Antimicrobial Stewardship Programs (ASPs) yakave mbiru inokosha yekugadzirisa kushandiswa kwemishonga inorwisa mabhakitiriya, kuvandudza kutarisira kwevarwere, uye kuderedza antimicrobial resistance (AMR) .Pano, takaongorora kukanganisa kweASP pakushandiswa kwemishonga inorwisa mabhakitiriya uye AMR muColombia.
Isu takagadzira ongororo yekuongorora yekuongorora uye kuyerwa maitiro ekushandisa maantibiotic uye AMR pamberi uye mushure mekushandiswa kweASP pamusoro pemakore mana (mwedzi makumi maviri nemana isati yasvika uye 24 mwedzi mushure mekushandiswa kweASP) tichishandisa nguva yakatevedzana yekuongorora.
ASPs inoshandiswa zvichienderana nesangano rega rega rinowanikwa zviwanikwa.ASP isati yaitwa, pakanga pane maitiro ekuwedzera kushandiswa kwemishonga inorwisa mabhakitiriya kune zviyero zvose zvakasarudzwa zvemishonga inorwisa mabhakitiriya.Mushure mezvo, kuderera kwese kwekushandiswa kwemishonga inorwisa mabhakitiriya kwakaonekwa.Ertapenem uye meropenem kushandiswa kwakaderera mu Mawadhi emuchipatara, ukuwo ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, uye vancomycin zvakaderera munzvimbo dzinochengetwa varwere zvakanyanya. .
Muchidzidzo chedu, tinoratidza kuti ASP inzira yakakosha mukugadzirisa kutyisidzira kuri kubuda kwe AMR uye inokanganisa kuderera kwemishonga inorwisa mabhakitiriya uye kuramba.
Antimicrobial resistance (AMR) inonzi inotyisa pasi rose kuhutano hwevanhu [1, 2], ichikonzera kufa kwevanhu vanopfuura 700,000 pagore. Pakazosvika 2050, nhamba yevakafa inogona kunge yakakwira kusvika mamiriyoni gumi pagore [3] uye inogona kukuvadza zvakanyanya. chigadzirwa chemunyika chenyika, kunyanya nyika dzine mari yakaderera uye yepakati (LMICs) [4].
Kunyanya kuchinjika kwezvipembenene uye hukama pakati pekushandiswa zvisina kunaka kweantimicrobial uye AMR zvave zvichizivikanwa kwemakumi emakore [5].Muna 1996, McGowan naGerding vakadana "antimicrobial use stewardship," kusanganisira optimization yesarudzo yeantimicrobial, dose, uye nguva yekurapa, kugadzirisa. kutyisidzira kuri kubuda kwe AMR [6] .Mumakore mashoma apfuura, antimicrobial stewardship programs (ASPs) dzave mbiru inokosha mukugadzirisa kushandiswa kwemishonga inorwisa utachiona kuburikidza nekuvandudza kutevedza mitemo yemishonga inorwisa utachiona uye inozivikanwa nekuvandudza kuchengetwa kwevarwere asi iine ruzivo rwakanaka pa AMR. [7, 8]
Nyika dzine mari yakaderera nepakati kazhinji dzine huwandu hwe AMR nekuda kwekushaikwa kwekukurumidza kuongororwa bvunzo, chizvarwa chekupedzisira antimicrobials, uye epidemiological surveillance [9], saka nzira dzakanangana neASP dzakadai sekudzidziswa pamhepo, zvirongwa zvekupa mazano, nhungamiro yenyika. , uye Kushandiswa kwehuwandu hwemagariro evanhu kwave kunonyanya kukosha [8] .Zvisinei, kubatanidzwa kweASPs idzi kunonetsa nekuda kwekushaikwa kwevanyanzvi vehutano vakadzidziswa muhutachiona hwehutachiona, kushayikwa kwezvinyorwa zvehutano zvemagetsi, uye kushayikwa kwenyika. mutemo wehutano hweveruzhinji kugadzirisa AMR [9].
