Antimicrobial Stewardship Programs (ASPs) yakhala mzati wofunikira kwambiri wogwiritsa ntchito mankhwala oletsa tizilombo toyambitsa matenda, kupititsa patsogolo chisamaliro cha odwala, ndi kuchepetsa kukana kwa antimicrobial resistance (AMR) .Pano, tinayesa zotsatira za ASP pakugwiritsa ntchito mankhwala osokoneza bongo komanso AMR ku Colombia.
Tinapanga kafukufuku wowonera m'mbuyo ndikuyesa momwe maantibayotiki amagwiritsidwira ntchito ndi AMR isanayambe komanso itatha kukhazikitsidwa kwa ASP pazaka 4 (miyezi 24 isanayambe ndi miyezi 24 pambuyo pa kukhazikitsidwa kwa ASP) pogwiritsa ntchito kusokonezeka kwa nthawi.
ASPs akugwiritsidwa ntchito potengera zomwe bungwe lirilonse liri nalo.Asanayambe kukhazikitsidwa kwa ASP, panali chizolowezi chowonjezera kumwa ma antibiotic pamiyeso yonse yosankhidwa ya mankhwala oletsa tizilombo toyambitsa matenda.Pambuyo pake, kuchepa kwakukulu kwa ma antibiotic kunawonedwa.Ertapenem ndi meropenem ntchito inachepa mu M'zipatala, pamene ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ndi vancomycin zatsika m'zipinda zosamalira odwala mwakayakaya. .
Mu phunziro lathu, tikuwonetsa kuti ASP ndi njira yofunikira pothana ndi chiwopsezo chomwe chikubwera cha AMR ndipo imakhudzanso kuchepa kwa maantibayotiki ndi kukana.
Antimicrobial resistance (AMR) imaonedwa kuti ndi chiwopsezo padziko lonse lapansi ku thanzi la anthu [1, 2], zomwe zimapha anthu oposa 700,000 pachaka. Pofika chaka cha 2050, chiwerengero cha imfa chikhoza kufika pa 10 miliyoni pachaka [3] ndipo chikhoza kuwononga kwambiri. zinthu zapakhomo zamayiko, makamaka mayiko omwe ali ndi ndalama zotsika ndi zapakati (LMICs) [4].
Kusinthasintha kwakukulu kwa tizilombo tating'onoting'ono komanso mgwirizano pakati pa kugwiritsa ntchito molakwa mankhwala oletsa tizilombo toyambitsa matenda ndi AMR kwadziwika kwa zaka zambiri [5]. chiwopsezo chomwe chikubwera cha AMR [6] .Pazaka zingapo zapitazi, ma antimicrobial stewardship programme (ASPs) akhala mzati wofunikira pakuwongolera kugwiritsa ntchito mankhwala opha tizilombo popititsa patsogolo kutsatira malangizo a antimicrobial ndipo amadziwika kuti amawongolera chisamaliro cha odwala pomwe amathandizira pa AMR. [7, 8].
Maiko omwe ali ndi ndalama zochepa komanso zapakati nthawi zambiri amakhala ndi AMR chifukwa chosowa mayeso ofulumira, ma antimicrobial a m'badwo wotsiriza, komanso kuyang'anira matenda a Epidemiological surveillance [9], kotero njira zotsatiridwa ndi ASP monga maphunziro apaintaneti, mapulogalamu aulangizi, malangizo adziko. , ndi Kugwiritsa ntchito malo ochezera a pa Intaneti kwakhala chinthu chofunika kwambiri [8] .Komabe, kuphatikiza kwa ma ASPwa kumakhala kovuta chifukwa cha kusowa kwafupipafupi kwa akatswiri a zaumoyo omwe amaphunzitsidwa utsogoleri wa antimicrobial, kusowa kwa zolemba zamankhwala zamagetsi, komanso kusowa kwa dziko. mfundo zaumoyo wa anthu kuti athane ndi AMR [9].
Kafukufuku wambiri wachipatala wa odwala omwe ali m'chipatala asonyeza kuti ASP ikhoza kupititsa patsogolo kutsata malangizo a mankhwala oletsa tizilombo toyambitsa matenda komanso kuchepetsa kumwa mankhwala opha tizilombo toyambitsa matenda, pokhala ndi zotsatira zabwino pamitengo ya AMR, matenda obwera kuchipatala, ndi zotsatira za odwala [8, 10, 11], 12]. Njira zothandizira kwambiri zomwe zikuphatikizapo kuwunikiranso ndi kuyankha, kuvomereza kale, ndi ndondomeko zothandizira chithandizo chamankhwala [13] . [14,15,16,17,18].
