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OBJECTIVES: To identify the attributed mortality rate of bloodstream hospital infection by Staphylococcus aureus resistant to methicillin (MRSA) and its effect on length of hospital stay. DESIGN: Case-control study. SETTING: Hospital São Paulo da Universidade Federal de São Paulo, a 660-bed, tertiary-care teaching hospital in São Paulo, Brazil. PATIENTS: Seventy one adults patients with hospital-acquired MRSA bacteremia diagnosed between January 1, 1991, and September 30, 1992, and 71 MRSA-free controls were matched by the following criteria: age, sex, underlying disease, surgical procedure, same risk time and admission date. RESULTS: The incidence of patients with hospital sepsis by MRSA accounted for 73.22% of the patients with hospital bloodstream infection by Staphylococcus aureus. The mortality rate of the cases was 56.33 (40/71) and 11.26 (8/71) of the controls. The attributable mortality rate was 45.07% (OR = 17.0; IC 95% = 3.58-202.26; p = 0.000001). The length of hospital stay median time was of 32.55 days for the cases and 29.75 for the controls (p = 0.32). CONCLUSION: A high level of sepsis by MRSA was observed in all the Staphylococcus aureus bacteremia. The bloodstream hospital infection by MRSA itself does provide a high level of mortality independently from the patients base disease, without however, increasing their hospital length of stay.

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Objetivo. Determinar a letalidade atribuída à infecçao hospitalar da corrente sangüínea (IHCS) por Staphylococcus aureus resistente à oxacilina (SARO) e seu efeito sobre o tempo de hospitalizaçao. Casuística e Métodos. Estudo tipo caso controle envolvendo 71 pares de pacientes adultos internados em hospital de ensino no período de janeiro de 1991 a setembro de 1992, pareados para os seguintes critérios: idade, sexo, doença de base, procedimento cirúrgico, mesmo período de risco e data de admissao. Resultados. A incidência de pacientes com sepses hospitalar por SARO representou 73,22 por cento entre aqueles que desenvolveram bacteremia por Staphylococcus aureus. A taxa de letalidade dos casos foi de 56,33 por cento (40/71). Oito controles morreram, o que corresponde à taxa de letalidade de 11,26 por cento (8/71). A letalidade atribuída à infecçao hospitalar da corrente sangüínea por SARO foi de 45,07 por cento (OR=17,0; IC 95 por cento=3,58 - 202,26; p=0,000001). Os casos permaneceram, em média, 32,5 dias internados no hospital, enquanto que os controles 29,7 dias (p=0,32). Conclusoes. Observou-se elevada proporçao de sepses por SARO entre todas as bacteremias por Staphylococcus aureus. A IHCS por SARO acarreta, por si só, uma alta taxa de letalidade, independentemente da doença que causou a internaçao, sem contudo, aumentar o tempo de permanência hospitalar.

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BACKGROUND: Hemodialysis is a common but potentially hazardous procedure. From February 17 to 20, 1996, 116 of 130 patients (89 percent) at a dialysis center (dialysis center A) in Caruaru, Brazil, had visual disturbances, nausea, and vomiting associated with hemodialysis. By March 24, 26 of the patients had died of acute liver failure. METHODS: A case patient was defined as any patient undergoing dialysis at dialysis center A or Caruaru's other dialysis center (dialysis center B) during February 1996 who had acute liver failure. To determine the risk factors for and the source of the outbreak, we conducted a cohort study of the 130 patients at dialysis center A and the 47 patients at dialysis center B, reviewed the centers' water supplies, and collected water, patients' serum, and postmortem liver tissue for microcystin assays. RESULTS: One hundred one patients (all at dialysis center A) met the case definition, and 50 died. Affected patients who died were older than those who survived (median age, 47 vs. 35 years, P<0.001). Furthermore, all 17 patients undergoing dialysis on the Tuesday-, Thursday-, and Saturday-night schedule became ill, and 13 of them (76 percent) died. Both centers received water from a nearby reservoir. However, the water supplied to dialysis center B was treated, filtered, and chlorinated, whereas the water supplied to dialysis center A was not. Microcystins produced by cyanobacteria were detected in water from the reservoir and from dialysis center A and in serum and liver tissue of case patients. CONCLUSIONS: Water used for hemodialysis can contain toxic materials, and its quality should therefore be carefully monitored.

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OBJECTIVE: To investigate an outbreak of surgical site infections (SSI) in a vascular surgery unit. SETTING: A 60-bed unit of vascular surgery, where surgeons performed an average of 30 operations per month at the Hospital do Servidor Público Estadual, a 1,000-bed tertiary care hospital in São Paulo, Brazil. DESIGN: We included in the case group nine patients who had limb amputations or arterial reconstructions, October 16 through 23, 1992. We included in the control group patients whose operations were performed within 30 days of the outbreak period. Control patients were matched for sex and type of operation. RESULTS: Six of 9 case patients experienced SSI, as compared with 3 of 18 control patients (P = .026) and 28 of 244 patients in the pre-epidemic period (P = .0002). Risk factors were identical for case and control groups. Factors assessed were American Society of Anesthesiology (ASA) status, duration of surgery, wound class, emergency status, remote site infections, preoperative length of stay, use of prophylactic antibiotics, and underlying diseases. Possible common sources also were analyzed. No differences were observed concerning hair removal, preoperative shower, wound dressing, and surgical team present in the operating room. During the outbreak period, the operating room was not provided with povidone-iodine, used in our hospital for skin cleansing and handscrubbing. Surgeons from all departments, including vascular surgery, used 2% iodine with 70% alcohol for skin cleansing. Surgeons from other departments used this iodine solution for handscrubbing, but the vascular surgeons used plain soap for handscrubbing. No increases in SSI rates were reported in other services. Comparison of case and control groups for handscrubbing was statistically significant (P < .00001). After reinstitution of povidone-iodine, only one SSI was diagnosed in 13 vascular procedures. CONCLUSIONS: Although we could not demonstrate definitely that scrubbing with plain soap was related to SSI, we found a strong suggestion of this association.

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Since 1985, the Hospital Säo Paulo has a nosocomial infection (NI) control program. The NI control commitee acts in all sectors of the hospital, performing active epidemiologic surveillance. During a period of 58 months (March, 1985 to december, 1989) 8, 268 NI were identified in the 86,849 hospiytalized patients, representing a rate of 9.5 por cento. The most prevalent NI was that of the respiratory tract 21.8 per cent (1,803) followed by: surgical wound 16.7 per cent (1,383), urinary tract 12.2 per cent (1,011), bloodstream 11.2 per cents (924) and other sites 38 per cent (3,147). There was a significant fall in NI rate for each site, mainly respiratory and urinary tract. The patients admitted to the General Intensive Care Unit represented 11 per cent (897) of all detected NI. Some of most frequently isolated agents were: S. aureus 19 per cent (915), E. coli 14 per cent (673), Klebsiella spp 12.4 per cent (598) and pseudomonas spp 12.2 per cent (587)

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