Overview of the actions to combat bacterial resistance in large hospitals*

Objective: to analyze, in the clinical practice of large hospitals, how the adoption of measures to prevent and control the spread of bacterial resistance has occurred, and to propose a score for the institutions’ adherence. Method: a cross-sectional study carried out in 30 large hospitals of Minas Gerais, from February 2018 to April 2019, after approval by the Ethics and Research Committee. Interviews were conducted with hospital managers, with Hospital Infection Control Services coordinators, and with the care coordinators of the Inpatient Units and Intensive Care Center. In addition, observations were made of the adoption of preventive measures by the multidisciplinary team in the care units. Results: in the 30 participating hospitals, 93.3% (N=28) had protocols for prophylactic antibiotics, and 86.7% (N=26) performed their audit, 86.7% (N=26) for therapeutic antibiotics and 83.3% (N=25) their audit; 93.3% (N=56) used gloves and cloaks for patients in contact precautions, and 78.3% (N=47) of the professionals were unaware of or answered incompletely on the five moments for hand hygiene. In the score to identify the adoption of measures to control bacterial resistance, 83.3% (N=25) of the hospitals were classified as partially compliant, 13.3% (N=04) as deficient, and 3.4% (N=01) as non-adoption. Conclusion: it was found that the recommended measures to contain bacterial resistance are not consolidated in the clinical practice of the hospitals.


Introduction
Health care-related infections (HAIs) are defined by the National Healthcare Safety Network (NHSN) as systemic or localized conditions resulting from the action of infectious agents or their toxins, and can manifest themselves after 72 hours of admission or after the patient›s discharge (1) . It is estimated that 70% of the HAIs are associated with antibiotic-resistant bacteria as the causative agent (2) .
In a global context, bacterial resistance has direct implications for patient safety. It prolongs their stay in the hospital, increases the chances of hospital readmission, the use of extended-spectrum antibiotics and the risk of death, mainly due to the absence of therapeutic alternatives (3)(4)(5)(6)(7) .
Bacterial resistance can be considered an epidemic with severe consequences. According to the author's projection, starting in 2050, bacterial resistance will be responsible for the death of nearly ten million patients each year, surpassing the current number of deaths from cancer and other diseases (8) . In addition, a high percentage of potentially lost years of life was estimated due to infections related to resistant bacteria in the European Union, reinforcing the issue as a worldwide public health problem (9) .
Bacterial resistance associated with HAIs occurs in all patient care units. Despite being a concern of all services, it has been more frequently registered in patients in Intensive Care Units (ICUs). ICUs are identified as the epicenter of antibiotic-resistant bacteria, with an overall higher incidence rate than that of the rest of inpatient units in health care institutions (10)(11) .
In this sense, three main pillars for the prevention and control of bacterial resistance are pointed out: improved adherence to hand hygiene, standard and isolation precautions, and rational use of antibiotics (4, [12][13] . Although such measures are widely recognized as effective in reducing HAIs and, consequently, in the spread of resistant microorganisms, numerous studies point to a low knowledge of the measures for their adoption among the health professionals (14)(15)(16)(17) .
Given the above, it was proposed to answer the Agency (Agência Nacional de Vigilância Sanitária, Anvisa) (13) to prevent and control bacterial resistance by 2020.
To answer the question, the objective was to analyze how, in the clinical practice of large hospitals in Minas Gerais, the adoption of prevention and control measures for the spread of bacterial resistance has occurred and propose a score that identifies this adoption among the institutions. It is expected, as a contribution, that defining an overview for this adherence by the institutions may come to subsidize the outline of the set of actions and public policies directed to the specific needs pointed out, as well as to identify gaps that need to be filled, seeking to consolidate the good practices in the assistance to the patient.  The data collection instruments were based on the guidelines proposed by the WHO for hand hygiene (19) and For assessing the behaviors against bacterial resistance, the document for investigation and control of multi-resistant bacteria proposed by the Anvisa was adopted (21) . The instruments were previously submitted to content, criterion and construct validation in a pilot study, whose data were not included in the final analysis. The After this stage on identifying policies, knowledge and practices, the data were analyzed, and a score was developed based on guidelines considered as the gold standard for controlling the spread of bacterial resistance, such as the rational use of antibiotics, adherence to hand hygiene, and standard and contact precautions (22) . For constructing the ranking, scores were predicted, seeking to know and determine the degree of adherence to the measures and potential weaknesses in adhering to these guidelines (23) , as per Figure 2.

