Uterotonics, magnesium sulphate and antibiotics during childbirth and peripartum: Important obstetric drugs for the anaesthesiologist.

The main causes of maternal mortality are comorbidities, hypertensive pregnancy syndrome, obstetric haemorrhage, and maternal sepsis. For this reason, uterotonics, magnesium sulphate, and antibiotics are essential tools in the management of obstetric patients during labour and in the peripartum period. These drugs are widely used by anaesthesiologists in all departments, and play a crucial role in treatment and patient safety. For the purpose of this narrative review, we performed a detailed search of medical databases and selected studies describing the use of these drugs in patients during pregnancy, delivery and the pospartum period. Uterotonics, above all oxytocin, play an important role in the prevention and treatment of pospartum haemorrhage, and various studies have shown that in obstetric procedures, such as scheduled and emergency caesarean section, they are effective at lower doses than those hitherto accepted. We also discuss the use of carbetocin as an effective alternative that has a therapeutic advantage in certain clinical circumstances. Magnesium sulphate is the gold standard in the prevention and treatment of eclampsia, and also plays a neuroprotective role in preterm infants. We describe the precautions to be taken during magnesium administration. Finally, we discuss the importance of understanding microbiology and the pharmacology of antibiotics in the management of obstetric infection and endometritis, and draw attention to the latest trends in antibiotic regimens in labour and caesarean section.

Screening, biochemical characterization and antibiotics resistance/susceptibility of bacteria isolated from native soil and water samples / Triagem, caracterização bioquímica e resistência/suscetibilidade a antibióticos de bactérias isoladas de amostras nativas de solo e água

The present study was conducted to isolate and characterize bacteria from water and soil sample taken from the Lahore Canal at different sites i.e. Mall Road, Mohlanwal and Khera site. Isolated bacterial strains were identified on the basis of morphological and biochemical tests. Identification was confirmed by culturing bacteria on selective media. Antibiotic resistance test was also performed to observe the resistance of bacteria against different antibiotics. Blood agar test was performed for identification of different pathogenic bacteria. The result revealed that water and soil samples of Lahore Canal Lahore from different sites were contaminated with Escherichia coli, Salmonella sp., Vibrio sp., Bacillus spp., Enterococcus sp. and Staphylococcus spp. Due to presence of these pathogens, this water is not suitable for any domestic and irrigation use. Study also revealed that water of the Lahore Canal is harmful for human health as it is contaminated with bacteria that can cause severe disease e.g., Escherichia coli can cause gastroenteritis, Bacillus spp. can cause nausea and vomiting, Enterococcus may infect urinary tract, Salmonella sp. is responsible for Bacteremia, Staphylococcus spp. can cause mild fever and Vibrio sp. can be the reason of cholera. Thus it is rendered unfit for any kind of human use even other than drinking like swimming, bathing, washing etc., until and unless some remedial measures are employed to eradicate pathogenic microorganisms by WASA and LWMS according to standards of WHO. Similarly, it is quite harmful, when and where ever it is used for irrigation without proper treatment.

O presente estudo foi realizado para isolar e caracterizar bactérias de amostras de água e solo retiradas do Canal Lahore, em Lahore, em diferentes locais, ou seja, Mall Road, Mohlanwal e Khera. As cepas bacterianas isoladas foram identificadas com base em testes morfológicos e bioquímicos. A identificação foi confirmada por cultura de bactérias em testes de meios seletivos. O teste de resistência aos antibióticos também foi realizado para observar a resistência das bactérias a diferentes antibióticos. Foi realizado o teste de ágar sangue para identificar diferentes bactérias patogênicas. O resultado revelou que amostras de água e solo do Canal Lahore, Lahore, de diferentes localidades estavam contaminadas com Escherichia coli, Salmonella sp., Vibrio sp., Bacillus spp., Enterococcus sp. e Staphylococcus spp. Por causa da presença desses patógenos, essa água não é adequada para qualquer uso doméstico e de irrigação. O estudo revelou que a água do Canal Lahore é prejudicial à saúde humana, pois está contaminada com bactérias que podem causar doenças graves, por exemplo: Escherichia coli pode ocasionar gastroenterite; Bacillus spp. pode causar náuseas e vômitos; Enterococcus sp. pode infectar o trato urinário; Salmonella sp. é responsável pela bacteremia; Staphylococcus spp. pode causar febre leve; e Vibrio sp. pode ser a razão da cólera. Assim, torna-se imprópria para uso humano, como natação, banho, lavagem etc., até que algumas medidas corretivas sejam empregadas para erradicar microrganismos patogênicos por WASA e LWMS de acordo com os padrões da OMS. Da mesma forma, é bastante prejudicial, quando usada para irrigação sem tratamento adequado.

Los colirios antibióticos acortan la duración de las conjuntivitis infecciosas en niños / Antibiotic eye drops shorten the duration of infectious conjunctivitis in children

Conclusiones de los autores del estudio: el tratamiento de la conjuntivitis infecciosa aguda en niños con antibióticos tópicos se asoció con una duración significativamente menor de la sintomatología conjuntival. Comentario de los revisores: el uso de antibiótico tópico, aunque de forma modesta, beneficia al paciente, acortando la curación clínica en las conjuntivitis agudas. No obstante, dado el curso autolimitado de esta patología y la falta de estudios de coste-efectividad en este ámbito, no parece justificada su indicación generalizada desde Atención Primaria. Se necesitarían realizar dichos estudios para evaluar el impacto global en la sociedad del tratamiento en estos pacientes. (AU)

Authors´ conclusions: topical antibiotics were associated with significantly shorter durations of conjunctival symptoms in children with acute infective conjunctivitis. Reviewers´ commentary: the use of topical antibiotics modestly benefits the patient, shortening the clinical cure in acute conjunctivitis. However, given the self-limited course of this pathology and the lack of cost-effectiveness studies in this area, its generalized prescription in primary care does not seem justified. Such studies should be carried out to assess the overall impact on society of the treatment of these patients. (AU)

