Gruson D, Hilbert G, Vargas F, Valentino R, Bebear C, Allery A, Bebear C, Gbikpi-Benissan G, Cardinaud J P
Pulmonary and Critical Care Division and Department of Bacteriology, University Hospital of Bordeaux, Bordeaux, France.
Am J Respir Crit Care Med. 2000 Sep;162(3 Pt 1):837-43. doi: 10.1164/ajrccm.162.3.9905050.
To test the hypothesis that a new program of antibiotic strategy control can minimize the incidence of ventilator-associated pneumonia (VAP) caused by potentially antibiotic-resistant microorganisms, we performed a prospective before-after study in 3, 455 patients admitted to a single intensive care unit over a 4-yr period. Regarding the bacterial ecology and the increasing antimicrobial resistance in our medical intensive care unit (MICU), we decided to vary our choice of empiric and therapeutic antibiotic treatment, with a supervised rotation, and a restricted use of ceftazidime and ciprofloxacin, which were widely prescribed before this scheduled change. For all patients, VAP was diagnosed based on the results of quantitative culture of bronchoalveolar lavage specimens (>/= 10(4) cfu/ml). We studied 1,044 and 1,022 patients requiring more than 48 h of mechanical ventilation (MV), respectively, in the before-period (2 yr: 1995-1996) and the after-period (2 yr: 1997-1998). We observed a decrease from 231 consecutive episodes of VAP in the before-period to 161 episodes of VAP in the after-period (p < 0.01), particularly for VAP occurring before 7 d of MV. The total number of potentially antibiotic-resistant gram-negative bacilli responsible for VAP such as Pseudomonas aeruginosa, Burkholderia cepacia, Steno-trophomonas maltophilia, and Acinetobacter baumanii decreased from 140 to 79 isolated bacilli. The susceptibilities of these bacteria to the antibiotics regimen increased significantly, especially for P. aeruginosa and B. cepacia. The percentage of methicillin-sensitive Staphylococcus aureus increased significantly from 40% to 60% of S. aureus responsible for VAP. These results suggest that a new strategy of antibiotics use could be an efficient means to reduce the incidence of VAP caused by antibiotic-resistant bacteria. Nevertheless, further studies are needed to validate these data.
为验证一项新的抗生素策略控制方案能够使由潜在耐药微生物引起的呼吸机相关性肺炎（VAP）发病率降至最低这一假设，我们在4年期间对入住单一重症监护病房的3455例患者进行了一项前瞻性前后对照研究。鉴于我们医学重症监护病房（MICU）中的细菌生态学及日益增加的抗菌药物耐药性，我们决定改变经验性和治疗性抗生素治疗的选择，采用有监督的轮换用药，并限制使用头孢他啶和环丙沙星，这两种药物在此次计划变更前被广泛使用。对于所有患者，根据支气管肺泡灌洗标本定量培养结果（≥10⁴ cfu/ml）诊断VAP。我们分别研究了前期（2年：1995 - 1996年）和后期（2年：1997 - 1998年）中需要机械通气（MV）超过48小时的1044例和1022例患者。我们观察到VAP的连续发作次数从前期的231次降至后期的161次（p < 0.01），尤其是MV 7天前发生的VAP。导致VAP的潜在耐药革兰氏阴性杆菌总数，如铜绿假单胞菌、洋葱伯克霍尔德菌、嗜麦芽窄食单胞菌和鲍曼不动杆菌，从140株分离菌降至79株。这些细菌对抗生素治疗方案的敏感性显著增加，尤其是铜绿假单胞菌和洋葱伯克霍尔德菌。对VAP负责的金黄色葡萄球菌中，甲氧西林敏感金黄色葡萄球菌的比例从40%显著增加到60%。这些结果表明，一种新的抗生素使用策略可能是降低耐药菌引起的VAP发病率的有效手段。然而，需要进一步研究来验证这些数据。