Zvidzidzo zvakawanda zvechipatara zvevarwere vari muchipatara zvakaratidza kuti ASP inogona kuvandudza kuomerera kune mishonga inorwisa mabhakitiriya uye kuderedza kushandiswa kusingakoshi kwemishonga inorwisa mabhakitiriya, asi iine migumisiro yakanaka pamitengo ye AMR, zvirwere zvinowanikwa muchipatara, nemigumisiro yevarwere [8, 10, 11], 12]. Kupindira kunonyanya kushanda kunosanganisira kutarisisa kuongororwa uye mhinduro, pre-mvumo, uye nzvimbo-yakananga kurapa mazano [13] .Kunyange zvazvo kubudirira kweASP kwakabudiswa muLatin America, kune mishumo mishomanana pamusoro pekiriniki, microbiological, uye hupfumi hwezvirongwa izvi. [14,15,16,17,18].
Chinangwa chechidzidzo ichi chaiva chekuongorora maitiro eASP pakushandiswa kwemishonga inorwisa mabhakitiriya uye AMR muzvipatara zvina zvakanyanya-complexity muColombia vachishandisa yakavharwa nguva yekuongorora.
A retrospective observational study yemisha ina mumaguta maviri eColombia (Cali neBarranquilla) pamusoro pemwedzi ye48 kubva ku2009 kusvika ku2012 (24 mwedzi isati yasvika uye 24 mwedzi mushure mekushandiswa kweASP) Inoitwa muzvipatara zvakaoma zvikuru (masangano AD) . meropenem-resistant Acinetobacter baumannii (MEM-R Aba), ceftriaxone-resistant E. coli (CRO-R Eco), ertapenem-resistant Klebsiella pneumoniae (ETP-R Kpn), The incidence of Ropenem Pseudomonas aeruginosa (ME-R Kpn) Oxacillin-resistant Staphylococcus aureus (OXA-R Sau) yakayerwa panguva yekudzidza.Kuongorora kwekutanga kweASP kwakaitwa pakutanga kwenguva yekudzidza, kuteverwa nekuongorora kufambira mberi kweASP mumwedzi mitanhatu inotevera uchishandisa Indicative Compound Antimicrobial (ICATB) Antimicrobial Stewardship Index [19].Average ICATB scores yakaverengwa.Mawadhi makuru uye zvikwata zvekuchengetedza zvakanyanya (ICUs) zvakabatanidzwa mukuongorora.Makamuri ekukurumidzira uye mawadhi evana akaiswa kunze kwekudzidza.
Maitiro akajairika ekutora chikamu cheASPs emasangano anosanganisira: (1) Multidisciplinary ASP zvikwata: chirwere chetachiona vanachiremba, vemishonga, microbiologists, vanamukoti mamaneja, hutachiona hwehutachiona uye kudzivirira makomiti;(2) Mirayiridzo yeAntimicrobial yezvirwere zvakanyanya kupararira, zvakagadziridzwa neboka reASP uye zvichibva pane epidemiology yesangano;(3) kubvumirana pakati penyanzvi dzakasiyana-siyana pamusoro pemishonga inorwisa mabhakitiriya mushure mekukurukurirana uye isati yaitwa;(4) kuongororwa uye mhinduro inzira yevose kunze kwesangano rimwe chete (sangano D rakashandisa mitemo inorambidza (5) Mushure mokunge kurapwa kwemishonga inorwisa mabhakitiriya kwatanga, boka reASP (kunyanya naGP rinoshuma kune chiremba wechirwere chinotapukira) rinoongorora kunyorerwa kwevakasarudzwa. vetted antibiotic uye inopa mhinduro yakananga uye mazano ekuenderera mberi, kugadzirisa, kuchinja kana kurega kurapwa; (6) nguva dzose (yega yega 4-6 mwedzi) kupindira kwekudzidzisa kuyeuchidza vanachiremba nezvemishonga inorwisa mabhakitiriya; (7) rubatsiro rwechipatara chekubatsira kweASM team interventions.
