Marschall Jonas, Agniel Denis, Fraser Victoria J, Doherty Joshua, Warren David K
Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA.
J Antimicrob Chemother. 2008 Jun;61(6):1376-83. doi: 10.1093/jac/dkn104. Epub 2008 Mar 15.
A considerable number of gram-negative bacteraemias occur outside intensive care units (ICUs). Inadequate antibiotic therapy in ICUs has been associated with adverse outcomes; however, there are no prospective studies in non-ICU patients.
A 6 month (1 August 2006-31 January 2007), prospective cohort study of non-ICU patients with gram-negative bacteraemia in a tertiary-care hospital was performed. Inadequate empirical antibiotic therapy was defined as no antibiotic or starting a non-susceptible antibiotic within 24 h after the initial positive blood culture.
Two hundred and fifty non-ICU patients had gram-negative bacteraemia. The mean age was 56.4 (+/-16.1) years. The predominant bacteria in monomicrobial infections were Escherichia coli (24%), Klebsiella pneumoniae (18%) and Pseudomonas aeruginosa (8%). Sixty-one (24%) patients had polymicrobial bacteraemia. Seventy patients (28%) required ICU transfer and 35 (14%) died. Seventy-nine (31.6%) received inadequate empirical antibiotic therapy. These patients were more likely to have a hospital-acquired infection [odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.11-3.56, P = 0.02] and less likely to have E. coli monomicrobial bacteraemia [OR 0.40 (95% CI 0.19-0.86), P = 0.02]. There were no differences in occurrence of sepsis [72 (91.1%) patients with inadequate versus 159 (93.0%) with adequate therapy; P = 0.6], ICU transfer [20 (25.3%) versus 50 (29.2%); P = 0.5], post-bacteraemia length of stay (median = 6.8 versus 6.1 days; P = 0.09) or death [11 (13.9%) versus 24 (14.0%); P = 1.0].
Nearly one-third of the non-ICU patients with gram-negative bacteraemia received inadequate empirical antibiotic therapy. There was no difference in adverse outcomes between patients receiving inadequate or adequate therapy in this study.
相当数量的革兰阴性菌血症发生在重症监护病房（ICU）之外。ICU中抗生素治疗不足与不良预后相关；然而，在非ICU患者中尚无前瞻性研究。
在一家三级医院对非ICU革兰阴性菌血症患者进行了为期6个月（2006年8月1日至2007年1月31日）的前瞻性队列研究。经验性抗生素治疗不足定义为在初次血培养阳性后24小时内未使用抗生素或开始使用不敏感的抗生素。
250例非ICU患者发生革兰阴性菌血症。平均年龄为56.4（±16.1）岁。单微生物感染中主要的细菌为大肠杆菌（24%）、肺炎克雷伯菌（18%）和铜绿假单胞菌（8%）。61例（24%）患者发生多微生物菌血症。70例（28%）患者需要转入ICU，35例（14%）死亡。79例（31.6%）接受了经验性抗生素治疗不足。这些患者更有可能发生医院获得性感染[比值比（OR）=1.99，95%置信区间（CI）=1.11 - 3.56，P = 0.02]，而发生大肠杆菌单微生物菌血症的可能性较小[OR 0.40（95%CI 0.19 - 0.86），P = 0.02]。在脓毒症的发生[经验性治疗不足的患者中有72例（91.1%），治疗充分的患者中有159例（93.0%）；P = 0.6]、转入ICU[20例（25.3%）对50例（29.2%）；P = 0.5]、菌血症后住院时间（中位数分别为6.8天和6.1天；P = 0.09）或死亡[11例（13.9%）对24例（14.0%）；P = 1.0]方面无差异。
近三分之一的非ICU革兰阴性菌血症患者接受了经验性抗生素治疗不足。在本研究中，接受治疗不足或充分治疗的患者在不良预后方面无差异。
