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BACKGROUND: Healthcare-associated infections and antibiotic resistance worsen globally. Antibiotic stewardship programs (ASP) aim to optimise infection treatment and curb resistance, yet implementation hurdles persist. This study examined ASP challenges in ICUs. METHODS: This study employed a qualitative methodological design to evaluate the implementation process of an antibiotic stewardship program (ASP) in eight intensive care units (ICUs) across Argentina. Thirty-four semi-structured interviews with healthcare workers (HCWs) were conducted. Interviews were analysed guided by Normalisation Process Theory, examining coherence, cognitive participation, collective action, and reflexive monitoring constructs. RESULTS: Key challenges included insufficient human resources, lack of institutional support, and resistance to change, particularly among staff not initially involved in the study. Despite these challenges, the program saw partial success in improving ICU practices, particularly in antibiotic use and communication across departments. The main strategy implemented in this quality improvement collaborative was the use of improvement cycles, which served as the central component for driving change. However, participation in improvement cycles was inconsistent, and sustainability post-intervention remains uncertain due to workload pressures and the need for continuous education. Concerns about workload and communication barriers persisted. Many participants did not perceive training as a separate component, which led to low engagement. Resistance to change became evident during modifications to clinical guidelines. The intervention had a positive impact on various processes, including communication and record keeping. CONCLUSION: This study underscores the persistent challenges in implementing ASPs in healthcare, emphasising the need for enhanced collaboration, workforce capacity building, and evidence-based practices to overcome barriers and optimize antimicrobial use to improve patient outcomes.

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BACKGROUND: There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country. METHODS: We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training. RESULTS: We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs. CONCLUSION: Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

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Worldwide, bacterial resistance is one of the most severe public health problems. Currently, the failure of antibiotics to counteract superbugs highlights the need to search for new molecules with antimicrobial potential to combat them. The objective of this research was to evaluate the antimicrobial activity of Bacillus amyloliquefaciens BS4 against Gram-negative bacteria. Thirty yeasts and thirty-two Bacillus isolates were tested following the agar well-diffusion method. Four Bacillus sp. strains (BS3, BS4, BS17, and BS21) showed antagonistic activity against E. coli ATCC 25922 using bacterial culture (BC) and the cell-free supernatant (CFS), where the BS4 strain stood out, showing inhibitory values of 20.50 ± 0.70 mm and 19.67 ± 0.58 mm for BC and CFS, respectively. The Bacillus sp. BS4 strain can produce antioxidant, non-hemolytic, and antimicrobial metabolites that exhibit activity against several microorganisms such as Salmonella enterica, Klebsiella pneumoniae, Shigella flexneri, Enterobacter aerogenes, Proteus vulgaris, Yersinia enterocolitica, Serratia marcescens, Aeromonas sp., Pseudomonas aeruginosa, Candida albicans, and Candida tropicalis. According to the characterization of the supernatant, the metabolites could be proteinaceous. The production of these metabolites is influenced by carbon and nitrogen sources. The most suitable medium to produce antimicrobial metabolites was TSB broth. The one-factor-at-a-time method was used to standardize parameters such as pH, agitation, temperature, carbon source, nitrogen source, and salts, resulting in the best conditions of pH 7, 150 rpm, 28 °C, starch (2.5 g/L), tryptone (20 g/L), and magnesium sulfate (0.2 g/L), respectively. Moreover, the co-culture was an excellent strategy to improve antimicrobial activity, achieving maximum antimicrobial activity with an inhibition zone of 21.85 ± 1.03 mm. These findings position the Bacillus amyloliquefaciens BS4 strain as a promising candidate for producing bioactive molecules with potential applications in human health.

