbidity and mortality rates for these patients. Objectives: Study the clinical outcome, the predisposing factors, and the mortality rate in patients with positive hemoculture during a 30-day period in a tertiary hospital in the city of Maceió. Methodology: A total of 143 patients referred to the hospital between October 2005 and December 2006 took part in the study. They all had at least one positive hemoculture result. All variables were systematically assessed for the study protocol during a 30-day interval. The Chi-square test (SIEGEL) was employed when verifying the association between the qualitative variables. Significance level was at 5%. The statistical analysis software used was the SPSS 15.0 for Windows. Results: At the end of 30 days, 30.1% of the patients had been diagnosed as having only bacteremia and 69.9% had developed sepsis. Out of this latter group, 20.3% went on to severe sepsis and 10.5% suffered from septic shock. Throughout the study, the overall mortality rate for the Hospital was 3.7%, whilst the like rate attributed to this malady was at 37.8%. Mortality rates for patients who had been diagnosed as having bacteremia with no clinical repercussions, with sepsis, severe septis, and septic shock, were, respectively, 9.3%, 50%, 65.5% and 84.6% thirty days after diagnosis. Secondary foci of infection were the most prevalent and were found in the respiratory (32.2%), urinary (14%), and intra-abdominal (7.7%) tracts. Fourteen percent of BSIs were related to the central venous catheter. The medical specialties accounting for most of the cases in this study were neurology, cardiology, general clinical practice, oncology, pediatrics, and neonatology. Their respective figures were 19.6%, 18.9%, 16.8%, 12.6%, 8.4%, and 7.7%. The bacteremia rate in intensive care units (ICUs) was 1.2%, as opposed to 0.33% in wards. Out of these latter cases, 55.12% of them turned into sepsis, while at the ICU this figure rose significantly to 87.69% ( p<0,05). Diabetes mellitus in 26.6% of the patients, chronic renal failure in 21.7%, neuropathy in 29.4%, and chronic obstructive pulmonary disease in 11.2% were the most prevalent comorbidities. Most commonly isolated etiological agents were: coagulase-negative staphylococcus (25.9%), Staphylococcus aureus (21%), Klebsiella pneumoniae (14%), Escherichia coli (9.1%), and Candida Spp. (8.4%). S. aureus was the isolated pathogen in 24.1% of fatal cases. Nosocomial BSIs accounted for 14% of the cases. Conclusion: With regard to prevalence, progression, and mortality attributed to distinct BSI cases, the results herein presented are in compliance with data published elsewhere. In addition, they lend support to the need for setting down the features that clearly define this disease, which in turn will lead to more effective treatment and greater preventive measures. / TEDE

Bacterial bloodstream infections (BSIs) are a major healthcare problem causing high mortality and economic cost. BSIs require an immediate initiation of antibiotic therapy as any delay is associated with a mortality increase. With the emergence of antimicrobial resistance, the choice of the appropriate antibiotic becomes increasingly difficult, thus creating an urgent need for new diagnostics, ideally to be done at the point of care. The current gold standard is blood culture with subsequent susceptibility testing although several molecular methods have recently entered the market. However, in many instances there is a discrepancy between the in-vitro data provided by the test and the outcome of antimicrobial therapy in-vivo because current diagnostics fail to take into account the impact of the environment in the patient such as the immune system, pharmacokinetics and pharmacodynamics or bacterial fitness. In this thesis, it was hypothesised that the measurement of the bacterial gene expression after the beginning of antibiotic therapy might be a more accurate indicator of the therapy outcome because it reflects the bacterial response under in-vivo conditions. In the first part of the thesis the expression of a set of pre-defined mRNA markers was investigated under various conditions. Experiments conducted with clinical E. coli isolates incubated in human whole blood revealed an excellent correlation between the gene expression, the treatment outcome, the antibiotic susceptibility and the genetic background for three different classes of antimicrobial drugs. The second part of the thesis describes the extraction of bacterial RNA from human whole blood specimen. The effect of different agents for the lysis of human blood cells and the impact of co-purified human RNA were analysed and a method for high yield extraction of undegraded bacterial RNA was established. The third part of the thesis investigates two methods for the sensitive measurement of the bacterial gene expression. This is relevant because the bacterial loads in BSI patients are extremely low. For genes with high gene expression levels both methods yielded reliable results but were unable to quantify the expression of the previously investigated mRNA markers due to their low copy numbers. Other approaches, especially those based on single cell measurements, might be able to overcome the problem in the future and should be explored in greater detail. Overall, the foundations for a future diagnostic test based on the measurement of the bacterial gene expression have been laid in this work. Future work should address the mRNA quantification and further evaluate the connection between gene expression and therapy outcome, e.g. in animal models. A future diagnostic test should also fulfil point-of-care requirements. This will include integrated sample preparation and quantification as well as a time-to-result in the range of a few minutes.

