臺灣博碩士論文加值系統

由於抗生素的大量使用會衍生出許多抗藥性細菌的問題，已引起高度關注;要預防和控制抗藥性的發生，有賴於兩個主要的策略：感染管制政策的落實和抗生素的正確使用；落實的感染管制政策能減少抗藥性細菌的傳播和蔓延，正確的使用抗生素能預防及減少細菌的突變。正確的抗生素管制觀念，並非只有一味的「管制」醫師不能使用後線抗生素，而是在最適當的時機、最充份的佐證下，選擇最適合的抗生素；從文獻中得知會使用各種不同的方法介入，以求減少抗生素的不當處方，譬如教育訓練、治療準則（treatment guidelines）的使用、醫師開方限制、會診感染科醫師評估使用適當性、自動停藥機制、臨床藥師審核處方機制、建立處方事前審查機制及實施電腦輔助系統等，都是常用的管制手法；其中以建立處方事前審查機制及實施電腦輔助系統這類型的措施，似乎較為有效。
本研究目的為了解台灣北部某區域教學醫院電腦化抗生素線上審核系統管理成效評估，此系統在2005年12月建置除了急診單位以外，全院所有住診單位均須遵循此系統的管制原則本研究為回溯性研究，蒐集自2003年1月1日至2013年12月31日期間住院有使用相關抗生素的資訊；分析不同的介入措實施施前後，如.電腦化抗生素線上審核系統實施前後，抗生素管理小組開始監控實施前後，對後線抗生素的耗用、費用佔率、抗藥細菌趨勢、住院天數、院內感染等指標進行成效分析。
結果顯示抗生素的使用率在抗生素線上審核系統實施前呈現較高的趨勢約在1.2%之上，在2005年底開始實施後有逐漸下滑趨勢 (P<0.001) ，顯示在抗生素線上審核系統實施後，抗生素的使用率有下降。抗生素的藥費占率資料從2008年的47.45%降至2013年的34.25%。平均住院日在抗生素線上審核系統實施前為10.07±0.06天實施後為10.53±0.18天(P<0.001) ，顯示實施後天數略有增加。院內感染相關ORSA菌株發生率在抗生素線上審核系統實施前73.95±4.03%實施後為56.03±9.75%，(P=0.015)顯示實施後發生率降低。此研究在電腦化抗生素線上審核系統實施後對抗生素使用率、藥費佔率、平均住院日、院內感染率、院內感染相關ORSA菌株發生率有顯著降低; 抗生素線上審核系統實施後對平均住院日略有增加。

Concerns related to increasing antimicrobial resistance have been elevated recently by numerous reports pertaining to outbreaks of infection caused by multidrug-resistant (MDR) organisms worldwide.Two complementary strategies help prevention and control antimicrobial resistance: infection control measures to reduce the spread of MDR organisms; and optimization of antibiotic usage for therapy and prophylaxis. The latter strategy is commonly mentioned under the term ‘antibiotic stewardship.When antibiotic stewardship is implemented, there are several interventions required. Single interventions such as healthcare provider education or formulary restriction are not sufficient alone . Prior literature on the effectiveness and safety of antibiotic optimization were conducted in small or specific patient populations, including patients in diagnosis-related group assignment.Only few research available regarding the impacts of a comprehensive hospital-based antimicrobial control program on healthcare quality in a large hospital setting.
The purpose of this study is to evaluate the outcomes of a hospital-wide computerized antimicrobial stewardship program in aregional teaching hospital in Northern Taiwan.
A hospital-wide computerized antimicrobial approval system (HCAAS) was developed to guide the use of 30 parenteral antimicrobial agents, in a hospital with 1078-beds [60beds in Intensive Care Units (ICUs)] in northern Taiwan in December 2005. The HCAAS is an intranet-based application, which was built under the Health Information System (HIS) and linked to the comprehensive electronic medical records.This study used the retrospective analysis of hospitalized patients who used restricted antimicrobial agents between January 1, 2003 to December 31, 2013. The objective of the study was to evaluate and report the impacts of HCAAS before and after the implementation on the hospital. The program outcomes examined here include antibiotic consumption and expenditures, changes in antimicrobial resistance of major healthcare-associated bacterial pathogens, length of hospital stay, hospital acquired infection, and patients outcomes before and after implementation of the program were examined.
The results indicate that the antibiotic comsumption rate was above 1.2 % before the implementation of HCAAS. After implementing the HCAAS in 2006, there was a statistically significant decrease in antibiotic consumption (P<0.001). The antibiotic expendicture was also significantly decreased after the HCAAS (P=0.024). The length of hospital stay before the HCAAS implementation was about 10 days. There was a significant change on hospital stay before and after the implementation of HCAAS (P<0.001). Finally, the hospital acquired infection related ORSA rate was significantly decreased by comparing before and after the HCAAS (P=0.015). This research has demonstrated that the HCAAS along with the strict infection control measure would help decrease the spread of resistant organism in the hospital.

