01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 N61 Pan American Journal of Public Health Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 1 Original research Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica José Pablo Díaz-Madriz,1 Eugenia Cordero-García,2 José Miguel Chaverri-Fernández,2 Esteban Zavaleta-Monestel,1 Josué Murillo-Cubero,3 Hellen Piedra-Navarro,2 Marian Hernández- Guillén,2 and Tiffany Jiménez-Méndez2 Suggested citation Díaz-Madriz JP, Cordero-García E, Chaverri-Fernández JM, Zavaleta-Monestel E, Murillo-Cubero J, Piedra-Navarro H, et al. Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica. Rev Panam Salud Publica. 2020;44:e57. https://doi.org/10.26633/RPSP.2020.57 1 Hospital Clínica Bíblica, San José, Costa Rica. *  José Pablo Díaz-Madriz, jp.diazm27@gmail.com 2 University of Costa Rica, San Pedro, Costa Rica 3 Universidad de Ciencias Médicas (UCIMED), San José, Costa Rica ABSTRACT Objective. To measure the impact generated by the implementation of the pharmacy-driven antimicrobial stewardship program of the Clínica Bíblica Hospital. Methods. This is a retrospective observational study that evaluates the consumption of antibiotics for the periods before and during implementation of the Clínica Bíblica Hospital antimicrobial stewardship program, calculated by means of defined daily dose per 1 000 patient-days and days of therapy per 1 000 patient-days. In addition, bacterial resistance patterns for the periods 2014–2015 and 2016–2017 were compared. Results. Consumption of most-used antibiotics was calculated, looking for trends that might be associated with the activities implemented by the Clínica Bíblica Hospital antimicrobial stewardship program. Comparing some of the antibiotics with the highest consumption in periods I and II, use of levofloxacin and ceftriaxone showed a decrease of 54.0% (p < 0.001) and 14.6% (p = 0.003), respectively, whereas there was an increase in the use of cefazolin of 4 539.3% (p < 0.001). Regarding percentage of bacterial resistance, in most bacterial isolates no statistically significant changes were observed between the two periods. Conclusions. A reduction in the overall consumption of antibiotics has been achieved over time, most likely attributable to the antimicrobial stewardship program. However, this trend was not observed for all the anti- biotics studied. The pattern of resistance among the commonly isolated microorganisms did not vary greatly between the periods studied, which suggests that either the antimicrobial stewardship program may have prevented an increase in bacterial resistance since its implementation, or that it is too soon to see impact on bacterial resistance. Keywords Antimicrobial stewardship; anti-infective agents; drug utilization; drug resistance, microbial; Costa Rica. Antimicrobials are a group of successful drugs that have allowed a radical change in the health landscape, reducing historical morbidity and mortality by preventing infectious dis- eases from being the main cause of death (1–3). However, in recent decades the indiscriminate use and abuse of these drugs in animals and humans has generated problems, including adverse reactions in patients, leading to an increase of unnecessary expenses for the health system and the appear- ance of bacterial resistance (4–9). Health centers are an ideal setting for the appearance of multidrug-resistant bacteria (7). Antimicrobial stewardship programs (AMS) have been established to address this problem, and to set standards and guidelines for health care profession- als (10). This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. http://www.paho.org/journal www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57 https://doi.org/10.26633/RPSP.2020.57 mailto:jp.diazm27@gmail.com https://creativecommons.org/licenses/by-nc-nd/3.0/igo/legalcode Original research Díaz-Madriz et al. • Pharmacist-driven antimicrobial stewardship program 2 Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 The aim of this study was to measure the impact generated by the AMS of the Clínica Bíblica Hospital (AMS-HCB), one of the first hospitals in Central America to implement this initia- tive. The AMS-HCB is pharmacy driven and works without restrictions on the use of antimicrobials. The main practices implemented by this program are prospective audit and feed- back, clinical guidelines development, and educational sessions. MATERIALS AND METHODS This is a retrospective observational study conducted at the Clínica Bíblica Hospital, a 68-bed private health center located in San José, Costa Rica. The records