Care bundle: estratégias para gestão de antimicrobianos em um hospital referência em transplantes no nordeste brasileiro

Abstract

Introduction: Infections caused by multidrug-resistant bacteria represent a serious public health problem and are associated with high mortality rates. Among the strategies recommended to deal with this problem is the implementation of Antimicrobial Stewardship Programs (AMPs). Immunosuppressive therapy has been effective in reducing rejection in transplant patients, but vulnerability to opportunistic infections and multidrug-resistant pathogens remains a complication with a significant impact. To this end, the use of a care bundle for the management of antibiotic therapy is an important tool for guiding conduct, ensuring patient safety through the systematization of care. Objective: To evaluate the use of a care bundle in the management of antimicrobial use in a transplant unit. Methods: This is an observational, descriptive, and retrospective study based on the analysis of data from a database stored by the Antimicrobial Stewardship Program unit, containing the record of antimicrobial stewardship strategies (ATM) carried out during the years 2020, 2021, and 2023 in a high-complexity hospital, which were processed and interpreted through a quantitative analysis of the information. Results: 398 patients were followed up in the transplant unit, with a mean age of 52±17 years, and 98.2% (n=1683) of the strategies were accepted. The average length of stay for liver transplantation (LT) was 67 days in 2020, 32.08 days in 2021, and 18.82 days in 2023, while for kidney transplantation (RT) it was 33.5 days in 2020, 32.16 days in 2021, and 21.66 days in 2023. The average treatment time for HT was 37 days in 2020, 26.23 days in 2021, and 17.88 days in 2023, and for RT it was 28.7 in 2020, 24.44 in 2021, and 20.09 in 2023. The most prevalent indications for TMJ treatment were ICS (47.2%), ITRS (21.6%), and ITGU (11.8%). A total of 1,390 prescribed ATMs were monitored, of which 73.38% (n=1020) were therapeutic reserves and 11.37% (n=158) were strategic, and the most prescribed classes were penicillins in association with beta-lactamase inhibitors (21.2%), glycopeptides (19%), carbapenems (18.6%), polymyxins (8.3%), and aminoglycosides (8.2%). A total of 1,713 proposed strategies were identified, 98.2% of which were accepted (n=1,683), and those with the highest frequency were reducing treatment time (30.8%), ending treatment (18%), escalation (15.9%), and dose adjustment (15.5%). Discussion: The strategies used are consistent with the recommendations of the Infectious Diseases Society of America (IDSA), which point out the importance of adjusting the time and antimicrobial spectrum according to the patient's clinical profile in order to avoid antimicrobial resistance. The registration of 73.38% of ATMs as therapeutic reserves shows a strategic focus on their rational use. The main types of infections transmitted are consistent with the literature, which associates bloodstream and respiratory infections with higher morbidity and mortality rates in immunosuppressed patients. Conclusion: The study demonstrated the relevance of using care bundles as part of the PGA, which can improve clinical outcomes and control antimicrobial resistance. The strategies applied revealed a possible positive impact on reducing the average length of stay and the rational use of antimicrobials. However, under-reporting and data loss reinforce the need to integrate digital technologies for real-time and more accurate antimicrobial monitoring and the need for continuous training of multi-professional teams in order to ensure greater reliability.