The overall aim of this research was to explore why some hospitals are more successful than others at reducing the acquisition rates of multidrug-resistant organisms. Using a socio-ecological perspective on health systems adapted from works in ecological restoration, ecosystems management, and healthcare, a participatory comparative case study design was employed. The study was collaboratively conducted on a surgical unit at a Netherlands hospital with very low rates of multidrug-resistant organisms and a surgical unit in a Canadian hospital with higher rates of these pathogens. The cases were selected on the basis that they were both academic health sciences centres of similar size in publicly funded systems; yet, they reported differing rates of MDRO infections. Research methods included a total of six unit observations, nine practitioner-led photo walkabouts of the units (n=13), six photo elicitation focus groups with practitioners (n=26), and the review of relevant policies and procedures and related infection prevention and control data. Common findings across both cases include the perceived importance of engaged leadership, the presence of environmental design issues, a lack of antibiotic prescribing restrictions, and the frequent use of workarounds that may be problematic for infection prevention and control. Disparate findings between cases include differences in ratios of hospital beds per capita, bed occupancy rates, staffing practices, equipment cleaning processes, bed cleaning systems (centralized versus manual) and the presence, in one hospital, of an active grass roots Hygiene in Practice group engaging practitioners in several ongoing activities to promote infection prevention and control. There is a lack of comparable findings between the two cases on hand hygiene audit protocols, surveillance strategies, reporting of acquisition rates, and the nature and extent of high risk populations for community-acquired methicillin-resistant Staphylococcus aureus in the two hospitals catchment areas. The findings and methodological challenges identified in this study suggest that case selection in future comparative infection prevention and control case studies should be based on an expanded list of criteria. These criteria should include comparable audits, surveillance, and reporting practices and comparable demographic and other relevant data, such as data on the agricultural practices within and demographic attributes of vulnerable populations within the hospital catchment areas.

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Orientador: Carlos Magno Castelo Branco Fortaleza / Resumo: Microrganismos multidroga-resistentes (MDR) tem se disseminado em hospitais, e apresentam potencial de transmissão em serviços não hospitares e saúde e mesmo na comunidade. Partindo deste princípio, desenvolvemos um estudo de metodologia mista de base individual e ecológica. O estudo foi conduzido no Hospital Estadual Bauru e distribuiu-se, resumidamente, em três etapas: (i) identificação de preditores para infecções por MDR com origem na comunidade (Community-onset [CO]-MDR); (ii) georreferenciamento e estudo da proximidade de domicílios de sujeitos com CO-MDR e outros que receberam alta hospitalar enquanto carreados de agente MDR (Retornando à Comunidade, RC) a serviços de saúde de complexidades diversas. No primeiro estudo, de delineamento caso-controle, identificamos internação prévia (com mais de seis meses de antecedência do diagnóstico) e doença pulmonar como fatores de risco para CO-MDR. Esses fatores apresentaram diferenças entre Gram-positivos e Gram-negativos. Já no segundo estudo, foi possível constatar a proximidade de domicílios de sujeitos dos grupos CO e RC com serviços de saúde, fossem eles Unidades Básicas (UBS), hospitais ou ambulatórios de especialidade. Em geral, quando comparados ao Methicillin-resistant Staphylococcus aureus (MRSA), outros agentes apresentavam maior dispersão em torno dos serviços de saúde. Os dados sugerem, ainda que indiretamente, a possibilidade de transmissão de microrganismos multidrogra-resistentes em espaços comunitários ou de as... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Multidrug-resistant microorganisms (MDR) have spread in hospitals, and have a potential for transmission in non-hospital healthcare settings and even in the community. This study was conducted in Bauru State Hospital and was distributed in three stages: (i) identification of predictors for community-onset MDR infections (CO-MDR); (ii) georeferencing and study of the proximity of CO-MDR and others who are discharged while harboring MDR (Returning to the Community, RC) to health services of diverse complexities.In the first case-control study, we identified previous hospitalization (with more than six months of the diagnosis) and pulmonary disease as risk factors for CO-MDR. These factors showed differences between Gram-positive and Gram-negative pathogens. In the second study, it was possible to verify the proximity of households of CO and RC subjects to health services, whether they were Basic Units (BHU), hospitals or specialty outpatient clinics. In general, when compared to Methicillin-resistant Staphylococcus aureus (MRSA), other agents were more dispersed around health services. The data suggest, albeit indirectly, the possibility of transmission of multidrug-resistant microorganisms in community or non-hospital care spaces. / Mestre