抗菌藥物管理工作制度

XXXX大學XXXX醫院抗菌藥物管理工作制度為了促進抗菌藥物的合理使用，有效控制細菌耐藥，保證醫療質量和醫療安全，本醫院按照衛生部的相關規定，制定了抗菌藥物管理工作制度。（一）明確抗菌藥物臨床應用管理責任制。臨床科室負責人是科室抗菌藥物臨床應用管理的第一責任人?？剖覒獙⒖咕幬锱R床應用管理作為醫療質量和科室管理的重要工作之一，并建立、健全抗菌藥物臨床應用管理工作制度和監督管理機制。同時，明確抗菌藥物合理應用的控制指標，醫院與臨床科室負責人簽訂抗菌藥物合理應用責任狀，將抗菌藥物合理應用情況作為科室和醫務人員績效考核的重要依據，并作為科室主任綜合目標考核以及醫務人員晉升、評先評優的重要指標。（二）發揮職能科室管理作用，建立抗菌藥物合理使用長效管理機制。在醫務科的總體協調下，醫院感染管理科負責落實抗菌藥物分級專業資料管理制度、抗菌藥物臨床應用和細菌耐藥動態管理控制以及住院患者微生物送檢情況的督導檢查。藥劑科負責抗菌藥物采購供應管理、抗菌藥物處方、醫囑專項點評以及圍手術期預防用藥監控等專項工作。醫療質量管理科負責抽查檢審抗菌藥物使用病歷記錄分析，并將抗菌藥物專項檢查結果納入醫療質量公示考評。信息科負責完善抗菌藥物分線管理相關審核程序，協助抗菌藥物相關數據的統計分析。機關和各職能科室通過加強管理、加強監督，對全院醫務人員抗菌藥物臨床應用行為進行檢查和干預，以控制抗菌藥物的不合理使用。（三）定期開展抗菌藥物臨床應用基本情況調查?？咕幬锕芾砉ぷ鹘M定期對院、科兩級抗菌藥物臨床應用情況開展調查，包括抗菌藥物品種、劑型、規格、使用量、使用金額、使用量和使用金額排名前10位的抗菌藥物品種、住院患者抗菌藥物使用率、使用強度、I類切口手術和介入診療抗菌藥物預防使用率、特殊使用級抗菌藥物使用率、使用強度、門診抗菌藥物處方比例、急診抗菌藥物處方比例等。（四）建立完善抗菌藥物臨床應用技術支撐體系。本醫院將建立完善抗菌藥物臨床應用技術支撐體系，為醫務人員提供必要的技術支持和培訓，以提高抗菌藥物的合理使用率和細菌耐藥控制水平。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