Background. Infectious diseases societies recommend that hospitals risk-adjust their antimicrobial use before comparing it to their peers, a process called benchmarking. The purpose of this investigation is to apply and compare 3 risk-adjustment procedures for benchmarking hospital antibacterial consumption (AbC). Two standardization of rates procedures, direct and indirect standardization, are compared with one another as well as with regression modeling. Methods. Total aggregate adult AbC for 52 systemic antibacterial agents was measured in 70 hospitals that subscribed to the University HealthSystem Consortium Clinical Resource Manager database in 2009 and expressed as days of therapy (DOTs) per either 1000 patients days (PDs) or 1000 discharges. The two AbC rates served the role of the outcome while several known risk factors for AbC served the role of potential predictor variables in the linear regression models. Selection criteria were applied to select a model that represented the first rate (Model I) and another that represented the second (Model II), respectively, and outliers were identified. Adult discharges in each hospital were then stratified into 35 clinical service lines based upon their Medicare Severity-Diagnosis Related Group (MS-DRG) assignment. Direct and indirect standardization were applied to this set and the expected-to-observed (E/O) and observed-to-expected (O/E) ratios, respectively, for AbC were determined. The agreement of the different methods in ranking hospitals according to their risk-adjusted rates and in identifying outliers was determined. Results. The mean total AbC rate was 821.2 DOTs/1000 PDs or 4487.6 DOTs/1000 discharges. Model I explained 31% of the variability in AbC measured in DOTs/1000 PDs while Model II explained 64% of the variability in AbC measured in DOTs/1000 discharges. The E/O ratios ranged from 0.76-1.44 while the O/E ratios ranged from 0.73-1.45. The comparison of the risk-adjustment methods revealed a very good agreement between the two regression models as well as between the two standardization methods whereas the agreement of Model II with either standardization method was moderate. Conclusion. Standardization provides a viable alternative to regression for benchmarking hospital AbC rates. Direct standardization appears to be especially useful for benchmarking purposes since it allows the direct comparison of risk-adjusted rates.

Terapia empírica com antimicrobiano de amplo espectro faz parte do manejo inicial padrão de pacientes com neutropenia febril (NF). Evidências suficientes de quais esquemas antibióticos devem ser inicialmente prescritos já existem; embora, nenhum estudo randomizado tenha avaliado se a aderência a programas de controle de antimicrobianos (PCAs) resulta em diminuição das taxas de mortalidade por esta síndrome. No presente estudo de coorte prospectivo, realizado em um hospital terciário no período de outubro de 2009 a agosto de 2011, avaliou-se o impacto da aderência ao PCA, aferida através da prescrição antimicrobiana inicial, na mortalidade em 295 episódios de NF (em 145 indivíduos adultos) que necessitaram de tratamento endovenoso hospitalar. Após análise multivariada através de regressão de Cox, incluindo outros preditores de mortalidade, a aderência ao PCA mostrou-se fator de proteção independente para morte 28 dias após início do episódio de NF (razão de hazard ajustada[HR], 0.29; intervalo de confiança de 95% [IC 95%], 0.11 a 0.72). Os fatores de risco encontrados para a não-aderência ao PCA foram presença de hipotensão (risco relativo ajustado[RR], 1.90; IC 95%, 1.37 a 2.63), diarreia (RR, 2.13; IC 95%, 1.66 a 2.73), dor perianal (RR, 2.08; IC 95%, 1.54 a 2.82), suspeita de foco infeccioso em cavidade oral (RR, 2.45; IC 95%, 1.75 a 3.43) e manifestações cutâneas de infecção (RR, 2.34; IC 95%, 1.81 a 3.04). A escolha antimicrobiana inicial é particularmente importante no manejo inicial do paciente com febre em vigência de neutropenia; a aderência ao PCA, que preconiza o uso racional de antibióticos, mostrou ser efetiva na redução de mortalidade durante o curso da doença. A presença de fatores modificadores da terapia inicial representa risco para não-adesão ao programa de controle de antimicrobianos. / Empirical therapy with broad-spectrum antimicrobial is part of the initial management of patients with febrile neutropenia (FN). Enough evidence on which antibiotics schemes should be initially prescribed already exists; however, no randomized study has evaluated whether adherence to antimicrobial stewardship programs (ASPs) results in lower rates of mortality from this syndrome. In the present prospective cohort study performed in a tertiary hospital, from October 2009 to August 2011, we evaluated the impact of adherence to ASP, measured by initial antimicrobial prescribing, in mortality of 295 episodes of FN (in 145 adults) that required intravenous inpatient treatment. After multivariate analysis through Cox regression, including other predictors of mortality, adherence to ASP proved to be an independent protective factor for death 28 days after the beginning of the episode of FN (adjusted hazard ratio [HR], 0.29; 95% confidence interval [95% CI], 0.11 to 0.72). The risk factors found to noncompliance to ASP were presence of hypotension (adjusted relative risk [RR], 1.90; 95% CI, 1.37 to 2.63), diarrhea (RR, 2.13; 95% CI, 1.66 to 2.73), perianal pain (RR, 2.08; 95% CI, 1.54 to 2.82), suspected source of infection in oral cavity (RR, 2.45; 95% CI 1.75 to 3.43) and cutaneous manifestations of infection (RR, 2.34; 95% CI, 1.81 to 3.04). The choice of antimicrobial is particularly important in the initial management of patients with fever in the presence of neutropenia; the adherence to ASP, which calls for rational use of antibiotics, was effective in reducing mortality during the course of the disease. The presence of signs or symptoms that demand changes in the initial therapy poses risks to nonadherence to the antimicrobial management program.