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Em nosso meio, a resistência às cefalosporinas de amplo espectro em enterobactérias tem sido associada à produção de β-lactamases de espectro ampliado (ESβL). Porém, nos últimos anos, a produção de cefalosporinases do tipo AmpC mediadas por genes plasmídiais (pAmpC) também tem sido responsabilizada pela resistência a essas drogas. O objetivo deste estudo foi avaliar a presença de pAmpCs entre amostras de enterobactérias isoladas de pacientes internados no Hospital São Paulo que apresentaram infecção de corrente sangüínea, entre janeiro e julho de 2006. Foram estudadas 133 amostras de enterobactérias identificadas como K. pneumoniae (65 amostras), K. oxytoca (5 amostras), E. coli (41 amostras), P. mirabilis (18 amostras) e Salmonella spp. (4 amostras). O perfil de sensibilidade aos antimicrobianos selecionados foi avaliado pela técnica de diluição em ágar, segundo as recomendações do CLSI. A detecção fenotípica da produção de pAmpC foi realizada pelos testes tri-dimensional e de Hodge modificado. Adicionalmente, foi realizada a detecção fenotípica da produção de ESβL. A pesquisa e identificação dos genes que codificam pAmpC foram realizados pela técnica de reação em cadeia da polimerase (PCR) e seqüenciamento. Entre os antimicrobianos testados, imipenem (99,2%) apresentou a maior taxa de sensibilidade, seguido pela cefoxitina (80,5%). De forma geral, os isolados de K. pneumoniae apresentaram alto grau de resistência aos β- lactâmicos e os isolados de P. mirabilis apresentaram a menor taxa de sensibilidade para ciprofloxacino (27,8%). Entre as 133 amostras estudadas, 59 (44,4%) foram classificadas fenotipicamente como produtoras de ESβL pela metodologia de disco aproximação. Foi observada discordância entre os resultados dos testes fenotípicos para detecção de pAmpC. A produção de pAmpC foi observada em seis isolados de acordo com o teste tri-dimensional, enquanto, o método de Hodge modificado classificou 19 isolados como possíveis produtores de pAmpC. Além disso, resultados duvidosos foram observados em ambas as técnicas. Um único isolado de K. pneumoniae foi identificado como produtor de CMY-2. Este isolado foi corretamente identificado como produtor de pAmpC por ambos métodos fenotípicos empregados. / The broad-spectrum cephalosporins are the main therapeutic options to Enterobacteriaceae infections and the resistance to these agents has been associated to ESβL production. However, plasmid-mediated AmpC β-lactamases (pAmpC) have been associated with this resistance phenotype. The aim of this study was to determine the occurrence of pAmpC among clinical isolates recovered from bloodstream from patients hospitalized at a Brazilian teaching hospital, collected between January and July 2006. A total of 133 non-repetitive Enterobacteriaceae per patients (65 K. pneumoniae, 41 E. coli, 18 P. mirabilis, 05 K. oxytoca and 04 Salmonella spp.) were studied. The antimicrobial susceptibility profile was determined by CLSI agar dilution method. ESβL phenotype was detected by doubledisk diffusion method while pAmpC production was evaluated by two phenotypic methods: modified three-dimensional and modified Hodge tests and the presence of pAmpC genes was confirmed by PCR and sequencing. Among tested antimicrobial, imipenem showed the highest susceptibility rate (99.2%), followed by cefoxitin (80.5%). K. pneumoniae presented high resistance to β-lactams. P. mirabilis isolates showed the lower susceptibility rate to ciprofloxacin (27.8%). Fifty-nine (44.4%) of studied isolates were phenotypically classified as ESβL producers. Modified threedimensional and Hodge methods classified 06 and 19 Enterobacteriaceae strains as pAmpC producers, respectively. Discordant results were observed between phenotypic pAmpC detection methods. Of those, a single K. pneumoniae isolate was confirmed as CMY-2 producer. / TEDE / BV UNIFESP: Teses e dissertações

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Nosocomial infections are a serious public health problem. In recent years, bloodstream infections (BSI) has increased significantly in hospitals, accounting for high morbidity and mortality rates. These, mostly are caused by bacteria, which are detected by performing blood cultures. Currently, due to the frequency and severity of BSI in the hospital environment, it is necessary to evaluate the epidemiological importance data, improving the control and prevention of these infections. Thus, this study aimed to analyze the microorganisms related to BSI from patients admitted to the University Hospital of Santa Maria (HUSM) in the one-year period (2012-2013). We analyzed the epidemiological profile and sensitivity of positive blood cultures of patients admitted at HUSM from April 2012 to March 2013. During the study period, 1080 samples were positive, 69.3% caused by gram-positive