| [Background]Since penicillin was discovered in 1928, antimicrobial agents have been widely used in clinic, which made great contributions to the prevention and treatment of various infectious diseases. Now, the antibacterial drugs have become a "double-edged sword", on the one hand, they can prevent and treat disease, save the lives of patients, on the other hand, because of the unreasonable use, even abuse, which has brought a lot of bad consequences to the patients and society. In order to standardize the use of antimicrobial agents and reduce the incidence of adverse reactions, the Ministry of Health started to implement "the Special Rectification Activities of Clinical Application of Antibiotics in 2011" in the medical institutions all over the country. In response to the requirements of The Ministry of Health? a tertiary hospital started to renovate the use of the antibiotic since the second half of 2011. According to "the Guidelines for Clinical Use of Antibacterial Drugs", made out a series implementation rules of clinical application of antibacterial drugs in the hospital, including graded authorization, limited use, controlled total amount, etc. Pediatric intensive care unit (PICU) became the focus of monitoring management for its more problems of irrational use of antimicrobial agents.Part IThe change of each index before and after intervention of antimicrobial agents[Objective]To investigate the status of use of antibiotics in the pediatric intensive care unit (PICU) before and after intervention, compare of the utilization rates of antibiotics, the rates of combined antibiotics, antibacterial use density, submission rates, the types and amounts of antibiotics and the top ten antimicrobials in use before and after intervention, so as to provide evidence-based medical for reasonable clinical use of antibiotics.[Methods]The children who were hospitalized the PICU were recruited from the HIS system as the study objects, totally 2333 children who were hospitalized the PICU from Jan 2008 to Dec 2014. The information for cases was extracted, which including age, gender, hospital stays, the first diagnosis for discharge, the usage of antimicrobial agents(medicine name, specifications, dosage, using time) and the etiology of specimen. Totally 1045 children who were hospitalized the PICU from Jan 2008 to Dec 2010 (before the intervention) were assigned as the control group, while 952 children who were hospitalized from Jan 2012 to Dec 2014(after the intervention) were set as the intervention group.According to "the Special Rectification Activities of Clinical Application of Antibiotics in 2011", the hospital made out the implementation rules of clinical application of antibacterial drugs. First of all, the hospital held the training and testing about "The Guideline Principle on the Clinical Use of Antimicrobial Drug" and "the Surveillance of Pathogens and Bacterial Resistance" for all doctors, and signed the responsibility agreement of rational use of antibiotics. Physicians who passed the examinations would be granted the authority of prescription of antibiotics. Secondly, the hospital made sure the approval process of use and consultation personnel qualifications and list of special antimicrobial drugs. Finally, set up a special team, vice President took charge of the leader of the team, team members was composed of clinician, clinical pharmacists, infection control physicians, medical department. According to the guiding principles and detailed rules, inspected and supervised the use of antibacterial agents regularly, commented the irrational use and proposed improvements.According to the standard of "the Medical Quality Management and ControlIndex for Third-tier General Hospital (2011 edition)" issued by the Ministry of Health, calculated the utilization rates of antibiotics, the rates of combined antibiotic, intensity of use of antibiotics, submission rates, the ratio of antibacterial drug costs to total.According to defined daily dose (DDD) recommended by WHO, calculated the frequency of antimicrobial drug use (DDDs) and antibacterial use density (AUD), DDD values refer to "the antibacterial drugs surveillance network medicine dictionary and DDD values "or the instructions of antibacterial drugs. Using the Excel software to establish the database, using SPSS 20.0 software for statistical analysis, t-test was used for measurement data; ratio or constituent ratio was used for describing the enumeration data, which using chi-square test. With P< 0.05 for the difference was statistically significant.[Results]The utilization rate of antibacterial agents was 40.34% in the intervention group, 82.68% in the control group; the combination rate of antibiotics was 29.69% in the intervention group,50.12% in the control group; the submission rate of microbial specimens was 88.80% in the intervention group,50.58% in the control group; the submission rate of microbial specimens of specialized antibacterial agents was 96.55% in the intervention group,83.24% in the control group, there was significant difference between the two group (P<0.001). The AUD in the intervention group was 28.86DDD, lower than 34.89DDD in the control group; the AUD of specialized antibacterial agents in the intervention group was 6.87DDD, lower than 7.29DDD in the control group. The proportion of antibiotics cost in the total drug cost was 31.33% in the intervention group, lower than 33.17%in the control group; The proportion of specialized antibacterial agents cost in the total drug cost was 15.84% in the intervention group, lower than 16.79% in the control group. The categories of antibiotics used in the intervention group was 20, lower than 24 in the control group; the species of antibiotics used in the intervention group was 41, lower than 55 in the control group; the average length of stay was 9.88 days in the intervention group, lower than 10.63 days in the control group; the mortality was 14.60% in the intervention group, significant lower than 18.18% in the control group (P<0.05).