Leroy O, d'Escrivan T, Devos P, Dubreuil L, Kipnis E, Georges H
Dept. of Intensive Care and Infectious Diseases, University of Lille, Chatiliez Hospital, 135 rue du Président Coty, 59208 Tourcoing, France.
Infection. 2005 Jun;33(3):129-35. doi: 10.1007/s15010-005-4021-8.
Inadequate initial antimicrobial therapy represents one of the factors associated with mortality of patients suffering from hospital-acquired pneumonia. According to its wide antimicrobial spectrum, imipenem belongs to the usual antibiotics proposed by current guidelines for such a therapy. However, major changes in the antibiotic susceptibility patterns of bacteria in the intensive care unit (ICU) have occurred. Our goal was to determine the incidence of hospital-acquired pneumonia (HAP) due to imipenem-resistant organism(s) in our ICU and to identify factors associated with such a resistance.
From January 1994 to December 2001, all consecutive patients admitted to our ICU for HAP or exhibiting HAP during their ICU stay were included in an observational cohort. Patients with a bacteriologically documented HAP were studied. For each causative pathogen, imipenem susceptibility was routinely determined. Patients with an HAP episode due to at least one imipenem-resistant causative organism were compared with patients who developed HAP in which all incriminated pathogens were imipenem susceptible.
235 patients were included in our observational cohort. Among them, 168 had an HAP episode with a bacteriologically proven infection. In 42 patients (25%), at least one causative organism was resistant to imipenem. The 44 imipenem-resistant organisms were Staphylococcus aureus (n = 15), Pseudomonas aeruginosa (n = 14), Stenotrophomonas maltophilia (n = 13), and Acinetobacter baumannii (n = 2). Multivariate analysis identified four significant independent factors associated with resistance of causative organism(s) to imipenem: prior use of a fluoroquinolone (AOR = 3.9; 95% CI: 1.8 to 8.8; p < 0.0001), prior use of an aminoglycoside (AOR = 2.6; CI: 1.2 to 5.9; p = 0.02), use of invasive blood pressure monitoring (AOR = 2.7; CI: 1.0 to 7.0; p = 0.04) and bilateral chest X-ray involvement (AOR = 2.6; CI: 1.1 to 5.8; p = 0.02).
Factors associated with potential inadequacy of imipenem used as the single antibiotic for initial empiric treatment for HAP were identified. When they are present, imipenem should be either combined with antibiotics such as vancomycin and ciprofloxacin or replaced with another broad-spectrum antimicrobial regimen.
初始抗菌治疗不足是与医院获得性肺炎患者死亡率相关的因素之一。根据其广泛的抗菌谱，亚胺培南属于当前此类治疗指南中推荐的常用抗生素。然而，重症监护病房（ICU）中细菌的抗生素敏感性模式已发生重大变化。我们的目标是确定我们ICU中由耐亚胺培南菌引起的医院获得性肺炎（HAP）的发生率，并确定与这种耐药性相关的因素。
从1994年1月至2001年12月，所有因HAP入住我们ICU或在ICU住院期间出现HAP的连续患者被纳入一个观察队列。对有细菌学记录的HAP患者进行研究。对于每种致病病原体，常规测定亚胺培南敏感性。将因至少一种耐亚胺培南致病生物体导致HAP发作的患者与所有涉案病原体对亚胺培南敏感的HAP患者进行比较。
235名患者被纳入我们的观察队列。其中，168名患者有细菌学证实感染的HAP发作。在42名患者（25%）中，至少一种致病生物体对亚胺培南耐药。44株耐亚胺培南菌为金黄色葡萄球菌（n = 15）、铜绿假单胞菌（n = 14）、嗜麦芽窄食单胞菌（n = 13）和鲍曼不动杆菌（n = 2）。多变量分析确定了与致病生物体对亚胺培南耐药相关的四个显著独立因素：先前使用氟喹诺酮类药物（比值比[AOR]=3.9；95%置信区间[CI]：1.8至8.8；p<0.0001）、先前使用氨基糖苷类药物（AOR = 2.6；CI：1.2至5.9；p = 0.02）、使用有创血压监测（AOR = 2.7；CI：1.0至7.0；p = 0.04）和双侧胸部X线受累（AOR = 2.6；CI：1.1至5.8；p = 0.02）。
确定了与将亚胺培南用作HAP初始经验性单一治疗抗生素的潜在不足相关的因素。当存在这些因素时，亚胺培南应与万古霉素和环丙沙星等抗生素联合使用或用另一种广谱抗菌方案替代。
