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Abstract(s)
Introdução: A emergência de Enterobacteriaceae produtoras de beta-lactamases de espectro estendido, cujas opções de tratamento são limitadas, traduziu-se numa crescente utilização de carbapenemes e, subsequentemente, na identificação de estirpes produtoras de carbapenemases. Neste contexto, existe a necessidade de serem implementadas medidas de controlo ao desenvolvimento e disseminação destas resistências – “programas de incentivo ao uso inteligente de antibióticos” e “estratégias de vigilância epidemiológica dos microrganismos”. Em Portugal, após o inquérito nacional de prevalência (2012) ter revelado um elevado consumo de carbapenemes e excessiva duração da terapêutica, foi criado o Programa de Apoio à Prescrição Antibiótica, o qual, no Centro Hospitalar Cova da Beira teve início em Outubro de 2014. Com o presente trabalho pretende-se analisar conjuntamente o programa de gestão antibiótica e os dados da vigilância epidemiológica. Esta integração visa analisar a adaptação das terapêuticas às características dos microrganismos e proceder à elaboração de recomendações que possam ser integradas num contexto futuro.
Materiais e Métodos: No presente estudo utilizaram-se os dados disponibilizados pelo Grupo de coordenação local do programa de prevenção e controlo das infeções e resistências aos antimicrobianos do Centro Hospitalar Cova da Beira. Procedeu-se à análise dos dados referentes ao consumo de carbapenemes e à vigilância epidemiológica dos microrganismos Escherichia coli e Klebsiella spp epidemiologicamente significativas, nos três primeiros trimestres dos anos de 2014 e 2015. Quanto ao consumo de carbapenemes, foram ainda analisados os dados da monitorização realizada pelo programa de apoio à prescrição antibiótica nos três primeiros trimestres de 2015.
Resultados: Em 2014, no período em estudo, 378 pacientes encontravam-se sob terapêutica com carbapenemes; em 2015, este valor era de 296. No que concerne à monitorização realizada pelo programa, em 2015, 62% dos pacientes efetuaram tratamento por mais de 96 horas, e 42% destes tiveram as suas prescrições analisadas pelo responsável pelo programa, o que resultou na alteração de 7 prescrições com consentimento do médico responsável pelo paciente. Em 2015 e relativamente a 2014, a vigilância epidemiológica demonstrou que, para a E.coli epidemiologicamente significativa, a incidência de infeção hospitalar cresceu 48% tendo para as “infeções/colonizações” este valor sido de 40%; por sua vez, para a Klebsiella spp epidemiologicamente significativa, a incidência de infeção hospitalar decresceu 55%, enquanto para as “infeções/colonizações” esse valor foi de 29%. As estirpes produtoras de beta-lactamases de espetro estendido corresponderam, em 2015, por esta ordem, a 69,6 e 70,8% dos casos de “infeção/colonização” e de infeção hospitalar por E.coli epidemiologicamente significativa, e a 74,2% e 85,7% dos casos de “infeção/colonização” e de infeção hospitalar por Klebsiella spp epidemiologicamente significativa, respetivamente. Conclusão: Nos períodos analisados verificou-se uma diminuição no consumo de carbapenemes e a presença de uma elevada proporção de estirpes produtoras de beta-lactamases de espectro estendido. Este estudo ilustra como os programas de gestão antibiótica poderão ser efetivos na diminuição da opção por antibióticos de largo espetro, como os carbapenemes, devendo fazer-se acompanhar de práticas de vigilância epidemiológica que apontem e analisem as variações observadas na incidência e no aparecimento de resistências, permitindo o desenvolvimento e a aplicação de medidas de controlo integradas.
