La investigación “Beneficios del uso del apósito con clorhexidina en la prevención de infecciones por el catéter venoso central en el paciente crítico”, tuvo como objetivo determinar los beneficios del uso del apósito con clorhexidina para prevención de infecciones por catéter venoso central. Se desarrolló mediante una metodología de investigación secundaria bajo el enfoque de la enfermería basada en la evidencia, para lo cual se formuló la pregunta clínica ¿Cuáles son los beneficios del uso del apósito con clorhexidina para prevención de infecciones por catéter venoso central en el paciente crítico? Se realizó la búsqueda de la información en bases de datos como BVS, Scielo, Epistemonikos, Pubmed y Cochrane de donde se obtuvo un total de 761 artículos, de los cuales, finalmente solo quedaron 7 investigaciones que fueron validadas con la guía de Gálvez Toro, siendo la investigación sujeta a revisión “Apósito impregnado de clorhexidina para la profilaxis de complicaciones relacionadas con el catéter venoso central: una revisión sistemática y un metaanálisis”, a la cual se aplicó la guía CASPe, el cual tuvo un nivel de evidencia 1++ y grado recomendación A según guía SIGN. Finalmente para dar respuesta a la pregunta se determinó que el apósito impregnado de clorhexidina es beneficioso en la reducción de riesgo de infecciones del torrente sanguíneo relacionados al uso de catéter venoso central en una unidad de cuidados intensivos. / The research “Benefits of the use of a dressing with chlorhexidine in the prevention of infections due to the central venous catheter in critically ill patients” aimed to determine the benefits of the use of a dressing with chlorhexidine for the prevention of infections due to a central venous catheter. It was developed through a secondary research methodology under the approach of evidence-based nursing, for which the clinical question was formulated: What are the benefits of using chlorhexidine dressing for the prevention of central venous catheter infections in critically ill patients? The information was searched in databases such as BVS, Scielo, Epistemonikos, Pubmed and Cochrane, from which a total of 761 articles were obtained, of which, finally, only 7 investigations remained that were validated with the guide of Gálvez Toro. The research being subject to review “Chlorhexidine-impregnated dressing for the prophylaxis of complications related to the central venous catheter: a systematic review and meta-analysis”, to which the CASPe guideline was applied, which had a level of evidence 1++ and recommendation grade A according to SIGN guide. Finally, to answer the question, it was determined that the chlorhexidine-impregnated dressing is beneficial in reducing the risk of bloodstream infections related to the use of a central venous catheter in an intensive care unit.

Yes / It is estimated that 5-10% of hospitalised patients in developed countries contract hospital acquired infections (HAI). Increasing levels of antimicrobial resistance manifested by many HAI-causing pathogens such as Acinetobacter spp in the intensive care unit (ICU) setting present a significant challenge to those managing these infections. Consequently, much attention has been focused on the prevention of HAIs. Particular emphasis has been placed on interventions intended to interrupt patient-to-patient transmission of pathogens, such as enhanced hand hygiene and identification of patients colonised with methicillin-resistant Staphylococcus aureus (MRSA) using rapid DNA-based screening techniques. However, comparatively little attention has been given to the hospital environment, including water supplies, as a source of nosocomial pathogens of importance for patients on the critical care unit. This article reviews the role of hospital water sources in the epidemiology of HAI and new technologies which can be employed in the prevention and control of such infections.

Bibliography / Thesis (MMed (Pathology. Medical Microbiology))--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Acinetobacter baumannii has emerged as one of the most troublesome nosocomial pathogens globally. This organism causes infections that are often extremely difficult to treat because of the widespread resistance to the major antibiotic groups. Colonization or infection with multidrugresistant A. baumannii is associated with the following risk factors: prolonged hospital stay, admission to an intensive care unit (ICU), mechanical ventilation, and exposure to broad spectrum antibiotics, recent surgery, invasive procedures, and severe underlying disease. A. baumannii has been isolated as part of the skin flora, mostly in moist regions such as axillae, groin and toe webs. It has also been isolated from the oral cavity and respiratory tract of healthy adults. Debilitated hospitalized patients have a high rate of colonization, especially during nosocomial Acinetobacter outbreaks. This organism is an opportunistic pathogen as it contains few virulence factors. Clinical manifestations of A. baumannii include nosocomial pneumonia, nosocomial bloodstream infections, traumatic battlefield and other wound infections, urinary tract infections, and post-neurological surgery meningitis. Fulminant community-acquired pneumonia has recently been reported, indicating that this organism can be highly pathogenic. The number of multidrug-resistant A. baumannii strains has been increasing worldwide in the past few years. Therefore the selection of empirical antibiotic treatment is very challenging. Antibiotic combinations are used mostly as empirical therapy in critically ill patients. One rationale for the use of combination therapy is to achieve synergy between agents. The checkerboard and time-kill methods are two traditional methods that have been used for synergy testing. These methods are labor intensive, cumbersome, costly, and time consuming. The E-test overlay method is a modification of the E-test method to determine synergy between the different antibiotics. This method is easy to perform, flexible and time efficient. The aim of this study was to assess the in vitro activity of different combinations of colistin, rifampicin, imipenem, and tobramycin against selected clinical strains of A. baumannii using the checkerboard and the E-test synergy methods. The MICs obtained with the E-test and broth microdilution method were compared. The results of the disk diffusion for imipenem and tobramycin as tested in the