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Introduction: Adherence to evidence-based practices (EBP) allows better management of the health-disease process in critical ill patients, with a close relationship between compliance and the quality achieved. We set out to improve adherence to EBP in patients admitted to a Pediatric Intensive Care Unit (PICU) and to improve the quality-of-care indicators. Methods: Controlled before-after study, developed at the PICU of the Pedro de Elizalde Children's General Hospital (PECGH), which involved all patients admitted in the period 12/01/2019 to 08/31/2020. The implementation consisted of a checklist (CL) that included 27 EBP, segmented into 10 improvement areas. Adherence to the CL was considered if it met 80% of EBP. Results: During the study period, 153 patients were admitted to the PECGH PICU. The pre- and post-intervention groups were similar in mechanical ventilatory assistance (MVA) requirements and pre-established mortality. In the last stage, adherence to the CL increased 23% (p <0.001). The MVA usage rate experienced the greatest decrease (18%, p = 0.033). In relation to quality indicators, a decrease in episodes of MVA-associated pneumonia (p = 0.002) and bladder catheter-associated infection (p = 0.001) was evident. There were no differences in mortality or stay in the PICU. Conclusion: The implementation of a CL allowed to increase compliance with the different EBP studied, a lower rate of MVA use, and a reduction in the rate of device-associated infections.

Introducción: La adherencia a prácticas basadas en la evidencia (PBE) permite una mejor gestión del proceso salud-enfermedad en pacientes críticos, existiendo una estrecha relación entre su cumplimiento y la calidad alcanzada. Nos propusimos mejorar la adherencia a PBE en pacientes internados en una Unidad de Cuidados Intensivos Pediátrico (UCIP) y mejorar los indicadores de calidad de la atención. Métodos: Estudio controlado, tipo antes-después de una implementación, desarrollado en la UCIP del Hospital General de Niños Pedro de Elizalde (HGNPE), que involucró a todos los pacientes internados en el período 01/12/2019 al 31/08/2020. La implementación consistió en una lista de verificación (LV) que incluía 27 PBE, segmentadas en 10 áreas de mejoras. Se consideró adherencia a la LV si cumplía el 80% de las PBE. Resultados: Durante el período de estudio ingresaron a la UCIP del HGNPE 153 pacientes. Los grupos pre-intervención y post-intervención, fueron similares en requerimientos de asistencia respiratoria mecánica (ARM) y mortalidad preestablecida. En la última etapa, la adherencia a la lista aumento un 23% (p<0,001). La tasa de uso de ARM experimentó el mayor descenso (18%, p=0,033). En relación a los indicadores de calidad, se evidenció una disminución de los episodios de neumonía asociada a ARM (p=0,002) e infección asociada a sonda vesical (p=0,001). No hubo diferencias en la estadía ni en la mortalidad en UCIP. Conclusión: La implementación de una LV permitió aumentar el cumplimiento de las distintas PBE estudiadas, una menor tasa de uso de ARM y reducción en la tasa de infecciones asociadas a dispositivos.

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BACKGROUND: There are only a few studies on handoff quality and adverse events (AEs) rigorously evaluating handoff improvement programmes' effectiveness. None of them have been conducted in low and middle-income countries. We aimed to evaluate the effect of a handoff programme implementation in reducing AE frequency in paediatric intensive care units (PICUs). METHODS: Facility-based, cluster-randomised, stepped-wedge trial in six Argentine PICUs in five hospitals, with >20 admissions per month. The study was conducted from July 2018 to May 2019, and all units at least were involved for 3 months in the control period and 4 months in the intervention period. The intervention comprised a Spanish version of the I-PASS handoff bundle consisting of a written and verbal handoff using mnemonics, an introductory workshop with teamwork training, an advertising campaign, simulation exercises, observation and standardised feedback of handoffs. Medical records (MR) were reviewed using trigger tool methodology to identify AEs (primary outcome). Handoff compliance and duration were evaluated by direct observation. RESULTS: We reviewed 1465 MRs: 767 in the control period and 698 in the intervention period. We did not observe differences in the rates of preventable AE per 1000 days of hospitalisation (control 60.4 (37.5-97.4) vs intervention 60.4 (33.2-109.9), p=0.99, risk ratio: 1.0 (0.74-1.34)), and no changes in the categories or AE types. We evaluated 841 handoffs: 396 in the control period and 445 in the intervention period. Compliance with all items in the verbal and written handoffs was significantly higher in the intervention group. We observed no difference in the handoff time in both periods (control 35.7 min (29.6-41.8) vs intervention 34.7 min (26.5-42.1); difference 1.43 min (95% CI -2.63 to 5.49, p=0.49)). The providers' perception of improved communication did not change. CONCLUSIONS: After the implementation of the I-PASS bundle, compliance with handoff items improved. Nevertheless, no differences were observed in the AEs' frequency or the perception of enhanced communication. TRIAL REGISTRATION NUMBER: NCT03924570.

