Η Λεγιονέλλωση είναι μια λοιμώδης νόσος που αναγνωρίστηκε το δεύτερο μισό του 20ου αιώνα. Η σοβαρότητα της Νόσου ποικίλει από μια ήπια εμπύρετη ασθένεια (Pontiac πυρετός), μέχρι σοβαρής μορφής πνευμονία (Νόσος των Λεγεωνάριων). Μέχρι στιγμής, το γένος Legionella περιλαμβάνει τουλάχιστον 50 είδη, τα οποία περιλαμβάνουν 70 ξεχωριστές υποομάδες. Συγκεκριμένα η L.pneumophila περιλαμβάνει 16 υποομάδες, τις περισσότερες συγκριτικά με τα άλλα είδη. Το βακτήριο L.pneumophila είναι το πιο συνηθισμένο και επικίνδυνο μέλος της οικογένειας Legionella. Η L.pneumophila serogroup 1 προκαλεί τον μεγαλύτερο αριθμό κρουσμάτων της νόσου στην Ευρώπη και Αμερική. Πρόκειται για ένα υδατογενές παθογόνο βακτήριο που βρίσκεται παντού στο υδάτινο περιβάλλον και αναπτύσσεται σε θερμοκρασίες 20οC-45οC, ενώ η θερμοκρασία των 35οC είναι η ιδανικότερη για την ανάπτυξη της Legionella pneumophila. Η ικανότητα του βακτηρίου να επιβιώνει σε υψηλές θερμοκρασίες, του επιτρέπει να αποικίζει σε τεχνητά υδάτινα συστήματα, τα οποία λειτουργούν σε υψηλότερες θερμοκρασίες από την θερμοκρασία περιβάλλοντος. Μεταδίδεται αερογενώς μέσω των εισπνεόμενων υδατοσταγονιδίων, ενώ μέχρι σήμερα δεν έχει διαπιστωθεί μετάδοση της νόσου από άτομο σε άτομο. Από την στιγμή που το βακτήριο είναι ευρέως διαδεδομένο στο περιβάλλον, μπορεί να εγκατασταθεί και να αναπτυχθεί σε τεχνητά συστήματα νερού, όπως οι πύργοι ψύξης και τα συστήματα ζεστού και κρύου νερού. Το 1986 συγκροτήθηκε η Ευρωπαϊκή Ομάδα Εργασίας για την Νόσο των Λεγεωνάριων (EWGLI: European Working Group for Legionella Infections) και το 1987 υλοποιήθηκε η επιτήρηση των περιπτώσεων της Νόσου των Λεγεωνάριων που συνδέονται με ταξίδια, μέσω του Ευρωπαϊκού Δικτύου Επιτήρησης της Νόσου των Λεγεωνάριων. Στην Ελλάδα, η Νόσος των Λεγεωνάριων αποτελεί νόσημα υποχρεωτικής δήλωσης σε χρονικό διάστημα 24 ωρών από την διάγνωση. Είναι όμως χαρακτηριστικό ότι το ΚΕΕΛΠΝΟ, αναφέρει περιστατικά της Νόσου των Λεγεωνάριων, από το 1998 έως το 2008, ενώ μετά το 2008 δεν παρέχει κάποια δεδομένα για την Νόσο των Λεγεωνάριων. Περιστατικά της Νόσου των Λεγεωνάριων στην Ελλάδα, έχουν αναφερθεί ήδη από το 1982. Κάθε χρόνο δηλώνονται κατά μέσον όρο 13 κρούσματα της Νόσου των Λεγεωνάριων. Ο σκοπός της παρούσας μελέτης ήταν η εξέταση των υδάτινων συστημάτων σε νοσοκομεία και ξενοδοχεία της Νοτιοδυτικής Ελλάδος για την ανίχνευση των ειδών Legionella. Επιπλέον πραγματοποιήθηκε προσπάθεια καταγραφής των κρουσμάτων πνευμονίας και της Νόσου των Λεγεωνάριων που νοσηλεύονταν στα νοσοκομεία, έτσι ώστε να υπάρχει μια γενικότερη εικόνα της παρουσίας του βακτηρίου στην Νοτιοδυτική Ελλάδα. Συνολικά αναλύθηκαν 91 δείγματα νερού από τα υδάτινα συστήματα 8 νοσοκομείων και 25 δείγματα από 9 ξενοδοχεία για το χρονικό διάστημα Μάιος 2008-Δεκέμβριος 2009. Αρχικά πραγματοποιήθηκε ταυτοποίηση του βακτηρίου με την καλλιεργητική μέθοδο (ISO 11731:1998) και στην συνέχεια ακολούθησε απομόνωση του DNA του βακτηρίου. Έπειτα έγινε ταυτοποίηση της Legionella pneumophila με τη Μοριακή Μέθοδο της PCR και τέλος τα θετικά προϊόντα της PCR επιβεβαιώθηκαν με αλληλούχιση που πραγματοποιήθηκε στην Μονάδα Αλληλουχίας του Τμήματος Ανοσολογίας και Ιστοσυμβατότητας της Ιατρικής Σχολής του Πανεπιστημίου Θεσσαλίας. Παράλληλα πραγματοποιήθηκαν φυσικοχημικές αναλύσεις όπως μέτρηση του pH, θερμοκρασία, αγωγιμότητα και μικροβιολογικές αναλύσεις, όπως έλεγχος παρουσίας της Ολικής Μεσόφιλης Χλωρίδας στους 220C και 370C (ISO 6222:1999) και του βακτηρίου Pseudomonas aeruginosa (ISO 16266:2006) . Tο 33% των δειγμάτων νερού που ελήφθησαν από τα Νοσοκομεία της Νοτιοδυτικής Ελλάδας βρέθηκαν θετικά για το βακτήριο L.pneumophila. Όσο αναφορά τα Ξενοδοχεία της περιοχής των Πατρών, στο 36% των δειγμάτων νερού υπήρξε παρουσία του βακτηρίου. Η φυλογενετική ανάλυση έδειξε, πως τα ελληνικά στελέχη που απομονώθηκαν στην παρούσα μελέτη επέδειξαν υψηλή ομολογία με στελέχη L.pneumophila που έχουν χαρακτηριστεί γονοτυπικά με στελέχη της Ιταλίας. Καταγράφηκαν 325 κρούσματα πνευμονίας, εκ των οποίων τα 2 ήταν θετικά για το βακτήριο. Συμπερασματικά η παρούσα μελέτη υποδηλώνει μια συχνή παρουσία του βακτηρίου Legionella pneumophila, στα υδάτινα συστήματα των νοσοκομείων