of patients who received antibiotic therapy with any of the following medications were analyzed: meropenem, ertapenem, moxifloxacin, levofloxacin, ciprofloxacin, cefuroxime, ceftriaxone, ceftazidime, cefazolin, cefalotin, vancomycin, ampicillin/sulbactam, and linezolid. The consumption levels for the period before implemen- tation of the AMS, or period  I (April 2013–March 2015), and during the implementation of the AMS, or period  II (April 2015–March 2017), were determined by calculating the defined daily dose (DDD1) per 1 000 patient-days and days of therapy (DOT2) per 1 000 patient-days (1,  11–13). The results for both periods were compared using IBM SPSS software. When cal- culating the values of DDD per 1  000 patient-days and DOT per 1 000 patient-days, the monthly average of each of the anti- biotics was calculated and subjected to a descriptive statistical analysis. The Kruskal-Wallis nonparametric test was performed (14–16). In addition, bacterial resistance patterns were compared for the periods 2014–2015 and 2016–2017. These patterns were based on the resistance reports on bacteria cultivated in the hospital during these periods, as reported by the Clínica Bíblica Hospital’s Clinical Laboratory and Infection Prevention Com- mittee. The resistance reports were obtained from the VITEK-2® automated identification and antibiotic susceptibility testing system. These data were analyzed using the chi-squared test, to identify statistically significant changes in resistance that might be associated with the implementation of the AMS. Regarding the data analysis, the first isolate of each infec- tious episode was considered, as well as the verification of the data by a microbiologist, and recommendations issued by the Clinical and Laboratory Standards Institute (CLSI) and the Spanish Society of Infectious Diseases and Clinical Microbiol- ogy (SEIMC) (17, 18). For Pseudomonas aeruginosa and Enterococcus faecalis, elimina- tion of some reports of resistance was required, due to the fact that they might have intrinsic resistance for some of the antibi- otics studied. In addition, the report of colistin resistance was eliminated for all bacteria, as it is a more restricted antibiotic and requires a comprehensive analysis of each case before its use (19). Information for the study was obtained from the electronic clinical records from the Clínica Bíblica Hospital’s Hospitalized Patients Management system, Integrated Hospital Management System, and pharmacy records. The bacterial identification and 1 DDD is a clinical parameter established by the World Health Organization that represents the average daily dose of an antibiotic for a standard patient. 2 DOT is defined as the number of days a patient has received antibiotics regard- less of the prescribed dose. resistance test results were also extracted through the computer system, along with other patient data of interest to the study. There was also access to the physical clinical records of these patients, as necessary. It is important to mention that the ethical use of the data and patient confidentiality were guaranteed at all times. This work was approved by the Clínica Bíblica Hospital and the Scientific Ethics Committee of the University of Costa Rica (VI-3253-2018). RESULTS DDD With the data obtained from the study, a DDD calculation was made for every 1  000 patient-days for the 13 most-used antibiotics in the hospital. Table 1 compares the average use of antibiotics in the Clínica Bíblica Hospital in the two periods. Broad-spectrum antibiotics such as quinolones, third- generation cephalosporins, and carbapenems were found to be the most widely used. Comparing the four antibiotics with the highest consumption in periods I and II, the DDD per 1 000 patient-days for levoflox- acin showed a decrease of 54.0% (p < 0.001). Similarly, although with a smaller magnitude of change, ceftriaxone use decreased by 14.6% (p = 0.003), while the decrease in ciprofloxacin use was not statistically significant (1.5%, p  =  0.47). In contrast, there was a statistically significant increase in the use of ertapenem by 15.6% (p = 0.041). Although their consumption was lower, there was an upward trend in use of some of the reduced-spectrum antibiotics follow- ing the implementation of the AMS-HCB. Such was the case for cefazolin and cefuroxime, which showed a significant increase in the DDD per 1 000 patient-days of 4 539.3% (p < 0.001) and 406.4% (p  <  0.001), respectively. In addition, there were sta- tistically significant decreases in the consumption of cefalotin TABLE 1. Comparison of the changes