Tellor Bethany, Skrupky Lee P, Symons William, High Eric, Micek Scott T, Mazuski John E
1 Pharmacy Department, Barnes-Jewish Hospital , St Louis, Missouri.
2 Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine , St Louis, Missouri.
Surg Infect (Larchmt). 2015 Dec;16(6):785-93. doi: 10.1089/sur.2014.166. Epub 2015 Aug 10.
Patients with intra-abdominal sepsis and associated bacteremia have a high mortality rate. However, outcomes studies in this population are limited, in part because of the small numbers of such patients. The objective of this study was to describe characteristics of critically ill patients with secondary blood stream infection (BSI) of intra-abdominal origin and identify predictors of mortality.
This retrospective, single-center study evaluated patients admitted between January 2005 and January 2011 with bacteremia because of an intra-abdominal source. Patients were included if they met criteria for severe sepsis based on International Classification of Diseases, 9th Revision (ICD 9) codes for acute organ dysfunction, had a positive blood culture, had at least one ICD 9 code indicative of an intra-abdominal process, and had a confirmed or clinically suspected intra-abdominal infection (IAI) within 72 h of the blood culture. Chart review was performed to confirm the presence of these criteria and also the absence of any other potential source of bacteremia. Data were collected on patient demographics, BSI source, source control procedure details, microorganisms isolated, and antibiotics administered. Multivariable logistic regression analysis was performed to identify independent predictors of mortality.
Three hundred six patients with BSI were identified, of which 108 episodes were deemed to be of intra-abdominal origin. Gram-negative organisms comprised 43% of blood isolates, followed by gram-positives (33%), anaerobes (14%), and yeast (9%). Appropriate antimicrobial therapy was administered in 71% of patients. The overall mortality rate was 27.8%. As compared with survivors, non-survivors were older, more likely to have underlying COPD or asthma, and have renal or metabolic failure (p<0.05 for all). Among non-survivors, adequate source control was obtained less frequently (64% vs. 91%, p=0.002) and median time to appropriate antibiotics was longer (23 h vs. 4 h, p=0.004). Logistic regression analysis revealed inadequate source control (p=0.002) and inappropriate antibiotics (p=0.016) to be independently associated with mortality.
Critically ill patients with a BSI of abdominal origin are at high risk for mortality. Failure to achieve adequate source control and administration of inappropriate antibiotics were independent predictors of mortality. Thus, these represent potential opportunities to impact outcomes in patients with complicated IAI.
腹内脓毒症及相关菌血症患者的死亡率很高。然而，针对这一人群的预后研究有限，部分原因是这类患者数量较少。本研究的目的是描述腹内源性继发性血流感染（BSI）的重症患者的特征，并确定死亡率的预测因素。
这项回顾性单中心研究评估了2005年1月至2011年1月因腹内感染源导致菌血症而入院的患者。如果患者符合基于国际疾病分类第九版（ICD-9）急性器官功能障碍编码的严重脓毒症标准、血培养呈阳性、至少有一个ICD-9编码表明存在腹内病变，并且在血培养后72小时内确诊或临床怀疑存在腹内感染（IAI），则纳入研究。进行病历审查以确认这些标准的存在以及不存在任何其他潜在的菌血症来源。收集患者人口统计学资料、BSI来源、源头控制程序细节、分离出的微生物以及使用的抗生素等数据。进行多变量逻辑回归分析以确定死亡率的独立预测因素。
共识别出306例BSI患者，其中108例被认为是腹内源性的。革兰氏阴性菌占血培养分离菌的43%，其次是革兰氏阳性菌（33%）、厌氧菌（14%）和酵母菌（9%）。71%的患者接受了适当的抗菌治疗。总体死亡率为27.8%。与幸存者相比，非幸存者年龄更大，更有可能患有潜在的慢性阻塞性肺疾病（COPD）或哮喘，以及存在肾或代谢衰竭（所有p值均<0.05）。在非幸存者中，获得充分源头控制的频率较低（64%对91%，p = 0.002），且开始使用适当抗生素的中位时间更长（23小时对4小时，p = 0.004）。逻辑回归分析显示，源头控制不充分（p = 0.002）和抗生素使用不当（p = 0.016）与死亡率独立相关。
腹内源性BSI的重症患者死亡风险很高。未能实现充分的源头控制和使用不当的抗生素是死亡率的独立预测因素。因此，这些是影响复杂性IAI患者预后的潜在机会。
