Uso da tigeciclina em hospital de ensino

Introdução: A tigeciclina é agente antimicrobiano, aprovada para o tratamento de infecções complicadas na pele e tecidos moles, pneumonia hospitalar e adquirida na comunidade, infecções intra-abdominal e infecções anaeróbias ou atípicas. Objetivo: Descrever o uso da tigeciclina em hospital de ensino e comparar dados de pacientes que tiveram suas prescrições auditadas pela comissão de infecção hospitalar com os que não tiveram prescrições auditadas. Métodos: Estudo de coorte retrospectivo observacional realizado em hospital de ensino de abril de 2012 a março de 2014 incluindo pacientes que receberam tigeciclina. Foram coletadas variáveis ​​demográficas, comorbidades, achados microbiológicos, antibióticos prescritos e pareceres técnicos emitidos pelo Serviço de Controle de Infecção Hospitalar. Resultados: Foram incluídos 71 pacientes, com idade entre 13 e 92 anos, 63,4% eram do sexo masculino e 56,3% eram não brancos. A tigeciclina foi primeira escolha antimicrobiana em 19,7% (14/71) dos casos, enquanto o uso associado a outros antibióticos foi observado em 66,2% (45/71) das prescrições. principalmente com meropenem (28,9%). O uso empírico foi realizado em 69,0% dos casos, após cultura e o antibiograma em 31,0% e o uso off label em 81,7%. Os microrganismos frequentemente identificados pelos testes de cultura foram Enterococcus faecalis (17,6%), Pseudomonas aeruginosa (14,7%) e Klebsiella penumoniae (11,8%). Conclusão: O estudo demonstrou que o uso empírico e off label é comum na prática clínica e poucas prescrições foram orientadas pelos resultados da cultura e do antibiograma, demonstrando necessidade de prescritores avaliarem os benefícios/riscos do uso desse antibiótico, risco de resistência, efeitos adversos e interações medicamentosas, além do custo.

Hepatotoxicity associated with the use of teriflunomide in a patient with multiple sclerosis: A case report

RATIONALE

Teriflunomide is an inhibitor of pyrimidine synthesis available as a first-line treatment for relapsing-remitting multiple sclerosis. Drug-induced liver damage is a relevant problem in clinical practice, representing a frequent cause of treatment discontinuation. This case report describes the occurrence of liver injury, with a 33.7-fold increase in the upper limit of normality of the liver enzyme alanine aminotransferase during treatment with teriflunomide 14 mg.

PATIENT CONCERN

A 44-year-old woman receiving teriflunomide 14 mg for the treatment of multiple sclerosis presented symptoms suggestive of liver dysfunction 54 days after starting treatment. The patient had no history of using disease-modifying therapy, neither previous liver disease nor other comorbidities.

DIAGNOSTICS

The suggested diagnosis was drug-induced liver injury, classified as hepatocellular. Other possible hepatic and autoimmune etiologies were ruled out.

INTERVENTIONS

Replacement of teriflunomide treatment with glatiramer acetate and follow-up of the disease.

OUTCOMES

Signs and symptoms regressed after treatment with teriflunomide 14 mg was discontinued, with normalization of liver enzyme activity in ∼5 months. The causality assessment of the adverse drug reaction was determined by the Naranjo scaling system, resulting in probable, with a final score of 7.

CONCLUSIONS

Teriflunomide-induced liver injury in patients with multiple sclerosis is a serious adverse reaction. The report of this case contributes to updating knowledge about the safety aspects of treatment with teriflunomide and planning of monitoring strategies and patient risk management.

Medication discrepancies in transition of care of hospitalised children in Brazil: a multicentric study

OBJECTIVE

To determine the incidence of medication discrepancies in transition points of care of hospitalised children.

DESIGN

A prospective observational multicentre study was carried out between February and August 2019. Data collection consisted of the following steps: sociodemographic data collection, clinical interview with the patient's caregiver, review of patient prescriptions and evaluation of medical records. Medication discrepancies were classified as intentional (documented or undocumented) and unintentional. In addition, discrepancies identified were categorised according to the medication discrepancy taxonomy. Unintentional discrepancies were assessed for potential clinical harm to the patient.

