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Revista Habanera de Ciencias Médicas
versión On-line ISSN 1729-519X
Rev haban cienc méd vol.16 no.4 La Habana jul.-ago. 2017
CLINICAL
AND PATHOLOGICAL SCIENCES
REVIEW ARTICLE
Antimicrobial policy. Imperative need in view of the current increasing microbial resistance
Política antimicrobiana. Necesidad imperiosa ante la creciente resistencia microbiana actual
Miguel Ángel Serra Valdés
Universidad
de Ciencias Médicas de La Habana. Hospital General Docente "Dr.
Enrique Cabrera". La Habana, Cuba. maserra@infomed.sld.cu
This
paper is a translation to English of its original version, available on:
http://www.revhabanera.sld.cu/index.php/rhab/article/view/2072/1856
ABSTRACT
Introduction:
Antimicrobials are one of the most used pharmacological groups in the clinical
practice. Their relation to microbial resistance has been demonstrated.
The rational use of antibiotics can be beneficial from the social and medical
point of view; however, their use is not always the most correct one, which
demands a systematic and special surveillance. A rational antimicrobial policy
is necessary in the health care centers.
Objective: To review
national and international consensuses and criteria on antimicrobial policy
in order to unify criteria and apply them the best way possible in health care
centers.
Material and method:
A bibliographic review on antimicrobial policy, antibiotics commission, and
antibiotics policy was made through a search on different databases; some of
them were: Clinical Evidence, The Cochrane Library, PUBMED, Google Scholar,
MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS,
NIH Reporter and the Web sites of the PAHO/ WHO.
Development: Concepts
on different Cuban publications, international consensus, human components,
objectives, functions, resources, methods, strategies, and controls were considered.
Conclusions: The
implementation of any therapeutic modification in the medical attention has
to be analyzed correctly in all its dimensions: scientific, technological, and
social ones. When the microbiological study is not possible or there is
no antibiogram, the selection of the antibiotic should be made on the local
epidemiological and clinical basis. The creation of an Antimicrobial Policy
with all its components, resources, and methodology is a necessary more than
ever at present. It can be submitted to modifications with new evidences, but
it has to be fulfilled to reduce both microbial resistance and the costs, in
order to obtain better results.
Keywords: Antimicrobial policy, antibiotics policy, antibiotics commission, microbial resistance, health actions.
RESUMEN
Introducción:
Los antimicrobianos constituyen uno de los grupos farmacológicos más
utilizados en la práctica clínica y está demostrada su
relación con la resistencia microbiana. El uso racional de antibióticos
puede producir beneficios desde el punto de vista médico y social, pero
su uso en ocasiones no es el más adecuado y debe ser objeto de una vigilancia
especial y sistemática. Es necesaria una política antimicrobiana
coherente en las unidades de salud.
Objetivo: Revisar
consensos y criterios nacionales e internacionales sobre política antimicrobiana
para tratar de unificar criterios aplicables lo más uniforme posible
en las instituciones de salud.
Material y Método:
Se realizó una búsqueda bibliográfica en diferentes bases
de datos: Clinical Evidence, The Cochrane Library, PUBMED, Google Académico,
MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS,
NIH Reporter y en la web de la OPS/OMS sobre política antimicrobiana,
comisión de antibióticos, política de antibióticos.
Desarrollo: Se consideraron
conceptos de diferentes publicaciones cubanas y consensos internacionales, componentes
humanos, objetivos, funciones, recursos, métodos, estrategias y control.
Conclusiones: Introducir
cualquier modificación terapéutica en la atención médica
tiene que ser correctamente valorado en todas sus dimensiones: científica,
tecnológica y social. La selección del antibiótico cuando
no es posible el estudio microbiológico y/o se carece de antibiograma
debe ser hecha sobre las bases clínicas y epidemiológicas locales.
La creación de una Política Antimicrobiana con todos sus componentes,
recursos y metodología es necesaria más que nunca en estos tiempos.
Puede estar sujeta a modificaciones con nuevas evidencias; pero tiene que ser
cumplida para disminuir la resistencia microbiana, los costos y obtener mejores
resultados.
Palabras claves: Política antimicrobiana, política de antibióticos, comisión de antibióticos, resistencia microbiana, acciones de salud.
INTRODUCTION
Antimicorbials
are one of the most widely used pharmacological drugs in the clinical practice
both in Community Medicine and Hospital Medicine. They can cause much
expense to the health care systems. Some studies have demonstrated that
the percentage of hospitalized patients that use antimicrobial agents is high
both in underdeveloped and developed countries, ranging from 22 to 66 %, but
it can be even higher in Intensive Care Units. Their relation with microbial
resistance has been demonstrated, among other reasons, for their inadequate
use and especially because of the lack of evidence of the most frequent infection.1-7
The evaluation of
the quality of prescription of antimicrobials allows to guide managers and professionals
towards the efficient and safe use of them, which implies a knowledge about
the prescription of the drug and the existence of a consensus for this prescription.
The evaluation of indication-prescription constitutes the best way to measure
the use of drugs, and it is the most accepted by doctors and international consensus
group.8 On the other hand, we should point out that the unnecessary use of antimicrobials
not only leads to microbial resistance, but can also have evident side effects
for the patient (eradication of the normal flora, increase and selection of
resistant strains, dangerous allergic reactions which many times are mortal,
etc.). Also, from the socio-economic point of view, they cause high sanitary
expenses. According to the World Health Organization (WHO), the inadequate
prescription of antimicrobials, among other factors, has contributed to the
current microbial resistance and has become one of the current biggest health
problems, which is difficult to solve for the moment and constitutes a great
challenge at an international scale.9,10,11
The increase of antimicrobial
resistance rates is not a recent phenomenon. The discussion about the
capacity of the new antimicrobials to kill the existing microorganisms effectively,
the emergent ones, and the ones which have become multi-resistant is widely
analyzed at present. They will only be available for use in some years.
