Senaryoya Dayalı Bir Sanal Hasta Programının Hekimlerin Diyabetik Ayak Enfeksiyonu ve Komplike İntraabdominal Enfeksiyon için Mevcut Kılavuzlara Uyumlarını Artırmaya Yönelik Kullanımı

Diyabetik ayak enfeksiyonu (DAE) ve komplike intraabdominal enfeksiyon (KIE) hedefli sanal bir hasta programına katılım sağlayan hekimlerin tanı ve tedavi pratiklerinin değerlendirilmesi amaçlanmıştır. Bu çalışma DAE (n=210) ve KIE (n=42) hedefli sanal bir hasta programına katılım sağlayan 252 hekim ile gönüllülük esasına göre yürütüldü. Hekimlerin bilgisayar grafik teknolojileri temelinde geliştirilen program dahilinde yaptıkları aşamalı hasta değerlendirilmesi verileri (hasta özellikleri, hastalık özellikleri, fizik muayene, laboratuvar ve radyolojik bulgular) kaydedildi. KIE Olgu Senaryosunda, tanı; hekimlerin %75,0’i tarafından doğrulanırken, cerrahi girişim ve seftriakson + metronidazol (37,6%) veya ertapenem (34,1%) en sık yapılan tedavi seçimi idi. DAE Olgu Senaryosunda tanı, hekimlerin %98,0’i tarafından doğrulanırken, hekimlerin %71,0’i en sık ertapenem (%55,0) olmak üzere antibiyotik tedavisi başlanmasını uygun buldu. Sonuç olarak, bulgularımız “senaryoya dayalı” sanal hasta programlarının sağladığı hızlı ve güncel geri bildirim ve öğrenim çıktılarının bireysel takibi yoluyla hekimlerin KIE ve DAE klinik karar alma becerilerinin gelişimine katkıda bulunabileceğini göstermektedir. Dolayısıyla, bulgularımız hekimlerin KIE için tedavi uygulamalarının özellikle ampirik antibiyotik seçimi konusunda, DAE tanı ve tedavi uygulamalarının ise enfeksiyon riskinin daha dikkatli değerlendirilerek daha uygun ampirik antibiyotik tedavi seçimi yapılması açısından iyileştirilmesi gerektiğine işaret etmektedir.

Anahtar Kelimeler:

Komplike intraabdominal enfeksiyon, diyabetik ayak enfeksiyonu, tanı, tedavi uygulamaları, senaryoya dayalı sanal hasta programı

A Scenario-Based Virtual Patient Program To İmprove Adherence To Guidelines for Diabetic Foot İnfection and Complicated İntra-Abdominal İnfection among Physicians

In the study it was aimed to evaluate diagnostic and practice patterns of physicians who participated for scenario-based virtual patient programs on complicated intra-abdominal infection (IAI) and diabetic foot infection (DFI). This study was conducted with 252 physicians who participated on a voluntary basis in two scenario-based virtual patient programs relating to complicated IAI (n=210) and DFI (n=42) which provide data on stepwise evaluation of patient (patient characteristics, disease characteristics, physical examination, laboratory and radiological findings) as requested by the physician and were developed using computer graphics technology. For IAI Case Scenario, the diagnosis was confirmed by 75.0% of physicians, while surgical intervention with ceftriaxone + metronidazole (37.6%) or with ertapenem (34.1%) was the most commonly selected treatment modalities. For DFI Case Scenario, the diagnosis was confirmed by 98.0% of physicians, and 71.0% of physicians considered initiation of antibiotic treatment and mostly with ertapenem (55.0%). In conclusion, our findings revealed that use of “scenario-based” virtual patient programs provided rapid and up-to-date feedback and self-monitoring of learning outcomes to improve clinical reasoning skills of physicians on IAI and DFI. Accordingly, our findings indicate practice pattern of physicians for complicated IAI should be improved in terms of more appropriate selection of empirical antibiotherapy, while diagnostic and practice patterns for DFI should also be improved in terms of more careful assessment of risk factors for infection and appropriate selection of empirical antibiotherapy.

Keywords:

Intraabdominal enfeksiyon, diyabetik ayak enfeksiyonu, tanı, tedavi uygulamaları, senaryoya dayalı sanal hasta programı,

