Impacto de un programa de optimización de uso de antimicrobianos en un hospital pediátrico de tercer nivel en Panamá / Impact of an antimicrobial stewardship program in a pediatric third level hospital in Panama

Resumen Introducción: Los programas de optimización de uso de antimicrobianos (PROA) se enfocan en el uso apropiado de antimicrobianos para ofrecer mejores resultados clínicos y menores riesgos de eventos adversos. Objetivos: Comparar consumo y costos de antimicrobianos antes y después de instauración de un programa de regulación de antimicrobianos y describir la proporción de resistencia de bacterias prioritarias. Métodos: Estudio cuasi-experimental, retrospectivo y prospectivo, descriptivo y analítico, que comparó el consumo y costo de antimicrobianos en un período pre- intervención (2007-2010) y un período post-intervención (2011-2017). Se realizó análisis descriptivo de resistencias bacterianas prioritarias. Resultados: El consumo de gentamicina, vancomicina, meropenem, cefotaxima, ceftazidima e imipenem disminuyó significativamente en el período post-intervención comparado con el período pre-intervención (p < 0,05), mientras que el consumo de amikacina, piperacilina/tazobactam, cefepime y levofloxacina en el período post-intervención mostró un aumento significativo. La reducción de costos no fue significativa para gentamicina, vancomicina, meropenem, cefotaxima, ceftazidima e imipenem. Para amikacina, cefepime, piperacilina/tazobactam y levofloxacina el aumento de costos no fue significativo. Los aislamientos de Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus y Enterococcus faecalis disminuyeron durante el período post-intervención. Conclusión: el PROA demostró disminución en consumo y costos de algunos antimicrobianos.

Abstract Background: Antimicrobial Stewardship Programs (ASP) focus in the appropriate use of antimicrobials to improve clinical results and minimize risk of adverse events. Aims: To compare consumption and costs of antimicrobials before and after the establishment of an antimicrobial stewardship program and to describe the resistance proportion of priority bacteria. Methods: Quasi-experimental, retrospective and prospective, descriptive and analytical study, to compare consumption and costs of antimicrobials in a pre- intervention period (2007-2010) and a post- intervention period (2011-2017). Additionally, a descriptive analysis of bacterial resistance from 2010 was performed. Results: Gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem consumption decreased significantly in the post-intervention period compared to the pre-intervention period (p < 0.05) while consumption of amikacin, piperacillin/tazobactam, cefepime and levofloxacin increased significantly in the post-intervention period. The reduction in costs was not significant for gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem, meanwhile, costs increased for amikacin, piperacillin/tazobactam, cefepime and levofloxacin, but this was not significant. The isolation of Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus and Enterococcus faecalis decreased during the post-intervention period. Conclusion: The ASP showed a decrease in consumption and costs of some antimicrobials.

Níveis de prevenção cardiovascular / Cardiovascular disease prevention levels

Epidemiologia clínica é o campo de conhecimento que estuda as melhores práticas assistenciais, com foco nos interesses do paciente de compartilhar as decisões com os médicos e demais profissionais de saúde que realizam o atendimento ou prestam cuida-dos. Vale-se da mesma metodologia usada pela epidemiologia tradicional para qualificar e desenvolver a pesquisa aplicada à prática clínica. A vacinação contra a febre amarela, mostra bem a diferença entre os interesses da epidemiologia clínica e os da epidemiologia tradicional. A estratégia populacional pode trazer muitos benefícios para a coletividade que, no geral, apresenta baixo risco e muitos malefícios para um grupo muito menor de indivíduos de alto risco. Os padrões de ações preventivas modificam-se de acordo com a evolução no tempo. Além da prevenção primordial, primária, secundária e terciária este texto discute a prevenção quaternária por meio de ações que visam evitar os danos associados ao uso excessivo de procedimentos diagnósticos e terapêuticos. O diálogo sobre saúde é um contraponto entre o saber científico e o saber popular, a informação dada a partir do conhecimento prévio do indivíduo e da comunidade deve respeitar seus valores, como exemplificado por trabalhos realizados em escolas de ensino fundamental.

