CURB65 指导下的抗生素治疗在社区获得性肺炎中的安全性和疗效。

Safety and efficacy of CURB65-guided antibiotic therapy in community-acquired pneumonia.

机构信息

MRC Centre For Inflammation Research, Queens Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK.

出版信息

J Antimicrob Chemother. 2011 Feb;66(2):416-23. doi: 10.1093/jac/dkq426. Epub 2010 Nov 16.

DOI:10.1093/jac/dkq426

PMID:21081545

Abstract

OBJECTIVES

To determine whether the introduction of a community-acquired pneumonia (CAP) severity assessment tool to guide antibiotic selection could reduce broad-spectrum antibiotic prescribing without compromising patient safety.

METHODS

A prospective before and after evaluation study. Empirical antibiotic prescribing was studied for 18 months from June 2006 to January 2008 (pre-intervention) and then for 18 months following the implementation of a CURB65-guided antibiotic therapy guideline in June 2008. The primary outcome was the use of broad-spectrum antibiotics (cephalosporin, amoxicillin plus clavulanic acid and macrolides) in patients with CAP. Safety outcomes were 30 day mortality, requirement for mechanical ventilation and/or vasopressor support (MV/VS), development of complicated pneumonia, time to clinical stability (TCS) and length of hospital stay.

RESULTS

The introduction of CURB65-guided therapy resulted in an overall reduction in the prescription of cephalosporins (from 27.1% of patients receiving this agent in the overall pre-intervention cohort to 8.0% in the post-intervention cohort, P < 0.0001) and macrolides (72.8% to 58.7%, P < 0.0001), particularly among low-risk patients. There was a corresponding increase in the prescription of the narrower-spectrum agent amoxicillin (29.7% to 41.7%, P < 0.0001) and an increase in the use of amoxicillin monotherapy (10.4% to 29.9%, P < 0.0001). Co-amoxiclav use increased slightly as this agent replaced cephalosporins as first-line treatment for severe CAP. The guideline had no impact on 30 day mortality, MV/VS, complicated pneumonia, TCS or length of stay. Following the intervention, adherence to national guidelines increased from 25.4% of prescriptions to 61.9%, suggesting the potential for further improvements.

CONCLUSIONS

CURB65-guided antibiotic therapy was associated with a significant decrease in broad-spectrum antibiotic use. The intervention was safe with no impact on mortality, treatment failure or clinical response.

摘要

目的

确定社区获得性肺炎（CAP）严重程度评估工具的引入是否可以指导抗生素选择，从而减少广谱抗生素的使用，同时不影响患者安全。

方法

前瞻性的前后评估研究。2006 年 6 月至 2008 年 1 月期间进行了 18 个月的经验性抗生素处方研究（干预前），然后在 2008 年 6 月实施 CURB65 指导抗生素治疗指南后进行了 18 个月的研究。主要结局是 CAP 患者使用广谱抗生素（头孢菌素、阿莫西林加克拉维酸和大环内酯类）。安全性结局为 30 天死亡率、需要机械通气和/或血管加压支持（MV/VS）、发生复杂肺炎、临床稳定时间（TCS）和住院时间。

结果

CURB65 指导治疗的引入导致头孢菌素（从总体干预前队列中接受该药物的患者的 27.1%降至干预后队列中的 8.0%，P<0.0001）和大环内酯类（72.8%至 58.7%，P<0.0001）的处方总体减少，特别是在低风险患者中。相应地增加了较窄谱的阿莫西林（29.7%至 41.7%，P<0.0001）和阿莫西林单药治疗的使用（10.4%至 29.9%，P<0.0001）。由于该药物取代头孢菌素作为严重 CAP 的一线治疗药物，复方阿莫西林的使用略有增加。该指南对 30 天死亡率、MV/VS、复杂肺炎、TCS 或住院时间没有影响。干预后，处方遵守国家指南的比例从 25.4%增加到 61.9%，表明有进一步改进的潜力。