Tleyjeh Imad M, Tlaygeh Haytham M, Hejal Rana, Montori Victor M, Baddour Larry M
Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA.
Clin Infect Dis. 2006 Mar 15;42(6):788-97. doi: 10.1086/500140. Epub 2006 Feb 8.
The clinical impact of penicillin resistance on the outcome of pneumococcal pneumonia has remained controversial. We performed a meta-analysis of prospective cohort studies to examine the association between penicillin resistance and short-term all-cause mortality for pneumococcal pneumonia.
We retrieved studies published in any language by a comprehensive search of the Medline, Current Contents, and Embase databases for all appropriate articles published up to January 2005. We also manually reviewed bibliographies of retrieved articles, recent national treatment guidelines, and review articles. We included prospective cohort studies that involved adult subjects, and we examined the association between penicillin resistance and short-term mortality for pneumococcal pneumonia. Two reviewers independently extracted data on crude and adjusted risk estimates of all-cause mortality for pneumococcal infections with different levels of penicillin resistance and assessed the methodological quality of selected studies. We also contacted authors to obtain additional information. We performed meta-analyses using a random-effect model.
Of 1152 articles identified in the search, 10 studies that involved 3430 patients (most of whom were hospitalized) were included. The mortality rate was 19.4% in the penicillin-nonsusceptible Streptococcus pneumoniae group and 15.7% in the penicillin-susceptible S. pneumoniae group. The combined relative risks of all-cause mortality for the penicillin-nonsusceptible, -intermediate, and -resistant S. pneumoniae groups, compared with the penicillin-susceptible S. pneumoniae group, were 1.31 (95% confidence interval [CI], 1.08-1.59), 1.34 (95% CI, 1.13-1.60), and 1.29 (95% CI, 1.01-1.66), respectively. The combined adjusted relative risks of mortality for penicillin-nonsusceptible versus penicillin-susceptible S. pneumoniae group was 1.29 (95% CI, 1.04-1.59) for the 6 studies that adjusted for age, comorbidities, and severity of illness. There was minimal between-study heterogeneity in these analyses.
Penicillin resistance is associated with a higher mortality rate than is penicillin susceptibility in hospitalized patients with pneumococcal pneumonia. Additional efforts are needed to understand the mechanisms of this association.
青霉素耐药性对肺炎球菌肺炎预后的临床影响一直存在争议。我们进行了一项前瞻性队列研究的荟萃分析，以检验青霉素耐药性与肺炎球菌肺炎短期全因死亡率之间的关联。
我们通过全面检索Medline、《现刊目次》和Embase数据库，检索截至2005年1月发表的所有合适文章，不限语言。我们还人工查阅了检索到的文章的参考文献、近期的国家治疗指南和综述文章。我们纳入了涉及成年受试者的前瞻性队列研究，并检验了青霉素耐药性与肺炎球菌肺炎短期死亡率之间的关联。两名审阅者独立提取了不同青霉素耐药水平的肺炎球菌感染全因死亡率的粗风险估计值和调整风险估计值的数据，并评估了所选研究的方法学质量。我们还联系了作者以获取更多信息。我们使用随机效应模型进行荟萃分析。
在检索到的1152篇文章中，纳入了10项涉及3430例患者（大多数为住院患者）的研究。青霉素不敏感肺炎链球菌组的死亡率为19.4%，青霉素敏感肺炎链球菌组的死亡率为15.7%。与青霉素敏感肺炎链球菌组相比，青霉素不敏感、中介和耐药肺炎链球菌组全因死亡率的合并相对风险分别为1.31（95%置信区间[CI]，1.08 - 1.59）、1.34（95%CI，1.13 - 1.60）和1.29（95%CI，1.01 - 1.66）。在对年龄、合并症和疾病严重程度进行调整的6项研究中，青霉素不敏感与青霉素敏感肺炎链球菌组死亡率的合并调整相对风险为1.29（95%CI，1.04 - 1.59）。这些分析中的研究间异质性极小。
在患有肺炎球菌肺炎的住院患者中，青霉素耐药性与比青霉素敏感性更高的死亡率相关。需要进一步努力了解这种关联的机制。
