Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
Hepatology. 2012 Dec;56(6):2305-15. doi: 10.1002/hep.25931.
It is unclear whether practice-related aspects of antimicrobial therapy contribute to the high mortality from septic shock among patients with cirrhosis. We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in patients with cirrhosis and septic shock. This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, the United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group between 1996 and 2008. We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of patients with cirrhosis and septic shock. Among 635 patients with cirrhosis and septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time to appropriate antimicrobial administration was 7.3 hours (interquartile range, 3.2-18.3 hours). The use of inappropriate initial antimicrobials was associated with increased mortality (adjusted odds ratio [aOR], 9.5; 95% confidence interval [CI], 4.3-20.7], as was the delay in appropriate antimicrobials (aOR for each 1 hour increase, 1.1; 95% CI, 1.1-1.2). Among patients with eligible bacterial septic shock, a single rather than two or more appropriate antimicrobials was used in 226 (72.9%) patients and was also associated with higher mortality (aOR, 1.8; 95% CI, 1.0-3.3). These findings were consistent across various clinically relevant subgroups.
In patients with cirrhosis and septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high-risk group should be restructured.
尚不清楚抗菌治疗的实践相关方面是否会导致肝硬化患者脓毒性休克的高死亡率。本研究旨在探讨肝硬化合并脓毒性休克患者初始经验性抗菌治疗的各个方面与死亡率之间的关系。
这是一项嵌套队列研究，纳入了 1996 年至 2008 年期间来自加拿大、美国和沙特阿拉伯的 28 个医学中心的脓毒性休克大型回顾性数据库中合作抗菌治疗脓毒性休克数据库研究组的数据。研究分析了初始经验性抗菌治疗变量对肝硬化合并脓毒性休克患者住院死亡率的影响。
共纳入 635 例肝硬化合并脓毒性休克患者，住院死亡率为 75.6%。155 例（24.4%）患者接受了不适当的初始经验性抗菌治疗。开始使用适当抗菌药物的中位时间为 7.3 小时（四分位间距，3.2-18.3 小时）。使用不适当的初始抗菌药物与死亡率增加相关（校正比值比[OR]，9.5；95%置信区间[CI]，4.3-20.7），适当抗菌药物延迟使用（每增加 1 小时，OR 为 1.1；95%CI，1.1-1.2）也是如此。在有明确细菌感染性休克的患者中，226 例（72.9%）患者仅使用了一种而非两种或更多种适当的抗菌药物，死亡率也更高（OR，1.8；95%CI，1.0-3.3）。这些发现与各种临床相关亚组一致。
在肝硬化合并脓毒性休克患者中，不适当和延迟使用适当的初始经验性抗菌治疗与死亡率增加相关。细菌性脓毒性休克的单一治疗也与死亡率增加相关。应重新构建该高危人群经验性抗菌治疗的选择和实施过程。
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