Menéndez R, Torres A, Zalacaín R, Aspa J, Martín Villasclaras J J, Borderías L, Benítez Moya J M, Ruiz-Manzano J, Rodríguez de Castro F, Blanquer J, Pérez D, Puzo C, Sánchez Gascón F, Gallardo J, Alvarez C, Molinos L
Servicio de Neumología, Hospital Universitario La Fe, Valencia, Spain.
Thorax. 2004 Nov;59(11):960-5. doi: 10.1136/thx.2003.017756.
An inadequate response to initial empirical treatment of community acquired pneumonia (CAP) represents a challenge for clinicians and requires early identification and intervention. A study was undertaken to quantify the incidence of failure of empirical treatment in CAP, to identify risk factors for treatment failure, and to determine the implications of treatment failure on the outcome.
A prospective multicentre cohort study was performed in 1424 hospitalised patients from 15 hospitals. Early treatment failure (<72 hours), late treatment failure, and in-hospital mortality were recorded.
Treatment failure occurred in 215 patients (15.1%): 134 early failure (62.3%) and 81 late failure (37.7%). The causes were infectious in 86 patients (40%), non-infectious in 34 (15.8%), and undetermined in 95. The independent risk factors associated with treatment failure in a stepwise logistic regression analysis were liver disease, pneumonia risk class, leucopenia, multilobar CAP, pleural effusion, and radiological signs of cavitation. Independent factors associated with a lower risk of treatment failure were influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease (COPD). Mortality was significantly higher in patients with treatment failure (25% v 2%). Failure of empirical treatment increased the mortality of CAP 11-fold after adjustment for risk class.
Although these findings need to be confirmed by randomised studies, they suggest possible interventions to decrease mortality due to CAP.
对社区获得性肺炎（CAP）初始经验性治疗反应不足给临床医生带来了挑战，需要早期识别和干预。开展了一项研究，以量化CAP经验性治疗失败的发生率，确定治疗失败的危险因素，并确定治疗失败对结局的影响。
对来自15家医院的1424例住院患者进行了一项前瞻性多中心队列研究。记录早期治疗失败（<72小时）、晚期治疗失败和住院死亡率。
215例患者（15.1%）出现治疗失败：134例早期失败（62.3%）和81例晚期失败（37.7%）。病因是感染性的86例（40%），非感染性的34例（15.8%），未确定的95例。在逐步逻辑回归分析中，与治疗失败相关的独立危险因素为肝病、肺炎风险分级、白细胞减少、多叶CAP、胸腔积液和空洞形成的影像学表现。与治疗失败风险较低相关的独立因素为流感疫苗接种、初始使用氟喹诺酮类药物治疗和慢性阻塞性肺疾病（COPD）。治疗失败患者的死亡率显著更高（25%对2%）。在对风险分级进行调整后，经验性治疗失败使CAP的死亡率增加了11倍。
尽管这些发现需要通过随机研究来证实，但它们提示了可能降低CAP所致死亡率的干预措施。