The quality of prescription becomes crucial, and constitutes the most
important action to preserve the effectiveness of antimicrobial drugs available
at present. This is the reason why it is very important to establish an
antimicrobial policy in each health care center, which should be able to guarantee
the correct use of these drugs in order to diminish the effects of the current
drug resistance.
The dilemma of the act
of prescribing is difficult, even more if multiple causes such as internal,
external, objective, and subjective ones, influence when taking the decision
that only the ability and skill of the prescriber overcomes12; but
then it is necessary to have some kind of guidance, information, protocol, and
control of the fulfillment of this activity to conduct it the best way possible
in each health care center.
It is extremely difficult
to establish relationships among antimicrobial policies and the evolution of
microbial resistance. Despite some studies referring to apparent beneficial
effects of certain interventions on resistance have been published, the degree
of evidence is considerable low.13 In a recent review, it has been
observed that less than a third of the intervention studies of antibiotics policy
has an adequate methodology not only to demonstrate the effects on resistance,
but also to present a general evaluation of them. Most part of the studies
are not controlled, and even if they deal with time series, less than three
observations are undertaken. We should add other important problems
to all this situation such as risk of participation, absence of randomization,
and lack of follow-up as part of the interventions studied; the shortage
of multicentric studies that allow to generalize the results or difficulties
in order to know whether the effects are due to the own programs, or they are
due to either personal or institutional factors. Besides, it is probable
that in the evolution and dissemination of microbial resistance, the epidemiological
factors (relations among populations, ecological niches, control measures, etc.),
and the purely biological ones (nature of resistance mechanisms, possibilities
of expansion of them) become more decisive in our antibiotic policies, also
limited by the urgent need to use them.2-18
In Cuba, there is
an Antimicrobial Policy, a Pharmaco-Therapeutic Committee, and specifically,
an Antibiotics Committee in each health care center. In the recent context,
it becomes imperative to join national and international consensus and positions
on antimicrobial policy, its importance, components, methodology, and control
activities in order to unify criteria based on consensus and apply them the
most uniform way possible in the different health care centers, where these
criteria apparently differ.12,14,19,20
OBJECTIVE
The objective of this research is to review consensus and national and international criteria on antimicrobial policy in order to unify criteria to apply them the most uniform way possible in health care centers.
MATERIAL AND METHOD
In the last ten years, a bibliographic review on antimicrobial policy, antibiotics policy, and antibiotics commission was made through a search on different databases; some of them were: Clinical Evidence, The Cochrane Library, PUBMED, Google Scholar, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter, and the Web sites of the PAHO/ WHO. The ones which had high evidences in accordance with the criteria of Grading of Recommendations of Assessment Development and Evaluations (GRADE) were considered.21
Level
1: Data from controlled randomized clinical trials, meta-analysis, and systematic
reviews.
Level 2: Results from cohort
studies or case studies, and case controls. Considerations on professional
experience and author´s knowledge on the topic.
The terms antimicrobial policy, and antibiotics policy have been used interchangeably as it appears in the literature reviewed.
DEVELOPMENT
Some antecedents
A
policy for the reasonable use of antimicrobials has been implemented for more
than three decades in face of the increasing microbial resistance. The resolution
WHA51.17 of the World Health Meeting in 1998 urged the united members to adopt
measures with the aim of promoting the appropriate use and economic cost of
antimicrobials; prohibiting the distribution of antimicrobials without prescription
or qualified medical prescription; improving practices to prevent the spreading
of infections and the extension of resistant pathogen germs; reinforcing
the legislation to impede the manufacture, sale, and distribution of falsified
antimicrobial drugs and the sale of antimicrobials in the drugstores where medications
are sold to the population ; and reducing the use of antimicrobials in the raising
of animals used in human consumption. Also, countries were encouraged
to develop sustainable systems to detect resistant pathological germs, and keep
a watch on the quantities and modalities of the use of antimicrobials and the
effects of control measures.22 As early as in 1983, an appeal
was made by the WHO on this respect, that advised: You should always use an
antibiotic which sensitivity to the germ causing the infection has been proven,
or at least when it is hoped it could be possibly evidenced. Use, whenever
possible, an antibiotic that has a narrow antimicrobial spectrum. Administer
the drug selected at the dose and by the appropriate route to achieve the desired
therapeutic effect. Administer the antibiotic during the shortest time possible.
Use them by parenteral way, whenever possible. Never use two antimicrobials
of the same family. Prescribe a bactericidal together with a bacteriostatic.
Benefit from the synergism of the drugs used. Keep in mind, the plasma
proteins binding that the indicated antibiotic requires. Take advantage
of the post-antibiotic effect of the drug used in the global strategy.23
In general, all the
countries and regional consensus take some measures directed to implement a
policy about the use of antimicrobials. They follow the advice from WHO
experts concerning the existence of differences in views on expert
roles, but consistent in most of the cases. Cuba has not been irrespective
of the situation, and began to develop a policy in hospitals and other health
care centers towards a better organization and purpose on this respect. Previously,
in the 60´s of the past century, some control measures of antimicrobials
were already implemented. It started from some basis recommended by other
countries.24-27
At present, the existing
microbial resistance which includes multidrug-resistant and ultra-resistant
organisms, requires the improvement and a better control of the antimicrobial
policies in each health care center.
