Thomas Ann R, Cieslak Paul R, Strausbaugh Larry J, Fleming David W
Division of Applied Public Health Training, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Infect Control Hosp Epidemiol. 2002 Nov;23(11):683-8. doi: 10.1086/501994.
In Oregon in 1994, a population-based study of 66 nonpsychiatric hospitals indicated that 40% of vancomycin orders were inappropriate according to Centers for Disease Control and Prevention guidelines. We repeated the study to determine whether vancomycin use had been affected by pharmacy policies implemented following the 1994 study.
We surveyed pharmacists in nonpsychiatric hospitals in Oregon regarding vancomycin use policies in their hospitals. Using pharmacy records, we identified and abstracted the charts of all patients in Oregon hospitals receiving vancomycin during a 3-week period to determine appropriate use of vancomycin.
Thirteen (20%) of 64 hospitals had implemented a vancomycin restriction policy since 1994; none ofthe remaining hospitals in the study had a policy. In 1999, hospitals with vancomycin restriction policies had substantially decreased rates of inappropriate vancomycin use compared with hospitals without such policies (1.0 vs 1.8 orders per 1,000 patient-days; P = .01). Compared with 1994 baseline rates of inappropriate use, hospitals that adopted policies experienced a decrease (from 1.5 orders per 1,000 patient-days in 1994 to 1.0 in 1999; P= .13), whereas hospitals without policies experienced a statistically significant increase (from 0.9 orders per 1,000 patient-days in 1994 to 1.8 in 1999; P= .001). Restriction policies were most effective at reducing rates of inappropriate use for treatment of confirmed gram-positive infections and prophylaxis.
Vancomycin restriction policies were associated with a decrease in inappropriate therapeutic and prophylactic vancomycin use, but had no effect on inappropriate empiric use. Hospitals considering limits regarding inappropriate use should consider implementation of institution-based vancomycin restriction policies as part of an overall strategy.
1994年在俄勒冈州，一项针对66家非精神科医院的基于人群的研究表明，根据疾病控制与预防中心的指南，40%的万古霉素医嘱是不恰当的。我们重复了这项研究，以确定万古霉素的使用是否受到1994年研究后实施的药房政策的影响。
我们就俄勒冈州非精神科医院的万古霉素使用政策对药剂师进行了调查。利用药房记录，我们识别并提取了俄勒冈州医院在3周期间接受万古霉素治疗的所有患者的病历，以确定万古霉素的合理使用情况。
自1994年以来，64家医院中有13家（20%）实施了万古霉素限制政策；研究中的其余医院均未制定相关政策。1999年，与没有万古霉素限制政策的医院相比，实施该政策的医院不恰当使用万古霉素的比例大幅下降（每1000个患者日分别为1.0次和1.8次医嘱；P = 0.01）。与1994年不恰当使用的基线率相比，采取政策的医院有所下降（从1994年每1000个患者日1.5次医嘱降至1999年的1.0次；P = 0.13），而没有政策的医院则出现了统计学上的显著上升（从1994年每1000个患者日0.9次医嘱升至1999年的1.8次；P = 0.001）。限制政策在降低确诊革兰氏阳性菌感染治疗和预防中不恰当使用比例方面最为有效。
万古霉素限制政策与不恰当的治疗性和预防性万古霉素使用的减少有关，但对不恰当的经验性使用没有影响。考虑对不恰当使用进行限制的医院应考虑实施基于机构的万古霉素限制政策，作为整体策略的一部分。