in average of con- sumption as measured by DDD per 1 000 patient-days for the hospitalized population between periods I and II in Clínica Bíblica Hospital DDD/1 000 patient-days   Period I Period II Magnitude of change % p Amp/sulb 119.5 123.3 ▲ 3.8 ▲ 3.2 0.741 Cefalotin 26.4 18.9 ▼ 7.5 ▼ 28.4 0.006 Cefazolin 1.1 49.4 ▲ 48.3 ▲ 4 539.3 <0.001 Ceftazidime 27.0 25.2 ▼ 1.8 ▼ 6.6 0.523 Ceftriaxone 223.3 190.6 ▼ 32.7 ▼ 14.6 0.003 Cefuroxime 26.0 131.6 ▲ 105.6 ▲ 406.4 <0.001 Ciprofloxacin 218.8 215.6 ▼ 3.2 ▼ 1.5 0.470 Ertapenem 151.3 174.9 ▲23.6 ▲ 15.6 0.041 Levofloxacin 325.6 149.9 ▼ 175.7 ▼ 54.0 <0.001 Linezolid 69.0 79.8 ▲ 10.8 ▲15.5 0.174 Meropenem 108.4 86.8 ▼ 21.6 ▼ 19.9 0.076 Moxifloxacin 84.1 80.8 ▼ 3.3 ▼ 3.9 0.496 Vancomycin 74.7 56.1 ▼ 18.6 ▼ 25.0 0.029 DDD, defined daily dose; Amp/sulb, ampicillin/sulbactam; ▼ decrease; ▲ increase. Source: Prepared by the authors based on data from Clínica Bíblica Hospital Antimicrobial Stewardship Program www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 N61 Díaz-Madriz et al. • Pharmacist-driven antimicrobial stewardship program Original research Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 3 choice for surgical antibiotic prophylaxis, as indicated by the clinical guideline implemented at that time. These strategies explain the significant increase in the use of cefazolin (2 215.1%, p  <  0.001) and the decrease in the consumption of ceftriax- one (19.1%, p  <  0.001), and partially explain the decrease of levofloxacin (49.9%, p < 0.001), according to the consumption calculated in DOT (Figure 1). Ertapenem is another antibiotic that was recommended to be avoided in surgical prophylaxis, as well as in a wide number of other indications. However, this is the only antibiotic that did not show a reduction in consump- tion. On the contrary, it increased over time (17.4%, p = 0.037). This suggests that different strategies are needed in order to control the overprescription of ertapenem. The decrease in the consumption of meropenem (19.1%, p  =  0.02) represents valuable progress in the initiative to and vancomycin by 28.4% (p  =  0.006) and 25.0% (p  =  0.029), respectively. DOT For the 13 most-used antibiotics, calculated as DOT per 1 000 patient days, between period I and period II there was an apparent reduction of 3.2% (p = 0.108). This is equivalent to that calculated by DDD per 1 000 patient-days, 3.2% (p = 0.174), both not statistically significant. According to DOT per 1 000 patient-days, there was a highly significant decrease in consumption of ceftriaxone and levo- floxacin, by 19.1% (p < 0.001) and 49.9% (p < 0.001), respectively (Table 2). There was also a statistically significant decrease in the consumption of meropenem and vancomycin, by 19.1% (p  =  0.02) and 30.7% (p  =  0.005), respectively. On the other hand, there was a significant increase of 17.4% (p = 0.037) in the consumption of ertapenem, the antibiotic with the second high- est DOT per 1 000 patient-days in both periods I and II. This is similar to the results obtained according to DDD per 1 000 patient days. In addition, there were other important changes for cefazolin consumption, with an increase of 2 215.1% (p < 0.001), and for cefuroxime, with an increase of 309.8% (p < 0.001). These results are consistent with the data for DDD per 1 000 patient-days. Antibiotic resistance The bacteria with greater clinical relevance or a greater num- ber of isolates were analyzed for each period (Table 3) and the number of final strains isolated obtained, which was then used to perform comparisons of antibiotic resistance profiles for each bacteria. An example of the analysis done for each of the bacteria is shown in Table 4, which presents the resistance profile of Staphylococcus epidermidis against a range of antibiotics for the periods 2014–2015 and 2016–2017. A highly significant decrease in the resistance of S. epidermidis to rifampicin was observed with a magnitude of change of 36% (p < 0.001). In addition, sig- nificant differences were found in the resistance of E. faecalis to gentamicin, a decrease of 18% (p = 0.032); as well as a decrease in resistance of Staphylococcus haemolyticus to rifampicin (44%, p = 0.004), and an increase in resistance to trimethoprim/sul- famethoxazole (36%, p = 0.038). For the rest of the bacteria, no statistically significant changes were found in the percentages of resistance comparing the two periods. DISCUSSION In 2015, the Clínica Bíblica Hospital implemented a pharmacist- driven antimicrobial stewardship program (20,  21), the AMS- HCB. Since its implementation, it has been