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El síndrome inflamatorio multisistémico en niños asociado con enfermedad por coronavirus 2019 se define por la presencia de fiebre persistente, inflamación y disfunción orgánica, con evidencia de infección pasada o reciente por coronavirus tipo 2 del síndrome respiratorio agudo grave, y exclusión de otra causa microbiana. Acarrea la superposición con otras enfermedades inflamatorias (enfermedad de Kawasaki y síndrome de shock tóxico) y comparte características con entidades que presentan hipercitocinemia (linfohistiocitosis hemofagocítica y síndrome de activación macrofágica). Se diferencia de estas y de la forma aguda grave de enfermedad por coronavirus 2019 en su presentación clínica y parámetros de laboratorio. Su evolución es potencialmente grave y puede presentar falla cardiovascular; la mortalidad es baja (del 2 %).Se realiza una actualización de este síndrome, y se describe la presentación de 2 casos clínicos con disfunción cardiovascular, que requirieron sostén vasoactivo y asistencia ventilatoria invasiva. El laboratorio sérico evidenció parámetros de inflamación. Ambos recibieron tratamiento con gammaglobulina endovenosa y corticoides sistémicos, con evolución favorable

Multisystem inflammatory syndrome in children related to COVID-19 is defined as the presence of persistent fever, inflammation, and organ dysfunction, with evidence of past or recent severe acute respiratory syndrome coronavirus 2 infection, and excluding other microbial causes. It overlaps with other inflammatory diseases (Kawasaki disease and toxic shock syndrome) and shares some features with hypercytokinemia conditions (hemophagocytic lymphohistiocytosis and macrophage activation syndrome). It differs from these and severe acute COVID-19 in its clinical presentation and laboratory parameters. It has a potentially severe course and may occur with cardiovascular failure; mortality is low (2 %).Here we provide an update on this syndrome and describe the presentation of two clinical cases with cardiovascular dysfunction who required vasoactive support and invasive ventilation. Serum lab tests showed inflammation parameters. Both patients were treated with intravenous immunoglobulin and systemic corticosteroids and had a favorable course

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Multisystem inflammatory syndrome in children related to COVID-19 is defined as the presence of persistent fever, inflammation, and organ dysfunction, with evidence of past or recent severe acute respiratory syndrome coronavirus 2 infection, and excluding other microbial causes. It overlaps with other inflammatory diseases (Kawasaki disease and toxic shock syndrome) and shares some features with hypercytokinemia conditions (hemophagocytic lymphohistiocytosis and macrophage activation syndrome). It differs from these and severe acute COVID-19 in its clinical presentation and laboratory parameters. It has a potentially severe course and may occur with cardiovascular failure; mortality is low (2 %). Here we provide an update on this syndrome and describe the presentation of two clinical cases with cardiovascular dysfunction who required vasoactive support and invasive ventilation. Serum lab tests showed inflammation parameters. Both patients were treated with intravenous immunoglobulin and systemic corticosteroids and had a favorable course.

El síndrome inflamatorio multisistémico en niños asociado con enfermedad por coronavirus 2019 se define por la presencia de fiebre persistente, inflamación y disfunción orgánica, con evidencia de infección pasada o reciente por coronavirus tipo 2 del síndrome respiratorio agudo grave, y exclusión de otra causa microbiana. Acarrea la superposición con otras enfermedades inflamatorias (enfermedad de Kawasaki y síndrome de shock tóxico) y comparte características con entidades que presentan hipercitocinemia (linfohistiocitosis hemofagocítica y síndrome de activación macrofágica). Se diferencia de estas y de la forma aguda grave de enfermedad por coronavirus 2019 en su presentación clínica y parámetros de laboratorio. Su evolución es potencialmente grave y puede presentar falla cardiovascular; la mortalidad es baja (del 2 %). Se realiza una actualización de este síndrome, y se describe la presentación de 2 casos clínicos con disfunción cardiovascular, que requirieron sostén vasoactivo y asistencia ventilatoria invasiva. El laboratorio sérico evidenció parámetros de inflamación. Ambos recibieron tratamiento con gammaglobulina endovenosa y corticoides sistémicos, con evolución favorable.

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