routine microbiology laboratory were presented for comparison. Overall good reproducibility was obtained with all three methods of sensitivity testing. The agreement of MICs between the broth dilution and E-test methods was good with not more than two dilution differences in MIC values for all isolates, except one in which the rifampicin E-test MIC differed with three dilutions from the MIC obtained with the microdilution method. However, the categorical agreement between the methods for rifampicin was poor. Although MICs did not differ with more than two dilutions in most cases, many major errors occurred because the MICs clustered around the breakpoints. The combinations of colistin + rifampicin, colistin + imipenem, colistin + tobramycin, rifampicin + tobramycin, and imipenem + tobramycin all showed indifferent or additive results by the E-test method. No results indicating synergy were obtained for all the above-mentioned combinations. There was one result indicating antagonistic effect for the combination of colistin + tobramycin. The results of the checkerboard method showed results indicating synergy in four of the six isolates for which the combination of colistin and rifampicin was tested. The other two isolates showed indifferent/additive results. All the other combinations showed indifferent/additive results for all isolates except isolate 30 (col + tob) and isolate 25 (rif + tob) which showed synergism. No antagonistic results were observed by the checkerboard method. When the results obtained with the E-test and checkerboard methods were compared, it was noted that for most antibiotic combinations an indifferent/additive result was obtained. However, for the colistin + rifampicin combination, the checkerboard method showed synergism for 4 of 6 isolates, whereas the E-test method showed indifference and an additive result in one. For the rifampicin + tobramycin, and colistin + tobramycin combinations, synergism was also shown with the checkerboard method in one isolate for each combination. The E-test method however showed an indifferent and additive result respectively. . The E-test method was found to be a rapid, reproducible, easy-to-perform, and flexible method to determine synergistic antibiotic activity. This study was however limited by low numbers of isolates. This might explain why no synergistic results were obtained with the E-test method and few synergistic results with the checkerboard method. Genotypic analysis using pulse-field gel electrophoresis (PFGE) may be considered in future studies to determine relatedness of the isolates which will facilitate the selection of different strains for synergy testing. Furthermore, clinical studies are needed to establish whether in vitro synergy testing is useful in the clinical setting and whether the results of synergy testing will have any bearing on the clinical outcome of patients infected with multidrug resistant A. baumannii. / AFRIKAANSE OPSOMMING: Acinetobacter baumannii het wêreldwyd as een van die mees problematiese nosokomiale patogene verskyn. Hierdie organisme veroorsaak infeksies wat dikwels baie moeilik is om te behandel weens wydverspreide weerstandigheid teen major antibiotikagroepe. Kolonisasie of infeksie met multi-weerstandige A. baumannii word geassosieer met die volgende riskofaktore: verlengde hospitaalverblyf, toelating tot ‘n intensiewe sorgeenheid (ICU), meganiese ventilasie, blootstelling aan breëspektrum antibiotika, onlangse chirurgie, indringende prosedures en ernstige onderliggende siekte. A. baumannii kan deel vorm van die normale velflora, veral in die axillae, inguinale area en tussen die tone. Dit is ook al vanuit die mondholte en die respiratoriese traktus van gesonde volwassenes geïsoleer. Verswakte gehospitaliseerde pasiënte word veral gekoloniseer gedurende nosokomiale Acinetobacter uitbrake. Hierdie organisme is ‘n opportunistiese patogeen en bevat min virulensie faktore. Kliniese manifestasies van A. baumannii sluit nosokomiale pneumonie, nosokomiale bloedstroom infeksies, troumatiese slagveld- en ander wondinfeksies, urienweginfeksies en meningitis wat volg op neurologiese chirurgie in. Fulminerende gemeenskapsverworwe pneumonie is onlangs beskryf en dui aan dat hierdie organisme hoogs patogenies kan wees. Die aantal multi-weerstandige A. baumannii stamme het wêreldwyd toegeneem oor die laaste paar jare. Daarom is die seleksie van empiriese antibiotiese behandeling ‘n uitdaging. Antibiotika kombinasies word meestal as empiriese behandeling in ernstige siek pasiënte gebruik. Die beginsel hiervan is om sinergistiese werking tussen agente te verkry. Die “checkerboard” en “time-kill” metodes is twee tradisionele metodes van sinergisme toetsing. Hierdie metodes is werksintensief, duur en tydrowend. Die E-toets sinergisme metode is gebaseer op die E-toets metode. Hierdie metode is maklik, buigbaar en tydseffektief. Die doel van hierdie studie was om die in vitro aktiwiteit tussen verskillende antibiotika kombinasies van colistin, rifampisien, imipenem, en tobramisien teen geselekteerde kliniese A. baumannii isolate te toets met die “checkerboard” en E-toets sinergisme toetsing metodes. Die minimum inhibitoriese konsentrasies (MIKs) verkry met die E-toets en “broth microdilution” metode is ook vergelyk. Die resultate van die skyfie diffusie metode (die metode wat in die roetiene mikrobiologie laboratorium gebruik word) vir imipenem en tobramisien word ook verskaf vir vergelyking van die resultate van verskillende sensitiwiteitsmetodes. In oorsig is goeie herhaalbaarheid van resultate verkry met al drie metodes van sensitiwiteitstoetsing. Die ooreenstemming van MIKs tussen die “broth dilution” en E-toets metodes was goed en resultate het met nie meer as twee verdunnings in MIK waardes verskil nie. Daar is een uitsondering waar die rifampisien E-toets MIK waarde met drie verdunnings van die MIK waarde verkry met die “microdilution” metode verskil. Die ooreenstemming tussen die sensitiwiteitskategorie resultate tussen die twee metodes was egter swak vir rifampisien. Alhoewel die MIKs in die meeste gevalle met nie meer as twee verdunnings in waarde verskil het nie, was daar baie major foute aangetoon omdat die MIKs rondom die breekpunte geval het. Die kombinasies van colistin + rifampisien, colistin + imipenem, colistin + tobramisien, rifampisien + tobramisien, en imipenem + tobramisien het oorwegend slegs matige interaksie met die E-toets metode getoon. Geen sinergisme is