Cholinga cha phunziroli chinali kuyesa zotsatira za ASP pa kumwa maantibayotiki ndi AMR m'zipatala zinayi zovuta kwambiri ku Colombia pogwiritsa ntchito kusokonezeka kwa nthawi.
Kafukufuku wobwerezabwereza wa nyumba zinayi m'mizinda iwiri ya Colombia (Cali ndi Barranquilla) pa nthawi ya miyezi 48 kuchokera ku 2009 mpaka 2012 (miyezi 24 isanayambe ndi miyezi 24 pambuyo pa kukhazikitsidwa kwa ASP) Kuchitidwa m'zipatala zovuta kwambiri (mabungwe 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) anayesedwa panthawi yophunzira.Kufufuza koyambirira kwa ASP kunachitika kumayambiriro kwa nthawi yophunzira, kutsatiridwa ndi kuyang'anira kupitirira kwa ASP m'miyezi isanu ndi umodzi yotsatira pogwiritsa ntchito Indicative Compound Antimicrobial (ICATB) Antimicrobial Stewardship Index [19] .Chiwerengero cha ICATB chinawerengedwa.Mawodi akuluakulu ndi magulu osamalira odwala kwambiri (ICUs) anaphatikizidwa mu kusanthula.Zipinda zadzidzidzi ndi zipinda za ana sizinaphatikizidwe pa phunziroli.
Makhalidwe odziwika a ma ASP a mabungwe omwe akugwira nawo ntchito ndi awa: (1) Magulu a ASP amitundu yambiri: madokotala a matenda opatsirana, akatswiri a zamankhwala, akatswiri a tizilombo toyambitsa matenda, oyang'anira anamwino, makomiti oletsa matenda ndi kupewa;(2) Malangizo oletsa tizilombo toyambitsa matenda omwe amapezeka kwambiri, osinthidwa ndi gulu la ASP komanso malinga ndi miliri ya bungwe;(3) mgwirizano pakati pa akatswiri osiyanasiyana pa malangizo oletsa tizilombo toyambitsa matenda pambuyo pokambirana ndi musanagwiritse ntchito;(4) kafukufuku woyembekezeredwa ndi ndemanga ndi njira kwa onse kupatula bungwe limodzi (bungwe D lidakhazikitsa malamulo oletsa (5) Pambuyo poyambitsa mankhwala opha maantibayotiki, gulu la ASP (makamaka ndi GP lipoti kwa dokotala wa matenda opatsirana) limayang'ananso malangizo a osankhidwa. mankhwala opha maantibayotiki ndipo amapereka ndemanga zolunjika ndi malangizo kuti apitirize, kusintha, kusintha kapena kusiya chithandizo; (6) nthawi zonse (miyezi iliyonse ya 4-6) maphunziro opititsa patsogolo kukumbutsa madokotala za malangizo oletsa tizilombo toyambitsa matenda; (7) Thandizo loyang'anira chipatala kwa magulu a ASM.
Mlingo watsiku ndi tsiku (DDDs) wotengera kuwerengera kwa World Health Organisation (WHO) unagwiritsidwa ntchito kuyeza kumwa maantibayotiki.DDD pa 100 masiku ogona asanayambe komanso atatha kulowererapo ndi ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, ndi vancomycin ankalembedwa mwezi uliwonse kuchipatala chilichonse.
Kuyeza zochitika za MEM-R Aba, CRO-R Eco, ETP-R Kpn, MEM-R Pae, ndi OXA-R Sau, chiwerengero cha odwala omwe ali ndi matenda opatsirana kuchipatala (malinga ndi CDC ndi microbial culture-positive prophylaxis [CDC] Surveillance System Standards) yogawidwa ndi chiwerengero cha anthu ovomerezeka kuchipatala (m'miyezi ya 6) × kuvomereza kwa odwala 1000. Kupatula kumodzi kokha kwa mtundu womwewo kunaphatikizidwa kwa wodwala. Komano, panalibe kusintha kwakukulu paukhondo wamanja. , njira zodzipatula, kuyeretsa ndi kupha tizilombo toyambitsa matenda m'zipatala zinayi.Panthawi yowunika, ndondomeko yomwe inakhazikitsidwa ndi Komiti Yoyang'anira Matenda ndi Kuteteza Matenda sinasinthe.
Maupangiri a 2009 ndi 2010 Clinical and Laboratory Standards Institute (CLSI) adagwiritsidwa ntchito kuti adziwe momwe amakanira, poganizira za kusweka kwa aliyense payekhapayekha panthawi yophunzira, kuwonetsetsa kufananizidwa kwa zotsatira.
