铜绿假单胞菌呼吸机相关性肺炎。治疗失败的预测因素。

Pseudomonas aeruginosa ventilator-associated pneumonia. predictive factors of treatment failure.

机构信息

André Mignot Hospital, Versailles-Le Chesnay, France.

出版信息

Am J Respir Crit Care Med. 2013 Jul 1;188(1):69-76. doi: 10.1164/rccm.201210-1897OC.

DOI:10.1164/rccm.201210-1897OC

PMID:23641973

Abstract

RATIONALE

The predictive factors of treatment failure for ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa (PA) remain uncertain.

OBJECTIVES

To describe PA-VAP recurrence prognosis and to identify associated risk factors in a large cohort of intensive care unit patients with PA-VAP.

METHODS

From the multicenter OUTCOMEREA database (1997-2011), PA-VAP onset and recurrence were recorded. All suspected cases of VAP were confirmed by a positive quantitative culture of a respiratory sample. Multidrug-resistant PA strains were defined by the resistance to two antibiotics among piperacillin, ceftazidime, imipenem, colistine, and fluoroquinolones (FQ). An extensively resistant PA was defined by resistance to piperacillin, ceftazidime, imipenem, and FQ. A treatment failure was defined as a PA-VAP recurrence or by the death occurrence.

MEASUREMENTS AND MAIN RESULTS

A total of 314 patients presented 393 PA-VAP. Failure occurred for 112 of them, including 79 recurrences. Susceptible, multidrug resistant, and extensively resistant PA represented 53.7%, 32%, and 14.3% of the samples, respectively. Factors associated with treatment failure were age (P = 0.02); presence of at least one chronic illness (P = 0.02); limitation of life support (P = 0.0004); a high Sepsis-Related Organ Failure Assessment score (P < 0.0001); PA bacteremia (P = 0.003); and previous use of FQ before the first PA-VAP (P = 0.0007). The failure risk was not influenced by the strain resistance profile or by the biantibiotic treatment, but decreased in case of VAP treatment that includes FQ (subdistribution hazard ratio, 0.5 [0.3-0.7]; P = 0.0006). However, the strain resistance profile slowed down the intensive care unit discharge hazard (subdistribution hazard ratio, 0.6 [0.4-1.0]; P = 0.048).

CONCLUSIONS

Neither resistance profile nor biantibiotic therapy decreased the risk of PA-VAP treatment failure. However, the profile of PA resistance prolonged the length of stay. Better evaluation of the potential benefit of an initial treatment containing FQ requires further randomized trials.

摘要

背景

铜绿假单胞菌（PA）引起的呼吸机相关性肺炎（VAP）的治疗失败的预测因素仍不确定。

目的

描述铜绿假单胞菌 VAP 复发的预后，并确定重症监护病房中大量铜绿假单胞菌 VAP 患者的相关危险因素。

方法

来自多中心 OUTCOMEREA 数据库（1997-2011 年），记录了铜绿假单胞菌 VAP 的发病和复发情况。所有疑似 VAP 病例均通过呼吸道样本的定量培养阳性来确认。耐多药铜绿假单胞菌菌株定义为对哌拉西林、头孢他啶、亚胺培南、黏菌素和氟喹诺酮类（FQ）中的两种抗生素耐药。广泛耐药的铜绿假单胞菌定义为对哌拉西林、头孢他啶、亚胺培南和 FQ 的耐药性。治疗失败定义为铜绿假单胞菌 VAP 复发或死亡发生。

测量和主要结果

共 314 例患者出现 393 例铜绿假单胞菌 VAP。其中 112 例发生治疗失败，包括 79 例复发。敏感、耐多药和广泛耐药的铜绿假单胞菌分别占样本的 53.7%、32%和 14.3%。与治疗失败相关的因素包括年龄（P=0.02）；至少存在一种慢性疾病（P=0.02）；生命支持受限（P=0.0004）；高 Sepsis-Related Organ Failure Assessment 评分（P＜0.0001）；铜绿假单胞菌菌血症（P=0.003）；以及首次铜绿假单胞菌 VAP 前使用 FQ（P=0.0007）。菌株耐药谱或联合使用抗生素治疗并不影响治疗失败的风险，但在包含 FQ 的 VAP 治疗中，失败风险降低（亚分布危险比，0.5[0.3-0.7]；P=0.0006）。然而，菌株耐药谱延长了入住重症监护病房的时间（亚分布危险比，0.6[0.4-1.0]；P=0.048）。