OBJECTIVE: To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy. METHODS: This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h. RESULTS: All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups. CONCLUSIONS: Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.

The objective of the study was to determine the effect of switching from an open (glass or semi-rigid plastic) infusion container to a closed, fully collapsible plastic infusion container (Viaflex®) on rate and time to onset of central lineassociated bloodstream infections (CLABSI). An open-label, prospective cohort, active healthcare-associated infection surveillance, sequential study was conducted in three intensive care units in Brazil. The CLABSI rate using open infusion containers was compared to the rate using a closed infusion container. Probability of acquiring CLABSI was assessed over time and compared between open and closed infusion container periods; three-day intervals were examined. A total of 1125 adult ICU patients were enrolled. CLABSI rate was significantly higher during the open compared with the closed infusion container period (6.5 versus 3.2 CLABSI/1000 CL days; RR=0.49, 95%CI=0.26- 0.95, p=0.031). During the closed infusion container period, the probability of acquiring a CLABSI remained relatively constant along the time of central line use (0.8% Days 2-4 to 0.7% Days 11-13) but increased in the open infusion container period (1.5% Days 2-4 to 2.3% Days 11-13). Combined across all time intervals, the chance of a patient acquiring a CLABSI was significantly lower (55%) in the closed infusion container period (Cox proportional hazard ratio 0.45, p= 0.019). CLABSIs can be reduced with the use of full barrier precautions, education, and performance feedback. Our results show that switching from an open to a closed infusion container may further reduce CLABSI rate as well as delay the onset of CLABSIs. Closed infusion containers significantly reduced CLABSI rate and the probability of acquiring CLABSI.

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8% or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7% of cases, resistant to ceftazidime in 79.3% of cases, and resistant to piperacillin-tazobactam in 85.7% of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3% of cases, resistant to ceftazidime in 75.5% of cases, and resistant to imipenem in 27.7% of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3% (RR 1.79, P = 0.0149) for VAP, 27.8% (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7% (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an active infection control program comprising surveillance of DAIs and infection prevention guidelines. These actions should become a priority in every country.

OBJETIVOS: Determinar las tasas de infección asociadas a aparatos (IAA), los perfiles microbiológicos, la resistencia bacteriana, la estancia hospitalaria adicional y la mortalidad atribuible en las unidades de cuidados intensivos (UCI) de tres hospitales brasileños miembros de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales (INICC). MÉTODOS: Se realizó una vigilancia prospectiva de cohorte de las IAA en cinco UCI de tres hospitales urbanos de Brasil, según las definiciones del Sistema Nacional de Vigilancia de Infecciones Nosocomiales de los Centros para el Control y la Prevención de Enfermedades (CDC-NNIS) de los Estados Unidos de América. RESULTADOS: Entre abril de 2003 y febrero de 2006 se hospitalizaron 1 031 pacientes en las cinco UCI estudiadas, con un total de 10 293 días en los que se adquirieron 307 IAA, para una tasa de 29,8% (29,8 IAA por 1 000 días-UCI). Las tasas fueron: de 20,9 casos por 1 000 días-ventilador en neumonía asociada a respiradores (NAR); de 9,1 por 1 000 días-catéter en infecciones circulatorias asociadas con cateterismo venoso central (IC-CVC); y de 9,6 por 1 000 días-catéter en infecciones urinarias asociadas con el uso de catéteres (IUAC). De las IAA causadas por Staphylococcus aureus, 95% se debieron a cepas resistentes a la meticilina. De las infecciones causadas por Enterobacteriaceae, 96,7% fueron resistentes a la ceftriaxona, 79,3% a la ceftazidima y 85,7% a la combinación piperacilina-tazobactam. De las IAA causadas por Pseudomonas aeruginosa, 71,3% resultaron resistentes a la ciprofloxacina, 75,5% a la ceftazidima y 27,7% al imipenem. Los pacientes con IAA en las UCI estudiadas presentaron tasas de mortalidad adicional de 15,3% (riesgo relativo [RR] = 1,79; P = 0,0149) por NAR, 27,8% (RR = 2,44; P = 0,0004) por IC-CVC y 10,7% (RR = 1,56; P = 0,2875) por IUAC. CONCLUSIONES: Las tasas de IAA en las UCI de los hospitales brasileños estudiados fueron elevadas. Se puede mejorar la seguridad de los pacientes mediante la implementación de un programa de control activo de las infecciones, que contemple la vigilancia de las IAA y directivas para la prevención de las infecciones. Estas acciones deben ser una prioridad en todos los países.

CD4+ and CD8+ T lymphocyte counts, naive and memory/effector CD4+ T subpopulations, and the expression of CD38 on CD8+ T lymphocytes were evaluated in four groups: AIDS patients with tuberculosis (HIV/TB, n=14), HIV-1 infected patients (HIV, n=10), HIV-1 negative patients with tuberculosis (TB, n=20) and healthy controls (CTL, n=17). TB and HIV had fewer CD4+ T cells than CTL, with the lowest values observed in TB/HIV (p<0.001). No difference between groups was observed in the percentage of naive and memory/effector subpopulations in CD4+ T lymphocytes. TB (355 cells/mL) and HIV (517 cells/mL) had diverging effects on CD8+ T cell counts, with a marked depletion observed in HIV/TB (196 cells/mL). TB and HIV up-regulated CD38 expression on CD8+ T cells, a finding also present in TB/HIV. While the decrease of CD4+ T cell counts in HIV/TB may be attributed to HIV and tuberculosis, the decrease of CD8+ T cell counts is likely to be due to tuberculosis.