韩晶 史丽霞 谢祎 黄淑萍 张丽霞 张洁

摘 要 目的：为肺结核患者合理使用碳青霉烯类药物提供参考。方法：收集我院12 576例住院的肺结核患者，采用多学科诊疗模式（MDT），从政策干预、技术支持和人员培训等方面对碳青霉烯类药物的使用进行管理。比较管理前（2016年3月-2017年3月）与管理后（2017年4月-2019年3月）患者平均住院天数、病死率、医院感染率、碳青霉烯类药物使用情况和耐药率;采用中断时间序列分析法（ITS）对管理前后碳青霉烯类药物使用率、用药频度（DDDs）、其DDDs占抗菌药物DDDs比例、其费用占抗菌药物费用比例进行分析;并对碳青霉烯类药物DDDs与医疗质量指标、耐该类药物的细菌检出率等进行Pearson相关性分析。结果：管理后，患者平均住院日、抗菌药物费用以及碳青霉烯类药物DDDs、该类药物费用占抗菌药物费用比例、该类药物DDDs占抗菌药物DDDs比例、该类药物使用率、部分细菌对该类药物的耐药率均较管理前显著下降（P<0.05）。ITS分析结果显示，管理后碳青霉烯类药物使用率、DDDs、其DDDs占抗菌药物DDDs比例、其费用占抗菌药物费用比例分别下降4.491%、220.276、6.535%、11.747%，差异均有统计学意义（P<0.05）;与管理前比较，上述指标平均每月分别下降0.330%、17.625、0.308%、0.304%，其中碳青霉烯类药物使用率、DDDs下降趋势显著（P<0.05）。管理前，肺结核患者铜绿假单胞菌对亚胺培南的耐药率为21.80%，鲍曼不动杆菌对美罗培南、亚胺培南的耐药率均为4.60%;管理后，铜绿假单胞菌对亚胺培南的耐药率为13.00%，鲍曼不动杆菌对美罗培南、亚胺培南的耐药率均为16.30%，管理前后差异均有统计学意义（P<0.05）。而肠杆菌科细菌的耐药率在管理前后差异无统计学意义（P>0.05）。Pearson相關性分析显示，碳青霉烯类药物DDDs与患者平均住院日、抗菌药物费用均呈显著正相关（P<0.05）;亚胺培南DDDs与铜绿假单胞菌耐药率呈显著正相关（P<0.05）。结论：MDT管理能有效规范肺结核患者的碳青霉烯类药物使用，并可缩短患者的住院时间，降低药物费用、DDDs及部分细菌的耐药率。

关键词 多学科诊疗模式;抗菌药物;碳青霉烯类药物;肺结核;中断时间序列分析法;耐药性

中图分类号 R978.1 文献标志码 A 文章编号 1001-0408（2021）03-0364-06

DOI 10.6039/j.issn.1001-0408.2021.03.19

ABSTRACT   OBJECTIVE： To provide reference for the rational use of carbapenems in tuberculosis patients. METHODS： Totally 12 576 tuberculosis inpatients were collected from our hospital. Multi-disciplinary team （MDT） model was adopted for carbapenems management in aspects of policy intervention， technical support and staff training. Average hospitalization duration， mortality， nosocomial infective rate， use and drug resistance of carbapenems were compared before （Mar. 2016-Mar. 2017） and after management （Apr. 2017 to Mar. 2019）. Interrupted time series （ITS） analysis was used to analyze the utilization rate of carbapenems， DDDs， the proportion of carbapenems DDDs in the total antibiotics DDDs， the proportion of carbapenems cost in the total antibiotics cost before and after management. Pearson correlation analysis was conducted for DDDs of carbapenems with medical quality indicators and detection rate of carbapenems-resistant bacteria. RESULTS： After the management， average hospitalization stay， the cost of antibiotics， DDDs of carbapenems， the proportion of carbapenems DDDs in the total antibiotics DDDs， the proportion of carbapenems cost in the total antibiotics cost， the utilization rate of carbapenems， and the drug resistance rate of some bacteria to carbapenems were significantly lower than those before the management （P<0.05）. ITS analysis results showed that after management， the utilization rate of carbapenems， DDDs， the proportion of carbapenems DDDs in the total antibiotics DDDs and the proportion of carbapenems cost in the total antibiotics cost were decreased by 4.491%， 220.276， 6.535%， 11.747%， with statistical significance （P<0.05）. Compared with before management， above indexes were decreased by 0.330%， 17.625， 0.308%， 0.304% monthly， among which the utilization rate and DDDs of carbapenems were decreased significantly （P<0.05）. Before management， drug resistance rate of Pseudomonas aeruginosa to carbapenems was 21.80%， and those of Acinetobacter baumannii to meropenem and imipenem were both 4.60%; after management， drug resistance rate of P. aeruginosa to imipenem was 13.00%， and those of  A. baumannii to meropenem and imipenem were both 16.30%， with statistical significance before and after management （P<0.05）. There was no statistical significance in drug resistance rate of Enterobacteriaceae （P>0.05）. Pearson correlation analysis showed that carbapenems DDDs was significantly positively correlated with average hospitalization duration and antibiotics cost （P<0.05）; imipenems DDDs was positively correlated with drug resistance rate of P. aeruginosa （P<0.05）. CONCLUSIONS： MDT management can effectively standardize the use of carbapenem in  tuberculosis patients， shorten hospitalization duration， and reduce drug cost， DDDs and drug resistance rate of some bacteria.

KEYWORDS   Multi-disciplinary team; Antibiotics; Carbapenems; Tuberculosis; Interrupted time series analysis; Drug resistance

目前，细菌耐药问题已成为我国乃至全球公共健康领域的重大挑战，也是社会广泛关注的热点，已被世界卫生大会、联合国大会等列为主要议题。碳青霉烯类药物具有高效、广谱、耐酶的特点，其抗菌谱几乎可以包括目前所有临床常见的病原菌，已经成为治疗严重医院获得性肺炎、混合感染以及多重耐药菌感染的有效药物[1]。……