Mitchell Kaitlin F, Safdar Nasia, Abad Cybele L
1Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, WI USA.
5Present Address: Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO USA.
Arch Public Health. 2019 Jul 4;77:31. doi: 10.1186/s13690-019-0358-9. eCollection 2019.
Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval.
The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as 'adherent' or 'non-adherent' according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation.
Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive ( = 56), empiric ( = 127), or prophylactic ( = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy.
Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist.
在菲律宾等抗生素耐药感染高发的国家，医院抗菌药物管理计划尤为关键。在菲律宾马尼拉的研究机构，非感染性疾病专科医生开具某些抗菌药物（包括碳青霉烯类）需要获得限制使用抗菌药物预先批准（PARA）。PARA申请表包括根据诊断测试指定经验性或确定性治疗。经验性使用的推荐治疗疗程通常为3天，确定性治疗为7天，经专科医生批准可能延长疗程。
该研究在一家拥有800张床位的三级医院进行。我们对2016年1月1日至12月31日期间的患者病历和实验室报告进行了回顾性分析。收集了与患者人口统计学、碳青霉烯类药物处方、实验室诊断和治疗相关的信息。根据与感染诊断、治疗疗程和降阶梯治疗相关的临床指南，将碳青霉烯类药物处方分为“依从性”或“非依从性”。
在接受碳青霉烯类治疗的185例患者中，根据开单医生的定义，碳青霉烯类药物的处方为确定性（=56）、经验性（=127）或预防性（=2）。185例处方中有69例（37%）被认为不符合指南，尽管各自的申请已获得批准。其中，72%的不依从是由于未能降阶梯使用碳青霉烯类药物，28%的不依从是由于疗程不完整。
尽管碳青霉烯类治疗最初获得了PARA批准，但37%的处方不符合指南，凸显了实施此类管理策略面临的持续挑战。为了提高PARA的有效性，可能需要采取其他方法，包括应用严格政策加强对现有培养结果的随访、治疗延长的理由说明或转诊至感染病专科医生。
