Stewardship Brasil : avaliação dos componentes dos programas de gerenciamento de antimicrobianos em hospitais brasileiros com Unidade de Terapia Intensiva adulto.

Abstract

Introduction: Antimicrobial Stewardship Programs (ASPs) in Intensive Care Units (ICUs) have been consolidated as a fundamental strategy, increasingly standing out globally for their importance in ensuring the rational and appropriate use of antimicrobials, playing an importante role in combating microbial resistance. General Objective of the Thesis: To analyze the landscape of ASPs in Brazilian hospitals with adult ICUs, encompassing the implementation of program components, the challenges faced by institutions that have not yet established such programs, and the strategies adopted to improve antimicrobial use. Manuscript I: Implementation of components of Antimicrobial Stewardship Programs in adult Intensive Care Units: A regional analysis in Brazil. Objective: To analyze the components of ASP in adult ICUs by Brazilian regions. Method: Cross-sectional, retrospective, and multicenter study. Data collection took place between October 2022 and January 2023, using a validated questionnaire, made available on the official National Health Surveillance Agency (ANVISA) portal through the Google Forms platform. The participation of Brazilian hospitals in completing the questionnaire was voluntary. All Brazilian hospitals with adult ICUs were included in the study. The questionnaire consisted of 94 items and seven associated sections. In the first section, comprising 31 questions, demographic information related to hospital data and the presence or absence of ASP implementation was requested. In the subsequent sections, the 63 questions were formulated following the essential components for program implementation (C1: Leadership support = 170 points; C2: Definition of responsibilities = 170 points; C3: Education = 145 points; C4: Actions to improve antimicrobial use = 340 points; C5: Program monitoring = 75 points; and C6: Dissemination of results = 120 points). Each assessment item was assigned a specific score, considering the relative weight of importance and relevance of each evaluated component. Results: A total of 1,170 Brazilian hospitals with adult ICUs completed the national assessment form, corresponding to 59% of Brazilian institutions. Of these, 594 (50.8%) stated that they had implemented the EMP, of which 37 (6.2%) were from the North Region, 80 (13.5%) from the Central-West Region, 111 (18.7%) from the Northeast Region, 136 (22.9%) from the South Region and 230 (38.7%) from the Southeast Region of the country. It can be observed that, in four of the five regions, the C4 scores presented the highest percentage relative to the maximum possible score, with the exception of the South region, which achieved the highest percentage relative to the maximum possible in C1. Regarding C2 “definition of responsibilities”, there was no significant difference between the regions, all of which presented similar scores and below 50% of the total, demonstrating a weakness in this component. All Brazilian regions recorded a low performance in C3 “education”, suggesting a potential area for improvement in educational programs aimed at the rational use and prescription of antimicrobials. This component presented a significant difference between the North region, with the highest score, and the Southeast region, with the lowest index, suggesting that the Southeast region should improve educational measures. All regions demonstrated a notable performance in C4 “Monitoring of prescriptions”, indicating a strong emphasis on strategies to improve the prescription of antimicrobials, since this action has been developed by the Hospital Infection Control Committees for a longer time and has been incorporated into ASPs. Conclusion: Structural weaknesses were observed in the implementation of the programs, particularly in components related to institutional support, definition of responsibilities, strategic planning, and, most concerningly, in the education component. The findings highlight the need for national policies aimed at strengthening the educational component. Furthermore, it is essential to develop strategies that enhance the effective implementation of these programs across the country, considering that a significant proportion of the evaluated hospitals have not yet established them in a consolidated manner. Manuscript 2: Characteristics and Challenges of Brazilian Hospitals with Adult Intensive Care Units Without Antimicrobial Stewardship Programs: A Comparison Between Public and Private Management. Objective: To analyze the characteristics and challenges faced by Brazilian hospitals with Adult Intensive Care Units that have not yet implemented the ASP, comparing differences between public and private healthcare institutions. Method: Cross sectional, prospective, multicenter study, with data collection carried out from October 2022 to January 2023, through an electronic questionnaire made available on the portal of the ANVISA. Data from the first section of the instrument were used, which included 31 questions aimed at obtaining demographic information, including hospital data and the presence or absence of the ASP and the reasons that contributed to the hospital not having yet developed or implemented the ASP. Descriptive statistics were performed for data analysis, including absolute and percentage frequencies. Results: Of the 1,070 participating institutions, 574 reported not having implemented the program. Among these, 204 (35%) were publicly administered and 370 (65%) privately administered, with most institutions having between 10 and 20 ICU beds. Among the highlighted challenges, the shortage of human resources was identified as one of the main barriers (47.3% of private hospitals and 62.7% of public ones), in addition to the lack of professionals to develop the programs (47% in private and 63% in public hospitals) and insufficient support from other hospital departments (25% private and 34% public). The lack of qualified professionals was also reported as one of the greatest difficulties, affecting a large proportion of both public (47%) and private (53%) hospitals. Conclusion: Publicly administered hospitals face more challenges compared to privately administered ones, especially in areas such as institutional support, professional training, and financial and technological resources. Article I: Actions to Improve the Management and Use of Antimicrobials in Brazilian Hospitals with Adult Intensive Care Units. Objective: To analyze actions to improve the use of antimicrobials implemented by ASPs in adult ICUs in Brazilian hospital institutions. Method: This is a cross-sectional, retrospective, and multicenter study. Data collection was carried out between October 2022 and January 2023, using an electronic ASP self-assessment tool previously validated and made available on the official ANVISA portal. The evaluation criteria for institutions with ASP were organized into six essential components for the implementation of these programs. This research specifically addressed data related to Component 4 - Actions to improve the use of antimicrobials, and included issues related to policies, clinical protocols, strategic and complementary actions carried out in the management of antimicrobials in hospitals. Results: When analyzing the characteristics of the hospitals, it can be observed that most of the participating hospitals with EMP have up to 20 ICU beds (60%). Regarding the composition of the management teams in the institutions, it is observed that infectious disease doctors are the most frequent professionals, followed by nurses and clinical pharmacists. Among the hospitals evaluated, 75% reported having an operational team dedicated to ASP. Conclusion: The results demonstrate that some practices related to antimicrobial control are already rooted in the hospitals, being a solid basis for expanding and improving ASPs. Final Considerations: ASPs can be considered an essential strategy to combat antimicrobial resistance (AMR) in ICUs. The study reveals significant advances and gaps that must be addressed to strengthen the implementation and effectiveness of these programs in Brazilian hospitals. Expanding studies on ASPs is crucial for combating AMR, adapting strategies to regional needs, and identifying effective practices.