Antimicrobial Policy
Antimicrobial
Policy can be defined as: "A group of measures that have the main purpose to
adapt the antimicrobial treatment for each patient in an effective way with
a minimum of complications, avoid adverse reactions, control the possibility
of development and the spreading of strains of resistant microorganisms, and
diminish the hospital costs as much as possible". It is the set of rules
that regulate the use of antibiotics in an area or sanitary center. It
is a continuous process of formulation of criteria for the adequate selection
of antimicrobials.28 The European Consensus about the
use of antibiotics also recommends: "To control the consumption of antimicrobial
agents, institute a selective list of antibiotics to be used in the therapeutic
guidelines of the hospitals, and limit the introduction of all new antibiotics
without certain criteria for activity, toxicity, pharmacokinetics, and costs.17,24,26
We refer to the definition
of policy given by the Diccionario de la Academia de la Lengua Española:
"Principles or rules that govern an activity and that are expected to be fulfilled
by the employees, members of an institution, organization, party, govern, system,
that leads to surveillance, regulations, controls, and measures to the offenders…"
For that reason, antimicrobial policy should be sustained by a uniform methodology,
as well as some components and resources that will be analyzed in more detail.
A program on Antimicrobial Policy should mainly start and be sustained by Evidences.
These evidences come from studies on hospital-based epidemiology conducted
in each center and studies conducted in other similar centers; the determination
of resistance to antimicrobials used according to the level and hospital complexity
presented by the department of Microbiology; the priority of their use; and
the consumption and costs reported by the Chemist Department, taking into account
the work features of different specialties. On the other hand, we have
to consider the evidence of up-to-date scientific information, and personal
experience of those high scientific and academic level professionals, which
has been demonstrated by their performance and competence. The results
of medical research are of extraordinary value as a basis for making clinical
decisions. It is important to point out that most part of the decisions
are empirical, but based on a reasoning and a hypothesis made by the professional,
which means that it has a philosophic scientific basis.27,28
An education on this
respect is extremely necessary for all the medical staff and the continuous
education activities in which professionals are involved. For its effectiveness,
control measures should be taken when a specific policy is carried out and established;
also, it is necessary to keep in mind that these are individual programs for
each institution that are subject to modifications according to new evidences.
(Figure 1). Protocol and acting according clinical guidelines
is very important in this stage.27,28
Considering
the previous information as a starting point, we create what we call Hospital
Infection Control Committee and Antibiotics Policy Committee composed of one
or more representations of Clinical Services; Surgical Services; Gynecobstetric
Service; Intensive Care Units; Pharmacy; Microbiology; Hospital Epidemiology;
and Computing; with high-ranking resources, places, and administrative services
that advice and respond directly to the director of the health care center.
All this group of services and resources constitutes the known Antibiotic Commission
or Antibiotic Committee.27
The objectives
of the Antibiotic Commission or Antibiotic Committee are to guarantee the formulation
of a coherent, wide, integrated, and interdisciplinary hospital criterion directed
to treat infections and stop bacterial resistance to the antimicrobials used;
promote the rational and correct use of antimicrobial agents; strengthen the
adequate availability of these drugs in general, and the important antimicrobial
agents in particular; create a culture that facilitates the efficient surveillance
and controls the intra-hospital infections, as well as the degree of resistance
to antimicrobials in all pertinent sectors; and most of all, control the ones
at the highest risk. Other important objectives are to present the main
guidelines for the treatment of infections in the center to the Direction of
the Hospital: Protocol or Clinical Practice Guidelines; to evaluate
hospital costs periodically in this sensible area; and manage the professional
activity in this field throughout the hospital.17,24,27,29-34
Some of the main
functions are: Scientific study of the hospital phenomenon of antimicrobial
resistance. Adequate control of the antimicrobials which are used daily. Identification
and preservation of strategies for antibiotic use in the institution. Maintenance
of an interdisciplinary relation, with a sense of feedback, and the necessary
effectiveness of a complex system, open to the continuous improvement and the
participation of the services involved.17,24,27,30-34
Resources and Members:17,24,27,30-34
-
A place furnished for daily meetings and case discussions.
- Experts' Committee composed
of a president, a secretary, and the members that represent the clinical and
surgical services that report higher incidences of infections, and have more
experience to fight against them (they should be selected considering their
scientific and academic level, and the accumulated fruitful work experience).
Microbiology, Hospital Epidemiology, and Pharmacy. If possible, there
should be a Master in Infectious Diseases or Infectiology.
- Each session should be
chaired by an expert who supervises, give advice, and comments on the developmental
and periodical follow-up of the patients who are registered in the database
of the hospital.
- A pharmacist should be
present daily to offer the control and reliability of the selected antimicrobial,
which should comply with the indication and use on the same day.
Methodology of the Hospital Infection Committee and Antibiotics Policy
All
the system should be interrelated through the Hospital Intranet, being the following
services the more important and useful: Admission and Statistics, Microbiology,
Epidemiology, and Hospital Pharmacy. A weekly report on the existence
of antibiotics in the hospital should be made, as well as an estimate of the
ones that will be needed during the period under analysis to facilitate the
pertinent management, and if necessary, with the direction of the hospital and
the different authorities of the Ministry of Public Health (MINSAP). A
monthly evaluation meeting of the analysis and control of the work of all the
system should be carried out. The following factors that take part in
the process should be taken into account: antimicrobial use, evaluation of the
microbiological spectrum of the hospital, study of monthly microbiological reports,
and discussion of the data reported by the Department of Hospital Epidemiology.