και των ξενοδοχείων. Η έρευνα μας επιβεβαιώνει την ανάγκη τακτικής παρακολούθησης των μικροβιολογικής ποιότητας των υδάτινων συστημάτων των νοσοκομείων και των ξενοδοχείων της Νοτιοδυτικής Ελλάδος. / Legionellosis is an infectious disease that was recognized in the second half of the 20th century. The severity of the disease varies from a mild febrile illness (Pontiac fever) to severe pneumonia (Legionnaires' disease). To date, the genus Legionella comprises at least 50 species, comprising 70 separate subgroups. Specifically, the L.pneumophila includes 16 subgroups, most compared to other species. The bacterium L.pneumophila is the most common and dangerous member of the family of Legionella. L.pneumophila serogroup 1 causes the majority of cases reported in Europe and in the US. Legionella species are aquatic bacteria that are widespread in nature and have been found everywhere in the aquatic environment, developed at temperature 20oC-45oC and 35oC temperature is ideal for growth of Legionella pneumophila. Their tolerance to relatively to high temperatures probably helps them to colonize in artificial water systems that are often above temperatures. Legionellosis is transmitted via airborne aerosols by aspiration and as far there have been no reported cases of inter-human transmission. Once the bacterium is widespread in the environment can be established and developed in artificial water systems such as cooling towers and systems for hot and cold water.In 1986, the European Working Group for legionnaire's disease (EWGLI: European Working Group for Legionella Infections) established and in 1987 was realized the surveillance of cases of the legionnaires' disease associated with travel through the European Network Monitoring legionnaire's disease. In Greece, the Legionnaires' disease is a modifiable disease in period of 24 hours of diagnosis. It is significant that the KEELPNO states cases of Legionnaires ‘disease from 1998 to 2008, but after 2008 does not provide any data on legionnaire's disease. Cases of Legionnaires ‘disease in Greece have been reported since 1982 and every year reported an average of 13 cases of legionnaires' disease. The aim of the present study was to determine the prevalence of Legionella spp. in water systems of hospitals and hotels located in South Western Greece. Furthermore, attempt to record the incidence of pneumonia and legionnaire's disease hospitalized in hospitals, so that there is a general overview of the presence of the bacterium in South Western Greece. A prevalence survey for Legionella spp. by culturing techniques in water distribution systems of eight hospitals (total 91 water samples) and nine hotels (total 25 water samples) occurred in South Western Greece, for the period May 2008-December 2009. Initially carried out identification of the bacterium with the classic culture methods (ISO 1173:1998) and followed by isolation of DNA of the bacterium. Following, was made identification of Legionella pneumophila by molecular methods of PCR and the positive PCR products were confirmed by sequencing conducted in Sequencing Unit of the Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly. In parallel physicochemical analysis carried out, such as residual free chlorine, pH, temperature, conductivity and microbiological analysis such as, Total Count (220C and 370C) and Pseudomonas aeruginosa presence according to ISO 6222:1999 and ISO 16266:2006, respectively. Legionella pneumophila was detected in 33% and 36% of the distribution systems of hospitals and hotels. The phylogenetic analysis showed that Greek strains showed a high homology to L.pneumophila strains isolated during a study of genotypic characterization of Legionella species isolated in Italy. 325 cases of pneumonia were recorded, and 2 of them were positive for the bacterium. In conclusion, our survey results suggest a frequent prevalence of elevated concentrations of Legionella spp. in water systems of hospitals and hotels. Our investigation has confirmed the need to regularly monitor the microbiological condition of water systems in hospitals and hotels in South Western Greece.