Clasificación de riesgo y tiempo puerta-antibiótico en pacientes con sospecha de sepsis / Risk classification and door-to-antibiotic time in patients with suspected sepsis / Classificação de risco e tempo porta-antibiótico no paciente com suspeita de sepse

Objetivo: evaluar la asociación entre la clasificación de riesgo y el tiempo puerta-antibiótico en pacientes con sospecha de sepsis. Método: estudio de cohorte retrospectivo, con una muestra de 232 pacientes con sospecha de sepsis atendidos en el departamento de emergencias. Se dividieron en 2 grupos: con y sin clasificación de riesgo. Una vez identificado el tiempo puerta-antibiótico, se realizó un análisis de varianza de un factor con la prueba post hoc de Bonferroni o la prueba t de Student independiente para variables cuantitativas continuas; pruebas de correlación de Pearson, correlación biserial puntual o correlación biserial para análisis de asociación; y procedimiento de bootstrap cuando no había distribución normal de variables. Para el análisis de los datos se utilizó el software Statistical Package for the Social Sciences. Resultados: el tiempo puerta-antibiótico no difirió entre el grupo que recibió clasificación de riesgo en comparación con el que no fue clasificado. El tiempo puerta-antibiótico fue significativamente más corto en el grupo que recibió una clasificación de riesgo de alta prioridad. Conclusión: no hubo asociación entre el tiempo puerta-antibiótico y si se realizó o no la clasificación de riesgo, ni con la hospitalización en enfermería y en unidad de cuidados intensivos, ni con la duración de la estancia hospitalaria. Se observó que cuanto mayor era la prioridad, más corto era el tiempo puerta-antibiótico.

Objective: to evaluate the association between risk classification and door-to-antibiotic time in patients with suspected sepsis. Method: retrospective cohort study, with a sample of 232 patients with suspected sepsis treated at the emergency department. They were divided into 2 groups: with and without risk classification. Once the door-to-antibiotic time was identified, one-way analysis of variance was performed with Bonferroni post hoc test or independent Student's t-test for continuous quantitative variables; Pearson correlation tests, point-biserial correlation or biserial correlation for association analyses; and bootstrap procedure when there was no normal distribution of variables. For data analysis, the Statistical Package for the Social Sciences software was used. Results: the door-to-antibiotic time did not differ between the group that received risk classification compared to the one that was not classified. Door-to-antibiotic time was significantly shorter in the group that received a high priority risk classification. Conclusion: there was no association between door-to-antibiotic time and whether or not the risk classification was performed, nor with hospitalization in infirmaries and intensive care units, or with the length of hospital stay. It was observed that the higher the priority, the shorter the door-to-antibiotic time.

Objetivo: avaliar a associação entre a realização de classificação de risco e o tempo porta-antibiótico no paciente com suspeita de sepse. Método: estudo de coorte retrospectivo, com amostra de 232 pacientes com suspeita de sepse atendidos no pronto atendimento. Foram distribuídos em 2 grupos: com e sem classificação de risco. Identificado o tempo porta-antibiótico, realizou-se análise de variância de um fator com post hoc de Bonferroni ou teste T-Student independente para variáveis quantitativas contínuas; testes de correlação de Pearson, correlação bisserial por pontos ou correlação bisserial para análises de associação; e procedimento de bootstrap quando não havia distribuição normal de variáveis. Para a análise dos dados foi utilizado o software Statistical Package for the Social Sciences. Resultados: o tempo porta-antibiótico não diferiu entre o grupo que recebeu classificação de risco comparado ao que não foi classificado. O tempo porta-antibiótico foi significativamente menor no grupo que recebeu classificação de risco de alta prioridade. Conclusão: não houve associação entre o tempo porta-antibiótico e a realização ou não da classificação de risco, tampouco com internação em enfermaria e em unidade de terapia intensiva, ou com o tempo de internação hospitalar. Observou-se que quanto maior a prioridade, menor o tempo porta-antibiótico.

Consumo de antibióticos en pediatría de atención primaria antes y durante la pandemia de COVID-19 / Use of antibiotics in Paediatric Primary Health Care before and during the COVID-19 pandemic

Introducción: En España existe un alto consumo de antibióticos, especialmente en los primeros años de vida. Un uso excesivo de antimicrobianos contribuye a la aparición de resistencias. El objetivo de este estudio es analizar la evolución del consumo de antibióticos en población pediátrica entre 2014 y 2021 en la atención primaria del Principado de Asturias, y estudiar el impacto de la pandemia por COVID-19 sobre el mismo. Métodos: Estudio observacional y retrospectivo que recoge las prescripciones de antibacterianos para uso sistémico dispensadas a partir de recetas oficiales emitidas para pacientes menores de 14 años en atención primaria. Se mide el consumo en dosis diarias definidas (DDD) por 1.000 habitantes y día (DHD). Resultados: La tasa de consumo de antibióticos descendió desde 13,9DHD en 2014 a 4,0 en 2021 (β=−1,42; p=0,002) con un punto de inflexión en el año 2019. Entre 2019 y 2020 el descenso fue del 47,1%. El consumo se mantuvo en niveles muy bajos entre abril de 2020 y septiembre de 2021, con un repunte contenido desde octubre de 2021. La prevalencia de uso de antibióticos cayó desde el 39,9% en 2014 al 17,5% en 2021 (β=−3,64; p=0,006). Disminuyó el consumo relativo de amoxicilina-clavulánico y aumentó el de amoxicilina y cefalosporinas de tercera generación. Conclusión: En Asturias, el consumo pediátrico de antibióticos en atención primaria se desplomó a partir de 2020, coincidiendo con la COVID-19. La monitorización de estos indicadores permitirá comprobar en qué medida se mantienen los cambios en el tiempo.(AU)

