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. 

4. 

5. 

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 Urina coletada por punção suprapúbica colhe-se por punção vesical; muito usada para pesquisa de infecções por anaeróbios 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

AutoSCAN - 4

Walkaway 40 e 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®)

laminocultivo

Polimixina B Aztreonam Anfotericina B + VANCOMICINA

Azida + Polimixina B Aztreonam Anfotericina B

Azida + Polimixina B Aztreonam Anfotericina B + VANCOMICINA

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
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cIAI Definition

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Abscess Formation

Peritonitis

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

Primary Secondary (Monomicrobial) (Polymicrobial)

Microbiology of Peritonitis

B. fragilis group E. coli E. coli Klebsiella spp. Streptococcus spp. Clostridium spp. Klebsiella spp. Enterococcus spp. Other gram-negativeStreptococcus spp. bacilli Enterococcus spp. S. anginosus Pseudomonas spp.
E. coli

(Polymicrobial) Enterococci Pseudomonas S. epidermidis Candida

Tertiary

S. epidermidis B. fragilis

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©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.

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Intra-abdominal Infections
Surgical procedure Inappropriate Inappropriate Appropriate Appropriate Antibiotics Inappropriate Appropriate Inappropriate Appropriate Mortality (%) 100 90 71 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 Infe ion ct
1% 3 2% 2 3% 8

2% 7
Pe rfora d a ndix te ppe Colon G stroduode a num O r the

425 patients in 20 clinics 6,521 patient days 54 (13%) received inappropriate initial parenteral therapy

Clinical success achieved in 322 patients (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, 41.169.3) 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 Michigan, 1997 New Jersey, 1997 New York, 1998 Illinois, 1999 Minnesota, 2000 Nevada, 2000

Site Peritonitis Blood Blood Endocarditis Bone Liver

PD/HD* Chronic PD Recent PD Chronic HD Chronic HD Chronic HD -----

PD=peritoneal dialysis , HD=hemodialysis

Fridkin, Clin Infect Diseases 2001;32:111