Revisión por pares

Respiratory assistance devices bypass essential host defenses and allow these pathogens direct access to the lower respiratory tract and hinder these defense systems to effectively clear respiratory pathogens (1). Mechanical ventilation in the presence of dental plaque with respiratory pathogens has the potential to lead to ventilator-associated pneumonia (VAP). Ventilator-associated pneumonia is the leading cause of morbidity and mortality in intensive care units. VAP influences increasing need for medical treatment and hospital length of stay (LOS) (2-4). Lower respiratory tract infections (LRTI) have been found to be the most expensive site per infection with 13% of all infections accounting for 29% of the total recorded cost (5). The purpose of this systematic review is to perform a comprehensive literature search to identify published randomized clinical trials relating to the efficacy of chlorhexidine gluconate (CHX) oral rinse in preventing VAP. CHX has been identified as the "gold standard" to reduce the number of microorganisms. This review also addresses the importance of oral health and the increased risk of respiratory infections from colonization by harmful pathogens within the oral mucosa. Clinical trials relating to the hypothesis in question were evaluated using Consolidated Standards of Reporting Trials (CONSORT) checklist for validity. Quality and strength of each randomized clinical trial were evaluated based on the requirements of the Agency for Healthcare Research and Quality (AHRQ). Nine bibliographic databases, from 1965-2012 were used to conduct the literature inquiry. Ten studies included populations greater than or equal to 18 years of age and admitted to the intensive care unit receiving mechanical ventilation. The patients were, ventilated due to either trauma, undergoing elective cardiothoracic surgery, or from some other form of surgery, at risk for VAP. In one study, CHX oral rinse decreased microbial colonization of the respiratory tract and hospital-acquired pneumonia (HAP) in patients who underwent open-heart surgery and were intubated less than 24 hours. Yet the difference was not significant in patients intubated more than 24 hours who had a higher amount of bacterial colonization (6). Modulation of oropharyngeal colonization by the use of oral chlorhexidine has reduced the number of ICU-acquired HAP in selected patient populations such as those undergoing coronary bypass grafting, but its routine use is not recommended until more data become available (7). Findings from several studies suggest a significant decrease in the incidence of total nosocomial respiratory infections and systemic antibiotic use in patients who underwent open heart and used a CHX oral rinse as compared with ventilator patients who did not use the rinse; there was also a 65% decrease (13% vs. 4%) in the overall nosocomial infection rate in the chlorhexidine group (7,8,9). Using 2% chlorhexidine solution presents the strongest evidence for decreasing VAP (10,11). From Scannapieco and colleagues' study we can conclude that twice daily is not necessarily better than once daily, but maybe a four times daily regimen with 2% instead of 0.12% CHX does make a difference in reducing the incidence of VAP (12).

A resistência aos antibióticos dos patógenos mais comuns do trato respiratório está aumentando mundialmente. Recentemente, Streptococcus pneumoniae resistente à penicilina tem sido isolado em diversos países, e a freqüência dessas cepas tem elevado de modo alarmante. O aumento da resistência, com conseqüentes implicações terapêuticas, tem levado a uma reavaliação do uso dos antibióticos ß-lactâmicos para o tratamento de infecções pneumocócicas. No presente trabalho, um total de 107 amostras de Streptococcus pneumoniae, obtidas de materiais provenientes de pacientes adultos ambulatoriais e hospitalizados, em dois centros médicos de duas cidades do Rio Grande do Sul (Porto Alegre e Caxias do Sul), os quais apresentavam quadro clínico-radiológico de infecção pulmonar, foram analisadas com o objetivo de estudar-se a resistência do germe à penicilina. As amostras constituídas de escarro (80,4%), lavado brônquico (13,5%) e aspirado traqueal (6,6%) foram coletadas no período compreendido entre Julho de 1998 e Julho de 1999. O material foi semeado em meio de Agar sangue e as colônias suspeitas de Streptococcus pneumoniae foram transferidas para meio de Mueller-Hinton para teste de optoquina e de sensibilidade à penicilina com discos de oxacilina. Um halo de inibição da oxacilina menor do que 20 mm indicava a realização de teste para determinação da concentração inibitória mínima (MIC) com E-test. Um total de nove cepas foi identificado como tendo resistência intermediária à penicilina (MIC 0,1-1,0μg/ml) e nenhuma cepa resistente (resistência elevada: MIC > 2,0 μg/ml) foi identificada. Uma monitorização local das cepas quanto à resistência antimicrobiana é de grande importância para os clínicos no manejo de infecções pneumocócicas. / Antibiotic resistance to the common respiratory tract pathogens is increasing worldwide. Recently, penicillin-resistant pneumococci have been isolated in several countries, and the incidence of these strains has risen alarmingly. The increased of resistance with consequence therapeutic implications has led to a re-evaluation of ß-lactam antibiotics for the treatment of streptococcal infections. In present study a total of 107 isolates of Streptococcus pneumoniae from samples of adult hospitalizated patients ando outpatients were prospectively collected in 2 different medical centers of Rio Grande do Sul - Brazil (Caxias do Sul and Porto Alegre) with clinical and radiologyc signs of respiratory infections, were analyzed with objective to study the penicillin-resistant pneumococci. The samples consisting of sputum (80,4%), bronchial lavage (13,5%) and inhaled traqueal (6,6%) had been colected in the period understood between 98 July and 99 July. The material was sown in agar-blood and the colonies suspicion of Streptococcus pneumoniae had been transferred to Mueller-Hinton for test of optochin and for sensitivity to penicillin test with oxacilin disks. One inhibition of the lesser that 20 mmm for oxacilin indicates the test accomplishment to determine minimum inhibitory concentration (MIC) with E-test. A total of 9 strains were intermediate-resistant to penicillin (MIC 0,1-1,0μg/ml) and neither was resistant to penicillin (MIC > 2,0 μg/ml). Monitoring local of antimicrobial resistant strains is of great importance to clinicians for the management of pneumococcal infections.