Terapia empírica com antimicrobiano de amplo espectro faz parte do manejo inicial padrão de pacientes com neutropenia febril (NF). Evidências suficientes de quais esquemas antibióticos devem ser inicialmente prescritos já existem; embora, nenhum estudo randomizado tenha avaliado se a aderência a programas de controle de antimicrobianos (PCAs) resulta em diminuição das taxas de mortalidade por esta síndrome. No presente estudo de coorte prospectivo, realizado em um hospital terciário no período de outubro de 2009 a agosto de 2011, avaliou-se o impacto da aderência ao PCA, aferida através da prescrição antimicrobiana inicial, na mortalidade em 295 episódios de NF (em 145 indivíduos adultos) que necessitaram de tratamento endovenoso hospitalar. Após análise multivariada através de regressão de Cox, incluindo outros preditores de mortalidade, a aderência ao PCA mostrou-se fator de proteção independente para morte 28 dias após início do episódio de NF (razão de hazard ajustada[HR], 0.29; intervalo de confiança de 95% [IC 95%], 0.11 a 0.72). Os fatores de risco encontrados para a não-aderência ao PCA foram presença de hipotensão (risco relativo ajustado[RR], 1.90; IC 95%, 1.37 a 2.63), diarreia (RR, 2.13; IC 95%, 1.66 a 2.73), dor perianal (RR, 2.08; IC 95%, 1.54 a 2.82), suspeita de foco infeccioso em cavidade oral (RR, 2.45; IC 95%, 1.75 a 3.43) e manifestações cutâneas de infecção (RR, 2.34; IC 95%, 1.81 a 3.04). A escolha antimicrobiana inicial é particularmente importante no manejo inicial do paciente com febre em vigência de neutropenia; a aderência ao PCA, que preconiza o uso racional de antibióticos, mostrou ser efetiva na redução de mortalidade durante o curso da doença. A presença de fatores modificadores da terapia inicial representa risco para não-adesão ao programa de controle de antimicrobianos. / Empirical therapy with broad-spectrum antimicrobial is part of the initial management of patients with febrile neutropenia (FN). Enough evidence on which antibiotics schemes should be initially prescribed already exists; however, no randomized study has evaluated whether adherence to antimicrobial stewardship programs (ASPs) results in lower rates of mortality from this syndrome. In the present prospective cohort study performed in a tertiary hospital, from October 2009 to August 2011, we evaluated the impact of adherence to ASP, measured by initial antimicrobial prescribing, in mortality of 295 episodes of FN (in 145 adults) that required intravenous inpatient treatment. After multivariate analysis through Cox regression, including other predictors of mortality, adherence to ASP proved to be an independent protective factor for death 28 days after the beginning of the episode of FN (adjusted hazard ratio [HR], 0.29; 95% confidence interval [95% CI], 0.11 to 0.72). The risk factors found to noncompliance to ASP were presence of hypotension (adjusted relative risk [RR], 1.90; 95% CI, 1.37 to 2.63), diarrhea (RR, 2.13; 95% CI, 1.66 to 2.73), perianal pain (RR, 2.08; 95% CI, 1.54 to 2.82), suspected source of infection in oral cavity (RR, 2.45; 95% CI 1.75 to 3.43) and cutaneous manifestations of infection (RR, 2.34; 95% CI, 1.81 to 3.04). The choice of antimicrobial is particularly important in the initial management of patients with fever in the presence of neutropenia; the adherence to ASP, which calls for rational use of antibiotics, was effective in reducing mortality during the course of the disease. The presence of signs or symptoms that demand changes in the initial therapy poses risks to nonadherence to the antimicrobial management program.

