Nachtigall I, Tafelski S, Deja M, Halle E, Grebe M C, Tamarkin A, Rothbart A, Uhrig A, Meyer E, Musial-Bright L, Wernecke K D, Spies C
Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
Charité-Universitaetsmedizin Berlin, Institute for Microbiology and Hygiene, Berlin, Germany.
BMJ Open. 2014 Dec 22;4(12):e005370. doi: 10.1136/bmjopen-2014-005370.
Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.
This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.
Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.
Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.
Implementation of a CDSS.
The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.
Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).
Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.
ISRCTN54598675.
在过去几年中，抗生素耐药性急剧上升。对于个体患者而言，充分的初始抗生素治疗对临床结果至关重要。提倡使用计算机辅助决策支持系统（CDSSs）来支持基于指南的合理抗感染治疗策略的实施。本研究的目的是评估CDSS实施后的长期效果。
这项前瞻性的“前后”队列研究在5年内的四个观察期内进行。将一个干预前期（pre）与三个干预后期进行比较：在大力实施后的直接时期（post1）、实施后2年（post2）和实施后3年（post3）。
一所大学医院的五个由麻醉科管理的重症监护病房（ICU）（一个心脏外科、一个神经外科、两个综合科和一个中级护理病房）。
入住ICU超过48小时的成年患者纳入分析。共有1316例患者纳入分析，总计12965个ICU日。
实施CDSS。
主要终点是ICU治疗期间符合指南天数的百分比。次要终点是比较低指南依从性和高指南依从性患者的无抗生素天数和全因死亡率。
指南依从性从实施前的61%提高到post1时的92%，在post2时降至76%，在post3时仍显著高于基线水平，为71%（p=0.178）。此外，在研究期间无抗生素天数增加。在所有时间段，低指南依从性患者的死亡率更高，为12.3%，而高指南依从性患者为8%（p=0.014），调整后的OR为1.56（95%CI 1.05至2.31）。
实施针对抗生素治疗的计算机化区域适应性指南与依从性提高并行。即使没有进一步措施，依从性在较长时间内保持较高水平，同时抗生素暴露减少。指南依从性的提高与ICU死亡率降低相关。
ISRCTN54598675。
