臺灣博碩士論文加值系統

本研究採用2002年健保門診承保資料歸人抽樣檔，作泌尿道感染之抗生素處方合理性之分析。對象為12歲及以上女性之急性膀胱炎及急性腎盂腎炎之泌尿道感染病人。本研究對不合理處方之判定，係以1999年美國感染症醫學會所訂定之「婦女單純急性細菌性膀胱炎及急性腎盂腎炎之抗生素指引」，及2000年新加坡衛生部所訂定之「成人抗生素使用準則」二份實證為基礎之指引作為抗生素用藥合理性之判斷準則。
對於合理或不合理之判斷，係以符合診療指引推薦治療使用之抗生素種類及天數即為合理處方，符合種類但天數不合即為不合理處方，不合理處方中又分為不足處方及過度處方。另有關不符合診療指引推薦治療使用之抗生素種類部分，因無法做判斷，故不在本研究討論範圍之內。
研究結果發現急性膀胱炎的治療，依照診療指引可使用Fluoroquinolone、Nitrofurantoin、Cephalosporin、Trimethoprim – Sulfamethoxazole四類抗生素。在治療急性膀胱炎病人的處方中，使用這四類抗生素治療之合理與不合理性比例為：合理性比例最高，佔60.06﹪、其次為不足處方佔27.9﹪、過度處方佔12.05﹪。另這四類抗生素中，以使用cephalosporin之人次最多，佔46.89%，其不合理處方之比例卻最低，佔22.45%；使用Trimethoprim – Sulfamethoxazole之人次最少，佔3.77%，其不合理處方之比例約為六成（59.46%）；使用Nitrofurantoin佔17.42%之不合理處方之比例為四者中最高，佔91.67%，其中以不足處方最多，佔87.38%。
急性腎盂腎炎的治療，依照診療指引可使用Fluoroquinolone、Cephalosporin 、Amoxicillin - Clavulanic acid、Trimethoprim – Sulfamethoxazole四類抗生素。在治療急性腎盂腎炎病人的處方中，使用這四類抗生素治療之合理與不合理比例為：不足處方比例最高，佔48.92﹪、其次為合理處方佔39.83﹪、過度處方佔11.26﹪。另這四類抗生素中，以使用cephalosporin之人次最多，佔59.74%，其不合理處方之比例約為六成（60.15%），且以不足處方為主，佔58.7%；使用Trimethoprim – Sulfamethoxazole之人次最少，佔6.93%，但其不合理處方之比例為四類藥物中最高，佔87.5%。
至於影響不合理處方之可能因素，經對數複廻歸分析後，發現在治療急性膀胱炎部分，病人年齡層愈高，愈容易出現不合理處方；在醫院層級別方面，出現不合理處方之機會無顯著差異；在醫院權屬別方面，發現私立醫院及法人醫院出現不合理處方之機會較大；在醫院健保分局別方面，中區分局及東區分局所屬醫院出現不合理處方之機會較小；在就醫科別方面，內科及婦產科出現不合理處方之機會較大，而家醫科、小兒科及腎臟內科則相對較不易出現不合理處方。
另在治療急性腎盂腎炎部分，病人年齡層愈高，反而愈不容易出現不合理處方；此結果恰與治療急性膀胱炎時相反。在醫院層級別方面，區域醫院出現不合理處方之機會較小；在醫院權屬別方面，出現不合理處方之機會並無顯著差異；在醫院健保分局別方面，北區分局及中區分局所屬醫院出現不合理處方之機會較小；在就醫科別方面，僅發現內科出現不合理處方之機會較小，其餘各科則無顯著差異。
經由本研究之結果，建議衛生主管機關建立有效的藥品使用評估制度，並會同醫療專業團體共同擬訂本土化之泌尿道感染疾病診療指引、加強醫師實證醫學教育，以期降低不合理處方比例，提升病人用藥之安全，進而提高病人照護品質。

