急性中耳炎患者抗生素處方遵從度與預後之相關研究－以某醫學中心耳鼻喉科為例

Adherence to the Clinical Practice Guidelines for Acute Otitis Media and It’s Relationship to Outcomes

褚嘉慧(Chia-Huei Chu)

指導教授 ： 賴美淑

國立臺灣大學/公共衛生學院/預防醫學研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.02748

摘要

前言及目的：
急性中耳炎 (AOM，Acute otitis media)是兒童罹患急性上呼吸道感染常見的併發症，也是醫師開立抗生素予兒童最常見的原因之一。美國小兒科醫學會、家庭醫學科醫學會和耳鼻喉頭頸外科醫學會，於2004年組成委員會，共同發表急性中耳炎臨床診療指引，提供醫師治療兩個月到十二歲兒童非複雜型(Uncomplicated acute otitis media)急性中耳炎之初步處理方法及藥物使用建議。本研究欲探討急性中耳炎患者之抗生素處方型態及其影響因子，並探討抗生素處方型態遵從度和急性中耳炎預後之相關性。
研究方法：
本研究資料來源為台北榮民總醫院耳鼻喉科2005年~2008年，年齡2個月~12歲大，主診斷碼為急性中耳炎之兒童病患。以病歷回溯的方式，紀錄病患基本資料 (年齡、性別、體重)、醫師開立抗生素處方 (包括品項、劑量、天數)、就診日期及病程以評估短期預後及中期預後。以該臨床診療指引為判斷抗生素處方型態遵從度之依歸，評估抗生素處方遵從度與分析急性中耳炎預後之相關性。以統計軟體SPSS 14.0版進行整體描述性統計和相關分析。
研究結果：
共收集207名急性中耳炎患者，年齡以2~6歲最多(占60.4%)；春、秋季就診人數較多(占58.5%)。醫師處方抗生素處方遵從度(包括品項、劑量、給藥天數)為8.2%。其中處方品項皆為指引建議品項，遵從度100%；其中92.7%醫師處方抗生素品項為「Amoxicillin類」類藥物。抗生素劑量遵從度極低，僅11.6%，絕大多數為劑量不足(占85%)。給藥天數遵從度為50.7%。專科醫師年資超過20年者，處方遵從度較低(p=0.006)；處方抗生素品項為「非Amoxicillin類」者，處方遵從度較高(p=0.006)。
總體來說，處方遵從度與急性中耳炎患者短期預後、中期預後皆無關。將處方品項、劑量、給藥天數分開檢視，抗生素「劑量」遵從度和急性中耳炎短期預後顯著相關(p=0.047)；劑量符合指引建議者，短期控制失敗的勝算比較低。就「Amoxicillin類」類抗生素而言，「劑量」遵從度和急性中耳炎預後之相關性在體重低於20Kg且雙側患病的孩童具顯著意義，藥物劑量不足者，短期控制失敗的勝算比較高(p=0.045)。「給藥天數」遵從度與短期預後無關，與中期預後顯著相關(p=0.42)。

關鍵字

臨床診療指引 ； 急性中耳炎 ； 抗生素 ； 遵從度

並列摘要

Background and Objectives:
AOM (Acute otitis media) is one of the most common childhood infections, especially after acute upper respiratory tract infections. It is also the leading cause of clinic’s visits by children, and the most frequent reason doctors prescribe antibiotics. The American Academy of Pediatrics, American Academy of Family Physicians and American Academy of Otorhinolaryngology Head-and-Neck surgery develop a clinical practice guideline for AOM. This evidence-based guideline provides recommendations to clinicians for the management of children from 2 months through 12 years of age with uncomplicated AOM. Our goal is to assess the variability and appropriateness of antibiotics prescribing patterns and also to evaluate the relationships between guideline adherence and prognosis of AOM.
Methods:
Data source of this study was based on outpatient clinic of Otolaryngology Head-and-Neck surgery department in Taipei Veterans General Hospital from 2005 to 2008. Medical records of children from 2 months through 12 years of age with ICD-9 CM diagnosis code of AOM were reviewed. The adherence of doctors’ prescribing patterns focusing on antibiotics was considered appropriate when in accord with clinical practice guideline for AOM. The study also examines the relationships between guideline adherence and primary control (defined as the eardrum condition at the evaluation point closest to 1~14 days after therapy of antibiotics finished), secondary control (defined was the eardrum condition at the evaluation point closest to 30 days after first visit owing to this episode) of AOM.
Results:
Complete medical record review was conducted in a total of 207 children, aged mostly from 2 to 6 years old (60.4%). Numbers of the visits were higher in Spring and Autumn (58.5%). Amoxicillin with or without β‐lactamase inhibitor was prescribed to majority of the patients (92.7%). The overall adherence of antibiotics prescription was only 8.2%. Among them, all of the antibiotics “items” fulfill the recommendations of guideline, while the “dosage” was under in 85%. The “duration” of prescribing antibiotics was adherent to guideline in 50.7%. Specialists who had been practicing for more than 20 years have poorer adherence to the guideline (p=0.006). The overall adherence was associated neither with primary nor secondary control of AOM. Better adherence of “dosage” was found to be significantly related to better primary control (p=0.047). As to the prescription containing amoxicillin, the
relationship was stronger in children below 20Kg with bilateral AOM (p=0.045). Better adherence of “duration of prescribing antibiotics” was related to better secondary control (p=0.42).

並列關鍵字

Acute otitis media ； Clinical practice guideline ； Adherence ； Antibiotics

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