RESUMO
BACKGROUND: Improving obstetric care in resource-limited countries is a major international health priority. OBJECTIVE: To reduce infection rates after cesarean section by optimizing systems of obstetric care for low-income women in Colombia by means of quality improvement methods. METHODS: Multidisciplinary teams in 2 hospitals used simple methods to improve their systems for prescribing and administering perioperative antibiotic prophylaxis. Process indicators were the percentage of women in whom prophylaxis was administered and the percentage of these women in whom it was administered in a timely fashion. The outcome indicator was the surgical site infection rate. RESULTS: Before improvement, prophylaxis was administered to 71% of women in hospital A; 24% received prophylaxis in a timely fashion. Corresponding figures in hospital B were 36% and 50%. Systems improvements included implementing protocols to administer prophylaxis to all women and increasing the availability of the antibiotic in the operating room. These improvements were associated with increases in overall and timely administration of prophylaxis (P<.001) in both hospitals by time series analysis, with adjustment for volume and case mix. After improvement, overall and timely administration of prophylaxis was 95% and 96% in hospital A and 89% and 96% in hospital B. In hospital A, the surgical site infection rate decreased immediately after the improvements (P<.001). In hospital B, the infection rate began a downward trend before the improvements that continued after their implementation (P =.04). CONCLUSION: Simple quality improvement methods can be used to optimize obstetric services and improve outcomes of care in resource-limited settings.
Assuntos
Ampicilina/uso terapêutico , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Cefalosporinas/uso terapêutico , Cefalotina/uso terapêutico , Cesárea/efeitos adversos , Gentamicinas/uso terapêutico , Penicilina G/uso terapêutico , Penicilinas/uso terapêutico , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/prevenção & controle , Gestão da Qualidade Total , Colômbia , Endometrite/tratamento farmacológico , Endometrite/etiologia , Endometrite/prevenção & controle , Feminino , Hospitais Filantrópicos , Humanos , Unidade Hospitalar de Ginecologia e Obstetrícia , Assistência Perioperatória , Pobreza , Gravidez , Indicadores de Qualidade em Assistência à Saúde , Infecção da Ferida Cirúrgica/etiologiaRESUMO
UNLABELLED: We determined whether a beta-lactam and an aminoglycoside have efficacy greater than a beta-lactam alone in the management of a pulmonary exacerbation in patients with cystic fibrosis. STUDY DESIGN: Azlocillin and placebo or azlocillin and tobramycin were administered to 76 patients with a pulmonary exacerbation caused by Pseudomonas aeruginosa in a randomized double-blind, third-party monitored protocol. Improvement was assessed by standardized clinical evaluation, pulmonary function testing, sputum bacterial density, sputum DNA content, and time to the next pulmonary exacerbation requiring hospitalization. RESULTS: No significant difference was seen between the 2 treatment groups in clinical evaluation, sputum DNA concentration, forced vital capacity, forced expiratory volume in second 1, or peak expiratory flow rate at the end of treatment (33 receiving azlocillin alone and 43 both antibiotics); adverse reactions were equivalent in each group. Sputum P. aeruginosa density decreased more with combination therapy (P =.034). On follow-up evaluation, an average of 26 days after the end of treatment, all outcome indicators had worsened in both groups. Time to readmission for a new pulmonary exacerbation was significantly longer in the group receiving azlocillin plus tobramycin (P <.001). Treatment-emergent tobramycin resistance occurred in both groups and was more frequent with combination therapy. CONCLUSION: We conclude that the combination of a beta-lactam and an aminoglycoside produces a longer clinical remission than a beta-lactam alone and slightly better initial improvement.
Assuntos
Antibacterianos/uso terapêutico , Azlocilina/uso terapêutico , Fibrose Cística/tratamento farmacológico , Quimioterapia Combinada/uso terapêutico , Penicilinas/uso terapêutico , Tobramicina/uso terapêutico , Adolescente , Análise de Variância , Antibacterianos/efeitos adversos , Azlocilina/efeitos adversos , Criança , DNA Bacteriano/efeitos dos fármacos , DNA Bacteriano/isolamento & purificação , Método Duplo-Cego , Feminino , Humanos , Injeções Intravenosas , Masculino , Penicilinas/efeitos adversos , Pseudomonas aeruginosa/efeitos dos fármacos , Pseudomonas aeruginosa/isolamento & purificação , Testes de Função Respiratória , Escarro/efeitos dos fármacos , Escarro/microbiologia , Tobramicina/efeitos adversos , Capacidade Vital/efeitos dos fármacosRESUMO
We sought to define objective indicators of the resolution of Pseudomonas aeruginosa endobronchial infection in patients with cystic fibrosis. We prospectively studied 75 patients admitted for treatment of a pulmonary exacerbation and quantitated sputum bacterial density, DNA content, and the concentration of albumin and total protein in sputum, and compared these values with clinical evaluation. Eleven of the 75 patients had systemic signs, fever, and leukocytosis, which we arbitrarily defined as due to endobronchial infection. At the end of hospitalization, these 11 patients were afebrile, had peripheral leukocyte counts in the normal range, and were judged improved. Sputum P. aeruginosa density, DNA content, and total protein content on admission were similar in the two illness groups. Hospitalization and parenteral antibiotic administration for an average of 14.6 days were associated with improved pulmonary function in all 75 subjects (P values for forced vital capacity, forced expiratory volume at 1 second, and peak expiratory flow rate were all less than 0.001). With improvement, there was a decrease in sputum P. aeruginosa density (mean of both groups decreased from 10(7.80) CFU/g on admission to 10(5.96) CFU/g; P less than 0.001), and a decreased DNA concentration (overall mean 4.73 +/- 4.75 on admission to 2.76 +/- 2.49 mg/g; P less than 0.002). The decrease in sputum total protein concentration for both groups was not significant (overall mean 60.5 +/- 48.4 to 43.9 +/- 38.2 mg/g; P = 0.06). Sputum albumin concentrations did not change in either group. We conclude that in cystic fibrosis subjects with a pulmonary exacerbation, bacterial density, sputum DNA and protein content decrease with hospitalization and parenteral antibiotic therapy. At the end of treatment, these indices of sputum infection and inflammation correlate with improved pulmonary function and clinical improvement. These changes are independent of the presence or absence of fever on admission.