Defined daily doses (DDDs) zvichienderana neWorld Health Organization (WHO) calculation system yakashandiswa kuyera kushandiswa kwemishonga inorwisa mabhakitiriya.DDD per 100 bed-day before and after intervention with ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, and vancomycin yakanyorwa mwedzi wega wega kuchipatara chimwe nechimwe.Global metrics yezvipatara zvose inogadzirwa mwedzi wega wega panguva yekuongorora.
Kuyera chiitiko cheMEM-R Aba, CRO-R Eco, ETP-R Kpn, MEM-R Pae, uye OXA-R Sau, nhamba yevarwere vane zvirwere zvinowanikwa muchipatara (maererano neCDC uye microbial tsika-positive prophylaxis [CDC] Surveillance System Standards) yakakamurwa nenhamba yekugamuchira chipatara (mumwedzi ye6) × 1000 kugamuchirwa kwevarwere. Imwe chete yega yega yemhando imwechete yakabatanidzwa nemurwere.Kune rumwe rutivi, pakanga pasina kuchinja kukuru kwehutsanana hwemaoko. , zvidziviriro zvekuzviparadzanisa, kuchenesa uye nzira dzekudzivirira zvirwere muzvipatara zvina.Mukati menguva yekuongorora, protocol inoshandiswa neInfection Control and Prevention Committee yakaramba isina kuchinja.
Iyo 2009 uye 2010 Clinical uye Laboratory Standards Institute (CLSI) nhungamiro yakashandiswa kuona mafambiro ekuramba, tichifunga nezvekunzwa kwekutyora kwega yega panguva yekudzidza, kuve nechokwadi chekuenzaniswa kwemhedzisiro.
Yakapindirwa nguva yekuongorora kuenzanisa kushandiswa kwepasirese pamwedzi DDD mishonga inorwisa mabhakitiriya uye mwedzi mitanhatu yakawedzera chiitiko cheMEM-R Aba, CRO-R Eco, ETP-R Kpn, MEM-R Pae, uye OXA-R Sau mumawadhi echipatara uye nzvimbo dzekuchengeta varwere. .Antibiotic kushandiswa, coefficients uye chiitiko chezvirwere zvisati zvaitika, maitiro asati apindira uye mushure mekupindira, uye kuchinja kwemazinga akazara mushure mekupindira kwakanyorwa.Idzi tsanangudzo dzinotevera dzinoshandiswa: β0 inogara iripo, β1 ndiyo coefficient ye pre-intervention trend. , β2 ndiyo inoshanduka-shanduka, uye β3 ndiyo mushure mekupindira kwemaitiro [20].Kuongorora kwenhamba kwakaitwa muSTATA® 15th Edition.A p-value <0.05 yaifungidzirwa nhamba inokosha.
Zvipatara zvina zvakabatanidzwa panguva yekutevera-mwedzi we48;maitiro avo anoratidzwa muTafura 1.
Kunyange zvazvo mapurogiramu ose aitungamirirwa nevanoongorora zvirwere kana vanachiremba vezvirwere zvinotapukira (Table Tafura 2), kugoverwa kwevanhu kune ASPs kwakasiyana-siyana muzvipatara.Ivhareji yemari yeASP yaiva $ 1,143 pamabhedha zana. kushanda maawa 122.93 uye 120.67 pamibhedha zana pamwedzi, zvichiteerana.Varapi vezvirwere zvinotapukira, vanoongorora epidemiologists uye vafemisi vechipatara pamasangano ese ane nguva dzakakwirira.Institution D's ASP yaisvika $2,158 pamibhedha 100 pamwedzi, uye ndicho chinhu chinodhura pakati pe4. masangano nekuda kwenyanzvi dzakazvipira.