A pneumonia é a principal causa de morte dentre as infecções hospitalares. Quando associada à ventilação mecânica (VM) desenvolve-se após 48 horas da sua instalação. É um importante fator independente de mortalidade para os doentes graves. As limitações e imprecisões dos recursos diagnósticos incentivaram o emprego de técnicas diagnósticas de PAV (pneumonia associada à ventilação mecânica), que incluem uma variedade de métodos para coleta de material, tais como aspirado traqueal, métodos broncoscópicos e não broncoscópicos. A escolha de uma ou de outra técnica diagnóstica depende da experiência local, dos custos e da disponibilidade das diferentes técnicas. E o tratamento da pneumonia pode ser baseado nestes testes diagnósticos.

Racional: Aproximadamente um de cada cinco pacientes hospitalizados por pneumonia adquirida na comunidade (PAC) apresenta uma resposta clínica inadequada, sendo a mortalidade nestes pacientes de 40%. Os objetivos do estudo foram: determinar a incidência e as variáveis de associação independente com fracasso terapêutico da PAC, e os fatores prognósticos da PAC tratada em ambiente hospitalar. Métodos: Estudo de coorte, prospectivo, multicêntrico, com 425 pacientes hospitalizados por PAC. Os pacientes foram acompanhados de forma sistemática para identificação do fracasso terapêutico e seguidos até a alta hospitalar. Resultados: A incidência de fracasso terapêutico foi de 14,6% (62/425). Os preditores independentes de risco para o fracasso foram: insuficiência renal aguda à admissão (OR 2,9; IC 95% 1,2-7,2; p=0,017), progressão radiológica (OR 29,8; IC 95 8,1-109,7%; p<0,001), derrame pleural (OR 3,4; IC 95% 1,3-8,6; p=0,010), relação PaO2/FiO2 inferior a 250 à admissão (OR 2,7; IC 95% 1,1-6,7; p=0,017) e PSI classe V (OR 2,7; IC 95% 1,1-7,0; p=0,042). A mortalidade geral foi de 7,5%, e de 40,3% nos pacientes com fracasso. O fracasso terapêutico foi o principal fator independente de mortalidade na PAC (OR 85,3, IC 95% 18,8-387,4, p<0,0001). Conclusão: O fracasso terapêutico da PAC é freqüente, está associado a marcadores clínicos, radiológicos e laboratoriais identificáveis desde a admissão hospitalar (ou nos primeiros dias de acompanhamento), sendo o principal preditor independente de mortalidade. / Rational: One out of five patients hospitalized for community-acquired pneumonia (CAP) might have an inadequate response to empirical antimicrobial treatment, and the mortality among these patients may reach rates of up to 40%. The aims of the study were to: quantify the incidence of empirical treatment failure in CAP, identify risk factors for therapeutic failure and prognostic factors in CAP. Methods: Prospective, multicenter cohort study of 425 hospitalized patients for CAP. The systematic identification of treatment failure required a daily follow-up until hospital discharge. Results: The incidence of treatment failure was 14.6% (62/425). The independent risk factors associated with therapeutic failure in a logistic analysis were: acute renal failure (OR 2.9; 95% CI 1.2-7.2; p=0.017), radiological progression (OR 29.8; IC 95 8.1-109.7%; p<0.001), pleural effusion (OR 3.4; 95% CI 1.3-8.6; p=0.010), PaO2/FiO2 ratio < 250 (OR 2.7; 95% CI 1.1-6.7; p=0.017) e pneumonia severity index Class V (OR 2.7; 95% CI 1.1-7.0; p=0.042). Mortality was significantly higher in patients with therapeutic failure (40.3% vs. 7.5%). Treatment failure was the main prognostic factor associated with CAP (OR 85.3; 95% CI 18.8-387.4, p<0.0001). Conclusion: The treatment failure is frequently found and it is associated with clinical, radiological and laboratorial markers. It is also an important independent predictor of mortality in CAP.

