Yokota Paula K O, Marra Alexandre R, Martino Marines D V, Victor Elivane S, Durão Marcelino S, Edmond Michael B, dos Santos Oscar F P
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Laboratory of Microbiology, Hospital Israelita Albert Einstein, São Paulo, Brazil.
PLoS One. 2014 Nov 6;9(11):e104475. doi: 10.1371/journal.pone.0104475. eCollection 2014.
There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes.
This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock.
A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023).
The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.
关于抗生素使用时间、抗生素使用合理性与脓毒症临床结局之间的关联，已有大量文献。事实上，当前的争论焦点在于，在及时进行经验性治疗与谨慎选择合适抗生素（既要考虑感染病原体的敏感性，又要尽量减少因使用广谱药物而产生的耐药性）之间如何取得平衡。本研究的目的是确定严重脓毒症和脓毒性休克患者的脓毒症集束化治疗依从性、抗菌治疗的合理性及其对结局的影响。
本研究在巴西圣保罗一家三级护理私立医院的重症监护病房进行。对2005年7月至2012年12月期间患有严重脓毒症和脓毒性休克的患者进行了一项回顾性队列研究。
共识别出1279例严重脓毒症和脓毒性休克患者，其中358例（32.1%）发生血流感染（BSI）。住院死亡率为29%。在对脓毒症集束化治疗的评估中，随着时间的推移，血清动脉乳酸采集、在使用抗生素前进行血培养、在1小时内使用广谱抗生素以及使用合适的抗菌药物均呈逐步增加趋势，在研究后期有统计学显著差异。我们还观察到死亡率显著下降。在血流感染患者中，在对其他协变量进行调整后，使用合适的抗菌治疗与严重脓毒症和脓毒性休克患者死亡率降低相关（p = 0.023）。
对于因血流感染导致的严重脓毒症和脓毒性休克患者，使用合适的抗菌治疗与死亡率下降独立相关。随着对方案的依从性随时间增加，粗死亡率降低，这强化了实施机构指南并监测合适抗菌治疗依从性的必要性。