PDF

___

Menichetti F, Sganga G. Definition and classification of intra-abdominal infections. J Chemother. 2009;21(Suppl 1):3-4.
Armstrong C. Updated guideline on diagnosis and treatment of intra-abdominal infections. Am Fam Phys. 2010;82:694-709.
Brun-Buisson C, Doyon F, Carlet J, et al. Incidence, risk factors, and outcome of severe sepsis and septic shock in adults: a multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA. 1995;274:968-974.
Sartelli M, Catena F, Ansaloni L, et al. Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study. World J Emerg Surg. 2014;9:37.
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133-164.
Nordmann P, Poirel L, Walsh TR, Livermore DM. The emerging NDM carbapenemases. Trends Microbiol. 2011;19:588-595.
Perez F, Van Duin D. Carbapenem-resistant Enterobacteriaceae: a menace to our most vulnerable patients. Cleve Clin J Med. 2013;80:225-233.
Mazuski JE, Gasink LB, Armstrong J, et al. Efficacy and Safety of Ceftazidime-Avibactam Plus Metronidazole Versus Meropenem in the Treatment of Complicated Intra-abdominal Infection: Results From a Randomized, Controlled, Double-Blind, Phase 3 Program. Clin Infect Dis. 2016;62:1380-1389.
Uçkay I, Aragón-Sánchez J, Lew D, Lipsky BA. Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis. 2015;40:81-91.
Lipsky BA, Berendt AR, Cornia PB, et al.; Infectious Diseases Society of America. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54:132-173.
Amin N, Doupis J. Diabetic foot disease: From the evaluation of the "foot at risk" to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016;7:153-164.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998; 352: 837-853.
Zingg M, Nicodeme JD, Uckay I, Ray A, Suva D. Lower limb amputation: indication, preoperative workup and complications. Rev Med Suisse. 2014;17:2409-2413.
McKimm J, Jollie C, Cantillon P. ABC of learning and teaching: Web based learning. BMJ. 2003;326:870-873.
Maxwell S, Mucklow J. E-Learning initiatives to support prescribing. Br J Clin Pharmacol. 2012; 74: 621-631.
Zlotos L, Power A, Hill D, Chapman P. A Scenario-Based Virtual Patient Program to Support Substance Misuse Education. Am J Pharm Educ. 2016;80:48.
Cook DA, Erwin PJ, Triola MM. Computerized virtual patients in health professions education: a systematic review and meta-analysis. Acad Med. 2010;85:1589-1602.
Makransky G, Bonde MT, Wulff JS, et al. Simulation based virtual learning environment in medical genetics counseling: an example of bridging the gap between theory and practice in medical education. BMC Med Educ. 2016;16:98.
Benedict N. Virtual patients and problem-based learning in advanced therapeutics. Am J Pharm Educ. 2010;74:143.
Hawser SP, Bouchillon SK, Hoban DJ, Badal RE, Cantón R, Baquero F. Incidence and antimicrobial susceptibility of Escherichia coli and Klebsiella pneumoniae with extended-spectrum beta-lactamases in community- and hospital-associated intra-abdominal infections in Europe: results of the 2008 Study for Monitoring Antimicrobial Resistance Trends (SMART). Antimicrob Agents Chemother. 2010;54:3043-3046.
Paterson DL, Rossi F, Baquero F, et al. In vitro susceptibilities of aerobic and facultative Gram-negative bacilli isolated from patients with intraabdominal infections worldwide: the 2003 Study for Monitoring Antimicrobial Resistance Trends (SMART). J Antimicrob Chemother. 2005;55:965-973.
Yellin AE, Heseltine PN, Berne TV, et al. The role of Pseudomonas species in patients treated with ampicillin and sulbactam for gangrenous and perforated appendicitis. Surg Gynecol Obstet. 1985;161:303-307.
Bradley JS, Behrendt CE, Arrieta AC, et al. Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis. Pediatr Infect Dis J. 2001;20:19-24.
Lin WJ, Lo WT, Chu CC, Chu ML, Wang CC. Bacteriology and antibiotic susceptibility of community-acquired intra-abdominal infection in children. J Microbiol Immunol Infect. 2006;39:249-254.
Mosdell DM, Morris DM, Voltura A, et al. Antibiotic treatment for surgical peritonitis. Ann Surg. 1991;214:543-549.
Montravers P, Gauzit R, Muller C, Marmuse JP, Fichelle A, Desmonts JM. Emergence of antibiotic-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy. Clin Infect Dis. 1996;23:486-494.
Schaper NC, Apelqvist J, Bakker K. The international consensus and practical guidelines on the management and prevention of the diabetic foot. Curr Diab Rep. 2003; 3: 475-479.
Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Fam Physician. 2002;66:1655-1662.
Lipsky BA, Berendt AR, Deery HG, et al; Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39:885-910.
Uzun G, Solmazgul E, Curuksulu H, et al. Procalcitonin as a diagnostic aid in diabetic foot infections. Tohoku J Exp Med. 2007;213:305-312.
Jeandrot A, Richard JL, Combescure C, et al. Serum procalcitonin and C-reactive protein concentrations to distinguish mildly infected from non-infected diabetic foot ulcers: a pilot study. Diabetologia. 2008;51:347-352.
Armstrong DG, Lavery LA, Sariaya M, Ashry H. Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. J Foot Ankle Surg. 1996;35:280-283.
Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J Diabetes Complications. 1999;13:254-263.
Frykberg RG. An evidence-based approach to diabetic foot infections. Am J Surg. 2003;186:44-54.
Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51:747-755.
Rajbhandari SM, Sutton M, Davies C, Tesfaye S, Ward JD. ‘Sausage toe’: a reliable sign of underlying osteomyelitis. Diabet Med. 2000;17:74-77.
Newman LG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA. 1991;266:1246-1251.
Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. Arch Intern Med. 2007;167:125-132.
Rao N, Lipsky BA. Optimising antimicrobial therapy in diabetic foot infections. Drugs. 2007;67:195-214.
Lipsky BA, Aragón-Sánchez J, Diggle M, et al; International Working Group on the Diabetic Foot. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1):45-74.