Karanika Styliani, Paudel Suresh, Grigoras Christos, Kalbasi Alireza, Mylonakis Eleftherios
Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.
Medical Oncology Department, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
Antimicrob Agents Chemother. 2016 Jul 22;60(8):4840-52. doi: 10.1128/AAC.00825-16. Print 2016 Aug.
The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.
实施抗菌药物管理计划（ASPs）是帮助解决抗菌药物耐药性问题的一项很有前景的策略。我们试图确定抗菌药物管理计划的疗效及其对临床和经济参数的影响。我们检索了PubMed、EMBASE和谷歌学术，以查找关于医院中抗菌药物管理计划疗效的研究。基于26项研究（从24917篇文献中提取），实施前后时间为6个月至3年，实施抗菌药物管理计划后抗菌药物总消耗量的合并百分比变化为-19.1%（95%置信区间[CI]=-30.1至-7.5），限制使用抗菌药物的使用量下降了-26.6%（95%CI=-52.3至-0.8）。有趣的是，在重症监护病房，抗菌药物消耗量下降了-39.5%（95%CI=-72.5至-6.4）。广谱抗生素的使用（碳青霉烯类为-18.5%[95%CI=-32至-5.0]，糖肽类为-14.7%[95%CI=-27.7至-1.7]）、抗菌药物总成本（-33.9%[95%CI=-42.0至-25.9]）和住院时间（-8.9%[95%CI=-12.8至-5]）均有所下降。在医院病原体中，实施抗菌药物管理计划与耐甲氧西林金黄色葡萄球菌感染的减少相关（风险差异[RD]=-0.017[95%CI=-0.029至-0.005]）、耐亚胺培南铜绿假单胞菌感染的减少相关（RD=-0.079[95%CI=-0.114至-0.040]）以及产超广谱β-内酰胺酶克雷伯菌属感染的减少相关（RD=-0.104[95%CI=-0.153至-0.055]）。值得注意的是，这些改善与不良结局无关，因为实施抗菌药物管理计划后全因、感染相关的30天死亡率和感染率没有显著差异（RD=-0.001[当提及死亡率时95%CI=-0.009至0.006]，RD=-0.005[当提及感染率时95%CI=-0.016至0.007]，以及RD=-0.045%[当提及感染率时95%CI=-0.241至0.150]，分别对应死亡率、感染率和感染率情况）。医院抗菌药物管理计划可显著降低抗菌药物消耗量和成本，在重症监护环境中益处更大。特定抗菌药物耐药病原体引起的感染以及总体住院时间也有所改善。未来的研究应关注这些结果的可持续性，并评估抗菌药物管理计划在死亡率和感染率方面潜在的长期有益影响。 （注：原文中关于死亡率和感染率RD值对应的95%CI在描述时有些混淆，翻译时尽量按原文呈现并做了一定注释说明以助理解）