Clinical Epidemiology is the field of knowledge that studies the best care practices, focusing on the patient's interest in sharing decisions with physicians and other health professionals who provide treatment or health care. It employs the same methodology used by traditional epidemiology to qualify and develop research applied to clinical practice. Vaccination against yellow fever clearly shows the difference between the interests of clinical epidemiology and those of traditional epidemiology. Population strategy can produce many benefits for society as a whole, which generally involves a lower risk, to the detriment of a much smaller group of high-risk individuals. Preventive care patterns change according to temporal evolution. In addition to primordial, primary, secondary and tertiary prevention, this text also discusses quaternary prevention through actions aimed at avoiding the damage associated with the excessive use of diagnostic and therapeutic procedures. The dialogue on health is a counterpoint between scientific knowledge and common knowledge. Information produced from the prior knowledge of the individual and the community must respect their values, as exemplified by work carried out in elementary schools

Costo-efectividad de prácticas en salud pública: revisión bibliográfica de las intervenciones de la Iniciativa Mesoamericana de Salud / Cost-effectiveness of public health practices: A literature review of public health interventions from the Mesoamerican Health Initiative

OBJETIVO: Presentar y analizar información de costo-efectividad de intervenciones propuestas por la Iniciativa Mesoamericana de Salud (IMS) en las áreas de nutrición infantil, inmunizaciones, paludismo, dengue y salud materno-infantil y reproductiva. MATERIAL Y MÉTODOS: Se llevó a cabo una revisión sistemática de la literatura de evaluaciones económicas publicadas entre el año 2000 y agosto 2009 sobre intervenciones en las áreas de la salud mencionadas, en los idiomas inglés y español. RESULTADOS: Las intervenciones en nutrición y de salud materno-infantil mostraron ser altamente costo-efectivas (con rangos menores a US$200 por año de vida ajustado por discapacidad [AVAD] evitado para nutrición y US$100 para materno-infantil). En dengue sólo se encontró información sobre la aplicación de larvicidas, cuya razón de costo efectividad estimada fue de US$40.79 a US$345.06 por AVAD evitado. Respecto al paludismo, las intervenciones estudiadas resultaron costo-efectivas (

OBJECTIVE: Present and analyze cost-effectiveness information of public health interventions proposed by the Mesoamerican Health Initiative in child nutrition, vaccination, malaria, dengue, and maternal, neonatal, and reproductive health. MATERIAL AND METHODS: A systematic literature review was conducted on cost-effectiveness studies published between January 2000 and August 2009 on interventions related to the health areas previously mentioned. Studies were included if they measured effectiveness in terms of Disability-Adjusted Life Year (DALY) or death averted. RESULTS: Child nutrition and maternal and neonatal health interventions were found to be highly cost-effective (most of them below US$200 per DALY averted for nutritional interventions and US$100 for maternal and neonatal health). For dengue, information on cost-effectiveness was found just for application of larvicides, which resulted in a cost per DALY averted ranking from US$40.79 to US$345.06. Malarial interventions were found to be cost-effective (below US$150 per DALY averted or US$4,000 per death averted within Africa). In the case of pneumococcus and rotavirus vaccination, cost-effectiveness estimates were always above one GDP per capita per DALY averted. CONCLUSIONS: In Mesoamerica there are still important challenges in child nutrition, vaccination, malaria, dengue and maternal, neonatal, and reproductive health, challenges that could be addressed by scaling-up technically feasible and cost-effective interventions.

