Ni Riain U, Tierney M, Doyle C, Vellinga A, Fleming C, Cormican M
Department of Medical Microbiology, University Hospital Galway, Newcastle Rd, Galway, Ireland.
Pharmacy Department, University Hospital Galway, Galway, Ireland.
Ir J Med Sci. 2017 Aug;186(3):729-732. doi: 10.1007/s11845-016-1504-9. Epub 2016 Sep 29.
Use of meropenem in our hospital has doubled in recent years. An audit in 2013 showed that although initiation of therapy with meropenem was generally appropriate, therapy was rarely subsequently reviewed and de-escalated where appropriate. Therefore, a structured stewardship initiative focussed on meropenem de-escalation was developed.
A local guideline for review and de-escalation of meropenem was developed and approved by the Antimicrobial Stewardship Team. The guideline outlined clinical and microbiological criteria which when met should lead to recommendation for meropenem de-escalation. Implementation of the guideline was piloted for a period of 4 weeks by a consultant microbiologist and an antimicrobial pharmacist. Days of meropenem use and crude mortality in those in whom de-escalation was implemented were compared with those where de-escalation was not recommended or was recommended but not implemented.
Thirty-three patients were reviewed. Overall, a recommendation to de-escalate from meropenem to a specified alternative antibiotic was made for 18 (55 %) patients. This advice was followed for 12 (36 %) patients. The median days of meropenem use in patients where meropenem was de-escalated was 4.5 days (range 2-19) compared with 14 days (range 6-84) where de-escalation was not recommended or the recommendation was not implemented. There was no statistically significant difference in crude mortality between patients de-escalated from meropenem and those where meropenem was continued.
This pilot study suggests that targeted carbapenem de-escalation stewardship activity based on pre-determined criteria, while labour intensive, can effectively and safely reduce meropenem use in the acute hospital setting.
近年来，我院美罗培南的使用量翻了一番。2013年的一项审计显示，虽然美罗培南的初始治疗通常是恰当的，但随后很少对治疗进行评估并在适当时进行降阶梯治疗。因此，开展了一项以美罗培南降阶梯为重点的结构化管理举措。
制定了一份美罗培南评估与降阶梯的本地指南，并由抗菌药物管理团队批准。该指南概述了临床和微生物学标准，满足这些标准时应建议进行美罗培南降阶梯治疗。一名微生物学顾问和一名抗菌药物药剂师对该指南的实施进行了为期4周的试点。将实施降阶梯治疗患者的美罗培南使用天数和粗死亡率与未建议降阶梯治疗或建议了但未实施降阶梯治疗的患者进行比较。
对33例患者进行了评估。总体而言，对18例（55%）患者提出了从美罗培南降阶梯至特定替代抗生素的建议。12例（36%）患者遵循了该建议。美罗培南降阶梯治疗患者的美罗培南使用天数中位数为4.5天（范围2 - 19天），而未建议降阶梯治疗或建议未实施的患者为14天（范围6 - 84天）。从美罗培南降阶梯治疗的患者与继续使用美罗培南的患者之间的粗死亡率无统计学显著差异。
这项试点研究表明，基于预先确定的标准进行有针对性的碳青霉烯类降阶梯管理活动，虽然耗费人力，但能在急性医院环境中有效且安全地减少美罗培南的使用。
