The hospital environment is a potential source of exposure to pathogens such as bacteria, fungi and parasites that can cause infections in patients with cancer including transplanted hematopoietic precursors. To mitigate this risk, the design, construction and location elements of the patient care area must be taken into account. Recommendations are given to provide safe environments, including aspects related to characteristics and use of a protected environment, the definition of critical processes, clinical teams dedicated to the care of patients, suggestions of areas to be monitored, the microbiological quality of air and water.

Resumen El ambiente hospitalario es una fuente potencial de exposición a patógenos como bacterias, hongos y parásitos, que pueden provocar infecciones en pacientes con cáncer incluyendo receptores de trasplante de precursores hematopoyéticos. Para aminorar este riesgo, se deben tener en cuenta los elementos de diseño, construcción y emplazamiento del área de atención de pacientes. Se entregan recomendaciones para proveer ambientes seguros, incluyendo características y uso de ambiente protegido, la definición de procesos críticos, equipos clínicos destinados a la atención de pacientes, sugerencias de ámbitos a supervisar y aspectos relativos a la calidad microbiológica del aire y agua.

ABSTRACT Introduction: Patients submitted to hematopoietic stem cell transplantation have an increased risk of Clostridium difficile infection and multiple risk factors have been identi- fied. Published reports have indicated an incidence from 9% to 30% of transplant patients however to date there is no information about infection in these patients in Chile. Methods: A retrospective analysis was performed of patients who developed C. difficile infection after hematopoietic stem cell transplantations from 2000 to 2013. Statistical analysis used the Statistical Package for the Social Sciences software. Results: Two hundred and fifty patients were studied (mean age: 39 years; range: 17-69), with 147 (59%) receiving allogeneic transplants and 103 (41%) receiving autologous trans- plants. One hundred and ninety-two (77%) patients had diarrhea, with 25 (10%) cases of C. difficile infection being confirmed. Twenty infected patients had undergone allogeneic trans- plants, of which ten had acute lymphoblastic leukemia, three had acute myeloid leukemia and seven had other diseases (myelodysplastic syndrome, chronic myeloid leukemia, severe aplastic anemia). In the autologous transplant group, five patients had C. difficile infection; two had multiple myeloma, one had amyloidosis, one had acute myeloid leukemia and one had germinal carcinoma. The overall incidence of C. difficile infection was 4% within the first week, 6.4% in the first month and 10% in one year, with no difference in overall survival between infected and non-infected groups (72.0% vs. 67.6%, respectively; p-value = 0.56). Patients infected after allogeneic transplants had a slower time to neutrophil engraftment compared to non-infected patients (17.5 vs. 14.9 days, respectively; p-value = 0.008). In the autologous transplant group there was no significant difference in the neutrophil engraftment time between infected and non-infected patients (12.5 days vs. 11.8 days, respectively; p-value = 0.71). In the allogeneic transplant group, the median time to acute graft-versus- host disease was similar between the two groups (p-value = 0.08), as was the incidence of grades 1-4 acute graft-versus-host disease (40% vs. 48%; p-value >0.05). Conclusion: The incidence of C. difficile infection after hematopoietic stem cell transplantation was low, with a significant number of cases occurring shortly after transplantation. Allogeneic transplants had a three-time higher risk of infection compared to autologous transplants, but this was not associated with increased mortality, decreased overall survival or higher risk of acute graft-versus-host disease.

Visual assessment of surfaces may not be enough to document the level of cleanliness in the hospital setting. It is necessary to introduce quantitative methods to document the results of this practice.Objective:To evaluate the efficacy of hospital terminal cleaning procedures, using an adenosine triphosphate (ATP) bioluminescence method in a teaching hospital.Method:During 2008 we conducted an evaluation using ATP bioluminescence LIGHTNING MVP™ (Arquimed) of external and internal housekeeping service. After conducting an initial evaluation we implemented education of cleaning practices and finally we did a post intervention evaluation. Using chi-square method we compared prior versus after cleaning, quality of cleaning performed by external versus internal personnel, single versus double terminal cleaning procedures and prior versus after intervention. A finding of three RLU or less was considered a clean surface.Results:We performed 198 evaluations in 33 patient units and nine OR. Internal personnel accomplished 25.37% of clean surfaces before and 80% after the education intervention (p = 0.01). In contrast, external personnel obtained 68.8% before and 73.33% after intervention (p = 0.3).Conclusions:This study suggests that visual assessment is not enough to ensure quality of the process and it is necessary to document the level of cleanliness by quantitative methods.