Estudo retrospectivo de 80 casos de pneumonia por Pneumocystis jirovecii (PCP), diagnosticados no Laboratório de Micologia, Santa Casa-Complexo Hospitalar – Porto Alegre (RS), de agosto de 1984 à janeiro de 2006. Dos 80 pacientes, 23 (36,3%) já tinham diagnóstico de Aids; 40 (50%) tiveram diagnóstico de infecção pelo vírus da imunodeficiência humana (HIV) concomitantemente com o diagnóstico de PCP. O fator predisponente mais encontrado foi a linfopenia associada à síndrome da imunodeficiência adquirida (Aids), com mediana da dosagem de CD4+ 36,5 células/mm3. Os achados clínicos mais frequentes foram tosse (81,3%), febre e dispnéia (76,3%). Na radiologia de tórax 92,5% apresentavam infiltrado pulmonar intersticial. Os diagnósticos foram feitos por fibrobroncoscopia com lavado broncoalveolar em 67,5%. Apenas 11,6% dos pacientes com Aids faziam uso de terapia antiretroviral; e apenas 6,3% de todos os pacientes do estudo faziam profilaxia para pneumocistose. O tratamento da PCP constituiu de sulfametoxazol-trimetoprim (SMX+TMP) em 92,3%. A maior incidência de PCP foi entre pacientes infectados pelo HIV (86,3%). Os pacientes apresentaram uma mortalidade de 34,3%, e 74,1% naqueles que necessitaram de ventilação mecânica. Complicações ocorreram em 40% dos casos, aumentando os dias de internação e de outras medicações com aumento de custo do tratamento. / The present study is based on a retrospective research of 80 cases with Pneumocystis jirovecii pneumonia (PCP), diagnosed at the Mycology Laboratory - Santa Casa Complexo Hospitalar Porto Alegre (RS), from August 1984 to January 2006. Out of those 80 patients, 23 (36.3%) had diagnosis of AIDS, 40 (50%) were diagnosed with infection by human immunodeficiency virus (HIV) concomitantly with PCP diagnosis. The most common predisposing factor was lymphopenia associated with AIDS, with a median dose of CD4 + 36.5 cells/mm3. The clinical manifestations most frequent were cough (81.3%), fever and dyspnea (76.3%). Chest x-ray findings had interstitial pulmonary infiltrates in 92.5%. The diagnoses were made by bronchoscopy with bronchoalveolar lavage in 67.5% samples. Only 11.6% of patients with AIDS received antiretroviral therapy, and only 6.3% of all patients received prophylaxis for PCP. The treatment for PCP was trimethoprim-sulfamethoxazole (TMP + SMX) in 92.3% of patients. The highest incidence of PCP was among HIVinfected patients (86.3%). The mortality rate were 34.3% and 74.1% in those who required mechanical ventilation. Complications occurred in 40% of cases, increasing days of hospitalization and other medications, which increased the cost of treatment.

Made available in DSpace on 2015-12-06T23:46:41Z (GMT). No. of bitstreams: 0 Previous issue date: 2014 / Introdução: Os cuidados na prevencao de infeccoes nas unidades de terapia intensiva estao bem descritos e definidos, porem, a vigilancia dos pacientes internados em unidades de semi intensiva que necessitam de cuidados intermediarios e que dispoem de ventilacao mecanica via traqueostomia por equipamentos com 2 niveis de pressao, precisam ser compreendidos. Objetivo: Avaliar o efeito das intervencoes implementadas em uma unidade de semi intensiva em dois diferentes periodos, na reducao de pneumonia associada a traqueostomia. Metodos: Estudo de coorte historica (ou a quasi experimental study) conduzido em uma unidade de terapia semi intensiva. Foram implementadas varias intervencoes para otimizar a prevencao de pneumonia associada a traqueostomia e avaliadas em duas fases. De janeiro de a outubro de 2007 (fase 1), algumas praticas recomendadas pelo Centers for Disease Control and Prevention (CDC) foram implementadas e realizada a vigilancia pela equipe do Servico de Controle em Infeccao Hospitalar (SCIH) quanto aos casos de pneumonia associado a traqueostomia. De outubro de 2007 a agosto de 2008 (fase 2) mantivemos as mesmas praticas recomendadas pelo CDC, o acompanhamento pela mesma equipe do SCIH, porem iniciamos a auditoria destes processos de materiais, com intervencao a beira leito concomitantemente. Resultados: A densidade de incidencia de pneumonia associada a traqueostomia na semi intensiva por 1000 traqueostomias/dia foi de 6,0 na fase 1 e de 0,7 na fase 2. Ocorreu uma reducao de comparando a fase 1 com a fase 2. Conclusao: Estes resultados sugerem que a reducao na frequencia de pneumonia associada a traqueostomia e um processo continuo que envolve a mensuracao e a intervencao do desempenho multiprofissiona / BV UNIFESP: Teses e dissertações