verkry met enige van die antibiotika kombinasies met hierdie metode nie. Daar was egter een resultaat wat antagonisme getoon het vir die kombinasie van colistin + tobramycin. Die resultate van die “checkerboard” metode het sinergisme getoon in vier van die ses isolate wat vir die kombinasie van colistin en rifampisien getoets was. Die ander twee isolate het slegs matige interaksie getoon. Al die ander kombinasies het ook slegs matige interaksie getoon, behalwe in isolaat 30 (col + tob) en isolaat 25 (rif + tob) waar die spesifieke kombinasies sinergisme getoon het. Geen antagonisme is waargeneem met die “checkerboard” metode nie. Met vergelyking van die E-toets en “checkerboard” metodes, is dit opmerklik dat vir die meeste van die antibiotika kombinasies slegs matige interaksie verkry is. Vir die colistin + rifampisien kombinasie toon die “checkerboard” metode egter sinergisme vir 4 uit 6 isolate, terwyl die E-toets metode slegs matige interaksie toon. Vir rifampisien + tobramisien, en colistin + tobramisien kombinasies is sinergisme getoon met die “checkerboard” metode in een isolaat vir elke kombinasie. Die E-toets metode het slegs matige interaksie getoon. Die E-toets sinergisme metode was vinnig, herhaalbaar en maklik om uit te voer. Hierdie studie word egter beperk deur lae getalle van isolate. Dit mag verklaar waarom geen sinergistiese resultate met die E-toets metode verkry is nie en die min sinergistiese resultate met die “checkerboard” metode. Genotipiese analiese met “pulse-field gel electrophoresis” mag in aanmerking geneem word in toekomstige studies om die verwantskap tussen isolate te bepaal wat die seleksie van verskillende stamme vir sinergisme toetsing sal vergemaklik. Verder, kliniese studies is nodig om te bepaal of in vitro sinergisme toetsing van waarde is en of die resultate van sinergisme toetsing ‘n rol speel in die kliniese uitkoms van pasënte geïnfekteer met multiweerstandige A. baumannii. / The National Health Laboratory Serivice

Les infections nosocomiales demeurent un véritable défi de santé publique en dépit des progrès techniques considérables enregistrés. Inhérentes à la prise en charge de soins, se sont les services de réanimation qui comptabilisent les plus fort taux de prévalence. En effet, quelle que soit leur orientation (chirurgicale, médicale ou mixte), ces services, ont pour mission la prise en charge des patients dont le processus vital est menacé par la survenue brutale d’une ou de plusieurs défaillances organiques nécessitant un arsenal diagnostic et/ou thérapeutique souvent invasif.Parmi les conséquences induites par ces infections ; i) l’allongement de la durée de séjour, ii) le surcoût, iii) une augmentation de la mortalité, et iv) la résistance bactérienne.Pouvoir anticiper en amont et en aval cette problématique aux motifs complexes et aux conséquences parfois fatales serait un atout majeur au profit des patients et un outil stratégique pour les équipes soignantes.Organisée autour de trois étapes charnières, la présente étude s’est d’abord attelée à la phasede l’identification des facteurs de risque de l’évènement nosocomial et de mortalité au service de réanimation ou s’est passé l’étude –prise en compte du case-mix du service de réanimation CHU la TIMONE-. Réalisée grâce à deux méthodes statistiques différentes à savoir la régression logistique et la méthode des risques compétitifs. L’étape suivante a consisté dans un premier temps à comparer les capacités prédictives des scores APACHE II, LOD, SOFA et SAPS II chez ces patients -hospitalisés en réanimation-ayant développé un épisode nosocomial. Dans un second temps de déterminer si la variation des scores LOD, SOFA, APACHEII et SAPS II est un facteur pronostique du risque nosocomial. Les résultats obtenus révèlent que la meilleure performance prédictive est objectivée au profit du SOFA et que seule la variation de ce même score entre le premier jour d’hospitalisation et celui du diagnostic de l’infection nosocomiale mesurée grâce à l’AUC est prédictive du risque nosocomial.À l’issue de ces étapes et au moyen des résultats obtenus une construction d’un score prédictif est réalisée grâce à la méthode de régression logistique. L’objectif de ce score est d’éclairer voire d’influencer le prescripteur lors de ses prises de décisions ou d’éventuelle démarche d’ajustement de ses conduites thérapeutiques. / Limiting nosocomial infections is still a health challenge although the technical development has improved. They are inherent in medical care and the health care services have the highest prevalence. Indeed, whatever the service (surgical, medical or both), the patients life-giving process is under attack because of the emergence of one or several organ faillures;This generates a diagnostic and therapeutic arsenal which is often invasive.Among the consequences resulting from these infections we will take into account :i) a longer stay in hospitalii) an extra costiii) a higher mortality rateiv) bacterial resistance .If we could anticipate upstream and downstream this issue with complex origins and sometimes fatal consequences, it would be a major asset for patients and a strategic tool for medical teams.The present study is organized in three parts, and first focusses onto the identification of the nosocomial event and death risk factors in intensive care where the study took place. We took into account the the case-mix of the intensive care unit in the TIMONE University Hospital. The study was made with two different statistic methods that is logistic regression and the competitive risks method.The next step first consisted in comparing the predictive capacities of the APACHE II, LOD, SOFA and SAPS II scores in nosocomial patients hospitalized in intensive care . Then it tried to determine if the variation of the LOD, SOFA, APACHEII and SAPS II scores was a prognostic risk factor.Results showed that the best predictive performance was objectively measured by the SOFA and that only the variation of this score between the first day in hospital and the day of the diagnosis of a nosocomial infection, calculated thanks to the AUC, could be predictive of a nosocomal risk. After these steps, and with the results calculated , the construction of a predictive score could be established thanks to the logistic regression method. The objective of this score is to help, or even influence the prescribing doctors when they take decisions or when they try to adjust their therapeutic practices.