Kusanthula kwanthawi kosokoneza kuyerekeza kugwiritsa ntchito ma antibiotic a DDD pamwezi pamwezi komanso kuchuluka kwa miyezi isanu ndi umodzi ya MEM-R Aba, CRO-R Eco, ETP-R Kpn, MEM-R Pae, ndi OXA-R Sau m'mawodi azipatala komanso m'malo osamalira odwala kwambiri. .Kugwiritsira ntchito maantibayotiki, ma coefficients ndi zochitika zowonongeka zisanachitike, machitidwe asanayambe komanso atatha kulowererapo, ndi kusintha kwa msinkhu wathunthu pambuyo pochitapo kanthu kunalembedwa.Matanthauzo otsatirawa amagwiritsidwa ntchito: β0 ndi nthawi zonse, β1 ndi coefficient of pre-intervention trend. , β2 ndikusintha kwazomwe zikuchitika, ndipo β3 ndizomwe zimachitika pambuyo polowera [20].Kusanthula kwachiwerengero kunachitika mu STATA® 15th Edition.
Zipatala zinayi zinaphatikizidwa pakutsatira kwa mwezi wa 48;makhalidwe awo akuwonetsedwa mu Table 1.
Ngakhale kuti mapulogalamu onse amatsogoleredwa ndi akatswiri a miliri kapena madokotala opatsirana (Table 2), kugawa kwa anthu kwa ASPs kunali kosiyana m'zipatala. Mtengo wa ASP unali $ 1,143 pa mabedi 100. Mabungwe D ndi B adakhala nthawi yayitali kwambiri kuti ASP alowererepo, kugwira ntchito 122.93 ndi maola 120.67 pa mabedi 100 pamwezi, motero.Madokotala a matenda opatsirana, akatswiri a miliri ndi madokotala achipatala m'mabungwe onsewa akhala ndi maola apamwamba kwambiri.Institution D's ASP inali ya $2,158 pa mabedi 100 pamwezi, ndipo chinali chinthu chodula kwambiri pakati pa 4 mabungwe chifukwa cha akatswiri odzipereka kwambiri.
ASP isanakhazikitsidwe, mabungwe anayiwa anali ndi vuto lalikulu la maantibayotiki (ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, ndi vancomycin) m'mawodi ambiri ndi ma ICU.Pali njira yowonjezera yogwiritsira ntchito (Chithunzi 1) .Kutsatira kukhazikitsidwa kwa ASP, kugwiritsa ntchito maantibayotiki kunachepa m'mabungwe onse;Bungwe B (45%) linachepetsa kwambiri, kutsatiridwa ndi mabungwe A (29%), D (28%), ndi C (20%). nthawi yowerengera poyerekeza ndi nthawi yachitatu yokhazikitsidwa (p <0.001) .Pambuyo pa kukhazikitsidwa kwa ASP, kugwiritsa ntchito meropenem, cefepime, ndiceftriaxonekudatsika kwambiri mpaka 49%, 16%, ndi 7% m'mabungwe C, D, ndi B, motsatana (p <0.001). Kugwiritsa ntchito vancomycin, piperacillin/tazobactam, ndi ertapenem sikunali kosiyana mowerengera. kuchepetsa kumwa meropenem, piperacillin/tazobactam, ndiceftriaxoneadawonedwa mchaka choyamba pambuyo pa kukhazikitsidwa kwa ASP, ngakhale kuti khalidweli silinawonetse kutsika kulikonse mchaka chotsatira (p> 0.05).
Zomwe zimachitika mu DDD pakumwa maantibayotiki ambiri (ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, ndi vancomycin) ku ICU ndi mawodi ambiri.
Kuwonjezeka kwakukulu kwa chiwerengero kunawonedwa pa maantibayotiki onse omwe anayesedwa ASP isanayambe kukhazikitsidwa m'mawodi a chipatala.Kumwa kwa ertapenem ndi meropenem kunachepa kwambiri pambuyo pa kukhazikitsidwa kwa ASP. ) Ponena za ICU, isanayambe kukhazikitsidwa kwa ASP, kuwonjezereka kwakukulu kwa chiwerengero kunawonedwa kwa maantibayotiki onse omwe anayesedwa, kupatulapo ertapenem ndi vancomycin. Pambuyo pa kukhazikitsidwa kwa ASP, kugwiritsa ntchito ceftriaxone, cefepime, piperacillin / tazobactam, meropenem, ndi vancomycin kunachepa.
