碳青霉烯类耐药鲍曼不动杆菌呼吸机相关性肺炎的抗菌治疗及临床转归。

Antimicrobial treatment and clinical outcomes of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia.

机构信息

Department of Pharmacy, Harborview Medical Center, Seattle, WA 98104, USA.

出版信息

J Intensive Care Med. 2010 Nov-Dec;25(6):343-8. doi: 10.1177/0885066610377975.

DOI:10.1177/0885066610377975

PMID:20837632

Abstract

OBJECTIVES

Carbapenem-resistant (CR) Acinetobacter baumannii is an important pathogen in ventilator-associated pneumonia (VAP), but therapeutic options are limited. We describe the clinical outcomes of the largest case series of CR-Acinetobacter VAP reported to date.

METHODS

A retrospective analysis of 55 participants with CR-Acinetobacter VAP from July 2004 to December 2007 was undertaken. The primary endpoint was clinical response or microbiological eradication. Secondary endpoint was treatment-associated nephrotoxicity defined as ≥ 50% increase in serum creatinine or an increase of ≥ 0.5 mg/dL during therapy.

RESULTS

Forty-two (76.4%) participants achieved clinical response at the completion of therapy. Clinical responses were achieved in 60.0% of sulbactam-based, 66.7% of polymyxin-based, 77.8% of aminoglycoside-based, 80.6% of minocycline-based, and 90.0% of tigecycline-based regimens. Follow-up sputum cultures were available in 6 of 10 tigecycline-treated participants with 4 of 6 isolates developing intermediate resistance to tigecycline while on therapy. Ten (18.2%) participants without preexisting renal disease developed treatment-associated nephrotoxicity. Baseline serum creatinine was 0.9 ± 0.1 mg/dL (range: 0.6-1.0 mg/dL) at the start of therapy and peaked at 1.9 ± 0.5 mg/dL (range: 1.6-3.0 mg/dL) during therapy. After excluding other potential concomitant renal toxic agents, nephrotoxicity developed in 6 of 30 (20.0%) and 4 of 7 (57.1%) participants treated with an aminoglycoside-or polymyxin-based regimen, respectively.

CONCLUSIONS

Our results demonstrated that CR-Acinetobacter VAP can be effectively treated with second-line agents. However, colistin-related nephrotoxicity was much higher than recently reported and decreased susceptibility to tigecycline emerged on therapy demonstrating the limitations of alternative regimens.

摘要

目的

耐碳青霉烯类（CR）鲍曼不动杆菌是呼吸机相关性肺炎（VAP）的重要病原体，但治疗选择有限。我们描述了迄今为止报道的最大的耐碳青霉烯类鲍曼不动杆菌 VAP 病例系列的临床结果。

方法

对 2004 年 7 月至 2007 年 12 月期间 55 例耐碳青霉烯类鲍曼不动杆菌 VAP 患者进行回顾性分析。主要终点是临床反应或微生物学清除。次要终点是治疗相关的肾毒性，定义为治疗期间血清肌酐增加≥50%或增加≥0.5mg/dL。

结果

42 例（76.4%）患者在治疗结束时达到临床反应。基于舒巴坦、多粘菌素、氨基糖苷类、米诺环素和替加环素的方案的临床反应率分别为 60.0%、66.7%、77.8%、80.6%和 90.0%。10 例接受替加环素治疗的患者中有 6 例可获得随访痰液培养，其中 4 例在治疗期间对替加环素的中介耐药性增加。10 例（18.2%）无原有肾脏疾病的患者发生治疗相关的肾毒性。治疗开始时的血清肌酐为 0.9±0.1mg/dL（范围：0.6-1.0mg/dL），治疗期间峰值为 1.9±0.5mg/dL（范围：1.6-3.0mg/dL）。在排除其他潜在的肾毒性药物后，分别有 6 例（20.0%）和 4 例（57.1%）接受氨基糖苷类或多粘菌素类方案治疗的患者出现肾毒性。