Objectives: To report the results of 13 years worth of epidemiologic surveillance of ventilator-associated pneumonia (VAP) following heart surgery and the main interventions applied in order to reduce VAP incidence. Methods: This is a retrospective and descriptive study of active epidemiologic surveillance of VAP. National diagnostic criteria were used. Interventions associated with a decrease in VAlP incidence in adults who underwent heart surgery are described. Results: A significant and sustained reduction was observed in the rate of VAP; being 56.7 per 1,000 ventilator-days in 1998 vs 4.7 per 1,000 ventilator-days in 2010 (p < 0.001). The strongest reduction was observed following 2003 (34.4 to 14.8 per 1,000 ventilator-days in 2004, p < 0.001). The interventions with greatest impact were the implementation of an early-weaning protocol, the introduction of trained nurses to perform the mechanical ventilator equipment management and the routine use of alcohol-based hand rubs. Conclusion: Epidemiologic surveillance associated with the establishment of a multifactorial intervention program applied in collaboration with the attending team, have demonstrated a significant reduction of VAP incidence after heart surgery.

Objetivos: Comunicar los resultados de 13 años de vigilancia epidemiológica de neumonía asociada a ventilación mecánica (NAVM) post cirugía cardíaca y las principales intervenciones implementadas para reducir su incidencia. Metodología: Estudio retrospectivo, descriptivo, de vigilancia epidemiológica activa de NAVM utilizando los criterios del ]Ministerio de Salud (MINSAL) y de las intervenciones asociadas con una disminución de la tasa de NAVM en adultos operados de cirugía cardíaca. Resultados: Se observó una reducción significativa y sostenida de la tasa de NAVM, siendo 56,7 por 1.000 días de ventilación mecánica (VM) en 1998 vs 4,7 por 1.000 días de VM en 2010 (p < 0,001). La mayor reducción fue observada a partir de 2003 (desde 34,4 a 14,8 por 1.000 días de VM en 2004, p < 0,001). Las intervenciones con mayor impacto fueron la implementación de un protocolo de extubación precoz, la incorporación de enfermeras capacitadas en el manejo de los equipos de VM y el uso rutinario de alcohol gel. Conclusión: La vigilancia epidemiológica asociada a un programa de intervención multifactorial aplicado en conjunto con el equipo tratante permitió reducir significativamente la incidencia de NAVM post cirugía cardíaca.

Invasive candidiasis (IC) epidemiology has changed in critically ill patients and limited data are available in Chile. Objective: To describe the epidemiological and microbiological profile of IC in critically ill patients. Methods: Observational prospective study conducted from October 2001 to August 2003 in critically ill adults with suspected or confirmed IC. Results: 53 patients met criteria for IC, finding 18 (33.9%) candidemias, 22 (41.5%) disseminated IC, and 13 (24.5%) local IC. We identified 8 (44.4%) C. albicans and 10 (55.6%) non-albicans Candida in candidemias. C. tropicalis was the predominant non-albicans species (27.7%). An 88.8 % of Candidas sp recovered in candidemias were fluconazole susceptible. Overall hospital mortality was 24.5%. Mortality in candidemia was significantly lower than in disseminated IC (16.6 vs 31.8%, p = 0.02). Conclusions: A higher proportion of non-albicans Candida was observed in candidemias from critically ill patients. However, most of these strains were fluconazole susceptible. A lower overall mortality was observed in candidemias.

La epidemiología de candidiasis invasora (CI) ha cambiado, lo cual no ha sido suficientemente estudiado en Chile. Objetivo: Describir el perfil epidemiológico y microbiológico de CI en pacientes críticos. Métodos: Estudio observacional prospectivo entre octubre 2001 y agosto 2003, en pacientes críticos adultos con sospecha o confimnación de CI. Resultados: 53 pacientes cumplieron criterios de CI. De ellos, 18 (33,9%) tuvieron candidemia, 22(41,5%) CI diseminada y 13(24,5%) CI local. Entre las candidemias, hubo 8 C. albicans (44,4%) y 10 Candida no albicans (55,6%), predominando C. tropicalis (27,7%). Un 88,8% de las candidemias fueron susceptibles a fluconazol. La mortalidad hospitalaria global fue 24,5%, significativamente menor en pacientes con candidemias vs CI diseminada (16,6 vs 31,8%, p = 0,02). Conclusiones: Se observó una mayor proporción de Candida no albicans en candidemias de pacientes críticos. Sin embargo, la mayoría de estas cepas fue susceptible a fluconazol. La mortalidad global fue menor en candidemias.