ASP isati yaitwa, masangano mana aya aive nehuwandu hwepamusoro-soro hwemishonga inorwisa mabhakitiriya (ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, uye vancomycin) mumawadhi ese nemaICU.Pane kuwedzera kwekushandiswa kwekushandiswa (Mufananidzo 1) .Kutevera kushandiswa kweASP, kushandiswa kwemishonga inorwisa mabhakitiriya kwakaderera mumasangano ose;sangano B (45%) rakaona kuderedzwa kukuru, richiteverwa nemasangano A (29%), D (28%), neC (20%). Sangano C rakadzora maitiro ekudyiwa kwemishonga inorwisa mabhakitiriya, pamwero wakatoderera pane wekutanga. nguva yekudzidza ichienzaniswa neyechitatu mushure mekuita nguva (p <0.001) .Mushure mekushandiswa kweASP, kushandiswa kwemeropenem, cefepime, uyeceftriaxoneyakadzikira zvakanyanya kusvika 49%, 16%, uye 7% mumasangano C, D, uye B, zvichiteerana (p <0.001).Kushandiswa kwevancomycin, piperacillin/tazobactam, neertapenem kwakanga kusina kusiyana.Panyaya yenzvimbo A, kuderedza kushandiswa kwemeropenem, piperacillin/tazobactam, uyeceftriaxoneyakaonekwa mugore rekutanga mushure mekushandiswa kweASP, kunyangwe maitiro asina kuratidza kuderera kwegore rinotevera (p> 0.05).
DDD maitiro mukushandiswa kweakawanda-spectrum antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, uye vancomycin) muICU nemawadhi ese.
Chimiro chepamusoro chepamusoro chakaonekwa kune mishonga yose inorwisa mabhakitiriya yakaongororwa ASP isati yashandiswa mumawadhi echipatara.Kushandiswa kweertapenem uye meropenem kwakaderera zvakanyanya mushure mekunge ASP yaitwa.Zvisinei, hapana kuderera kwakanyanya kwakaonekwa mukushandiswa kwemamwe maantibioti (Table 3). ) Nezve ICU, kusati kwaitwa ASP, chiyero chepamusoro chepamusoro chakaonekwa kune mishonga yose inorwisa mabhakitiriya yakaongororwa, kunze kweertapenem uye vancomycin.Kutevera kushandiswa kweASP, kushandiswa kweceftriaxone, cefepime, piperacillin / tazobactam, meropenem, uye vancomycin kwakaderera.
Kana ari mabhakitiriya asingaurayiwi nemishonga yakawanda, paive nenhamba yakakosha yekukwira kumusoro muOXA-R Sau, MEM-R Pae, uye CRO-R Eco isati yaitwa maASPs.Mukupesana, maitiro eETP-R Kpn neMEM-R. Aba vaive vasina kukosha.Maitiro eCRO-R Eco, MEM-R Pae, uye OXA-R Sau akachinja mushure mekunge ASP yaitwa, ukuwo maitiro eMEM-R Aba neETP-R Kpn akange asina kukosha zvakanyanya (Tafura 4. )
Kuitwa kweASP uye kushandiswa kwakakwana kwemishonga inorwisa mabhakitiriya kwakakosha kudzvinyirira AMR [8, 21].Muchidzidzo chedu, takaona kuderedzwa kwekushandiswa kwemamwe mishonga inorwisa utachiona mumatatu emasangano mana akadzidzwa.Mazano akawanda anoshandiswa nezvipatara anogona kubatsira mukubudirira. yeASPs yezvipatara izvi.Chokwadi chokuti ASP inoumbwa neboka renyanzvi dzakasiyana-siyana inokosha zvikuru sezvo iine basa rokushamwaridzana, kuita, uye kuyera kutevedza mitemo yemishonga inorwisa utachiona.Dzimwe nzira dzakabudirira dzinosanganisira kukurukura nhungamiro dzemishonga inorwisa mabhakitiriya nenyanzvi dzinorayira dzisati dzaitwa. ASP uye kuunza maturusi ekutarisa mashandisirwo emishonga inorwisa mabhakitiriya, ayo anogona kubatsira kuchengeta ma tabo pane chero shanduko mune antibacterial kuraira.
