1 Department of Internal Medicine and.
Am J Respir Crit Care Med. 2014 May 15;189(10):1204-13. doi: 10.1164/rccm.201310-1875OC.
Mortality caused by septic shock may be determined by a systemic inflammatory response, independent of the inciting infection, but it may also be influenced by the anatomic source of infection.
To determine the association between the anatomic source of infection and hospital mortality in critically ill patients who have septic shock.
This was a retrospective, multicenter cohort study of 7,974 patients who had septic shock in 29 academic and community intensive care units in Canada, the United States, and Saudi Arabia from January 1989 to May 2008.
Subjects were assigned 1 of 20 anatomic sources of infection based on clinical diagnosis and/or isolation of pathogens. The primary outcome was hospital mortality. Overall crude hospital mortality was 52% (21-85% across sources of infection). Variation in mortality remained after adjusting for year of admission, geographic source of admission, age, sex, comorbidities, community- versus hospital-acquired infection, and organism type. The source of infection with the highest standardized hospital mortality was ischemic bowel (75%); the lowest was obstructive uropathy-associated urinary tract infection (26%). Residual variation in adjusted hospital mortality was not explained by Acute Physiology and Chronic Health Evaluation II score, number of Day 1 organ failures, bacteremia, appropriateness of empiric antimicrobials, or adjunct therapies. In patients who received appropriate antimicrobials after onset of hypotension, source of infection was associated with death after adjustment for both predisposing and downstream factors.
Anatomic source of infection should be considered in future trial designs and analyses, and in development of prognostic scoring systems.
感染性休克导致的死亡率可能取决于全身炎症反应，而与引发感染的病原体无关，但也可能受到感染源的解剖位置的影响。
确定感染源的解剖位置与患有感染性休克的危重病患者的院内死亡率之间的关联。
这是一项回顾性、多中心队列研究，纳入了 1989 年 1 月至 2008 年 5 月期间加拿大、美国和沙特阿拉伯的 29 家学术和社区重症监护病房的 7974 例患有感染性休克的患者。
根据临床诊断和/或病原体分离，将患者分配到 20 种感染源中的 1 种。主要结局为院内死亡率。总体粗死亡率为 52%（21-85%，各感染源之间存在差异）。在校正入院年份、入院地理来源、年龄、性别、合并症、社区获得性感染与医院获得性感染以及病原体类型后，死亡率的差异仍然存在。标准化院内死亡率最高的感染源是缺血性肠病（75%）；最低的是与梗阻性尿路病相关的尿路感染（26%）。调整后的院内死亡率的剩余差异无法用急性生理学和慢性健康评估 II 评分、第 1 天器官衰竭的数量、菌血症、经验性抗菌药物的适当性或辅助治疗来解释。在低血压发生后接受适当抗菌药物治疗的患者中，在调整了易患因素和下游因素后，感染源与死亡相关。
在未来的试验设计和分析中，以及在开发预后评分系统时，应考虑感染源的解剖位置。
