Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world’s major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption.Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements.Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of “structure”, “process” and “result” proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021.Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44).Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations

Farmacogenética da esquizofrenia

Exportado OPUSMade available in DSpace on 2019-08-13T13:57:11Z (GMT). No. of bitstreams: 1 tese_renan_pedra_de_souza.pdf: 3251518 bytes, checksum: 99292fc73259c979b3bf4a10da9d27be (MD5) Previous issue date: 1Conhecidos há aproximadamente 2500 anos, os transtornos do humor continuam a dominar o interesse da saúde pública. Cerca de 5% dos pacientes depressivos não respondem a qualquer medida farmacológica e/ou psicoterápica. Para esses pacientes, a eletroconvulsoterapia (ECT) constitui uma importante oportunidade de melhora. Indução de convulsões na forma de ECT tem sido usada no tratamento de desordens psiquiátricas por mais de 60 anos. As principais indicações diagnósticas incluem depressão, mania, catatonia e esquizofrenia. Devido às dificuldades na identificação dos mecanismos de ação da ECT, têm-se usado a estimulação eletroconvulsiva (EEC) aplicada experimentalmente a animais com o intuito de obter dados que contribuam para explicar alguns efeitos terapêuticos da ECT. Há relatados de alteração nos níveis das proteínas DARPP-32 (fosfoproteína regulada por AMPc e dopamina) e NCS-1 (sensora neuronal de cálcio 1) em pacientes com transtornos neuropsiquiátricos. Neste trabalho foram avaliados os níveis de expressão das proteínas DARPP-32 e NCS-1 em quatro regiões cerebrais (striatum, córtex, hipocampo e cerebelo) de ratos submetidos ao choque eletroconvulsivo agudo e crônico. A estimulação eletroconvulsiva aguda gerou aumento na expressão de DARPP-32 no córtex. É interessante notar que nessa área as alterações foram observadas logo após a realização do estímulo e após 24 horas sendo essa sustentada até às 48 horas. Nas outras áres avaliadas (striatum, hipocampo e cerebelo) não foram observadas alterações significativas. Tais achados corroboram a ausência de eficácia dessa terapêutica de modo agudo usualmente. A estimulação crônica provocou alterações significativas em todas as áreas estudadas, o que está de acordo com a utilização de repetidas sessões desta técnica na clínica. A estimulação eletroconvulsiva aguda gerou somente alterações pontuais nos níveis de NCS-1 no córtex (diminuição em 48 horas), hipocampo (diminuição em 03 horas) e cerebelo (aumento em 3 horas). A estimulação crônica gerou modificações importantes no striatum e córtex, cerebelo. No striatum, aumento é notado logo após do último estímulo e a partir de 03 horas até às 24 horas. No córtex e cerebelo, o aumento é evidente de 12 horas até às 48 horas. Tais dados, assim como os obtidos para DARPP-32, mostram uma maior eficiência da terapia crônica em relação à aguda e uma dinâmica temporal que favorece a aplicação da técnica num intervalo de 2-3 dias (tempo pelo qual manteve-se os níveis elevados das proteínas)

SARS-CoV-2 Genomic Surveillance in Brazil: A Systematic Review with Scientometric Analysis

Several studies have monitored the SARS-CoV-2 variants in Brazil throughout the pandemic. Here, we systematically reviewed and conducted a scientometric analysis of the SARS-CoV-2 genomic surveillance studies using Brazilian samples. A Pubmed database search on October 2022 returned 492 articles, of which 106 were included. Ninety-six different strains were reported, with variant of concern (VOC) gamma (n = 35,398), VOC delta (n = 15,780), and the variant of interest zeta (n = 1983) being the most common. The top three states with the most samples in the published articles were São Paulo, Rio de Janeiro, and Minas Gerais. Whereas the first year of the pandemic presented primary circulation of B.1.1.28 and B.1.1.33 variants, consecutive replacements were observed between them and VOI zeta, VOC gamma, VOC delta, and VOC omicron. VOI mu, VOI lambda, VOC alpha, and VOC beta were also detected but failed to reach significant circulation. Co-infection, re-infection, and vaccine breakthrough reports were found. Article co-citation differed from the co-authorship structure. Despite the limitations, we expect to give an overview of Brazil’s genomic surveillance studies and contribute to future research execution

AVALIAÇÃO DO PERFIL DE CONSUMO DE ANTIMICROBIANOS DE ALERTA SEGUNDO A CLASSIFICAÇÃO AWARE EM UM HOSPITAL DE BELO HORIZONTE