SETTING

Paediatric clinics of four teaching hospitals in Brazil.

PATIENTS

Children aged 1 month-12 years.

FINDINGS

A total of 248 children were included, 77.0% (n=191) patients had at least one intentional discrepancy; 20.2% (n=50) patients had at least one unintended discrepancy and 15.3% (n=38) patients had at least one intentional discrepancy and an unintentional one. The reason for the intentional discrepancy was not documented in 49.6% (n=476) of the cases. The most frequent unintentional discrepancy was medication omission (54.1%; n=66). Low potential to cause discomfort was found in 53 (43.4%) unintentional discrepancies, while 55 (45.1%) had the potential to cause moderate discomfort and 14 (11.5%) could potentially cause severe discomfort.

CONCLUSIONS

Although most medication discrepancies were intentional, the majority of these were not documented by the healthcare professionals. Unintentional discrepancies were often related to medication omission and had a potential risk of causing harm to hospitalised children.

Association of clinical epidemiological factors to polypharmacy among patients with multiple sclerosis: real-life data

Introduction: Treatment for multiple sclerosis should focus on relapse prevention and treatment, as well as symptom and disease progression control, which require the use of multiple medications. Objective: To evaluate the association of polypharmacy and related clinical, epidemiological factors in multiple sclerosis patient cohorts. Methods: It was conducted a prospective study of multiple sclerosis patients that held a prescription of disease-modifying drugs between January and December 2017. The medications were analyzed and classified as either long-term or as-needed medications for therapeutic objective and prescription status purposes. Results: During 2017, 124 patients were attended, 106 were eligible for the study, and 81 agreed to participate. The average age was 40.95±11.69 years. The disease duration varied between 6 months and 30 years, with a median of 7 years. More than half of the multiple sclerosis patients suffered from comorbidities (54.32%), and 76.54% were categorized as polypharmacy. The comparison of polypharmacy between the groups yielded significant differences for comorbidities and employment status and regarding age between patients with polypharmacy and patients without polypharmacy of long-term medications. Conclusion: The age of the patient and the presence of comorbidities are important factors related to polypharmacy.

Therapeutic Ride: Health Service Evaluation and Satisfaction of Patients and Their Caregivers

Objective: To evaluate the health service and the satisfaction of patients and their caregivers in relation to the therapeutic ride, in Integrated Continuous Care. Methods: Cross-sectional, descriptive study, conducted between January 2017 and January 2018, using a specific form for data collection and interview conducted before hospital discharge. Results: The study included 23 patients and 27 caregivers. Regarding the evaluation of the service related to the therapeutic ride, 95.6% (22/23) of the patients and 70.4% (19/27) of the caregivers confirmed that they understood the objectives of this practice. The duration of the therapeutic ride was considered sufficient by 69.6% (16/23) of patients and 70.4% (19/27) of caregivers. Most patients (52.2%) and caregivers (70.4%) declared to be very satisfied with the result of the therapeutic ride. Conclusion: The therapeutic ride demonstrates its differential aspect by adding training, contributing greatly to the safe transition from the hospital to the home.

A case report of successful treatment of necrotizing fasciitis using negative pressure wound therapy

RATIONALE

Necrotizing fasciitis is a destructive tissue infection with rapid progression and high mortality. Thus, it is necessary that high-performance dressings be introduced as possibilities of treatment.

PATIENT CONCERNS

Female patient, 44 years of age, admitted to hospital unit complaining of lesion in the gluteal region and drainage of purulent secretion in large quantity followed by necrosis.

DIAGNOSES

The diagnosis of necrotizing fasciitis was carried out with the computerized tomography examination result and its association with the patient's clinical condition.

INTERVENTIONS

Initially, successive debridements were carried out in lower limbs as well as primary dressing with enzymatic debriding action until indication of negative pressure wound therapy, for the period of 2 weeks in the right lower limb and for 5 weeks in the left lower limb, with changes every 72 h. Dressing with saline gauze was used at the end of this therapy until hospital discharge.

OUTCOMES

After the use of negative pressure wound therapy, we observed the presence of granulation tissue, superficialization and reduction of lesion extension. The patient presented good tolerance and absence of complications.

