Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Reducing Variability in Practice through a Collaborative Telemedicine Initiative

OBJECTIVE

 This study aimed to assess the viability of implementing a tele-educational training program in neurocritical care for newborns diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia (TH), with the goal of reducing practice variation.

STUDY DESIGN

 Prospective study including newborns with HIE treated with TH from 12 neonatal intensive care units in Brazil conducted from February 2021 to February 2022. An educational intervention consisting of 12 biweekly, 1-hour, live videoconferences was implemented during a 6-month period in all centers. Half of the centers had the assistance of a remote neuromonitoring team. The primary outcome was the rate of deviations from TH protocol, and it was evaluated during a 3-month period before and after the intervention. Logistic regression via generalized estimating equations was performed to compare the primary and secondary outcomes. Protocol deviations were defined as practices not in compliance with the TH protocol provided. A subanalysis evaluated the differences in protocol deviations and clinical variables between centers with and without neuromonitoring.

RESULTS

 Sixty-six (39.5%) newborns with HIE were treated with TH during the preintervention period, 69 (41.3%) during the intervention period and 32 (19.1%) after intervention. There was not a significant reduction in protocol deviations between the pre- and postintervention periods (37.8 vs. 25%, p = 0.23); however, a decrease in the rates of missing Sarnat examinations within 6 hours after birth was seen between the preintervention (n = 5, 7.6%) and postintervention (n = 2, 6.3%) periods (adjusted odds ratio [aOR]: 0.36 [0.25-0.52], p < 0.001). Centers with remote neuromonitoring support had significantly lower rates of seizures (27.6 vs. 57.5%; aOR: 0.26 [0.12-0.55], p < 0.001) and significant less seizure medication (27.6 vs. 68.7%; aOR: 0.17 [0.07-0.4], p < 0.001).

CONCLUSION

 This study shows that implementing a tele-educational program in neonatal neurocritical care is feasible and may decrease variability in the delivery of care to patients with HIE treated with TH.

KEY POINTS

· Neurocritical care strategies vary widely in low- and middle-income countries.. · Heterogeneity of care may lead to suboptimal efficacy of neuroprotective strategies.. · Tele-education and international collaboration can decrease the variability of neurocritical care provided to infants with HIE..

High prevalence of clindamycin resistance in Staphylococcus aureus blood culture isolates in São Paulo, Brazil

BACKGROUND:

Clindamycin has become an important antimicrobial option for the treatment of Staphylococcus aureus. However, little is known about the current patterns of clindamycin-susceptibility in S. aureus invasive isolates, both in our country and in other developing countries in the world.

AIMS:

The aim of this study was to determine the prevalence of constitutive and inducible clindamycin resistance in methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) blood culture isolates in São Paulo, Brazil.

MATERIALS AND METHODS:

From July 2011 to June 2012, all S. aureus isolates from blood cultures collected at our hospital were included in the study. Antimicrobial susceptibility testing was performed according to recommendations of the Clinical and Laboratory Standards Institute.

RESULTS:

Total prevalence of clindamycin resistance was 68%, including 7.2% with inducible resistance. In MRSA resistance rate was 90.8% whereas in MSSA the rate was 32.7%.

CONCLUSIONS:

Our high prevalence of clindamycin resistance highlights the importance of performing D-test in a routine base, as well of maintaining continued surveillance for the prevalence of clindamycin resistance.

Enterococcus spp. and S. aureus colonization in neutropenic febrile children with cancer

INTRODUCTION

Febrile neutropenia is one of the most serious treatment-related complications in cancer patients. Susceptible to rapidly progressing infections, which result in prolonged hospitalization and use of broad-spectrum antibiotics, neutropenic patients are subject to colonization by multiresistant agents, which enhances the risk of infections.

METHODS

In this study we included samples collected with nasal, oropharyngeal and anal swabs from hospitalized children with febrile neutropenia following chemotherapy, between March 2014 and 2015, aiming to elucidate colonization by S. aureus and Enterococcus spp., as well as their resistance profile.

RESULTS

S. aureus was found in 22% of the patients and 14% of the events. Methicillin-resistant S. aureus colonized 13.6% of patients. Including anal swabs in the screening increased the identification of colonized patients by 20%. Enterococcus spp. was found in 27% of patients and 17% of episodes. Enterococcal isolates resistant to vancomycin, accounting for 25% of the total, were not isolated in anal swabs at any time, with the oropharyngeal site being much more important. The rate of infection by Enterococcus spp. was 4.5% of all patients and 16% among the colonized patients.