According to WHO, tobacco is responsible of almost five million deaths annually and around 13 thousand daily deaths in the world. Mexico has 60 thousand deaths per year and 165 per day for smoking, 25.6% of the population are passive smokers and the initiated age in tobacco consumption has diminished to 11 either 12 years or less. Two decades ago the fight against tobacco began in Mexico, and recently it combined administrative actions and legislative related to tributary matter and sanitary regulation. Mexico was the first country in America in signing the FCTC in August 12, 2003 and in April 14, 2004 ratified it, which means it is part of our legislation. At present, Federal Government prevention and tobacco treatment are focus actions integrated in an Strategy, which is looking to articulate synergy of all public, private and social actors involved in the subject, to give fulfillment to the Framework Convention on Tobacco Control (WHO) specially in the contracted obligations and in 2008 they must show results.

Según la Organización Mundial de la Salud (OMS), el tabaquismo causa en todo el mundo cerca de cinco millones de muertes al año, es decir, alrededor de 13 mil muertes diarias. En México, cerca de 60 000 defunciones por año y 165 diarias se atribuyen a esa causa, 25.6% de la población es fumador pasivo y se estima que la edad de inicio de consumo disminuyó a 12 años de edad o menos. México inició la lucha contra el tabaquismo hace dos decenios y en años recientes se combinaron acciones administrativas y legislativas relacionadas con aspectos tributarios y de regulación sanitaria. México fue el primer país en América en adherirse al Convenio Marco para el Control del Tabaco (CMCT, de la OMS, firmado por México el 12 de agosto de 2003 y ratificado el 14 de abril del año siguiente). Para el gobierno federal, la prevención y el tratamiento del tabaquismo son parte de una estrategia que busca la sinergia de los actores públicos, privados y sociales involucrados en el tema; los resultados de ese esfuerzo deberán presentarse en 2008.

According to WHO, tobacco is responsible of almost five million deaths annually and around 13 thousand daily deaths in the world. Mexico has 60 thousand deaths per year and 165 per day for smoking, 25.6% of the population are passive smokers and the initiated age in tobacco consumption has diminished to 11 either 12 years or less. Two decades ago the fight against tobacco began in Mexico, and recently it combined administrative actions and legislative related to tributary matter and sanitary regulation. Mexico was the first country in America in signing the FCTC in August 12, 2003 and in April 14, 2004 ratified it, which means it is part of our legislation. At present, Federal Government prevention and tobacco treatment are focus actions integrated in an Strategy, which is looking to articulate synergy of all public, private and social actors involved in the subject, to give fulfillment to the Framework Convention on Tobacco Control (WHO) specially in the contracted obligations and in 2008 they must show results.

Según la Organización Mundial de la Salud (OMS), el tabaquismo causa en todo el mundo cerca de cinco millones de muertes al año, es decir, alrededor de 13 mil muertes diarias. En México, cerca de 60 000 defunciones por año y 165 diarias se atribuyen a esa causa, 25.6% de la población es fumador pasivo y se estima que la edad de inicio de consumo disminuyó a 12 años de edad o menos. México inició la lucha contra el tabaquismo hace dos decenios y en años recientes se combinaron acciones administrativas y legislativas relacionadas con aspectos tributarios y de regulación sanitaria. México fue el primer país en América en adherirse al Convenio Marco para el Control del Tabaco (CMCT, de la OMS, firmado por México el 12 de agosto de 2003 y ratificado el 14 de abril del año siguiente). Para el gobierno federal, la prevención y el tratamiento del tabaquismo son parte de una estrategia que busca la sinergia de los actores públicos, privados y sociales involucrados en el tema; los resultados de ese esfuerzo deberán presentarse en 2008.

A 45 years old patient under corticosteroid treatment for a probable sarcoidosis and a moderate pancytopenia, presents a pneumonia which did not respond to antibiotics nor to antifungal treatment indicated after isolation of aspergillus fumigatus in sputum. He progressively develops respiratory insufficiency and arterial hypotension. Immunofluorescense for parainfluenza 3 is positive. He dies after seven days and the necropsy shows a necrotizing pneumonia, diffuse alveolar damage and abundant viral particles

Un paciente de 45 años bajo tratamiento corticoidal por una probable sarcoidosis y una pancitopenia moderada ingresa por una neumonía que no responde a antibióticos ni a tratamiento antimicótico indicado a raíz del aislamiento de Aspergillus fumigatus en expectoración. Desarrolla una insuficiencia respiratoria progresiva e hipotensión y una inmunofluorescencia para virus parainfluenza 3 resulta positiva. Fallece al séptimo día y la necropsia muestra una neumonía necrotizante, daño alveolar difuso y abundantes partículas virales