Reports on the controls in the weekly Word Rounds are also important,
as well as the drawing up of a monthly report to the Organizational Quality
Unit, in which the most relevant aspects should be mentioned.17,24,27,30-34
The policy of antibiotics
should be based on criteria that are easy to observe, and modify (it should
be neither strict nor static). These are: acquired scientific experience
(cumulative, but changeable), that should be modified together with the progression
of the most recent scientific knowledge,28 that offers the availability
of the acquisition of new drugs, allows the follow-up and control of prescription
habits and patterns and adequate pharmaceutical service, and avoids the appearance
of undesired side effects.17,24,27,29,30-34
There are special
therapeutic problems in the prescription that should be taken into account:
impairment of liver function (some antimicrobials are metabolized in the liver
and excreted via the biliary route, and others have hepatotoxic effects); impairment
of renal function (a great number of antimicrobials or their metabolic products
are eliminated through the kidney, others are nephrotoxic, and cause a greater
damage to the renal function); alterations of the distribution volume (determined
by alterations of the vascular permeability, the decrease of oncotic pressure
of plasmatic proteins, hypermetabolic state, and alterations of the cardiac
output). It is also important to remember that fever does not always indicate
an infectious process, and that the clinical picture should correspond with
an infection. Generally, the temperatures ranging from 38.9 and 41.1 ºC
have an infectious origin, but the ones lower than 38.9 ºC can have either
an infectious origin or not, and the temperatures over 41.1 ºC rarely have
an infectious origin.30-35
Importance of Pharmacy in Antimicrobial Policy14,28,36,37,38
Hospital
pharmacy is an administrative and clinical hospital support unit which should
participate in control activities of hospital infections because it is directly
related to the quality of services the health care center offers to the institution
which it is part of. However, it contributes more effectively if it takes into
account professional pharmaceutical products.
No matter whether he is
member or consultant, the pharmacist plays an important role in the Antibiotic
Commission. This way, this professional contributes to the reduction of
the incidence of hospital infections, the rational and adequate use of antimicrobial
therapy, and the reduction of hospital costs resulting from the use of these
drugs. The pharmacist should participate in the development of regulations and
procedures relative to cleaning, disinfection, sterilization, and asepsis; regulate
the microbiological integrity of all products distributed by the drugstore,
especially those that should be sterile; make the control card for the use of
antimicrobials; conduct pharmacovigilance studies; participate in the development
of protocols for the use of antimicrobials, mainly the ones that have a prophylactic
use; inform about the use of antimicrobials and their resistance indicators;
provide up-to-date pharmacological information about the products
in a way that it contributes with the decisions of the Pharmacotherapeutic Committee;
carry out the quality control of the use of antimicrobials in the institution,
which should be based on the analysis of the indiscriminate use of certain antimicrobials,
the violation of the basic infection control rules, the analysis of the most
frequent germs, and the use of antimicrobials in the geriatric population starting
threshold in diminished immunological defenses and diminished renal excretion,
and in other non - geriatric patients that suffer from immunosuppressive
diseases. However, it is necessary to have a constant up-to-date knowledge
to adequately fulfill these rules and functions.
It is important to remember
that most of these intrahospital infections (IHI) are endemic and spread continuously,
they occur more frequently in the services given to the critically ill patients,
although no hospital area is exempted from it14 Unlike epidemiological
outbreaks, in which the measures should be adopted rapidly in endemic infections,
it is required to implement measures of a diverse degree of complexity in a
coordinated form, but it demands time, organization, resources, and an Antibiotic
Commission composed of a professional personnel with a high scientific and academic
level.28
The pharmacy professional
as an expert, consultant, and member of the Antibiotic Committee and the Pharmacotherapeutic
Committee, together with the head of the pharmacy service and the rest of the
members of the Antibiotic Committee should categorize the antimicrobials.
For all this, their participation should be based on the individual and collective
experience, economic indicators, efficiency indicators, and the results of susceptibility
studies (microbiological maps). This way, antimicrobials are divided into
3 groups: Non-controlled (group I), semi-controlled (group II), and
controlled or strategic reserve (group III).
The non-controlled
antimicrobials could be prescribed by all doctors from the health care center.
The semi-controlled could be prescribed by the head of the services, wards,
or doctors who work as teachers. The group of the controlled or reserve
ones could only be authorized by the members of the Experts Committee.
The head of the doctors on duty could use all of them because of the character
of Emergency Medicine. If group III antimicrobials are used, the drugstore
will inform directly to the Experts Committee, and the case will be evaluated
to continue the treatment whether approved or not. The Experts Committee
is allowed to avoid the use of some antibiotics or restrict those ones that
present a high level of resistance and have become ineffective drugs.2,7,12,14,27,30
Economic issues regarding antibiotic policy
The
reduction of the use of antimicrobials and the quality of the medical attention
is in relation to the Guidelines of the Social and Economic Policy that emerged
from the 6th Congress of the Communist Party of Cuba, which, in Chapter
6 about Social Policy (Public Health guideline 154) highlights
the need to "increase the quality of the service offered to the population,
and the satisfaction of all the people … guarantee the efficient use
of resources, saving, and elimination of unnecessary expenses". The last
aspect shows the intention of the socialist state to promote the implementation
of the scientific and technical advances in order to safeguard the health of
the population with the greatest possible efficiency.39 The
method used for the control should not violate the principle of not affecting
the patient´s therapy; should be designed in such a way that it should
be administered in the correct form, moment, and way required, keeping a watch
over the fulfillment of what has been established. These principles are
very clear in the resolution 60/2011 of the General Treasury Inspector´s
Office which establishes that its main objective "is based on a professional
criterion when comparing quantitative and qualitative results with parameters
and established rules" and defines the functions as the ones which "guarantee
the control and supervision of the processes, activities, and operations in
such a way that avoid the risk of their implementation and compensation, and
limit their review or change"40
In the Instruction
206 of the Vice- Minister of Economy and the Drugs Program, The Cuban Ministry
of Public Health ratifies the check and final destiny of drugs.41,42
We could summarize
the main basis of the policy about the use of antibiotics in the following chart.
(figure 2).
Limitations on the present article
There are few publications that show high scientific evidence on this topic. It is relevant that there is a great number of descriptive investigations (residents’ theses, Master’s Degree theses, and others) in the different levels of health attention, which only offer a photographic view of an identified scientific problem, but some of them could not be used in the development of this work. Other publications reviewed indicate some non-uniform criteria for undertaking an antimicrobial policy both in our country and in other latitudes; but in this article we look for a uniformity of such criteria.
