建構中部地區醫院抗生素合理使用

Implementation of Rational Antibiotic Use in Local Hospital

醫院中是抗生素使用最多、最頻繁的地方，因而醫院亦是抗藥性細菌最多的地方。部份病人住院後身上被分離出抗藥性細菌，或是住院中出現發燒，而使用前線抗生素並未退燒，醫師就進一步使用更後線或更廣效的抗生素，如此又進一步篩選出連後線抗生素都無效的菌株，不斷惡性循環。如此在醫院中抗生素使用一直高居不下之情況下，抗生素使用不適當，極可能增加抗藥菌株形成之機會；經統計顯示，在醫療機構中不適當的抗生素使用治療，佔了所有住院病患的41%，而一般地區醫院對於抗生素管制，普遍無專責感染科醫師，致使醫師在使用抗生素大多採經驗療法，無可以適用於地區醫院使用之抗生素使用規範可供依循。為確保病人在就醫過程中得到最高品質的醫療照護，落實抗生抗生素使用之適當性為現今重要之課題。本研究採取自願接受研究之地區醫院為主要樣本9家、醫護人員共計40人，邀集相關感染科專家4名成立專家群體，制定或修訂適合地區醫院使用之抗生素使用規範，可供醫師解決其抗生素臨床使用之問題，並參與、輔導中部地區醫院之感控委員會之有效運作、針對有使用抗生素治療感染的病患之病歷執行稽核及接受地區醫院醫師在使用抗生素過程如有疑慮以傳真方式予以專家群體會診，依各地區醫院型態不同，協助建立各地區醫院收集並分析監測指標、建立抗生素使用覆核制度，並參究跨理論模式及合理抗生素使用認知量表，以了解研究方案介入前後之差異、成效。本研究經過四次之修正及中區醫院感染管制聯合輔導委員會主任委員認可，制定完成適合地區醫院之抗生素使用規範。有55.56%醫院在經本研究相關作業執行後，第三季之監測指標皆較前壹年同期有顯著下降。本研究進行後，護理及藥事人員不同職務類別、年齡、學歷、科別、服務年資與自覺效益、障礙及效能皆沒有顯著性差異。在適當使用抗生素之認知情況部份，醫護及藥師人員在經本研究介入後，對於適當使用抗生素之認知情況有明顯的進步，各職務類別之平均達錯率皆較本研究進行前為少。本研究執行過程發現，管理階層為了業績無法管理少數醫師行為，其研究介入成效與院長。院方的支持及非稽查式介入方式成正向關連。建議各地區醫院除了設置專職感染科醫師與感控護理師之外，並強化經營管理者認知與藥師功能，才能有效落實抗生素管理。本研究以複合式方法，確實可提昇中區醫療區域內之醫護及藥師人員正確之抗生素使用應有認知及其行為，促使地區醫院病人之用藥安全、減少醫療資源浪費。

Objecitve: The cost of antibiotics remains high for hospitals, and inappropriate antibiotic use may lead to increased resistance to antibiotics. Consultations with full-time or part-time infectious disease specialists and infection control professionals are not available in small-size hospitals in central Taiwan. Due to the lack of consultants and on-the-job training, doctors practicing in these hospitals have always used antibiotics on an empirical basis. Our project aimed to help the medical staff in 9 such hospitals to optimize antibiotic use, establish an in-hospital system for antibiotic stewardship, determine guidelines for antibiotic use, and eventually to improve patient safety. Methods: Five infectious disease physicians were involved in determining the guidelines which were modified to suit different situations in our targeted hospitals. We helped to establish infection control committees in these hospitals, and offered consultations about antibiotic use. We also trained the medical staff to monitor antibiotic utilization and to practice antibiotic stewardship; finally, we hosted symposia for continuing education. Results: Over the 9-month intervention period, parameters regarding antibiotic utilization showed improvement in the quality of antibiotic use in 55.56% （5/9）of participating hospitals. We evaluated attitude and knowledge about appropriate antibiotic use in different medical personnel, including physicians, pharmacists, nursing specialists and nurses in the preintervention and post-intervention periods. Our results showed that there was a positive trend toward self-benefit and self-efficacy for pharmacists in the post-intervention period. There was no statistical difference among physicians. Study of the attitudes toward optimizing antibiotic use showed that there was a positive trend in different medical personnel in the postintervention period. We developed and implemented antibiotic guidelines and CLSI（The Clinical and Laboratory Standards Institute）-based antimicrobial susceptibility testing which was modified to meet individual needs of local hospitals. Our infectious disease physicians operated as independent consultants by fax, by phone and through in-hospital visits. Finally, we trained pharmacists to audit antibiotic prescriptions and to strengthen surveillance.Conclusion: To a great degree, the effectiveness of antibiotic stewardship depended on the support of supervisors or directors of the hospitals. To sustain these methods and interventions and to improve the quality of medical care, full-time infectious disease physicians and infection control professionals are needed in each hospital.