Coleta e Transporte -

HEMOCULTURA
Amostras coletadas por punção venosa
após assepsia com álcool a 70% e
aplicação de sol. de clorexidina alcoólica
a 0,5% ou sol. de iodo por meio de
movimentos circulares e centrífugos.
Deixa agir e secar.
Colocar em frasco de hemocultura com

tampa limpa por álcool a 70%;

homogeneizar por inversão; identificar o
frasco com nome, data, hora e nº da
amostra
 Hemocultura
 Amostras devem ser enviadas ao
laboratório em temperatura ambiente em
até 2 hs.
 UROCULTURA
Coleta
1. Urina de jato médio
 Realizar higiene prévia; desprezar 1º jato e
colher o jato médio em frasco estéril
2. Urina de qualquer jato
 Amostra obtida de crianças com saco
coletor; fazer higiene prévia e colocar o
saco coletor; trocar coletor a cada 30 min.
a 1h repetindo higiene
3. Urina de paciente com sonda vesical
 Pinçar a cânula do coletor e desinfectá-la com álcool
a 70%; puncionar com material estéril a cânula
retirando até 10 ml de urina
4. Urina coletada por punção suprapúbica
 colhe-se por punção vesical; muito usada para
pesquisa de infecções por anaeróbios
5. Urina do primeiro jato
 Higienizar região genital e coletar os primeiros 10ml
de urina
Transporte
 Em temperatura ambiente por até no
máximo 2 hs.
 Se estiver em tubo com preservativo
(ácido bórico), a amostra pode ficar até
24hs em temperatura ambiente
 Feridas e Secreções
Coleta
1. Lesões superficiais:
 Descontaminar as margens e a superfície da
lesão ( sol. fisiológica, sol. povidina – iodo ou
clorexidina 0,2% sol. aquosa)
 Coletar material da parte mais profunda da lesão
por punção.
 Swab somente em ÚLTIMO caso.
 Transporte: 2 horas em temperatura ambiente.
 Métodos Manuais

Cultura cega
Risco ocupacional
>Tempo para detecção
Incubação : 7 dias
Custo baixo
Metodologias Manuais
 Walkaway 40 e
AutoSCAN - 4
96

Painel

Sistema MicroScan
 Sistema Vitek®

Sistema Vitek 2 ®

Cartões
 Métodos automatizados
Detecção precoce ( maioria até 48 hs )
Agitação contínua
<< Manipulação
Incubação: 5 dias ( +/- 2 )
Software
Desnecessário cultura cega
Custo elevado
SISTEMA BACTEC® (BD)
SISTEMA BacTAlert® (BioMerrieux)
 FLUXO DE HEMOCULTURA +

Semeadura

Bacterioscópico
 Cultura de Cateter

Brun-Buisson

Técnica de Maki
SISTEMA HEMOBAC TRIFÁSICO® (Probac do Brasil)
ESBL
ESBL
 ESBL
 Testes confirmatórios:
 Ceftazidima e ceftazidima+ ác.clav
 Cefotaxima e cefotaxima + ác.clav

• >ou= 5 mm de diâmetro entre as leituras ou

• Acima de 3 diluições (ex:ceftazidima =8mcg/ml e

ceftazidima combinada = 1 mcg/ml)
ESBL
 Enterococos Resistentes à Vancomicina

Ágar cromogênico
(Chromagar orientation®)
Polimixina B
Aztreonam
laminocultivo Anfotericina B
+
VANCOMICINA

Azida +
Polimixina B
Aztreonam
Anfotericina B
+
Azida + VANCOMICINA
Polimixina B
Aztreonam
Anfotericina B
 Protocolos: Streptococcus agalactie

CDC

Swab Anal/Vaginal

Meio Todd
cIAI Diagnoses Include:

Complicated appendicitis
Complicated cholecystitis
Complicated diverticulitis
Gastric/duodenal perforation
Intra-abdominal abscess
Perforation of intestine
Peritonitis

62
 cIAI Definition

©Copyright 2005 cmsp.com / All rights reserved

Abscess Formation Peritonitis

Patients
Patients with
with cIAI
cIAI who
who were
were candidates
candidates for
for or
or had
had received:
received:
•• Laparotomy
Laparotomy
•• Laparoscopy
Laparoscopy
•• Percutaneous
Percutaneous drainage
drainage of
of intra-abdominal
intra-abdominal abscess
abscess

Babinchak T, et al. Clin Infect Dis. 2005;41 (Suppl 5):S354-S367.

Studd RC and Stewart PJ. N Engl J Med. 2004;350(17):1763. 68
 Microbiology of Peritonitis
Primary Secondary Tertiary
(Monomicrobial) (Polymicrobial) (Polymicrobial)
E. coli B. fragilis group Enterococci
Klebsiella spp. E. coli Pseudomonas
Streptococcus spp. Clostridium spp. S. epidermidis
Enterococcus spp. Klebsiella spp. Candida
Other gram-negativeStreptococcus spp.
bacilli Enterococcus spp.
S. anginosus Pseudomonas spp.
S. epidermidis

E. coli B. fragilis

©Copyright 2005 gbf.de / All rights reserved ©Copyright 2005 cmsp.com / All rights reserved ©Copyright 2005 cmsp.com / All rights reserved ©Copyright 2005 cmsp.com / All rights reserved

Barie PS. J Chemother. 1999;11:464-477.

