General Internal Medicine & Infectious Diseases, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
Int J Antimicrob Agents. 2010 Apr;35(4):375-81. doi: 10.1016/j.ijantimicag.2009.11.015. Epub 2010 Feb 1.
This prospective, observational multicentre (n=24) study investigated relationships between antimicrobial choices and rates of empiric appropriate or adequate therapy, and subsequent adaptation of therapy in 171 ICU patients with severe nosocomial infections. Appropriate antibiotic therapy was defined as in vitro susceptibility of the causative pathogen and clinical response to the agent administered. In non-microbiologically documented infections, therapy was considered adequate in the case of favourable clinical response <5 days. Patients had pneumonia (n=127; 66 ventilator-associated), intra-abdominal infection (n=23), and bloodstream infection (n=21). Predominant pathogens were Pseudomonas aeruginosa (n=29) Escherichia coli (n=26), Staphylococcus aureus (n=22), and Enterobacter aerogenes (n=21). In 49.6% of infections multidrug-resistant (MDR) bacteria were involved, mostly extended-spectrum beta-lactamase (EBSL)-producing Enterobacteriaceae and MDR non-fermenting Gram-negative bacteria. Prior antibiotic exposure and hospitalisation in a general ward prior to ICU admission were risk factors for MDR. Empiric therapy was appropriate/adequate in 63.7% of cases. Empiric schemes were classified according to coverage of (i) ESBL-producing Enterobacteriaceae and non-fermenting Gram-negative bacteria ("meropenem-based"), (ii) non-fermenting Gram-negative bacteria (schemes with an antipseudomonal agent), and (iii) first-line agents not covering ESBL-Enterobacteriaceae nor non-fermenting Gram-negative bacteria. Meropenem-based schemes allowed for significantly higher rates of appropriate/adequate therapy (p<0.001). This benefit remained when only patients without risk factors for MDR were considered (p=0.021). In 106 patients (61%) empiric therapy was modified: in 60 cases following initial inappropriate/inadequate therapy, in 46 patients in order to refine empiric therapy. In this study reflecting real-life practice, first-line use of meropenem provided significantly higher rates of the appropriate/adequate therapy, irrespective of presence of risk factors for MDR.
这项前瞻性、观察性的多中心研究（n=24）调查了 171 例重症医院获得性感染 ICU 患者中抗菌药物选择与经验性适当/充分治疗率之间的关系，以及随后治疗的调整。适当的抗生素治疗定义为病原体的体外敏感性和给予药物的临床反应。在未进行微生物学确诊的感染中，如果临床反应良好（<5 天），则认为治疗是充分的。患者患有肺炎（n=127；66 例与呼吸机相关）、腹腔内感染（n=23）和血流感染（n=21）。主要病原体为铜绿假单胞菌（n=29）、大肠杆菌（n=26）、金黄色葡萄球菌（n=22）和产气肠杆菌（n=21）。49.6%的感染涉及多药耐药（MDR）细菌，主要是产超广谱β-内酰胺酶（ESBL）的肠杆菌科和 MDR 非发酵革兰氏阴性菌。抗生素暴露史和 ICU 入院前在普通病房住院是 MDR 的危险因素。经验性治疗的适当/充分率为 63.7%。根据经验性方案对（i）产 ESBL 的肠杆菌科和非发酵革兰氏阴性菌（“美罗培南为基础”）、（ii）非发酵革兰氏阴性菌（含抗假单胞菌药物的方案）和（iii）不覆盖 ESBL-肠杆菌科或非发酵革兰氏阴性菌的一线药物的覆盖情况进行分类。美罗培南为基础的方案可显著提高适当/充分治疗率（p<0.001）。当仅考虑无 MDR 危险因素的患者时，这种益处仍然存在（p=0.021）。在 106 例（61%）患者中，经验性治疗进行了调整：在 60 例初始不适当/不充分治疗后，在 46 例患者中为了完善经验性治疗。在这项反映真实实践的研究中，一线使用美罗培南可显著提高适当/充分治疗率，无论是否存在 MDR 危险因素。