Nas últimas décadas, a incidência de infecções hospitalares causadas por bactérias Gramnegativas multidrogarresistentes (MDR) vem crescendo de maneira vertiginosa em todo o mundo, de modo que a Organização Mundial de Saúde (OMS) recentemente reconheceu essas infecções como uma preocupação mundial devido ao seu impacto negativo sobre as taxas de mortalidade intra-hospitalar e dos custos da assistência à saúde, afetando tanto os países desenvolvidos quanto os em desenvolvimento. Atualmente considera-se que a higienização das mãos, o uso racional de antimicrobianos e o isolamento de contato são as principais medidas disponíveis para contenção desse avanço. Porém, elas são apenas parcialmente efetivas e de implementação trabalhosa e onerosa. Assim, considera-se necessário o desenvolvimento de formas mais simples e eficientes paralidar com esse problema. No presente estudo, nos propusemos a avaliar o impacto da administração de um produto simbiótico a pacientes colonizados e/ou infectados por bactérias Gram-negativas MDR sobre as taxas de descolonização desses patógenos no trato digestivo. Trata-se de um ensaio clínico randomizado, duplamente cego, controlado com placebo, envolvendo 101 pacientes hospitalizados com colonização prévia por bactérias Gram-negativas MDR, demonstrada por meio de cultura seletiva de swab retal, cuja intervenção consistiu na administração oral ou enteral diária de 1010 unidades de Lactobacillus bulgaricus e 1010 unidades de Lactobacillus rhamnosus associados a fruto-oligossacarídeos durante (FOS) 7 dias. O desfecho primário do estudo foi a descolonização completa do trato digestivo posterior à intervenção, que, na análise do tipo \"intenção de tratar modificada\" foi de 16,7% (8/48) no grupo experimental e 20,7% (11/53) no grupo controle (p=0,600). Na análise \"per protocol\", a descolonização completa do trato observada foi de 18,9% (7/37) no grupo experimental e 23,3% (7/30) no grupo controle (p=0,659). Em uma análise multivariada por meio de modelo de regressão logística o uso do simbiótico não influenciou significativamente o risco de descolonização completa do trato digestivo (OR= 0,80, IC 95%= 0,28-2,27, p= 0,678). A ocorrência de eventos adversos de natureza leve a moderada foi semelhante entre os grupos: 7,55% no grupo que utilizou placebo e 6,25% no grupo sob intervenção (p= 1,000). Nenhum evento adverso grave potencialmente relacionado às medicações de estudo foi observado. Nas condições estudadas, os dados obtidos pelo estudo nos levam à conclusão de que o simbiótico estudado demonstrou-se inefetivo na descolonização do trato digestivo de pacientes previamente colonizados por bactérias Gram-negativas MDR. / In recent decades the incidence of multidrug resistant (MDR) Gram-negative nosocomial infections has been dramatically raising in the whole world. The World Health Organization (WHO) recently recognized nosocomial infections due to MDR pathogens as a global concern due to its negative impact on patients, health-care workers and health-care institutions, affecting developed countries as well as developing ones. They negatively impact in-hospital mortality and health-care related costs. Hand hygiene promotion, antibiotic stewardship and contact precautions are the main available measures to control such MDR Gram-negative organisms in hospitals. However, they are only partially effective as well as difficult to be implemented and expensive. Therefore, simpler and more effective actions are thought to be helpful and urgent. In the present study, we analyzed the impact of the administration of a symbiotic product on patients harboring Gram-negative multidrug-resistant bacteria upon the subsequent rates of decolonization of these pathogens from the gastro-intestinal tract.This is a double-blinded and placebo controlled randomized clinical trial evaluating the oral/enteral daily administration of 1010 units of Lactobacillus bulgaricusplus 1010 units of Lactobacillus rhamnosus associated with fructo-oligosacharide (FOS), or placebo, for 7 days, to 101 patients previously colonized by MDR Gram-negative bacteria, identified through selective culture of rectal swab. The primary study outcome was the rate of complete decolonization of the MDR microorganism from the gastro-intestinal tract following the intervention. In the \"modified intention to treat\" analysis, decolonization rates observed were 16.7% (8/48) in the experimental group and 20.7% (11/53) in the placebo group (p=0,600). In the \"per protocol\" analysis, decolonization rates were 18.9% (7/37) in the experimental group and 23.3% (7/30) in the placebo group (p=0,659). In a logistic regression model, symbiotic use did not produce any impact on the chance of decolonization (OR=0.80, CI95%=0.28-2.27, p=0.678). Mild to moderate adverse events occured similarly in both the placebo (7.55%) and the experimental group (6.25%), (p=1,000). No severe adverse event potentially related to the medications was detected during the study period. In the present study conditions, the results obtained lead to the conclusion that the studied symbiotic proved to be ineffective to decolonize patients harboring multidrug resistant Gram-negative bacilli.

