Cobos-Trigueros Nazaret, Solé Mar, Castro Pedro, Torres Jorge Luis, Hernández Cristina, Rinaudo Mariano, Fernández Sara, Soriano Álex, Nicolás José María, Mensa Josep, Vila Jordi, Martínez José Antonio
Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic, University of Barcelona, Barcelona, Spain.
Crit Care. 2015 May 4;19(1):218. doi: 10.1186/s13054-015-0916-7.
The objective of this work was to investigate the risk factors for the acquisition of Pseudomonas aeruginosa and its resistance phenotypes in critically ill patients, taking into account colonization pressure.
We conducted a prospective cohort study in an 8-bed medical intensive care unit during a 35-month period. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48 hours of admission and thrice weekly thereafter. During the study, a policy of consecutive mixing and cycling periods of three classes of antipseudomonal antibiotics was followed in the unit.
Of 850 patients admitted for ≥ 3 days, 751 (88.3%) received an antibiotic, 562 of which (66.1%) were antipseudomonal antibiotics. A total of 68 patients (8%) carried P. aeruginosa upon admission, and among the remaining 782, 104 (13%) acquired at least one strain of P. aeruginosa during their stay. Multivariate analysis selected shock (odds ratio (OR) = 2.1; 95% confidence interval (CI), 1.2 to 3.7), intubation (OR = 3.6; 95% CI, 1.7 to 7.5), enteral nutrition (OR = 3.6; 95% CI, 1.8 to 7.6), parenteral nutrition (OR = 3.9; 95% CI, 1.6 to 9.6), tracheostomy (OR = 4.4; 95% CI, 2.3 to 8.3) and colonization pressure >0.43 (OR = 4; 95% CI, 1.2 to 5) as independently associated with the acquisition of P. aeruginosa, whereas exposure to fluoroquinolones for >3 days (OR = 0.4; 95% CI, 0.2 to 0.8) was protective. In the whole series, prior exposure to carbapenems was independently associated with carbapenem resistance, and prior amikacin use predicted piperacillin-tazobactam, fluoroquinolone and multiple-drug resistance.
In critical care settings with a high rate of antibiotic use, colonization pressure and non-antibiotic exposures may be the crucial factors for P. aeruginosa acquisition, whereas fluoroquinolones may actually decrease its likelihood. For the acquisition of strains resistant to piperacillin-tazobactam, fluoroquinolones and multiple drugs, exposure to amikacin may be more relevant than previously recognized.
本研究旨在探讨重症患者感染铜绿假单胞菌及其耐药表型的危险因素，并考虑定植压力。
我们在一个拥有8张床位的医疗重症监护病房进行了一项为期35个月的前瞻性队列研究。入院后48小时内采集鼻咽拭子、直肠拭子和呼吸道分泌物，此后每周三次。在研究期间，该病房遵循了三类抗假单胞菌抗生素连续混合和循环使用的策略。
在850例住院≥3天的患者中，751例（88.3%）接受了抗生素治疗，其中562例（66.1%）使用了抗假单胞菌抗生素。共有68例患者（8%）入院时携带铜绿假单胞菌，在其余782例患者中，104例（13%）在住院期间至少获得了一株铜绿假单胞菌。多因素分析选择休克（比值比（OR）=2.1；95%置信区间（CI），1.2至3.7）、插管（OR = 3.6；95% CI，1.7至7.5）、肠内营养（OR = 3.6；95% CI，1.8至7.6）、肠外营养（OR = 3.9；95% CI，1.6至9.6）、气管切开术（OR = 4.4；95% CI，2.3至8.3）和定植压力>0.43（OR = 4；95% CI，1.2至5）作为与铜绿假单胞菌感染独立相关的因素，而暴露于氟喹诺酮类药物>3天（OR = 0.4；95% CI，0.2至0.8）具有保护作用。在整个队列中，先前接触碳青霉烯类药物与碳青霉烯类耐药独立相关，先前使用阿米卡星可预测哌拉西林-他唑巴坦、氟喹诺酮类和多重耐药。
在抗生素使用率高的重症监护环境中，定植压力和非抗生素暴露可能是铜绿假单胞菌感染的关键因素，而氟喹诺酮类药物实际上可能降低其感染可能性。对于获得对哌拉西林-他唑巴坦、氟喹诺酮类和多种药物耐药的菌株，接触阿米卡星可能比之前认识到的更为重要。
