抗菌药物临床干预对ICU多药耐药菌影响的研究
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摘要
目的分析抗菌药物使用管理前后重症监护病房(ICU)多药耐药菌检出变化情况,以及抗菌药物使用强度(AUD)改变对多药耐药菌(MDROs)的影响效应。方法通过对医院抗菌药物使用量(DDDs)排名前五位的抗菌药物予以干预或限量,对特殊级抗菌药物的临床使用实行信息化全程在线监控及信息化预警屏障干预等专档监管,观察干预管理前后,目标性监测MDROs检出情况。并对干预效果进行评价。结果医院临床抗菌药物使用干预方案实施后ICU三代头孢、三代头孢含酶抑制剂使用强度均下降,喹诺酮类药物使用强度有所增长,差异均有统计学意义(P <0.05);CRE的检出率从7.38%下降至0.94%,CRAB的检出率从92.86%下降至77.78%,CRPA检出率却从47.83%上升至63.46%,差异均具有统计学意义(P<0.05);MRSA、VRE的检出率变化不大,差异无统计学意义。通过Spearman相关性分析显示:CRE检出率下降与三代头孢、三代头孢含酶抑制剂的限量使用呈现正相关(r=0.551,0.649,P<0.05);CRAB感染率下降与喹诺酮类药物增量呈现负相关(r=-0.499,P<0.05)。但同时显示CRPA检出率升高与三代头孢、三代头孢含酶抑制剂、碳青霉烯类以及抗菌药物总使用量下降都呈现负相关性(r=-0.524,-0.581,-0.615,-0.633,P<0.05)。结论抗菌药物管理实施后,ICU中异常增长的抗菌药物消耗量得到控制,CRE、CRAB检出率、感染率均有一定程度的下降,但CRPA检出率出现反弹性升高,应当引起重视。提升抗菌药物专业化管理水平,阶段性优化抗菌药物治疗方案,可能是阻遏抗菌药物诱导细菌耐药更为有效的方法。
OBJECTIVE To investigate the changes of multidrug-resistant organisms(MDROs)isolated from intensive care unit(ICU)before and after the management of use of antibiotics and observe the effect of antibiotics use density(AUD)on the MDROs.METHODS The interventions or limitation of dose were taken to the antibiotics that ranked the top 5 defined daily dose system,the dedicated files supervisions such as the information and whole process online monitoring and information pre-warning barrier intervention were performed for the clinical use of special antibiotics.The isolation rate of MDROs was observed by targeted monitoring before and after the intervention,and the effects of the interventions were evaluated.RESULTS The use intensities of the third generation cephalosporins and third generation cephalosporins containing enzyme inhibitor declined after the interventions were taken,while the use intensities of quinolones were increased,and there were significant differences(P<0.05).The isolation rate of CRE was decreased from 7.38%to 0.94%,the isolation rate of CRAB was decreased from92.86%to 77.78%,the isolation rate of CRPA was increased from 47.83%to 63.46%,and there were significant differences(P <0.05).There were no significant differences in the isolation rates of MRSA and VRE.The Spearman correlation analysis indicated that the decline of isolation rate of CRE was positively correlated with the limited use of the third generation cephalosporins and the third generation cephalosporins containing enzyme inhibitors(r=0.551,0.649,P<0.05),the decrease of incidence of CRAB infection was negatively correlated with the increase of dose of quinolones(r=-0.499,P<0.05),and the increase of isolation rate of CRPA was negatively correlated with the decrease of the total dosage of the third generation cephalosporins,third generation cephalosporins containing enzyme inhibitors,carbapenems and antibiotics(r=-0.524,-0.581,-0.615,-0.633,P<0.05).CONCLUSIONThe abnormal growth of consumption of antibiotics is under control after the interventions are taken,the isolation rates of CRE and CRAB and the infection rates are decreased to some extent,however,the isolation rate of CRPA shows the rebound increase,which should be attached great importance to.It is a more effective way to improve the professional management of antibiotics and optimize the staged antibiotic therapy so as to curb the bacterial resistance induced by antibiotics.
