Critical Care Department, Mater Misericordiae University Hospital, Dublin, Ireland.
Intensive Care Med. 2010 Apr;36(4):612-20. doi: 10.1007/s00134-009-1730-y. Epub 2009 Dec 2.
To assess the effect on survival of macrolides or fluoroquinolones in intubated patients admitted to the intensive care unit (ICU) with severe community-acquired pneumonia (severe CAP).
Prospective, observational cohort, multicenter study conducted in 27 ICUs of 9 European countries. Two hundred eighteen consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of CAP were recruited.
Severe sepsis and septic shock were present in 165 (75.7%) patients. Microbiological documentation was obtained in 102 (46.8%) patients. ICU mortality was 37.6% (n = 82). Non-survivors were older (58.6 +/- 16.1 vs. 63.4 +/- 16.7 years, P < 0.05) and presented a higher score on the simplified Acute Physiology Score II at admission (45.6 +/- 15.4 vs. 50.8 +/- 17.5, P < 0.05). Monotherapy was given in 43 (19.7%) and combination therapy in 175 (80.3%) patients. Empirical antibiotic therapy was in accordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines in 100 (45.9%) patients (macrolides in 46 patients and fluoroquinolones in 54). In this cohort, a Cox regression analysis adjusted by severity identified that macrolide use was associated with lower ICU mortality (hazard ratio, HR 0.48, confidence intervals, 95% CI 0.23-0.97, P = 0.04) when compared to the use of fluoroquinolones. When more severe patients presenting severe sepsis and septic shock were analyzed (n = 92), similar results were obtained (HR 0.44, 95% CI 0.20-0.95, P = 0.03).
Patients with severe community-acquired pneumonia had a low adherence with the 2007 IDSA/ATS guidelines. Combination therapy with macrolides should be preferred in intubated patients with severe CAP.
评估重症监护病房（ICU）中患有严重社区获得性肺炎（CAP）的插管患者使用大环内酯类或氟喹诺酮类药物对生存的影响。
这是一项在欧洲 9 个国家的 27 个 ICU 进行的前瞻性、观察性队列、多中心研究。共纳入 218 例因 CAP 入院需行有创机械通气的连续患者。
165 例（75.7%）患者发生严重脓毒症和脓毒性休克。102 例（46.8%）患者获得了微生物学诊断。ICU 死亡率为 37.6%（n=82）。非幸存者年龄更大（58.6+/-16.1 岁比 63.4+/-16.7 岁，P<0.05），入院时简化急性生理学评分 II 更高（45.6+/-15.4 分比 50.8+/-17.5 分，P<0.05）。43 例（19.7%）患者接受单药治疗，175 例（80.3%）患者接受联合治疗。100 例（45.9%）患者的经验性抗生素治疗符合 2007 年美国传染病学会（IDSA）/美国胸科学会（ATS）指南（46 例患者使用大环内酯类，54 例患者使用氟喹诺酮类）。在该队列中，通过严重程度调整的 Cox 回归分析发现，与使用氟喹诺酮类药物相比，大环内酯类药物的使用与 ICU 死亡率降低相关（风险比，HR 0.48，95%可信区间，95%CI 0.23-0.97，P=0.04）。当分析更严重的出现严重脓毒症和脓毒性休克的患者（n=92）时，也得到了类似的结果（HR 0.44，95%CI 0.20-0.95，P=0.03）。
患有严重社区获得性肺炎的患者对 2007 年 IDSA/ATS 指南的依从性较低。在严重 CAP 插管患者中，应优先使用大环内酯类联合治疗。
