Servei de Pneumologia, Institut del Torax, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
Crit Care Med. 2012 Sep;40(9):2552-61. doi: 10.1097/CCM.0b013e318259203d.
The use of corticosteroids is frequent in critically-ill patients. However, little information is available on their effects in patients with intensive care unit-acquired pneumonia. We assessed patients' characteristics, microbial etiology, inflammatory response, and outcomes of previous corticosteroid use in patients with intensive care unit-acquired pneumonia.
Prospective observational study.
Intensive care units of a university teaching hospital.
Three hundred sixteen patients with intensive care unit-acquired pneumonia. Patients were divided according to previous systemic steroid use at onset of pneumonia.
None.
Survival at 28 days was analyzed using Cox regression, with adjustment for the propensity for receiving steroid therapy. One hundred twenty-five (40%) patients were receiving steroids at onset of pneumonia. Despite similar baseline clinical severity, steroid treatment was associated with decreased 28-day survival (adjusted hazard ratio for propensity score and mortality predictors 2.503; 95% confidence interval 1.176-5.330; p = .017) and decreased systemic inflammatory response. In post hoc analyses, steroid treatment had an impact on survival in patients with nonventilator intensive care unit-acquired pneumonia, those with lower baseline severity and organ dysfunction, and those without etiologic diagnosis or bacteremia. The cumulative dosage of corticosteroids had no significant effect on the risk of death, but bacterial burden upon diagnosis was higher in patients receiving steroid therapy.
In critically-ill patients, systemic corticosteroids should be used very cautiously because this treatment is strongly associated with increased risk of death in patients with intensive care unit-acquired pneumonia, particularly in the absence of established indications and in patients with lower baseline severity. Decreased inflammatory response may result in delayed clinical suspicion of intensive care unit-acquired pneumonia and higher bacterial count.
皮质类固醇在危重症患者中使用较为频繁。然而，关于皮质类固醇在重症监护病房获得性肺炎患者中的作用的信息却很少。我们评估了重症监护病房获得性肺炎患者的临床特征、微生物病因、炎症反应和皮质类固醇治疗史对预后的影响。
前瞻性观察性研究。
一所大学附属医院的重症监护病房。
316 例重症监护病房获得性肺炎患者。根据肺炎发病时是否接受全身皮质类固醇治疗，将患者分为两组。
无。
使用 Cox 回归分析 28 天的生存率，调整皮质类固醇治疗的倾向性。125 例（40%）患者在肺炎发病时接受皮质类固醇治疗。尽管基线临床严重程度相似，但皮质类固醇治疗与 28 天生存率降低（倾向性评分和死亡率预测因素的调整后危险比为 2.503；95%置信区间为 1.176-5.330；p=0.017）和全身炎症反应降低有关。在事后分析中，皮质类固醇治疗对非呼吸机重症监护病房获得性肺炎患者、基线严重程度和器官功能障碍较低的患者、无病因诊断或菌血症的患者的生存率有影响。皮质类固醇的累积剂量对死亡风险没有显著影响，但接受皮质类固醇治疗的患者在诊断时的细菌负荷更高。
在危重症患者中，全身皮质类固醇的使用应非常谨慎，因为这种治疗与重症监护病房获得性肺炎患者死亡风险增加密切相关，特别是在没有明确适应证且基线严重程度较低的患者中。炎症反应降低可能导致对重症监护病房获得性肺炎的临床怀疑延迟，以及细菌计数升高。
