Multimodal intervention to promote antimicrobial stewardship and reduce device-associated infections in intensive care units of hospitals in Paraguay, 2021-2023.

The effective implementation of antimicrobial stewardship programs (ASP) that are well integrated with infection prevention and control (IPC) programs have proven to prevent the emergence and transmission of multidrug-resistant organisms (MDROs) in health care settings, particularly in intensive care units (ICUs). In Paraguay, similarly to other countries in Latin America, the development of ASP at the local level has been challenging, and has reached varying degrees of implementation across the country. In order to address this gap, the Ministry of Public Health and Social Welfare, through the Communicable Disease Surveillance Directorate (DIVET), requested the support of the Pan American Health Organization (PAHO) to pilot a multimodal intervention for the prevention and control of device-associated infections (catheter-associated bloodstream infections, catheter-associated urinary tract infections and ventilator-associated pneumonia) and optimization of antimicrobial use in adult and pediatric ICUs in Paraguayan hospitals. The project, denominated “INTEGRAR”, began in November 2021 and its pilot phase was completed in March 2023, informing the development of a national roll-out proposal. Five public hospitals and one social security hospital (non-profit center providing treatment to syndicated patients) participated in the project, namely Itaugua National Hospital; Trauma Hospital "Dr. Manuel Giagni"; Institute of Tropical Medicine; National Cardiology Institute - San Jorge; Regional Hospital of Encarnacion; Central Hospital - Social Security Institute. All hospitals had IPC programs implemented prior to this project. The proposal was aligned with Paraguay’s National Action Plan on antimicrobial resistance (AMR) (2019-23), specifically the strategic lines of action of aiming to reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures and optimizing the use of antimicrobials in human health.

✓ Post-intervention (3 months): data analysis, final report and dissemination.

Building on the existing IPC committees, IPC teams (Table 1) including an infectious diseases specialist, microbiologist and IPC nurse, with the new inclusion of a pharmacy staff member, were committed to improve the IPC program and to incorporate antimicrobial stewardship capacity according to their specific role (infectious diseases specialist: adaptation of clinical guidelines for common infections, pre-authorization of restricted antimicrobials, prospective audit with feedback; microbiologist: diagnostic stewardship; IPC personnel: hand hygiene, isolation measures, environmental cleaning and disinfection and bundles; pharmacy staff member: dosage adjustments and optimization of duration of treatments based on recommendations in the Proanet app). All team members took part in data collection on adherence to preventive measures, incidence of device-associated infections and MDRO infections and antimicrobial use and consumption surveillance.

The multidisciplinary teams received tailored training in antimicrobial stewardship by PAHO, including in the implementation, monitoring and evaluation of an ASP. An open access platform (www.proanet.org) was used to record data and allowed participating hospitals to monitor their progress and compare it to that of other hospitals, while ensuring data confidentiality. In addition, a free mobile app that provides access to clinical guidelines and antimicrobial dosage (Proanet app) was distributed. Previously validated instruments were used to determine the level of development of IPC programs1 and ASP2 and capacities in place. Based on the self-evaluations, opportunities for improvement were identified and prioritized with a matrix, which made it possible to identify strategies, objectives, personnel in charge and evaluation indicators. Local teams recorded, on a monthly basis in Proanet, data on adherence to preventive measures, the reason for use of central venous catheter, urinary catheter or mechanical ventilation, and the incidence of infections associated with these devices. In addition, the use of antimicrobials was recorded through appropriateness indicators using a one-day prevalence survey and the monthly consumption of these agents measured in Defined Daily Doses (DDD) per 100 patient-days. Throughout the project, monthly follow-up meetings were held with the teams of the participating hospitals led by a representative of DIVET (AB) and PAHO (RQ). During the meetings, each team presented the strategies implemented and the evolution of IPC and antimicrobial stewardship indicators in order to make the necessary adjustments.

Main findings

Overall, participating hospitals showed a good level of development of IPC programs at baseline using the IPC Assessment Framework at the Facility Level (1 advanced and 5 intermediate) and the project allowed to further identify opportunities for their consolidation. On the other hand, ASP were generally less developed (1 intermediate and 5 basic) and their assessment also led to tailored recommendations for improvement (i.e. specific intervention strategies, antimicrobial use and consumption indicator monitoring, prescriber education and training). The review of the indicators measuring appropriateness of antimicrobial use led to informed specific antimicrobial stewardship interventions. Throughout implementation, the average adult ICU antimicrobial consumption was 110 DDD per 100 patient-days, and a progressive decrease in total antimicrobial consumption in adult ICUs was observed (Figure 1), accompanied with improvements in appropriateness (i.e. 30% improvement in adherence to clinical guidelines). An analysis of antimicrobial consumption by AWaRe classification demonstrated a distribution of Access: 26%; Watch: 42%, and Reserve: 32%. Reserve antibiotic use largely consisted of colistin and tigecycline. Although an increase in adherence to preventive measures was observed, the rates of device-associated infections remained at levels above expected values. There were no significant changes observed for in-ICU mortality. During implementation, barriers which hindered implementation included: lack of a specific budget, work overload, lack of standardization of processes, resistance from medical chiefs, and limited support from information technology for data collection. On the other hand, the existence of a previously developed IPC program, support of senior hospital management, as well as active involvement of DIVET authorities were identified as enablers. These enablers were used to mitigate the barriers identified, through the empowerment of the teams and the provision of technical support and material resources.

The findings of this pilot were shared with national authorities and teams of the participating institutions, as well as with DIVET authorities, and presented at a workshop held in August 2023. Recognizing its value, national authorities committed to sustaining the initiative and to extend it to other hospitals through training and logistical support.

Conclusion

This innovative initiative from Paraguay demonstrated a reduction in antimicrobial consumption by implementing and/or strengthening IPC programs and ASP in a coordinated and integrated manner at the local level. In addition, it was possible to measure the impact of these measures on the rate of device-associated infections, incidence of MDRO infections and in-ICU mortality rate. Reserve antibiotics made up a significant proportion of total antibiotic consumption in the participating ICUs and warrants further investigation and development of strategies to improve and reduce use. This model, still rare in Latin America and the Caribbean, holds great promise to optimize AMR containment.

During implementation, the teams were engaged and benefitted from online and in-person training and exchanges including online regional mentoring sessions. Some teams developed local guidelines for antimicrobial prescribing and use and conducted training for health professionals in their own facilities. In addition, communication between the infectious disease specialists, microbiologists, infection control personnel and pharmacy staff were strengthened through coordinated work. Finally, the collaboration between DIVET and PAHO country and regional offices contributed to establishing a constructive network of multidisciplinary professionals that shared knowledge and good practices, thus contributing to strengthening IPC programs and ASP. The network also integrated antimicrobial surveillance data and key stakeholders such as the national reference laboratory for AMR, given its importance to optimize decision-making for patient treatment at the local level and public health decision-making at all levels.

Figure 1. Progressive decrease in the use of common antimicrobial classes across 6 participating hospitals between March to December 2022.

The “INTEGRAR” Project Team: Ada Brizuela, Ana Laura Nuñez; Francisco Ovando, and Viviana De Egea, Communicable Disease Surveillance Directorate, “DIVET” by its Spanish acronym (Dirección de Vigilancia de Enfermedades Transmisibles) - Ministry of Public Health and Social Welfare of Paraguay; Rodolfo Quirós, Marcelo Galas, and Romeo Montoya, Pan American Health Organization (PAHO); and participating hospitals (see list below).

Table 1. Members of the IPC programs and ASP teams in participating hospitals, INTEGRAR project, 2021-2023, Paraguay.