Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective

Abstract

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world’s major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption.Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements.Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of “structure”, “process” and “result” proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021.Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44).Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations.

Avaliação dos elementos essenciais de um programa de gerenciamento de antimicrobianos: perspectiva dos profissionais de saúde em um hospital de Ensino

“…At the institution, it was observed that there is a need to improve the electronic systems to improve antimicrobial use. Time-sensitive automatic stop requests for specific antimicrobial prescriptions have not yet been fully implemented at the institution 14 . Time-sensitive alert systems and discontinuation requests may improve therapy outcomes with these medications [18][19][20] .…”

“…This data survey is part of the strategic planning of the study institution, whose methods were improved to deepen the discussion in this paper. It is also worth noting that ASP actions at the institution have been gradually implemented since 2008 with the implementation of the Hospital-acquired Infection Control Service (Serviço de Controle de Infecção Hospitalar, SCIH) and improved over the years 14 Two meetings were held with representatives from the SCIH, pharmacy and laboratory to adjust the questionnaire format and improve the established language, aiming for complete understanding by the team. The final questionnaire, adapted for the institution, contained 56 questions (supplementary material).…”