Department of Pharmacy, UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
Infection. 2010 Oct;38(5):357-62. doi: 10.1007/s15010-010-0042-z. Epub 2010 Jul 21.
Published guidelines for the treatment of healthcare-associated pneumonia (HCAP) recommend initial broad-spectrum antibiotics with appropriate de-escalation based on culture results. Guideline recommendations are based on data from intubated patients, in whom cultures are easily obtained. The approach to antibiotic de-escalation for culture-negative patients has not been addressed. Consequently, there are no published reports that describe the current standard of practice.
All patients admitted to a university hospital with a diagnosis of HCAP, as defined by use of a pneumonia orderset, were identified retrospectively over a 2-year period. Antibiotics prescribed on admission, during hospital stay, and on discharge were recorded. De-escalation was defined as a change in the initial antibiotic therapy from broad- to narrow-spectrum coverage within 14 days of the initial prescription. The Pneumonia Severity Index was used for risk-adjustment.
A total of 102 patients were included in the analysis; of these, 72% (n = 73) were culture-negative. There were more males in the culture-negative than culture-positive group; otherwise, baseline characteristics were similar. Antibiotic therapy was de-escalated in 75% of the culture-negative group and 77% of the culture-positive group (p = 1.00). Culture-negative patients were de-escalated approximately 1 day earlier than culture-positive patients (3.93 vs. 5.04 days, p = 0.03). Culture-negative patients who were de-escalated had a shorter length of hospitalization, lower hospital costs, and lower mortality rates. In 70% of the culture-negative patients, a respiratory fluoroquinolone was chosen for de-escalation.
In this single-center study, most of the patients with culture-negative HCAP were safely de-escalated to a respiratory fluoroquinolone.
已发布的医疗相关性肺炎（HCAP）治疗指南建议根据培养结果，初始使用广谱抗生素，然后适当进行降阶梯治疗。指南推荐意见基于气管插管患者的数据，这些患者易于获取培养物。对于培养阴性患者的抗生素降阶梯治疗方法尚未确定。因此，目前没有描述当前实践标准的已发表报告。
在过去的两年中，我们回顾性地确定了所有因使用肺炎医嘱集而被诊断为 HCAP 的患者。记录入院时、住院期间和出院时开具的抗生素。抗生素降阶梯定义为在初始处方后 14 天内，将初始抗生素治疗从广谱转为窄谱。使用肺炎严重指数进行风险调整。
共有 102 例患者纳入分析，其中 72%（n=73）为培养阴性。培养阴性组中男性多于培养阳性组，除此之外，两组的基线特征相似。培养阴性组中有 75%的患者和培养阳性组中有 77%的患者（p=1.00）进行了抗生素降阶梯治疗。培养阴性患者的抗生素降阶梯时间比培养阳性患者早约 1 天（3.93 天 vs. 5.04 天，p=0.03）。接受抗生素降阶梯治疗的培养阴性患者的住院时间更短、住院费用更低、死亡率更低。在 70%的培养阴性患者中，选择呼吸氟喹诺酮类药物进行降阶梯治疗。
在这项单中心研究中，大多数培养阴性 HCAP 患者可安全地降阶梯为呼吸氟喹诺酮类药物。
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