Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea.
Crit Care. 2012 Feb 15;16(1):R28. doi: 10.1186/cc11197.
Although early use of broad-spectrum antimicrobials in critically ill patients may increase antimicrobial adequacy, uncontrolled use of these agents may select for more-resistant organisms. This study investigated the effects of early use of broad-spectrum antimicrobials in critically ill patients with hospital-acquired pneumonia.
We compared the early use of broad-spectrum antimicrobials plus subsequent de-escalation (DE) with conventional antimicrobial treatment (non-de-escalation, NDE) in critically ill patients with hospital-acquired pneumonia (HAP). This open-label, randomized clinical trial was performed in patients in a tertiary-care center medical intensive care unit (MICU) in Korea. Patients (n=54) randomized to the DE group received initial imipenem/cilastatin plus vancomycin with subsequent de-escalation according to culture results, whereas patients randomized to the NDE group (n=55) received noncarbapenem, nonvancomycin empiric antimicrobials.
Between November 2004 and October 2006, 109 MICU patients with HAP were enrolled. Initial antimicrobial adequacy was significantly higher in the DE than in the NDE group for Gram-positive organisms (100% versus 14.3%; P<0.001), but not for Gram-negative organisms (64.3% versus 85.7%; P=0.190). Mean intensive care unit (ICU) stay, and 14-day, 28-day, and overall mortality rates did not differ in the two groups. Among culture-positive patients, mortality from methicillin-resistant Staphylococcus aureus (MRSA) pneumonia was higher in the DE group, even after early administration of vancomycin. Multidrug-resistant organisms, especially MRSA, were more likely to emerge in the DE group (adjusted hazard ratio for emergence of MRSA, 3.84; 95% confidence interval, 1.06 to 13.91).
The therapeutic advantage of early administration of broad-spectrum antimicrobials, especially with vancomycin, was not evident in this study.
虽然在危重症患者中早期使用广谱抗生素可能会增加抗菌药物的充分性，但这些药物的不受控制使用可能会选择出更具耐药性的生物体。本研究调查了在患有医院获得性肺炎的危重症患者中早期使用广谱抗生素的影响。
我们比较了在韩国一家三级护理中心的医疗重症监护病房（MICU）中患有医院获得性肺炎（HAP）的危重症患者中早期使用广谱抗生素加随后的降级（DE）与常规抗生素治疗（非降级，NDE）的情况。这是一项开放标签、随机临床试验，在患者中进行。随机分配到 DE 组的患者接受初始亚胺培南/西司他丁加万古霉素治疗，并根据培养结果随后进行降级，而随机分配到 NDE 组的患者（n=55）接受非碳青霉烯类、非万古霉素经验性抗生素治疗。
2004 年 11 月至 2006 年 10 月期间，共有 109 例 MICU 中患有 HAP 的患者入组。DE 组革兰阳性菌初始抗菌药物的充分性明显高于 NDE 组（100%对 14.3%；P<0.001），但革兰阴性菌则不然（64.3%对 85.7%；P=0.190）。两组患者的重症监护病房（ICU）入住时间、14 天、28 天和总死亡率均无差异。在培养阳性的患者中，DE 组耐甲氧西林金黄色葡萄球菌（MRSA）肺炎的死亡率更高，即使早期给予了万古霉素。多药耐药生物体，特别是 MRSA，在 DE 组中更有可能出现（调整后的 MRSA 出现风险比，3.84；95%置信区间，1.06 至 13.91）。
在本研究中，早期使用广谱抗生素，特别是万古霉素，并没有明显的治疗优势。
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