80% 的医院过度使用抗生素

一组试图促进院内抗生素管理的研究者报告称，近八成医院存在过度联用静脉抗生素的现象（Infect. Control Hosp. Epidemiol. 2014; 35:1229-35）。

在《感染控制与医院流行病学》杂志10月刊发表的一篇文章中，夏洛特Premier 安全研究所的Leslie Schultz博士及其同事报告称，对500多家美国医院的调查发现，4年期间开具了大约150,000天的不合理抗生素治疗处方，总费用超过1,200万美元。在这些医院中，大约78%采用了不必要的联合治疗。

在这些不必要的治疗中，甲硝唑和哌拉西林联合用药占一半以上，大约32,500例患者接受了至少2天此类联合治疗。其他常见的过度治疗包括甲硝唑+氨苄西林、甲硝唑+厄他培南，加上甲硝唑+哌拉西林，总共占过度治疗的70%。

在9月10日举行的电话新闻发布会上，Schultz博士的一名合著者、美国疾病预防控制中心的Arjun Srinivasan博士指出：“人们还不够了解各种抗生素所能杀灭的细菌，我们需要确保人们知道应当何时、如何联用抗生素，以及在哪些情况下加用第二种药物毫无助益而只会增加副作用风险。”

一名与会者、约翰霍普金斯医院的Sara Cosgrove医生表示赞同：“医学生和住院医生在各种抗生素的抗菌谱方面没有得到理想的培训。”她还提到，医院工作方式的变化可能助长了这种现象。“医院内短期工作的医生越来越多，而且医生之间存在沟通问题。可能会出现这种情况：一名医生使用一种抗生素，而后续的医生启用另一种抗生素。有很多种办法可以解决这种无意重复治疗的问题，包括当药房接到一份过度用药的处方时发出警告。”

Srinivasan博士表示，采取了警告措施的医院已经证明了其有效性。不过同时也强调，不论采用哪种方法，建立专门的抗菌药物管理小组都是必要的，以确保避免过度治疗。兼任美国卫生流行病学会抗菌药物管理委员会主席的Cosgrove医生表示：“很多医院报告称正在考虑开展抗菌药物管理计划，我们愿意推动它们将这些计划付诸实施。”

尽管约翰霍普金斯医院早在2002年就已建立了抗菌药物管理小组，但多数医院目前仍未建立此类小组。美国卫生流行病学会将在2015年发布清单和指南，以帮助各医院建立此类小组。

这项研究的所有合著者，除了Srinivasan博士之外，均为Premier公司（一家经营性研究机构）的员工。Srinivasan博士报告称无相关利益冲突。

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By: JENNIE SMITH

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.