Terapia empírica com antimicrobiano de amplo espectro faz parte do manejo inicial padrão de pacientes com neutropenia febril (NF). Evidências suficientes de quais esquemas antibióticos devem ser inicialmente prescritos já existem; embora, nenhum estudo randomizado tenha avaliado se a aderência a programas de controle de antimicrobianos (PCAs) resulta em diminuição das taxas de mortalidade por esta síndrome. No presente estudo de coorte prospectivo, realizado em um hospital terciário no período de outubro de 2009 a agosto de 2011, avaliou-se o impacto da aderência ao PCA, aferida através da prescrição antimicrobiana inicial, na mortalidade em 295 episódios de NF (em 145 indivíduos adultos) que necessitaram de tratamento endovenoso hospitalar. Após análise multivariada através de regressão de Cox, incluindo outros preditores de mortalidade, a aderência ao PCA mostrou-se fator de proteção independente para morte 28 dias após início do episódio de NF (razão de hazard ajustada[HR], 0.29; intervalo de confiança de 95% [IC 95%], 0.11 a 0.72). Os fatores de risco encontrados para a não-aderência ao PCA foram presença de hipotensão (risco relativo ajustado[RR], 1.90; IC 95%, 1.37 a 2.63), diarreia (RR, 2.13; IC 95%, 1.66 a 2.73), dor perianal (RR, 2.08; IC 95%, 1.54 a 2.82), suspeita de foco infeccioso em cavidade oral (RR, 2.45; IC 95%, 1.75 a 3.43) e manifestações cutâneas de infecção (RR, 2.34; IC 95%, 1.81 a 3.04). A escolha antimicrobiana inicial é particularmente importante no manejo inicial do paciente com febre em vigência de neutropenia; a aderência ao PCA, que preconiza o uso racional de antibióticos, mostrou ser efetiva na redução de mortalidade durante o curso da doença. A presença de fatores modificadores da terapia inicial representa risco para não-adesão ao programa de controle de antimicrobianos. / Empirical therapy with broad-spectrum antimicrobial is part of the initial management of patients with febrile neutropenia (FN). Enough evidence on which antibiotics schemes should be initially prescribed already exists; however, no randomized study has evaluated whether adherence to antimicrobial stewardship programs (ASPs) results in lower rates of mortality from this syndrome. In the present prospective cohort study performed in a tertiary hospital, from October 2009 to August 2011, we evaluated the impact of adherence to ASP, measured by initial antimicrobial prescribing, in mortality of 295 episodes of FN (in 145 adults) that required intravenous inpatient treatment. After multivariate analysis through Cox regression, including other predictors of mortality, adherence to ASP proved to be an independent protective factor for death 28 days after the beginning of the episode of FN (adjusted hazard ratio [HR], 0.29; 95% confidence interval [95% CI], 0.11 to 0.72). The risk factors found to noncompliance to ASP were presence of hypotension (adjusted relative risk [RR], 1.90; 95% CI, 1.37 to 2.63), diarrhea (RR, 2.13; 95% CI, 1.66 to 2.73), perianal pain (RR, 2.08; 95% CI, 1.54 to 2.82), suspected source of infection in oral cavity (RR, 2.45; 95% CI 1.75 to 3.43) and cutaneous manifestations of infection (RR, 2.34; 95% CI, 1.81 to 3.04). The choice of antimicrobial is particularly important in the initial management of patients with fever in the presence of neutropenia; the adherence to ASP, which calls for rational use of antibiotics, was effective in reducing mortality during the course of the disease. The presence of signs or symptoms that demand changes in the initial therapy poses risks to nonadherence to the antimicrobial management program.

No description available.