Ponena za mabakiteriya osamva mankhwala ambiri, panali kuchulukira kwakukulu ku OXA-R Sau, MEM-R Pae, ndi CRO-R Eco asanayambe kukhazikitsidwa kwa ASPs. Mosiyana ndi izi, zomwe ETP-R Kpn ndi MEM-R Aba sanali ofunikira kwenikweni. Zomwe CRO-R Eco, MEM-R Pae, ndi OXA-R Sau zidasintha pambuyo poti ASP idakhazikitsidwa, pomwe machitidwe a MEM-R Aba ndi ETP-R Kpn sanali ofunikira (Table 4). ).
Kukhazikitsidwa kwa ASP ndi kugwiritsa ntchito bwino kwa maantibayotiki ndizofunikira kwambiri kuti zithetse AMR [8, 21]. a ASPs a zipatalazi.Mfundo yakuti ASP imapangidwa ndi gulu la akatswiri amitundu yosiyanasiyana ndi yofunika kwambiri chifukwa ali ndi udindo wocheza, kukhazikitsa, ndi kuyeza kutsatiridwa ndi malangizo oletsa tizilombo toyambitsa matenda.Njira zina zopambana zikuphatikizapo kukambirana malangizo oletsa tizilombo toyambitsa matenda ndi akatswiri olemba mankhwala asanagwiritse ntchito. ASP ndi zida zowunikira zowunikira momwe maantibayotiki amagwiritsidwira ntchito, zomwe zingathandize kuwunika kusintha kulikonse kwamankhwala a antibacterial.
Malo opangira chithandizo chamankhwala omwe akugwiritsira ntchito ASPs ayenera kusintha njira zawo zothandizira anthu omwe alipo komanso thandizo la malipiro a gulu la antimicrobial stewardship team.Zochitika zathu ndizofanana ndi zomwe Perozziello ndi anzake akugwira nawo kuchipatala cha ku France [22] .Chinthu china chofunika kwambiri chinali chithandizo cha chipatala. utsogoleri mu malo opangira kafukufuku, zomwe zinapangitsa kuti gulu la ogwira ntchito a ASP liyambe kulamulira. Komanso, kugawa nthawi yogwira ntchito kwa akatswiri a matenda opatsirana, madokotala achipatala, ogwira ntchito zachipatala ndi othandizira opaleshoni ndizofunikira kwambiri kuti ASP ikwaniritsidwe [23] .In Institutions B. ndi C, GPs 'kudzipereka kwa nthawi yochuluka yogwira ntchito kuti agwiritse ntchito ASP mwina adathandizira kuti azitsatira kwambiri malangizo a antimicrobial, ofanana ndi a Goff ndi anzake [24]. gwiritsani ntchito ndikupereka ndemanga za tsiku ndi tsiku kwa madokotala.Pamene panali ma diss ochepa kapena amodzi okha opatsiranaomasuka katswiri pa mabedi 800, zotsatira zabwino kwambiri zopezedwa ndi namwino-woyendetsa ASP zinali zofanana ndi za kafukufuku wofalitsidwa ndi Monsees [25].
Pambuyo pa kukhazikitsidwa kwa ASP m'mawodi akuluakulu a zipatala zinayi ku Colombia, kuchepa kwa kumwa kwa maantibayotiki onse omwe anaphunziridwa kunawonedwa, koma kofunika kwambiri kwa carbapenems. Mabakiteriya osamva mankhwala ambiri [26,27,28,29] .Choncho, kuchepetsa kugwiritsidwa ntchito kwake kudzakhudza zochitika za zomera zosamva mankhwala m'zipatala komanso kupulumutsa ndalama.
Mu phunziro ili, kukhazikitsidwa kwa ASP kunasonyeza kuchepa kwa chiwerengero cha CRO-R Eco, OXA-R Sau, MEM-R Pae, ndi MEM-R Aba. Maphunziro ena ku Colombia awonetsanso kuchepetsa kwa beta yowonjezereka. -lactamase (ESBL) -kutulutsa E. coli ndi kuwonjezereka kukana kwa cephalosporins ya m'badwo wachitatu [15, 16] . monga piperacillin/tazobactam ndi cefepime [15, 16] . ndi kuyeretsa ndi kupha tizilombo toyambitsa matenda, komanso kudziwa zambiri za AMR, zomwe zingakhale kapena sizingakhale zogwirizana ndi kafukufukuyu.
