Impacto da implementação de bundles de prevenção de infecções relacionadas à assistência à saúde em unidade de terapia intensiva especializada em cuidados de receptores de transplante de rim
Data
2023-08
Autores
Santos, Maria Bethânia Peruzzo 
Orientadores
Requiao Moura, Lucio Roberto
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: As infecções relacionadas à assistência à saúde (IRAS) são um grave problema de saúde pública. Nos últimos anos, a implementação de medidas agrupadas, sistemáticas e supervisionadas para prevenção de IRAS (bundles) reduziu de forma substancial a sua incidência, mas essas evidências não têm considerado a estratificação de pacientes, de acordo com seus perfis de vulnerabilidade. Os receptores de transplante de rim (TxR) estão sob elevado risco de apresentar quadros infecciosos mais graves, bem como de outras situações de saúde que necessitam de cuidados avançados de vida, com alta exposição de risco às IRAS. Ainda não há dados na literatura demonstrando o impacto da implementação de bundles de controle de IRAS nessa população.
Objetivo: Mensurar o impacto da implementação de bundles de prevenção das IRAS associadas à dispositivo na sua incidência de casos, em uma UTI especializada em cuidados de TxR.
Metodologia: Estudo de coorte retrospectiva realizado em centro único, com a inclusão de TxR admitidos na UTI entre 2016 e 2019, e que necessitaram de um dos dispositivos de interesse: cateter venoso central (CVC), cateter vesical de demora (CVD) e ventilação mecânica (VM). Em dezembro de 2017 os bundles de prevenção de IRAS foram completamente implementados na UTI e os pacientes internados 3 meses antes e 3 meses após esse período foram excluídos (período de adaptação). Dessa forma, foram incluídos 798 pacientes, 449 na era antes e 349 na era depois da implementação dos bundles. Desfecho primário: IRAS associadas à dispositivo, infecção de corrente sanguínea associada à CVC (ICS-CVC), infecção urinária associada à CVD (ITU-CVD) e PAV. O desfecho secundário: óbito em 30 e 90 dias. Análise multivariada para a ocorrência de IRAS foi realizada por regressão logística. Sobrevidas do paciente foram estimadas por Kaplan-Meier e comparadas de acordo com a ocorrência de IRAS por teste Logrank. Para estimar o impacto da ocorrência de IRAS nas chances de óbito do paciente, um modelo de regressão Poisson foi realizado através de sistema de equações estruturais generalizadas.
Resultados: Algumas diferenças significativas foram observadas nos pacientes de acordo com as eras (antes vs. depois, respectivamente): maior frequência de doadores falecidos (80,6 vs. 72,8%, p=0,009), maior incidência de infecção pelo citomegalovírus (CMV) prévia à internação na UTI (40,1 vs. 32,4%, p=0,024), menor tempo de transplante (47,0 vs. 65,2 meses, p=0,001); SOFA mais elevado (6,0 vs. 5,0, p=0,001), TFG ligeiramente maior (20,4 vs. 19,8 ml/min/1,73m2, p=0,02) e maior contagem de leucócitos totais (10.000 vs. 8.600 células/mm3, p=0,005) à admissão na UTI; e menor frequência de utilização de CVC (78,6 vs. 87,1%, p=0,002). Com a implementação dos bundles, a incidência de casos das IRAS-dispositivo reduziu de 8,7% para 4,0% (p=0,009) e as de ICS-CVC de 8,5% para 3,9% (p=0,017). Paras as ITU-CVD e PAV as reduções foram de 1,5% para 0,4% (p=0,34) e de 2,0% para 0,6% (p=0,38), respetivamente. Na análise de múltiplas variáveis, a implementação dos bundles reduziu o risco de IRAS-dispositivo em 59% (OR=0,411; p=0,006). As sobrevidas do paciente em 30 e 90 dias foram, respectivamente, de 76,4% e 71,7%, para os pacientes que não apresentaram IRAS-dispositivos, e de 58,5% e 37,7%, para os que apresentaram (p<0,001). Na análise de múltiplas variáveis, a ocorrência de IRAS-dispositivo aumentou em 2,63 o risco de óbito (HR=2,63; p<0,001).
Conclusão: Com a implementação de medidas de prevenção de IRAS em uma UTI especializada em cuidados de TxR houve uma redução significativa no risco de sua ocorrência, em linhas com as evidências em estudos realizados em populações não específicas. Independente da implementação de controle de IRAS, a sua ocorrência aumentou de forma significativa o risco de óbito em até 90 dias de seguimento.