constantly and actively monitored by a multidisciplinary team consisting of a clinical pharmacist (director), an infectious disease physician, a microbi- ologist, and the hospital’s assistant chief medical officer. In 2015, when high levels of consumption of broad- spectrum antibiotics were detected in the hospital, one of the main problems was the incorrect use of ceftriaxone and levo- floxacin in surgical prophylaxis. The AMS team executed educational activities to promote greater use of first-generation cephalosporins such as cefazolin, since these were the drugs of TABLE 2. Comparison of the changes in average consumption as measured by DOT per 1 000 patient-days for the hospitalized population between periods I and II in Clínica Bíblica Hospital DOT/1 000 patient-days Period I Period II Magnitude of change % p Amp/sulb 51.0 43.3 ▼ 7.8 ▼ 15.2 0.364 Cefalotin 32.8 26.0 ▼ 6.8 ▼ 20.7 0.055 Cefazolin 2.2 50.1 ▲ 48.0 ▲ 2 215.1 <0.001 Ceftazidime 23.8 25.7 ▲ 1.9 ▲ 7.8 0.711 Ceftriaxone 265.1 214.5 ▼ 50.6 ▼19.1 <0.001 Cefuroxime 2.0 8.0 ▲ 6.1 ▲ 309.8 <0.001 Ciprofloxacin 48.3 57.6 ▲ 9.3 ▲ 19.3 0.274 Ertapenem 125.1 146.9 ▲ 21.8 ▲ 17.4 0.037 Levofloxacin 74.3 37.2 ▼ 37.1 ▼ 49.9 <0.001 Linezolid 44.1 61.0 ▲ 16.9 ▲ 38.4 0.039 Meropenem 80.7 65.3 ▼ 15.4 ▼ 19.1 0.020 Moxifloxacin 42.4 47.1 ▲ 4.7 ▲ 11.1 0.496 Vancomycin 71.3 49.4 ▼ 21.9 ▼ 30.7 0.005 DOT, days of therapy; Amp/sulb, ampicillin/sulbactam;▼ decrease; ▲ increase. Source: Prepared by the authors based on data from Clínica Bíblica Hospital Antimicrobial Stewardship Program TABLE 3. Frequency of isolation of the bacteria analyzed in Clínica Bíblica Hospital, 2014–2015 and 2016–2017 Total strains isolated 2014–2015* Total strains isolated 2016–2017* Gram-negative bacilli Escherichia coli 137 178 Pseudomonas aeruginosa 87 94 Klebsiella pneumoniae 48 62 Stenotrophomonas maltophilia** 20 13 Gram-positive cocci     Staphylococcus aureus 81 78 Staphylococcus epidermidis 45 51 Enterococcus faecalis 35 37 Staphylococcus haemolyticus** 16 15 * The number of final strains corresponds to the number of strains that were included in the final analysis of the data, following the recommendations of the Clinical and Laboratory Standards Institute (CLSI) and the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). ** Those isolates with fewer than 30 reported strains should be interpreted with caution since they may not represent faithfully the resistance profile of the group of bacteria analyzed. Source: Prepared by the authors based on data from Clínica Bíblica Hospital Antimicrobial Stewardship Program www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57 Original research Díaz-Madriz et al. • Pharmacist-driven antimicrobial stewardship program 4 Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 FIGURE 1. Trend in the trimester averages of days of therapy (DOT) per 1 000 patient days for cefazolin and ceftriaxone in Clínica Bíblica Hospital for the period 2013–2017, before and during implementation of the antimicrobial stewardship program Source: Prepared by the authors based on data from Clínica Bíblica Hospital Antimicrobial Stewardship Program TABLE 4. Comparison of the reports of antibiotic resistance for Staphylococcus epidermidis in Clínica Bíblica Hospital, 2014–2015 and 2016–2017   Period 2014–2015 Period 2016–2017     Staphylococcus epidermidis n resistant* n total %R* n resistant* n total %R* Magnitude of change p Benzylpenicillin 45 45 100 40 42 95 ▼5 0.139 Beta-lactamases 39 45 87 37 43 86 ▼1 0.932 Ciprofloxacin 33 45 73 38 51 75 ▲2 0.896 Clindamycin 23 45 51 24 51 47 ▼4 0.692 Erythromycin 37 45 82 41 51 80 ▼2 0.819 Gentamicin 15 45 33 23 51 45 ▲12 0.239 Levofloxacin 33 45 73 38 51 75 ▲2 0.896 Linezolid 0 45 0 0 51 0 0 - Moxifloxacin 18 45 40 20 51 39 ▼1 0.937 Oxacillin MIC 36 45 80 43 50 86 ▲6 0.435 Inducible resistance to clindamycin 3 45 7 3 51 6 ▼1 0.874 Rifampicin 27 45 60 12 51 24 ▼36 <0.001 Tetracycline 30 45 67 38 51 75 ▲8 0.399 Tigecycline 0 45 0 0 43 0 0 - Trimethoprim/sulfamethoxazole 18 45 40 26 51 51 ▲11 0.281 Vancomycin 0 45 0 0 51 0 0 - R, resistance; n, number of isolations; ▼ decrease; ▲ increase. * Includes resistant strains with intermediate sensitivity. (-) Statistical significance was not calculated because the resistance of this bacteria to these antibiotics is a constant. Source: Prepared by the authors based on data from Clínica Bíblica Hospital Antimicrobial Stewardship Program improve the use of antimicrobials, since meropenem is con- sidered an antibiotic of last resort. Regarding P. aeruginosa, its resistance to meropenem has increased in the