Introdução: Educação é precisamente a atividade que pode expandir as estratégias de prevenção das Infecções Relacionadas à Assistência a Saúde (IRAS). As infecções da corrente sanguínea associadas a cateter (ICSC) são consideradas as mais importantes IRAS no cenário da assistência crítica por estarem associadas com altas taxas de mortalidade de pacientes sob cuidados intensivos. A interação existente entre entender como o conhecimento é adquirido e qual a melhor maneira de se ensinar, sugere uma mudança na prática tradicional do ensino. Partindo do pressuposto de que toda mudança provém de planejamento, execução, avaliação e implementações de melhoria, este estudo surge com a intenção de responder a seguinte questão de pesquisa: Quais métodos e técnicas de ensino se mostraram eficazes na redução das taxas de ICSC?. Objetivo: Identificar e caracterizar os métodos e técnicas de ensino utilizados em treinamentos para equipes de saúde envolvidas diretamente com a prevenção de ICSC. Método: Trata-se de uma Revisão Integrativa da Literatura (RIL) com a estruturação de uma questão de pesquisa conforme a estratégia PICO, sendo utilizados descritores controlados padronizados. As seguintes bases foram pesquisadas: PubMed/MEDLINE, CINAHL, LILACS, Embase, ERIC e Web of Science. Os artigos incluídos atenderam à critérios pré definidos, incluindo avaliação de qualidade metodológica. Resultados: O número total de referências encontradas foi de 300 e, 10 artigos (3,3%) foram incluídos como amostra final a ser analisada. O Método Expositivo foi utilizado por 100% da amostra. Observou-se que 80% optaram pela Técnica de Ensino Verbal, Ilustração (60%), Simulação (30%) e Exemplificação (20%). O Método de Elaboração em Conjunto configurou o segundo método mais utilizado pelos autores (80%). As técnicas de ensino mais exploradas nessa categoria foram a Conversa Dialogada (80%), Lista de discussões via internet (30%) e Aula Expositiva Dialogada (20%). Simpósio e Painel não foram testados. O Método de Ensino para Trabalho Individual foi o terceiro método mais explorado pelos autores (60%), sendo que a Técnica de Ensino mais utilizada foi a Revisão (50%), seguidos pelo Estudo Dirigido e Ficha Didática (10%). Portfólios, Mapa Conceitual, Solução de Problemas, Estudos de Caso e Pesquisas não foram exploradas como objetos de intervenção. Os Métodos de Ensino para Trabalho em Grupo e Atividades Especiais, com suas respectivas técnicas de ensino, não foram considerados em nenhum dos estudos analisados. Quanto aos recursos utilizados nas intervenções, o Feedback foi contemplado em 60%, seguidos pelo uso de cartazes, checklist a beira-leito, módulos de auto estudo (30%) e informativos, pôsteres, adesivos coloridos, carros e kits de inserção de CVC e internet (20%). Para os Métodos de Análise das intervenções realizadas, todos os estudos incluídos apresentaram as taxas de ICSC, seguidos pela Avaliação de Desempenho Pré e Pós Intervenção (60%), Auditorias e Testes Pré e Pós (50%), Checklist (40%), Indicadores gerais de IRAS, Avaliação diagnóstica prévia (20%) e Inspeção (10%). Conclusão: Os Métodos e Técnicas de Ensino utilizados nos estudos incluídos na presente pesquisa favoreceram a redução de ICSC. Entretanto, devido a uso combinado de diferentes métodos não foi possível identificar um método que isoladamente tenha sido mais eficaz / Introduction: Education is precisely the activity that can expand the strategies Healthcare Associated Infections (HAI). Catheter-related bloodstream infections (CRBSI) are considered to be the most important HAI in the critical care setting being associated with the high mortality rates of patients under intensive care. The interaction between the understanding of how knowledge is acquired and what would be the better way to teach, suggests a need for change in the traditional practices in teaching. Assuming that all changes should come from planning, implementation, evaluation and improving implementations, this study seeks to answer the following research question: \"What are the methods and teaching techniques that have proved to be effective in reducing CRBSI rates?\". Objective: Identify and describe the methods and teaching techniques used in training healthcare workers directly involved in the prevention of CRBSI. Method: This is an Integrative Review of Literature (IRL) with the structuring of a research question according to the PICO strategy which used standardized controlled descriptors. The following databases were searched: PubMed/MEDLINE, CINAHL, LILACS, EMBASE, ERIC and Web of Science. The articles that are included met the pre-defined criteria, including a methodological quality assessment. Results: Three hundred references were found and 10 articles (3.3%) were included as the final sample to be analyzed. The Expository Method was used by 100% of the sample. It was observed that 80% opted to the Verbal Teaching Technique, Illustration (60%), Simulation (30%) and Exemplification (20%). The Preparation Group Method configured the second method used the most by the authors (80%). The most explored teaching techniques in this category were the Dialogued Conversation (80%), List of discussions by internet (30%) and Dialogued Exposition Class (20%). Symposium and Panel were not tested. The teaching method for Individual Work was the third method further explored by the authors (60%), and the Review was the most used teaching technique on this category (50%), followed by the Directed Study and Teaching Sheet (10%). Portfolios, Concept Map, Problem Solving, Case Studies and Research where not explored as objects of intervention. The teaching methods for Group Work and Special Activities, with their respective teaching techniques were not considered in any of the studies analyzed. As for the resources used in the interventions studies, the Feedback was contemplated in 60%, followed by the use of banners, a bedside checklist, self study modules (30%) and newsletters, posters, colored stickers, car with the insertion kits of central lines and the internet (20%). According to the analysis methods for the implemented interventions, all included studies showing their CRBSI rates, followed by the Performance Assessment - Pre and Post Intervention (60%), Audits and Testing Before and After (50%), Checklist (40%), General HAI indicators, Prior diagnostic evaluation (20%) and Inspection (10%). Conclusion: The Methods and Teaching techniques used in the included studies from this research favored the reduction of CRBSI. However, due to the combined use of different methods, it was not possible to identify a method that alone was more effective

