抗菌药物管理工作制度

抗菌药物管理工作制度

XXXX大学XXXX医院抗菌药物管理工作制度为了促进抗菌药物的合理使用，有效控制细菌耐药，保证医疗质量和医疗安全，本医院按照卫生部的相关规定，制定了抗菌药物管理工作制度。（一）明确抗菌药物临床应用管理责任制。临床科室负责人是科室抗菌药物临床应用管理的第一责任人。科室应将抗菌药物临床应用管理作为医疗质量和科室管理的重要工作之一，并建立、健全抗菌药物临床应用管理工作制度和监督管理机制。同时，明确抗菌药物合理应用的控制指标，医院与临床科室负责人签订抗菌药物合理应用责任状，将抗菌药物合理应用情况作为科室和医务人员绩效考核的重要依据，并作为科室主任综合目标考核以及医务人员晋升、评先评优的重要指标。（二）发挥职能科室管理作用，建立抗菌药物合理使用长效管理机制。在医务科的总体协调下，医院感染管理科负责落实抗菌药物分级专业资料管理制度、抗菌药物临床应用和细菌耐药动态管理控制以及住院患者微生物送检情况的督导检查。药剂科负责抗菌药物采购供应管理、抗菌药物处方、医嘱专项点评以及围手术期预防用药监控等专项工作。医疗质量管理科负责抽查检审抗菌药物使用病历记录分析，并将抗菌药物专项检查结果纳入医疗质量公示考评。信息科负责完善抗菌药物分线管理相关审核程序，协助抗菌药物相关数据的统计分析。机关和各职能科室通过加强管理、加强监督，对全院医务人员抗菌药物临床应用行为进行检查和干预，以控制抗菌药物的不合理使用。（三）定期开展抗菌药物临床应用基本情况调查。抗菌药物管理工作组定期对院、科两级抗菌药物临床应用情况开展调查，包括抗菌药物品种、剂型、规格、使用量、使用金额、使用量和使用金额排名前10位的抗菌药物品种、住院患者抗菌药物使用率、使用强度、I类切口手术和介入诊疗抗菌药物预防使用率、特殊使用级抗菌药物使用率、使用强度、门诊抗菌药物处方比例、急诊抗菌药物处方比例等。（四）建立完善抗菌药物临床应用技术支撑体系。本医院将建立完善抗菌药物临床应用技术支撑体系，为医务人员提供必要的技术支持和培训，以提高抗菌药物的合理使用率和细菌耐药控制水平。Clinicaldoctorsshouldchooseantibioticsrationallybasedontheresultsofclinicallaboratorytesting.Furthermore,therateofsendingmicrobiologicalsamplesfortreatmentwithrestrictedantibioticsshouldbenolessthan50%,andforspecialantibiotics,itshouldbenolessthan80%.Thelaboratorydepartmentshouldactivelycarryoutbacterialresistancemonitoring,regularlyreleaseinformationonbacterialresistance,establishabacterialresistancewarningmechanism,andtakecorrespondingmeasuresbasedondifferentlevelsofbacterialresistance.Thehospitalshouldregularlypublishclinicalapplicationofantibioticsandbacterialresistancemonitoring,andsuperviseandguideclinicaldepartmentstouseantibioticsrationally.Theusagerateandintensityofantibioticsshouldbecontrolledwithinareasonablerange.Theusagerateofantibioticsforinpatientsshouldnotexceed60%,foroutpatientsshouldnotexceed20%,andforemergencypatientsshouldnotexceed40%.Theintensityofantibioticusageshouldbecontrolledtonomorethan40DDDsperhundredperson-days.Forinpatientswhorequireantibioticprophylaxisforsurgery,thetimeofantibioticadministrationshouldbecontrolledbetween30minutesto2hoursbeforesurgery,andtheselectionanddurationofantibioticuseshouldbereasonable.TheproportionofpatientswhorequireantibioticprophylaxisforI-classsurgicalincisionsshouldnotexceed30%,andforpatientsundergoingfemoralherniarepair(includingpatchrepair),thyroidsurgery,breastdiseasesurgery,arthroscopy,carotidarterymembranepeelingsurgery,skulltumorresectionsurgery,andvascularinterventiondiagnosticsurgery,antibioticsareusuallynotrequiredforprophylaxis(exceptforthosewithindications).ThetimeforantibioticprophylaxisforI-classsurgicalincisionsshouldnotexceed24hours.Thehospitalshouldprovidetrainingandstandardizedmanagementforphysiciansandpharmacistsonclinicalapplicationofantibiotics.Afterpassingthetrainingandexamination,physicianscanbegrantedcorrespondinglevelsofantibioticprescriptionrights,andpharmacistscanbegrantedthequalificationtoadjustantibioticuse.Thehospitalshouldimplementasystemforevaluatingantibioticprescriptions.Relevantprofessionalandtechnicalpersonnelintheinfectionandpharmacydepartmentsshouldconductspecialevaluationsofantibioticprescriptionsandmedicalorders.Usinginformationtechnology,thehospitalshouldconductmonthlyevaluationsof25%ofphysicianswhohaveantibioticprescriptionrights,witheachphysicianbeingevaluatedonnolessthan50prescriptionsandmedicalorders.Clinicaldepartmentssuchasrespiratorymedicineandintensivecareunits,aswellasI-classsurgicalincisionsandinterventionaldiagnosisandtreatmentcases,shouldbethefocusofinspections.Basedontheresultsofevaluations,thehospitalshouldnotifytheentirehospitalofphysicianswhouseantibioticsrationallyorirrationally.Theevaluationresultsshouldbeanimportantbasisfordepartmentalandmedicalstaffperformanceassessments.Physicianswhouseantibioticsexcessivelywithoutjustifiablereasonsmorethanthreetimesshouldbewarnedandhavetheirrightstoprescribespecialandrestrictedantibioticslimited.Iftheycontinuetouseantibioticsexcessivelywithoutjustifiablereasonsaftertheirrightshavebeenlimited,theirantibioticprescriptionrightsshouldbecancelled.Ifpharma