Diseño mixto de evaluación de la iniciativa Salud Mesoamérica 2015 / Mixed design for the evaluation of the Mesoamerica Health 2015 initiative

El propósito de la iniciativa Salud Mesoamérica 2015 (SM-2015) es mejorar el estado de salud y nutrición de la población con mayor grado de vulnerabilidad en Mesoamérica. El objetivo de la evaluación es generar evidencia sobre la efectividad conjunta de un paquete de intervenciones diseñadas para mejorar las condiciones de salud en la región. Se propone una evaluación de impacto con métodos mixtos, para conocer la magnitud de los cambios atribuibles a la SM-2015, e identificar los significados de estos cambios para la población objetivo, en el contexto de cada país. El eje conductor es un panel de localidades con el que se colectará información de individuos, hogares y unidades de salud de primero y segundo nivel de atención. El diseño que se describe en este documento fue desarrollado entre junio y diciembre de 2009, y su articulación se llevó a cabo en talleres realizados en Cuernavaca (México), Managua (Nicaragua), y San José (Costa Rica). El diseño propuesto permitirá generar evidencia sobre la efectividad conjunta del paquete de intervenciones propuesto en los planes maestros mesoamericanos. El éxito de este diseño radica en la voluntad y en el compromiso político de los países y los donantes.

Since the Salud Mesoamerica 2015 initiative (SM-2015) aim is to improve health and nutrition conditions of those most vulnerable in Mesoamerica, the goal of the evaluation is to generate evidence of the joint effectiveness of a package of interventions designed to improve the health conditions. We propose a mix design for the evaluation, which will allow to know the magnitude of changes attributable to the interventions, as well as the meanings of these changes for the target population, taking into account the specificities of each country. The main axis of this design is a locality panel where information about individuals, households, and health facilities (first and second level) will also be collected. The evaluation design described in this paper was developed between June and December, 2009, and it was integrated during workshops in Cuernavaca (Mexico), Managua (Nicaragua), and San Jose (Costa Rica). The proposed design will allow to generate evidence about the joint effectiveness of the package of interventions proposed for the SM-2015. The success of this design rests on the political commitment of countries and donors.

Custos diretos do programa de prevenção e controle da dengue no Município de São Paulo em 2005 / Direct costs of the dengue fever control and prevention program in 2005 in the City of São Paulo

Objetivo: Estimar o custo direto da prevenção e controle do Aedes aegypti no Programa Municipal de Controle da Dengue (PMCD) no Município de São Paulo, Brasil, em 2005. Métodos: Os seguintes itens foram considerados: recursos humanos, uniformes, material de campo, equipamento de proteção individual, equipamentos de pulverização e nebulização, insumos estratégicos (inseticidas e larvicidas) e veículos. Foram calculados os custos das ações de laboratório destinadas à vigilância entomológica e diagnóstico da doença, os custos do sistema de informação e material gráfico destinado às campanhas educativas e de informação. Resultados: O custo total do PMCD foi de R$ 21 774 282,82 em 2005 (US$ 12 486 941,34 considerando-se a taxa de câmbio dólar/real vigente em dezembro de 2009). Desse total, 59,4, 38,3 e 2,2 por cento, respectivamente, foram utilizados em gastos de pessoal, custeio e capital. O valor per capita gasto no combate ao vetor foi de R$ 1,99. Conclusões: O controle da dengue é imperativo diante do crescimento das epidemias. O conhecimento acerca dos custos das estratégias de ação e dos componentes prioritários dos programas de prevenção e controle da dengue pode orientar a tomada de decisões quanto à aplicação dos recursos orçamentários disponíveis tanto no Município de São Paulo como em todo o Brasil.

Objective: To estimate the direct costs associated with the control of Aedes aegypti and prevention of dengue fever in the City of São Paulo Dengue Control Program, Brazil, in 2005. Method: The following items were considered: human resources, uniforms, field materials, individual protection equipment, spraying equipment, strategic supplies (insecticides and larvicides), and vehicles. The costs associated with laboratory tests for entomological surveillance and dengue fever diagnosis were also calculated, as well as costs relating to information and printed materials for educational campaigns. Results: The total direct costs of the City of São Paulo Dengue Fever Program in 2005 were R$ 21 774 282.82 (US$ 12 486 941.34 considering the dollar/real exchange rate in December 2009). Of this amount, 59.4 percent were directed to human resources, 38.3 percent to epidemic control measures, and 2.2 percent to capital expenditure. The cost per capita was R$ 1.99 in 2005. Conclusions: The control of dengue fever is essential given the growth of epidemics. Knowledge about the costs of strategies and priority items employed in dengue fever control and prevention programs can guide decision-making regarding the application of budget resources in both the City of São Paulo and Brazil as a whole.