關鍵字：不良事件，病人安全，泌尿道感染，抗生素，不合理處方

The aim of this study was to analyze the appropriateness of prescription patterns of antibiotics used in treating outpatients with urinary tract infection.. The results of this study may serve as the references for promoting patient safety and clinical effectiveness.
The study was based on the sampling set of National Health Insurance claimed files of ambulatory care in 2002 from National Health Research Institute. Only female patients older than twelve-year-old who was diagnosed to have acute cystitis or acute pyelonephritis were included, but patients with renal dysfuction were excluded in this study. The appropriateness of prescription patterns were analyzed and compared among various patient、hospital and medical specialty. Multiple logistic regression was applied to explore the impact of these factors on the appropriateness. The judgement of appropriateness was based on two clinical practice guidelines from Infectios Disease Society of America,1999 and Ministry of Health, Singapore,2000. “Appropriate prescription” was defined as ‘ precribing the kinds of drugs and the time duration as proposed in the two guidelines’. “Under-use” was defined as shorter time duration than proposed in the guidelines, and “over-use” was defined as longer time duration than proposed in the guidelines. “Inappropriate prescription” was referred as both under-use and over-use presciptions.
For treatment of acute cystitis, four antibiotics including fluoroquinolone、nitrofurantoins、cephalosporins and trimethoprim–sulfamethoxazoles were analyzed. The results indicated that the most frequently prescribed antibiotics were cephalosporins（46.89%）, and the ratio of inappropriate prescription with cephalosporins was the lowest among the four drugs（22.45%）. The least often used antibiotics were trimethoprim-sulfamethoxazole（3.77%）, and the ratio of inappropriateness was 59.46%. The ratio of inappropriate prescription with nitrofurantoins was the highest among the four antibiotics, being 91.67%. Most of the inappropriateness with nitrofurantoins was under use, being 87.38%.
For treatment of acute pyelonephritis, four antibiotics including fluoroquinolone、cephalosporins 、amoxicillin-clavulanic acids and trimethoprim–sulfamethoxazoles were analyzed. The results revealed that the most frequently prescribed antibiotics were cephalosporins（59.74%）, and the ratio of inappropriate prescription with cephalosporins was 60.15%. Most of the inappropriateness with cephalosporins was under-use, being 58.7%. The least often used antibiotics were trimethoprim-sulfamethoxazole（6.93%）, and the ratio of inappropriateness was 87.5%, the highest among the four drugs.
For acute cystitis, the results of multiple logistic regression depicted that patient’s age、NHI branch locale、hospital ownership and medical specialty had significant impact on the inappropriateness of antibiotic prescription. For acute pyelonephritis, the influential factors are patient’s age、NHI branch locale、hospital accreditation level and medical specialty.
Based on the findings described above, it is suggested that the health authorities should create an effective drug utilization review system supported by evidence-based clinical practice guidelines. Also should the health authority establish, through co-operation with medical and pharmacological experts, our own National Clinical Practice Guidelines in order to promote drug safety and clinical effectiveness and to decrease unnecessary medical expenses .

Keywords: adverse event, patient safety, urinary tract infection, antibiotics, inapproriate prescription

目錄
表目錄 i
第一章 緒 論 1
第一節 研究動機 1
第二節 研究背景 2
第三節 研究目的 4
第二章 文獻探討 5
第一節 醫療錯誤 5
第二節 抗生素不合理使用的情況 6
第三節 影響抗生素處方行為之因素 8
第四節 抗生素國內外使用狀況 10
第五節 泌尿道感染 12
第六節 泌尿道感染的臨床診療指引 17
第三章 研究設計與研究方法 27
第一節 研究方法 27
第二節 研究架構 31
第三節 研究問題與假設 32
第四節 研究變項與操作型定義 33
第五節 研究材(資)料 34
第六節 研究流程 35
第四章 研究結果 36
第一節 泌尿道感染（Urinary Tract Infection）情形 36
第二節 急性膀胱炎（Acute Cystitis）使用抗生素之使用狀況 46
第三節 急性腎盂腎炎（Acute Pyelonephritis）使用抗生素之使用狀況 69
第四節 不合理使用抗生素處方治療泌尿道感染之對數複迴歸分析 90
第五章 討論 97
第一節 研究限制 97
第二節 泌尿道感染使用抗生素不合理處方之型態與病人特性之關係 98
第三節 泌尿道感染使用抗生素不合理處方之型態與醫院特性之關係 100
第四節 泌尿道感染使用抗生素不合理處方之型態與醫師特性之關係 101
第六章 結論與建議 102
第一節 結論 102
第二節 建議 104
參考文獻 106
附件 110

