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Andrade HB, da Silva IRF, Espinoza R, Ferreira MT, da Silva MST, Theodoro PHN, Detepo PJT, Varela MC, Ramos GV, da Silva AR, Soares J, Belay ED, Sejvar JJ, Bozza FA, Cerbino-Neto J, Japiassú AM. Clinical features, etiologies, and outcomes of central nervous system infections in intensive care: A multicentric retrospective study in a large Brazilian metropolitan area. J Crit Care 2024; 79:154451. [PMID: 37871403 DOI: 10.1016/j.jcrc.2023.154451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE The goal of this study was to investigate severe central nervous system infections (CNSI) in adults admitted to the intensive care unit (ICU). We analyzed the clinical presentation, causes, and outcomes of these infections, while also identifying factors linked to higher in-hospital mortality rates. MATERIALS AND METHODS We conducted a retrospective multicenter study in Rio de Janeiro, Brazil, from 2012 to 2019. Using a prediction tool, we selected ICU patients suspected of having CNSI and reviewed their medical records. Multivariate analyses identified variables associated with in-hospital mortality. RESULTS In a cohort of 451 CNSI patients, 69 (15.3%) died after a median 11-day hospitalization (5-25 IQR). The distribution of cases was as follows: 29 (6.4%) had brain abscess, 161 (35.7%) had encephalitis, and 261 (57.8%) had meningitis. Characteristics: median age 41 years (27-53 IQR), 260 (58%) male, and 77 (17%) HIV positive. The independent mortality predictors for encephalitis were AIDS (OR = 4.3, p = 0.01), ECOG functional capacity limitation (OR = 4.0, p < 0.01), ICU admission from ward (OR = 4.0, p < 0.01), mechanical ventilation ≥10 days (OR = 6.1, p = 0.04), SAPS 3 ≥ 55 points (OR = 3.2, p = 0.02). Meningitis: Age > 60 years (OR = 234.2, p = 0.04), delay >3 days for treatment (OR = 2.9, p = 0.04), mechanical ventilation ≥10 days (OR = 254.3, p = 0.04), SOFA >3 points (OR = 2.7, p = 0.03). Brain abscess: No associated factors found in multivariate regression. CONCLUSIONS Patients' overall health, prompt treatment, infection severity, and prolonged respiratory support in the ICU all significantly affect in-hospital mortality rates. Additionally, the implementation of CNSI surveillance with the used prediction tool could enhance public health policies.
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Affiliation(s)
- Hugo Boechat Andrade
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil; Sexually Transmitted Diseases Sector, Biomedical Institute, Federal Fluminense University (UFF), Niterói, RJ, Brazil.
| | | | - Rodolfo Espinoza
- Surgical Intensive Care Unit, Hospital Copa Star, Rio de Janeiro, RJ, Brazil; Intensive Care Unit II, Instituto Nacional do Cancer, Rio de Janeiro, RJ, Brazil
| | - Marcel Treptow Ferreira
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil
| | - Mayara Secco Torres da Silva
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil
| | - Pedro Henrique Nascimento Theodoro
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil
| | - Paula João Tomás Detepo
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil
| | - Margareth Catoia Varela
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil; Immunization and Health Surveillance Research Laboratory, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Grazielle Viana Ramos
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Aline Reis da Silva
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Jesus Soares
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Ermias D Belay
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - James J Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Fernando Augusto Bozza
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil; Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - José Cerbino-Neto
- Immunization and Health Surveillance Research Laboratory, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - André Miguel Japiassú
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Av. Brasil 4365, Manguinhos, Rio de Janeiro, RJ CEP 21040-360, Brazil
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Farias MG, Dal Bó S, Castro SMD, da Silva AR, Bonazzoni J, Scotti L, Costa SHAM. Flow Cytometry in Detection of Fetal Red Blood Cells and Maternal F Cells to Identify Fetomaternal Hemorrhage. Fetal Pediatr Pathol 2016; 35:385-391. [PMID: 27494244 DOI: 10.1080/15513815.2016.1209260] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Accurate detection and quantitation of fetomaternal hemorrhage (FMH) is critical to the obstetric management of rhesus D alloimmunization in Rh-negative pregnant women. The flow cytometry is based on the detection of fetal red blood cells using a monoclonal anti-HbF antibody, and is the method most indicated for this estimation. The objective of this study was to quantify fetal red blood cell levels of pregnant women using flow cytometry. We analyzed 101 peripheral blood samples from Rh-negative and Rh-positive women, whose mean age was 24 years (20-32 years), after vaginal delivery or cesarean section. Our study showed that 53% of pregnant women had fetal red blood cells levels <2.0 mL, 31% between 2.0-3.9 mL, 16% between 4.0-15.0 mL, and 1% >15.0 mL. Accurate quantitation of fetal red blood cells is necessary to determine the appropriate dose of anti-D (RHD) immunoglobulin to be administered to pregnant or postpartum women.
