総説・解説等

当院における血液培養陽性患者へのde-escalationの実施状況を調査し、その有用性(薬剤コスト削減効果)を明らかにした。菌種別のde-escalation実施率は、メチシリン感受性黄色ブドウ球菌(MSSA)が最も高く、次いで腸球菌属(Enterococcus spp.)が高かった。抗MRSA薬からの切り替えが最も多く、これはMSSAやEnterococcus spp.のde-escalation実施率の高さに反映されていると考えられた。de-escalation実施群と非実施群における治療失敗率の比較では、両群において有意差は認められなかった。治療失敗例は各群に1例ずつ認められ、その内訳はいずれも培養結果判明後30日以内の死亡であり、感染症の重篤度との関連が疑われた症例である。菌種はそれぞれMSSAとEnterococcus spp.であった。菌の持続的検出・菌血症の再発に関しては両群で認められなかった。治療期間と治療コストの比較については、de-escalation実施群に関して多剤で治療を行っていた症例が有意に多かったため、単剤で治療を行った症例を抽出し比較を行った。治療期間に関しては両群で差は認められなかった。一方、治療コストに関しては実施群で有意に低いという結果となった。

Objective: The objective of this study was to evaluate the impact of dental antibiotic guidelines recommending amoxicillin (AMPC) over third-generation cephalosporins (3GCs) for prophylactic use on surgical site infections (SSI), prescription patterns, and cost-effectiveness across facility types, considering the presence of infection control departments and ward pharmacists. Method: Using a health insurance claims database of individuals aged ≤ 75 years, we performed an interrupted time-series analysis of dental visits with tooth extractions from April 2012 to March 2024. A segmented regression model was applied to assess the impact of antibiotic guidelines (December 2014, 2014 guidelines; April 2016, 2016 guidelines) on 3GCs days of therapy (DOT) and SSI rates. Antibiotic costs and in-hospital vs out-of-hospital prescription patterns in dental clinics were also evaluated. Results: Overall, the number of 3GCs DOT decreased, although the impact of the guidelines differed between facilities. After the implementation of the 2014 guidelines, 3GCs use decreased in hospitals, but not in dental clinics. After the implementation of the 2016 guidelines, it was further reduced in hospitals with infection control departments and ward pharmacists, and a decline in 3GCs use in dental clinics was initiated. No changes were observed in hospitals with infection control departments alone. The shift from 3GCs to AMPC was more evident in out-of-hospital prescriptions than in in-hospital prescriptions. SSI rates remained unchanged; however, antibiotic costs decreased significantly over time. Conclusion: Guideline-based antimicrobial stewardship can reduce 3GC use and healthcare costs without compromising patient safety. Our findings highlight the importance of a multi-disciplinary collaboration to enhance the impact of guidelines.