指南一致的抗生素使用与 ICU 收治的社区获得性肺炎患者的生存。

Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit.

机构信息

University of Texas at Austin, College of Pharmacy, Austin, Texas, USA.

出版信息

Clin Ther. 2010 Feb;32(2):293-9. doi: 10.1016/j.clinthera.2010.02.006.

DOI:10.1016/j.clinthera.2010.02.006

PMID:20206787

Abstract

OBJECTIVE

This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting.

METHODS

We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates.

RESULTS

The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis.

CONCLUSION

Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.

摘要

目的

本研究评估了美国社区获得性肺炎（CAP）实践指南在重症监护病房（ICU）环境中的生存获益。

方法

我们对 1999 年 11 月 1 日至 2000 年 4 月 30 日期间入住 5 家社区医院 ICU 的成人 CAP 患者进行了回顾性队列研究。抗生素处方指南为 2007 年美国传染病学会/美国胸科学会指南。指南一致的抗菌治疗定义为β-内酰胺加氟喹诺酮或大环内酯类，抗假单胞菌β-内酰胺加氟喹诺酮，或抗假单胞菌β-内酰胺加氨基糖苷类加氟喹诺酮或大环内酯类。如果患者有β-内酰胺过敏病史，并接受氟喹诺酮类药物联合或不联合克林霉素，或氨曲南联合氟喹诺酮类药物联合或不联合氨基糖苷类药物，则认为接受了指南一致的治疗。所有其他抗生素方案均被认为与指南不一致。使用回归模型评估临床稳定时间、口服抗生素时间、住院时间和院内死亡率，其中将结局作为因变量，将指南一致的抗生素治疗作为自变量，并将肺炎严重指数（PSI）评分和医疗机构作为协变量。

结果

纳入研究的 129 例患者的中位年龄为 71 岁（四分位间距，60-79 岁）。129 例患者中有 62 例（48%）为男性。合并症包括肝功能障碍（7 例[5%]）、心力衰竭（62 例[48%]）、肾功能障碍（39 例[30%]）、脑血管病（21 例[16%]）和癌症（14 例[11%]）。PSI 评分中位数（25 至 75 分位数）为 119（98-142），总死亡率为 19%（25 例）。两组患者的人口统计学特征相似。53 例（41%）接受了指南推荐的治疗方法。指南不一致的治疗与住院死亡率增加相关（25%比 11%；比值比=2.99[95%置信区间，1.08-9.54]）。排除死亡患者后，接受指南一致的抗生素治疗与临床稳定时间、口服抗生素时间或住院时间的缩短无关。