Chimhini G, Chimhuya S, Madzudzo L, Heys M, Crehan C, Robertson V, Ferrand R A, Sado B, Sharland M, Walker A S, Klein N, Fitzgerald F C
Department of Paediatrics and Child Health University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
UCL Great Ormond Street Institute of Child Health, University College London, London, UK.
Infect Prev Pract. 2020 Feb 19;2(2):100046. doi: 10.1016/j.infpip.2020.100046. eCollection 2020 Jun.
Neonatal sepsis is a major cause of morbidity and mortality in low-income settings. As signs of sepsis are non-specific and deterioration precipitous, antibiotics are often used profusely in these settings where diagnostics may not be readily available. Harare Central Hospital, Zimbabwe, delivers 12000 babies per annum admitting ∼4800 to the neonatal unit. Overcrowding, understaffing and rapid staff turnover are consistent problems. Suspected sepsis is highly prevalent, and antibiotics widely used. We audited the impact of training and benchmarking intervention on rationalizing antibiotic prescription using local, World Health Organization-derived, guidelines as the standard.
An initial audit of admission diagnosis and antibiotic use was performed between 8 May - 6 June 2018 as per the audit cycle. An intern training programme, focusing on antimicrobial stewardship and differentiating between babies 'at risk of' versus 'with' clinically-suspected sepsis was instituted post-primary audit. Re-audit was conducted after 5 months.
Sepsis was the most common admitting diagnosis by interns at both time points but reduced at repeat audit (81% versus 59%, <0.0001). Re-audit after 5 months demonstrated a decrease in antibiotic prescribing at admission and discharge. Babies prescribed antibiotics at admission decreased from 449 (98%) to 96 (51%), <0.0001. Inpatient days of therapy (DOT) reduced from 1243 to 1110/1000 patient-days. Oral amoxicillin prescription at discharge reduced from 349/354 (99%) to 1% 1/161 (<0.0001).
A substantial decrease in antibiotic use was achieved by performance feedback, training and leadership, although ongoing performance review will be key to ensuring safety and sustainability.
在低收入地区，新生儿败血症是发病和死亡的主要原因。由于败血症的症状不具特异性且病情恶化迅速，在这些可能无法随时进行诊断的地区，抗生素常常被大量使用。津巴布韦哈拉雷中心医院每年接生12000名婴儿，约4800名婴儿入住新生儿病房。过度拥挤、人员不足和人员快速更替是一直存在的问题。疑似败血症非常普遍，抗生素被广泛使用。我们以世界卫生组织制定的当地指南为标准，审核了培训和基准干预对合理使用抗生素处方的影响。
根据审核周期，于2018年5月8日至6月6日对入院诊断和抗生素使用情况进行了首次审核。在初次审核后，开展了一个实习生培训项目，重点是抗菌药物管理以及区分“有临床疑似败血症风险”和“患有”临床疑似败血症的婴儿。5个月后进行了重新审核。
在两个时间点，败血症都是实习生最常见的入院诊断，但在重新审核时有所减少（81%对59%，<0.0001）。5个月后的重新审核显示，入院和出院时的抗生素处方量有所减少。入院时开具抗生素的婴儿从449例（98%）降至96例（51%），<0.0001。住院治疗天数（DOT）从1243天降至1110/1000患者日。出院时口服阿莫西林的处方量从349/354例（99%）降至1/161例（1%）（<0.0001）。
通过绩效反馈、培训和领导力，抗生素使用量大幅下降，不过持续的绩效评估对于确保安全性和可持续性至关重要。
