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Publico-10785.pdf: 1454333 bytes, checksum: 1773b999177d308849498e6df3d6f921 (MD5) === Objetivo: O estudo procurou determinar os fatores de risco independentes para o surgimento de pneumonia hospitalar por Pseudomonas aeruginosa resistente a carbapenem em uma UTI clinico-cirurgica. Foram tambem estudados os fatores relacionados a evolucao desfavoravel nesses episodios de pneumonia nosocomial tratados com polimixina B e os fatores de risco e evolucao dos episodios causados por cepas portadoras da metalo-ƒÀ-lactamase SPM-1. Metodo: O estudo foi realizado no Hospital Sao Paulo, hospital terciario de ensino da Universidade Federal de Sao Paulo. No estudo de fatores de risco para pneumonia hospitalar por Pseudomonas aeruginosa, foram avaliados pacientes internados na UTI da Anestesiologia, no periodo de 2002 a 2005, atraves de um estudo tipo caso-casocontrole. Pacientes com episodios de pneumonia com cepas resistentes a imipenem e pacientes com pneumonia por cepas sensiveis a imipenem foram designados como casos resistentes (estudos Ia) e sensiveis (estudo Ib), respectivamente. Os controles foram pacientes da mesma unidade, internados no mesmo periodo. O segundo estudo, sobre evolucao clinica em pacientes tratados com polimixina B, analisou pacientes internados em UTIs do hospital, no periodo de 1997 a 2005, atraves de um estudo caso-controle aninhado dentro dessa coorte. Os casos foram pacientes com evolucao desfavoravel, e os controles foram pacientes com evolucao favoravel. O terceiro estudo utilizou tambem a metodologia caso-controle aninhado nessa mesma coorte de pacientes. Os casos eram pacientes com pneumonia por cepas de Pseudomonas aeruginosa resistente a carbapenem e portadora da metaloenzima SPM-1, e os controles eram pacientes com cepas sem a presenca dessa metaloenzima. Resultados: Nos estudos Ia e Ib, 58 casos resistentes, 47 casos sensiveis e 237 controles foram avaliados. Os fatores independentemente relacionados ao surgimento de pneumonia no estudo Ia foram: tempo de hospitalizacao(OR 1,19 IC95%: 1,12-1,26, p< 0,001); escore APACHE II( OR 1,11 IC95%: 1,01-1,22, p=0,03); sexo masculino(OR 8,01 IC95%: 1,66-38,51, p=0,009); uso de hemodialise(OR 6,85 IC95%: 1,33-35,2, p=0,02); uso de corticoide (OR 13,18 IC95%:3,80-45,64,p<0,001); uso de piperacilina-tazobactam(OR 14,31 IC95%:1,02- 200,16, p=0,04) e uso de cefalosporinas de 3a geracao(OR 7,45 IC95%: 1,80-30,86, p=0,006). Os fatores independentemente relacionados ao surgimento de pneumonia nosocomial por Pseudomonas aeruginosa sensivel a carbapenem ( estudo Ib) foram: tempo de internacao na UTI( OR 1,02 IC95%: 1,01-1,04, p=0,004) e uso de corticoide(OR 12,32 IC95%: 5,81-26,10, p< 0,001). O unico fator independentemente relacionado ao surgimento de pneumonia nos dois estudos foi o uso de corticoide. Portanto, a razao de chances real do uso de corticoide no surgimento de episodios de pneumonia por Pseudomonas aeruginosa resistente a carbapenem foi de 1,06 (valor da OR do estudo Ia dividido pela OR do estudo Ib). Setenta e quatro pacientes com pneumonia hospitalar tratados com polimixina B foram avaliados quanto a evolucao. A mortalidade atribuivel a pneumonia causada por Pseudomonas aeruginosa resistente a carbapenem foi de 29,8%. Os fatores relacionados a evolucao desfavoravel nesses episodios de pneumonia foram: presenca de choque septico (OR 4,81 IC95%: 1,42-16,25, p=0,01) e presenca de sindrome do desconforto respiratorio agudo ( OR 11,29 IC95%: 2,64-48,22, p=0,001). Vinte e nove desses 74 pacientes foram analisados quanto a presenca de metalo-ƒÀ- lactamases. Apenas cinco pacientes apresentavam cepas produtoras de SPM-1. A presenca de SPM-1 nao teve impacto na evolucao desses episodios (p=0,67). O tratamento combinado com polimixina B e imipenem, em pacientes com Pseudomonas aeruginosa sem a presenca da SPM-1, nao teve impacto positivo na evolucao clinica (p=0,67), nem na sobrevida desses pacientes. Nenhuma variavel se mostrou independentemente associada ao surgimento de episodios de pneumonia por cepas portadoras de SPM-1. Apenas o sexo feminino apresentou uma tendencia na analise univariada (OR 9,71; IC95%: 0,92-103,04; p=0,05). Tambem nao houve diferenca nas variaveis relacionadas a evolucao clinica entre os pacientes com cepas de Pseudomonas aeruginosa produtora de SPM-1. Conclusoes: Em nosso estudo, o uso de corticoide foi a unica variavel independentemente relacionada ao