CONCLUSIONS
The
creation of an Antimicrobial Policy with all its components, capable experts,
resources, and an adequate methodology designed in a multidisciplinary way is
necessary more than ever at the present time. It should be controlled, and its
fulfillment should be demanded. It can be subjected to temporary modifications
according to the new evidences coming from studies about microbial resistance
in each institution of the Committee on Hospital Infection. The introduction
of a therapeutic modification in the medical attention has to be correctly assessed
in all its dimensions: scientific, technological, and social ones. For
all this, an adequate formation in the study of them is necessary.
The rational use of antibiotics
can have some benefits from the medical and social point of view, but, occasionally,
their use is not the most adequate one; that´s why the antibiotic therapy
should be subject to a special and systematic surveillance. When the microbiological
study is not possible for the selection of the antibiotic or there is not an
antibiogram, its selection should be made on local and epidemiological clinical
basis, but not on international reports since susceptibility varies on time
and space; then it is indispensable to count on reliable statistical and epidemiological
information that allows to give an appropriate and satisfactory treatment.
The new wisely used technologies,
that are at the service of society and the human wellbeing are one of the main
pillars for the satisfaction of the increasing needs in the health area. The
quality of medical attention goes on the way of economic efficiency since the
rational use of material, human, and financial resources at the moment expresses
a high scientific and technical qualification and work organization, which also
assures a greater use of these resources for the benefit of the patient.
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9. Fariña N. Resistencia bacteriana: un problema de salud pública mundial de difícil solución. Mem. Inst. Investig. Cienc. Salud [Internet]. 2016 Apr; 14(1): 04-05. [Cited: 2017 June 22]. Available from: http://dx.doi.org/10.18004/Mem.iics/1812-9528/2016.014(01)04-005
10. OMS. ¿Qué es la resistencia a los antimicrobianos? [Cited: 2017 Mar 18]. Available from: http://www.who.int/features/qa/75/es/
11. OMS. La OMS publica la lista de las bacterias para las que se necesitan emergentemente nuevos antibióticos. 27 Feb, 2017 | Ginebra. [Cited: 2017 March, 18]. Available at: http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/es/
12. Arbesú Michelen MA. Control of the use of antibiotics at the Cuban hospitals. Rev Cubana Farm [Internet]. 2014 Jun; 48(2): 165-167. [Cited: 2017 Jun 02]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75152014000200001&lng=es
13. De León Rosales SP, Hernández RA, Vidal YL. La resistencia a los antibióticos: Un grave problema global. Gaceta médica de México. 2015; 151(5), 681-689. [Cited: 2017 jun 22]. Available from: http//:ww.medigraphic.com/pdfs/gaceta/gm-2015/gm155r.pdf
14. Pérez Santana E, Pérez Pérez A, Mamposo Solano M, Pérez Pérez D. Importancia de la farmacia en la política antimicrobiana del Hospital Hermanos Ameijeiras. Rev Acta Médica 2011; 13(1):59-69.
15. Pasquau J, Svetlana Sadyrbaeva S, De Jesús S, Hidalgo-Tenorio C. El papel de los programas de optimización de la antibioterapia (PROA) en el control de las resistencias bacterianas. Rev Esp Quimioter. 2016; 29 (Suppl. 1): 47-51. [Cited: 2017 Mar 20]. Available from: http://seq.es/seq/0214-3429/29/sup1/11pasquau.pdf
16. Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312(1):90-2.
17. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013; 4.
18. Zilberberg MD, Shorr AF, Micek ST, Vazquez-Guillamet C, Kollef MH. Multi-drug resistance, inappropriate initial antibiotic therapy and mortality in Gram-negative severe sepsis and septic shock: a retrospective cohort study. Critical Care 2014; 18(6).
19. Elosua MC. Política de antibióticos. Revista de Medicina de la Universidad de Navarra, 2016; 20: 135.
20. Rodríguez Rondón Y, Pantoja Prosper C, Beatón Matamoros Ot, Zúñiga Moro A, Rodríguez Sánchez VZ. Antimicrobians prescription and their relationship with the bacterial resistance in a municipal general hospital. MEDISAN [Internet]. 2017 Mayo; 21(5):534-539. [Cited: 2017 Jun 02]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1029-30192017000500004&lng=es
21. Grade Working Group. Grading of recommendations of assessment development and evaluations [Internet]. Montreal: Grade Working Group. 2010. [Cited: 2017 Mar 18]. Available from: http://www.gradeworkinggroup.org/
22. OMS. Estrategia mundial OMS de contención de la resistencia a los antimicrobianos. Resolución WHA51.17. 1998. En: Estrategia mundial OMS de contención de la resistencia a los antimicrobianos. Resúmenes. CDS Centro de Recursos de Información. Ginebra. Suiza: Organización Mundial de la Salud; 2001.