OBJECTIVE To investigate the changes of multidrug-resistant organisms(MDROs)isolated from intensive care unit(ICU)before and after the management of use of antibiotics and observe the effect of antibiotics use density(AUD)on the MDROs.METHODS The interventions or limitation of dose were taken to the antibiotics that ranked the top 5 defined daily dose system,the dedicated files supervisions such as the information and whole process online monitoring and information pre-warning barrier intervention were performed for the clinical use of special antibiotics.The isolation rate of MDROs was observed by targeted monitoring before and after the intervention,and the effects of the interventions were evaluated.RESULTS The use intensities of the third generation cephalosporins and third generation cephalosporins containing enzyme inhibitor declined after the interventions were taken,while the use intensities of quinolones were increased,and there were significant differences(P<0.05).The isolation rate of CRE was decreased from 7.38%to 0.94%,the isolation rate of CRAB was decreased from92.86%to 77.78%,the isolation rate of CRPA was increased from 47.83%to 63.46%,and there were significant differences(P <0.05).There were no significant differences in the isolation rates of MRSA and VRE.The Spearman correlation analysis indicated that the decline of isolation rate of CRE was positively correlated with the limited use of the third generation cephalosporins and the third generation cephalosporins containing enzyme inhibitors(r=0.551,0.649,P<0.05),the decrease of incidence of CRAB infection was negatively correlated with the increase of dose of quinolones(r=-0.499,P<0.05),and the increase of isolation rate of CRPA was negatively correlated with the decrease of the total dosage of the third generation cephalosporins,third generation cephalosporins containing enzyme inhibitors,carbapenems and antibiotics(r=-0.524,-0.581,-0.615,-0.633,P<0.05).CONCLUSIONThe abnormal growth of consumption of antibiotics is under control after the interventions are taken,the isolation rates of CRE and CRAB and the infection rates are decreased to some extent,however,the isolation rate of CRPA shows the rebound increase,which should be attached great importance to.It is a more effective way to improve the professional management of antibiotics and optimize the staged antibiotic therapy so as to curb the bacterial resistance induced by antibiotics.
引文
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[3]李春辉,吴安华,艾宇航,等.ICU住院患者多药耐药菌定植影响因素[J].中华医院感染学杂志,2013,23(10):2302-2304.
[4]胡素佩,陈琳,许小敏,等.ICU常见革兰阴性菌的耐药性与抗菌药物使用强度相关性研究[J].中华医院感染学杂志,2015,25(11):2453-2455.
[5]Pien CJ,Kuo HY,Chang SW,et al.Risk factors for levofloxacin resistance in Stenotrophomonas maltophillia from respiratory tract in a regional hospital[J].J Microbiol Immunol Infect,2015,48(3):291-295.
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[7]中华医学会重症医学分会.中国重症加强治疗病房(ICU)建设与管理指南(2006)[J].中国危重病急救医学,2006,18(7):387-388.
[8]杨帆.《抗菌药物临床应用指导原则(2015年版)》解读[J].中华临床感染病杂志,2016,9(5):390-393.
[9]肖永红.国家细菌耐药控制行动计划:基于大健康理念的耐药控制宏图[J].中华临床感染病杂志,2016,9(4):289-293.
[10]贾会学,胡必杰,吴安华,等.多药耐药菌感染干预效果多中心研究[J].中国感染控制杂志,2015,14(8):524-529.
[11]Clinical and Laboratory Standards Institute.Performance standards for antimicrobial susceptibility testing[S].CLSI,Twentysixth informational supplement,2016,M100-S26.
[12]Kuo HY,Chang KC,Kuo JW,et al.Imipenem:apotent inducer of multidrug resistance in Acinetobacter baumannii[J].Int J Antimicrob Agents,2012,39(1):33-38.
[13]李鹏,李轶,张付华,等.耐碳青霉烯类肠杆菌医院感染风险分析[J].中华医院感染学杂志,2015,25(11):2417-2419.
[14]Wang Q,Zhang Y,Yao X,et al.Risk factors and clinical outcomes for carbapenem-resistant Enterobacteriaceae nosocomial infections[J].Eur J Clin Microbiol Infect Dis,2016,35(10):1679-1689.
[15]Kaki R,Elligsen M,Walker S,et al.Impact of antimicrobial stewardship in critical care:a systematic review[J].J Antimicrob Chemother,2011,66(6):1223-1230.
[16]Livermore DM,Hope R,Reynolds R,et al.Declining cephalosporin and fluoroquinolone non-susceptibility among bloodstream Enterobacteriaceae from the UK:links to prescribing change[J].J Antimicrob Chemother,2013,68(11):2667-2674.
[17]赵艳春,胡必杰,吴安华,等.全国多中心ICU抗菌药物使用与多药耐药菌监测分析[J].中华医院感染学杂志,2015,25(21):4867-4869.
[18]李晋,王婧,侯大鹏.实施抗菌药物管理对重症监护病房中病原菌耐药率变迁的影响[J].中华临床感染病杂志,2016,9(2):156-160.
