1Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain. 2Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Bunyola, Spain. 3Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milano, Italy. 4Department of Pulmonary Rehabilitation, Ospedale Villa Pineta, Pavullo nel Frignano, Modena, Italy. 5Department of Medicine, Winthrop University Hospital, Mineola, NY.
Crit Care Med. 2014 Feb;42(2):303-12. doi: 10.1097/CCM.0b013e3182a272a2.
We evaluated the association between severity of illness and microbial etiology of ICU-acquired pneumonia to define if severity should be used to guide empiric antibiotic choices.
Prospective observational study.
ICUs of a university hospital.
Three hundredy forty-three consecutive patients with ICU-acquired pneumonia clustered, according to the presence of multidrug resistant pathogens.
None.
Two hundred eight patients had ventilator-associated pneumonia and 135 had nonventilator ICU-acquired pneumonia. We determined etiology in 217 patients (63%). The most frequent pathogens were Pseudomonas aeruginosa, Enterobacteriaceae, and methicillin-sensitive and methicillin-resistant Staphylococcus aureus. Fifty-eight patients (17%) had a multidrug-resistant causative agent. Except for a longer ICU stay and a higher rate of microbial persistence at the end of the treatment in the multidrug-resistant group, no differences were found in clinical and inflammatory characteristics, severity criteria, and mortality or survival between patients with and without multidrug-resistant pathogens, even after adjusting for potential confounders. Patients with higher severity scores (Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment) and septic shock at onset of pneumonia had significantly lower 28- and 90-day survival and higher systemic inflammatory response. The results were similar when only patients with microbial diagnosis were considered, as well as when stratified into ventilator-associated pneumonia and nonventilator ICU-acquired pneumonia.
In patients with ICU-acquired pneumonia, severity of illness seems not to affect etiology. Risk factors for multidrug resistant, but not severity of illness, should be taken into account in selecting empiric antimicrobial treatment.
我们评估了 ICU 获得性肺炎的疾病严重程度与微生物病因之间的关联，以确定严重程度是否应用于指导经验性抗生素选择。
前瞻性观察性研究。
一家大学医院的 ICU。
343 例连续 ICU 获得性肺炎患者，根据多药耐药病原体的存在进行聚类。
无。
208 例患者患有呼吸机相关性肺炎，135 例患者患有非呼吸机 ICU 获得性肺炎。我们确定了 217 例患者（63%）的病因。最常见的病原体是铜绿假单胞菌、肠杆菌科和耐甲氧西林敏感和耐甲氧西林金黄色葡萄球菌。58 例患者（17%）有多重耐药病原体。除了在多药耐药组中 ICU 停留时间更长和治疗结束时微生物持续存在的发生率更高之外，在多药耐药组和非多药耐药组患者的临床和炎症特征、严重程度标准以及死亡率或存活率方面，没有发现差异，即使在调整了潜在的混杂因素后也是如此。在肺炎发病时具有较高严重程度评分（急性生理学和慢性健康评估 II 评分和脓毒症相关器官衰竭评估）和感染性休克的患者，28 天和 90 天的生存率显著降低，全身炎症反应更高。当仅考虑有微生物诊断的患者时，以及当分为呼吸机相关性肺炎和非呼吸机 ICU 获得性肺炎时，结果也是相似的。
在 ICU 获得性肺炎患者中，疾病严重程度似乎不会影响病因。应考虑多药耐药的危险因素，而不是疾病严重程度，用于选择经验性抗菌治疗。
