Department of Pharmacy Practice, UIC-College of Pharmacy, Chicago, IL, USA.
Crit Care Med. 2011 Aug;39(8):1859-65. doi: 10.1097/CCM.0b013e31821b85f4.
To determine whether exposure to antimicrobial agents in the previous 90 days resulted in decreased bacterial susceptibility and increased hospital mortality in patients with severe sepsis or septic shock attributed to Gram-negative bacteremia.
A retrospective cohort study of hospitalized patients (January 2002 to December 2007).
Barnes-Jewish Hospital, a 1200-bed urban teaching hospital.
Seven hundred fifty-four consecutive patients with Gram-negative bacteremia complicated by severe sepsis or septic shock.
Data abstraction from computerized medical records.
Escherichia coli (30.8%), Klebsiella pneumoniae (23.2%), and Pseudomonas aeruginosa (17.6%) were the most common isolates from blood cultures. Three hundred ten patients (41.1%) had recent antibiotic exposure. Cefepime was the most common agent with previous exposure (50.0%) followed by ciprofloxacin (32.6%) and imipenem or meropenem (28.7%). Patients with prior antibiotic exposure had significantly higher rates of resistance to cefepime (29.0% vs. 7.0%), piperacillin/tazobactam (31.9% vs. 11.5%), carbapenems (20.0% vs. 2.5%), ciprofloxacin (39.7% vs. 17.6%), and gentamicin (26.1% vs. 7.9%) (p < .001 for all comparisons). Patients with recent antibiotic exposure had greater inappropriate initial antimicrobial therapy (45.4% vs. 21.2%; p < .001) and hospital mortality (51.3% vs. 34.0%; p < .001) compared with patients without recent antibiotic exposure. Multivariate logistic regression analysis demonstrated that recent antibiotic exposure was independently associated with hospital mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.41-2.06; p = .005). Other variables independently associated with hospital mortality included use of vasopressors, infection resulting from P. aeruginosa, inappropriate initial antimicrobial therapy, increasing Acute Physiology and Chronic Health Evaluation II scores, and the number of acquired organ failures.
Recent antibiotic exposure is associated with increased hospital mortality in Gram-negative bacteremia complicated by severe sepsis or septic shock. Clinicians caring for patients with severe sepsis or septic shock should consider recent antibiotic exposure when formulating empiric antimicrobial regimens for suspected Gram-negative bacterial infection.
确定在过去 90 天内接触抗菌药物是否会导致革兰氏阴性菌血症引起的严重败血症或感染性休克患者的细菌敏感性降低和住院死亡率增加。
对住院患者（2002 年 1 月至 2007 年 12 月）进行回顾性队列研究。
巴恩斯-犹太医院，一家拥有 1200 张床位的城市教学医院。
754 例革兰氏阴性菌血症合并严重败血症或感染性休克的连续患者。
从计算机病历中提取数据。
大肠埃希菌（30.8%）、肺炎克雷伯菌（23.2%）和铜绿假单胞菌（17.6%）是血培养中最常见的分离株。310 例患者（41.1%）有近期抗生素暴露史。以前暴露过的最常见的药物是头孢吡肟（50.0%），其次是环丙沙星（32.6%）和亚胺培南或美罗培南（28.7%）。有先前抗生素暴露的患者对头孢吡肟（29.0%对 7.0%）、哌拉西林/他唑巴坦（31.9%对 11.5%）、碳青霉烯类（20.0%对 2.5%）、环丙沙星（39.7%对 17.6%）和庆大霉素（26.1%对 7.9%）的耐药率显著更高（所有比较均<0.001）。近期使用抗生素的患者初始抗菌治疗不当的比例更高（45.4%对 21.2%；<0.001），住院死亡率也更高（51.3%对 34.0%；<0.001）。与没有近期抗生素暴露的患者相比。多变量逻辑回归分析表明，近期抗生素暴露与住院死亡率独立相关（调整优势比，1.70；95%置信区间，1.41-2.06；p=0.005）。与住院死亡率独立相关的其他变量包括使用血管加压药、铜绿假单胞菌引起的感染、初始抗菌治疗不当、急性生理学和慢性健康评估 II 评分增加以及获得性器官衰竭的数量。
在革兰氏阴性菌血症合并严重败血症或感染性休克患者中，近期抗生素暴露与住院死亡率增加有关。治疗严重败血症或感染性休克患者的临床医生在制定疑似革兰氏阴性菌感染的经验性抗菌治疗方案时，应考虑近期抗生素暴露情况。