Nas últimas décadas, a incidência de infecções hospitalares causadas por bactérias Gramnegativas multidrogarresistentes (MDR) vem crescendo de maneira vertiginosa em todo o mundo, de modo que a Organização Mundial de Saúde (OMS) recentemente reconheceu essas infecções como uma preocupação mundial devido ao seu impacto negativo sobre as taxas de mortalidade intra-hospitalar e dos custos da assistência à saúde, afetando tanto os países desenvolvidos quanto os em desenvolvimento. Atualmente considera-se que a higienização das mãos, o uso racional de antimicrobianos e o isolamento de contato são as principais medidas disponíveis para contenção desse avanço. Porém, elas são apenas parcialmente efetivas e de implementação trabalhosa e onerosa. Assim, considera-se necessário o desenvolvimento de formas mais simples e eficientes paralidar com esse problema. No presente estudo, nos propusemos a avaliar o impacto da administração de um produto simbiótico a pacientes colonizados e/ou infectados por bactérias Gram-negativas MDR sobre as taxas de descolonização desses patógenos no trato digestivo. Trata-se de um ensaio clínico randomizado, duplamente cego, controlado com placebo, envolvendo 101 pacientes hospitalizados com colonização prévia por bactérias Gram-negativas MDR, demonstrada por meio de cultura seletiva de swab retal, cuja intervenção consistiu na administração oral ou enteral diária de 1010 unidades de Lactobacillus bulgaricus e 1010 unidades de Lactobacillus rhamnosus associados a fruto-oligossacarídeos durante (FOS) 7 dias. O desfecho primário do estudo foi a descolonização completa do trato digestivo posterior à intervenção, que, na análise do tipo \"intenção de tratar modificada\" foi de 16,7% (8/48) no grupo experimental e 20,7% (11/53) no grupo controle (p=0,600). Na análise \"per protocol\", a descolonização completa do trato observada foi de 18,9% (7/37) no grupo experimental e 23,3% (7/30) no grupo controle (p=0,659). Em uma análise multivariada por meio de modelo de regressão logística o uso do simbiótico não influenciou significativamente o risco de descolonização completa do trato digestivo (OR= 0,80, IC 95%= 0,28-2,27, p= 0,678). A ocorrência de eventos adversos de natureza leve a moderada foi semelhante entre os grupos: 7,55% no grupo que utilizou placebo e 6,25% no grupo sob intervenção (p= 1,000). Nenhum evento adverso grave potencialmente relacionado às medicações de estudo foi observado. Nas condições estudadas, os dados obtidos pelo estudo nos levam à conclusão de que o simbiótico estudado demonstrou-se inefetivo na descolonização do trato digestivo de pacientes previamente colonizados por bactérias Gram-negativas MDR. / In recent decades the incidence of multidrug resistant (MDR) Gram-negative nosocomial infections has been dramatically raising in the whole world. The World Health Organization (WHO) recently recognized nosocomial infections due to MDR pathogens as a global concern due to its negative impact on patients, health-care workers and health-care institutions, affecting developed countries as well as developing ones. They negatively impact in-hospital mortality and health-care related costs. Hand hygiene promotion, antibiotic stewardship and contact precautions are the main available measures to control such MDR Gram-negative organisms in hospitals. However, they are only partially effective as well as difficult to be implemented and expensive. Therefore, simpler and more effective actions are thought to be helpful and urgent. In the present study, we analyzed the impact of the administration of a symbiotic product on patients harboring Gram-negative multidrug-resistant bacteria upon the subsequent rates of decolonization of these pathogens from the gastro-intestinal tract.This is a double-blinded and placebo controlled randomized clinical trial evaluating the oral/enteral daily administration of 1010 units of Lactobacillus bulgaricusplus 1010 units of Lactobacillus rhamnosus associated with fructo-oligosacharide (FOS), or placebo, for 7 days, to 101 patients previously colonized by MDR Gram-negative bacteria, identified through selective culture of rectal swab. The primary study outcome was the rate of complete decolonization of the MDR microorganism from the gastro-intestinal tract following the intervention. In the \"modified intention to treat\" analysis, decolonization rates observed were 16.7% (8/48) in the experimental group and 20.7% (11/53) in the placebo group (p=0,600). In the \"per protocol\" analysis, decolonization rates were 18.9% (7/37) in the experimental group and 23.3% (7/30) in the placebo group (p=0,659). In a logistic regression model, symbiotic use did not produce any impact on the chance of decolonization (OR=0.80, CI95%=0.28-2.27, p=0.678). Mild to moderate adverse events occured similarly in both the placebo (7.55%) and the experimental group (6.25%), (p=1,000). No severe adverse event potentially related to the medications was detected during the study period. In the present study conditions, the results obtained lead to the conclusion that the studied symbiotic proved to be ineffective to decolonize patients harboring multidrug resistant Gram-negative bacilli.