Introduction: Consumption of antibiotics is high in Spain, primarily in children. Excessive use of then contributes to the development of antimicrobial resistance. The aim of our study is to analyse the evolution of antibiotic consumption at the Primary Health Care in the paediatric population of Asturias, Spain, from 2014 to 2021, and to evaluate the impact of COVID-19 pandemic on it. Methods: Retrospective and observational study using data about antibacterial agents for systemic use dispensed for official prescriptions to children under 14 years in Primary Care. Antibiotic consumption is expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID). Results: The antibiotic consumption rate dropped from 13.9 DID in 2014 to 4.0 in 2021 (β=−1.42, P=.002), with and inflection point in 2019. From 2019 to 2020 antibiotic use dropped by 47.1%. Antibiotic consumption remained very low from April 2020 to September 2021, and then moderately increased from October 2021. Prevalence of antibiotic use dropped from 39.9% in 2014 to 17.5% in 2021 (β=−3.64, P=.006). Relative consumption of amoxicillin/clavulanic acid decreased, while those of amoxiciline and third-generation cephalosporins increased. Conclusions: Paediatric antibiotic consumption collapsed in Asturias in 2020, coinciding with COVID-19 pandemic. Monitoring of antimicrobial usage indicators will allow to check if these changes are sustained over time.(AU)

Terapia con antibióticos versus apendicectomía en la apendicitis aguda no complicada: Una revisión sistemática y metaanálisis

Introducción: Existe una controversia acerca del mejor enfoque para el tratamiento de la apendicitis aguda no complicada. Este metaanálisis buscó evaluar la eficacia, recurrencia de la patología, presencia de complicaciones mayores, y duración de la estancia hospitalaria en adultos con apendicitis aguda no complicada. Materiales y Método: Se realizó una búsqueda sistemática de ensayos clínicos aleatorizados en las bases de datos PubMed, Scopus, Web of Science, Embase y Cochrane Library hasta finales de octubre del 2022. El riesgo de sesgo y calidad de los estudios incluidos en el estudio fueron evaluados mediante la herramienta RoB 2.0. de la Colaboración Cochrane. La síntesis de datos fue realizada a través del software Cochrane Review Manager (RevMan; version 5.3). Resultados: 6 estudios fueron incluidos, con un total de 1.862 pacientes. La probabilidad de presentar una mejoría clínica definitiva en el grupo que recibió antibioticoterapia fue menor (RR 0,5; IC95% 0,92-0,98; p = 0,004; IC2 = 44%). La probabilidad de presentar una recurrencia de la apendicitis en el grupo que recibió antibioticoterapia fue notablemente superior (RR 94,86; IC95% 30,73-292,81; p < 0,00001; IC2 = 0%). El grupo conservador presentó un menor riesgo de presentar una complicación mayor (RR 0,55; IC95% 0,36-0,85; p = 0,007; IC2 = 0%). El tratamiento conservador presentó una duración de la estancia hospitalaria superior que la apendicectomía (MD 0,34; IC95% 0,25-0,42; p < 0,00001; IC2 = 64%). Conclusiones: Esta revisión sistemática demuestra que, en términos de eficacia, recurrencia del cuadro y duración de la estancia hospitalaria, la antibioticoterapia es inferior a la apendicectomía en adultos con apendicitis aguda no complicada y superior en evitar la presencia de complicaciones mayores.

Introduction: There is controversy about the best approach for the treatment of uncomplicated acute appendicitis. This meta-analysis sought to assess efficacy, disease recurrence, presence of major complications, and length of hospital stay in adults with uncomplicated acute appendicitis. Materials and Method: A systematic search for randomized clinical trials was performed in the PubMed, Scopus, Web of Science, Embase, and Cochrane Library databases up to the end of October 2022. The risk of bias and quality of the studies included in the study were assessed. using the RoB 2.0 tool. of the Cochrane Collaboration. Data synthesis was performed using the Cochrane Review Manager software (RevMan; version 5.3). Results: 6 studies were included, with a total of 1.862 patients. The probability of presenting a definitive clinical improvement in the group that received antibiotic therapy was lower (RR 0.5; CI95% 0.92-0.98; p = 0.004; CI2 = 44%). The probability of presenting a recurrence of appendicitis in the group that received antibiotic therapy was notably higher (RR 94.86; 95%CI 30.73-292.81; p < 0.00001; CI2 = 0%). The conservative group presented a lower risk of presenting a major complication (RR 0.55; CI95% 0.36-0.85; p = 0.007; CI2 = 0%). Conservative treatment had a longer hospital stay than appendectomy (MD 0.34; 95%CI 0.250.42; p < 0.00001; CI2 = 64%). Conclusions: This systematic review shows that, in terms of efficacy, recurrence of the condition, and length of hospital stay, antibiotic therapy is inferior to appendectomy in adults with uncomplicated acute appendicitis, and superior in avoiding the presence of major complications.

Reducción del tiempo de tratamiento antimicrobiano en unidades de cuidados intensivos en Fortaleza, Brasil / Reduction of antimicrobial treatment time in intensive care units in Fortaleza, Brazil