Mtengo wa ASPs wachipatala ukhoza kusiyana kwambiri m'mayiko osiyanasiyana.adawonetsa kuti atatha kugwiritsa ntchito ASP, ndalama zambiri zopulumutsira ndalama zimasiyana malinga ndi kukula kwa chipatala ndi dera.Avereji yosungira ndalama mu kafukufuku wa US inali $732 pa wodwala (2.50-2640), ndi zofanana zofanana mu phunziro la ku Ulaya. mtengo wapamwezi wa zinthu zodula kwambiri unali $2,158 pa mabedi 100 ndi maola 122.93 ogwirira ntchito pa mabedi 100 pamwezi chifukwa cha nthawi yomwe akatswiri azachipatala amaikapo.
Tikudziwa kuti kafukufuku wokhudza njira za ASP ali ndi malire angapo.Zosintha zoyezetsa monga zotsatira zabwino zachipatala kapena kuchepetsa kwa nthawi yaitali kwa mabakiteriya kukana kunali kovuta kugwirizana ndi njira ya ASP yogwiritsidwa ntchito, mwa zina chifukwa cha nthawi yochepa yoyezera kuyambira pamene ASP iliyonse inali yovuta. kugwiritsiridwa ntchito.Kumbali inayi, kusintha kwa miliri ya AMR yam'deralo kwa zaka zambiri kungakhudze zotsatira za phunziro lililonse.Kuonjezera apo, kufufuza kwa chiwerengero kunalephera kufotokoza zotsatira zomwe zinachitika ASP isanayambe [31].
Mu phunziro lathu, komabe, tinagwiritsa ntchito kusanthula kwa nthawi kosalekeza ndi miyeso ndi zochitika mu gawo lachidziwitso chisanachitike monga zowongolera za gawo lotsatilapo, ndikupereka ndondomeko yovomerezeka yovomerezeka yoyezera zotsatira. mfundo zenizeni panthawi yomwe kulowererapo kunakhazikitsidwa, kufotokozera kuti kuchitapo kanthu kumakhudza mwachindunji zotsatira pambuyo pa nthawi yothandizira kumalimbikitsidwa ndi kukhalapo kwa gulu lolamulira lomwe silinayambepopopopopopopopopopopopopopopondepo, motero, kuchokera ku chisanadze kulowererapo kupita ku Pambuyo pa kulowererapo palibe kusintha.Kuonjezera apo, mapangidwe a nthawi amatha kulamulira zotsatira zowonongeka zokhudzana ndi nthawi monga nyengo [32, 33]. , ndi miyeso yokhazikika, ndi kufunikira kwa zitsanzo za nthawi kuti zikhale zolimba poyesa ASP.Ngakhale ubwino wa njirayi,pali zolephera zina.Kuchuluka kwa ziwonetsero, kufanana kwa deta isanayambe komanso itatha kulowererapo, komanso kukhazikika kwapamwamba kwa deta zonse zimakhudza mphamvu ya phunzirolo.Choncho, ngati kuchepetsa kuchepa kwa maantibayotiki ndi kuchepetsa kukana kwa mabakiteriya. zimanenedwa pakapita nthawi, chiwerengero cha chiwerengero sichilola kuti tidziwe kuti ndi njira ziti zomwe zimagwiritsidwa ntchito panthawi ya ASP ndizothandiza kwambiri chifukwa ndondomeko zonse za ASP zikugwiritsidwa ntchito panthawi imodzi.
Utsogoleri wa antimicrobial ndi wofunikira kwambiri pothana ndi ziwopsezo za AMR zomwe zikubwera.Kuwunika kwa ASP kukufotokozedwa mochulukira m'mabuku, koma zolakwika zamakina pakupanga, kusanthula, ndi malipoti azinthu izi zimalepheretsa kutanthauzira ndi kukhazikitsidwa kokulirapo kwa njira zowoneka bwino. ASPs yakula mofulumira padziko lonse lapansi, zakhala zovuta kuti LMIC iwonetse kupambana kwa mapulogalamu oterowo.Ngakhale kuti pali zolephera zina, maphunziro apamwamba omwe amasokoneza nthawi atha kukhala othandiza pofufuza njira za ASP. zipatala zinayi, tinatha kusonyeza kuti n'zotheka kukhazikitsa pulogalamu yotereyi mu chipatala cha LMIC.Timasonyezanso kuti ASP imagwira ntchito yofunika kwambiri pa kuchepetsa kumwa ma antibiotic ndi kukana.Timakhulupirira kuti, monga ndondomeko ya thanzi la anthu, ASPs Ayenera kulandira thandizo loyang'anira dziko, pokumbukira kuti nawonso ali mbali ya inezinthu zotsimikizika za kuvomerezeka kwachipatala zokhudzana ndi chitetezo cha odwala.
Nthawi yotumiza: May-18-2022