[19]Pena C,Gomez-zorrlla S,Suarez C,et al.Extensively drug-resistant Pseudomonas aeruginosa:risk of bloodstream infection in hospitalized patients[J].Eur J Clin Microbiol Infect Dis,2012,31(10):2791-2797.
[20]Gales AC,Castanheira M,Jones RN,et al.Antimicrobial resistance among gram-negative bacilli isolated from Latin A-merica:results from the SENTRY Antimicrobial Surveillance Program(Latin America,2008-2010)[J].Diagn Microbiol Infect Dis,2012,73(4):354-360.
[2]Papakonstantinou I,Angelopoulos E,Baraboutis I,et al.Risk factors for tracheobronchial acquisition of resistant gram-negative bacterial pathogens in mechanically ventilated ICU patients[J].J Chemother,2015,27(5):283-289.
[3]李春辉,吴安华,艾宇航,等.ICU住院患者多药耐药菌定植影响因素[J].中华医院感染学杂志,2013,23(10):2302-2304.
[4]胡素佩,陈琳,许小敏,等.ICU常见革兰阴性菌的耐药性与抗菌药物使用强度相关性研究[J].中华医院感染学杂志,2015,25(11):2453-2455.
[5]Pien CJ,Kuo HY,Chang SW,et al.Risk factors for levofloxacin resistance in Stenotrophomonas maltophillia from respiratory tract in a regional hospital[J].J Microbiol Immunol Infect,2015,48(3):291-295.
[6]Tacconelli E,Cataldo MA,Dancer SJ,et al.ESCMID guidelines for the management of the infection control measure to reduce transmission of multidrug-resistant gram-negative bacteria in hospitalized patients[J].Clin Microbiol Infect,2014,20(Suppl 1):1-55.
[7]中华医学会重症医学分会.中国重症加强治疗病房(ICU)建设与管理指南(2006)[J].中国危重病急救医学,2006,18(7):387-388.
[8]杨帆.《抗菌药物临床应用指导原则(2015年版)》解读[J].中华临床感染病杂志,2016,9(5):390-393.
[9]肖永红.国家细菌耐药控制行动计划:基于大健康理念的耐药控制宏图[J].中华临床感染病杂志,2016,9(4):289-293.
[10]贾会学,胡必杰,吴安华,等.多药耐药菌感染干预效果多中心研究[J].中国感染控制杂志,2015,14(8):524-529.
[11]Clinical and Laboratory Standards Institute.Performance standards for antimicrobial susceptibility testing[S].CLSI,Twentysixth informational supplement,2016,M100-S26.
[12]Kuo HY,Chang KC,Kuo JW,et al.Imipenem:apotent inducer of multidrug resistance in Acinetobacter baumannii[J].Int J Antimicrob Agents,2012,39(1):33-38.
[13]李鹏,李轶,张付华,等.耐碳青霉烯类肠杆菌医院感染风险分析[J].中华医院感染学杂志,2015,25(11):2417-2419.
[14]Wang Q,Zhang Y,Yao X,et al.Risk factors and clinical outcomes for carbapenem-resistant Enterobacteriaceae nosocomial infections[J].Eur J Clin Microbiol Infect Dis,2016,35(10):1679-1689.
[15]Kaki R,Elligsen M,Walker S,et al.Impact of antimicrobial stewardship in critical care:a systematic review[J].J Antimicrob Chemother,2011,66(6):1223-1230.
[16]Livermore DM,Hope R,Reynolds R,et al.Declining cephalosporin and fluoroquinolone non-susceptibility among bloodstream Enterobacteriaceae from the UK:links to prescribing change[J].J Antimicrob Chemother,2013,68(11):2667-2674.
[17]赵艳春,胡必杰,吴安华,等.全国多中心ICU抗菌药物使用与多药耐药菌监测分析[J].中华医院感染学杂志,2015,25(21):4867-4869.
[18]李晋,王婧,侯大鹏.实施抗菌药物管理对重症监护病房中病原菌耐药率变迁的影响[J].中华临床感染病杂志,2016,9(2):156-160.
[19]Pena C,Gomez-zorrlla S,Suarez C,et al.Extensively drug-resistant Pseudomonas aeruginosa:risk of bloodstream infection in hospitalized patients[J].Eur J Clin Microbiol Infect Dis,2012,31(10):2791-2797.
[20]Gales AC,Castanheira M,Jones RN,et al.Antimicrobial resistance among gram-negative bacilli isolated from Latin A-merica:results from the SENTRY Antimicrobial Surveillance Program(Latin America,2008-2010)[J].Diagn Microbiol Infect Dis,2012,73(4):354-360.