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Affiliation(s)
- Mariela Granero Farias
- a Department of Clinical Pathology , Flow Cytometry, Hospital de Clínicas de Porto Alegre , Porto Alegre , Brazil
| | - Suzane Dal Bó
- b Department of Clinical Pathology , Hematology Unit, Hospital de Clínicas de Porto Alegre , Porto Alegre , Brazil
| | | | | | - Joyce Bonazzoni
- c Universidade Federal do Rio Grande do Sul , School of Pharmacy , Porto Alegre , Brazil
| | - Luciana Scotti
- b Department of Clinical Pathology , Hematology Unit, Hospital de Clínicas de Porto Alegre , Porto Alegre , Brazil
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Cavalcanti AB, Machado F, Bozza F, Ibrain J, Salluh F, Campagnucci VP, Guimarães HP, Normilio-Silva K, Chiattone VC, Vendramim P, Carrara F, Lubarino J, da Silva AR, Viana G, Damiani LP, Romano E, Teixeira C, da Silva NB, Chang CCH, Angus DC, Berwanger O. A cluster randomized trial of a multifaceted quality improvement intervention in Brazilian intensive care units: study protocol. Implement Sci 2015; 10:8. [PMID: 25928627 PMCID: PMC4342101 DOI: 10.1186/s13012-014-0190-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/09/2014] [Indexed: 01/01/2023] Open
Abstract
Background The uptake of evidence-based therapies in the intensive care environment is suboptimal, particularly in limited-resource countries. Checklists, daily goal assessments, and clinician prompts may improve compliance with best practice processes of care and, in turn, improve clinical outcomes. However, the available evidence on the effectiveness of checklists is unreliable and inconclusive, and the mechanisms are poorly understood. We aim to evaluate whether the use of a multifaceted quality improvement intervention, including the use of a checklist and the definition of daily care goals during multidisciplinary daily rounds and clinician prompts, can improve the in-hospital mortality of patients admitted to intensive care units (ICUs). Our secondary objectives are to assess the effects of the study intervention on specific processes of care, clinical outcomes, and the safety culture and to determine which factors (the processes of care and/or safety culture) mediate the effect of the study intervention on mortality. Methods/design This is a cluster randomized trial involving 118 ICUs in Brazil conducted in two phases. In the observational preparatory phase, we collect baseline data on processes of care and clinical outcomes from 60 consecutive patients with lengths of ICU stay longer than 48 h and apply the Safety Attitudes Questionnaire (SAQ) to 75% or more of the health care staff in each ICU. In the randomized phase, we assign ICUs to the experimental or control arm and repeat data collection. Experimental arm ICUs receive the multifaceted quality improvement intervention, including a checklist and definition of daily care goals during daily multidisciplinary rounds, clinician prompting, and feedback on rates of adherence to selected care processes. Control arm ICUs maintain usual care. The primary outcome is in-hospital mortality, truncated at 60 days. Secondary outcomes include the rates of adherence to appropriate care processes, rates of other clinical outcomes, and scores on the SAQ domains. Analysis follows the intention-to-treat principle, and the primary outcome is analyzed using mixed effects logistic regression. Discussion This is a large scale, pragmatic cluster-randomized trial evaluating whether a multifaceted quality improvement intervention, including checklists applied during the multidisciplinary daily rounds and clinician prompting, can improve the adoption of proven therapies and decrease the mortality of critically ill patients. If this study finds that the intervention reduces mortality, it may be widely adopted in intensive care units, even those in limited-resource settings. Trial registration ClinicalTrials.gov NCT01785966 Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0190-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandre Biasi Cavalcanti
- Research Institute - Hospital do Coração (IEP- HCor), Rua Abílio Soares 250, 12th floor, CEP: 04005-000 - São Paulo, SP, Brazil.
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