Made available in DSpace on 2015-07-22T20:50:07Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-04-30. Added 1 bitstream(s) on 2015-08-11T03:25:45Z : No. of bitstreams: 1 Publico-10837.pdf: 469015 bytes, checksum: ff516dcb87e966ef780eaf0f1e16ce8e (MD5) / Objetivo: Descrever os aspectos clínico-epidemiológicos das infecções pulmonares no grupo de pacientes transplantados renais submetidos à broncoscopia ou à biópsia sob visualização direta. Avaliar o impacto dos métodos invasivos na modificação do tratamento antimicrobiano, a acurácia diagnóstica e complicações da biópsia pulmonar transbrônquica e da biópsia pulmonar sob visualização direta neste grupo específico de pacientes. Métodos: Trata-se de um estudo retrospectivo, realizado no Hospital do Rim e Hipertensão e no Hospital São Paulo, ambos filiados à Universidade Federal de São Paulo, durante o período de 2000 a 2005. Através do banco de dados do serviço de Anatomia Patológica foram identificados pacientes com transplante de rim submetidos à biópsia transbrônquica (BTB) ou biópsia pulmonar sob visualização direta (BVD) para investigação de pneumonia. Os pacientes foram avaliados quanto aos aspectos clínico-epidemiológicos, incluindo tempo de transplante, uso de imunossupressores e apresentação clínica e radiológica do quadro pulmonar. Os métodos diagnósticos invasivos foram avaliados quanto sua acurácia, impacto na terapia antimicrobiana e complicações relacionadas aos procedimentos. Resultados: Foram incluídos no estudo 110 pacientes, dos quais 104 realizaram BTB, 18 realizaram BTB seguida de BVD e 6 pacientes foram submetidos apenas à BVD. Os patógenos mais frequentemente encontrados foram agentes bacterianos (26,4%), incluindo dois casos de Legionella pneumophila e um de Nocardia spp, seguido de Mycobacterium tuberculosis (18,2%), fungos (10,9%), incluindo Criptococcus neoformans, P. jiroveci e Histoplasma capsulatum, e CMV (4,5%). A apresentação clínica e radiológica foi bastante variável, sendo que a tomografia computadorizada de alta resolução, realizada em 68 pacientes, adicionou informações em 51,5% dos casos quando comparada à radiografia de tórax. A BTB apresentou acurácia de 58,4%, levou a modificação de terapia antimicrobiana em 29,6% dos pacientes e apresentou taxa de complicação relacionada ao procedimento de 28,8%. Enquanto que para BVD os resultados obtidos foram de 87,5%, 76,5% e 16,7%, respectivamente. A taxa de mortalidade geral do estudo foi de 16,4% e não houve nenhum óbito relacionado aos procedimentos invasivos. Conclusões: A variedade de apresentações clínicas e radiológicas dificulta a suspeita etiológica e escolha da terapia antimicrobiana empírica. A tomografia de alta resolução traz benefícios ao diagnóstico e auxílio na indicação e execução de métodos invasivos. Em 11,8% dos casos os métodos invasivos diagnosticaram agente não suspeito. A biópsia sob visualização direta apresentou maior impacto (37,5%) na modificação ou instituição de terapia antimicrobiana que a biópsia transbrônquica (18,3%), assim como melhor acurácia, sem que as complicações relacionadas ao procedimento cirúrgico sejam um fator limitante a sua indicação. / Purposes: To describe clinical and epidemiological aspects of pulmonary infection in kidney transplant recipients who underwent transbronchial biopsy or open lung biopsy. To measure the impact of invasive diagnosis on antimicrobial therapy, diagnosis accuracy and procedures related complications. Methods: Retrospective review of pulmonary infection in kidney transplant recipients who underwent pulmonary transbronchial biopsy (TBB) or open lung biopsy (OLB) during the period of 2000-2005 at Hospital do Rim e Hipertensão and Hospital São Paulo, both affiliated to Federal University of Sao Paulo. Recipients of kidney transplant who underwent lung biopsy for pneumonia investigation were identified from the Pathology Service’s database. Clinical and radiology aspects, such as time of presentation, immunessupressant regimen and antimicrobial empiric therapy were analyzed. Invasive methodology was evaluated regarding accuracy, impact on antimicrobial therapy and procedure related complication. Results: One hundred and ten patients were included, 104 underwent TBB, 18 underwent TBB followed by OLB and 6 underwent only OLB. The most frequent pathogens were bacterial agents with a 26.4% occurrence (including Legionella pneumophila and Nocardia spp), followed by 18.2% Mycobacterium tuberculosis, 10.9% fungi (Criptococcus neoformans, P. jiroveci and Histoplasma capsulatum) and 4.5% CMV. Clinical and radiological presentations were variable. High resolution computed tomography weas performed in 68 patients and showed additional information in 51,5% of the cases. The TBB accuracy was 58.4%, antimicrobial therapy was modified in 29.6% patients and procedure complication occurred in 28.8%. The OLB procedure results were 87.5%, 76.5% and 16.7%, respectively. The overall mortality was 16.4% and there were no deaths related to any invasive procedure. Conclusions: The variable clinical and radiological variety presentation makes etiological determination and empiric antimicrobial therapy hard to define. High resolution computed tomography is a helpful tool not only in diagnosis but also as a guide to invasive methods for diagnosis. TBB and OLB had impact on determining 11.8% of non-suspected diagnosis. Open lung biopsy showed greater impact (37.5%) on antimicrobial therapy modification than the transbronchial biopsy (18.3%), as either better accuracy without procedure related complications that limited its use. / TEDE / BV UNIFESP: Teses e dissertações