Introdução/Objetivo: O uso inadequado de antimicrobianos é apontado como importante contribuinte para a disseminação de resistência microbiana. Para acompanhar e contribuir com a gestão do consumo de antimicrobianos, a Organização Mundial de Saúde (OMS) propôs a categorização AWaRe (Access, Watch, Reserve) que estabelece os medicamentos de alerta ou watch como aqueles de alto potencial de resistência. O objetivo desse trabalho foi avaliar o perfil de consumo de medicamentos classificados como alerta em um hospital público de ensino. Métodos: Foi realizado estudo retrospectivo no período de setembro/2019 a dezembro/2021 em um hospital público de ensino em Belo Horizonte. O consumo dos antimicrobianos da categoria AWaRe “alerta” monitorados nos hospitais brasileiros com leitos de UTI foi estimado a partir da Dose Diária Definida (DDD/1000 pacientes-dia). Dividiu-se o período de análise em três fases: pré-pandemia da COVID-19 (setembro/2019-fevereiro/2020), fase aguda da pandemia (março/2020-junho/2021) e pós-fase aguda da pandemia (julho/2021-dezembro/2021). Os resultados foram apresentados de modo descritivo utilizando-se o software Jamovi 2.3.21. O código de aprovação pelo Comitê de Ética em Pesquisa foi CAAE 54060321.8.0000.5149. Resultados: A ceftriaxona e o meropenem foram os antibacterianos mais utilizados em cada um dos três períodos de análise, tendo, na fase aguda da pandemia o maior DDD médio, 140,7 e 85,0 DDD/1000 pacientes-dia, respectivamente. A média geral de consumo no período agudo da pandemia foi o maior dentre os três períodos (422,2 DDD/1000 pacientes-dia), sendo evidenciado também o aumento no consumo de cefalosporinas (30,1%), glicopetídeos (4,2%), penicilinas (8,7%) e carbapenêmicos (12,7%) em comparação ao período pré-pandemia. No período pós-fase aguda, o consumo diminuiu em relação ao período anterior, exceto para as quinolonas, com aumento 45,0% e 40,5% no consumo de levofloxacino parenteral e ciprofloxacino oral, respectivamente, sendo este o período de maior consumo de quinolonas (37,7 DDD/1000 pacientes-dia). Conclusão: O aumento no consumo de antimicrobianos durante a pandemia, principalmente cefalosporinas e carbapenêmicos, pode impactar no aumento da disseminação de resistência microbiana. Assim, se faz necessária a intensificação de ação de Programas de Gerenciamento de Antimicrobianos (PGA) para melhor avaliação do uso de antimicrobianos a fim, principalmente, de reduzir a resistência microbiana

Disentangling the Environmental Factors That Shape Genetic and Phenotypic Leaf Trait Variation in the Tree Qualea grandiflora Across the Brazilian Savanna

Identifying the environmental factors that shape intraspecific genetic and phenotypic diversity of species can provide insights into the processes that generate and maintain divergence in highly diverse biomes such as the savannas of the Neotropics. Here, we sampled Qualea grandiflora, the most widely distributed tree species in the Cerrado, a large Neotropical savanna. We analyzed genetic variation with microsatellite markers in 23 populations (418 individuals) and phenotypic variation of 10 metamer traits (internode, petiole and corresponding leaf lamina) in 36 populations (744 individuals). To evaluate the role of geography, soil, climate, and wind speed in shaping the divergence of genetic and phenotypic traits among populations, we used Generalized Dissimilarity Modelling. We also used multiple regressions to further investigate the contributions of those environmental factors on leaf trait diversity. We found high genetic diversity, which was geographically structured. Geographic distance was the main factor shaping genetic divergence in Qualea grandiflora, reflecting isolation by distance. Genetic structure was more related to past climatic changes than to the current climate. We also found high metamer trait variation, which seemed largely influenced by precipitation, soil bulk density and wind speed during the period of metamer development. The high degree of metamer trait variation seems to be due to both, phenotypic plasticity and local adaptation to different environmental conditions, and may explain the success of the species in occupying all the Cerrado biome

Epidemiological Surveillance Reveals the Rise and Establishment of the Omicron SARS-CoV-2 Variant in Brazil

