Perfil de utilização e custos de carbapenêmicos em uma unidade de terapia intensiva de um hospital público do Distrito Federal – Brasil

Atualmente o contexto de resistência microbiana tem exigido gerenciamento do uso de antimicrobianos, especialmente no âmbito hospitalar. Assim, o objetivo desse trabalho foi analisar o perfil de utilização de carbapenêmicos na Unidade de Terapia Intensiva (UTI) de um hospital público brasileiro e os custos associados. Para tal, foi realizado um estudo observacional retrospectivo, de análise documental, que avaliou prontuários, prescrições e laudos microbiológicos de pacientes que utilizaram carbapenêmicos em 2019. Foram analisados dados de 25 pacientes com mediana de idade igual a 65 anos e de tempo de internação de 24 dias. Resultaram 36 análises do uso dos carbapenêmicos: 19 (57,8%) remetiam ao uso do meropenem e 17 (47,2%) ao uso de ertapenem. A mediana de dias de uso do meropenem foi de 11 e a do ertapenem foi de sete. A DDD/1000 pacientes-dia do meropenem teve mediana mensal de 115,5g (menor quando utilizado com o ertapenem) e a do ertapenem foi de 50,7g. O gasto anual total foi de R$16.652,00 para o meropenem e de R$41.072,00 para o ertapenem. Foram realizados 60 laudos microbiológicos e os microrganismos mais frequentes foram Klebsiella pneumoniae (n=18; 30,0%) e Acinetobacter baumannii complex/haemolyticus (n=14; 23,3%); a taxa de sensibilidade geral foi 18,3% para o meropenem e 13,6% para o ertapenem. Os dados sugerem a necessidade do gerenciamento no uso de carbapenêmicos considerando aspectos do paciente e do agente infeccioso com potencial impacto positivo nos desfechos clínicos e econômicos. Para isso, propostas de uso racional e seguro de antimicrobianos devem ser implementadas ressaltando a importância de cada profissional no contexto da equipe multidisciplinar.

Association between antibiotic pressure and the risk of colonization/infection by multidrug-resistant Acinetobacter baumannii complex: a time series analysis

Introduction. To analyze the association between antibiotic pressure and the risk of colonization/infection by Acinetobacter baumannii complex (AB), evaluating both the individual and general prescriptions of antibiotics. Methods. This is an analytical, observational, case-control study on patients admitted to an Intensive Care Unit (ICU) during an AB outbreak (14 months). A five-year time series was constructed with the monthly incidence of cases of infection/colonization with strains of AB resistant to each antibiotic administered and with the monthly consumption of these antibiotics in the ICU. Results. We identified 40 patients either infected (23) or colonized (17) by AB and 73 controls. We found an epidemic multidrug-resistant clone of AB in 75% of cases. Risk factors associated with the development of AB infection/colonization were: greater use of medical instruments, the presence of a tracheostomy, cutaneous ulcers, surgical lesions and prior antibiotic therapies. The regression analysis of individual use of antibiotics showed that prior treatment with ceftazidime, ceftriaxone, amoxicillin/clavulanate, imipenem, levofloxacin, linezolid, and vancomycin was a risk factor for acquiring AB. ARIMA models showed that the relationship were greatest and statistically significant when the treatment occurred between 6 months (ceftazidime) and 9 months (imipenem and levofloxacin) prior. Conclusions. The dynamic and aggregate relationship between the incidence of infection/colonization by multidrug-resistant strains of AB and prior antibiotic treatment was statistically significant for intervals of 6 to 9 months.

Seasonality and weather dependance of Acinetobacter baumannii complex bloodstream infections in different climates in Brazil

Recent studies report seasonality in healthcare-associated infections, especially those caused by Acinetobacter baumannii complex. We conducted an ecologic study aimed at analyzing the impact of seasons, weather parameters and climate control on the incidence and carbapenem-resistance in A. baumannii complex bloodstream infections (ABBSI) in hospitals from regions with different climates in Brazil. We studied monthly incidence rates (years 2006–2015) of ABBSI from hospitals in cities from different macro-regions in Brazil: Fortaleza (Ceará State, Northeast region), Goiânia (Goiás State, Middle-west) and Botucatu (São Paulo State, Southeast). Box-Jenkins models were fitted to assess seasonality, and the impact of weather parameters was analyzed in Poisson Regression models. Separate analyses were performed for carbapenem-resistant versus carbapenem-susceptible isolates, as well as for infections occurring in climate-controlled intensive care units (ICUs) versus non-climate-controlled wards. Seasonality was identified for ABSSI ICUs in the Hospitals from Botucatu and Goiânia. In the Botucatu hospital, where there was overall seasonality for both resistance groups, as well as for wards without climate control. In that hospital, the overall incidence was associated with higher temperature (incidence rate ratio for each Celsius degree, 1.05; 95% Confidence Interval, 1.01–1.09; P = 0.006). Weather parameters were not associated with ABBSI in the hospitals from Goiânia and Fortaleza. In conclusion, seasonality was found in the hospitals with higher ABBSI incidence and located in regions with greater thermal amplitude. Strict temperature control may be a tool for prevention of A. baumanii infections in healthcare settings.

ХАРАКТЕРИСТИКА И УРОВНИ ВЫЯВЛЕНИЯ БАКТЕРИАЛЬНЫХ ПАТОГЕНОВ У БОЛЬНЫХ ВНЕБОЛЬНИЧНОЙ ПНЕВМОНИЕЙ В ЗАВИСИМОСТИ ОТ СРОКОВ ИХ ПРЕБЫВАНИЯ СТАЦИОНАРЕ

Представлены состав, характеристика лекарственной устойчивости и уровни выявления бактериальных патогенов в пробах мокроты 82 больных с внебольничной пневмонией в зависимости от сроков их пребывания в стационаре: 44 человека обследованы в 1-3 день, 17 человек –на 4-10 день, 21 пациент на 11-22 день. В целом, бактериальная флора выявлена у 64 из 82 наблюдаемых больных (78,0±4,6%). Значимые грамотрицательные патогены (Klebsiella pneumoniae, Escherichiae coli, Acinetobacter baumannii complex, Pseudomonas aeruginosa, Stenotrophomonas maltophilia) выделяли в анализируемый период среди больных со средней степенью тяжести болезни с незначительной частотой (7,3±2,9%; 2,4±1,7%; 3,7±2,1%; 2,4±1,7%; 1,2±1,2%, соответственно возбудителям). Лекарственноустойчивые формы K. pneumoniae, E. coli – продуценты БЛРС, выделяли исключительно на поздних сроках пребывания больных в стационаре. Возбудители из группы неферментирующих грамотрицательных бактерий (A. baumannii complex, P. aeruginosa, S. maltophilia) были выявлены как на ранних, так и на поздних сроках госпитализации. Однако выделители штаммов-продуцентов карбапенемаз A. baumannii complex прошли длительный курс (до 1 месяца) амбулаторного лечения. Установлен высокий уровень выявления грибов рода Candida во все периоды стационарного наблюдения (65,9±7,1%; 70,6±11,4%; 42,8±11,1%). Все 4 вида грибов рода Candida (albicans, glabrata, tropicalis, krusei) выделяли как на ранних, так и на поздних сроках стационарного лечения.