藉由教育及電腦輔助軟體提升預防性抗生素使用合適率

Increasing Appropriate Perioperative Prophylactic Antibiotic Usage through Education and Computer Assistance-Experience of a Medical Center in Central Taiwan

醫學文獻支持於受術前適當使用預防性抗生素，可以降低術後傷口感染率；但是過度使用反而會造成抗藥性菌種之移生以及醫療資院浪費等問題。本研究藉由教育及溝通推廣外科預防性抗生素於目前感染管制要求的使用規範，並以資訊系統做為輔助，有效管理外科預防性抗生素的使用情況。首先邀請8大外科系醫師召開共識會議，說明預防性抗生素監測重點，包括確認清淨手術名稱、給予抗生素之劑量應考慮病人體重與腎功能、第一劑預防性抗生素應再手術劃刀前1小時內給予、若手術時間大於4小時應追加劑量，以及清淨手術使用預防性抗生素應小於等於24小時，並且修訂預防性抗生素使用之標準作業書。另外我們運用資訊系統擷取病人體重、血液肌酸酐值、入開刀房時間、第一劑抗生素施打時間、手術總時間及預防性抗生素追加時間，若發現不符合規定之案件，則藉由雙向回饋機制加強醫師對於預防性抗生素的使用概念進而避免相同情況再發生。在達成外科系醫師的手術預防性抗生素使用共識後，配合資訊系統建置，感管師能更有效率地監測預防性抗生素使用情形。結果顯示cefazolin劑量與體重符合率（94.3%, 2011年vs. 96.2%, 2012年，P＜0.001）、首劑cefazolin符合率（93.8%, 2011年vs. 95.4%, 2012年，P＜0.001）、以及心臟血管外科手術時間超過4小時cefazolin追加比率（91.5%, 2011年vs. 98.1%, 2012年，P＜0.001），都有顯著進步。未來我們將持續與資訊人員合作，建立手術預防性抗生素自動監測系統，即時提供預防性抗生素使用狀況並自動發出回饋單，節省監控人力需求。

Published articles support the appropriate use of prophylactic antibiotics to reduce post-operative skin and soft tissue infections. However, antibiotic overuse may increase unexpected bacterial colonization and medical costs. We introduced doctors from eight surgical sub-departments to the main points associated with prophylactic antibiotic administration, including making sure the surgery is clean, adjusting the dosage to reflect the estimated creatinine clearance giving the first prophylactic dose within one hour of the start of surgery, giving a bolus dose every four hours after the start of surgery, and creating a standard operating procedure. We also designed a computer-assisted system to inform doctors of their patients’ body weights, laboratory data, operation timings, and first prophylactic dose timings. Cefazolin was also made available in operating rooms to ensure that a second dose could be given immediately, when necessary. We provided feedback to the doctors when an incorrect use was detected. After our intervention, surgeons achieved a consensus regarding prophylactic antibiotic usage. Infection control nurses could easily monitor information in our computer system. We found that correct rates of prophylactic cefazolin and gentamicin usage reached 95%. In the future, we wish to design a computer system that offers a more prompt analysis of prophylactic antibiotic administration