23. Medina-Morales DA, Machado-Duque ME, Machado-Alba JE. Resistencia a antibióticos, una crisis global. Rev. Méd. Risaralda [Internet]. 2015; 21(1): 74. [Cited: 2017 Jun 22]. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0122-06672015000100013
24. Hernández Martínez EM, Marín Conde Y, Carrazana García D, Vales Almodóva M, Ramos Villanueva Y. Consumo y resistencia a los antibacterianos en un hospital de segundo nivel. Medicentro Electrónica [Internet]. 2016 Dec; 20(4): 268-277. [Cited: 2017 Jun 22]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1029-30432016000400004&lng=es
25. Medina I.D, Díaz J, Pérez G. Perfil microbiológico de las infecciones Nosocomiales en el Hospital Universitario Hernando Moncaleano Perdomo de Neiva. RFS, [S.l.], 2015 5(2): 41-51. ISSN 2389-9298. [Cited: 2017 Jun 22]. Available from: https://www.journalusco.edu.co/index.php/rfs/article/view/141/250
26. Ruvinsky S, Mónaco A, Pérez G, Taicz M, Inda L, Epelbaum C, et al. Efectividad de un programa para mejorar el uso de antibióticos en niños internados en un hospital pediátrico de tercer nivel de atención en Argentina. Arch. argent. pediatr. [Internet]. 2014 Apr; 112(2): 124-131. [Cited: 2017 Jun 22]. Available from: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0325-00752014000200004&lng=es
27. Zamora Marín R. Política de antibióticos en un hospital del tercer nivel, Conferencia Magistral. Hospital Hermanos Ameijeiras, La Habana: Septiembre 2007.
28. Serra Valdés MA. La resistencia microbiana en el contexto actual y la importancia del conocimiento y aplicación en la política antimicrobiana. Revista Habanera de Ciencias Médicas [revista en Internet]. 2017; 16(3): [aprox. 0 p.]. [Cited: 2017 Jun 16] Available from: http://www.revhabanera.sld.cu/index.php/rhab/article/view/2013
29. Fleitas Estévez AS. Terapia antimicrobiana utilizada de forma empírica y prudente en los pacientes con enfermedades vasculares periféricas. Rev Cubana Angiol Cir Vasc [Internet]. 2015 Dec; 16(2):190-204. [Cited: 2017 Jun 02]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1682-00372015000200007&lng=es
30. Massó RM, Honorato J, Giradles J, Sánchez O, Velasco J. Fundamentos de política antibiótica hospitalaria. Revista de Medicina de la Universidad de Navarra. 2016; 20: 221.
31. Rodríguez-Baño J, Pardo Pardo JR, Álvarez Rocha L, Asensio A, Calbo E, Cerce-Nado E, et al. Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH. Enferm Infecc Microbiol Clin. 2012; 30(22):1-23.
32. Raineri E, Pan A, Mondello P, Acquarolo A, Candiani A, Crema L. Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit. Am J Infect Control [Internet]. 2008; 36(4):283-90.
33. Cisneros JM, Pérez-Moreno MA, Gil-Navarro MV. Política de antibióticos. Comisión de infecciones y uso de antimicrobianos. Enfermedades Infecciosas y Microbiología Clínica. 2014; 32(8): 533-536.
34. Fiterre Lancis I, Mir Narbona I, Enseñat Sánchez R, Pisonero Sosias J, Pardo Gómez G, Guanche Garcell H. Calidad de prescripción de agentes antimicrobianos en pacientes hospitalizados en servicios clínicos. Rev cubana med [Internet]. 2011 Mar; 50(1): 49-56. [Cited: 2017 Jun 10]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75232011000100005&lng=es
35. Pinilla González R, Pisonero Socías JJ, Guanche Garcell H, Fiterre Lancis I, Mir Narbona I, Enseñat Sánchez R. Impacto de un programa de control en los consumos de antibióticos en pacientes quirúrgicos. Rev Cubana Cir [Internet]. 2013 Mar; 52(1): 2-12. [Cited: 2017 Jun 22]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932013000100002&lng=es
36. Guanche Garcell H, Enseñat Sánchez R, Fiterre Lancis I, Mir Narbona I, Pisonero Socías JJ, Pardo Gómez G,et al. Efectividad de un programa de control de antimicrobianos en una unidad de cuidados críticos en Cuba. Rev Cubana Cir 2011 Sep; 50(3): 249-256. [Cited: 2017 Jun 10]. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932011000300001&lng=es
37. Romero Viamonte K. Impacto farmacoeconómico de la revisión diaria de la prescripción de antibióticos controlados. Rev Cubana Farm [Internet]. 2014 Mar; 48(1): 55-62. [Cited: 2017 Jun 08] Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75152014000100007&lng=es
38. Ruvinsky S, Mónaco A, Pérez G, Taicz M, Inda L, Kijko I, et al. Motivos de la prescripción inadecuada de antibióticos en un hospital pediátrico de alta complejidad. Rev Pan Sal Publ. 2011; 30(6):580-5.
39. Partido Comunista de Cuba. Lineamientos de la Política Económica y Social del Partido y la Revolución. VI Congreso del Partido Comunista de Cuba. La Habana: PCC; 2011.
40. Bejerano Portela GM. Resolución No. 60/11: Normas del Sistema de Control Interno. La Habana: Contraloría General de la República de Cuba; 2011.
41. Ministerio de Salud Pública. Programa Nacional de Medicamentos. Versión VI. La Habana: MINSAP; 2012.
42. Instrucción General No. 206. Revisiones de los consumos de alimentos, medicamentos, fondos fijos y materiales de mantenimiento en las entidades del Sistema Nacional de Salud, Viceministerio de Economía. La Habana: MINSAP; 1989.
Received: June 18, 2017.
Approved: July 6, 2017.
Miguel
Ángel Serra Valdés. Universidad de Ciencias Médicas
de La Habana. La Habana, Cuba.