organisms (GP), 22.9% by Gram-negative (GN) and 7.9% by fungus. The most common organism was Staphylococcus epidermidis (24%), followed by Staphylococcus hominis (6.8%), Staphylococcus haemolyticus (6.8%) and Pseudmonas aeruginosa (6%). The isolates predominated in male patients (50.6%) and aged between 0-20 years, and the Pediatric/Neonatal Intensive Care Unit was the sector with the highest number of insulation, 24.3% (10.3%/14%). The evaluation of the sensitivity profile showed 100% sensitivity daptomycin, linezolid, tigecycline and vancomycin front of GP microorganisms, and a rate of 42.31% of Staphylococcus were characterized phenotypically as coagulase negative Staphylococcus resistant to methicillin (MRSCoN). Already, between the GN, all microorganisms in study showed 100% of resistance to ampicillin, and Pseudomonas aeruginosa 100% of resistance to cephalothin and cefoxitin, and 1.57% of these isolates showed ESBL mechanism resistance. Impact assessment studies of BSI have significant impact in reducing mortality, especially in patients with weakened immune system, since that provide an immediate start of effective empirical antimicrobial therapy, also decreasing hospital costs. Through this study it was observed that there was a predominance of GP bacteria, and approximately 50% of the isolates were caused by Staphylococcus spp. and 42.31% of strains were resistant to methicillin. This fact should be reconsidered when the empirical antibiotic therapy institution, especially in patients admitted to critical care units. ICS impact assessment studies have significant impact on mortality, especially in patients with weakened immune system, since provide immediate onset of effective empiric antibiotic therapy. These infections should be investigated along the Hospital Infection Control Commission for further steps to be taken, reducing the incidence of ICS, hospital costs and also mortality rates. / Infecções hospitalares constituem um sério problema de saúde pública. Nos últimos anos, as infecções de corrente sanguínea (ICS) vem aumentando significativamente nos hospitais, sendo responsáveis por elevadas taxas de morbi-mortalidade. Estas, majoritariamente são ocasionadas por bactérias, as quais são detectadas pela realização de hemoculturas. Atualmente, devido a frequência e a gravidade das ICS no ambiente hospitalar, torna-se necessário a avaliação de dados de importância epidemiológica, melhorando o controle e prevenção destas infecções. Dessa forma, este estudo teve como objetivo analisar os microrganismos relacionados à ICS, de pacientes admitidos no Hospital Universitário de Santa Maria (HUSM), no período de um ano (2012-2013). Foi realizada a avaliação do perfil epidemiológico e de sensibilidade das hemoculturas positivas dos pacientes admitidos no HUSM entre abril de 2012 a março de 2013. No período de estudo, 1080 amostras foram consideradas positivas, sendo 69,3% causadas por microrganismos gram-positivos (GP), 22,9% por gram-negativos (GN) e 7,9% fungos. O microrganismo mais frequente foi o Staphylococcus epidermidis (24%), seguido pelo Staphylococcus hominis (6,8%), Staphylococcus haemolyticus (6,8%) e Pseudmonas aeruginosa (6%). Os isolamentos predominaram em pacientes do sexo masculino (50,6%) e na faixa etária compreendida entre 0-20 anos, sendo a Pediatria/Unidade de terapia intensiva neonatal, o setor com maior número de isolamentos, 24,3% (10,3%/14%). A avaliação do perfil de sensibilidade evidenciou 100% de sensibilidade a daptomicina, linezolida, tigeciclina e vancomicina frente aos microrganismos GP, sendo que uma taxa de 42,31% dos isolados do gênero Staphylococcus foram caracterizados fenotipicamente como Staphylococcus coagulase negativa resistentes à meticilina (MRSCoN). Já, entre os GN, todos os microrganismos em estudo apresentaram 100% de resistência frente a ampicilina, e a Pseudomonas aeruginosa 100% de resistência a cefalotina e cefoxitina, e 1,57% destes isolados apresentaram mecanismo de resistência ESBL. Através deste estudo foi possível observar que houve o predomínio de bactérias GP, sendo que aproximadamente 50% dos isolamentos foram causados por Staphylococcus spp. e 42,31% destas cepas foram resistentes a meticilina. Esse fato deve ser reconsiderado quando da instituição da antibioticoterapia empírica, principalmente nos pacientes admitidos em unidades críticas. Estudos de avaliação da incidência de ICS apresentam impacto significativo na mortalidade, principalmente dos pacientes com sistema imune debilitado, uma vez que propiciam o início imediato da efetiva terapia antimicrobiana empírica. Estas infecções devem ser investigadas juntamente da Comissão de Controle de Infecção Hospitalar para que novas medidas sejam adotadas, reduzindo a incidência das ICS, os custos hospitalares e também as taxas de mortalidade.

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