Avaliação do uso de antimicrobianos em hospitais de pequeno porte localizados no interior do Estado de São Paulo
Carregando...
Data
2017-02-10
Autores
Giacomini, Júlia Laurindo [UNESP]
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Antimicrobianos são medicamentos essenciais à prática clínica, mas seu uso tem sido associado a eventos adversos graves e à emergência de resistência bacteriana. Apesar de haver extensa pesquisa na área, não se conhecem os padrões desse uso e a presença de mecanismos de controle nos hospitais de pequeno porte (HPP), definidos como aqueles com até 50 leitos de internação. Esse aspecto é particularmente relevante no Brasil, onde se estima que dois terços dos serviços hospitalares é composto por HPP. Com o objetivo de preencher essa lacuna, realizamos estudo ecológico incluindo 48 HPP do interior do Estado de São Paulo. Foram levantados dados de contexto regional, e características administrativas e assistenciais dos serviços. Também investigamos a existência de mecanismos de controle de uso de antimicrobianos, tais como: Comissão de Controle de Infecção Hospitalar (CCIH), médico infectologista, protocolos terapêuticos, treinamentos para corpo clínico, controle restritivo de prescrição e existência de retaguarda laboratorial microbiológica. Realizamos análise descritiva dos serviços e do uso de antimicrobianos, utilizando para este último parâmetro a classificação ATC/DDD (Anatomical-Therapeutical-Clinical / Defined Daily Doses). Modelos uni e multivariados de Regressão Binomial Negativa foram aplicados para identificar fatores associados ao maior ou menor uso. Abordamos com especial interesse os antimicrobianos de administração parenteral. Estes tiveram uso agregado de 242,04 DDD/100 admissões. Houve grande variação nos padrões de prescrição entre diferentes hospitais, mas predominou o uso de cefalosporinas e quinolonas. Após ajuste para variáveis de contexto e características dos hospitais, houve associação negativa entre uso de antimicrobianos parenterais e a existência de CCIH ativa há pelo menos 5 anos (Razão de Taxas [RT]= 0,65; Intervalo de Confiança [IC] 5%=0,47-0,87), existência de protocolos terapêuticos (RT=0,63; IC95%=0,46-0,88), realização de capacitações para corpo clínico (RT=0,50; IC95%=0,38-0,67) e controle restritivo do uso de antimicrobianos (RT=0,64; IC=0,47-0,87). O uso de antimicrobianos de amplo espectro foi de 64,79 DDD/100 admissões e correspondeu a 26,7% do uso parenteral total. Pare esses, identificouse nos modelos ajustados associação negativa com presença de CCIH há pelo menos 5 anos (RT=0,40; IC95%=0,19-0,83) e realização de capacitações para corpo clínico (RT=0,44; IC95%=0,22-0,89). Em conclusão, detectamos intenso uso de antimicrobianos – inclusive de amplo espectro - em HPP, e associação da instituição de mecanismos de educação e controle com a redução do emprego desses agentes.
Antimicrobials are necessary for clinical practice, but their overuse has been associated with severe adverse events and to the emergence of microbial resistance. In spite of extensive research, the patterns of prescription of antimicrobials in very small hospitals (VSH, defined as those with up to 50 admission beds) are largely unknown. This is a especial concern in Brazil, where two thirds of hospitals are VSH. Our study aimed at addressing this gap in knowledge, using an ecological approach. The study included 48 VSH from inner São Paulo State, Brazil. We collected regional demographic data, as well as information on hospitals’ administrative and healthcare characteristics. Finally, we investigated the existence of infection control committees (ICC), infectious diseases specialists, protocols for use of antimicrobials, prescription trainings for medical doctors, restrictive control of prescriptions and microbiology laboratory. The use of antimicrobials was collected from hospital pharmacies and described using the ATC/DDD (Anatomical-Therapeutical-Clinical / Defined Daily Doses) classification. We were especially interested in parenteral antimicrobials (PA). Univariate and multivariable models of negative binomial regression were used to identify factors associated with greater or lesser use of those drugs. The overall use of PA was 242.04 DDD / 100 admissions. There was huge difference among patterns of usage, but cephalosporins and quilonones predominated. Afeter adjusting for regional context and hospital variables, there was negative association of antimicrobial use and an ICC active for more than 5 years (Rate Ratio [RR], 0.65; 95% Confidence Interval [CI], 0.47- 0.87), the existence of therapeutic guidelines (RR, 0.53; 95%CI, 0.46- 0.88), trainings for doctors (RR, 0.50; 95%CI, 0.38-0.67) and restrictive control of antimicrobial use (RR, 0.64; 95%CI, 0.47-0.87). The overall use of broad-spectrum antimicrobials was 64.79 DDD/100 admissions (26.7% of total PA usage), and was negatively associated with ICC active for 5 years of more (RR, 0.40; 95%CI, 0.19-0.83) and trainings (RR, 0.44; 95%CI, 0.22-0.89). In conclusion, we identified extensive use of antimicrobials – including those with broad spectrum - in VSH. That use was negatively associated with the existence of educational and restrictive practices in the hospitals.
Antimicrobials are necessary for clinical practice, but their overuse has been associated with severe adverse events and to the emergence of microbial resistance. In spite of extensive research, the patterns of prescription of antimicrobials in very small hospitals (VSH, defined as those with up to 50 admission beds) are largely unknown. This is a especial concern in Brazil, where two thirds of hospitals are VSH. Our study aimed at addressing this gap in knowledge, using an ecological approach. The study included 48 VSH from inner São Paulo State, Brazil. We collected regional demographic data, as well as information on hospitals’ administrative and healthcare characteristics. Finally, we investigated the existence of infection control committees (ICC), infectious diseases specialists, protocols for use of antimicrobials, prescription trainings for medical doctors, restrictive control of prescriptions and microbiology laboratory. The use of antimicrobials was collected from hospital pharmacies and described using the ATC/DDD (Anatomical-Therapeutical-Clinical / Defined Daily Doses) classification. We were especially interested in parenteral antimicrobials (PA). Univariate and multivariable models of negative binomial regression were used to identify factors associated with greater or lesser use of those drugs. The overall use of PA was 242.04 DDD / 100 admissions. There was huge difference among patterns of usage, but cephalosporins and quilonones predominated. Afeter adjusting for regional context and hospital variables, there was negative association of antimicrobial use and an ICC active for more than 5 years (Rate Ratio [RR], 0.65; 95% Confidence Interval [CI], 0.47- 0.87), the existence of therapeutic guidelines (RR, 0.53; 95%CI, 0.46- 0.88), trainings for doctors (RR, 0.50; 95%CI, 0.38-0.67) and restrictive control of antimicrobial use (RR, 0.64; 95%CI, 0.47-0.87). The overall use of broad-spectrum antimicrobials was 64.79 DDD/100 admissions (26.7% of total PA usage), and was negatively associated with ICC active for 5 years of more (RR, 0.40; 95%CI, 0.19-0.83) and trainings (RR, 0.44; 95%CI, 0.22-0.89). In conclusion, we identified extensive use of antimicrobials – including those with broad spectrum - in VSH. That use was negatively associated with the existence of educational and restrictive practices in the hospitals.
Descrição
Palavras-chave
Antimicrobianos, Hospitais de pequeno porte, Controle de infecção, Farmacoepidemiologia, Auditoria do uso de antimicrobianos, Antimicrobials, Very small hospitals, Infection control, Pharmacoepidemiology, Antimicrobial stewardship