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-07-18T11:44:03Z No. of bitstreams: 1 Regina Silvia Chaves de Lima.pdf: 1502566 bytes, checksum: 13df8f50607c72373833f47cbfb6de16 (MD5) / Made available in DSpace on 2018-07-18T11:44:03Z (GMT). No. of bitstreams: 1 Regina Silvia Chaves de Lima.pdf: 1502566 bytes, checksum: 13df8f50607c72373833f47cbfb6de16 (MD5) Previous issue date: 2018-03-26 / Introduction: Introduction: hand hygiene of health-care workers is the measure with the greatest impact on the effectiveness of prevention and control of infections related to the health-care system. This basic and easily implemented measure has been a worldwide challenge due to its low compliance, despite several strategies made by the World Health Organization. Objectives: the main goal was to evaluate the improvements in hand hygiene of medical students achieved by a DLP. The secondary objectives were to enable medicine students in hand hygiene, to assess hand hygiene training by DLP and to establish a collaboration between the hand hygiene training DLP and the hospital infection control program. Material and method: 99 students of the UNIFEV Medicine course were evaluated through a qualitative and quantitative approach and exploratory methods. The training consisted of six activities, being five online and one on-site. The first was the application of a multiple-choice test with summative evaluation to survey the previous knowledge of the students. The second was carried out through a discussion forum, with a focus on raising the awareness of health professionals to improve compliance – the evaluation was qualitative. In the third a reapplication of the multiple-choice test was performed with automatic feedback by the system. The fourth was practical – the participants analyzed two videos published on the platform. This analysis should be performed in accordance with the eleven steps of the hand hygiene technique recommended by the Brazilian Ministry of Health, identifying the shortcomings in the videos. In the fifth the students had to prepare their own hand sanitation video following the proposed technique – the evaluation included individual feedback. The sixth evaluation was performed on site and carried a Structured Objective Clinical Examination in a simulated situation, in which the student should report the appropriate moments for hand hygiene. Afterwards the students demonstrated the hand hygiene technique and received instantenous individual feedback. Results: among the 99 students enrolled, eight students did not attend (8.1%), 84 students (92.3%; N=91) passed, and seven (7.7%; N=91) failed for not completing all required activities. The first activity presented the average score of 8.00 among all participants. In the second activity, healthcare education and ratings of infection control were the factors with the greatest impact on awareness. Implementing the trainings was the most frequent proposal of the participants to improve awareness. The third, fourth, fifth and sixth activities respectively had average scores of 8.50, 6.50, 9.80 and 9.60 among the students. Conclusion: the participants presented a good performance in the evaluation of previous knowledge, which suggests an adequate theoretical learning in the medicine graduation course. The discussions and reflections were coherent, with feasible proposals, for implementation to improve compliance. The evaluation of handwashing ability initially presented a poor performance, despite the theoretical knowledge being satisfactory. There was a gap between "knowing" and "demonstrating how it is done", revealing the need to implement activities that contemplate the skill of hand hygiene in the curriculum. Several evaluation methods were used, the predominant being the formative evaluation associated with feedback, which contributed to a meaningful learning throughout the training, in which the student demonstrated "how to be done". The modality of DLPs as a fundamental tool in curricular and extracurricular activities should be considered for hand hygiene training as well as its implementation in hospital infection control / Introdução: a higienização das mãos do profissional de saúde é a medida de maior impacto na eficácia da prevenção e controle de infecções relacionadas à assistência à saúde. Medida básica e de simples execução, vem sendo um desafio mundial pela sua baixa adesão, apesar de várias estratégias utilizadas pela Organização Mundial da Saúde. Objetivos: avaliar a aprendizagem na capacitação em higiene das mãos, em acadêmicos do curso de Medicina, por meio de EaD. Os objetivos específicos foram de capacitar estudantes de Medicina em higienização das mãos; avaliar uma capacitação de higiene de mãos em EaD e colaborar com o programa de controle de infecção hospitalar com uma capacitação de higiene de mãos por meio da EaD. Material e método: foram incluídos 99 acadêmicos do curso de Medicina UNIFEV, com uma abordagem qualitativa e quantitativa, de forma exploratória. A capacitação foi composta por seis atividades, cinco online, sendo a sexta presencial. A primeira foi a aplicação de questões de múltipla escolha, com avaliação somativa, para a análise dos conhecimentos prévios dos acadêmicos. A segunda foi realizada por meio de um Fórum de discussão, com abordagem na sensibilização dos profissionais de saúde para melhorar a sua apreensão, a avaliação foi qualitativa. Na terceira, foi realizada a reaplicação das questões de múltipla escolha com feedback automático pelo sistema. A quarta foi prática; os participantes fizeram uma análise de dois vídeos publicados na plataforma. Esta análise deveria ser de acordo com os onze passos da técnica de higiene das mãos preconizados pelo Ministério da Saúde, referenciando-se as inadequações apresentadas por estes, na plataforma. Na quinta foi proposto para que os acadêmicos elaborassem um vídeo de higienização das mãos, seguindo a técnica proposta, a avaliação incluiu feedback individual. A sexta avaliação foi presencial com realização de um Exame Clínico Objetivo Estruturado (OSCE), com simulação de situação real, na qual o acadêmico deveria relatar os momentos oportunos para higienização das mãos. Posteriormente, os estudantes demonstraram a técnica da higiene das mãos, com realização de feedback individual e oportuno. Resultados: dentre os 99 acadêmicos inscritos, houve