Objetivo: Evaluar la aplicación de la estrategia reducción del tiempo de tratamiento Antimicrobiano (ATM) en Unidades de Cuidados Intensivos (UCI) en un Programa Stewardship de Antimicrobiano (ASP). Método: Este es un estudio descriptivo y transversal, realizado en dos UCI de un hospital universitario de Fortaleza, Brasil, de enero/2017 a enero/2019. Se incluyeron pacientes adultos, acompañados por un farmacéutico y utilizando ATM, en los que se aplicó la estrategia de reducción del tiempo de tratamiento. La evaluación de la estrategia se realizó a través de la diferencia entre el tiempo previsto establecido al inicio del tratamiento y los días efectivos de uso de cada ATM. Resultados: De los 100 pacientes incluidos, 51,0 % eran del sexo masculino y 64,0 % ancianos. El sistema respiratorio fue el más frecuentemente afectado (37,4 %) y las clases de ATM más prevalentes fueron los carbapenémicos (23,0 %) y los glicopéptidos (20,1 %). Hubo una disminución de 831 días innecesarios de terapia antimicrobiana y de un promedio de 13,7 a 8,9 días de tratamiento. Las mayores reducciones en días se observaron para meropenem, con 202 días reducidos. El estudio también permitió identificar asociaciones entre la reducción > 8 días de tratamiento y las variables estancia > 22 días y pacientes en cuidados paliativos exclusivos; y asociaciones entre alta hospitalaria y reducciones de hasta 7 días de terapia. Conclusiones: Los datos obtenidos sugieren que la presencia de un ASP influye en las prácticas de uso de ATM y su tiempo de tratamiento y enfatizan el papel de los profesionales farmacéuticos en estos programas. (AU)

Objective: To evaluate the application of the Antimicrobial (ATM) treatment time reduction strategy in Intensive Care Units (ICU) in an Antimicrobial Stewardship Program (ASP).Method: This is a descriptive and cross-sectional study, carried out in two ICU of a university hospital in Fortaleza, Brazil, from January/2017 to January/2019. Adult patients were included, accompanied by a pharmacist, and using ATM, in which the treatment time reduction strategy was applied. The evaluation of the strategy was made through the difference between the predicted time established at the beginning of the treatment and the effective days of use of each ATM.Results: Of the 100 patients included, 51.0 % were male and 64.0 % were elderly. The respiratory system was the most frequently affected by the infections (37.4 %) and the most prevalent classes of ATM were carbapenems (23.0 %) and glycopeptides (20.1 %). There was a decrease from 831 unnecessary days of antimicrobial therapy and from an average of 13.7 to 8.9 days of treatment. The greatest reductions in days were observed for meropenem, with 202 days reduced. The study also allowed the identification of associations between the reduction > 8 days of treatment and the variables length of stay > 22 days and patients in exclusive palliative care, and associations between hospi-tal discharge and reductions of up to 7 days of therapy.Conclusions: The data obtained suggest that the presence of an ASP influences the practices of ATM use and its treatment time and emphasize the role of pharmaceutical professionals in these programs. (AU)

New paradigms on antibiotic recommendations for community-acquired infections in Spain / Nuevos paradigmas en las recomendaciones antibióticas en las infecciones comunitarias en España

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use.(AU)

En los últimos años han cambiado significativamente los porcentajes de sensibilidad de los microorganismos más comunes que causan infecciones adquiridas en la comunidad en España. A partir de los porcentajes de sensibilidad de Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli y Klebsiella pneumoniae, recogidas de aislados de pacientes ambulatorios de 15 años o más, con síntomas de infecciones respiratorias o urinarias en servicios de microbiología de Cataluña en 2021, fenoximetilpenicilina debería ser la primera opción en la mayoría de los infecciones respiratorias, amoxicilina y ácido clavulánico en las exacerbaciones de la enfermedad pulmonar obstructiva crónica y la monodosis de fosfomicina o la pauta corta de nitrofurantoína como tratamiento de primera línea en las infecciones urinarias no complicadas. Es importante que los médicos de familia dispongan de información actualizada sobre la resistencia a los antimicrobianos para lograr un manejo empírico adecuado de las infecciones más frecuentes al promover un uso más racional de los antibióticos.(AU)

Trends in the epidemiological and microbiological profiles of infectious keratitis in southeastern Brazil / Perfil epidemiológico e microbiológico das ceratites infecciosas no sudeste do Brasil

ABSTRACT Purpose: To investigate the antibiotic susceptibility as well as the clinical, epidemiological, and microbiological profiles of microbial keratitis. Methods: This was a longitudinal retrospective study, and we retrospectively reviewed medical and laboratory records from 2015 to 2019. Results: In total, 380 pathogens (321 bacteria and 59 fungi) were isolated from the corneas of 352 patients. Staphylococcus species (45%) were most abundant within the organisms that were isolated, followed by Pseudomonas (18.4%), fungi (15.5%), Streptococcus (7.9%), and Serratia species (3.2%). The isolated gram-positive bacteria were not resistant to amikacin or vancomycin, although 14.8% of the gram-positive isolates were resistant to ciprofloxacin (p<0.05). All the gram-negative isolates were susceptible to amikacin. Male patients represented 62.8% of the 129 cases with accessible clinical data. The mean age of the patients was 53.17 ± 21 years. The time to presentation (from onset of symptoms) was 14.9 ± 19.4 days (median: 7 days). Large ulcers (>5 mm in any dimension) were present in 49.6% (64 eyes) of the cases. The duration of treatment was 49 ± 45.9 days (median: 38 days). Direct ocular trauma was reported by 48 (37.2%) patients, and 15 patients (11.6%) reported using contact lenses. For 72 (55.8%) patients, topical treatment had been previously prescribed, and 16 (12.4%) patients reported using other classes of drugs. Hospitalizations were required for 79 (61.2%) patients, and in terms of major complications, 53 (41.1%) patients had corneal perforations. A total of 40 patients (31%) underwent tectonic penetrating keratoplasty, and 28 (21.7%) developed secondary glaucoma. A progression to endophthalmitis occurred in 8 (6.2%) patients, with 50% of those patients' (3.1% of the total) endophthalmitis evolving to evisceration. The patients' microbial keratitis was largely treated empirically, with 94 (72.9%) patients prescribed moxifloxacin and 56 (43.4%) prescribed ciprofloxacin before receiving their culture results. Conclusions: For the most part, our hospital treated patients with severe microbial keratitis. Despite identifying gram-positive bacteria in most of the isolates, we also frequently identified gram-negative rods and fungi. Our susceptibility results support prescribing a combination of vancomycin and amikacin as an effective empirical therapeutic regimen to treat microbial keratitis.