Background: The burden of healthcare-associated infections (HAI) is a public health challenge . In recent years, implementing systematic measures to prevent multiples HAI, known as bundles, significantly reduced the risk of these infections. The available evidence, however, has not considered patients stratified according to some vulnerability profiles. For example, kidney transplant recipients (KTRs) have a high risk of severe infections and other clinical conditions that can require advanced life support and, consequently, high risk of HAI. To date, no study has been dedicated to investigating the impact of the bundle’s implementation on the HAI incidence for this specific cluster of patients. Purpose: to measure the impact of the bundles’ implementation aimed at preventing device-related HAI in an intensive care unit (ICU) specialized in the KTRs’ clinical assistance. Method: Single-center cohort study enrolling KTRs admitted to ICU between 2016 and 2019 and who required one of three devices of interest: central line catheters (CLC), urinary catheter (UC), or mechanical ventilation (MV). In December 2017, the bundles were implemented entirely in the ICU, and all patients admitted three months before or after this date were excluded (time of adaptation). Thus, 789 patients were included, 449 before the bundles’ implementation and 349 after. The primary outcome was the HAI-device incidence of cases and the specific HAI-devices: central line-associated bloodstream infections (CLABI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP). The secondary outcome was death at 30 and 90 days. Multivariable analysis for HAI-device was performed by logistic regression. Patients' survival was estimated by Kaplan-Meier and compared according to HAI by Logrank test. A Poisson regression model was performed by Generalized Structural Equation Modeling to estimate the HAI impact on the risk of death. Results: Some significant differences were observed when the patients were stratified by the era (before and after the bundles’ implementation, respectively): higher frequency of deceased donors (80.6 vs. 72.8%, p=0.009), higher incidence of cytomegalovirus infection previous to ICU admission (40.1 vs. 32.4%, p=0.024), lower time after transplantation (47.0 vs. 65.2 months, p=0.001), higher SOFA (6.0 vs. 5.0, p=0.001), higher GFR (20.4 vs. 19.8 ml/min/1.73m2, p=0.02) and higher number of total white blood cell (10,000 vs. 8,600 cells/mm3, p=0.005) at ICU admission; and a lower rate of CLC use (78.6 vs. 87.1%, p=0.002). After the bundles’ implementation, the HAI case incidence reduced from 8.7% to 4.0% (before vs. after, p=0.009), and CLABI reduced from 8.5% to 3.9% (p=0.017). For CAUTI and VAP, the reductions were from 1.5% to 0.4% (p=0.34) and from 2.0% to 0.6% (p=0.38), respectively. In the multivariable analysis, the bundles’ implementation reduced the risk of HAI 59% (OR=0.411; p=0.006). The 30- and 90-day patients' survivals were 76.4% and 71.7% for patients who did not have HAI and 58.5% and 37.7% for those who had (p<0.001). Lastly, in the multivariable analysis, the risk of death was 2.6-fold higher for patients with HAI (HR=2.63; p<0.001). Conclusions: Implementing systematic measures to prevent multiple HAI in an ICU specialized in the KTRs clinical assistance significantly reduced the risk of HAI occurrence, in line with the previous evidence based on nonspecific populations. However, independently of the preventing measures implementation, the HAI increased the risk of death whiting 90 days of follow-up after the ICU admission.
Background: The burden of healthcare-associated infections (HAI) is a public health challenge . In recent years, implementing systematic measures to prevent multiples HAI, known as bundles, significantly reduced the risk of these infections. The available evidence, however, has not considered patients stratified according to some vulnerability profiles. For example, kidney transplant recipients (KTRs) have a high risk of severe infections and other clinical conditions that can require advanced life support and, consequently, high risk of HAI. To date, no study has been dedicated to investigating the impact of the bundle’s implementation on the HAI incidence for this specific cluster of patients. Purpose: to measure the impact of the bundles’ implementation aimed at preventing device-related HAI in an intensive care unit (ICU) specialized in the KTRs’ clinical assistance. Method: Single-center cohort study enrolling KTRs admitted to ICU between 2016 and 2019 and who required one of three devices of interest: central line catheters (CLC), urinary catheter (UC), or mechanical ventilation (MV). In December 2017, the bundles were implemented entirely in the ICU, and all patients admitted three months before or after this date were excluded (time of adaptation). Thus, 789 patients were included, 449 before the bundles’ implementation and 349 after. The primary outcome was the HAI-device incidence of cases and the specific HAI-devices: central line-associated bloodstream infections (CLABI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP). The secondary outcome was death at 30 and 90 days. Multivariable analysis for HAI-device was performed by logistic regression. Patients' survival was estimated by Kaplan-Meier and compared according to HAI by Logrank test. A Poisson regression model was performed by Generalized Structural Equation Modeling to estimate the HAI impact on the risk of death. Results: Some significant differences were observed when the patients were stratified by the era (before and after the bundles’ implementation, respectively): higher frequency of deceased donors (80.6 vs. 72.8%, p=0.009), higher incidence of cytomegalovirus infection previous to ICU admission (40.1 vs. 32.4%, p=0.024), lower time after transplantation (47.0 vs. 65.2 months, p=0.001), higher SOFA (6.0 vs. 5.0, p=0.001), higher GFR (20.4 vs. 19.8 ml/min/1.73m2, p=0.02) and higher number of total white blood cell (10,000 vs. 8,600 cells/mm3, p=0.005) at ICU admission; and a lower rate of CLC use (78.6 vs. 87.1%, p=0.002). After the bundles’ implementation, the HAI case incidence reduced from 8.7% to 4.0% (before vs. after, p=0.009), and CLABI reduced from 8.5% to 3.9% (p=0.017). For CAUTI and VAP, the reductions were from 1.5% to 0.4% (p=0.34) and from 2.0% to 0.6% (p=0.38), respectively. In the multivariable analysis, the bundles’ implementation reduced the risk of HAI 59% (OR=0.411; p=0.006). The 30- and 90-day patients' survivals were 76.4% and 71.7% for patients who did not have HAI and 58.5% and 37.7% for those who had (p<0.001). Lastly, in the multivariable analysis, the risk of death was 2.6-fold higher for patients with HAI (HR=2.63; p<0.001). Conclusions: Implementing systematic measures to prevent multiple HAI in an ICU specialized in the KTRs clinical assistance significantly reduced the risk of HAI occurrence, in line with the previous evidence based on nonspecific populations. However, independently of the preventing measures implementation, the HAI increased the risk of death whiting 90 days of follow-up after the ICU admission.
Descrição
Citação
SANTOS, Maria Bethânia Peruzzo. Impacto da implementação de bundles de prevenção de infecções relacionadas à assistência à saúde em unidade de terapia intensiva especializada em cuidados de receptores de transplante de rim. 2023. 95 f. Dissertação (Mestrado em Nefrologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). São Paulo, 2023.