健保門診治療泌尿道感染之不合理抗生素處方型態分析

Analysis of Inappropriate Prescription Patterns of Antibiotics in Treating Outpatients with Urinary Tract Infection among NHI Contracted Medical Care Institution

徐慧觀(Hui-Kuan Shu)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.00751

摘要

本研究採用2002年健保門診承保資料歸人抽樣檔，作泌尿道感染之抗生素處方合理性之分析。對象為12歲及以上女性之急性膀胱炎及急性腎盂腎炎之泌尿道感染病人。本研究對不合理處方之判定，係以1999年美國感染症醫學會所訂定之「婦女單純急性細菌性膀胱炎及急性腎盂腎炎之抗生素指引」，及2000年新加坡衛生部所訂定之「成人抗生素使用準則」二份實證為基礎之指引作為抗生素用藥合理性之判斷準則。
對於合理或不合理之判斷，係以符合診療指引推薦治療使用之抗生素種類及天數即為合理處方，符合種類但天數不合即為不合理處方，不合理處方中又分為不足處方及過度處方。另有關不符合診療指引推薦治療使用之抗生素種類部分，因無法做判斷，故不在本研究討論範圍之內。
研究結果發現急性膀胱炎的治療，依照診療指引可使用Fluoroquinolone、Nitrofurantoin、Cephalosporin、Trimethoprim – Sulfamethoxazole四類抗生素。在治療急性膀胱炎病人的處方中，使用這四類抗生素治療之合理與不合理性比例為：合理性比例最高，佔60.06﹪、其次為不足處方佔27.9﹪、過度處方佔12.05﹪。另這四類抗生素中，以使用cephalosporin之人次最多，佔46.89%，其不合理處方之比例卻最低，佔22.45%；使用Trimethoprim – Sulfamethoxazole之人次最少，佔3.77%，其不合理處方之比例約為六成（59.46%）；使用Nitrofurantoin佔17.42%之不合理處方之比例為四者中最高，佔91.67%，其中以不足處方最多，佔87.38%。
急性腎盂腎炎的治療，依照診療指引可使用Fluoroquinolone、Cephalosporin 、Amoxicillin - Clavulanic acid、Trimethoprim – Sulfamethoxazole四類抗生素。在治療急性腎盂腎炎病人的處方中，使用這四類抗生素治療之合理與不合理比例為：不足處方比例最高，佔48.92﹪、其次為合理處方佔39.83﹪、過度處方佔11.26﹪。另這四類抗生素中，以使用cephalosporin之人次最多，佔59.74%，其不合理處方之比例約為六成（60.15%），且以不足處方為主，佔58.7%；使用Trimethoprim – Sulfamethoxazole之人次最少，佔6.93%，但其不合理處方之比例為四類藥物中最高，佔87.5%。
至於影響不合理處方之可能因素，經對數複廻歸分析後，發現在治療急性膀胱炎部分，病人年齡層愈高，愈容易出現不合理處方；在醫院層級別方面，出現不合理處方之機會無顯著差異；在醫院權屬別方面，發現私立醫院及法人醫院出現不合理處方之機會較大；在醫院健保分局別方面，中區分局及東區分局所屬醫院出現不合理處方之機會較小；在就醫科別方面，內科及婦產科出現不合理處方之機會較大，而家醫科、小兒科及腎臟內科則相對較不易出現不合理處方。
另在治療急性腎盂腎炎部分，病人年齡層愈高，反而愈不容易出現不合理處方；此結果恰與治療急性膀胱炎時相反。在醫院層級別方面，區域醫院出現不合理處方之機會較小；在醫院權屬別方面，出現不合理處方之機會並無顯著差異；在醫院健保分局別方面，北區分局及中區分局所屬醫院出現不合理處方之機會較小；在就醫科別方面，僅發現內科出現不合理處方之機會較小，其餘各科則無顯著差異。
經由本研究之結果，建議衛生主管機關建立有效的藥品使用評估制度，並會同醫療專業團體共同擬訂本土化之泌尿道感染疾病診療指引、加強醫師實證醫學教育，以期降低不合理處方比例，提升病人用藥之安全，進而提高病人照護品質。