RESUMO Objetivo: Investigar a susceptibilidade a antibió­ticos, o perfil clínico, epidemiológico e microbiológico das ce­ratites infecciosas. Métodos: Estudo retrospectivo longitu­dinal. Registros médicos e laboratoriais de 2015 a 2019 fo­ram revisados retrospectivamente. Resultados: Trezentos e oitenta patógenos (321 bactérias e 59 fungos) foram isolados das córneas de 352 pacientes. As espécies de Staphylococcus foram os microorganismos mais isolados (45%), seguidos de Pseudomonas (18,4%), fungos (15,5%), Streptococcus (7,9%) e Serratia (3,2%). Não houve resistência das bactérias Gram-positivas à amicacina ou vancomicina, enquanto 14,8% isolados Gram-positivos foram resistentes à ciprofloxacina (p<0,05). Todos os organismos Gram-negativos eram suscetíveis à amicacina. Pacientes do sexo masculino representaram 62,8% de 129 casos com dados clínicos acessíveis. A média de idade foi 53,17 ± 21 anos. O tempo até a apresentação (desde o início dos sintomas) foi de 14,9 ± 19,4 dias (mediana: 7 dias). Úlceras grandes (>5mm em qualquer extensão) representaram 49,6% (64 olhos) dos casos. A duração do tratamento foi de 49 ± 45,9 dias (mediana: 38 dias). Trauma ocular direto foi relatado por 48 (37,2%) pacientes e uso de lentes de contato por 15 (11,6%) pacientes. Foi prescrito tratamento prévio para 72 (55.8%) pacientes. Outras classes de medicamentos foram prescritas para 16 (12.4%). Setenta e nove (61,2%) pacientes tiveram que ser hospitalizados. Como complicações maiores, 53 (41,1%) pacientes apresentaram perfuração corneana, 40 pacientes (31%) foram submetidos à ceratoplastia penetrante tectônica e 28 (21,7%) desenvolveram glaucoma secundário. Oito pacientes (6,2%) evoluíram para endoftalmite. O tratamento empírico da ceratite microbiana foi amplamente empregado, com 94 (72,9%) pacientes em uso de moxifloxacina e 56 (43,4%) em uso de ciprofloxacina antes do resultado da cultura. Conclusões: Nosso hospital tratou predominantemente de pacientes com úlceras microbianas graves. Embora bactérias Gram-po­sitivas constituíssem a maioria dos isolados, bacilos e fungos Gram-negativos também foram frequentemente identificados nas ceratites microbianas. Os resultados de suscetibilidade sugerem a combinação de vancomicina e amicacina como um regime terapêutico empírico eficaz para essa condição grave com risco de perda visual permanente.

Description of changes in clinical outcomes following the implementation of an antibiotic stewardship program in a level IV hospital / Descripción del cambio en desenlaces clínicos posteriores a la implementación de un programa de gestión de antibióticos en un hospital de cuarto nivel de atención en salud

Introduction. Inadequate prescription of antibiotics has been recognized as a public health problem by the World Health Organization. In this context, antibiotic stewardship programs have been implemented as a tool to mitigate its impact. Objective. To describe the changes in clinical outcomes after the implementation of an antibiotic stewardship program in a level IV hospital. Materials and methods. We conducted a unique cohort study of patients hospitalized for infectious pathologies that were treated with antibiotics in an advanced medical facility. We collected the clinical history before the implementation of the antibiotic stewardship program (2013 to 2015) and then we compared it to the records from 2018 to 2019 collected after the implementation of the program. We evaluated changes in clinical outcomes such as overall mortality, and hospital stay, among others. Results. We analyzed 1,066 patients: 266 from the preimplementation group and 800 from the post-implementation group. The average age was 59.2 years and 62% of the population was male. Statistically significant differences were found in overall mortality (29% vs 15%; p<0.001), mortality due to infectious causes (25% vs 9%; p<0.001), and average hospital stay (45 days vs 21 days; p<0.001); we also observed a tendency to decrease hospital re- admission at 30 days for infectious causes (14% vs 10%; p=0.085). Conclusions. The antibiotic stewardship program implemented was associated with a decrease in overall mortality and mortality due to infectious causes, as well as in average hospital stay. Our results evidenced the importance of interventions aimed at mitigating the impact of inadequate prescription of antibiotics.

Introducción. La inadecuada prescripción de antibióticos es un problema de salud pública, reconocido por la Organización Mundial de la Salud. Los programas de gestión de antibióticos son implementados como una herramienta para mitigar su impacto. Objetivo. Describir los cambios observados en los desenlaces clínicos después de la implementación de un programa de gestión de antibióticos en un hospital de IV nivel de atención. Materiales y métodos. Se llevó a cabo un estudio de cohorte única de pacientes hospitalizados por patologías infecciosas y tratados con antibióticos en una institución médica de alta complejidad. Inicialmente, se recolectaron las historias clínicas anteriores a la implementación del programa de gestión de antibióticos (2013 a 2015) y luego se compararon con los datos obtenidos después de la implementación del programa de gestión de antibióticos de 2018 a 2019. Se evaluaron los cambios en los desenlaces clínicos como mortalidad y estancia hospitalaria, entre otros. Resultados. Se analizaron las historias clínicas de 1.066 pacientes: 266 con historia previa a la implementación del programa y 800 con historia posterior a la implementación. El promedio de edad fue 59,2 años y 62 % de la población era masculina. Se encontraron diferencias estadísticamente significativas en mortalidad global (29 Vs. 15 %; p<0,001), mortalidad por causa infecciosa (25 % Vs. 9 %; p<0,001) y promedio de estancia hospitalaria (45 Vs.21 días; p<0,001), con tendencia a disminuir nuevas hospitalizaciones en 30 días por patología infecciosa (14 Vs.10 %; p=0,085). Conclusiones. El desarrollo del programa de gestión de antibióticos se asoció con a una disminución en la mortalidad global, la mortalidad por causa infecciosa y la estancia hospitalaria. Esto demuestra la importancia de desarrollar intervenciones dirigidas a mitigar el impacto de la prescripción inadecuada de antibióticos.