Results
From the interviews with the health managers, it was observed that the majority (70.0%; N=21) of the  Non-accredited institutions were prevalent in this study, which is in line with data from the ONA, which revealed 43 accredited hospitals in the state of Minas Gerais (27) . National or international accreditation processes that evaluate and certify health services in terms of meeting patient care requirements contribute to improving safety, process quality, and continuous improvement (28)(29)(30) .
The literature argues that accredited institutions invest in the implementation of processes and policies to promote improvement and adherence to good practices, as accreditation is able to promote changes in hospital management and decision-making processes, in addition to stimulating the commitment of the hospital with the quality and patient safety assessment processes (28)(29)(30) . resistance (32)(33) .
A number of studies indicate that protocols developed based on local microbiology have a direct impact on reducing infections and colonization by resistant bacteria in hospitalized patients (33)(34) . In addition, it is emphasized that these protocols focus on continuing education, provide information feedback, and measure the results by means of indicators of adherence to good practices and actual consumption of antimicrobials by care unit (35)(36)(37) .  (38) . In two hospitals of Paraná, the knowledge of Nursing professionals on hand hygiene was assessed and it was concluded that 86.5% of the interviewees did not fully know the five moments (39) .
These findings confirm that, although the professionals recognize hand hygiene as one of the essential measures to control the spread of resistant microorganisms in the hospital environment, knowledge on the five moments remains a challenge (38)(39)(40) . Above all, the different opportunities for adhering to the care of the same patient.
The moments after contact with surfaces close to the patient and after exposure to body fluids were the indications most overlooked by the professionals.
Differently from the current study, a research study that evaluated the opportunities for hand hygiene by health professionals demonstrated that the opportunities before contact with the patient and before the aseptic procedure were the ones with the lowest adherence (41) .  (42) .
A study conducted in Europe revealed that 21% of the professionals are unaware of hand hygiene as an indication of the standard precaution (43) . The importance of the professionals' knowledge in adhering to the recommendations and the relevance of training to change the reality found is reinforced (44) .
With regard to the mandatory PPE in the care of patients in contact precautions, in this study, the use of cloaks and gloves by the professionals in most of the hospitals was evidenced. The national and international recommendations reinforce that contact precautions should be initiated from proof of colonization/infection by resistant bacteria (22,45) .
A study that evaluated the impact of implementing contact precautions for all patients in a burn unit after an outbreak of Acinetobacter baumanii demonstrated that the application of contact precautions for all the patients in an ICU may not reduce colonization by resistant microorganisms among the patients (46) .
It was verified that the reduction in the spread of resistant microorganisms among the patients is due to multifaceted strategies, which involve the rational Rev. Latino-Am. Enfermagem 2021;29:e3407.
use of antibiotics, hand hygiene, and adherence to the standard and contact precautions (45) .
However, a study that evaluated the adoption of contact precautions, before confirmation of colonization or infection by resistant microorganisms, highlighted the importance of surveillance cultures in the tracking of patients in an ICU and the implementation of contact precautions for all the patients (47) .
It is also emphasized that the identification of the colonized/infected patient before contact isolation is necessary (45) , the importance is reinforced that the contact precaution is implemented for all the colonized patients Despite the high adherence to the PPE to provide assistance to patients in contact precautions, in the present study, communication failures, work overload, inadequate physical structure, inaccessibility to protective equipment, and organizational and managerial aspects were referred to as factors that interfere with the use of personal protective equipment by the professionals (48) .
For the proposal of the score, in the group of  (38,44) . In this sense, it is essential to carry out institutional training, which results in improving the knowledge of the multidisciplinary team, care processes and activities. The trainings should promote the development of new skills in care, integrating all the professional categories (51) .
Finally, the inadequate infrastructure, associated with the provision of soap and alcohol at the points of assistance, are also important for the containment of bacterial resistance. The side-by-side arrangement of the dispensers in the Nursing stations, evidenced in the present study, can implicitly reinforce the sequential procedure, a practice that should not be adopted by the team (7,(52)(53) .
In addition, a number of studies reinforced the importance of the existence of alcohol dispensers at the points of assistance, as recommended by Resolution RDC No. 42, 2010 (54) , as well as booklets that remind the professional to perform hand hygiene, availability of good quality personal protective equipment and in sufficient numbers to favor adherence to hand hygiene and to the standard and contact precautionary measures (7,55) .
Containing bacterial resistance is a WHO goal and, year period was published, among whose objectives is to www.eerp.usp.br/rlae prevent and control the spread of microbial resistance in the health services (56) . is not controlled by 2050, it will be responsible for the death of ten million more people each year and for a reduction between 2.0% and 3.5% of the countries' gross domestic product (GDP), which will cost the world more than 100 trillion dollars (8) .
As for the limitations, it can be pointed out that Although the professionals were followed up in a way that they did not realize that they were being observed and according to the opportunity of the action performed,

Conclusion
Regarding the prevention and control actions carried out by the hospitals, it was noticed that most of them monitored adherence to hand hygiene, had protocols and conducted antibiotic audits, implemented standard and contact precautions, identified the bed of the patient with resistant bacteria, and adopted routine surveillance cultures.
When analyzing the measures that constituted the score, it was evidenced that most of the hospitals participating in the study partially adopted the measures for the prevention and control of bacterial resistance.