Infecção de corrente sanguínea de natureza hospitalar associada ao cateter venoso central: impacto da adoção de um pacote de medidas de prevenção e controle e patogenia de infecções por Staphylococcus epidermidis em neonatos críticos

Abstract

Nocomial bloodstream infections (BSI) are most frequent infection in neonatal intensive care units (NICU), increasing considerably the length of stay in the unit and hospital costs besides contributing to poor prognosis, manly in hospitals developing countries settings. The aims of the study were to assess the impact of a care bundle for managment of Central Venous Catheter (CVC) to reduce nosocomial bloodstream infection, and to describe the pathogenesis and molecular epidemiology of infections due to S. epidermidis in a NICU of a Brazilian university hospital. The study included newborns admitted to the unit of Clinical Hospital of Federal University of Uberlândia from October / 2010 to August / 2012. Epidemiological surveillance used to follow BSI was the \"National Healthcare Safety Network\" (NHSN), and an insertion protocol for insetion and maintenance of central venous catheter based on Center for Disease Control (CDC) guidelines was adopted in unit. For the study of the pathogenesis of these infections due to S. epidermidis, cultures of the skin in the insertion site and CVC hub, as well as the nasal and intestinal mucosa of neonates were performed from 48 hrs to 14 days using the invasive procedure, or positive hemoculture, and the tip of the CVC after its withdrawal. The study was approved by the ethics committee in research of the UFU (protocol 464/10). A total of 112 infants developed BSI (20.3%) totaling 178 episodes (32.3%), 139 (25.2%) defined as hospital acquired. Incidence rates of BSI during the sudy research were 16.1 /1000 patient-days and 23.0/1000 CVC-days, but with significant variations during the investigation period, with increasing rates (59.6 / 1000 patient-days) in January 2011 and 2012 when compared with the rates of other months (16.6/1000 patient-days; IRR 3.59; P <0.001) In addition, there was also a significant reduction in the rate of these infections during the relocation of the unit for a provisory site, with rate of 10.3/1000 patient-days vs 26.7 / 1000 patient-days in the previous monitoring period (IRR= 2.59; P=0.007). The adoption the bundle resulted in significant reduction of BSI incidence of 23.4/1000 patient-days during the pre-intervention period to 14.7 / 1000 patient-days (IRR = 1.59; P = 0.04). S. epidermidis was the most frequent etiologic agent, accounting for 38.3% of the episodes of sepsis, followed by Staphylococcus aureus (12.5%). When analyzed by molecular techniques 8 cases of BSI due S. epidermidis 50,0% were related to CVC. The contamination of hub (68.4%), and skin at the insertion site colonization (57.8%), and nasal and intestinal mucoca (73.6%) of neonates was high. All isolates of S. epidermidis of 19 newborns in the study of the pathogenesis were resistant to oxacillin and 63.1% with multidrug resistance profile. S distinct genotypic profiles of MRSE were found by a 80.0% similarity coefficient, with the presence of a dominant clone in the unit (clone A), including 77.8% of the samples, suggesting horizontal transmission through the hands of unit staff. Half of bloodstream infections by S. epidermidis analyzed by molecular techniques were indicative as acquired by intestinal translocation. It is necessary to continue these investigations using a larger population of neonates for a better definition of the origin of S. epidermidis, to enable adoption of effective measures to prevent these infection in newborns.