我们所有人都可能同意，成功的抗微生物管理计划（AMS）应旨在改善患者治疗结果，改善患者的安全性并减少抗菌耐药性（AMR）对患者和更广泛的社会的影响。然而，如何实施成功的，有弹性的AMS程序知之甚少。
已显示限制抗菌药物访问权限的计划限制了不适当的抗菌用法并改善了短期的患者预后，但是这种干预对与AMS团队和前线临床医生的合作发展产生的影响尚不清楚。有时可能会发生分裂关系，并导致长期参与度丧失。
Recent sepsis campaigns, new NICE Sepsis guidance in the UK, and litigious consequences of missed infected diagnosis, have understandably introduced a cautious approach to empirical antimicrobial prescribing. Diagnostic insufficiency, heterogeneous presentation of many infections and increased awareness of multi-drug resistant organisms make empiric prescribing a leap of faith for many clinicians.
当目标不造成伤害时，将患者面前的患者的需求与开处方超小行谱抗菌剂的社会影响保持平衡是具有挑战性的。因此，AMS计划需要强大的监视系统，以更好地识别经验抗菌剂不适当的患者，并根据当前或最近的微生物学结果迅速改变为有针对性的治疗。
Challenges of antimicrobial stewardship programs
With one in three patients expected to be receiving systemic antimicrobials at any one time within a hospital, the scale of a hospital-based AMS program becomes problematic. AMS teams in the main do not have the resource to review all patients to ensure appropriateness of prescribing.
审计和反馈通常在3 - 12个月的周期上，可能会改善离散过程指标，但此反馈循环对于真实的行为改变仍然太长了。取而代之的是，实时反馈可能会在纠正措施同时改善处方习惯，从而最大程度地减少不适当治疗对患者的影响。
As healthcare evolves and adapts to technological advances, AMS programs must also change. The availability of Electronic Prescribing and Medicines Administration (EPMA) systems should provide this stimulus for change; now with access to real-time prescribing information and patient specific measures (including inflammatory markers, recent microbiology & susceptibility results, and physiological observations) to make informed decisions on antimicrobial prescribing decisions. Using computerized decision support systems (CDSS), an AMS team can quickly identify patients for targeted review.
Testing computerized decision support systems
我们最近将这种CDSS（ICNET®药房）引入了实践中，以检验该假设。使用自动警报，目标患者被“推动”到AMS团队进行及时审查。例如，使用实时饲料，患有ESBL的患者e.coliinfection started by the clinical team on an empiric cephalosporin in line with local guidelines can be promptly identified and prescription amended within minutes by the AMS team.
Any off-guideline prescribing can be quickly identified and the AMS team can then discuss concerns with the parent team; rarely is off-guideline prescribing done in disregard or contempt for guidelines but usually in response genuine concern for patients.
The CDSS we trialed is web-based, requires minimal technological input and ‘pushes’ patients to the team for review.
Here, the AMS team can work with the parent team, advise the most appropriate treatment, and reassure the prescriber. This collaborative working enables the parent team to build their AMS knowledge and confidence, empowers them to take more responsibility for their patients’ AMR risks, and changes AMS behaviors within the organization.
The CDSS we trialed is web-based, requires minimal technological input and ‘pushes’ patients to the team for review. Time taken to identify patients in need of review is minimal, enabling the AMS team to evolve from office-based activity to a ward-based service. End-of-bed consults with the patient and clinical team are now the norm. Expansion of the service to the whole hospital including the less-traditionally AMS serviced areas of maternity and pediatric wards has been possible with no additional changes in staffing resource through efficiencies made using the CDSS.
除了在我们给出的客观数据evaluation published in ARIC, we feel the CDSS empowered our AMS team to progress from ‘policing’ to ‘enabling’ our clinical teams in their antimicrobial prescribing. Interventions recorded for correcting inappropriate prescribing dropped significantly indicative of behavioral change.
Instead the AMS team are making interventions to optimize dosing, escalate therapy in early treatment failure, and facilitating early discharges. These patient-orientated interventions are aligned closely with trust priorities thus further supporting the AMS team activities.
eHealth和MHealth（移动健康）的景观正在迅速发展，内部和商业CDS均为AMS和其他医疗保健领域开发。尽管我们对这些系统寄予厚望，从而改善了患者的结果并影响AMR趋势，但我们坚定地提倡在广泛采用之前对此类系统进行多模式评估。我们的论文抗菌素抵抗和感染控制帮助详细介绍该景观的一部分，我们期待进一步评估CDSS工具在临床实践中的发展和集成。
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