There is a pandemic of low-value clinical care that threatens the sustainability of our publicly funded healthcare systems. Over 30% of the health services provided to patients provide no benefit or may actually result in harm. Health services research is needed to critically evaluate our clinical practices and programs to ensure we create systems that consistently deliver high-value care. Unlike drug trials, health services research is complicated by enormous heterogeneity across cultures, environments, behaviours and systems. Ideally, local research communities should devise and conduct health services research to ensure that both the research questions and outcomes are relevant to community members, and thus more likely to result in sustainable healthcare systems. Embedded researcher models are emerging as a viable approach to supporting local research activities. Embedded researchers are part of the community they serve, provide research expertise to local investigators and community members, and help develop local research systems that facilitate health services research activities. While they may still collaborate with academic partners, this is not necessary for their research success. This thesis documents the transformation of a large community hospital in Ontario into a learning health centre through the use of an embedded researcher model. The first part of the thesis is focused on the results of incorporating an embedded research plan into the hospital’s new antimicrobial stewardship program. The research that emerges from this work contributes new knowledge about the value of antimicrobial stewardship to important patient outcomes such as reduced lengths of hospital stay and rates of Clostridium difficile infections. The thesis concludes with a discussion of the implementation of all the necessary components needed to support a learning health centre and how an embedded researcher model facilitated this transformation and could be used by any similar organization to achieve the same result. / Thesis / Doctor of Philosophy (PhD) / Over 30% of the health services provided by our healthcare systems does not benefit and may actually harm patients. Health services research is therefore a necessary activity required to reduce this waste. In Ontario, over 65% of patients receive their acute care in large community-based hospitals, and yet, these hospitals have minimal research activity and capacity despite repeated attempts by the academic research community to engage these institutions through a variety of collaborative models such as integrated knowledge translation. This thesis provides a blueprint for the transformation of a large community hospital into a learning health centre through the use of a locally created, locally relevant, embedded researcher model. Starting with a proof of concept through the systematic evaluation of an antimicrobial stewardship program, the thesis ends with a ‘how to’ guide for the implementation of the foundational elements needed to support health services research in similar organizations.

