Department of Paediatrics, Royal Aberdeen Children's Hospital, Aberdeen, UK.
Medicine Preventive-Infection Control Team, Hospital Vega Baja, Orihuela, Spain.
Lancet Infect Dis. 2015 Dec;15(12):1438-49. doi: 10.1016/S1473-3099(15)00315-1. Epub 2015 Sep 25.
Restriction of antibiotic consumption to below predefined total use thresholds might remove the selection pressure that maintains antimicrobial resistance within populations. We assessed the effect of national antibiotic stewardship and infection prevention and control programmes on prevalence density of meticillin-resistant Staphylococcus aureus (MRSA) infections across a region of Scotland.
This non-linear time-series analysis and quasi-experimental study explored ecological determinants of MRSA epidemiology among 1,289,929 hospital admissions and 455,508 adults registered in primary care in northeast Scotland. Interventions included antibiotic stewardship to restrict use of so-called 4C (cephalosporins, co-amoxiclav, clindamycin, and fluoroquinolones) and macrolide antibiotics; a hand hygiene campaign; hospital environment inspections; and MRSA admission screening. Total effects were defined as the difference between scenarios with intervention (observed) and without intervention (predicted from time-series models). The primary outcomes were prevalence density of MRSA infections per 1000 occupied bed days (OBDs) in hospitals or per 10,000 inhabitants per day (IDs) in the community.
During antibiotic stewardship, use of 4C and macrolide antibiotics fell by 47% (mean decrease 224 defined daily doses [DDDs] per 1000 OBDs, 95% CI 154-305, p=0·008) in hospitals and 27% (mean decrease 2·52 DDDs per 1000 IDs, 0·65-4·55, p=0·031) in the community. Hospital prevalence densities of MRSA were inversely related to intensified infection prevention and control, but positively associated with MRSA rates in neighbouring hospitals, importation pressures, bed occupancy, and use of fluoroquinolones, co-amoxiclav, and third-generation cephalosporins, or macrolide antibiotics that exceeded hospital-specific thresholds. Community prevalence density was predicted by hospital MRSA rates and above-threshold use of macrolides, fluoroquinolones, and clindamycin. MRSA prevalence density decreased during antibiotic stewardship by 54% (mean reduction 0·60 per 1000 OBDs, 0·01-1·18, p=0·049) in hospital and 37% (mean reduction 0·017 per 10,000 IDs, 0·004-0·029, p=0·012) in the community. Combined with infection prevention and control measures, MRSA prevalence density was reduced by 50% (absolute difference 0·94 cases per 1000 OBDs, 0·27-1·62, p=0·006) in hospitals and 47% (absolute difference 0·033 cases per 10,000 IDs, 0·018-0·048, p<0·0001) in the community.
Alongside infection control measures, removal of key antibiotic selection pressures during a national antibiotic stewardship intervention predicted large and sustained reductions in hospital-associated and community-associated MRSA.
NHS Grampian Research & Development Fund.
将抗生素的使用量限制在预先设定的总使用阈值以下，可能会消除维持人群中抗菌药物耐药性的选择压力。我们评估了国家抗生素管理和感染预防与控制计划对苏格兰某一地区耐甲氧西林金黄色葡萄球菌（MRSA）感染流行密度的影响。
本非线性时间序列分析和准实验研究探索了东北部苏格兰 1289929 例住院患者和 455508 例初级保健注册成年人中 MRSA 流行病学的生态决定因素。干预措施包括限制使用所谓的 4C（头孢菌素、复方阿莫西林、克林霉素和氟喹诺酮类）和大环内酯类抗生素的抗生素管理；手部卫生运动；医院环境检查；以及 MRSA 入院筛查。总效应定义为干预情况下（观察）与无干预情况下（时间序列模型预测）之间的差异。主要结局是每 1000 个占用病床日（OBD）医院或每 10000 名居民每天（IDs）社区中 MRSA 感染的流行密度。
在抗生素管理期间，4C 和大环内酯类抗生素的使用量在医院减少了 47%（每 1000 OBD 减少 224 个定义日剂量，95%CI 154-305，p=0.008），在社区减少了 27%（每 1000 IDs 减少 2.52 个 DDD，0.65-4.55，p=0.031）。医院 MRSA 流行密度与强化感染预防和控制呈负相关，但与邻近医院的 MRSA 发生率、输入压力、床位占用率以及氟喹诺酮类、复方阿莫西林和第三代头孢菌素或大环内酯类抗生素的使用呈正相关，这些药物的使用超过了医院特定的阈值。社区流行密度由医院 MRSA 率和超过医院特定阈值的大环内酯类、氟喹诺酮类和克林霉素的使用来预测。在抗生素管理期间，医院的 MRSA 流行密度下降了 54%（每 1000 OBD 减少 0.60，0.01-1.18，p=0.049），社区的流行密度下降了 37%（每 10000 IDs 减少 0.017，0.004-0.029，p=0.012）。与感染预防和控制措施相结合，医院的 MRSA 流行密度下降了 50%（每 1000 OBD 减少 0.94 例，0.27-1.62，p=0.006），社区的流行密度下降了 47%（每 10000 IDs 减少 0.033 例，0.018-0.048，p<0.0001）。
除了感染控制措施外，在国家抗生素管理干预期间消除关键抗生素选择压力，预测了医院相关和社区相关 MRSA 的大量和持续减少。
NHS 格兰扁研究与发展基金。
