Mongardon Nicolas, Max Adeline, Bouglé Adrien, Pène Frédéric, Lemiale Virginie, Charpentier Julien, Cariou Alain, Chiche Jean-Daniel, Bedos Jean-Pierre, Mira Jean-Paul
Crit Care. 2012 Aug 15;16(4):R155. doi: 10.1186/cc11471.
Community-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP.
We performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded.
Two hundred and twenty two patients were included, with a median SAPS II score reaching 47 [36-64]. Acute respiratory failure (n = 154) and septic shock (n = 54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteraemia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age (OR 1.05 (95% CI: 1.02-1.08)), male sex (OR 2.83 (95% CI: 1.16-6.91)) and renal replacement therapy (OR 3.78 (95% CI: 1.71-8.36)). Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome.
In ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.
社区获得性肺炎（CAP）在重症监护病房（ICU）收治患者中占比很高，肺炎链球菌是这些感染的主要病原体。然而，对于肺炎球菌肺炎的ICU患者的临床特征和预后知之甚少。本研究的目的是提供流行病学数据，并确定因重症肺炎链球菌CAP入住ICU患者的死亡危险因素。
我们对两个前瞻性收集的多中心ICU数据库（2001 - 2008年）进行了回顾性分析。因重症肺炎链球菌CAP入院治疗的患者，如果符合2001年美国胸科学会重症肺炎标准、存在危及生命的器官功能衰竭且肺炎链球菌微生物样本呈阳性，则纳入研究。排除患有支气管炎、吸入性肺炎或非肺部肺炎球菌感染的患者。
共纳入222例患者，简化急性生理学评分（SAPS）II中位数达到47[36 - 64]。急性呼吸衰竭（n = 154）和感染性休克（n = 54）是他们入住ICU最常见的原因。170例患者（77%）发生感染性休克，186例患者（84%）需要机械通气；70例患者（32%）开始接受肾脏替代治疗。101例患者诊断为菌血症。对青霉素敏感性降低的肺炎链球菌菌株患病率为39.7%。尽管92.3%的病例抗菌治疗充分，但医院死亡率仍达到28.8%。多因素分析显示，死亡的独立危险因素为年龄（比值比[OR]1.05（95%置信区间[CI]：1.02 - 1.08））、男性（OR 2.83（95%CI：1.16 - 6.91））和肾脏替代治疗（OR 3.78（95%CI：1.71 - 8.36））。合并症、大环内酯类药物使用、合并菌血症或青霉素敏感性不影响预后。
在ICU中，尽管抗菌治疗充分，但肺炎球菌CAP的死亡率仍然很高。基线人口统计学数据和肾脏替代治疗对不良预后有重大影响。