country; thus, strategies to optimize the use of this antibiotic and of all carbapenems should be reinforced (22). Multiple studies have compared the relationship between the consumption of antibiotics and the reported rates of resistance. In the case of P. aeruginosa, it has a high capacity to acquire new resistance www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 N61 Díaz-Madriz et al. • Pharmacist-driven antimicrobial stewardship program Original research Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 5 generally required to appreciate changes in the microbiota of a hospital center (28, 29). Some limitations include the design of the study, since it can- not assure that the AMS is the direct cause or the only cause of the changes described in the results. Variations in the level of antimicrobial resistance can also be influenced by the actions of the hospital’s Infection Prevention Committee, as well as other factors external to this hospital, such as the use of antibiotics in other health facilities. Nonetheless, when determining the consumption by means of DDD per 1 000 patient-days and DOT per 1 000 patient-days, it is evident that reductions in the overall consumption of anti- biotics have been achieved over time, possibly attributable to AMS implementation. However, this is not a common trend for all antibiotics, and the continuation of the program should be evaluated in the near future. The development and implemen- tation of more clinical guidelines is the next step to cover more antibiotics used in the hospital setting. Author contributions. All authors contributed to the study design, data analysis and interpretation, and writing of the paper. All authors reviewed and approved the final version. Conflicts of interest. None declared. Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or the Pan Amer- ican Health Organization. mechanisms under selective antibiotic pressure, including loss of outer membrane proteins, efflux pumps, and produc- tion of certain beta-lactamases, among others. In vitro and in vivo studies have documented that exposure to carbapenems increases the risk of carbapenem-resistant P. aeruginosa, which is also associated with cross-resistance to other antibiotics (23). On the other hand, the consumption of linezolid increased (38.4%, p = 0.039), while vancomycin consumption decreased (30.7%, p = 0.005). This change can be related to the preferences of the prescriber, since these are two antibiotics that are used for Gram-positive infections. Linezolid may be preferred over vancomycin based on some reports that show similar activity for meticillin-resistant Staphylococcus aureus specific infections with less nephrotoxicity. It is also dosed easier than vancomy- cin, which must be adjusted according to the pharmacokinetic profile of each patient. In addition, conversion to oral admin- istration is easily performed in the case of linezolid, and no dosage adjustment is necessary in case of renal failure. Its resis- tance profile has not changed and it remains 100% sensitive (24–26). One of the main reasons why AMSs are necessary in hospitals is the constant growth of resistance (27). A non-increase in resis- tance, as shown in the results, is considered a positive result, suggesting that the actions of the AMS are having an impact on physicians’ prescriptions. 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Vancomycin therapeutic guidelines: a summary of consensus recommendations from the Infectious Diseases Society Impacto de un programa de optimización del uso de antimicrobianos conducido por la farmacia de un hospital privado en Costa Rica RESUMEN Objetivo. Medir el impacto de la ejecución de un programa de optimización del uso de antimicrobianos con- ducido por la farmacia del Hospital Clínica Bíblica. Métodos. En este estudio retrospectivo y de observación se evaluó el consumo de antibióticos antes y después de la ejecución del programa de optimización del uso de antimicrobianos en el Hospital Clínica Bíblica. El consumo se calculó tomando como base la dosis diaria por 1.000 días-paciente y los días de trata- miento por 1.000 días-paciente. Además, se compararon los perfiles de resistencia bacteriana en los períodos 2014-2015 y 2016-2017. Resultados. Se calculó el consumo de los antibióticos más usados para establecer las tendencias que podrían estar relacionados con las actividades ejecutadas por el programa de optimización del uso de anti- microbianos del Hospital Clínica Bíblica. Se compararon algunos de los antibióticos de mayor consumo en los períodos I y II, el uso de la levofloxacina y