SILVIA F. COSTA DMIP-FMUSP [email protected]/wp-content/uploads/2017/10/31.pdf · IPC in...
71
Transcript of SILVIA F. COSTA DMIP-FMUSP [email protected]/wp-content/uploads/2017/10/31.pdf · IPC in...
IPCinHematology
Epidemiology• SiteofInfecDons• RiskFactors• ColonizaDonxInfecDon• Bacteria,Virus,Fungi
Denominator• Neutropenia-days
IntervenDons
RiskfactorsHCAIinHematologyCVCChemotherapyMucositeNeutropeniaCrossTransmissionATBBMTptsGVHD
Virulancefactors HostFactors
esp
byl
acm
VRE
ATB
Gastric protector
Dialysis
CrossInfecDon
VRE BSI
Mucositis Neutropenia
GI Tract colonization
Translocation
CDC• 3,253Hospitais
CLABSIreported2014• 10%MBI-CLABSI
RestrospecDveStudy
374HSCT
MBI-LCBSIdefiniDon:
374HSCTPts
BSIMBI-LCBSICLBSISecondaryBSI
17080(47%)68(40%)22(13%)
MBI-LCBSImorefrequentAlogeinicHSCT18%x7%p=0.07
Klastersky J et al. Int J Antimicrob Agents 2007; 30 (suppl 1) S51-9 Freifeld et al. Clinical Practice Guideline. CID 2011; 52 (4) e56-93
BSIagentsFebrileNeutropenia
BSIinNeutropenicpts
2001-2006 2008-2010
BGN 23% 84%
200EpisodesFebrileNeutropenia• 30%MicrobiologyConfirmed• 26%BSI• 30%HSCT
Ghosh et al. Med Oncol 2012;29:1354-60
BGNFebrileNeutropeniaN (%)
Gram-negativo 44 (55.7%) P. aeruginosa 12 (15%) E. coli 11 (14%) Acinetobacter spp 10 (13%) Klebsiella spp 10 (13%) Gram-positivo 35 (44.3%) S. aureus 20 (25.4%) Enterococcus spp 8 (10%) CONS 6 (8%)
Ghosh et al. Med Oncol 2012;29:1354-60
R Carbapenem 80% Acinetobacter e 50% P. aeruginosa
HCAIinneutropenicptsHC-FMUSP424HSCT,5.988neutropeniadays
GN-43(54%)
GP-33(41%)
PathogensurveillanceinHematology/BMTpts
Moulds
C.difficile
Respiratoryvirus
MDR
REFORMAENFERMARIA
REFORMAENFERMARIA
IncidenceoffungiInfecQonsinBMtUNITHC-FMUSP
0"
20"
40"
60"
80"
100"
120"
140"
160"
180"
2007" 2008" 2009" 2010" 2011" 2012" 2013" 2014" 2015"Candidíase" 4,27" 0,00" 0,00" 9,71" 0,00" 17,24" 12,90" 8,55" 45,45"
Fusariose" 0,00" 0,00" 10,15" 9,71" 0,00" 0,00" 12,90" 0,00" 0,00"
Aspergilose" 4,27" 24,51" 25,38" 82,52" 34,97" 17,24" 161,29" 102,56" 136,36"
Galactomanan-IFI
GalactomananpreempQveIFI
ThoraxCT
1 1
5 52
17
2 2
5
3 3 2 2
25
12
3
1
1
EPIDEMIOLOGYANDRISKFACTORSFORINFECTION
GraçaMG,vanderHeijdenIM,PerdigãoL,TairaC,CostaSF,LevinAS.EvaluaQonoftwomethodsfordirectdetecQonofFusariumspp.inwater.JMicrobiolMethods.2016Apr;123:39-43.LitvinovN,daSilvaMT,vanderHeijdenIM,GraçaMG,MarquesdeOliveiraL,FuL,GiudiceM,ZildadeAquinoM,Odone-FilhoV,MarquesHH,CostaSF,LevinAS.Anoutbreakofinvasivefusariosisinachildren'scancerhospital.ClinMicrobiolInfect.2015Mar;21(3):268.e1-7.