New paradigms on antibiotic recommendations for community-acquired infections in Spain.

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use.

Duración de la antibioticoterapia en pacientes con colecistitis aguda manejados con colecistostomía. ¿Afecta los desenlaces clínicos? / Duration of antibiotic therapy in patients with acute cholecystitis managed with cholecystostomy. Does it affect clinical outcomes?

Introducción. En pacientes con diagnóstico de colecistitis aguda tratados con colecistostomía, el tiempo óptimo de duración de la terapia antibiótica es desconocido. El objetivo de este trabajo fue comparar los resultados clínicos en pacientes con diagnóstico de colecistitis aguda manejados inicialmente con colecistostomía y que recibieron cursos cortos de antibióticos (7 días o menos) versus cursos largos (más de 7 días). Métodos. Se llevó a cabo un estudio de cohorte observacional, retrospectivo, que incluyó pacientes con diagnóstico de colecistitis aguda manejados con colecistostomía, que recibieron tratamiento antibiótico. Se hizo un análisis univariado y de regresión logística para evaluar la asociación de variables clínicas con la duración del tratamiento antibiótico. El desenlace primario por evaluar fue la mortalidad a 30 días. Resultados. Se incluyeron 72 pacientes. El 25 % (n=18) recibieron terapia antibiótica por 7 días o menos y el 75 % (n=54) recibieron más de 7 días. No hubo diferencias significativas en la mortalidad a 30 días entre los dos grupos ni en las demás variables estudiadas. La duración de la antibioticoterapia no influyó en la mortalidad a 30 días (OR 0,956; IC95% 0,797 - 1,146). Conclusión. No hay diferencias significativas en los desenlaces clínicos de los pacientes con colecistitis aguda que son sometidos a colecistostomía y que reciben cursos cortos de antibióticos en comparación con cursos largos

Introduction.In patients with acute cholecystitis who receive treatment with cholecystostomy, the optimal duration of antibiotic therapy is unknown. The objective of this study is to compare short courses of antibiotics (7 days or less) with long courses (more than 7 days) in this population. Methods. We performed a retrospective observational cohort study which included patients diagnosed with acute cholecystitis, who received antibiotic therapy and were taken to cholecystostomy. Univariate analysis and logistic regression were performed to evaluate the association between clinical variables and the duration. The main outcome evaluated was 30-day mortality. Results. Seventy-two patients were included, 25% (n=18) were given 7 or fewer days of antibiotics while 75% (n=54) were given them for more than 7 days. Demographic data between both groups were similar (age, severity of cholecystitis, comorbidities). There were no significant differences in 30-day mortality between both groups. Antibiotic duration did not influence mortality at 30 days (OR 0.956, 95% CI 0.797 - 1.146). Conclusion. There are no significant differences in the clinical outcomes of patients with acute cholecystitis who undergo cholecystostomy and receive short courses of antibiotics compared to long courses

El tratamiento no quirúrgico de la apendicitis aumenta el riesgo de complicaciones / Nonoperative management of appendicitis increases the risk of complications

El manejo no quirúrgico de la apendicitis pediátrica no perforada ha aumentado en los hospitales infantiles de los Estados Unidos entre 2011 y 2020. Aunque la mayoría son tratados con éxito, este estudio sugiere que las tasas de reconsulta y hospitalizaciones son mayores, así como un aumento del riesgo de perforación en el momento del fracaso con ese tipo de manejo. Se necesitan estudios adicionales rigurosos y a gran escala del manejo no quirúrgico de la apendicitis en niños para determinar su uso óptimo (AU)

Nonoperative management of nonperforated pediatric appendicitis has increased in U.S.A. children's hospitals between 2011 and 2020. Although most children are successfully treated, this study suggests bigger rates of subsequent check-ups and hospitalizations, as well as an increased risk of perforation at the time of failure with that type of management. Further rigorous, large-scale studies of nonoperative management in children are needed to determine its optimal use. (AU)

[Translated article] Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study.

OBJECTIVE: A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription. METHOD: Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to seven different days of the week, in seven consecutive weeks. INCLUSION CRITERIA: patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by two specialists in emergencies, two pharmacists and one specialist in infectious diseases, all unrelated to prescriptions. RESULTS: 168 patients with 192 prescriptions were evaluated. Seventy-six (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa = 0.71). CONCLUSIONS: A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

Puntos farmacéuticos clave de la terapia antimicrobiana parenteral domiciliaria: revisión narrativa / Pharmaceutical key points in domiciliar prenteral antimicrobian therapy: narrative review

Introducción: Los buenos resultados de la terapia intravenosa domiciliaria, la mayor complejidad de los pacientes y el aumento de presión hospitalaria provocan que cada vez que los requerimientos técnicos sobre la misma sean más exigentes. Método: De todos los principios activos se realizó una búsqueda ordenada mediante términos MESH buscando: [“principio activo” and stability], [“principio activo” and storage], [“principio activo” and solvent]. Resultados: En este artículo se detallan los aspectos técnicos críticos a la hora de plantear una estrategia de antibioterapia intravenosa a domicilio: se revisan los antimicrobianos (antibióticos, antifúngicos y antivirales) candidatos a ser administrados en el domicilio por vía intravenosa en un paciente ingresado cargo de un servicio de hospitalización a domicilio: se revisan los principios activos candidatos, la concentración a la que se debe administrar, los tiempos de infusión mínimos, las condiciones de conservación, las estabilidades máximas, los solventes compatibles más frecuentes tipo de vía en la que deberíamos administrar según las propiedades fisicoquímicas del fármaco, el dispositivo de administración y la duración prevista del tratamiento. Conclusiones: Es fundamental a la hora de plantear una terapia intravenosa antibiótica domiciliaria que los fármacos se encuentren correctamente acondicionados y seleccionados.(AU)