Mapeando programas de redução de danos da Região Metropolitana de Porto Alegre, Rio Grande do Sul, Brasil / Mapping harm reduction programs in Greater Metropolitan Porto Alegre, Rio Grande do Sul State, Brazil

Neste estudo mapeamos e descrevemos 11 programas/ações em redução de danos vigentes nos anos de 2004 a 2006, na Região Metropolitana de Porto Alegre, Rio Grande do Sul, Brasil. A descrição e análise se construíram por meio de entrevistas com as coordenações dos programas, de análise documental e da comparação com um mapeamento realizado em 2003. Buscou-se discutir a sustentabilidade (política, financeira e administrativa) e as características de funcionamento dos programas. A análise utilizou as seguintes categorias: tipo de vínculo do programa/ação; formas de inserção nos municípios; histórico, financiamento; ações típicas; forma de contratação da equipe; existência de trabalho voluntário; recursos (humanos e financeiros); parcerias; existência de legislação municipal; e participação em espaços de representação política. Apesar da diversidade de vínculos e formas de organização dos locais analisados, algumas características são comuns, como: inserção profissional precária; dependência do trabalho voluntário para a execução das atividades; influência das mudanças de gestão municipal e estadual para a continuidade de projetos e de parcerias, assim como para a manutenção de recursos humanos e financeiros dos programas. Concluímos que estes elementos geram descontinuidade no atendimento à população.

This study mapped and described 11 harm reduction interventions/programs in Greater Metropolitan Porto Alegre, Rio Grande do Sul State, Brazil, in 2004-2006. Mapping was based on interviews and analysis of available documents and comparison with a previous study with data from 2003. We aimed to discuss the programs' sustainability (political, financial, and administrative) and operational characteristics, based on the following categories: type of links in the program or intervention; forms of inclusion in the municipalities; background, financing; typical activities; team hiring practices; volunteer work, if any; resources (human and financial); partnerships; municipal legislation, if any; and participation in forums for political representation. Despite the diversity of links and organizational formats, there were some common characteristics: precarious professional status; dependence on volunteer work to implement activities; influence of turnover in Municipal and State administration on the continuity of projects and partnerships, as well as on the maintenance of human and financial resources. We conclude that such factors lead to lack of continuity in the services provided to the target population.

Universal vaccination of children against hepatitis a in Chile: a cost-effectiveness study / La vacunación infantil universal contra la hepatitis a en Chile: análisis de la relación costo-efectividad

OBJECTIVE: To evaluate the healthcare and economic impact of routine hepatitis A vaccination of toddlers in Chile. METHODS: We used a dynamic model of hepatitis A infection to evaluate the impact of a two-dose vaccination program, administered at ages 12 and 18 months. The model incorporated the changing epidemiology of hepatitis A in Chile and the development of vaccine-induced herd immunity. Our analysis was conducted from the public payer perspective, and an estimation of the societal perspective was performed. Costs are expressed in 2005 U.S. dollars. RESULTS: Vaccination of toddlers rapidly reduced the healthcare burden of hepatitis A. In the base case (95 percent vaccination coverage, 100-year time horizon, 1 percent annual decrease in force of infection), the average number of infections fell by 76.6 percent annually, and associated deaths fell by 59.7 percent. Even at 50 percent coverage, the program reduced infection rates substantially. Routine vaccination of toddlers had economic as well as health benefits, saving $4 984 per life-year gained (base case scenario). The program became cost saving after 6 years, and its overall cost-effectiveness per life-year gained was largely unaffected by changes in disease-related costs, herd immunity, coverage rate, and annual decrease in force of infection. CONCLUSIONS: Routine vaccination of toddlers will reduce the rates of symptomatic hepatitis A and associated mortality. The two-dose schedule evaluated here will be less expensive than disease-related costs in the absence of vaccination from the sixth year of its implementation. These findings support the establishment of a routine vaccination program for toddlers in Chile.