CONCLUSION

Especially in this population, colonization studies including more sites can yield a higher chance of positive results. Establishing the colonization profile in febrile neutropenic children following chemotherapy may help to institute an empirical antibiotic treatment aimed at antibiotic adequacy and lower induction of resistance, thereby decreasing the risk of an unfavorable clinical outcome.

Accuracy of a vancomycin brain heart infusion screening plate for the screening of Staphylococcus aureus isolates with increased vancomycin minimum inhibitory concentrations

Vancomycin susceptibility was determined in 125 S. aureus isolates by disk diffusion, microdilution, Etest and vancomycin brain heart infusion (BHI) plate. A 2.0 mg/L vancomycin BHI was highly sensitive (100% and 91% compared to Etest and microdilution) for detecting a MIC≥2 mg/L, and could be used as a simple and affordable screening test.

Vancomycin minimum inhibitory concentrations and lethality in Staphylococcus aureus bacteremia

BACKGROUND

After the dissemination of penicillin and oxacillin resistance in Staphylococcus aureus, vancomycin-intermediate and vancomycin resistant isolates have been reported. Even between isolates with minimum inhibitory concentrations (MICs) within the susceptible range, some authors have demonstrated that higher MICs correlate with higher lethality.

METHODS

To test this hypothesis in our setting, we compared vancomycin MICs evaluated by two methods and clinical outcomes in hospitalized patients with S. aureus bacteremia.

RESULTS

We compared lethality in patients infected with isolates that had MICs under or over 2 mg/L. Among patients infected with isolates that had microdilution MICs <2 mg/L, the lethality was 25%; among patients infected with strains that had microdilution MICs ≥2 mg/L, 33% died. Among patients infected with isolates that had Etest MICs <2 mg/L, 23% died; in comparison, patients infected with strains that had Etest MICs ≥2 mg/L had a lethality of 44%.

CONCLUSION

Our results showed a slight tendency of higher lethality when higher MICs were present. However, this difference did not reach statistical significance, possibly due to the relatively small number of patients included in the study. Future prospective studies are needed to further evaluate this correlation and to help clinicians guide antimicrobial therapy.

Mupirocin susceptibility in Staphylococcus aureus nasal and oropharyngeal isolates from Brazilian children

Mupirocin is a topical antimicrobial agent and part of most Staphylococcus aureus decolonization regimens. Thus, knowing the mupirocin susceptibility profile of colonizing S. aureus is paramount for the proper use of this agent. We evaluated S. aureus isolates from 128 colonized children, using disc diffusion (with 5 mcg and 200 mcg discs) and Etest. None were low-level or high-level mupirocin-resistant. Since mupirocin will be increasingly needed for the control of S. aureus infection, continuous monitoring of its susceptibility status is necessary.

Comparison of five methods for oxacillin susceptibility testing of Staphylococcus aureus isolates from cystic fibrosis patients

Methicillin-resistant Staphylococcus aureus (MRSA) are now a worldwide problem. Cystic fibrosis (CF) patients are commonly colonized and infected by MRSA. Accurate oxacillin susceptibility testing is mandatory for the adequate management of these patients. We performed a comparison of the accuracy of different tests in CF isolates, including methicillin-susceptible S. aureus and MRSA with different SCCmec types, and using the mecA gene as the gold-standard. The sensitivity and specificity of oxacillin disc, Etest, and oxacillin agar screening plate were 100%. Sensitivity of the cefoxitin disc was 85% and specificity was 100%. For clinically relevant isolates, laboratories may consider the use of a combination of two phenotypic methods.

Detection of methicillin resistance in Staphylococcus aureus isolated from pediatric patients: is the cefoxitin disk diffusion test accurate enough?

We evaluated the performance of several methods for the detection of methicillin resistance in Staphylococcus aureus using 101 clinical S. aureus isolates from pediatric patients in a tertiary hospital in Brazil; 50 isolates were mecA-positive and 51 were mecA-negative. The Etest and oxacillin agar screening plates were 100% sensitive and specific for mecA presence. Oxacillin and cefoxitin disks gave sensitivities of 96 and 92%, respectively, and 98% specificity. Alterations of CLSI cefoxitin breakpoints increased sensitivity to 98%, without decreasing specificity. Our results highlight the importance of a continuing evaluation of the recommended microbiological methods by different laboratories and in different settings. If necessary, laboratories should use a second test before reporting a strain as susceptible, especially when testing strains isolated from invasive or serious infections. With the new (2007) CLSI breakpoints, the cefoxitin-disk test appears to be a good option for the detection of methicillin resistance in S. aureus.