O descobrimento do primeiro antimicrobiano foi início do desenvolvimento de inúmeros antimicrobianos. No entanto, proporcionalmente a amplitude deste arsenal terapêutico, o seu consumo tornou-se excessivo e inadequado, levando ao quadro atual, no qual a resistência das bactérias a estes medicamentos vem dificultando a farmacoterapia de doenças infecciosas. Assim, o estudo do consumo destes medicamentos deve ser realizados para que estratégias sejam elaboradas no combate ao uso irracional de antimicrobianos. Portanto, o objetivo deste estudo é avaliar o consumo de antimicrobianos com finalidades terapêuticas e profiláticas em um hospital de alta complexidade por um período equivalente a um ano, bem como de seus respectivos setores de internação. Sendo assim, decidiu-se realizar um estudo observacional, retrospectivo, descritivo com desenho transversal no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP com pacientes adultos internados que receberam prescrição de antimicrobianos durante o ano de 2014. A coleta de dados será realizada por meio dos sistemas eletrônicos de informação do hospital. Assim, os dados coletados consistiram no registro dos pacientes, nas informações sociodemográficas, nas informações sobre a internação do paciente, resultados dos exames de cultura e antibiograma, e informações sobre a prescrição do antimicrobiano. A análise descritiva dos dados sociodemográficos, de internação, dos resultados dos exames, e da prescrição de antimicrobianos foi feita por meio de medidas resumos (média e desvio padrão) e distribuição de frequências absoluta e relativa. A comparação das médias de consumo entre os grupos profilaxia x tratamento e tratamento empírico x direcionado foi feita pelo teste t de Student para amostras dependentes. A Análise de Componentes Principais e análise de agrupamentos por método hierárquico foram ferramentas utilizadas para a análise exploratória do consumo de antimicrobianos profiláticos. Foram encontrados 7287 pacientes com 90475 prescrições de antimicrobianos (entre prescrições profiláticas, terapêutica empírica e direcionada). O consumo de antimicrobianos profiláticos abrange 11,7% de todo o consumo destes medicamentos, sendo que mais da metade deste consumo provém da ortopedia, unidade de terapia intensiva pós-operatória e unidade pós-operatória tórax e cardiovascular, além disso a cefazolina foi o medicamento mais consumido para profilaxia (52,0%). Dentre o consumo para o tratmento, 84% aconteceu de maneira empírica com utilização de antimicrobianos de amplo espectro de ação. Ao observar os antimicrobianos utilizados de maneira direcionada, destaca-se o aparecimento da oxacilina, polimixina B e os aminoglicosídeos. Diante dos resultados, há um elevado consumo profilático de antimicrobianos em alguns setores de internação, além de uma proporção maior de consumo no tratamento empírico, assim maiores investigações devem ser feitas para entender o comportamento deste excesso na utilização destes medicamentos / The discovery of the first antimicrobial was the beginning of the development of numerous antimicrobials. However, proportionately the amplitude of this therapeutic arsenal, its consumption has become excessive and inadequate, leading to the current situation, in which the resistance of bacteria to these drugs has been making difficult the pharmacotherapy of infectious diseases. Thus, the study of the consumption of these drugs must be carried out so that strategies are developed in the fight against the irrational use of antimicrobials. Therefore, the objective of this study is to evaluate the consumption of antimicrobials for therapeutic and prophylactic purposes in a hospital of high complexity for a period equivalent to one year, as well as of their respective sectors of hospitalization. Therefore, it was decided to carry out a study observational, retrospective, descriptive and cross-sectional study at Hospital das Clínicas of the Medical School of Ribeirão Preto - USP with hospitalized adult patients who received antimicrobial prescription during the year 2014. The data collection will be performed through the hospital\'s electronic information systems. Thus, the data collected consisted of patient registration, sociodemographic information, patient hospitalization information, culture and antibiogram examination results, and information on antimicrobial prescription. Descriptive analysis of sociodemographic data, hospitalization, test results, and antimicrobial prescription was done by means of summary measures (mean and standard deviation) and absolute and relative frequency distribution. The comparison of the means of consumption between the prophylaxis vs treatment groups and empirical x direct treatment was done by the Student t test for dependent samples. The Principal Component Analysis and Hierarchical grouping analysis were tools used for the exploratory analysis of prophylatic antimicrobial consumption. We found 7287 with 90475 antimicrobial prescriptions (between prophylactic prescriptions, empirical and targeted therapy). The consumption of prophylactic antimicrobials covers 11.69% of all consumption of these drugs, and more than half of this consumption comes from orthopedics, a postoperative intensive care unit and a postoperative chest and cardiovascular unit. In addition, cefazolin was the Most commonly used medication for prophylaxis (52%). Among the consumption for the treatment, 84% happened in an empirical way with the use of broad-spectrum antimicrobial agents. When looking at the antimicrobials used in a targeted manner, we highlight the appearance of oxacillin, polymyxin B and aminoglycosides. In view of the results, there is a high prophylaxis of antimicrobial use in some hospitalization sectors, in addition to a greater proportion of consumption in empirical treatment, so further investigations should be made to understand the behavior of this excess in the use of these drugs

Orientador: Carlos Magno Castelo Branco Fortaleza / 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 D... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

The threat of antimicrobial resistance particularly in the intensive care unit has become a global issue. This study aimed to evaluate the effectiveness of antimicrobial stewardship in limiting the spread of antimicrobial resistance in the hospital’s ICU. The study further determined the deficiencies of the ASP and recommended strategies to remedy the identified deficiencies. A quasi-experimental descriptive quantitative design was used in this study. The study was conducted at the intensive care unit of an academic hospital. A structured questionnaire was used to extract information from patients’ medical records. This evaluation showed that the antimicrobial stewardship program had a sufficient impact on the appropriate use of antimicrobials in the hospital’s ICU. While there were a small (19.05 %) number of patients inappropriately prescribed antimicrobials, a moderate (35.59%) number of patients developed hospital acquired infections during the study period. In addition, the results revealed a lack of the facility’s leadership commitment to antimicrobial stewardship, which is crucial for ensuring the availability of human, financial and information technology resources Through the evaluation of the program the deficiency in the program’s performance can be identified and optimised. For the studied facility, the performance of the program could be improved by gaining the support of the facility leadership. The present study endorses the evaluation of health promotion initiatives to improve patients’ safety and outcome in healthcare institutions. Keywords / Health Studies / D. Litt. et Phil. (Health Studies)

No description available.