Ibrahim E H, Sherman G, Ward S, Fraser V J, Kollef M H
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, Seattle, WA, USA.
Chest. 2000 Jul;118(1):146-55. doi: 10.1378/chest.118.1.146.
To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission.
Prospective cohort study.
A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital.
Between July 1997 and July 1999, 492 patients were prospectively evaluated.
Prospective patient surveillance and data collection.
One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment.
The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.
评估入住重症监护病房（ICU）的患者中，血流感染抗菌治疗的充分性与临床结局之间的关系。
前瞻性队列研究。
一所大学附属城市教学医院的内科ICU（19张床位）和外科ICU（18张床位）。
1997年7月至1999年7月期间，对492例患者进行了前瞻性评估。
对患者进行前瞻性监测和数据收集。
147例患者（29.9%）的血流感染抗菌治疗不充分。血流感染抗菌治疗不充分的患者的医院死亡率（61.9%）在统计学上高于血流感染抗菌治疗充分的患者的医院死亡率（28.4%；相对危险度，2.18；95%置信区间[CI]，1.77至2.69；p<0.001）。多因素逻辑回归分析确定抗菌治疗不充分是医院死亡率的独立决定因素（调整优势比[AOR]，6.86；95%CI，5.09至9.24；p<0.001）。最常见的血流病原体及其抗菌治疗不充分的相关发生率包括耐万古霉素肠球菌（n = 17；100%）、念珠菌属（n = 41；95.1%）、耐苯唑西林金黄色葡萄球菌（n = 46；32.6%）、凝固酶阴性葡萄球菌（n = 96；21.9%）和铜绿假单胞菌（n = 22；10.0%）。发现个体微生物抗菌治疗不充分的发生率与其相关的医院死亡率之间存在统计学显著关系（斯皮尔曼相关系数 = 0.8287；p = 0.006）。多因素逻辑回归分析还表明，由念珠菌属引起的血流感染（AOR，51.86；95%CI，24.57至109.49；p<0.001）；同一住院期间先前使用过抗生素（AOR，2.08；95%CI，1.58至2.74；p = 0.008）；血清白蛋白浓度降低（每降低1g/dL）（AOR，1.37；95%CI，1.21至1.56；p = 0.014）；以及中心静脉导管留置时间延长（每延长1天）（AOR，1.03；95%CI，1.02至1.04；p = 0.008）与抗菌治疗不充分独立相关。
与对血流感染进行充分的抗菌治疗相比，对患有血流感染的重症患者进行不充分的抗菌治疗与更高的医院死亡率相关。这些数据表明，临床工作应致力于减少对住院血流感染患者，尤其是感染耐药菌和念珠菌属的患者进行不充分的抗菌治疗。