OBJETIVO: Evaluar el impacto sanitario y económico de la vacunación sistemática de infantes contra la hepatitis A en Chile. MÉTODOS: Se empleó un modelo dinámico de hepatitis A para evaluar el impacto de un programa de vacunación de dos dosis administradas a los 12 y 18 meses. El modelo incorporó la epidemiología cambiante de la hepatitis A en Chile y la aparición de la inmunidad de grupo inducida por la vacuna. El análisis se realizó desde la perspectiva del financiador público y se hizo un estimado desde la perspectiva de la sociedad. Los costos se expresaron en dólares estadounidenses del año 2005. RESULTADOS: La vacunación de los infantes redujo rápidamente la carga de la hepatitis A para los servicios de salud. En la variante de base (cobertura de la vacunación: 95 por ciento; horizonte temporal: 100 años; reducción anual de la virulencia de la infección: 1 por ciento), el número promedio de casos se redujo anualmente en 76 por ciento y el número de muertes asociadas disminuyó en 59,7 por ciento. Incluso con una cobertura de vacunación de 50 por ciento, el programa redujo notablemente la tasa de infección. La vacunación sistemática de los infantes presentó beneficios económicos y sanitarios y ahorró US$ 4 984,00 por año de vida ganado (en el escenario base). El programa generó ahorros a partir del sexto año y la efectividad general en función del costo por año de vida ganado no se afectó por cambios en los costos relacionados con la enfermedad, la inmunidad de grupo, la cobertura de vacunación o la reducción anual de la virulencia de la infección. CONCLUSIONES: La vacunación sistemática de los infantes reduciría la tasa de hepatitis A sintomática y la mortalidad asociada. A partir del sexto año del programa, los costos de aplicar el esquema evaluado de dos dosis serían menores que los relacionados con la enfermedad si no se aplicara la vacuna. Estos resultados apoyan la implantación de programas de vacunación sistemática de infantes...

[Costs of basic health services in a health district in Tunisia]

Information on the cost of health services is essential for good planning and management and the efficient use of resources. We calculated the total costs incurred in running primary health services for one year [1995] in the health district of Enfidha [Tunisia]. The yearly operating expenditure for the health district was 1 219 099 Tunisian dinars and the cost per inhabitant was 17.494 dinars [US dollar 1 = Tunisian dinar 0.950 in 1995]; 65.37% of total costs went on staff and 17.03% on drugs. Looked at another way, 84,96% went on curative services and 14.04% on preventive services.The cost of a consultation for curative care was 6.847dinars, for perinatal care was 2.764 dinars, for immunization was 3.680 and for school visit was 6.680 dinars. The study helps to identify ways in which cost analysis can be used to explore efficiency and resource adequacy in the district

Assembly-line health check up in digitalized hospital / 华中科技大学学报（医学）（英德文版）

The health check up flow of digital hospital can be consulted with the assembly line of industry factory. Because they have the following same features: highly specialized workstation, closeness and continuance, rhythm, balanced production, continuous production. The essential prerequisites are as the follows: The inspecting items and methods should be stable; advanced product mix and stable production design; standardized raw material, consumption, procedure, inspection method; there are lots of request for health inspection; the customers move at the least unit; the space arrangement should be reasonable; the time arrangement should be proportion. With the computer net, the digital inspection can achieves the raw material controlling accurately. The basis of check up line concerns about equipment, net and software, data collection, and personnel. The group technology is used in the health inspection flow design of the digital hospital in the field of items customers and zone redivided. The digital assembly linemic health inspect has the following stages: member registering, notice, check in, arrange order, time control, report, feedback and analysis. The assembly linemic has following advantages: increasing the productivity, the space utility, satisfaction of customer, fund returning, lowering the cost and ensuring the quality.