AlloHCTrecipients,otherhighlyimmunocompromisedpaDentsatincreasedriskforIAshouldbeplacedinaprotectedenvironment
• (strongrecommendaDon;low-qualityevidence).
LeukemiaandtransplantcentersshouldperformregularsurveillanceofcasesofinvasivemoldinfecDon. • (strongrecommendaDon;low-qualityevidence).
MouldsinHematologyWards:intervenQons
SurveillanceWhen?
Cleaningofcoldwaterreservoirswithchlorine
conQnuouschlorinaQonofwater
0.2-μmfiltersinalltapfaucetsandshowers
Water,andairculture,PCR?
MDRINHEMATOLOGYSETTINGIMPORTANTQUESTIONSTOASK:PREVIOUSHOSPITALIZATIONLASTYEAR?PREVIOUSUSEOFANTIBIOTICLASTYEAR?TRAVEL-ENDEMICCOUNTRIESMRSA,NDMCOLONIZATIONANDINFECTIONDUETOMDRCULTURESRESULTSCLASSIFYPATIENTRISK
• HematologicalptscolonizedbyVREover2years• Acinetobacter>42months• MRSAover6months
Marchaimetal.JClinMicrob2007,151-5Feldmanetal.JClinMicrob2013,19:190-6
RiskFactorforMDRinHematologyandBMTpaDents
CVC
PreviousbroadspectrumanDbioDc
ICU MucosiDs/GVHD
PreviouscolonizaDon
Imunossupression
HSCT
Mikulskaetal.CurropinHematol2014;21:451-8VanDuinetal.JTranplant2013;13:31-41
Averbuchetal.Haematologica2013;98:12
Gram-NegaQve• Pseudomonas,Enterobacteria
Gram-posiQve• VRE,SCN
WhichsiteshouldMDRscreeningbeperformed
RectalRespiratoryNaresInguinal
• MRSAX
• VREX
• CREXX
• AcinetobacterXX
• PseudomonasXX
• Gram-negaDve:morethan1siteincreasesposiDvityDalbenetal.JHI2010;74:395-411Taconelli.ClinMicrobInfect2014;1:1-55
• RectalSwab• 3rectalswabs• 21/185(11%)ptswerecolonized
– 10E.coli– 5Pseudomonas– 4K.pneumoniae– Enterobacter– 1Stenotrophomonas– 1A.baumannii
24dayshospitalizaDontocolonizaDon
MajorityspontaneousdecolonizaDon6monthsalerdischarged
1ptimunossupresion+anDbioDccolonized>3years
AmJInfectControl2014;42:376-80
RiskfactorsmulDvariateanalysisRR(95%IC)PTransferfromanotherHospital7.8(2.0-31.2)0.003Transferbetweenunits9.3(27-31.9)<0.001Busulfan11.9(2.5-56)0.002Fludarabine6.4(1.5-27)0.011Centralvenouscatheter5.1(1.1-23.5)0.037
65centers25countries• BSIpost-THSCTupto6months
RatesandRiskfactors
ResistanceGNR• Fluorquinolones• Carbapenems• MDR
655episodesBSI-591pts
1.1episodes/pt(1-4episodes)
Resistance
• 50%fluorquinolones• 18%Carbapenems• 35%MDR
RF:DuraDonHospitalizaDon
VREHematologyWard
ColonizaDonxInfecDon
Onlyseveritymarker?
