Rello J, Sa-Borges M, Correa H, Leal S R, Baraibar J
Pulmonary and Critical Care Departments, Hospital de Sabadell, Barcelona, Spain.
Am J Respir Crit Care Med. 1999 Aug;160(2):608-13. doi: 10.1164/ajrccm.160.2.9812034.
This retrospective multicenter study compared microorganisms documented by quantitative cultures from bronchoscopic samples in episodes of ventilator-associated pneumonia (VAP) from three different institutions in Barcelona (B), Montevideo (M), and Seville (S). The observations were compared with the findings reported by Trouillet and coworkers (AJRCCM 1998;157:531-539) in Paris (P). The objective was to evaluate whether a classification of etiologies of VAP in four groups, based on the number of ventilation days and previous antimicrobial use, might contribute to establishing generalized guidelines for empirical therapy. Significant variations in etiologies (p < 0.05) were found in all of the microorganisms isolated from VAP episodes across three treatment sites when compared with the reference site (P). In Group 1 (< 7 d and absence of antibiotics), Pseudomonas aeruginosa remained extremely infrequent (3 of 89, 3.3%) in the joint category, whereas the incidence of Acinetobacter baumannii was significantly higher, owing to M findings. On the other hand, one site (B) had a significantly lower incidence of multiresistant pathogens (Methicillin-resistant Staphylococcus aureus [MRSA] and nonfermenters other than P. aeruginosa), even in Group 2 (< 7 d and antibiotics), Group 3 (>/= 7 d and absence of antibiotics), and Group 4 (antibiotics and >/= 7 days). Similar findings were documented when episodes were grouped according to Groups 1 and 3 of the ATS guidelines. We conclude that causes of VAP varied markedly across four treatment sites, resulting in the need for large-scale variations in antimicrobial prescribing practices. Instead of following general recommendations, antimicrobial prescribing practices for VAP should be based on up-to-date information of the pattern of multiresistant isolates from each institution.
这项回顾性多中心研究比较了巴塞罗那（B）、蒙得维的亚（M）和塞维利亚（S）这三个不同机构中，呼吸机相关性肺炎（VAP）发作时支气管镜样本定量培养记录的微生物。将这些观察结果与特鲁耶及其同事（《美国呼吸与危重症医学杂志》1998年；157：531 - 539）在巴黎（P）报告的结果进行比较。目的是评估基于通气天数和先前抗菌药物使用情况将VAP病因分为四组，是否有助于制定经验性治疗的通用指南。与参考地点（P）相比，在三个治疗地点的VAP发作中分离出的所有微生物的病因均存在显著差异（p < 0.05）。在第1组（< 7天且未使用抗生素）中，联合类别中铜绿假单胞菌仍然极为罕见（89例中有3例，3.3%），而鲍曼不动杆菌的发生率显著更高，这是由于M地的结果。另一方面，一个地点（B）的多重耐药病原体（耐甲氧西林金黄色葡萄球菌[MRSA]和除铜绿假单胞菌外的非发酵菌）发生率显著较低，即使在第2组（< 7天且使用抗生素）、第3组（≥ 7天且未使用抗生素）和第4组（使用抗生素且≥ 7天）也是如此。根据美国胸科学会（ATS）指南的第1组和第3组对发作进行分组时，也记录到了类似的结果。我们得出结论，VAP的病因在四个治疗地点有显著差异，导致抗菌药物处方实践需要大规模变化。VAP的抗菌药物处方实践不应遵循一般建议，而应基于每个机构多重耐药菌株模式的最新信息。
