臨床決策輔助系統於抗生素管理之應用

Use of clinical decision support systems for antimicrobial stewardship

抗生素抗藥性被世界衛生組織視為「無聲的大流行」，對全球的病患照護安全造成重大威脅，世界各國莫不積極推動或發展抗生素管理策略以對抗抗生素抗藥性之威脅。臨床決策輔助系統(clinical decision support system, CDSS)乃是藉由整合醫學知識、病人資訊、以及其他相關臨床照護訊息等，以優化與輔助醫療決策，實際運作上具多元化之樣態，包含警示與提醒系統、電子化診治指引與臨床路徑工具、電子病歷範本、或病患個人資料整合等。CDSS應用於抗生素管理的領域，包含可協助抗生素前瞻式審核與回饋、抗生素處方限制與預授權、以抗生素處方調整提醒機制優化抗生素之開立，以及透過結合具實證基礎之診治指引與臨床路徑以促進臨床照護團隊對於診治指引的順從性等。雖然有文獻實證顯示適當地導入與應用CDSS可促進抗生素適當使用、降低患者死亡率、減少抗生素使用量、讓患者可提早接受適當之抗生素治療、以及減少醫療照護相關費用等優點，能更有效率地推動抗生素管理之業務與提升病人照護品質。但醫療機構導入CDSS亦存在有建置成本、系統使用率、以及警示疲勞等挑戰與風險，在實際的推展層面上皆須納入考量。

Antimicrobial resistance (AMR) is a multi-faceted global challenge known as a“silent pandemic”. If no action is taken, AMR could soar dramatically, leading to higher public health, economic, and social costs. Antimicrobial stewardship programs are important measures for reducing and preventing AMR. Clinical decision support systems (CDSSs) are designed to improve healthcare delivery by optimizing medical decisions with collaboration with pharmacy, clinical microbiology, radiology, and infectious disease workforce. CDSSs use in antimicrobial stewardship include prospective audit and feedback, formulary restriction, and preauthorization in antimicrobial stewardship programs; optimizing antimicrobial choice; reducing time to appropriate antibiotics use; and increasing compliance with guidelines. CDSSs have shown many benefits such as improvement in antibiotic selection, reduction in antibiotic usage, decreased mortality, increased pharmacy interventions, decreased time to optimal therapy, and decreased healthcare costs. Nevertheless, several potential challenges and barriers remain for the implementation of CDSS, including costs of systems establishment and maintenance, adherence and utility of CDSS, excessive alerts related alert fatigue, and ethical and legal issues.