Made available in DSpace on 2015-07-22T20:50:36Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-06-25. Added 1 bitstream(s) on 2015-08-11T03:25:44Z : No. of bitstreams: 1 Publico-10785.pdf: 1454333 bytes, checksum: 1773b999177d308849498e6df3d6f921 (MD5) / Objetivo: O estudo procurou determinar os fatores de risco independentes para o surgimento de pneumonia hospitalar por Pseudomonas aeruginosa resistente a carbapenem em uma UTI clinico-cirurgica. Foram tambem estudados os fatores relacionados a evolucao desfavoravel nesses episodios de pneumonia nosocomial tratados com polimixina B e os fatores de risco e evolucao dos episodios causados por cepas portadoras da metalo-ƒÀ-lactamase SPM-1. Metodo: O estudo foi realizado no Hospital Sao Paulo, hospital terciario de ensino da Universidade Federal de Sao Paulo. No estudo de fatores de risco para pneumonia hospitalar por Pseudomonas aeruginosa, foram avaliados pacientes internados na UTI da Anestesiologia, no periodo de 2002 a 2005, atraves de um estudo tipo caso-casocontrole. Pacientes com episodios de pneumonia com cepas resistentes a imipenem e pacientes com pneumonia por cepas sensiveis a imipenem foram designados como casos resistentes (estudos Ia) e sensiveis (estudo Ib), respectivamente. Os controles foram pacientes da mesma unidade, internados no mesmo periodo. O segundo estudo, sobre evolucao clinica em pacientes tratados com polimixina B, analisou pacientes internados em UTIs do hospital, no periodo de 1997 a 2005, atraves de um estudo caso-controle aninhado dentro dessa coorte. Os casos foram pacientes com evolucao desfavoravel, e os controles foram pacientes com evolucao favoravel. O terceiro estudo utilizou tambem a metodologia caso-controle aninhado nessa mesma coorte de pacientes. Os casos eram pacientes com pneumonia por cepas de Pseudomonas aeruginosa resistente a carbapenem e portadora da metaloenzima SPM-1, e os controles eram pacientes com cepas sem a presenca dessa metaloenzima. Resultados: Nos estudos Ia e Ib, 58 casos resistentes, 47 casos sensiveis e 237 controles foram avaliados. Os fatores independentemente relacionados ao surgimento de pneumonia no estudo Ia foram: tempo de hospitalizacao(OR 1,19 IC95%: 1,12-1,26, p< 0,001); escore APACHE II( OR 1,11 IC95%: 1,01-1,22, p=0,03); sexo masculino(OR 8,01 IC95%: 1,66-38,51, p=0,009); uso de hemodialise(OR 6,85 IC95%: 1,33-35,2, p=0,02); uso de corticoide (OR 13,18 IC95%:3,80-45,64,p<0,001); uso de piperacilina-tazobactam(OR 14,31 IC95%:1,02- 200,16, p=0,04) e uso de cefalosporinas de 3a geracao(OR 7,45 IC95%: 1,80-30,86, p=0,006). Os fatores independentemente relacionados ao surgimento de pneumonia nosocomial por Pseudomonas aeruginosa sensivel a carbapenem ( estudo Ib) foram: tempo de internacao na UTI( OR 1,02 IC95%: 1,01-1,04, p=0,004) e uso de corticoide(OR 12,32 IC95%: 5,81-26,10, p< 0,001). O unico fator independentemente relacionado ao surgimento de pneumonia nos dois estudos foi o uso de corticoide. Portanto, a razao de chances real do uso de corticoide no surgimento de episodios de pneumonia por Pseudomonas aeruginosa resistente a carbapenem foi de 1,06 (valor da OR do estudo Ia dividido pela OR do estudo Ib). Setenta e quatro pacientes com pneumonia hospitalar tratados com polimixina B foram avaliados quanto a evolucao. A mortalidade atribuivel a pneumonia causada por Pseudomonas aeruginosa resistente a carbapenem foi de 29,8%. Os fatores relacionados a evolucao desfavoravel nesses episodios de pneumonia foram: presenca de choque septico (OR 4,81 IC95%: 1,42-16,25, p=0,01) e presenca de sindrome do desconforto respiratorio agudo ( OR 11,29 IC95%: 2,64-48,22, p=0,001). Vinte e nove desses 74 pacientes foram analisados quanto a presenca de metalo-ƒÀ- lactamases. Apenas cinco pacientes apresentavam cepas produtoras de SPM-1. A presenca de SPM-1 nao teve impacto na evolucao desses episodios (p=0,67). O tratamento combinado com polimixina B e imipenem, em pacientes com Pseudomonas aeruginosa sem a presenca da SPM-1, nao teve impacto positivo na evolucao clinica (p=0,67), nem na sobrevida desses pacientes. Nenhuma variavel se mostrou independentemente associada ao surgimento de episodios de pneumonia por