一种新的医疗相关性肺炎策略：一项使用多重耐药病原体危险因素选择初始经验性治疗的 2 年前瞻性多中心队列研究。
A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy.
机构信息
Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu.
出版信息
Clin Infect Dis. 2013 Nov;57(10):1373-83. doi: 10.1093/cid/cit571. Epub 2013 Sep 2.
BACKGROUND
Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) is uncertain.
METHODS
We prospectively applied a therapeutic algorithm, based on the presence of risk factors for multidrug-resistant (MDR) pathogens in a multicenter cohort study of 445 pneumonia patients, including both community-acquired pneumonia (CAP; n = 124) and HCAP (n = 321).
RESULTS
MDR pathogens were more common (15.3% vs 0.8%, P < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0-1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, yet 92.9% received appropriate therapy for the identified pathogen. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0-1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .012). In multivariate analysis, initial treatment failure, but not inappropriate empiric antibiotic therapy, was a mortality risk factor (odds ratio, 72.0).
CONCLUSIONS
Basing empiric HCAP therapy on its severity and the presence of risk factors for MDR pathogens is a potentially useful approach that achieves good outcomes without excessive use of broad-spectrum antibiotic therapy.
CLINICAL TRIALS REGISTRATION
Japan Medical Association Center for Clinical Trials, JMA-IIA00054.
背景
对于医院获得性肺炎（HCAP）患者，最佳经验性治疗方法尚不确定。
方法
我们前瞻性地在一项多中心队列研究中应用了一种治疗算法，该研究纳入了 445 例肺炎患者，包括社区获得性肺炎（CAP；n=124）和 HCAP（n=321），该算法基于多药耐药（MDR）病原体危险因素的存在情况。
结果
HCAP 患者中 MDR 病原体更为常见（15.3%比 0.8%，P<0.001），包括金黄色葡萄球菌（11.5%比 0.8%，P<0.001）；耐甲氧西林金黄色葡萄球菌（6.9%比 0%，P=0.003）；肠杆菌科（7.8%比 2.4%，P=0.037）；和铜绿假单胞菌（6.9%比 0.8%，P=0.01）。根据提出的算法，≥2 种 MDR 危险因素且其中一种为疾病严重程度（n=170）的 HCAP 患者与 0-1 种危险因素的 HCAP 患者（n=151）相比，MDR 病原体的发生率明显更高（27.1%比 2%，P<0.001）。总体而言，93.1%的 HCAP 患者按照治疗算法接受治疗，仅有 53%接受了广谱经验性治疗，但 92.9%接受了针对鉴定病原体的适当治疗。HCAP 的 30 天死亡率明显高于 CAP（13.7%比 5.6%，P=0.017），但在 0-1 种 MDR 危险因素的 HCAP 患者中，死亡率低于≥2 种 MDR 危险因素的患者（8.6%比 18.2%，P=0.012）。多变量分析显示，初始治疗失败是死亡的危险因素，但经验性抗生素治疗不当不是（比值比，72.0）。
结论
根据疾病严重程度和 MDR 病原体危险因素制定经验性 HCAP 治疗方案可能是一种有用的方法，它可以在不过度使用广谱抗生素治疗的情况下获得良好的效果。
临床试验注册
日本医学会临床试验中心，JMA-IIA00054。
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