重症监护病房抗菌药物降阶梯治疗策略实施情况调查

Survey on de-escalation of empiric broad-spectrum antibiotics treatment for patients in intensive care unit

目的 分析重症监护病房（ICU）患者抗菌药物降阶梯治疗实施情况,为促进抗菌药物合理使用提供依据.方法 回顾性调查2012年7月1日至12月31日和2013年7月1日至12月31日从浙江大学医学院附属第二医院ICU出院的所有病例,选取3d内联合用药或单独使用特殊使用级广谱抗菌药物病例,对患者感染状况、初始经验性广谱抗菌药物使用、病原菌培养以及抗菌药物调整情况进行统计.结果 841例出院病例中,786例（93.5％）使用过抗菌药物.389例（49.5％）接受过初始经验性广谱抗菌药物治疗,其中269例（69.2％）有明确感染证据.389例患者中,5d内仅有6例（1.54％）实现了降阶梯治疗;269例感染患者中,248例（92.2％）在3d内送检了样本,165例（66.5％）样本培养阳性,但只有4例（1.49％,4/269）实现了降阶梯治疗.送检样本临床分离菌以多重耐药革兰阴性杆菌和口咽部定植菌为主.结论 ICU患者初次使用广谱抗菌药物比较普遍,即使病原菌培养阳性,也极少能实施降阶梯治疗.

Objective To investigate de-escalation of empiric broad-spectrum antibiotics treatment for patients in intensive care unit （ICU）.Methods Data of the patients discharged from ICU in the Second Affiliated Hospital of Zhejiang University from July 1 to December 31 of 2012 and from July 1 to December 31 of 2013 were retrospectively reviewed.Patients with initial use of empirical broad-spectrum antibiotics within 3 d after ICU admission were included in the study.Clinical data including status of infection,the initial empiric antimicrobial therapy,pathogens culture and adjustment of antibiotics in 5 days were analyzed.Results A total of 841 patients were discharged from ICU during the study periods and antibiotics were used in 786 （93.5%） patients.Among 786 patients,389 （49.5%） were treated empirically with broad-spectrum antibiotics,but only 269 （69.2%） had evidences of bacterial infections.Of the 389 patients with empiric antibiotics use,de-escalation of antibiotics was applied only in 6 （1.54%） patients within 5 days after the initiation of treatment.In 269 patients with evidence of infection,specimen sampling and culture were performed in 248 （92.2%） patients within 3 days,among which 165 samples were positive,and the clinical isolates were mainly multi-drug resistant gram negative bacilli and colonized bacteria in oropharyngeal cavity.De-escalation was applied only in 4 （1.49%,4/269） patients with evidences of bacterial infections.Conclusion Broad-spectrum antibiotics as initial empiric therapy is common for patients in ICU,however de-escalation of empiric therapy is rarely applied even in patients with positive results in pathogen isolation and culture.