cepas portadoras de SPM-1. Apenas o sexo feminino apresentou uma tendencia na analise univariada (OR 9,71; IC95%: 0,92-103,04; p=0,05). Tambem nao houve diferenca nas variaveis relacionadas a evolucao clinica entre os pacientes com cepas de Pseudomonas aeruginosa produtora de SPM-1. Conclusoes: Em nosso estudo, o uso de corticoide foi a unica variavel independentemente relacionada ao surgimento de pneumonia nosocomial por Pseudomonas aeruginosa resistente a carbapenem. A presenca de choque septico e da sindrome do desconforto respiratorio agudo foram fatores relacionados a evolucao desfavoravel nesses episodios. Nao encontramos variaveis relacionadas a presenca da metalo-enzima SPM-1. A presenca dessa enzima nao teve impacto na evolucao clinica nesse tipo de infeccao. / Objective: The study sought to determine the risk factors independently associated to nosocomial pneumonia due to carbapenem-resistant Pseudomonas aeruginosa in a medical-surgical ICU. The factors associated to unfavorable outcome on those patients who were treated with polymyxin B were evaluated as well as the outcome in episodes caused by strains harboring the metallo-ƒÀ- lactamase SPM-1. Methods: The study was undertaken at Hospital Sao Paulo, a university-affiliated hospital. We evaluated patients admitted to Anestesiology ICU through a case-case-control study, between 2002 and 2005. Patients with nosocomial pneumonia caused by resistant and susceptible strains were designed as resistant cases (study 1) and susceptible cases ( study 2), respectively. The controls were patients admitted to the same unit in the same period. The second study addressed the outcome of patients admitted to ICUs with nosocomial pneumonia due to carbapenem-resistant Pseudomonas aeruginosa who were treated with polymyxin B. Patients admitted to the ICUs between 1997-2005 were enrolled for the study. A nested case-control was undertaken. Cases were patients with unfavorable outcome and controls were patients with favorable outcome. The third study was undertaken through a nested case-control methodology as well. Cases were patients with nosocomial pneumonia caused by carbapenem-resistant Pseudomonas aeruginosa harboring the metalloenzyme SPM-1, and controls were patients without SPM-1. Results: 58 resistant cases, 47 susceptible cases and 237 controls were evaluated.The risk factors independently associated to nosocomial pneumonia in study 1 were: duration of hospitalization( OR 1,19 CI95%: 1,12-1,26, p< 0,001); APACHE II score(OR 1,11 CI95%: 1,01-1,22, p=0,03); male sex(OR 8,01 CI95%: 1,66-38,51, p=0,009); receipt of hemodyalisis(OR 6,85 CI95%:1,33-35,2, p=0,02); receipt of corticosteroid (OR 13,18 CI95%:3,80-45,64, p< 0,001); receipt of piperacillin-tazobactam ( OR 14,31 CI95%:1,02-200,16, p=0,04) and receipt of 3rd-generation cephalosporins( OR 7,45 CI95%: 1,80-30,86, p=0,006). The risk factors independently associated to nosocomial pneumonia caused by carbapenem-susceptible Pseudomonas aeruginosa( study 2) were: duration of ICU stay(OR 1,02 CI95%: 1,01-1,04, p= 0,004) and receipt of corticosteroid( OR 12,32 CI95%: 5,81-26,10, p< 0,001). The sole independently risk factor that was present in the two studies was the corticosteroid use. Thus, the real OR for the variable found in the study was 1,06 ( OR of study 1 divided by OR of study 2). 74 patients with nosocomial pneumonia treated with polymyxin B were evaluated. The factors associated to a unfavorable outcome were: presence of septic shock(OR 4,81 CI95%:1,42-16,25, p= 0,01) and presence of acute respiratory distress syndrome( OR 11,29 CI95%:2,64-48,22, p=0,001). 29 strains were evaluated concerning the presence of metallo-â- lactamases. Only five strains were positive for SPM-1. The presence of SPM-1 didn’t have impact on the outcome of these episodes (p=0,67). The combined treatment with polymyxin B and imipenem in patients without SPM-1 did not have positive impact on the outcome (p=0,67). None variable was independently associated to nosocomial pneumonia caused by SPM-1-positive strains. Only female sex showed a trend in univariate analysis (OR 9,71; CI95%: 0,92-103,04; p=0,05). There was no difference in outcome in episodes caused by Pseudomonas aeruginosa strains harboring SPM-1 compared to strains without SPM-1. Conclusions: The receipt of corticosteroid was the sole independently risk factor associated to nosocomial pneumonia caused by carbapenem-resistant Pseudomonas aeruginosa. The presence of septic shock and acute respiratory distress syndrome (ARDS) were the only factors related to unfavorable outcome. None variable was associated to the presence of metallo-â-lactamase SPM-1. In addition, the presence of this enzyme did not have impact on clinical outcome. / TEDE / BV UNIFESP: Teses e dissertações