以抗生素治療敗血症的成本效益分析

An Analysis of the Cost- Effectiveness of Antibiotic Choices for the Treatment of Sepsis

背景：健保資源應有效利用，醫師如為敗血症患者選用不適當的抗生素，可能導致住院日延長與醫療資源的浪費或病況惡化、死亡。本研究針對敗血症住院病人之抗生素使用進行成本效益分析，以提供醫師對敗血症病人治療之參考。方法：資料來源為某區域教學醫院2005年1月1日至2008年3月31日，14歲以上，曾接受抗生素治療的社區感染敗血症病患，血液培養為陽性並符合入院時APACHE Ⅱ score 小於 15分且未接受手術的病人，共計392位，依抗生素使用情況分為四組，以chi-square、one way ANOVA、logistic regression等方法進行統計分析。結果：每日抗生素費、每日總藥費以血液培養結果前後只用後線抗生素之組別最高；每日醫療費、住院天數、死亡率以血液培養結果前先用第一線抗生素，得知結果後再改後線抗生素之組別最高。糖尿病患、APACHE Ⅱscore 9到14分、感染Staphylococcus aureus 的死亡率較高。結論：APACHE Ⅱscore 9到14分的敗血症病患與死亡率較高的糖尿病敗血病患，宜先用後線抗生素，等細菌培養結果後再調整抗生素，以獲得較佳的成本效益。

Aims: Investigate the cost-effectiveness of antibiotic choices for the treatment of sepsis. Cost included daily cost for antibiotics, daily cost for all medication, and daily in-hospital cost; effectiveness included length of stay and mortality rate in the hospital. Methods: The choices of antibiotic treatment for sepsis could be divided into four groups: in group one, a first line antibiotic was administered before and after a positive blood culture; in group two, a second line antibiotic was administered before and after a positive blood culture; in group three, a first line antibiotic was administered before a positive blood culture and a second line antibiotic was administered after a positive blood culture; in group four, a second line antibiotic was administered before a positive blood culture and a first line antibiotic was administered after a positive blood culture. We then compared the costs for these four groups. Results: Group 2 had higher average daily antibiotic costs and all drug costs than did the other three groups. Group 3 has the highest average medical expense and mortality rate and the longest average length of stay. Sepsis patients whose APACHE Ⅱ scores were between 9 and 14 in combination with diabetes had a higher mortality rate than did other patients. Those sepsis patients infected with Staphylococcus aureus had a higher mortality rate than those infected with other bacteria. Conclusion: For sepsis patients whose APACHE Ⅱscores are between 9 and 14 or have comorbid diabetes and a higher mortality rate, the use of a second line antibiotic before confirmation by a positive blood culture is recommended.