Cranny G, Elliott R, Weatherly H, Chambers D, Hawkins N, Myers L, Sculpher M, Eastwood A
Centre for Reviews and Dissemination, University of York, UK.
Health Technol Assess. 2008 Jan;12(1):iii-iv, xi-xii, 1-147. doi: 10.3310/hta12010.
To determine whether there is a level of methicillin-resistant Staphylococcus aureus (MRSA) prevalence at which a switch from non-glycopeptide to glycopeptide antibiotics for routine prophylaxis is indicated in surgical environments with a high risk of MRSA infection.
Major electronic databases were searched up to September 2005.
The effectiveness review included controlled clinical trials comparing a glycopeptide with an alternative antibiotic regimen that reported effectiveness and/or adverse events. Controlled observational studies were also included for adverse events. The cost-effectiveness review included economic evaluations comparing glycopeptide prophylaxis with any alternative comparator. Study validity was assessed using standard checklists. The supplementary economic reviews assessed evaluations of non-glycopeptide antibiotic prophylaxis; evaluations where antibiotic resistance is a problem; methods of modelling resistance in infectious diseases; and developing a conceptual framework. An indicative decision analytic model was developed to compare vancomycin with a cephalosporin and with a combination of vancomycin and cephalosporin, using hip arthroplasty as an exemplar. Available data on, for example, surgical site infection (SSI) rates, MRSA rates, effectiveness of the antibiotics, were incorporated into the model. Costs were estimated from the perspective of the NHS.
The effectiveness review included 16 randomised controlled trials, with a further three studies included for adverse events only. There was no evidence that glycopeptides were more effective than non-glycopeptides in preventing SSIs. Most of the trials did not report either the baseline prevalence of MRSA at the participating surgical units or MRSA infections as an outcome. The cost-effectiveness review included five economic evaluations of glycopeptide prophylaxis. Only one study incorporated health-related quality of life and undertook a cost-utility analysis. None of the studies was undertaken in the UK and none explicitly modelled antibiotic resistance. The supplementary reviews provided few insights into how to assess cost-effectiveness in the context of resistance. No studies modelled cost-effectiveness alongside epidemiological models of resistance. There was little information regarding the impact of surgical infections on costs post-discharge and patient quality of life. The lack of available clinical evidence limited the development of the cost-effectiveness model and meant that the modelling could only be indicative in nature. The model can be used to show the threshold baseline risk at which the use of vancomycin as prophylaxis might be cost-effective (the model did not include teicoplanin). The indicative model suggests that the baseline risk of MRSA can be fairly modest at below the national average and it would still appear cost-effective to use glycopeptide prophylaxis. The model indicates that the use of glycopeptides as a form of prophylaxis in addition to a treatment for MRSA infections is unlikely to decrease the total usage and hence reduce the risk of future problems with glycopeptide-resistant bacteria.
There is insufficient evidence to determine whether there is a threshold prevalence of MRSA at which switching from non-glycopeptide to glycopeptide antibiotic prophylaxis might be clinically effective and cost-effective. Future research needs to address the complexities of decision-making relating to the prevention of MRSA and infection control in general. Research including evidence synthesis and decision modelling comparing a full range of interventions for infection control, which extends to other infections, not just MRSA, is needed. A long-term research programme to predict the pattern of drug resistance and its implications for future costs and health is also needed.
确定在耐甲氧西林金黄色葡萄球菌（MRSA）感染风险高的手术环境中，是否存在一个MRSA流行水平，使得在常规预防中需从非糖肽类抗生素转换为糖肽类抗生素。
检索主要电子数据库直至2005年9月。
有效性综述纳入了比较糖肽类与其他抗生素方案并报告有效性和/或不良事件的对照临床试验。不良事件方面也纳入了对照观察性研究。成本效益综述纳入了比较糖肽类预防与任何其他对照方案的经济评估。使用标准清单评估研究的有效性。补充经济综述评估了非糖肽类抗生素预防的评估；抗生素耐药性成为问题的评估；传染病中耐药性建模方法；以及构建概念框架。以髋关节置换术为例，开发了一个指示性决策分析模型，比较万古霉素与头孢菌素以及万古霉素和头孢菌素联合使用的情况。将例如手术部位感染（SSI）率、MRSA率、抗生素有效性等现有数据纳入模型。成本从英国国家医疗服务体系（NHS）的角度进行估算。
有效性综述纳入了16项随机对照试验，另有3项研究仅纳入了不良事件。没有证据表明糖肽类在预防SSI方面比非糖肽类更有效。大多数试验未报告参与手术单位的MRSA基线流行率或作为结果的MRSA感染情况。成本效益综述纳入了5项糖肽类预防的经济评估。只有1项研究纳入了与健康相关的生活质量并进行了成本效用分析。没有一项研究在英国进行，也没有一项明确对抗生素耐药性进行建模。补充综述几乎没有提供关于如何在耐药背景下评估成本效益的见解。没有研究将成本效益与耐药性的流行病学模型一起建模。关于手术感染对出院后成本和患者生活质量的影响信息很少。缺乏可用的临床证据限制了成本效益模型的开发，意味着该建模本质上只能是指示性的。该模型可用于显示使用万古霉素作为预防可能具有成本效益的阈值基线风险（该模型未包括替考拉宁）。指示性模型表明，在低于全国平均水平时，MRSA的基线风险可以相当低，使用糖肽类预防似乎仍然具有成本效益。该模型表明，除了治疗MRSA感染外，将糖肽类用作预防形式不太可能减少总使用量，因此无法降低未来出现耐糖肽类细菌问题的风险。
没有足够的证据来确定是否存在一个MRSA流行阈值，在该阈值下从非糖肽类抗生素转换为糖肽类抗生素预防在临床和成本效益方面可能是有效的。未来的研究需要解决与MRSA预防和一般感染控制相关的决策复杂性。需要进行包括证据综合和决策建模的研究，比较一系列感染控制干预措施，这些措施应扩展到其他感染，而不仅仅是MRSA。还需要一个长期研究计划来预测耐药模式及其对未来成本和健康的影响。