surgimento de pneumonia nosocomial por Pseudomonas aeruginosa resistente a carbapenem. A presenca de choque septico e da sindrome do desconforto respiratorio agudo foram fatores relacionados a evolucao desfavoravel nesses episodios. Nao encontramos variaveis relacionadas a presenca da metalo-enzima SPM-1. A presenca dessa enzima nao teve impacto na evolucao clinica nesse tipo de infeccao. === Objective: The study sought to determine the risk factors independently associated to nosocomial pneumonia due to carbapenem-resistant Pseudomonas aeruginosa in a medical-surgical ICU. The factors associated to unfavorable outcome on those patients who were treated with polymyxin B were evaluated as well as the outcome in episodes caused by strains harboring the metallo-ƒÀ- lactamase SPM-1. Methods: The study was undertaken at Hospital Sao Paulo, a university-affiliated hospital. We evaluated patients admitted to Anestesiology ICU through a case-case-control study, between 2002 and 2005. Patients with nosocomial pneumonia caused by resistant and susceptible strains were designed as resistant cases (study 1) and susceptible cases ( study 2), respectively. The controls were patients admitted to the same unit in the same period. The second study addressed the outcome of patients admitted to ICUs with nosocomial pneumonia due to carbapenem-resistant Pseudomonas aeruginosa who were treated with polymyxin B. Patients admitted to the ICUs between 1997-2005 were enrolled for the study. A nested case-control was undertaken. Cases were patients with unfavorable outcome and controls were patients with favorable outcome. The third study was undertaken through a nested case-control methodology as well. Cases were patients with nosocomial pneumonia caused by carbapenem-resistant Pseudomonas aeruginosa harboring the metalloenzyme SPM-1, and controls were patients without SPM-1. Results: 58 resistant cases, 47 susceptible cases and 237 controls were evaluated.The risk factors independently associated to nosocomial pneumonia in study 1 were: duration of hospitalization( OR 1,19 CI95%: 1,12-1,26, p< 0,001); APACHE II score(OR 1,11 CI95%: 1,01-1,22, p=0,03); male sex(OR 8,01 CI95%: 1,66-38,51, p=0,009); receipt of hemodyalisis(OR 6,85 CI95%:1,33-35,2, p=0,02); receipt of corticosteroid (OR 13,18 CI95%:3,80-45,64, p< 0,001); receipt of piperacillin-tazobactam ( OR 14,31 CI95%:1,02-200,16, p=0,04) and receipt of 3rd-generation cephalosporins( OR 7,45 CI95%: 1,80-30,86, p=0,006). The risk factors independently associated to nosocomial pneumonia caused by carbapenem-susceptible Pseudomonas aeruginosa( study 2) were: duration of ICU stay(OR 1,02 CI95%: 1,01-1,04, p= 0,004) and receipt of corticosteroid( OR 12,32 CI95%: 5,81-26,10, p< 0,001). The sole independently risk factor that was present in the two studies was the corticosteroid use. Thus, the real OR for the variable found in the study was 1,06 ( OR of study 1 divided by OR of study 2). 74 patients with nosocomial pneumonia treated with polymyxin B were evaluated. The factors associated to a unfavorable outcome were: presence of septic shock(OR 4,81 CI95%:1,42-16,25, p= 0,01) and presence of acute respiratory distress syndrome( OR 11,29 CI95%:2,64-48,22, p=0,001). 29 strains were evaluated concerning the presence of metallo-â- lactamases. Only five strains were positive for SPM-1. The presence of SPM-1 didn’t have impact on the outcome of these episodes (p=0,67). The combined treatment with polymyxin B and imipenem in patients without SPM-1 did not have positive impact on the outcome (p=0,67). None variable was independently associated to nosocomial pneumonia caused by SPM-1-positive strains. Only female sex showed a trend in univariate analysis (OR 9,71; CI95%: 0,92-103,04; p=0,05). There was no difference in outcome in episodes caused by Pseudomonas aeruginosa strains harboring SPM-1 compared to strains without SPM-1. Conclusions: The receipt of corticosteroid was the sole independently risk factor associated to nosocomial pneumonia caused by carbapenem-resistant Pseudomonas aeruginosa. The presence of septic shock and acute respiratory distress syndrome (ARDS) were the only factors related to unfavorable outcome. None variable was associated to the presence of metallo-â-lactamase SPM-1. In addition, the presence of this enzyme did not have impact on clinical outcome. === TEDE === BV UNIFESP: Teses e dissertações
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