Introduction: The good results of home intrave-nous therapy, the greater complexity of patients and the increase in hospital pressure cause that every time the technical requirements on it are more demanding. Method: Of all drugs, a search was carried out in order using MESH terms searching: [“drug” and stability], [“drug” and storage], [“drug” and solvent]. Results: This article details the critical technical aspects when considering a home intravenous antibiotic therapy strategy: antimicrobials (an-tibiotics, antifungals and antivirals) candidates to be administered at home intravenously in an inpatient in charge of a home hospitalization service are reviewed: the candidate drugs, the concentration to be administered, the minimum infusion times, storage conditions, maximum stability, the most frequent compatible solvents and the vascular access in which we should ad-minister according to the physicochemical prop-erties of the drug, the delivery device and the expected duration of treatment. Conclusions: It is essential when considering a home antibiotic intravenous therapy that the drugs are correctly conditioned and selected.(AU)

Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study. / Evaluación de la prescripción de antibióticos en un servicio de urgencias hospitalarias: estudio piloto.

OBJECTIVE: A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription. METHOD: Observational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to 7 different days of the week, in 7 consecutive weeks. INCLUSION CRITERIA: patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by 2 specialists in emergencies, 2 pharmacists and one specialist in infectious diseases, all unrelated to prescriptions. RESULTS: One hundred sixty eight patients with 192 prescriptions were evaluated. 76 (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa=0.71). CONCLUSIONS: A high rate of inappropriate antimicrobial prescriptions was obtained in a hospital emergency department according to local guidelines. The hospital pharmacist has an opportunity to improve the use of antimicrobials in this area.

Use of antibiotics in Paediatric Primary Health Care before and during the COVID-19 pandemic.

INTRODUCTION: Consumption of antibiotics is high in Spain, primarily in children. Excessive use of then contributes to the development of antimicrobial resistance. The aim of our study is to analyse the evolution of antibiotic consumption at the Primary Health Care in the paediatric population of Asturias, Spain, from 2014 to 2021, and to evaluate the impact of COVID-19 pandemic on it. METHODS: Retrospective and observational study using data about antibacterial agents for systemic use dispensed for official prescriptions to children under 14 years in Primary Care. Antibiotic consumption is expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID). RESULTS: The antibiotic consumption rate dropped from 13.9 DID in 2014 to 4.0 in 2021 (ß=-1,42, p=0,002), with and inflection point in 2019. From 2019 to 2020 antibiotic use dropped by 47.1%. Antibiotic consumption remained very low from April 2020 to September 2021, and then moderately increased from October 2021. Prevalence of antibiotic use dropped from 39.9% in 2014 to 17.5% in 2021 (ß=-3,64, p=0,006). Relative consumption of amoxicillin/clavulanic acid decreased, while those of amoxiciline and third-generation cephalosporins increased. CONCLUSIONS: Paediatric antibiotic consumption collapsed in Asturias in 2020, coinciding with COVID-19 pandemic. Monitoring of antimicrobial usage indicators will allow to check if these changes are sustained over time.

Evaluación de la prescripción de antibióticos en un servicio de urgencias hospitalarias: estudio piloto / Evaluation of the antibiotic prescription in a hospital emergency department: Pilot study

Objetivo: describir la adecuación de las prescripciones de antimicrobianos a las guías de tratamiento locales de infecciones, en el área de urgencias hospitalarias, así como conocer las características clínicas y epidemiológicas de los pacientes que reciben dichos tratamientos. Llevar a cabo un estudio de viabilidad para el diseño y la ejecución de investigaciones que aborden aspectos específicos de la inadecuación de prescripción de antimicrobianos.Métodoestudio piloto observacional, descriptivo y transversal, con recogida de datos retrospectiva de prescripción de antimicrobianos en un servicio de urgencias hospitalario. Se realizaron 7 cortes transversales, correspondientes a los 7 días diferentes de la semana, en 7 semanas consecutivas. Criterios de inclusión: paciente mayor de 14 años de edad, con al menos una primera dosis de tratamiento antimicrobiano prescrita el día del estudio. La variable principal fue la prescripción de antimicrobianos inadecuada según las guías locales. Como variables secundarias se recogieron parámetros epidemiológicos y clínicos de los pacientes. La evaluación de la adecuación la realizaron 2 especialistas médicos de urgencias y 2 especialistas en farmacia hospitalaria, más un tercer evaluador, especialista en enfermedades infecciosas, todos ajenos a la prescripción.Resultadosse evaluaron 168 pacientes con 192 prescripciones. Setenta y seis (39,6%) de las prescripciones no se ajustaron a las guías de tratamiento locales, de estas el 55% fueron con cobertura antimicrobiana activa frente al microorganismo, pero no recomendada, el 23,5% con fármacos inactivos, el 13,7% presentaban una dosis inapropiada y el 7,8% eran tratamientos innecesarios. La fuerza de la concordancia en la evaluación de la adecuación del tratamiento entre médicos y farmacéuticos fue alta (kappa=0,71). (AU)

Objective: A study about the adherence of the antimicrobial prescriptions to the local guidelines of treatment of infections was conducted in a hospital emergency department to study the clinical and epidemiological characteristics of the patients who received these treatments. Conducting a feasibility study for supporting the design and execution of future studies, addressing specific aspects of the appropriateness of the antimicrobial prescription.MethodObservational, descriptive and cross-sectional pilot study, with retrospective data collection about the antimicrobial prescription in a hospital emergency department. Seven cross sections were made, corresponding to 7 different days of the week, in 7 consecutive weeks. Inclusion criteria: patient over 14 years of age, with at least one first dose of antimicrobial treatment prescribed on the day of recruitment. The main variable was the inappropriate antimicrobial prescription according to the local guidelines. Epidemiological and clinical parameters of the patients were collected as secondary variables. In order to determine inappropriate prescription a revision was carried out by 2 specialists in emergencies, 2 pharmacists and one specialist in infectious diseases, all unrelated to prescriptions.ResultsOne hundred sixty eight patients with 192 prescriptions were evaluated. 76 (39.6%) of the prescriptions were not conformed to the local treatment guidelines. Of these, 55% were with active antimicrobial coverage against the microorganism but not recommended, 23.5% with inactive drugs, 13.7% presented an inappropriate dose and 7.8% were unnecessary treatment. The strength of agreement in the evaluation of the adequacy of treatment between doctors and pharmacists was high (kappa=0.71). (AU)

