Public policies on healthcare-associated infections: a Brazil and UK case study

Polymyxin for treatment of ventilator-associated pneumonia in a setting of high carbapenem resistance

Objectives

To analyse the use of polymyxins for the treatment of ventilator-associated pneumonia (VAP) at a teaching hospital where carbapenem-resistant gram-negative bacteria are endemic.

Patients and methods

This was a historical cohort study of patients receiving polymyxins to treat VAP in ICUs at a public university hospital in southern Brazil between January 1, 2017 and January 31, 2018.

Results

During the study period, 179 cases of VAP were treated with polymyxins. Of the 179 patients, 158 (88.3%) were classified as having chronic critical illness. Death occurred in 145 cases (81.0%). Multivariate analysis showed that the factors independently associated with mortality were the presence of comorbidities (P<0.001) and the SOFA score of the day of polymyxin prescription (P<0.001). Being a burn patient was a protective factor for mortality (P<0.001). Analysis of the 14-day survival probability showed that mortality was higher among the patients who had sepsis or septic shock at the time of polymyxin prescription (P = 0.028 and P<0.001, respectively). Acinetobacter baumannii was identified as the etiological agent of VAP in 121 cases (67.6%). In our cohort, polymyxin consumption and the incidence density of VAP were quite high.

Conclusions

In our study, comprised primarily of chronically critically ill patients, there was a high prevalence of VAP caused by multidrug-resistant bacteria, consistent with healthcare-associated infections in low- and middle-income countries. Presence of comorbidities and the SOFA score at the time of polymyxin prescription were predictors of mortality in this cohort. Despite aggressive antimicrobial treatment, mortality was high, stressing the need for antibiotic stewardship.

The concept of vulnerability applied to Healthcare-associated Infections

OBJECTIVE

To discuss the potentialities of using the concept of vulnerability to support measures for preventing and controlling healthcare-associated infections (HAIs).

METHODS

This theoretical study was conducted in steps: 1) presentation of markers that frame the concept of vulnerability; 2) presentation of the characteristics of the health events to which the concept of vulnerability is intended to be applied; 3) identification of research gaps that could be potentially filled by using the concept of vulnerability; 4) identification of the potentialities of using the concept of vulnerability to deal with HAIs.

RESULTS

Proposal of a framework for analyzing HAIs from a vulnerability perspective, including the individual and collective dimensions.

CONCLUSION

Using the concept of vulnerability to study and deal with HAIs favors a new approach to an old problem, unlike the dominant studies that highlight the individual aspects of the practices in healthcare services.