LaRoche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550. 64
 Proportions of Bacterial Isolates (%)
in Community-acquired Peritonitis

Dupont H. Antimicrob Agents Chemother 2000;44:2028-33

Roehrborn A. Clin Infect Dis 2001;33:1513-9
 Proportions of Bacterial Isolates (%)
in Nosocomial Postoperative Infections

Aerobe
Montravers P et al. Clin Infect Dis. 1996;23:486-494
Dupont H. Antimicrob Agents Chemother 2000;44:2028-33
Roehrborn A. Clin Infect Dis 2001;33:1513-9
 Who is at risk for P.aeruginosa: IAI?
Guidelines of the Surgical Infection Society (SIS)

 Higher-Risk Patients (defined as those patients with risk

factors for post-operative mortality)
 Risk factors include:
• Higher APACHE II score

• Advanced age

• Malnutrition

• Inadequate initial source control

• Presence of significant medical condition (CV, renal,

cancer)
• Use of corticosteroid therapy

 Presence of resistant organisms as a common feature

 Require broader-spectrum Rx incl. anti-pseudomonal
coverage

Mazuski JE et al. Surg Infect 2002;3:175-233, Therapeutic Principles in the 2002 IAI
 Who is at risk for P.aeruginosa: IAI?
Guidelines of the
Infectious Disease Society of America (IDSA).
 Community-acquired vs. Health care-associated infections
 Community-acquired high-risk patients (defined as those
with risk factors for post-operative mortality)
• Risk factors include:

• higher APACHE II score

• poor nutritional status
• inadequate initial source control
• significant CV disease
• Immunosuppression
• Requires broader-spectrum Rx incl anti-pseudomonal

coverage

Solomkin JS et al. Clin Infect Dis 2003; 37:997-1005 , Therapeutic Principles in the 2003 Complicated IAI
 Classification of Peritonitis
 Primary
• Ascites
 Secondary
• Predominantly bowel
perforation with gut flora
• Mortality varies with
organ involved and host
factors
 Tertiary
• Recurrent infection,
failure of source control
• Impaired host unable to
clear infection
• High mortality
• Resistant organisms incl
P.aeruginosa

Farthmann EH, Schöffel U. Infection. 1998;26:329-334.

LaRoche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.
Malangoni MA. Am Surg. 2000;66:157-161. 63
 Intra-abdominal Infections
Surgical Antibiotics Mortality
procedure (%)
Inappropriate Inappropriate 100

Inappropriate Appropriate 90

Appropriate Inappropriate 71

Appropriate Appropriate 6

Carlet. Línfection en reanimation. Masson Paris 1996, P126-138

 Appropriate Initial Antibiotic Therapy Improves
Outcomes of Patients with Community-Acquired
IAIs Requiring Surgery
Sourceof Infection

13%
38%
22%

27%  Clinical success achieved in 322 patients

Perforated appendix Colon
425 patients in 20 clinics
6,521 patient days
54 (13%) received inappropriate
initial parenteral therapy
Gastroduodenum Other (75.7%; 95% CI, 70.6-81.2)
 Patients more likely to experience clinical
success with appropriate initial therapy
(78.6%; 95 CI, 73.6-83.9) than with
inappropriate therapy (53.4%; 95 CI, 41.1-
69.3)
 Estimated length of stay (LOS) 13.9 days in
patients having clinical success (95% CI,
13.1-14.7)
 Estimated LOS 19.8 days in those
experiencing clinical failure (95% CI,
17.3-22.3)

Krobot K, et al. Eur J Clin Microbiol Infect Dis. 2004;23:682-687.

Impact on outcome of appropriate initial
antibiotic choice: IAI
 Improved chance of successful clinical outcome
 Reduced mortality

 Decrease in need for re-operation

 Decrease in need for second-line therapy

 Decrease in re-hospitalization

 Decrease in additional antibiotic therapy

 Reduction in duration of antibiotic treatment

 Decrease in antibiotic costs

 Decrease in length of hospital stay

 Reduction in hospital costs

12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients
Step 7: Know when to say “No” to Vanco

Vancomycin- Intermediate S. aureus (VISA)

State, Year Site PD/HD*

Michigan, 1997 Peritonitis Chronic PD
New Jersey, 1997 Blood Recent PD
New York, 1998 Blood Chronic HD
Illinois, 1999 Endocarditis Chronic HD
Minnesota, 2000 Bone Chronic HD
Nevada, 2000 Liver -----

PD=peritoneal dialysis , HD=hemodialysis

Fridkin, Clin Infect Diseases 2001;32:111