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.

Antimicrobial stewardship of Chinese ministry of health reduces multidrug-resistant organism isolates in critically ill patients: a pre-post study from a single center.

2016年 BMC Inf Dis に発表された、中国単施設のICUにおける、多剤耐性菌に対するASPの効果を示した報告。

 

www.ncbi.nlm.nih.gov

 

 

Abstract

 

BACKGROUND: 

 

China's Ministry of Health (MOH) has established a policy about the antimicrobial stewardship. To date, the effects of this policy on multidrug-resistant organism (MDRO) in critically ill patients are unknown.

 

METHODS: 

 

A pre-post study was conducted on intensive care unit (ICU) patients from June 2010 to May 2011 and from June 2012 to May 2013. Bacterial cultures were conducted at ICU admission and discharge. In June 2011, our hospital started to administer the antimicrobial stewardship program of Chinese MOH. We collected the data on antimicrobial consumption during the 3-year period in all hospital and individual department every month, and analyzed the correlation between the proportion of critically patients colonized or infected with MDRO and antimicrobial consumption.

 

RESULTS: 

 

A total of 978 patients were involved in the present study. With the intervention, the monthly mean Defined Daily Dose (DDD) per 100 occupied bed-days throughout the hospital decreased from 96 ± 7 to 65 ± 6 (p < 0.001), and the proportion of patients colonized or infected with MDRO decreased from 36 to 13% at the time of ICU admission and declined from 48 to 29% at the time of ICU discharge (both p < 0.001). There was a significant positive relationship between the proportion of all critically ill patients colonized or infected with MDRO at ICU admission and the DDD of the entire hospital (R2 = 0.7858, p < 0.001).

 

CONCLUSION: 

 

The antimicrobial stewardship program of Chinese MOH reduced the consumption of antibiotics. Moreover, the proportion of patients colonized or infected with MDRO decreased along with reduced consumption of antibiotics.

 

 

Antimicrobial stewardship

 

According to the protocol of antibiotic administrative group, our hospital was directed to implement the protocol in June 2011.

The policy included antibiotic procurement was restricted to 50 agents in our hospital from June 2011.

Meanwhile, targets for antibiotic prescription are set at less than 60 and 20% of all prescriptions for hospitalized patients and outpatients, respectively.

Prophylactic use of antibiotics in clean operations should be lowered to 30% of patients and reduced to less than 24 h’ duration; and antibiotic utilization in hospitalized patients should be less than 40 Defined Daily Dose (DDD) per 100 patient; rationality of antibiotic use, which includes timing, duration and appropriate medications should be more than 90%.

In our hospital, special antimicrobial agents, such as carbapenem, glycopeptide, linezolid, daptomycin, and tigecycline, must be approved by a designated doctor of pharmacy; in particular case, such as during salvage, doctors are permitted to urgently use these special antimicrobial no more than one day.

The trained pharmacists and infection preventionists were all part of the antimicrobial stewardship in our hospital.

They were responsible for monitoring these medications, and every month, they announced the antimicrobial agents in every clinic and department.

If the individual department did not reach the targets which mentioned, the director of the department would provide the reason and be warned by the hospital.

If there was no desirable reason why they could not achieve the targets, the salary of all the staff of the department would be deducted.

During the study period, we practiced infection control measures according to the recommendations of the Centers for Disease Control (CDC) of the USA.

 

Data collection and definitions

Beginning in June 2011, the management of antibacterial drugs in clinical applications was implemented in every department in our hospital. For each month, we recorded the aggregate data on active surveillance testing and antibiotic consumption. We prospectively collected all data concerning patient characteristics at the time of ICU admission and during the patients’ ICU stay. We collected information about ICU patients’ microbiological culture results and antibiotic consumption between June 2010 and the end of May 2011. The antibiotic consumption data were obtained from the hospital computer center database.

We used the Defined Daily Dose DDD per 100 occupied bed-days to indicate antibiotic consumption in our hospital and every department. The DDD for adults was obtained from the anatomical therapeutic chemical (ATC) classification index from the WHO, with the DDD unit expressed in grams.

MDRO were defined as bacteria were resistant to at least three antimicrobial classes which included methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Pseudomonas aeruginosa, Acinetobacter baumannii, and extended-spectrum β-lactamase (ESBL)-producing or carbapenemase-producing gram-negative bacilli. We use laboratory tests to determine these MDRO. Minimal Inhibitory Concentration (MIC) method was used to determine the bacterial drug resistance. MRSA was defined as Staphylococcus aureus resistant to oxacillin and VRE was defined as enterococci resistant to vancomycin. ESBL-producing organisms were defined as Gram-negative bacilli resistant to ceftazidime but sensitive to enzyme inhibitor such as piperacillin–tazobactam.

 

 

Fig and Tab

 

f:id:akinohanayuki:20170623232117p:plain

 

f:id:akinohanayuki:20170623232146p:plain

f:id:akinohanayuki:20170623232207p:plain

 

f:id:akinohanayuki:20170623232136p:plain

 

Limitations

 

First, this study was performed in a single center. Because drug resistance rates vary among hospitals and units, the results may not be representative and reproducible in other institutions. However, in one hand, antibiotic overuse is common in China, and antimicrobial stewardship can improve the use of antibiotics. In another hand, the results of antimicrobial consumption in our study was in line with previous report. Additionally, studies have demonstrated that the rational use of antibiotics could prevent antimicrobial resistance. Therefore, we believe that our study can benefit other hospitals.

 

Second, we did not analyze the individual risk factors for colonization or infection with resistant microorganisms. Factors that would affect the MDRO isolation, such as hand hygiene, isolating the high-risk patients, and taking precautions, were not analyzed. However, during this pre-post study period in our hospital, we had taken executive infection control measures. We found that the compliance of hand hygiene did not significantly change in our department. Therefore, we believe that the decrease of DDD is an important factor for reducing the rate of MDRO. We also plan to investigate and analyze the risk factors concerning infection and MDRO.

 

Third, we did not screen the MDRO since rectal swabs, and the proportion of undetected MDRO colonizations could consequently be high. However, the policy of screen was the same during the two periods, therefore, it will not be influence our results hugely.

 

Finally, our study did not address the issue of antibiotic use and resistance in the community. The consumption of antimicrobials in agricultural industry may also promote antibiotic resistance. However, the MDRO isolation of patients who arrived from emergency department also decreased from 40 to 18% and may not affect our results.

 

感想

 

BMC Inf Dis は、査読のやりとりを公開している貴重な雑誌です。

https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-2051-8/open-peer-review

 

新規性や限界はイマイチ。

 

死亡率に差が見出せていなことは寂しいです。

APACHEII scoreは確認してますが、既往歴の調整はされていませんでした。

 

私は、DOTとの関連性が気になってます。