[Conclusion]After the comprehensive intervention, the status of use of antibiotics in the pediatric intensive care unit got obviously improvement and each evaluation index of the rational use of antimicrobial drugs significantly improved. ①The utilization rate of antibacterial agents decreased from 82.68% to 40.34% after intervention, which has reached the standard (the utilization rate of antibiotics should be no more than 60%) made by the Ministry of Health, and the combination rate of antibiotics decreased from 50.12% to 29.69% after intervention. ②The submission rate of microbial specimens increased from 50.58% to 88.80% after intervention, the submission rate of microbial specimens of specialized antibacterial agents increased from 83.24% to 96.55% after intervention, which has reached the standard (the submission rate of microbial specimens should be no less than 50% for antimicrobial agents and 80% for specialized antibacterial agents) made by the Ministry of Health. ③The antibiotics use density decreased from 34.89DDDs to 28.86DDDs after intervention, dropped by 17.28%,which has reached the standard (AUD should be no more 40DDDs) demanded by the Ministry of Health, and AUD for specialized antibacterial agents also decreased from 7.29DDDs to 6.87DDDs after intervention, dropped by 5.89%. ④The proportion of antibiotics cost in the total drug cost decreased from 33.17% to 31.33% after intervention, and the proportion of specialized antibacterial agents cost in the total drug cost also decreased from 16.79% to 15.84% after intervention.This research indicated that reasonable use of antibiotics could help patients to reduce the economic burden.⑤ The average length of stay has decreased froml0.63 days to 9.88 days after intervention, which indicated that reasonable use of antibiotics could help patients to reduce hospital stays.⑥The mortality of children in the PICU has decreased from 18.18% to 14.60% after intervention, which indicated that reasonable use of antibiotics could help patients to reduce the mortality to a certain extent.Part 2 The distribution of pathogens and drug resistance analysis before and after intervention of antimicrobial agents[Objective]To study the change of the submitted specimens, the pathogens distribution and the drug resistance of pathogenic bacteria in the pediatric intensive care unit (PICU), analysis on correlation between the use of antimicrobial agents with drug resistance, so as to provide evidence-based medical for reasonable clinical use of antibiotics.[Methods]The children who were hospitalized the PICU were recruited from the HIS system as the study objects, totally 1045 children who were hospitalized the PICU from Jan 2008 to Dec 2010 (before the intervention) were assigned as the control group, while 952 children who were hospitalized from Jan 2012 to Dec 2014(after the intervention) were set as the intervention group. The information about the situation of submitted specimens, pathogens and t bacterial resistance were collected.[Results]The submission rate of microbial specimens 88.80% in the intervention group, higher than 50.58% in the control group, the samples types mainly include blood, cerebrospinal fluid and sputum specimens, less proportion of other types of specimens.A total of 349 strains of pathogens were isolated from 2967 clinical specimens in the control group, the positive rate wasll.76%,which included 180 strains of gram-positive bacteria (51.58%),mainly streptococcus pneumonia 9.46% (33/349),methicillin resistant coagulase negative staphylococci 8.02%(28/349), staphylococcus aureus 6.02%(21/349); 133 strains of gram-negative bacteria (38.11%), mainly pseudomonas aeruginosa10.60%(37/349), Acinetobacter baumannii 7.16% (25/349), Escherichia coli 6.02%(21/349), Klebsiella pneumonia 5.16%(18/349);34 strains of fungus(9.74%), mainly Candida tropicalis 3.73%(13/349),Candida albicans 4.30%(15/349).A total of 955 strains of pathogens were isolated from 6749 clinical specimens in the intervention group, the positive rate was 14.15%, which included 407 strains of gram-positive bacteria (42.62%),mainly streptococcus pneumonia 8.59%(82/955),staphylococcus aureus 7.43%(71/955), staphylococcus epidermidis 6.91%(66/955);520 strains of gram-negative bacteria (54.45%), mainly pseudomonas aeruginosa 19.58%(187/955),Acinetobacter baumannii 7.43% (71/955), Escherichia coli 7.23%(69/955),Klebsiella pneumonia 7.12%(68/955); 23 strains of fungus (2.41%), mainly Candida albicans 1.26%(12/955),Candida parapsilosis 0.73%(7/955). There was significant difference between two group of the positive rate (P<0.001).Compared with the intervention group and control group, the drug resistance rates of the common pathogenic bacteria to commonly used antimicrobial agents have a downward trend. the constituent ration of methicillin-resistant staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococcus (MRCNS) in the intervention group was 2.62%(25/955), significant lower than 11.17%(39/349) in the control group. The sensitive rate of staphylococcus aureus to linezolid, teicoplanin and vancomycin is 100%, and the sensitive rate of Klebsiella pneumoniae and Escherichia coli to meropenem, imipenem and piperacillin/tazobactam is more than 95%.[Conclusion]① After the comprehensive intervention of reasonable use of antibacterial drugs in PICU of the hospital, clinical doctors have the further understanding of the importance of the etiology and drug susceptibility tests guiding clinical rational use of antimicrobial agents, the submission rate of microbial specimens has increased from 50.58% to 88.80% after intervention.②As the inspection equipment update and the level of clinical laboratory technician enhancement, the positive detection rate has increased from 11.76% to 14.15% after the intervention. ③The drug resistance rates of the common pathogenic bacteria to commonly used antimicrobial agents have a downward trend, The positive detection rate of methicillin-resistant staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococcus (MRCNS) has decreased from 11.17% to 2.62% after the intervention, which indicated that the rational comprehensive intervention to antibiotics is beneficial to reduce the bacterial resistance ratio.④The positive detection rate of fungus has decreased from 9.74% to 2.41% after the intervention, which indicated that the rational comprehensive intervention to antibiotics could help reduce the incidence of fungal infection. |
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