Sómarcador
752ptsTCTH• 14%colonizaDon 7%InfecDon
93BSI1yearpost-THSCT66%VRE• RF:colonizaQonandneutropenia
30daysMortalitys 38%VRE=VSE
1yearsurvival
VRE 20%
VSE 48%
VRELinezolid-resistant• HSCT
• SuscepQbilityLinezolid
• 48casesx96controls• RFMVOR 95%ICP• PrevioususeLinezolid31.844,20-259<0.001
• Santayanaetal.DiagMicrobInfecDisJuly,2012
• 89VREstrains2005-2014
• 78pts
• 1BSIisolateLinezolid-resistant
Isolates TotalE.faecalis
ColonizaQon 18
E.faecium 79
ColonizaQon 69
BloodstreaminfecQon 7
Pneumonia 2
SkinandsooQssue 1
Total 97
• 127P.aeruginosaresistanttoCarbapenem• 12-year
– CarbapenemMIC:8-128– SuscepQbleonlytocolisQn– NewclusterBMT-2012
• IsolatesharboringKPC,VIM,SPM
• Outbreak-29casesBSI• Mortalityover70%(inpress)
• PrevioushospitalizaDoninSerbia
• D+15allogeneicHSCTBSIshock
• ColisDn12/12hs-9milions
• D+17death
EuroSurveillance2013;18:46
PrevenDonandControlMDRintransplantaDon
ContactprecauQon
HandHygiene
BundlesprevenQonBSI-CVC,VAP,UTI
RatesFeedbackothersintervenQons
BoucherHW.ClinicalInfecTousDiseases.2010Taconellietal.ClinMicrobInfect2014;1:1-55
AnDbioDcstewardshiptransplantaDonserng
BMT• ProphylaxisonlyforHighRiskpaQents• LeukemiaandAllogeneicHSCT
Febrileneutropenia• DuraQonanQbioQc• Avoidvancomycin
• DonottreatcolonizaDon
• De-escalaDon
• 6monthsintervenDonxnon-intervenDon• 7727pts• 9ICU• 1BMT
BSIratespreandpostChlorexedineBath
HCAIratespreandpostChlorexedineBath
VREinfecDontemporalseriescomparingpreandpostintervenDoninBMTUNIT(2005-2009)x2009-2013HC-FMUSP,1.323pts
Den
sity
of V
RE
infe
ctio
n(/1
000
pt-d
ay)
02
46
810
1214
jan
05
jul 0
5
jan
06
jul 0
6
jan
07
jul 0
7
jan
08
jul 0
8
jan
09
jul 0
9
jan
10
jul 1
0
jan
11
jul 1
1
jan
12
jul 1
2
jan
13
jul 1
3
jan
14
INTERVENÇÃO
Model (0,0,4) (0,0,1)
Variable Betta SE P value
Constant 0.557 0.564 0.326
Secular 0.054 0.018 0.003
Intervention -1.429 0.813 0.082
Post-intervention
-0.086 0.025 0.001
- - - TaxasobservadasModelocompleto
- - - Previsãosemaintervenção
- - - Previsãocomaintervenção
- - - Momentodaintervenção
VRE-INF
• Gram-negaDveratesincreased• VREChlorhexidineMIC
Chlorhexidinebath
TMOHC-FMUSPJanuary-March2015
PCR16SRibosomic
• Outbreak 2008 • BMT Unit, Israel • Colonization and BSI
Oral Genta 80mg Up to erradication
• Erradication: 03 negatives rectal swabs weekly
KPCHSCT
15 pts colonized KPC
5 months
Zuckerman et al. Bone Marrow Transplant 2011;46:1226-30
KPCHSCT15ptscolonizedKPC
10/15decolonized
Zuckerman et al. Bone Marrow Transplant 2011;46:1226-30
8/15BSI 4/8nodecolonized
KCPsuscepDbletoColisDna;
GentaeTige
6Death• 3deathrelatedKPCInfecDon
CyclinganDbioDcinBMT• ProspecDvecohortptsneutropenicfever
Pre-cyclingPeriodAPeriodBP
• InfecDon1.000pts-day
• Gram-negaDve5.32.13.30.001• Gram-posiDve4.45.34.80.28• VRE0.11.11.60.005
Cumpstonetal.TransplInfectDis2013;15:1425
PeriodA:cycling8months
PeriodB:cycling3months
PeriodA:8months PeriodB:3months
AmJInfectControl2013;1167-77
OtherspossibiliQesMDRdecolonizaQon
FecalTransplant• Save• CasesReports
ProbioQcs• 1trialinchildren
TakeHomeMessage
TalktoyourpaDent
Screen
Local/CountryMDRRates
ClassifypaDent
UsetheinformaDonwisely
Thankyou