Assuntos
Fibrose Cística/complicações , Infecções por Pseudomonas/diagnóstico , Infecções Respiratórias/diagnóstico , Escarro/análise , Adolescente , Adulto , Albuminas/análise , Antibacterianos/uso terapêutico , Criança , DNA/análise , Hospitalização , Humanos , Proteínas/análise , Infecções por Pseudomonas/complicações , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa/análise , Testes de Função Respiratória , Infecções Respiratórias/complicações , Infecções Respiratórias/tratamento farmacológicoRESUMO
Pseudomonas cepacia, originally described as a plant pathogen, has emerged as an important cause of infection in altered hosts, particularly in the hospital setting. This organism's ability to survive and proliferate in a variety of solutions, medications, and even disinfectants and antiseptics has resulted in numerous clusters of common-source nosocomial infections. Many patients exposed to P. cepacia are merely colonized, but serious infections, including surgical and burn wound infections, bacteremia, meningitis, pneumonia, peritonitis, and urinary tract infections, are not rare. The virulence properties of this pathogen remain poorly characterized. Recently, P. cepacia has been reported in some cystic fibrosis centers as an increasingly frequent pulmonary pathogen. This trend has caused considerable concern because of reports of occasional cases of fulminant necrotizing pneumonia and bacteremia. Conversely, many patients with CF who become colonized with this organism have no ill effects. The epidemiology of P. cepacia in the CF population is unclear, but some patients probably acquire the organism from colonized siblings with CF. Circumstantial evidence suggests that the organism may also be acquired in the hospital. Treatment of infections is exceedingly difficult, particularly in patients with CF, because P. cepacia is resistant to a broad range of antibiotics.
Assuntos
Infecção Hospitalar/etiologia , Fibrose Cística/complicações , Infecções por Pseudomonas/complicações , Pseudomonas/patogenicidade , Infecção Hospitalar/epidemiologia , Resistência Microbiana a Medicamentos , Humanos , Pneumopatias/etiologia , Pneumonia/etiologia , Pseudomonas/efeitos dos fármacos , Infecções por Pseudomonas/epidemiologia , Infecções por Pseudomonas/etiologia , Sepse/etiologia , VirulênciaRESUMO
To determine the efficacy of rifampin chemoprophylaxis in eradication of oropharyngeal carriage of Haemophilus influenzae type b, we conducted a multicenter, double-blind, placebo-controlled trial among household contacts of patients hospitalized for invasive HIB infection. Seventy-nine index patients and 400 close contacts were studied; 26.5% of contacts were colonized. The efficacy of rifampin (10 mg/kg/dose, 600 mg/dose maximum, twice daily for two days) in eradicating carriage was 52% and varied with age (75.6% in persons greater than or equal to 5 and 27% in those less than 5 years). Eradication rates in those less than 5 years were not significantly better than for placebo. No resistant isolates were encountered in sensitivity testing. The low efficacy of this rifampin regimen in young children precludes its routine use as a chemoprophylactic agent for family contacts. The occurrence of three cases of invasive HIB infection in individuals outside the defined contact group raises concern regarding the efficacy of any chemoprophylactic regimen.
Assuntos
Infecções por Haemophilus/prevenção & controle , Rifampina/uso terapêutico , Ensaios Clínicos como Assunto , Método Duplo-Cego , Epiglote/microbiologia , Feminino , Infecções por Haemophilus/transmissão , Haemophilus influenzae , Humanos , Lactente , Laringite/prevenção & controle , Laringite/transmissão , Meningite por Haemophilus/prevenção & controle , Meningite por Haemophilus/transmissão , Testes de Sensibilidade Microbiana , Orofaringe/microbiologia , Placebos , Gravidez , Rifampina/efeitos adversosRESUMO
In order to elucidate some of the factors responsible for the high rate of nosocomial infection associated with neonatal intensive care, we studied bacterial colonization in 63 infants admitted to a neonatal intensive care unit. In a six-month period, cultures of nose, throat, umbilicus, and stool were obtained on admission and every three days from all infants staying in the NICU greater than or equal to 3 days. Study infants did not develop "normal" aerobic flora. Forty-eight percent of infants grew Escherichia coli from stool, but 52% had stool colonization with Klebsiella, Enterobacter, or Citrobacter, the only other Enterobacteriaceae encountered. KEC were also isolated from throat, nose, and umbilicus in 22%, 22%, and 24% of patients, respectively. The risk of stool colonization with KEC increased with duration of hospitalization: 2% of infants were colonized on admission, 60% after 15 days, and 91% after 30 days. Stool colonization with E. coli seemed to protect infants from colonization with other gram-negative bacilli. Thirteen of 20 infants, however, developed pharyngeal GNB colonization in spite of pre-existing abundant growth of alpha streptococci. Antibiotic therapy for greater than 3 days was associated with the isolation of KEC in stool and GNB in the throat, but birth weight less than 2,500 gm and lack of breast milk feedings were not.