中文參考文獻
1. 何曼德等：1998年臺灣地區之抗生素藥性監測。院內感染控制雜誌。2000。
2. 謝慧玲、林美智、胡幼圃：抗生素之管理策略。內科學誌12（1）：1-13，2001。
3. 謝曉菱等：中耳炎病患醫師使用抗生素療程日份是否合理之探討---以大台北分局門診費用申報資料為例。中央健保局九十一年研究成果報告，2002。
4. 方啓泰、張上淳：抗生素的合理使用。當代醫學，1998。
5. 衛生署疾病管制局新聞稿，2000年4月。
6. 姚淑慧：健保特約醫事服務機搆抗生素處方型態之探討。國立成奶j學臨床藥學研究所碩士論文，1998。
7. 郭正睿：中區醫學中心門診上呼吸道疾病患者之抗生素處方型態及利用分折。私立高雄醫學大學公共衛生研究所碩士論文，2002。
8. 葉梁蘭蘭：醫院特性與抗藥性型態。院內感染控制雜誌，10（1）：31-44。2000。
9. 何曼德：正視臺灣抗生素抗藥性問題。國家衛生研究院簡訊，1999。
10. 張上淳等：臺灣地區公立醫院抗生素使用情形之調查研究。微免感誌，1998。
11. 李杰年：民眾對抗生素使用的認知態度與其行為之研究。國立台灣大學公共衛生學院醫療機構管理研究所碩士論文，2002。
12. 黃肇明：醫師處方行為之研究：台北地區八家公私立醫學中心及區域醫院之高血壓處方型態分析。國防醫學院公共衛生學研究所碩士論文，1993。
13. 梁淑真：泌尿道感染及治療。藥學雜誌，13（4）：98-104。1997。
14. 吳慧慈：女性復發性泌尿道感染之探討。永信藥訊，193：10-11。1997。
15. 陳其翔、陳尚民：婦女泌尿道感染的診斷與治療。基層醫學，10（6）：102-106。1995。
16. 林達雄、黃富源：兒童泌尿道感染。當代醫學，27（5），29-33，2000。
17. 麥Z男：新生兒泌尿道感染。中華民國新生兒科醫學會會刊，8（1），6-10，1999。
18. 黃柏青、鄧進楠：小兒泌尿道感染。基層醫學，15（7）141-144。2000。
19. 林佩津：某醫學中心Fluoroquinolone類抗生素之使用評估。國立成奶j學臨床藥學研究所碩士論文，1997。