Background: The emergence of beta-lactamase producing extended spectrum Enterobacteriaceae, which have limited treatment options, resulted in a growing use of carbapenemes and the emergence of carbapenemase producing strains. Therefore, the need for measures to control the development and dissemination of these resistances emerged together with incentive programs for the intelligent use of antibiotics and appropriate microorganism surveillance strategies. In Portugal, following the national prevalence survey (2012) which revealed a high consumption of carbapenems and long therapy periods, the Guidance Program for Antibiotic Prescription was developed, and later implemented, in October 2014, at the Centro Hospitalar Cova da Beira. The present work aims to analyse the antibiotic management program together with the surveillance data, considering the importance integrating therapeutic adaptation to microorganism characteristics and to develop recommendations that can be integrated in future contexts. Materials and Methods: For this study we used data provided by the local coordination group of the program for prevention and control of infections and antimicrobial resistance from Centro Hospitalar Cova da Beira. We analysed data on carbapenemes consumption and Escherichia coli and Klebsiella spp epidemiologically significant surveillance, for the first three quarters of 2014 and 2015. Regarding the consumption of carbapenemes we analysed monitoring data from the antibiotic prescription support program for the first three quarters of 2015. Results: In 2014, during the study period, 378 patients were under treatment with carbapenemes; in 2015 this value was 296. Regarding the monitoring carried out by the program in 2015, 62% of patients effected treatment for more than 96 hours, and 42% of these had their prescriptions analyzed by the program coordinator, which resulted in 7 prescriptions changes with the consent of doctor in charge of the patient. In 2015 relatively to 2014, the epidemiological surveillance showed that the incidence of hospital infection of epidemiologically significant E.coli increased 48%, being this value for “infections/colonization” 40%; for the epidemiologically significant Klebsiella spp, we observed a 55% decrease in the incidence of hospital infection and 29% in “infection/colonization”. The extended spectrum beta-lactamase producing strains corresponded to 69,6 and 70,8% of cases of “infection/colonization” and hospital infection for epidemiologically significant E.coli, respectively, and to 74,4 and 85,7% of the cases of “infection/colonization” and hospital infection in epidemiologically significant Klebsiella spp, respectively. Conclusion: Considering the periods evaluated, this research has found a decrease in the consumption of carbapenemes and a high proportion of strains producing beta-lactamases of extended spectrum. The study illustrates how antibiotic stewardship programs can be effective in reducing broad spectrum antibiotics use such as carbapenemes and how these programs should be associated with epidemiological surveillance practices that identify and analyze variations in incidence and the emergence of resistances, allowing the development and implementation of integrate control measures.
Background: The emergence of beta-lactamase producing extended spectrum Enterobacteriaceae, which have limited treatment options, resulted in a growing use of carbapenemes and the emergence of carbapenemase producing strains. Therefore, the need for measures to control the development and dissemination of these resistances emerged together with incentive programs for the intelligent use of antibiotics and appropriate microorganism surveillance strategies. In Portugal, following the national prevalence survey (2012) which revealed a high consumption of carbapenems and long therapy periods, the Guidance Program for Antibiotic Prescription was developed, and later implemented, in October 2014, at the Centro Hospitalar Cova da Beira. The present work aims to analyse the antibiotic management program together with the surveillance data, considering the importance integrating therapeutic adaptation to microorganism characteristics and to develop recommendations that can be integrated in future contexts. Materials and Methods: For this study we used data provided by the local coordination group of the program for prevention and control of infections and antimicrobial resistance from Centro Hospitalar Cova da Beira. We analysed data on carbapenemes consumption and Escherichia coli and Klebsiella spp epidemiologically significant surveillance, for the first three quarters of 2014 and 2015. Regarding the consumption of carbapenemes we analysed monitoring data from the antibiotic prescription support program for the first three quarters of 2015. Results: In 2014, during the study period, 378 patients were under treatment with carbapenemes; in 2015 this value was 296. Regarding the monitoring carried out by the program in 2015, 62% of patients effected treatment for more than 96 hours, and 42% of these had their prescriptions analyzed by the program coordinator, which resulted in 7 prescriptions changes with the consent of doctor in charge of the patient. In 2015 relatively to 2014, the epidemiological surveillance showed that the incidence of hospital infection of epidemiologically significant E.coli increased 48%, being this value for “infections/colonization” 40%; for the epidemiologically significant Klebsiella spp, we observed a 55% decrease in the incidence of hospital infection and 29% in “infection/colonization”. The extended spectrum beta-lactamase producing strains corresponded to 69,6 and 70,8% of cases of “infection/colonization” and hospital infection for epidemiologically significant E.coli, respectively, and to 74,4 and 85,7% of the cases of “infection/colonization” and hospital infection in epidemiologically significant Klebsiella spp, respectively. Conclusion: Considering the periods evaluated, this research has found a decrease in the consumption of carbapenemes and a high proportion of strains producing beta-lactamases of extended spectrum. The study illustrates how antibiotic stewardship programs can be effective in reducing broad spectrum antibiotics use such as carbapenemes and how these programs should be associated with epidemiological surveillance practices that identify and analyze variations in incidence and the emergence of resistances, allowing the development and implementation of integrate control measures.
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Keywords
Carbapenemes Estirpes Produtoras de Beta-Lactamases. Infeções Associadas Aos Cuidados de Saúde Resistência Antibiótica Vigilância Epidemiológica