desistência de oito acadêmicos (8,1%), aprovação de 84 acadêmicos (92,3%; N=91) e sete reprovas (7,7%; N=9) por não realizarem as atividades propostas. A primeira atividade apresentou como resultado a nota média de 8,00 entre os participantes. Na segunda, os indicadores de controle de infecções e a educação em saúde foram os fatores de maior impacto na sensibilização. Implementar as capacitações foi a proposta mais frequente dos participantes para melhorar a sensibilização. A terceira, quarta, quinta e sexta atividades obtiveram respectivamente notas médias de 8,5; 6,5; 9,80 e 9,60 entre os acadêmicos. Conclusão: os acadêmicos apresentaram um bom desempenho na avaliação de conhecimento prévio, que sugeriu uma abordagem teórica adequada na graduação do curso de Medicina. As discussões e reflexões foram coerentes, com propostas factíveis, nas ações para melhoria da adesão. A avaliação da habilidade da lavagem das mãos apresentou inicialmente um baixo desempenho, apesar do conhecimento teórico ter-se apresentado satisfatório. Notou-se uma lacuna entre o “saber” e o “demonstrar como se faz”, revelando a necessidade de implementação de atividades que contemplem a habilidade de higienização das mãos na grade curricular. Diversos métodos para avaliação foram utilizados, a predominante foi a avaliação formativa associada ao feedback, que colaborou para uma aprendizagem significativa ao longo da capacitação, em que os acadêmicos demonstraram neste momento o “fazer”. A modalidade de EaD, enquanto ferramenta fundamental nas atividades curriculares e extracurriculares, deve ser considerada para capacitações de higiene das mãos, e sua implementação em programas de controle de infecção hospitalar

Bakgrund: Vårdrelaterade infektioner (VRI) är ett stort problem i Sverige och resten av världen och en av de viktigaste patientsäkerhetsfrågorna. Det leder till ett ökat lidande för patienten, längre vårdtider samt stora kostnader för samhället. Hälften av de VRI som sker kan förebyggas med åtgärder som bland annat följsamheten till basala hygienrutiner. Trots riktlinjer är följsamheten låg. Hälso-och sjukvården ska vara av god kvalitet med hög hygienisk standard. En av sjukvårdspersonalens viktigaste uppgifter är att förhindra att vårdskador sker och undvika onödigt lidande för patienten. Därför är det av stor vikt att ta reda på vilka faktorer som påverkar hälso- och sjukvårdspersonalens följsamhet till basala hygienrutiner. Syfte: Litteraturöversiktens syfte var att belysa olika faktorer som kan påverka hälso- och sjukvårdspersonals följsamhet till basala hygienrutiner på en akutmottagning (AKM). Metod: Denna studie har genomförts som en litteraturöversikt på 13 vetenskapliga artiklar av kvantitativ design. Av dessa har tolv artiklar sökts fram genom databaserna Cinahl och PubMed och en genom sekundär sökning. Resultat: Resultatet visar på att det finns flera faktorer som påverkar hälso- och sjukvårdspersonalens följsamhet till basala hygienrutiner på en AKM. Fyra huvudfaktorer som framkom var Miljön, Kunskap och utbildning, Attityder till basala hygienrutiner och Förbättringsarbete. Slutsats: Följsamheten till basala hygienrutiner var låg och det fanns flera faktorer som påverkade att hälso- och sjukvårdspersonalen inte följde de riktlinjer som fanns. / Background: Nosocomial infections are a huge problem in Sweden and the rest of the world and the most important issue of patient safety. These infections can lead to increased patient suffering, prolonged hospital stays and higher costs for the society. Half of the nosocomial infections that happens can be prevented with measures, such as the compliance with basic hygiene routines. Despite the guidelines, the compliance is low. Healthcare must be of good quality and have a high hygienic level and preventing injury is one of the most important tasks of healthcare personnel to prevent suffering. Therefore, it is very important to find out what factors affect compliance of the staff with basic hygiene routines. Aim: The purpose of the literature review is to highlight various factors that may affect the compliance of healthcare personnel with basic hygiene routines in emergency department. Method: This study has been formed as a literature review based on 13 scientific articles quantitative design. 12 of these have been found when search through the databases Cinahl and Pubmed and one by manual search. Findings: The result shows that there are several factors that affect healthcare personnel compliance of basic hygiene routines in an emergency department. Four head factors that showed are Environment, Knowledge and education, Attitudes to basic hygiene routines, and Improvement. Conclusion: The compliance of basic hygiene routines is low and there are several factors that affect that healthcare personnel does not follow the guidelines that is available.

Treatment failure in community-acquired pneumonia (CAP) is the failure to normalize the clinical features (eg, fever, cough, sputum production), or nonresolving image in chest radiograph, despite antimicrobial therapy. The incidence of treatment failure in CAP has not been clearly established; according to several studies it ranges between 6% and 15%. The rate of mortality increases significantly, especially in those patients with severe CAP. It is important to be able to identify what patients are at risk for progressive or treatment failure pneumonia that may make them candidates for a more careful monitoring. This doctoral thesis has been structured following the guidelines of the rules for submission of doctoral theses as a compendium of publications, adopted by the Council, Department of Medicine, University of Barcelona. The studies are part of this thesis belong to the same line of research, validated the current guidelines of pneumonia-community acquired and hospital acquired. The results of the studies have provided relevant and innovative in this field and were collected in 2 original articles published in international journals with a widespread global impact factor of 16,37 points.