さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use.

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use.

www.ncbi.nlm.nih.gov

 

2017年5月 Plos One に報告された、カナダ1施設3病棟によるPAFの効果を検討した研究。

 

 

 

場所

a 490-bed urban community teaching hospital in Toronto, Ontario, Canada. 

surgical, respiratory, and medical wards

 

デザイン

before and after

 

ASP

Prospective audit and feedback (PAAF) 

 

Education was provided to clinicians about the importance and goals of antimicrobial stewardship prior to intervention implementation. This was completed through informal and formal presentations provided by an ASP physician during pre-planned department or division meetings. During these meetings, consultation was sought to determine preferred feedback mechanisms. The ASP team consisted of one of two infectious diseases physicians and two ASP pharmacists. The two ASP pharmacists had prior formal training in antimicrobial stewardship provision. The infectious diseases physicians involved with the ASP started working at the hospital providing infectious disease consultations in 2006 and 2011.

Every weekday at 06:00, automated reports were generated for inpatients on intervention wards who were receiving any systemic antibiotic at that time. These reports were available for the pharmacists in hardcopy in the inpatient pharmacy. The ASP pharmacists were encouraged to be physically present on the ward to review cases with an aim to optimize antimicrobial use according to local published antimicrobial guidelines. The pharmacists were free to discuss changes to antimicrobial management with the clinical team caring for the patient before review with the infectious disease physician. After initial pharmacist evaluation, all pharmacist recommendations for optimization and challenging cases were reviewed with an infectious diseases physician daily. Following this discussion, a note was placed in the patient’s electronic medical record providing specific recommendations regarding optimizing antibiotic therapy. If the suggestions were of a more urgent or challenging manner, an ASP pharmacist or physician would provide the recommendations by phone or in person with the patient’s most responsible physician. The decision to change an antibiotic was left to the discretion of the clinical team caring for the patient.

 

Metrics

rates of total antibiotic use

measured in days on therapy (DOTs)

Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses.

 

結果

 

total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation.

 

On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation.

 

図表

 

f:id:akinohanayuki:20170602052508p:plain

f:id:akinohanayuki:20170602052518p:plain

f:id:akinohanayuki:20170602052534p:plain

f:id:akinohanayuki:20170602052549p:plain

f:id:akinohanayuki:20170602052558p:plain

f:id:akinohanayuki:20170602052607p:plain

 

感想

 

毎日のPAFは重要である事が強調された。多くの病院で毎日PAFは実践されている戦略だとと思うが、戦略論文を作成することは困難である。提案数を見ると、チーム貢献の大きさを感じる。

結果は、今までの様々な報告と矛盾しない。

再入院率、死亡率、LOSを求めると、交絡因子が多く解釈が難しいが、査読者が求めてくる事が多い。

 

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