Pharmacy Department, St. George Hospital, Sydney, Australia; St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
Clinical Governance Unit, South Eastern Sydney Local Health District, Sydney, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.
Int J Antimicrob Agents. 2018 Apr;51(4):620-628. doi: 10.1016/j.ijantimicag.2018.01.017. Epub 2018 Jan 31.
The long-term outcomes and sustainability of antimicrobial stewardship (AMS) in the intensive care unit (ICU) require evaluation. This study analysed the effect of a multimodal ICU AMS introduced in a 15-bed medical-surgical tertiary Australian adult ICU in November 2008, using interrupted time-series analysis of antibiotic usage, Gram-negative resistance and cost from November 2005 to October 2015, including national ICU average usage as a control. Overall ICU mortality, 30-day blood stream infection (BSI) mortality and length of stay (LOS) were compared over the same period. There were 2512 patients admitted to ICU before and 6435 after AMS intervention. Post-AMS there was a reduction in the trend of aminoglycoside usage both absolute from 63.3 DDD/1000 occupied bed days (OBD)/month (-1.1; 95% confidence interval [CI] -2.2, -0.1; P = 0.033) and relative to the national trend (-1.3; 95%CI -2.4, -0.3; P = 0.016). Vancomycin usage increased both absolute from 161.2 DDD/1000 OBD/month (1.8; 95%CI 0.03, 3.6; P = 0.046) and relative to the national trend (1.8; 95%CI -0.3, 3.9; P = 0.092). There were sustained post-AMS downward trends in carbapenem, antipseudomonal penicillin, third-generation cephalosporin and fluoroquinolone use that did not reach statistical significance. Post-AMS, antipseudomonal penicillin resistance declined (-12.8%; 95%CI -24.9, -0.6; P = 0.040). Antimicrobial acquisition costs declined by AUD$0.5/OBD/month (95%CI -1.1, 0.1; P = 0.096). Over the study period, severity-adjusted ICU mortality declined from 12.9% to 10.4%; risk ratio (RR) 0.92 (95%CI 0.82, 1.03) and BSI 30-day mortality from 37.9% to 26.3%; RR, 0.76 (95%CI 0.56, 1.03). Median ICU LOS for ICU survivors increased from 2.3 to 2.6 days. Multimodal AMS sustainably embedded in ICU was associated with reductions in broad-spectrum Gram-negative antibiotic use, overall antibiotic costs and Gram-negative resistance, without adverse clinical impact.
抗菌药物管理（AMS）在重症监护病房（ICU）中的长期效果和可持续性需要进行评估。本研究分析了 2008 年 11 月在澳大利亚一家 15 床的医学外科成人 ICU 中引入多模式 ICU AMS 的效果，使用抗生素使用、革兰氏阴性菌耐药性和成本的中断时间序列分析，时间范围为 2005 年 11 月至 2015 年 10 月，包括全国 ICU 的平均使用情况作为对照。在同一时期，比较了 ICU 总死亡率、30 天血流感染（BSI）死亡率和住院时间（LOS）。在 AMS 干预之前有 2512 名患者入住 ICU，之后有 6435 名患者入住 ICU。AMS 后，氨基糖苷类药物的使用趋势无论是绝对值（从 63.3 DDD/1000 占用床日（OBD）/月下降 1.1；95%置信区间[CI] -2.2，-0.1；P=0.033）还是相对于全国趋势（下降 1.3；95%CI -2.4，-0.3；P=0.016）都有所下降。万古霉素的使用量无论是绝对值（从 161.2 DDD/1000 OBD/月增加 1.8；95%CI 0.03，3.6；P=0.046）还是相对于全国趋势（增加 1.8；95%CI -0.3，3.9；P=0.092）都有所增加。AMS 后，碳青霉烯类、抗假单胞菌青霉素类、第三代头孢菌素类和氟喹诺酮类药物的使用呈持续下降趋势，但未达到统计学意义。AMS 后，抗假单胞菌青霉素的耐药率下降了（下降 12.8%；95%CI -24.9，-0.6；P=0.040）。抗菌药物获得成本每月下降 0.5 澳元/OBD（95%CI -1.1，0.1；P=0.096）。在研究期间，经过严重程度调整的 ICU 死亡率从 12.9%下降到 10.4%；风险比（RR）0.92（95%CI 0.82，1.03），30 天 BSI 死亡率从 37.9%下降到 26.3%；RR，0.76（95%CI 0.56，1.03）。存活 ICU 患者的 ICU 住院时间中位数从 2.3 天增加到 2.6 天。多模式 AMS 可持续地嵌入 ICU 中，与广谱革兰氏阴性抗生素的使用减少、总体抗生素成本和革兰氏阴性菌耐药性降低有关，而没有不良的临床影响。