Field activity cost estimates for the first 3 years of the World Bank Loan Project for schistosomiasis control in China.

The World Bank Loan Project for schistosomiasis in China commenced field activities in 1992. In this paper, we describe disease control strategies for levels of different endemicity, and estimate unit costs and total expenditure of screening, treatment (cattle and humans) and snail control for 8 provinces where Schistosoma japonicum infection is endemic. Overall, we estimate that more than 21 million US dollars were spent on field activities during the first three years of the project. Mollusciciding (43% of the total expenditure) and screening (28% of the total) are estimated to have the most expensive field activities. However, despite the expense of screening, a simple model predicts that selective chemotherapy could have been cheaper than mass chemotherapy in areas where infection prevalence was higher than 15%, which was the threshold for mass chemotherapy intervention. It is concluded that considerable cost savings could be made in the future by narrowing the scope of snail control activities, redefining the threshold infection prevalence for mass chemotherapy, defining smaller administrative units, and developing rapid assessment tools.

From research to practice: use of short course zidovudine to prevent mother-to-child HIV transmission in the context of routine health care in Northern Thailand.

Thailand has made remarkable progress in battling the HIVepidemic, as the decreases in HIV prevalence and changes in sexual behavior attest. Yet, in Phayao, a northern province severely affected by HIV, approximately 280 HIV-infected women, or 5% of all pregnant women, gave birth to an estimated 70 infected children in 1997. As many of these infants die within their first year of life, the infant mortality rate is on the rise after years of decline. The province, however, responded quickly to this crisis. Since July 1997, the Ministry of Public Health (MOPH) offers through Phayao's seven public hospitals a short regimen of zidovudine to all consenting HIV-infected women to prevent mother-to-child transmission of the virus. The overall prophylactic coverage for the province reached 68% of all HIV-infected pregnant women in the fourth quarter of 1997, either through the MOPH program or through the North Thailand Perinatal HIV Prevention Trial, the parallel clinical trial conducted by the MOPH and the Ministry of University Affairs. Analysis of the data collected showed that compliance to the intervention was excellent, around 90%. This was achieved at an additional cost of US$ 0.13 per capita per year, affordable even in the context of the economic crisis, and represents less than 1% of public health expenditures in Thailand. The cost per Disability Adjusted Life Years saved is approximately US$35, making it highly cost-effective. In less than a year, the MOPH implemented this program on a large scale in this relatively poor province, with limited external support. Women receive pretest counseling at their first prenatal visit, are offered HIV testing and, if they accept, return for posttest counseling two weeks later. In the case of a positive test result, a confirmation test is performed at the provincial hospital. HIV-infected women are offered zidovudine the 34th week of pregnancy or as soon as possible thereafter. Before starting treatment, the women's hemoglobin, CBC and platelets are measured. Infants begin taking oral zidovudine shortly after birth and continue until they are one week old. Subsequently, health centers regularly follow the infants, and volunteers provide case management of childhood illness, nutrition problem solving, childhood immunizations and home visits. Mothers feed the infants breastmilk substitutes, and women with insufficient income receive the substitutes free of charge. The northern Thailand experience provides important insights into the feasibility of large scale interventions to prevent perinatal HIV, such as the need for the reorganization of the delivery of health care and quality counseling. On the basis of this experience, a simplified schedule of three intervention phases (Screen, Treat and Care), which can be incorporated into routine mother and child health care, is proposed. Follow-up of the child, however, will require more frequent and intensive contact with health care services than usual. At a time when many countries are reevaluating their health care systems, these insights should be considered, so as to additional better the needs of HIV-infected women during pregnancy and beyond.