The introduction of SARS-CoV-2 variants of concern (VOCs) in Brazil has been associated with major impacts on the epidemiological and public health scenario. In this study, 291,571 samples were investigated for SARS-CoV-2 variants from August 2021 to March 2022 (the highest peak of positive cases) in four geographical regions of Brazil. To identify the frequency, introduction, and dispersion of SARS-CoV-2 variants in 12 Brazilian capitals, VOCs defining spike mutations were identified in 35,735 samples through genotyping and viral genome sequencing. Omicron VOC was detected in late November 2021 and replaced the Delta VOC in approximately 3.5 weeks. We estimated viral load differences between SARS-CoV-2 Delta and Omicron through the evaluation of the RT-qPCR cycle threshold (Ct) score in 77,262 samples. The analysis demonstrated that the Omicron VOC has a lower viral load in infected patients than the Delta VOC. Analyses of clinical outcomes in 17,586 patients across the country indicated that individuals infected with Omicron were less likely to need ventilatory support. The results of our study reinforce the importance of surveillance programs at the national level and showed the introduction and faster dispersion of Omicron over Delta VOC in Brazil without increasing the numbers of severe cases of COVID-19

DataSheet1_Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective.pdf

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world’s major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption.Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements.Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of “structure”, “process” and “result” proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021.Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44).Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations.</p

Indian food habit & food ingredients may have a role in lowering the severity & high death rate from COVID-19 in Indians: findings from the first nutrigenomic analysis

Background & objectives: During the COVID-19 pandemic, the death rate was reportedly 5-8 fold lower in India which is densely populated as compared to less populated western countries. The aim of this study was to investigate whether dietary habits were associated with the variations in COVID-19 severity and deaths between western and Indian population at the nutrigenomics level. Methods: In this study nutrigenomics approach was applied. Blood transcriptome of severe COVID-19 patients from three western countries (showing high fatality) and two datasets from Indian patients were used. Gene set enrichment analyses were performed for pathways, metabolites, nutrients, etc., and compared for western and Indian samples to identify the food- and nutrient-related factors, which may be associated with COVID-19 severity. Data on the daily consumption of twelve key food components across four countries were collected and a correlation between nutrigenomics analyses and per capita daily dietary intake was investigated. Results: Distinct dietary habits of Indians were observed, which may be associated with low death rate from COVID-19. Increased consumption of red meat, dairy products and processed foods by western populations may increase the severity and death rate by activating cytokine storm-related pathways, intussusceptive angiogenesis, hypercapnia and enhancing blood glucose levels due to high contents of sphingolipids, palmitic acid and byproducts such as CO2 and lipopolysaccharide (LPS). Palmitic acid also induces ACE2 expression and increases the infection rate. Coffee and alcohol that are highly consumed in western countries may increase the severity and death rates from COVID-19 by deregulating blood iron, zinc and triglyceride levels. The components of Indian diets maintain high iron and zinc concentrations in blood and rich fibre in their foods may prevent CO2 and LPS-mediated COVID-19 severity. Regular consumption of tea by Indians maintains high high-density lipoprotein (HDL) and low triglyceride in blood as catechins in tea act as natural atorvastatin. Importantly, regular consumption of turmeric in daily food by Indians maintains strong immunity and curcumin in turmeric may prevent pathways and mechanisms associated with SARS-CoV-2 infection and COVID-19 severity and lowered the death rate. Interpretation & conclusions: Our results suggest that Indian food components suppress cytokine storm and various other severity related pathways of COVID-19 and may have a role in lowering severity and death rates from COVID-19 in India as compared to western populations. However, large multi-centered case-control studies are required to support our current findings

Monitoring the Establishment of VOC Gamma in Minas Gerais, Brazil: A Retrospective Epidemiological and Genomic Surveillance Study

Since its first identification in Brazil, the variant of concern (VOC) Gamma has been associated with increased infection and transmission rates, hospitalizations, and deaths. Minas Gerais (MG), the second-largest populated Brazilian state with more than 20 million inhabitants, observed a peak of cases and deaths in March&ndash;April 2021. We conducted a surveillance study in 1240 COVID-19-positive samples from 305 municipalities distributed across MG&rsquo;s 28 Regional Health Units (RHU) between 1 March to 27 April 2021. The most common variant was the VOC Gamma (71.2%), followed by the variant of interest (VOI) zeta (12.4%) and VOC alpha (9.6%). Although the predominance of Gamma was found in most of the RHUs, clusters of Zeta and Alpha variants were observed. One Alpha-clustered RHU has a history of high human mobility from countries with Alpha predominance. Other less frequent lineages, such as P.4, P.5, and P.7, were also identified. With our genomic characterization approach, we estimated the introduction of Gamma on 7 January 2021, at RHU Belo Horizonte. Differences in mortality between the Zeta, Gamma and Alpha variants were not observed. We reinforce the importance of vaccination programs to prevent severe cases and deaths during transmission peaks