Utilización de antibióticos restringidos en la práctica clínica: ceftolozano/tazobactam, ceftazidima/avibactam, ceftarolina y dalbavancina / Use of restricted antibiotics in clinical practice: ceftolozane/tazobactam, ceftazidime/avibactam, ceftaroline and dalbavancin

Objetivo: Evaluar la utilización en la práctica clínica de cuatro antibióticos de amplio espectro o innovadores: ceftolozano/tazobactam, ceftazidima/avibactam, ceftarolina y dalbavancina. Métodos: Estudio retrospectivo en que se han recogido datos de los pacientes que han recibido dichos antibióticos entre julio de 2018 y junio de 2019 en un hospital terciario. Se recogen las condiciones de uso y los resultados en efectividad a los 30 días para dalbavancina, y para el resto de antimicrobianos a los 3-5 días del inicio, a los 14 y a los 30 días para determinar mortalidad. Resultados: Se recogieron datos de 51 pacientes, con una mediana de edad de 63 años. La infección más comúnmente tratada fue neumonía (41,2%). Tres pacientes (5,9%) recibieron la terapia en estudio como primera línea y 43 (84,3%) recibieron antibióticos concomitantes. En el 66,7% de las infecciones se había aislado previamente un microorganismo sensible. En el 19,6% de los casos el cultivo fue negativo. En el grupo dalbavancina, el 75% de los pacientes se curaron a los 30 días. En el resto de antimicrobianos, el tratamiento resultó efectivo a los 3-5 días en el 65,1%. El 51,2% se curaron a los 14 días y un 30,2% fallecieron a los 30 días. Conclusiones: Los resultados de efectividad resultan comparables a estudios publicados con diseños similares. Se detecta la importancia de fomentar un uso adecuado de los antibióticos, como tratamientos dirigidos o empíricos en casos de riesgo de resistencias, priorizando su desescalada. Es esencial la implantación de equipos multidisciplinares PROA. (AU)

Objective: To evaluate the use in clinical practice of four recently marketed antibiotics: ceftolozane/tazobactam, ceftazidime/avibactam, ceftaroline, and dalbavancin. Methods: Retrospective study in which data have been collected from patients who have received these antibiotics between July 2018 and June 2019, in a third-level hospital. The conditions of use and the results in clinical efficacy measured in three periods have been studied: 3-5 days after the start of treatment, 14 days and 30 days to determine mortality. Results: Data were collected from a total of 51 patients, with a median age of 63 years. The most commonly treated infection was pneumonia (41.2%). Three patients (5.9%) received study therapy as the first line of treatment and 43 (84.3%) received concomitant antibiotics. In 66.7% of the infections, a sensitive microorganism to the antibiotic under study had been previously isolated. In 19.6% of the cases, the culture was negative. In the dalbavancin group, 75% of the pacients cured at day 30. In the other groups, the treatment was effective at 3-5 days in 65.1% of the cases. 51.2% experienced clinical cure at 14 days and 30.2% died at 30 days. Conclusions: The effectiveness results are comparable to published studies with similar designs. The importance of promoting an adequate use of antibiotics is detected, as directed or empirical treatments in cases of risk of resistance, prioritizing their de-escalation. The implementation of multidisciplinary PROA teams is essential. (AU)

Auditoría de la dispensación de antibióticos en la farmacia comunitaria (proyecto ‘Happy Patient’) / Audit of antibiotic dispensing in the community pharmacy ('Happy Patient' project)

Resumen: La dispensación y la prescripción de antibióticos no se adecúa a los estándares científicos en muchos de los países en la Unión Europea, entre los que se encuentra España, resultando una amenaza para la salud de la población. Para hacer frente al crecimiento de las resistencias antimicrobianas surgió el proyecto “Happy Patient” bajo el auspicio de la Comisión Europea. Objetivos: conocer las características de la dispensación de antibióticos en farmacias comunitarias españolas. Comparar la variabilidad entre las diferentes farmacias comunitarias españolas. Material y métodos: se utilizó el método “Audit Project Odense®” para conocer cómo eran las dispensaciones de antibióticos en las farmacias comunitarias, pidiendo a los farmacéuticos participantes registrar durante 5 días consecutivos entre los meses de febrero y abril de 2022, las actuaciones llevadas a cabo durante la dispensación de antibióticos por vía oral para uso humano y para el tratamiento de infecciones agudas. Resultados: se entrevistaron a 573 usuarios (59,9 % mujeres) de todas las edades. Los usuarios conocían en un 83,6 % para qué había sido prescrito el antibiótico siendo el más demandado la amoxicilina seguido de la amoxicilina con ácido clavulánico. En un 15 % de las dispensaciones (n=86) se realizaron los tres controles de seguridad: interacciones, contraindicaciones y alergias. El dispensador contactó muy raramente con el prescriptor (4 veces), pero cuando lo hizo, éste cambió la prescripción. En el 62,3 % de los casos se ofreció información sobre la duración del tratamiento y la amoxicilina con y sin ácido clavulánico fue el antibiótico dispensado en el que en más ocasiones se advirtió de los efectos secundarios. En un 24,6 % de las dispensaciones no se ofreció ninguna información personalizada del medicamento. En el 81,7 % el farmacéutico estuvo de acuerdo con el tratamiento prescrito (AU)