E-mail: maserra@infomed.sld.cu
1. Duque Vizcaíno M, Fiterre Lancis I, Alonso Galbán P, Castellanos García A. Uso inadecuado de antimicrobianos en pacientes con insuficiencia cardiaca descompensada. Rev Cubana Farm [Internet]. 2014 Sep; 48(3): 416-422. [Consultado: 2017 Jun 02]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75152014000300008&lng=es
2. Pisonero Socías JJ, Pardo Gómez G, Cabrera López N, Prieto Torres N, Piñeiro Fernández J, Lorenzo Álvarez O. Política de antibióticos. Rev Cubana Cir [Internet]. 1998 Dic; 37(3): 143-151. [Consultado: 2017 Jun 07]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74931998000300002&lng=es
3. Guanche Garcell H, Pisonero Socias JJ, Enseñat Sánchez R, Fiterre Lancis I, Mir Narbona I, García Arzola B, et al. Impacto de un programa de control de la calidad de la prescripción de antibióticos en un hospital de La Habana, Cuba. Rev Panamericana de la Salud. [Internet]. 2011; 30(6):598-602. [Consultado: 2017 Jun 17]. Disponible en: http://www.scielosp.org/pdf/rpsp/v30n6/a17v30n6
4. Guanche Garcell H, Izquierdo-Cubas F, Zambrano A. Uso de antimicrobianos en instituciones de salud de Cuba. MEDICRIT [Internet]. 2009;6(1):24-30. [Consultado: 30 abr 2017] Disponible en: https://www.researchgate.net/profile/Francisco_Izquierdo-Cubas/publication/47641887_Uso_de_Antimicrobianos_en_Instituciones_de_Salud_de_Cuba/links/02e7e517eed0006889000000.pdf
5. Navarro LH, Hernández A, & Vázquez EG. Estrategias para optimizar el uso de antibióticos en los hospitales. Rev Esp Quimioter,. 2017; 30(3): 169-176.
6. Organización Panamericana de la Salud [Internet]. Washington, DC: Resistencia antimicrobiana; 2011: [aprox. 10 pantallas]. [Consultado: 30 abr 2017]. Disponible en: http://www.paho.org/spanish/ad/dpc/cd/antimicrob.htm
7. Fernández Betancourt Y, Cardosa Aguilar E, Fernández Falcón L, Martínez Dedieu D. Utilización de la terapéutica antimicrobiana. Algunas consideraciones. Rev Inf Cient. [Internet]. 2015; 91(3):606-620. [Consultado: 30 abr 2017]. Disponible en: http://www.revinfcientifica.sld.cu/index.php/ric/article/view/237/1352
8. Rodríguez Rondón Y, Pantoja Prosper C, Beatón Matamoros O, Zúñiga Moro A, Rodríguez Sánchez V Z. Antimicrobians prescription and their relationship with the bacterial resistance in a municipal general hospital. MEDISAN [Internet]. 2017 Mayo; 21(5): 534-539. [Consultado: 2017 Jun 02]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1029-30192017000500004&lng=es
9. Fariña N. Resistencia bacteriana: un problema de salud pública mundial de difícil solución. Mem. Inst. Investig. Cienc. Salud [Internet]. 2016 Apr; 14(1): 04-05. [Consultado: 2017 June 22]. Available from: http://dx.doi.org/10.18004/Mem.iics/1812-9528/2016.014(01)04-005
10. OMS. ¿Qué es la resistencia a los antimicrobianos? [Consultado: 18 Mar 2017]. Disponible en: http://www.who.int/features/qa/75/es/
11. OMS. La OMS publica la lista de las bacterias para las que se necesitan emergentemente nuevos antibióticos. 27 de Febrero de 2017 | Ginebra. [Consultado 18 de marzo del 2017]. Disponible en: http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/es/
12. Arbesú Michelen MA. Control of the use of antibiotics at the Cuban hospitals. Rev Cubana Farm [Internet]. 2014 Jun; 48(2): 165-167. [Consultado: 2017 Jun 02]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75152014000200001&lng=es
13. De León Rosales SP, Hernández RA, Vidal YL. La resistencia a los antibióticos: Un grave problema global. Gaceta médica de México. 2015; 151(5), 681-689. [Consultado: 22 june 2017]. Disponible en: http//:ww.medigraphic.com/pdfs/gaceta/gm-2015/gm155r.pdf
14. Pérez Santana E, Pérez Pérez A, Mamposo Solano M, Pérez Pérez D. Importancia de la farmacia en la política antimicrobiana del Hospital Hermanos Ameijeiras. Rev Acta Médica 2011; 13(1):59-69.
15. Pasquau J, Svetlana Sadyrbaeva S, De Jesús S, Hidalgo-Tenorio C. El papel de los programas de optimización de la antibioterapia (PROA) en el control de las resistencias bacterianas. Rev Esp Quimioter. 2016; 29 (Suppl. 1): 47-51. [Consultado: 2017 Mar 20]. Disponible en: http://seq.es/seq/0214-3429/29/sup1/11pasquau.pdf
16. Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312(1):90-2.
17. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013; 4.
18. Zilberberg MD, Shorr AF, Micek ST, Vazquez-Guillamet C, Kollef MH. Multi-drug resistance, inappropriate initial antibiotic therapy and mortality in Gram-negative severe sepsis and septic shock: a retrospective cohort study. Critical Care 2014; 18(6).
19. Elosua MC. Política de antibióticos. Revista de Medicina de la Universidad de Navarra, 2016; 20: 135.
20. Rodríguez Rondón Y, Pantoja Prosper C, Beatón Matamoros Ot, Zúñiga Moro A, Rodríguez Sánchez VZ. Antimicrobians prescription and their relationship with the bacterial resistance in a municipal general hospital. MEDISAN [Internet]. 2017 Mayo; 21(5):534-539. [Consultado: 2017 Jun 02]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1029-30192017000500004&lng=es
21. Grade Working Group. Grading of recommendations of assessment development and evaluations [Internet]. Montreal: Grade Working Group. 2010. [Consultado: 18 Mar 2017]. Disponible en: http://www.gradeworkinggroup.org/
22. OMS. Estrategia mundial OMS de contención de la resistencia a los antimicrobianos. Resolución WHA51.17. 1998. En: Estrategia mundial OMS de contención de la resistencia a los antimicrobianos. Resúmenes. CDS Centro de Recursos de Información. Ginebra. Suiza: Organización Mundial de la Salud; 2001.