英文參考文獻
1. Linda T. Kohn, Janet M. Corrigan, Molla S. Donaldson, eds. (Committee on Quality of Health Care in America, Institute of Medicine).To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, March 2000.
2. Brennan TA., Leap LL., Laird NM. et al. Incidence of adverse events and negligence in hospitalized patients: Results of of the Harvard Medical Practice Study I. N Engl J Med. 324:370-376,1991.
3. Philips DP., Christenfeld N., Glynn LM. Increased in US medication-error deaths between 1983 and 1993. Lancet 351:643-644, 1998.
4. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 274:29-34, 1995.
5. Lesar TS, Briceland L and Stein DS. Factors related to error in medication prescribing. JAMA. 277(4):312-317, 1997.
6. Burnum JF. Preventability of adverse drug reactions. Ann Intern Med. 85:80,1976.
7. Schneitman-McIntire O, Farnen TA, Gorden N et al. Medication misadventures resulting in emergency department visits at an HMO medical center. Am J Health Sys Pharm. 3:1416-1422,1996.
8. Sullivan SD, Kreling DH, Hazlet TK et al. Noncompliance with medication regimens and subsequent hospitalization: a literature analysis and cost of hospitalization estimate. J Res Pharm Econom. 2(2):19-33, 1990.
9. Einarson TR. Drug-related hospital admissions. Ann Pharmacother. 27:832-840,
1993.
10. Perlstein PH, Callison C, White M et al. Errors in drug computations during
newborn intensive care. Am J Dis Child. 33: 276-379, 1979.
11. Folli HL, Poole RL, Benitz WE et al. Medication error prevention by clinical
pharmacists in two children’s hospitals. Pediatrics 79:718-722, 1987.
12. Koren G and Haslam RH. Pediatric medication errors: predicting and preventing
tenfold disasters. J Clin Pharmacol. 34:1043-1045, 1994.
13. Nazam DM. Development of medication-use indicators by the Joint commission on Accreditation of Healthcare Organizations. AJHP. 48:1925-1930, 1991.
14. Manojlovic Z, Vrhovac B, Manojlovic S. Qualitative analysis of drug prescription in a geriatric population sample. International Journal of Clinical Pharmacology, Therapy, & Toxicology 1993;31:430-4.
15. Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Appropriateness in health care:
application to prescribing. Social Science & Medicine 1997;45:261-71.
16. Mainous AG 3rd, Hueston WJ, Love MM. Antibiotics for colds in children: who are the high prescribers? Archieves of Pediatrics & Aldolescent Medicine 152(4):349-352, 1998.
17. Norrby SR, Johansson H. Antibiotic consumption in Sweden 1975 to 1987:changes in prescription patterns. Scandinavian Journal of Infectious Diseases – Supplement 60:9-15,1989.
18. McCaig LF, Hughes JM. Trend in antimicrobial drug prescribing among
office-based physicians in the United State. JAMA. 273(3):214-219,1995.
19. Gould M, taylor EW, wood MJ. Hospital antibiotic control measures in the UK. J ournal of antimicrobial chemotherapy 34;21-42, 1994.
20. John JF Jr and Fishman NO. Programmatic role of infectious diseases physician in controlling antimicrobial costs in the hospital. Clinical Infectious Disease 24:471-485, 1997.
21. Baquero F. Antibiotic resistance in Spain: what can be done? Clinical Infectious
Disease 23: 819-823, 1996.
22. McManus P, Hammond ML, Whicker SD et al. Antibiotic use in the Australian community, 1990-1995. Medical Journal of Australia 167:124-127, 1997.
23. Sigvard Molstad, Anders Ekedahl, Birgitta Hovelius, Hankan Thimansson.
Antibiotics prescription in primary care: A 5-year follow-up of an educational
programme. Family Practice 11(3):282-286,1994.
24. Anthony J Schaeffer : Infections of the urinary tractin Campbell’s Urology, 7th ed, 1998.
25. Cincinnati Children’s Hospital Medical Center. Evidence based clinical practice
guideline for patients 6 years of age or less witj a fist time acute urinary tract infection（UTI）. Health Policy & Clinical Effectiveness Program 1999.
26. Infectious Disease Sociaty of America（IDSA）. Guidelines for treatment of
uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clinical Infectious Disease 29:745-758, 1999.
27. Sigapore Ministry of Health（MOH）. Use of antibiotics in adults. MOH Clinical Practice Guidelines. Apr 2000.
28. P. Denig, F.M. Haaijer-Ruskamp, D.H. Zijsling. How Physicians choose drugs. Soc. Sci. Med. 27(12):1381-1386,1988.
29. Ralph Gonzales, John F, Steiner, Merle A. Sande. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 278:901-904,1997.