Zvivako zvehutano zvinoshandisa ASPs zvinofanira kugadzirisa kupindira kwavo kune vanhu varipo uye rubatsiro rwekubhadhara kweboka rekuchengetedza antimicrobial.Chiitiko chedu chakafanana nezvakataurwa naPerozziello nevamwe vaaishanda navo muchipatara cheFrance [22] .Chimwe chinhu chinokosha chaiva kutsigirwa kwechipatara. hutungamiri munzvimbo yekutsvakurudza, iyo yakafambisa kutonga kweboka rebasa reASP.Uyezve, kugovera nguva yebasa kune nyanzvi dzezvirwere zvinotapukira, zvipatara zvemishonga, vashandi vezvehutano uye varapi vehutano chinhu chinokosha chekubudirira kweASP [23].In Institutions B. uye C, GPs 'kuzvipira kwenguva yakakosha yekushanda kwekushandisa ASP inogona kunge yakakonzera kutevedzera kwavo kwakanyanya nemirairo yeantimicrobial, yakafanana neyakataurwa naGoff nevamwe vaaishanda navo [24] .Panzvimbo C, mukoti mukuru aive nebasa rekutarisa kuomerera kweantimicrobial uye shandisa uye kupa mhinduro yezuva nezuva kune vanachiremba.Pakanga paine vashoma kana imwe chete inotapukira diskurerutsa nyanzvi pamibhedha ye800, mibairo yakanaka kwazvo yakawanikwa nemukoti-run ASP yakanga yakafanana neyechidzidzo chakabudiswa naMonses [25].
Kutevera kushandiswa kweASP mumawadhi akawanda ezvivakwa zvina zvehutano muColombia, kuderera kwemaitiro ekudyiwa kwemishonga yose inorwisa mabhakitiriya yakaongororwa yakaonekwa, asi chete nhamba inokosha kune carbapenems.Kushandiswa kwecarbapenems kwakambove kwakabatanidzwa nekukuvadzwa kwechibvumirano chinosarudza. mabhakitiriya anopesana nemishonga yakawanda [26,27,28,29] .Saka, kuderedza kushandiswa kwayo kuchava nemigumisiro yezviitiko zvemishonga inopesana nemishonga muzvipatara pamwe chete nekuchengetedza mari.
Muchidzidzo ichi, kushandiswa kweASP kwakaratidza kuderera kwechiitiko cheCRO-R Eco, OXA-R Sau, MEM-R Pae, uye MEM-R Aba. Zvimwe zvidzidzo muColombia zvakaratidzawo kuderedzwa kwebeta yakawedzerwa-spectrum. -lactamase (ESBL) -inogadzira E. coli uye kuwedzera kupikisa kuchizvarwa chechitatu che cephalosporins [15, 16]. zvakadai sepiperacillin/tazobactam uye cefepime [15, 16].Kugadzirwa kwechidzidzo ichi hakugoni kuratidza kuti migumisiro yekudzivirira kwebhakitiriya inokonzerwa zvachose nekushandiswa kweASP.Zvimwe zvikonzero zvinokonzera kuderedzwa kwebhakitiriya rinopesana zvinogona kusanganisira kuwedzera kuomerera kune hutsanana hwemaoko. nekuchenesa nekuuraya utachiona, uye kuziva zvakazara kwe AMR, zvinogona kana kusakodzera maitirwo echidzidzo chino.
Kukosha kwechipatara cheASPs kunogona kusiyana zvakanyanya munyika nenyika.Zvisinei, mukuongorora kwakarongeka, Dilip et al.[30]yakaratidza kuti mushure mekushandisa ASP, chiyero chekuchengetedza mari chakasiyana nehukuru hwechipatara uye nzvimbo.Ivhareji yemari yekuchengetedza muongororo yeUnited States yaiva $732 pamurwere (kusiyana 2.50-2640), ine maitiro akafanana mukudzidza kweEurope. avhareji yemutengo wepamwedzi wezvinhu zvinodhura zvakanyanya yaive $2,158 pamibhedha ye100 uye 122.93 maawa ekushanda pamibhedha ye100 pamwedzi nekuda kwenguva inoiswa nenyanzvi dzehutano.
