肝癌患者接受射頻燒灼術或經導管動脈(化學)栓塞之廣效性抗生素使用研究

Broad spectrum antibiotics prescribing among patients with hepatocellular carcinoma undergoing radiofrequency ablation or transcatheter arterial chemoembolization

陳怡君(Yi-Chun Chen)

指導教授 ： 楊俊毓

高雄醫學大學/健康科學院/公共衛生學系公共衛生學碩士班/碩士(2017年)

摘要

研究背景與目的：射頻燒灼術及經肝動脈（化學）栓塞是目前臨床上常用來治療肝細胞癌患者的方法，兩種侵入性處置皆伴隨著潛在感染的風險，這使得臨床醫師會嘗試使用處置前後的預防性抗生素試圖減低感染併發症，然而，這樣的操作的合理性未被明確的證實，臨床上常見的是，處置後預期性發燒的發生，常令臨床醫師擔憂是否為感染併發症之發生，即開立廣效性抗生素。本研究的主要目的為調查肝癌患者接受射頻燒灼術或經肝動脈（化學）栓塞的廣效性抗生素耗用情況及處置後續感染併發症發生情形，以作為抗生素管制實務上之參考依據。
材料方法：本研究分成兩部分，第一部分，利用2005健保資料庫百萬歸人檔，使用ICD-9-CM從醫療紀錄得到 2004 到 2013 年間住院就醫紀錄中以肝癌 (ICD-9-CM:155)為主診斷且接受了射頻燒灼術或經肝動脈（化學）栓塞的住院病患，分析他們於當次住院中使用非全民健康保險醫療常用第一線抗生素之比例； 第二部分，從高雄長庚醫院選擇2015年1月1日至2015年5月31日肝癌住院並有接受射頻燒灼術或經動脈(化學)栓塞的患者，收集人口學、處置後發燒狀況及針劑抗生素使用等變數，並分別分析接受此兩種處置的患者，有接受廣效性抗生素及未接受廣效性抗生素後續併發菌血症及肝膿瘍發生之狀況。
研究結果：從台灣健保資料庫得知，射頻燒灼術或經動脈(化學)栓塞的肝癌患者，臨床醫師開立廣效性抗生素有逐年上升的趨勢。接受射頻燒灼術處置的廣效性抗生素使用是接受經肝動脈（化學）栓塞的1.49倍（95%信賴區間, 1.21~1.84），有肝硬化的患者被處方廣效性抗生素是無肝硬化患者的0.59倍(95%信賴區間:0.49~0.71)。在高雄長庚醫院，414 次的針對肝癌進行經動脈(化學)栓塞處置，其中10.14%的處置使用廣效性抗生素，有17人次出院診斷呈現細菌感染之相關診斷，處置相關的菌血症或肝膿瘍發生率為每個處置1.21%；309 次射頻燒灼術處置中，有8.09%的處置使用廣效性抗生素，其中有4人次出院診斷呈現細菌感染之相關診斷，處置相關的菌血症或肝膿瘍發生率為每個處置0.97%。處置後發燒是影響兩種處置抗生素使用的獨立因子。
結論：對於每個接受了經動脈(化學)栓塞或射頻燒灼術的肝癌患者都全面地投予預防性之抗生素可能是不必要的，處置後立即的發燒極少代表感染併發症的發生，臨床醫師應仔細的臨床評估再做抗生素是否給予的決定，以減少不必要的抗生素耗用。

關鍵字

肝癌 ； 射頻燒灼術 ； 經肝動脈（化學）栓塞 ； 肝膿瘍 ； 抗生素

並列摘要

Background and Objective: Whether transcatheter arterial (chemo)embolization [TA(C)E] or radiofrequency ablation (RFA) carries the risk of infection. The issue of prophylactic antibiotic agents before and after the procedure is controversial. Fever often develop in patients with HCC receiving TA(C)E or RFA. Practitioner may concern sepsis development or subsequent liver abscess formation and prescribe broad spectrum antibiotic agents once fever is recognized after the procedure despite the low reported incidence rate of sepsis. We aim to investigate parenteral broad spectrum antibiotic consumption among patients with hepatocellular carcinoma (HCC) undergoing RFA or TA(C)E and the incidence of post procedure infection complications.
Methods: We requested data on patients with HCC who underwent TA(C)E or RFA during hospitalization between 2004 and 2013 from the Taiwan National Health Insurance(NHI) program and also reviewed the computerized medical records between January 2015 and May 2015 in Kaohsiung Chang Gung Memorial Hospital(KCGMH) and found procedures of RFA or TA(C)E were performed during this period. Differences in demographics, co-morbidity, post-treatment fever, antibiotic use and infection complications were compared between patients who received RFA and TA(C)E.
Results: From the NHIRD, Taiwan, there is an increasing trend of broad spectrum antibiotics prescription among patients with HCC receiving TA(C)E or RFA from 2004 to 2013. The percentage of broad spectrum antibiotics use was 13.99%. Broad spectrum antibiotics used with RFA were 1.49 times (95% CI, 1.21-1.84) of those used with TA(C)E. Patient with liver cirrhosis were less prescribed broad spectrum antibiotics than those without liver cirrhosis (OR: 0.59, 95% CI:0.49~0.71). In KCGMH, among 414 TA(C)E procedures, there were 10.14% broad spectrum antibiotic prescribing with 17 documented bacterial infection according to discharge diagnosis. The incidence of procedure associated bacteremia or hepatic abscess formation is 1.21%. As for 309 RFA procedures, the percentage of broad spectrum antibiotic prescribing is 8.09% with 4 documented bacterial infection. The incidence of procedure related infection complication is 0.97%. Post procedure fever is an independent predictor of antibiotic prescribing.
Conclusions: Universal pre and post TA(C)E or RFA prophylactic antibiotic use may be not necessary. Transient postprocedure fevers are ususally attributed to postablation and postembolization syndrome and are not thought to represent bacteremia. Careful clinical evaluation bring a more judicious use of antibiotic.

並列關鍵字

Hepatocelluar carcinoma ； transcatheter arterial chemoembolization ； radiofrequency ablation (RFA) ； infection

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