Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals

OBJECTIVES: Antimicrobial stewardship programs (ASPs) comprise coordinated interventions designed to improve antimicrobial use. Understanding the current structure of ASP hospitals will support interventions for the improvement of these programs. This study aimed to describe the status of ASPs in hospitals in São Paulo, Brazil. METHODS: A cross-sectional survey was conducted on the ASPs of hospitals in the state of São Paulo from March to July 2018. Through interviews by telephone or e-mail, we queried which components of the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and Centers for Disease Control and Prevention guidelines were implemented. RESULTS: The response rate was 30% (28/93 hospitals), and 26 hospitals (85%) reported having a formal ASP. The most frequently implemented strategies were antimicrobial surgical prophylaxis guidelines (100%), empiric sepsis guidelines (93%), and the presence of ASP team members during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring, and an adjustment program for patients on IV aminoglycosides (3%). Regarding the metrics of the ASP, the most common indicator was the rate of antimicrobial resistance (77%). Eighteen hospitals evaluated antimicrobial consumption using defined daily dose, and only 29% evaluated the days of therapy; 61% of hospitals reported their results to the hospital administration and 39% to the prescribers. CONCLUSIONS: Most hospitals have a formal and active ASP, but with timely actions. We observed inconsistencies between what program leaders understand as the main objective of ASP and the metrics used to evaluate it. Part of the effort for the next few years should be to improve program evaluation metrics and to provide feedback to physicians and hospital leadership

Evaluation of antimicrobial stewardship programs in hospitals of the state of São Paulo

As infecções relacionadas à assistência à saúde acrescentam custos monetários e humanos, principalmente quando são causados por bactérias resistentes aos antimicrobianos. A ocorrência de bactérias multirresistentes muitas vezes provoca a prescrição de antimicrobianos de amplo espectro o que leva a um círculo vicioso. Para evitar isso, os serviços de controle de antimicrobianos se esforçam em educar a equipe médica, criando as avaliações sistemáticas inseridas muitas vezes em programas de controle de antimicrobianos. Para realiza-las é necessário o planejamento e implantação de métodos, ferramentas e estratégias que incluem a pré-auditoria, a avaliação pós-prescrição, o uso de recursos laboratoriais e recursos humanos, tendo caráter restritivo ou educativo. Realizou-se uma pesquisa transversal com os hospitais de São Paulo, em que um questionário com conteúdo referente ao uso de antimicrobianos foi aplicado entre março e junho de 2018. Vinte e oito de 93 hospitais contatados aceitaram participar da pesquisa, dos quais 50% eram hospitais públicos, 25% eram privados e outros 25% eram filantrópicos. A média de leitos total foi de 341, e 47 leitos de UTI. Em 93% das instituições havia um programa de gerenciamento de antimicrobianos. Todos os serviços de controle de infecção contavam com médicos e enfermeiros, mas a proporção de serviços que contavam com farmacêuticos foi de 25%. Apesar disso, 57 % dos hospitais pesquisados tinham um farmacêutico atuando em algum momento do uso de antimicrobianos, o que constitui uma lacuna no uso responsável de antimicrobianos, já que este profissional é proficiente na orientação do uso correto de medicamentos. A estratégia mais comumente empregada foi a pós-auditoria com resposta ao prescritor. O protocolo de antibioticoprofilaxia esteve presente em 100% dos hospitais, mas apenas uma parte acompanhava a adesão ao protocolo, 11% utilizavam a pré-autorização para todos os antimicrobianos e 46% restringiam uma parte dos antimicrobianos. As visitas às unidades de internação foram relatadas por 93% das instituições e foi descrita como boa conduta por demonstrar parceria aos profissionais assistenciais. 67% possuíam uma diretriz para o uso e ajuste de vancomicina, 3% o faziam para amicacina, 68% faziam infusão prolongada de betalactâmicos e carbapenêmicos. Verificou-se que 25% dos laboratórios de microbiologia não tinham disponibilidade de método automatizado de bactérias. A maior parte dos programas tem como principal estratégia, educar o prescritor. Os objetivos principais dos programas foram: a segurança do paciente e prevenção de ocorrência de bactérias multirresistentes. Os indicadores predominantemente utilizados para avaliar os resultados dos programas foram perfil de resistência das bactérias (77%), infecção por bactérias multirresistentes (68%) e consumo de antimicrobianos (64%). Em conclusão, a maioria dos hospitais pratica alguma forma de avaliação dos antimicrobianos prescritos. Há lacunas quanto à atuação do farmacêutico no gerenciamento de antimicrobianos e nos recursos diagnósticos poderiam ser sugeridas melhoriasHospital-acquired infections adds economic and human costs, mainly the ones caused by drug resistant bacteria. The occurrence of multidrug resistant bacteria leads to prescription of broad-spectrum antibiotics, which can make a vicious circle. In order to avoid it, the infection control service make efforts to educate the medical staff by creation of systematic evaluation of prescription included um antimicrobial stewardship programs. To make it true, planning and implementation of methods and tools are needed including preauthorization, post prescription audit and feedback, lab and human resources. We have made a cross-sectional study with hospitals in São Paulo, a survey between march and June of 2018. Twenty-eight of 93 workers invited to participate o our survey accepted to answer the survey, 50% were public hospitals, 25% were private hospitals and 25% were philanthropic. The medium of beds were 341, and 47 of ICU beds. In 93% of these hospitals there were antimicrobial stewardship program. All the infection control services there were a medical doctor and a nurse, but only 25% of them had in their staff a pharmacist. On the other hand, 57% of the participants had a pharmacist in some moment of the antimicrobial use. This was considered a gap, as they are a medicine specialist. The most frequently used strategy was the post-prescription with feedback. All the hospitals had their guideline for antibiotics for surgical prophylaxis, but part of them followed their use. Eleven percent used preauthorization for all the antimicrobial agents and 46% used a restriction list. The face-to-face in units were reported as good practice by 93% because it demonstrates partnership. Sixty-seven percent of them had guidelines for vancomycin use, 3% for amikacin and 68% uses prolonged infusion for beta-lactams and carbapenems. We identified 25% of the microbiology laboratory didn´t had automated methods for bacteria identification. Most of the programs had as its mainly objective to educate the prescriber. The goals pointed by the participants were patient safety and prevention of multidrug bacteria. The predominant outcomes used to evaluate the programs were resistant bacteria profile (77%), incidence of multidrug resistant bacteria infections (68%) and antimicrobial consumption (64%). In conclusion, most of hospitals has a way to evaluate the prescription of antimicrobial agents. There are some gaps in the pharmacist practice and in the diagnosis resources that could improve