Servizio di Rianimazione, Terapia Intensiva e Neuroanestesia, Istituti Ospitalieri di Cremona, viale Concordia 1, Cremona, Italy.
Eur J Clin Microbiol Infect Dis. 2010 Aug;29(8):1015-24. doi: 10.1007/s10096-010-0964-5. Epub 2010 Jun 4.
The development of antibiotic resistance is associated with high morbidity and mortality, particularly in the intensive care unit (ICU) setting. We evaluated the effect of an antibiotic rotation programme on the incidence of ventilator-associated pneumonia (VAP) caused by antibiotic-resistant Gram-negative bacteria. We conducted a 2-year before-and-after study at two medical-surgical ICUs at two different tertiary referral hospitals. We included all mechanically ventilated patients admitted for > or =48 h who developed VAP. From 1 January through 31 December 2007, a quarterly rotation of antibiotics (piperacillin/tazobactam, fluoroquinolones, carbapenems and cefepime/ceftazidime) for the empirical treatment of VAP was implemented. We analysed the incidence of VAP and the antibiotic resistance patterns of the responsible pathogens in 2006, before (P1) and, in 2007, after (P2) the introduction of the scheduled rotation programme. Overall, there were 79 VAP episodes in P1 and 44 in P2; the mean incidence of VAP was 20.96 cases per 1,000 days of mechanical ventilation (MV) during P1 and 14.97 in P2, with no significant difference between periods on segmented regression analysis. We observed a non-significant reduction of the number of both the poly-microbial (14 [17.7%] in P1 and 5 [10.6%] in P2 [p = 0.32]) and of the antibiotic-resistant Gram-negative bacteria-related VAP (42 [45.2%] in P1 and 16 [34%] in P2 [p = 0.21]). Conversely, the number of VAP caused by Pseudomonas aeruginosa passed from 8.35 per 1,000 days of MV in P1 to 2.33 per 1,000 days of MV in P2 (p = 0.02). No difference in ICU mortality and crude in-hospital mortality between P1 and P2 was noted. Moreover, no significant change of microbial flora isolated through clinical cultures was observed. We were able to conclude that, despite global microbial flora not being affected by such a programme, antibiotic therapy rotation may reduce the incidence of VAP caused by antibiotic-resistant Gram-negative bacteria in the ICU, such as Pseudomonas aeruginosa. The application of this programme may also improve antibiotic susceptibility. However, further studies are needed to confirm our results.
抗生素耐药性的发展与高发病率和死亡率相关，尤其是在重症监护病房（ICU）环境中。我们评估了抗生素轮换方案对由抗生素耐药革兰氏阴性菌引起的呼吸机相关性肺炎（VAP）的发生率的影响。我们在两家不同的三级转诊医院的两个内科-外科 ICU 进行了为期两年的前后对照研究。我们纳入了所有机械通气时间超过 48 小时且发生 VAP 的患者。2007 年 1 月 1 日至 12 月 31 日，实施了针对 VAP 的经验性治疗的抗生素（哌拉西林/他唑巴坦、氟喹诺酮类、碳青霉烯类和头孢吡肟/头孢他啶）的季度轮换方案。我们分析了 2006 年（P1 前）和 2007 年（P2 后）引入定期轮换方案前后 VAP 的发生率和负责病原体的抗生素耐药模式。总体而言，P1 中有 79 例 VAP 发作，P2 中有 44 例；P1 中每 1000 天机械通气（MV）的 VAP 发生率为 20.96 例，P2 中为 14.97 例，分段回归分析无统计学差异。我们观察到多微生物（P1 中 14 例[17.7%]，P2 中 5 例[10.6%]，p = 0.32）和抗生素耐药革兰氏阴性菌相关 VAP（P1 中 42 例[45.2%]，P2 中 16 例[34%]，p = 0.21）的数量均无显著减少。相反，铜绿假单胞菌引起的 VAP 数量从 P1 中的每 1000 天 MV 8.35 例降至 P2 中的每 1000 天 MV 2.33 例（p = 0.02）。P1 和 P2 之间 ICU 死亡率和住院死亡率无差异。此外，通过临床培养分离的微生物菌群没有观察到明显变化。我们得出结论，尽管全球微生物菌群不受此类方案影响，但抗生素治疗轮换可能会降低 ICU 中由抗生素耐药革兰氏阴性菌引起的 VAP 的发生率，例如铜绿假单胞菌。该方案的应用还可能改善抗生素敏感性。然而，需要进一步的研究来证实我们的结果。
