中性粒细胞减少的脓毒症患者抗菌治疗的降级：一项观察性研究的结果。

De-escalation of antimicrobial treatment in neutropenic patients with severe sepsis: results from an observational study.

出版信息

Intensive Care Med. 2014 Jan;40(1):41-9. doi: 10.1007/s00134-013-3148-9.

Abstract

BACKGROUND

In severe sepsis, guidelines recommend de-escalating the empirical antimicrobial treatment as soon as the microbiological results are available. We aimed to determine the rate of de-escalation of the empirical antimicrobial treatment in neutropenic patients with severe sepsis. The characteristics of antimicrobial treatment associated with de-escalation and its impact on short- and long-term survival were also determined.

METHODS

In the intensive care unit (ICU) of a cancer referral center, we prospectively collected observational data related to the antimicrobial management in neutropenic patients who developed severe sepsis and were admitted to ICU for at least 48 h. De-escalation of antimicrobial therapy consisted either of deleting one of the empirical antibiotics of a combined treatment, or, whenever possible, to use a betalactam antibiotic with a narrower spectrum of activity. Multivariate logistic regression was conducted to determine the factors associated with de-escalation, while a Cox proportional hazards model with a time-dependent covariate was fitted to assess the effect of de-escalation on 30-day survival. Finally 1-year survival after ICU discharge was compared across de-escalation groups.

RESULTS

Cumulative incidence of de-escalation of the empirical antimicrobial treatment among the 101 patients of the cohort was 44%, [95% confidence interval (CI) 38-53%], including 30 (68%) patients with ongoing neutropenia. A microbiological documentation was available in 63 (63%) patients. Factors associated with de-escalation were the adequation of the empirical antimicrobial treatment in ICU [OR = 10.8 (95% CI 1.20-96)] for adequate documented treatment versus appropriate empirical treatment, the compliance with guidelines regarding the empirical choice of the anti-pseudomonal betalactam [OR = 10.8 (95% CI 1.3-89.5)]. De-escalation did not significantly modify the hazard of death within the first 30 days [HR = 0.51 (95% CI 0.20-1.33)], nor within 1 year after ICU discharge [HR = 1.06 (95% CI 0.54-2.08)].

CONCLUSION

Our data suggest that, in ICU, de-escalation of the empirical antimicrobial treatment is frequently applied in neutropenic cancer patients with severe sepsis. No evidence of any prognostic impact of this de-escalation was found.

摘要

背景

在严重脓毒症中，指南建议一旦获得微生物学结果，就应尽快降低经验性抗菌治疗的强度。我们旨在确定中性粒细胞减少症合并严重脓毒症患者经验性抗菌治疗降级的比率。还确定了与降级相关的抗菌治疗特征及其对短期和长期生存的影响。

方法

在癌症转诊中心的重症监护病房（ICU），我们前瞻性地收集了与中性粒细胞减少症患者抗菌管理相关的观察数据，这些患者发生严重脓毒症并在 ICU 住院至少 48 小时。抗菌治疗降级的方法包括删除联合治疗中的一种经验性抗生素，或者在可能的情况下使用具有更窄作用谱的β内酰胺类抗生素。进行多变量逻辑回归以确定与降级相关的因素，同时拟合具有时间依赖性协变量的 Cox 比例风险模型以评估降级对 30 天生存率的影响。最后，比较了 ICU 出院后 1 年的生存率。

结果

在队列的 101 例患者中，经验性抗菌治疗降级的累积发生率为 44%[95%置信区间（CI）38-53%]，其中 30 例（68%）患者持续中性粒细胞减少。在 63 例（63%）患者中获得了微生物学资料。与降级相关的因素包括 ICU 中经验性抗菌治疗的适当性[OR=10.8（95%CI 1.20-96）]，即适当记录的治疗与适当的经验性治疗相比，以及抗假单胞菌β内酰胺的经验性选择符合指南[OR=10.8（95%CI 1.3-89.5）]。降级并未显著改变 30 天内死亡的风险[HR=0.51（95%CI 0.20-1.33）]，也未改变 ICU 出院后 1 年内的死亡风险[HR=1.06（95%CI 0.54-2.08）]。