背景
抗微生物藥物是最常被處方予小兒族群的藥物，即使如此，關於微生物抗藥性的研究和用藥評估卻常常未納入小兒族群。過去研究已告訴我們抗微生物藥物的使用和抗藥性有關，但目前小兒族群的感染症致病菌相關的研究，仍僅限於特定的疾病族群或特殊的病房單位，例如血液腫瘤科或加護病房等。小兒族群的感染部位、感染來源和致病菌和成人族群不同，因此建立一套小兒族群的抗藥性監測系統是必要的。近年歐盟兒童抗生素抗藥性及處方計畫(Worldwide Antibiotic Resistance and Prescribing in European Children, ARPEC) 開始關注小兒族群的抗藥性問題，此計畫納入世界各地的醫院並分析抗藥性及處方型態，接著ARPEC計畫衍生至全球層級的GARPEC計畫。台灣尚未建立適用於小兒族群的監測作業流程。

目的
藉由參與GARPEC計畫，本研究目的有二：(1) 分析成大醫院小兒族群抗藥性菌血症的發生率及抗藥性情形；(2) 藉由點盛行率調查 (PPS) 評估成大醫院小兒族群抗微生物藥物處方型態。並且本研究為國內多中心研究的前驅研究。

方法
本研究以前瞻性病歷回顧的試驗設計進行，目的一的收案條件是2016年8月至2017年5月期間，血液培養出指定菌種、18歲以下的住院病患，並且依年齡分組分析病患的基本特性和抗藥性數據。目的二中每月一次PPS的調查期間為2016年1至12月，每個月隨機選出一天為調查日，納入調查日當天有使用抗微生物藥物或前一天有使用手術預防性抗生素的病人，依年齡或病房計算抗微生物藥物處方率，記錄抗微生物藥物處方的相關資訊，包含藥物、劑量、頻次、給藥途徑、適應症等，並且將這些處方依治療原因、感染部位、經驗性治療或確定治療 (definite/targeted therapy) 分類。研究中所有藥物依ATC level 3或4分類。以描述性統計呈現數據，包含次數、百分比、平均和中位數。本研究參與GARPEC計畫，符合該計畫期間的研究數據，去除個資後回報至GARPEC計畫。

結果
研究期間共有45位病人符合研究條件，包含49筆菌株報告，其中 31株 (63.3%) 對至少一種抗生素具有抗藥性。49株菌株中最常出現的是 Salmonella spp. (n=13)，且有85%係從1歲以上菌血症兒童血液培養而得。抗藥性菌株中最常見的是E. coli (n=9)，對ampicillin/sulbactam和cefazolin的敏感性分別僅有11%和22%。本研究發現7月齡以上的族群，造成菌血症的菌種已和成人族群相似。12次PPS納入的病房有1間小兒加護病房、1間新生兒加護病房和1間兒科普通病房，納入的573人次中有371 (65%) 人次使用至少一種抗微生物藥物，總計有645筆抗微生物處方，其中79.1%為治療性處方，20.9%為預防性處方。預防性處方中最常見的藥物類別是sulfonamides/trimethoprim (43%) 及antimycotics for systemic use (30%)；而combinations of penicillins including beta-lactamase inhibitor則是治療性處方中最常被開立的藥物類別，最常見的治療適應症是下呼吸道感染 (22%)。

結論
本前驅研究發現小兒族群菌血症較過去的小兒族群及整體族群有較高的抗藥性，尤其是E. coli多對臨床上常用的抗生素具抗藥性。小兒族群抗微生物處方率較過去研究的整體族群高，暗示小兒族群較成人更容易被處方抗微生物藥物，因此未來應建立多中心的小兒族群抗微生物抗藥性及藥物使用的監測計畫。

The antimicrobials are most common prescribed in children, but due to the lack of research in pediatric population, we know little about the resistance pattern and utilization of antimicrobials in this population. The existed literature about infections and pathogens in pediatric population often focus on specific situations or patients with specific diseases, such as oncological or community-acquired diseases. This study was aimed to estimate pediatric antimicrobial resistance, bloodstream infection rates and pathogens, and to describe the antimicrobial prescribing pattern by monthly point prevalence survey (PPS). We documented the positive blood cultures during August 2016 to May 2017 and the inclusion criteria were isolates reported studied pathogens, hospitalized patients aged less than 18 years old. Monthly PPS were conducted in 2016, selecting the survey days by simple random sampling. The participating wards were neonatal ICU (NICU), pediatric ICU (PICU) and general pediatric medical ward (GPMW). There were 49 isolates from 45 pediatric patients enrolled. Thirty-one (63%) of these 49 isolates were resistant pathogens. The resistance of E. coli to first-line empirical medications, like ampicillin/sulbactam and gentamicin, was serious than early study and general population. In the study of prescribing pattern, there were 573 person-times met the enrolled criteria, and 371 (65%) of them had been prescribed at least one antimicrobial. A total of 645 antimicrobial prescriptions were documented, in which the combinations of penicillins including beta-lactamase inhibitor were the most prescribed medications. Of all prescriptions, 79.1% were for therapeutic and 20.9% were for prophylactic use. The most common therapeutic indication was lower respiratory tract infections. In this pilot study, we establish a model that can be applied to multicenter studies in the future. Moreover, this study emphasized the need of antimicrobial resistance and utilization monitoring system for pediatric population.

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