Gindre S, Carles M, Aknouch N, Jambou P, Dellamonica P, Raucoules-Aimé M, Grimaud D
Département d'anesthésie et réanimation Est, hôpital Saint-Roch, 5, rue Pierre-Devoluy, BP 1319, 06006 Nice cedex 1, France.
Ann Fr Anesth Reanim. 2004 Mar;23(2):116-23. doi: 10.1016/j.annfar.2003.12.016.
Surgical wounds infections represent a major cause of morbidity and are at the origin of an increase in the postoperative mortality rate. Those infections represent in France one-fourth of the nosocomial infections. Combine with the elementary hygiene rules and the surgical "good practices", antimicrobial prophylaxis with antibiotics is an essential tool for the reduction of the surgical wound infections rate. In the French hospitals, antimicrobial prophylaxis represents one-third of the antibiotic prescriptions. The rules for the application of surgical prophylaxis are based on current guidelines for antibiotic prophylaxis, however, guidelines are not totally respected.
Study 1: assessment of the guidelines application (practical audit) of the antibiotic antimicrobial prophylaxis in surgery, and of their impact on the established prescriptions: three audits were realized with four years interval (1994, 1998 and 2002), in order to estimate the evolution in the application of the current guidelines, which indirectly estimate the evolution of the guidelines impact. Study 2: assessment of the use of an antibiotic kit through a prospective comparative study of two groups: exposed patients vs non-exposed patients. Nominatives kits contained the recommended antibiotics with recommended posology and the instructions for each surgical procedure.
Study 1: this study showed a significant increase in the antibiotics prescription volume since 1994 (+23%). After a temporary increase from 1994 to 1998, the conformity of the effective prescriptions with the current guidelines for the indication to realize or not to realize an antibiotic surgical prophylaxis decreases of 7% between 1998 and 2002. Nevertheless, we noticed an overall improvement in the guidelines application for the modalities of the antimicrobial prophylaxis when it was prescribed in a valid indication. Persistent weak points were in 2002 the antibiotic molecule choice (error rate of 25%), the duration of prescription (rate of abnormal prolonged antibiotic prophylaxis of 19%), and the timing of administration (error rate of 31%). Study 2: antibiotic kits have permitted to increase the accordance of the antimicrobial prophylaxis prescriptions with the guidelines. Antibiotic prophylaxis was in total agreement with guidelines for 82% of exposed patients vs 41 for non-exposed patients. Choice of the antibiotic molecule, timing of administration and duration of prescription were the parameters particularly well rectified by this new antibiotic prophylaxis technical.
In this study, guidelines diffusion seems to be an essential but also an insufficient point for the improvement of the quality prescriptions in surgical antimicrobial prophylaxis. The "day by day" nominative antibiotic prophylaxis deliverance in the shape of a << ready to use >> antibiotic kit went with an increase in the respect of the recommendations, by correcting in a significant way the persistent weak points identified during the first part of our study. The antibiotic prescriptions control is an imperative goal in individual health (the patient himself), but also in public health (the community). This radical change in habits is listed in a policy of antimicrobial agent prescription improvement (best efficacy with less cost).
手术伤口感染是发病的主要原因，也是术后死亡率上升的根源。在法国，此类感染占医院感染的四分之一。抗菌药物预防联合基本卫生规则和手术“良好操作规范”，是降低手术伤口感染率的重要手段。在法国医院，抗菌药物预防占抗生素处方的三分之一。手术预防用药规则基于当前抗生素预防指南，但这些指南并未得到完全遵守。
研究1：评估手术中抗生素抗菌药物预防的指南应用情况（实际审核）及其对既定处方的影响：每隔四年（1994年、1998年和2002年）进行三次审核，以评估当前指南应用情况的演变，从而间接评估指南影响的演变。研究2：通过对两组患者（暴露组与非暴露组）进行前瞻性比较研究，评估抗生素试剂盒的使用情况。命名试剂盒包含推荐的抗生素、推荐剂量以及每种手术操作的说明。
研究1：该研究表明，自1994年以来抗生素处方量显著增加（增长23%）。在1994年至1998年暂时增加后，1998年至2002年期间，实际处方与当前手术抗生素预防适应证指南的符合率下降了7%。然而，我们注意到，在有有效适应证时进行抗菌药物预防的方式方面，指南应用总体有所改善。2002年持续存在的薄弱环节包括抗生素分子选择（错误率25%）、处方持续时间（抗生素预防异常延长率19%）以及给药时间（错误率31%）。研究2：抗生素试剂盒提高了抗菌药物预防处方与指南的符合度。暴露组82%的患者抗菌药物预防完全符合指南，而非暴露组为41%。抗生素分子选择、给药时间和处方持续时间是这项新的抗菌药物预防技术特别能纠正的参数。
在本研究中，指南传播似乎是改善手术抗菌药物预防质量处方的一个重要但并不充分的方面。以“即用型”抗生素试剂盒形式每日发放命名抗生素预防药物，随着建议遵守情况的增加，显著纠正了我们研究第一部分中发现的持续存在的薄弱环节。抗生素处方控制是个体健康（患者自身）以及公共卫生（社区）的一项紧迫目标。这种习惯上的根本改变体现了抗菌药物处方改进政策（以更低成本实现最佳疗效）。