la ceftriaxona mostró una disminución de 54,0% (p < 0,001) y 14,6% (p = 0,003), respectivamente, mientras que se evidenció un aumento en el uso de la cefazolina de 4.539,3% (p < 0,001). Con respecto al porcentaje de resistencia bacteriana, no se encontró ningún cambio estadísticamente significativo entre los dos períodos para la mayoría de las cepas bacterianas aisladas. Conclusiones. Con el transcurso del tiempo se ha logrado una disminución en el consumo de antibióticos en general, probablemente relacionada con el programa de optimización del uso de antimicrobianos. Sin embargo, esta tendencia no se observó en todos los antimicrobianos analizados. No se evidenció una vari- ación significativa en los patrones de resistencia entre los microorganismos aislados comúnmente entre los períodos comparados, lo que puede significar dos cosas: que el programa de optimización del uso de anti- microbianos podría haber evitado un aumento de resistencia bacteriana desde que se puso en marcha o que es demasiado pronto para que se evidencie un impacto en la resistencia bacteriana. Palabras clave Programas de optimización del uso de los antimicrobianos; antiinfecciosos; utilización de medicamentos; farmacorresistencia microbiana; Costa Rica. www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57 https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/AMS%20policy.pdf https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/AMS%20policy.pdf https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/AMS%20policy.pdf https://www.inciensa.sa.cr/vigilancia_epidemiologica/informes_vigilancia/2019/Bacterias/INCIENSA%20-%20Vigilancia%20de%20RAM%20de%20P.%20aeruginosa%202013-2017.pdf https://www.inciensa.sa.cr/vigilancia_epidemiologica/informes_vigilancia/2019/Bacterias/INCIENSA%20-%20Vigilancia%20de%20RAM%20de%20P.%20aeruginosa%202013-2017.pdf https://www.inciensa.sa.cr/vigilancia_epidemiologica/informes_vigilancia/2019/Bacterias/INCIENSA%20-%20Vigilancia%20de%20RAM%20de%20P.%20aeruginosa%202013-2017.pdf https://www.inciensa.sa.cr/vigilancia_epidemiologica/informes_vigilancia/2019/Bacterias/INCIENSA%20-%20Vigilancia%20de%20RAM%20de%20P.%20aeruginosa%202013-2017.pdf 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 N61 Díaz-Madriz et al. • Pharmacist-driven antimicrobial stewardship program Original research Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.57 7 Impacto de um programa de gerenciamento do uso de antimicrobianos por profissionais farmacêuticos em um hospital particular na Costa Rica RESUMO Objetivo. Mensurar o impacto da implantação de um programa de gerenciamento do uso de antimicrobianos por profissionais farmacêuticos em um hospital particular. Métodos. Trata-se de um estudo observacional retrospectivo para avaliar o uso de antibióticos no período anterior e posterior à implantação do programa de gerenciamento do uso de antimicrobianos no Hospital Bíblica Clínica, em San José, Costa Rica. O consumo dos medicamentos foi calculado com base na dose diária definida por 1.000 pacientes-dia e dias de tratamento por 1.000 pacientes-dia. Foi realizada uma com- paração dos padrões de resistência bacteriana entre os períodos 2014–2015 e 2016–2017. Resultados. O consumo dos antibióticos mais utilizados foi calculado visando identificar possíveis tendên- cias associadas às ações do programa de gerenciamento do uso de antimicrobianos implantado no hospital. A comparação do consumo de alguns dos antibióticos mais utilizados no primeiro e no segundo períodos considerados apontou uma redução de 54,0% no uso de levofloxacina (p < 0,001) e 14,6% no uso de ceftri- axona (p = 0,003), com um aumento de 4.539,3% no uso de cefazolina (p < 0,001). Com relação à resistência bacteriana, não se observou variação estatisticamente significativa na maioria dos isolados bacterianos entre os dois períodos. Conclusões. Houve redução no consumo de antibióticos em geral, provavelmente atribuível ao programa de gerenciamento do uso de antimicrobianos. Porém, esta mesma tendência não foi observada para todos os antibióticos estudados. Não houve variação importante no padrão da resistência dos microrganismos mais frequentemente isolados entre os períodos estudados. Isso indica que o programa de gerenciamento do uso de antimicrobianos implantado possivelmente evitou o aumento da resistência bacteriana ou que é ainda muito cedo para se observar o impacto na resistência bacteriana. Palavras-chave Gestão de antimicrobianos; anti-infecciosos; uso de medicamentos; resistência microbiana a medicamentos; Costa Rica. www.paho.org/journal https://doi.org/10.26633/RPSP.2020.57