LESSONS

Negative pressure wound therapy constituted a good option for the treatment of necrotizing fasciitis, despite the scarcity of protocols published on the subject.

High vertical HIV transmission rate in the Midwest region of Brazil

OBJECTIVES

To estimate vertical HIV transmission rate in a capital city of the Midwest region of Brazil and describe the factors related to transmission.

METHODS

A descriptive epidemiological study based on the analysis of secondary data from the Notifiable Diseases Information System (SINAN). The analysis considered all HIV-infected pregnant women with delivery in Campo Grande-MS in the years 2007-2013 and their HIV-exposed infants.

RESULTS

A total of 218 births of 176 HIV-infected pregnant women were identified during the study period, of which 187 infants were exposed and uninfected, 19 seroconverted, and 12 were still inconclusive in July 2015. Therefore, the overall vertical HIV transmission rate in the period was 8.7%. Most (71.6%) of HIV-infected pregnant women were less than 30 years at delivery, housewives (63.6%) and studied up to primary level (61.9%). Prenatal information was described in 75.3% of the notification forms and approximately 80% of pregnant women received antiretroviral prophylaxis. Among infants, 86.2% received prophylaxis, but little more than half received it during the whole period recommended by the Brazilian Ministry of Health. Among the exposed children, 11.3% were breastfed.

CONCLUSION

The vertical HIV transmission rate has increased over the years and the recommended interventions have not been fully adopted. HIV-infected pregnant women need adequate prophylactic measures in prenatal, intrapartum and postpartum, requiring greater integration among health professionals.

Serum markers thrombophilia in pregnant women with Systemic Lupus Erythematosus

Abstract Objectives: to determine the frequency of serum markers for hereditary and acquired thrombophilia and their association with pregnancy in women with Systemic Lupus Erythematosus (SLE). Methods: a case-control study was conducted among 25 pregnant women with SLE (study group) and 32 pregnant women without known disease and with at least one previous pregnancy (control group). The presence of antiphospholipid antibodies and hereditary thrombophilia were examined in both groups. We used the y2 Test with Yates correction or Fisher's Exact Test to verify the associations and calculate the relative risk. Results: thrombophilia was present in 72.0% of pregnant women with SLE and in 6.0% of patients in the control group. A significant association was found between the presence of SLE and serum markers for hereditary thrombophilia / antiphospholipid antibodies (p<0.05). The relative risks for antiphospholipid antibodies were 13.20 (ICR95%= 1.81 - 96.46) in pregnant women with SLE, 7.26 (CI95%= 1.77 - 29.86) for the presence of serum markers of hereditary thrombophilia and 7.92 (CI95%= 2.62 - 3.94) for the presence of hereditary thrombophilia and/or antiphospholipid antibodies. Conclusions: the identification of markers for hereditary and/or acquired thrombophilia in pregnant women with lupus may be clinically useful to determine which patients have a higher risk of obstetric complications.

Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications

Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.

Doppler velocimetry in fetal rats exposed to enoxaparin and unfractionated heparin (UFH) during pregnancy

Purpose:

To evaluate the effects of enoxaparin and unfractionated heparin (UFH) administered in prophylactic and therapeutic doses on fetal vessels in healthy pregnant Wistar rats, according to Doppler velocimetry measurements.

Methods:

Fifty animals were assigned to one of five groups: controls (saline), prophylactic and therapeutic enoxaparin (1 and 2 mg/kg/day, respectively), and prophylactic and therapeutic UFH (72 and 400 UI/kg/day, respectively). Uterine horns were examined by ultrasound for identification of live fetuses. A sample of these fetuses underwent Doppler velocimetry. Spectral curves, peak systolic velocity (PSV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery, ductus venosus, and umbilical artery were investigated. Differences were considered statistically significant when p<0.05.

Results:

No significant differences in PSV, PI, or RI values were observed among the groups.

Conclusion:

Doppler velocimetry measurements revealed no significant effects of enoxaparin or unfractionated heparin on fetal vessels in pregnant Wistar rats.

