Poulikakos P, Tansarli G S, Falagas M E
Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23, Marousi, Athens, Greece.
Eur J Clin Microbiol Infect Dis. 2014 Oct;33(10):1675-85. doi: 10.1007/s10096-014-2124-9. Epub 2014 May 16.
Controversy surrounds combination treatment or monotherapy against multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) Acinetobacter infections in clinical practice. We searched the PubMed and Scopus databases for studies reporting on the clinical outcomes of patients infected with MDR, XDR, and PDR Acinetobacter spp. with regard to the administered intravenous antibiotic treatment. Twelve studies reporting on 1,040 patients suffering from 1,044 infectious episodes of MDR Acinetobacter spp. were included. The overall mortality between studies varied from 28.6 to 70 %; from 25 to 100 % in the monotherapy arm and from 27 to 57.1 % in the combination arm. Combination treatment was superior to monotherapy in three studies, where carbapenem with ampicillin/sulbactam (mortality 30.8 %, p = 0.012), carbapenem with colistin (mortality 23 %, p = 0.009), and combinations of colistin with rifampicin, sulbactam with aminoglycosides, tigecycline with colistin and rifampicin, and tigecycline with rifampicin and amikacin (mortality 27 %, p < 0.05) were used against MDR Acinetobacter spp. resistant at least to carbapenems. The benefit was not validated in the remaining studies. Clinical success varied from 42.4 to 76.9 % and microbiological eradication varied from 32.7 to 67.3 %. Adverse events referred mainly to polymixins nephrotoxicity that varied from 19 to 50 %. The emergence of resistance was noted with tigecycline regimens in off-label uses in three studies. The available data preclude a firm recommendation with regard to combination treatment or monotherapy. For the time being, combination treatment may be preferred for severely ill patients. We urge for randomized controlled trials examining the optimal treatment of infections due to MDR, XDR, and PDR Acinetobacter spp.
在临床实践中，针对多重耐药（MDR）、广泛耐药（XDR）和泛耐药（PDR）不动杆菌感染的联合治疗或单一疗法存在争议。我们检索了PubMed和Scopus数据库，以查找有关接受静脉抗生素治疗的MDR、XDR和PDR不动杆菌属感染患者临床结局的研究。纳入了12项研究，报告了1040例患有1044次MDR不动杆菌属感染发作的患者。各研究之间的总体死亡率从28.6%至70%不等；单一疗法组为25%至100%，联合疗法组为27%至57.1%。在三项研究中，联合治疗优于单一疗法，其中碳青霉烯类与氨苄西林/舒巴坦联合使用（死亡率30.8%，p = 0.012）、碳青霉烯类与多黏菌素联合使用（死亡率23%，p = 0.009），以及多黏菌素与利福平联合使用、舒巴坦与氨基糖苷类联合使用、替加环素与多黏菌素和利福平联合使用、替加环素与利福平和阿米卡星联合使用（死亡率27%，p < 0.05），用于治疗至少对碳青霉烯类耐药的MDR不动杆菌属。在其余研究中，这种益处未得到验证。临床成功率从42.4%至76.9%不等，微生物清除率从32.7%至67.3%不等。不良事件主要涉及多黏菌素肾毒性，发生率从19%至50%不等。在三项研究中，替加环素方案在超说明书使用时出现了耐药性。现有数据无法就联合治疗或单一疗法给出确切建议。目前，对于重症患者可能更倾向于联合治疗。我们敦促开展随机对照试验，以研究MDR、XDR和PDR不动杆菌属感染的最佳治疗方法。
