Soubirou Jean-François, Gault Nathalie, Alfaiate Toni, Lolom Isabelle, Tubach Florence, Andremont Antoine, Lucet Jean-Christophe, Wolff Michel, Barbier François
From Réanimation Médicale et des Maladies Infectieuses.
Scand J Infect Dis. 2014 Mar;46(3):215-20. doi: 10.3109/00365548.2013.871644. Epub 2014 Jan 21.
Risk factors for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Gram-negative bacilli (CR-GNB) have rarely been evaluated in intensive care units (ICU) without epidemic carbapenemase-producing Acinetobacter baumannii or Enterobacteriaceae. We addressed this issue in a cohort of 141 patients (previous antimicrobial exposure, n = 131) with a first episode of VAP in a medico-surgical ICU. Twenty-six VAP (18.4%) involved a CR-GNB (Pseudomonas aeruginosa, n = 14, Stenotrophomonas maltophilia, n = 11, and A. baumannii, n = 1), without previous carbapenem exposure in 12 (46.1%) cases. GNB resistant to all β-lactams except carbapenems were equally isolated in CR-GNB VAP (co-infections, 23%) and other episodes (30%). Previous exposure to aminoglycosides (odds ratio (OR) 1.14 per day, 95% confidence interval (CI) 1.02-1.30, p = 0.02) and the number of antimicrobial classes used before VAP (OR 1.38 per class, 95% CI 1.10-1.73, p = 0.006) were the only independent predictors of CR-GNB. These results suggest that the empirical use of a carbapenem-colistin combination should be evaluated in late-onset VAP following broad-spectrum antimicrobial exposure.
在没有产碳青霉烯酶鲍曼不动杆菌或肠杆菌科流行的重症监护病房（ICU）中，耐碳青霉烯革兰氏阴性杆菌（CR-GNB）引起的呼吸机相关性肺炎（VAP）的危险因素很少得到评估。我们在一个内科-外科ICU的141例首次发生VAP的患者队列（既往有抗菌药物暴露史，n = 131）中解决了这个问题。26例VAP（18.4%）涉及CR-GNB（铜绿假单胞菌，n = 14；嗜麦芽窄食单胞菌，n = 11；鲍曼不动杆菌，n = 1），其中12例（46.1%）既往没有碳青霉烯类药物暴露史。在CR-GNB VAP（合并感染，23%）和其他VAP发作（30%）中，对除碳青霉烯类以外的所有β-内酰胺类耐药的革兰氏阴性杆菌分离率相同。既往使用氨基糖苷类药物（比值比（OR）为每天1.14，95%置信区间（CI）为1.02-1.30，p = 0.02）和VAP发作前使用的抗菌药物种类数（OR为每类1.38，95%CI为1.10-1.73，p = 0.006）是CR-GNB的唯一独立预测因素。这些结果表明，在广谱抗菌药物暴露后的迟发性VAP中，应评估碳青霉烯类-黏菌素联合用药的经验性使用情况。