23. Medina-Morales DA, Machado-Duque ME, Machado-Alba JE. Resistencia a antibióticos, una crisis global. Rev. Méd. Risaralda [Internet]. 2015; 21(1): 74. [Consultado: 2017 Jun 22]. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0122-06672015000100013
24. Hernández Martínez EM, Marín Conde Y, Carrazana García D, Vales Almodóva M, Ramos Villanueva Y. Consumo y resistencia a los antibacterianos en un hospital de segundo nivel. Medicentro Electrónica [Internet]. 2016 Dic; 20(4): 268-277. [Consultado: 2017 Jun 22]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1029-30432016000400004&lng=es
25. Medina I.D, Díaz J, Pérez G. Perfil microbiológico de las infecciones Nosocomiales en el Hospital Universitario Hernando Moncaleano Perdomo de Neiva. RFS, [S.l.], 2015 5(2): 41-51. ISSN 2389-9298. [Consultado: 22 june 2017]. Disponible en: https://www.journalusco.edu.co/index.php/rfs/article/view/141/250
26. Ruvinsky S, Mónaco A, Pérez G, Taicz M, Inda L, Epelbaum C, et al. Efectividad de un programa para mejorar el uso de antibióticos en niños internados en un hospital pediátrico de tercer nivel de atención en Argentina. Arch. argent. pediatr. [Internet]. 2014 Abr; 112(2): 124-131. [Consultado: 2017 Jun 22]. Disponible en: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0325-00752014000200004&lng=es
27. Zamora Marín R. Política de antibióticos en un hospital del tercer nivel, Conferencia Magistral. Hospital Hermanos Ameijeiras, La Habana: Septiembre 2007.
28. Serra Valdés MA. La resistencia microbiana en el contexto actual y la importancia del conocimiento y aplicación en la política antimicrobiana. Revista Habanera de Ciencias Médicas [revista en Internet]. 2017; 16(3): [aprox. 0 p.]. [Consultado: 2017 Jun 16] Disponible en: http://www.revhabanera.sld.cu/index.php/rhab/article/view/2013
29. Fleitas Estévez AS. Terapia antimicrobiana utilizada de forma empírica y prudente en los pacientes con enfermedades vasculares periféricas. Rev Cubana Angiol Cir Vasc [Internet]. 2015 Dic; 16(2): 190-204. [Consultado: 2017 Jun 02]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1682-00372015000200007&lng=es
30. Massó RM, Honorato J, Giradles J, Sánchez O, Velasco J. Fundamentos de política antibiótica hospitalaria. Revista de Medicina de la Universidad de Navarra. 2016; 20: 221.
31. Rodríguez-Baño J, Pardo Pardo JR, Álvarez Rocha L, Asensio A, Calbo E, Cerce-Nado E, et al. Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH. Enferm Infecc Microbiol Clin. 2012; 30(22):1-23.
32. Raineri E, Pan A, Mondello P, Acquarolo A, Candiani A, Crema L. Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit. Am J Infect Control [Internet]. 2008; 36(4):283-90.
33. Cisneros JM, Pérez-Moreno MA, Gil-Navarro MV. Política de antibióticos. Comisión de infecciones y uso de antimicrobianos. Enfermedades Infecciosas y Microbiología Clínica. 2014; 32(8): 533-536.
34. Fiterre Lancis I, Mir Narbona I, Enseñat Sánchez R, Pisonero Sosias J, Pardo Gómez G, Guanche Garcell H. Calidad de prescripción de agentes antimicrobianos en pacientes hospitalizados en servicios clínicos. Rev cubana med [Internet]. 2011 Mar; 50(1): 49-56. [Consultado: 2017 Jun 10]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75232011000100005&lng=es
35. Pinilla González R, Pisonero Socías JJ, Guanche Garcell H, Fiterre Lancis I, Mir Narbona I, Enseñat Sánchez R. Impacto de un programa de control en los consumos de antibióticos en pacientes quirúrgicos. Rev Cubana Cir [Internet]. 2013 Mar; 52(1): 2-12. [Consultado: 2017 Jun 22]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932013000100002&lng=es
36. Guanche Garcell H, Enseñat Sánchez R, Fiterre Lancis I, Mir Narbona I, Pisonero Socías JJ, Pardo Gómez G,et al. Efectividad de un programa de control de antimicrobianos en una unidad de cuidados críticos en Cuba. Rev Cubana Cir 2011 Sep; 50(3): 249-256. [Consultado: 2017 Jun 10]. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932011000300001&lng=es
37. Romero Viamonte K. Impacto farmacoeconómico de la revisión diaria de la prescripción de antibióticos controlados. Rev Cubana Farm [Internet]. 2014 Mar; 48(1): 55-62. [Consultado: 2017 Jun 08] Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75152014000100007&lng=es
38. Ruvinsky S, Mónaco A, Pérez G, Taicz M, Inda L, Kijko I, et al. Motivos de la prescripción inadecuada de antibióticos en un hospital pediátrico de alta complejidad. Rev Pan Sal Publ. 2011; 30(6):580-5.
39. Partido Comunista de Cuba. Lineamientos de la Política Económica y Social del Partido y la Revolución. VI Congreso del Partido Comunista de Cuba. La Habana: PCC; 2011.
40. Bejerano Portela GM. Resolución No. 60/11: Normas del Sistema de Control Interno. La Habana: Contraloría General de la República de Cuba; 2011.
41. Ministerio de Salud Pública. Programa Nacional de Medicamentos. Versión VI. La Habana: MINSAP; 2012.
42. Instrucción General No. 206. Revisiones de los consumos de alimentos, medicamentos, fondos fijos y materiales de mantenimiento en las entidades del Sistema Nacional de Salud, Viceministerio de Economía. La Habana: MINSAP; 1989.