誌謝............................................ I
中文摘要.........................................II
英文摘要.........................................III
目次............................................ IV
表目錄...........................................VIII
圖目錄錄....................................... .XI
第 1章緒論.......................................1
第 2章文獻探討...................................2
2.1抗生素管理計畫內容...........................2
2.2抗生素管理計畫的核心策略.....................2
2.2.1事先稽核與直接介入及迴饋...................2
2.2.2處方限制使用和授權.........................3
2.3補強策略.....................................3
2.3.1教育訓練...................................3
2.3.2以實證為依據的治療準則和臨床路徑...........4
2.3.3不同抗生素輪流使用.........................4
2.3.4制定抗生素處方表格.........................4
2.3.5組合治療...................................5
2.3.6精簡或降階治療.............................5
2.3.7最佳化的抗生素使用.........................5
2.3.8針劑轉換到口服.............................5
2.4抗生素管理計畫的影響.........................6
2.5發展和施行抗生素管理計畫.....................6
2.6施行抗生素管理計畫的障礙.....................8
第3章研究目的...................................9
第4章研究方法 .................... ............10
4.1研究設計....................................10
4.2研究對象....................................10
4.2.1本研究納入條件...........................10
4.3資料收集...................................10
4.3.1資料收集內容.............................10
4.3.2後線針劑抗生素認定標準...................11
4.3.3判斷抗藥性細菌菌株件數標準...............11
4.3.4醫療相關照護感染標準.....................12
4.4統計分析...................................12
4.4.1統計軟體.................................12
4.4.2統計模式設定.............................12
4.4.3資料分析方法.............................12
第5章研究結果.................................13
5.1抗生素線上審核系統實施前後的抗生素使用率比較..13
5.2抗生素線上審核系統實施前後的抗生素藥費佔率比較.14
5.3抗生素線上審核系統實施前後的後線抗生素使用量比較..15
5.4抗生素線上審核系統實施前後的平均住院日比較........27
5.5抗生素線上審核系統實施前後院內感染率比較..........28
5.6抗生素線上審核系統實施前後院內感染相關ORSA菌株發生率
比 較..29
5.7抗生素線上審核系統實施前後ESBL-K.pneumonia菌株發生率
比較.. 30
5.8抗生素線上審核系統實施前後ESBL-E.coli菌株發生率
比較...31
5.9抗生素線上審核系統實施前後MDR-Acinetobacterbaumannii
菌株發生率比較…32
第 6 章 討論 .............................. .........33
6.1 抗生素使用率.....................................33
6.2抗生素藥費佔率....................................34
6.3抗生素使用量......................................35
6.4平均住院日........................................36
6.5院內感染率........................................37
6.5.1院內感染相關ORSA菌株發生率......................37
6.5.2 ESBL-K.pneumonia菌株發生率.....................37
6.5.3 ESBL-E.coli菌株發生率..........................37
6.5.4 MDR-Acinetobacterbaumannii菌株發生率...........38
6.6 研究限制及未來研究方向...........................39
第 7 章 結論 ........................................40
參考文獻.............................................41
表5.1抗生素線上審核系統實施前後的抗生素使用率比較.......13
表5.2抗生素線上審核系統實施前後的後線抗生素使用量比較...15
表5.3抗生素線上審核系統實施前後的平均住院日比較.........27
表5.4抗生素線上審核系統實施前後院內感染率比較...........28
表5.5抗生素線上審核系統實施前後院內感染相關ORSA菌株發生率比.......................................................29
表5.6抗生素線上審核系統實施前後ESBL-K.pneumonia菌株發生率比較.......................................................30
表5.7抗生素線上審核系統實施前後ESBL-E.coli菌株發生率比較.31
表5.8抗生素線上審核系統實施前後MDR-Acinetobacterbaumannii菌株發生率比較.............................................32
圖5.1抗生素使用率趨勢圖..................................13
圖5.2抗生素藥費佔率趨勢圖................................14
圖5.3 Cefuroxime 750mg/vial(pc)每千人日數使用量..........16
圖5.4 Piperacillin sodium 2gm/vial (pc)每千人日數使用量..17
圖5.5 Amikacin 500mg/vial(pc)每千人日數使用量...........18
圖5.6 Amoxicillin 500mg+Clavulanic acid 100mg/vial (pc)每千人日數使用量.............................................19
圖5.7 Ampicillin 1gm+Sulbactam 500mg/vial每千人日數使用量.20
圖5.8 Piperacillin 2gm/Tazobactam 0.25gm每千人日數使用量…21
圖5.9第三代Cephalosporins每千人日數使用量.................22
圖5.10第四代Cephalosporins每千人日數使用量................23
圖5.11 Glycopeptides每千人日數使用量......................24
圖5.12 Quinolones每千人日數使用量.........................25
圖5.13 Carbapenems每千人日數使用量........................26
圖5.14平均住院日趨勢圖....................................27
圖5.15 院內感染率趨勢圖...................................28
圖5.16院內感染率相關ORSA菌株發生率趨勢圖..................29
圖5.17 ESBL-K.pneumonia及ESBL-E.coli菌株發生率趨勢圖......30
圖5.18 MDR-Acinetobacter baumannii菌株發生率趨勢圖........32

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