Effects of enoxaparin and unfractionated heparin in prophylactic and therapeutic doses on the fertility of female Wistar rats

PURPOSE

To evaluate the effects of exposure of enoxaparin and unfractionated heparin (UFH) in prophylactic and therapeutic doses on the fertility rates of pregnant healthy Wistar rats.

METHODS

Enoxaparin and UFH were administered in prophylactic doses 1 mg/Kg/day 72 UI/Kg/day, and in therapeutic doses at 2 mg/kg/day 400UI/Kg/day. The rats were divided into five groups. The number of live and dead foetuses was quantified. The uterine horns were dissected and the presence of early and late reabsorptions (abortions) was determined. A p<0.05 was considered statistically significant.

RESULTS

We did not observe statistically significant differences between groups when comparing the average weight of the foetuses and placentas, rate of female VS males, rates of pre-implantation loss (RPL), rates of efficiency implantation (REI), rates of post-implantation loss (RPIL) and rates of foetal viability (RFV).

CONCLUSIONS

There was no significant effect on fertility with the use of anticoagulant drugs in pregnant healthy Wistar rats.

[Usefulness of a scoring system on perinatal outcomes in pregnant women with thrombophilia in the effectiveness of an enoxaparin-based intervention]

PURPOSES

To assess whether an enoxaparin-based intervention using a score system was effective in improving perinatal outcome in women with thrombophilia.

METHODS

STUDY DESIGN

Prospective, not randomized, uncontrolled, performed at a Clinic of High-Risk Pregnancy from November 2009 to November 2011. We included women with a diagnosis and therapeutic intervention for thrombophilia acquired and/or inherited in the current pregnancy. The obstetric and perinatal outcomes of pregnant women before the intervention were compared with outcomes after the intervention, and statistically analyzed using the χ2 test with Yates correction, considered significant when p<0.05. The initial dose of low-molecular-weight Heparin (LMWH) was guided by a scoring system based on the clinical and gestational history of the patients and screening tests for acquired and/or inherited thrombophilia.

RESULTS

We included 84 pregnant women with 175 pregnancies before diagnosis, 20.0% of which resulted in fetal ou perinatal death, 40.0% resulted in abortion, 17.7% developed preeclampsia/eclampsia, 10.3% resulted in full-term births, and 29.7% in premature births. In the 84 pregnancies after intervention, 6.0% resulted in fetal ou perinatal death, 1.2% in abortion, 4.8% developed preeclampsia/eclampsia, 22.6% resulted in premature birth, and 70.2% in full-term birth. A significant reduction in the rate of stillbirths/perinatal death (p<0.05) and abortion (p<0.0001) and a significant increase (p<0.05) in the number of live births were observed after intervention.

CONCLUSION

Enoxaparin-based intervention using a score system in pregnant women with thrombophilia is effective in improving perinatal outcome.

[Serum markers of inherited thrombophilia and antiphospholipid antibodies in pregnant women with previous history of severe pre-eclampsia]

PURPOSE

To determine the frequency and the association of serum markers for inherited and acquired thrombophilias in pregnant women with a history of severe pre-eclampsia in previous pregnancies.

METHODS

Case-control study consisting of 81 pregnant women with a history of severe pre-eclampsia in previous pregnancies (study group) and 32 women with no history of severe pre-eclampsia in previous pregnancies (control group). The presence of inherited thrombophilia and antiphospholipid antibodies was screened in both groups. We used the chi-square test with Yates correction to assess associations and calculate the relative risks.

RESULTS

The presence of thrombophilia was detected in 60.0% of patients with a previous history of pre-eclampsia and in 6.0% of the control patients. A significant association was found between pre-eclampsia in a previous pregnancy and the presence of markers for hereditary thrombophilia/antiphospholipid antibodies (p<0.05). The relative risk to develop pre-eclampsia was found to be 1.57 (1.34<RR<1.84) for pregnant women with antiphospholipid antibodies, 1.53 (1.26<RR<1.86) for women with hereditary thrombophilia markers and 1.86 (1.45<RR<2.38) considering the presence of hereditary thrombophilia and/or antiphospholipid antibodies.

CONCLUSION

Women with serum markers for inherited or acquired thrombophilia showed a high relative risk to develop pre-eclampsia.