Tinoziva kuti tsvakurudzo pamusoro peASP inopindira ine zvisingakwanisi. Zviyero zvakasiyana-siyana zvakadai semigumisiro yakanaka yekiriniki kana kuderedzwa kwenguva refu mukurwisana kwebhakitiriya kwakaoma kuenderana neASP nzira yakashandiswa, muchidimbu nekuda kwechinguva chiduku chekuyera kubva apo ASP imwe neimwe yakanga yakaitwa.Kune rumwe rutivi, kuchinja kwechirwere che AMR munharaunda mumakore kunogona kukanganisa migumisiro yekudzidza chero kupi zvako.Uyezve, kuongororwa kwenhamba kwakakundikana kutora migumisiro yakaitika kusati kwaitwa ASP [31].
Muchidzidzo chedu, zvisinei, takashandisa discontinuous time series analysis with levels and trends in the pre-intervention segment as controls for the post-intervention segment, zvichipa nzira inogamuchirwa inogamuchirwa yekuyera kupindira kwemigumisiro.Sezvo kuputsika muzvikamu zvenguva zvinoreva pfungwa dzakananga panguva iyo kupindira kwakashandiswa, chirevo chokuti kupindira kunobata zvakananga migumisiro munguva yekupindira kwemashure kunosimbiswa nekuvapo kweboka rinodzora risina kumbove nekupindira, uye naizvozvo, kubva kune-pre-kupindira kune post-kupindira nguva hapana shanduko.Uyezve, nguva dzakatevedzana magadzirirwo anogona kudzora kune zvinoenderana nenguva-inovhiringidza mhedzisiro yakadai semwaka [32, 33].Kuongororwa kweASP kwekuvhiringidzwa kwekuongorora nguva yekuongorora kunowedzera kudiwa nekuda kwekudiwa kwemaitiro akaenzana, matanho emhedzisiro. , uye zviyero zvakaenzana, uye kudiwa kwemhando dzenguva kuti dzive dzakasimba pakuongorora ASP.Pasinei nezvakanaka zvese zveiyi nzira,pane zvimwe zvisingakwanisi.Nhamba yekucherechedza, symmetry ye data isati yasvika uye shure kwekupindira, uye autocorrelation yakakwirira ye data yose inobata simba rekudzidza.Saka, kana kuderedzwa kwakakosha mukushandiswa kwemishonga inorwisa mabhakitiriya uye kuderedzwa kwekudzivirira kwebhakitiriya. zvinoshumwa nekufamba kwenguva, chimiro chenhamba hachitibvumidze kuziva kuti ndeipi yeakawanda nzira dzakaitwa panguva yeASP ndiyo inonyanya kushanda nekuti Yese maASP mitemo inoiswa panguva imwe chete.
Antimicrobial stewardship inokosha pakugadzirisa kutyisidzira kwe AMR.Kuongororwa kweASP kunowedzera kunyorwa mumabhuku, asi kukanganisa kwemaitiro mukugadzira, kuongorora, uye kushuma kwezvirongwa izvi kunodzivisa kududzira uye kushandiswa kwakakura kwezvinoitika zvinobudirira.Kunyange zvazvo nhamba yezvikuru zvakakura. ASPs yakakura nekukurumidza pasi rose, zvave zvakaoma kuti LMIC iratidze kubudirira kwezvirongwa zvakadaro.Pasinei nezvimwe zvisingakwanisi, zvemhando yepamusoro zvakakanganiswa nguva-yakatevedzana zvidzidzo zvekuongorora zvinogona kubatsira pakuongorora kupindira kweASP.Muchidzidzo chedu tichienzanisa maASPs e zvipatara zvina, takakwanisa kuratidza kuti zvinokwanisika kuita chirongwa chakadaro muchipatara cheLMIC.Tinowedzera kuratidza kuti ASP inoita basa rinokosha mukuderedza kushandiswa kwemishonga inorwisa mabhakitiriya uye kuramba.Tinotenda kuti, sehutano hwehutano hwevanhu, ASPs. vanofanirwa kugashira rutsigiro rwemitemo yenyika, tichirangarira kuti ivowo parizvino vari chikamu changuzvinhu zvinogoneka zvekubvumidzwa kwechipatara zvine chekuita nekuchengetedzwa kwemurwere.
Nguva yekutumira: May-18-2022