抗菌药物临床应用指导原则(指南)在合理用药中的价值推荐.pptVIP

* Dr.HU Bijie * Antibiotic guidelines and antibiotic use in adult bacterial meningitis in The Netherlands The consensus-based guidelines were developed by a multidisciplinary group of experts in bacterial meningitis. Patients were assigned to one of four categories: age 16–60 years, no risk factors; age 60 years, no risk factors; age 16 years with risk factors; age 16 years, recent neurosurgery. An antibiotic regimen was recommended for patients in each of the categories. The guidelines were disseminated in booklet form and the audit was begun 1 year after they were issued. Overall, only 87 patients (33%) received treatment that was in accordance with the guidelines; the rates of compliance for patients in the four groups ranged from 16% to 49%. Reassuringly, although adoption of the guidelines was poor, 95% of patients were treated with antibiotics to which their pathogens were susceptible. In the case of the 87 patients whose treatment was in accordance with the guidelines, 98% of pathogens were susceptible. van de Beek, D. et al. (2002) Journal of Antimicrobial Chemotherapy 49, 661–6 * Dr.HU Bijie * 抗菌药物应用指南的缺陷 没有指南适用于所有临床情况 指南建议所依据的证据并非均很充分 指南很少考虑合并存在的疾病或其他同时进行的治疗 指南不能考虑病人的意愿 以往的指南编写存在方法学上的不足 执行指南的理想方法尚无一致的观点 编写和执行指南可能花费较大 指南剥夺临床医生的自主权，威胁他们的医疗自由 一些指南质量存在问题，可影响病人的医疗 指南对医疗常规能否有效改变还存在不同研究结果 * Dr.HU Bijie * 指南的接受率为20%～ 90% 指南没有有效的散发 对指南建议缺乏足够的熟悉 对指南的一至多项建议不赞同 缺乏对预期良好结果的信心 不能克服惯性作用 外部障碍：指南、病人或环境等 指南缺乏科学性和有效性 不能代表重要成员的观点 非临床因素：补偿机制，害怕被起诉 指南对某些人群不合适 当地领导不支持 卫生保健系统存在问题 * Dr.HU Bijie * 通过多种渠道散发“指南” publication in journals; newsletters; local reports or documents; junior doctors handbooks; configuration into a brief and portable format that is readily accessible to clinicians; posters on wards and in relevant departments; patient literature; group educational programmes; personal visits. * Dr.HU Bijie * 指南编写的注意事项 专家组成有足够的人员（6–10人），至少有人员会进行系统综述 某一主题如已有循证指南存在，可减少工作量 指南应根据系统综述，文献检索应防范偏倚 指南各项建议所依据的证据应分级 指南不要太长（少于 20–25页） 指南应指出缺少的证据和需进一步研究的领域 指南应该让没有参加编写但系相关领域