關鍵字：不良事件，病人安全，泌尿道感染，抗生素，不合理處方

關鍵字

不良事件 ； 泌尿道感染 ； 抗生素 ； 病人安全 ； 不合理處方

並列摘要

The aim of this study was to analyze the appropriateness of prescription patterns of antibiotics used in treating outpatients with urinary tract infection.. The results of this study may serve as the references for promoting patient safety and clinical effectiveness.
The study was based on the sampling set of National Health Insurance claimed files of ambulatory care in 2002 from National Health Research Institute. Only female patients older than twelve-year-old who was diagnosed to have acute cystitis or acute pyelonephritis were included, but patients with renal dysfuction were excluded in this study. The appropriateness of prescription patterns were analyzed and compared among various patient、hospital and medical specialty. Multiple logistic regression was applied to explore the impact of these factors on the appropriateness. The judgement of appropriateness was based on two clinical practice guidelines from Infectios Disease Society of America,1999 and Ministry of Health, Singapore,2000. “Appropriate prescription” was defined as ‘ precribing the kinds of drugs and the time duration as proposed in the two guidelines’. “Under-use” was defined as shorter time duration than proposed in the guidelines, and “over-use” was defined as longer time duration than proposed in the guidelines. “Inappropriate prescription” was referred as both under-use and over-use presciptions.
For treatment of acute cystitis, four antibiotics including fluoroquinolone、nitrofurantoins、cephalosporins and trimethoprim–sulfamethoxazoles were analyzed. The results indicated that the most frequently prescribed antibiotics were cephalosporins（46.89%）, and the ratio of inappropriate prescription with cephalosporins was the lowest among the four drugs（22.45%）. The least often used antibiotics were trimethoprim-sulfamethoxazole（3.77%）, and the ratio of inappropriateness was 59.46%. The ratio of inappropriate prescription with nitrofurantoins was the highest among the four antibiotics, being 91.67%. Most of the inappropriateness with nitrofurantoins was under use, being 87.38%.
For treatment of acute pyelonephritis, four antibiotics including fluoroquinolone、cephalosporins 、amoxicillin-clavulanic acids and trimethoprim–sulfamethoxazoles were analyzed. The results revealed that the most frequently prescribed antibiotics were cephalosporins（59.74%）, and the ratio of inappropriate prescription with cephalosporins was 60.15%. Most of the inappropriateness with cephalosporins was under-use, being 58.7%. The least often used antibiotics were trimethoprim-sulfamethoxazole（6.93%）, and the ratio of inappropriateness was 87.5%, the highest among the four drugs.
For acute cystitis, the results of multiple logistic regression depicted that patient’s age、NHI branch locale、hospital ownership and medical specialty had significant impact on the inappropriateness of antibiotic prescription. For acute pyelonephritis, the influential factors are patient’s age、NHI branch locale、hospital accreditation level and medical specialty.
Based on the findings described above, it is suggested that the health authorities should create an effective drug utilization review system supported by evidence-based clinical practice guidelines. Also should the health authority establish, through co-operation with medical and pharmacological experts, our own National Clinical Practice Guidelines in order to promote drug safety and clinical effectiveness and to decrease unnecessary medical expenses .

Keywords: adverse event, patient safety, urinary tract infection, antibiotics, inapproriate prescription

並列關鍵字

adverse event ； patient safety ； urinary tract infec

參考文獻

1. 何曼德等：1998年臺灣地區之抗生素藥性監測。院內感染控制雜誌。2000。

4. 方啓泰、張上淳：抗生素的合理使用。當代醫學，1998。

5. 衛生署疾病管制局新聞稿，2000年4月。

8. 葉梁蘭蘭：醫院特性與抗藥性型態。院內感染控制雜誌，10（1）：31-44。2000。

10. 張上淳等：臺灣地區公立醫院抗生素使用情形之調查研究。微免感誌，1998。