甲型H7N9流感病毒性肺炎成人患者的辅助性皮质类固醇治疗

Adjuvant Corticosteroid Treatment in Adults With Influenza A (H7N9) Viral Pneumonia.

作者信息

Cao Bin, Gao Hainv, Zhou Boping, Deng Xilong, Hu Chengping, Deng Chaosheng, Lu Hongzhou, Li Yuping, Gan Jianhe, Liu Jingyuan, Li Hui, Zhang Yao, Yang Yida, Fang Qiang, Shen Yinzhong, Gu Qin, Zhou Xianmei, Zhao Wei, Pu Zenghui, Chen Ling, Sun Baoxia, Liu Xi, Hamilton Carol Dukes, Li Lanjuan

机构信息

1Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China. 2State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China. 3Shenzhen Third People's Hospital, Shenzhen City, Guangdong Province, China. 4Guangzhou No. 8 People's Hospital, Guangzhou City, Guangdong Province, China. 5Xiangya Hospital, Central South University, Changsha City, Hunan Province, China. 6First Affiliated Hospital of Fujian Medical University, Fuzhou City, Fujian Province, China. 7Shanghai Public Health Clinical Center, Fudan University, Shanghai, China. 8The First Affiliated Hospital, Wenzhou Medical College, Wenzhou City, Zhejiang Province, China. 9The First Affiliated Hospital, Medical College of Soochow University, Suzhou, Jiangsu Province, China. 10Beijing Ditan Hospital, Capital Medical University, Beijing, China. 11Global Health, Population and Nutrition, Global Research and Services, Family Health International 360, Durham, NC. 12Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical school, Nanjing University, Nanjing City, Jiangsu Province, China. 13Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing City, Jiangsu Province, China. 14The Second Affiliated Hospital of the Southeast University, Nanjing City, Jiangsu Province, China. 15Yantai Yu Huang-Ding Hospital, Yantai City, Shandong Province, China. 16Affiliated Hospital of Zunyi Medical College, Zunyi City, Guizhou Province, China. 17Zaozhuang Municipal Hospital, Zaozhuang City, Shandong Province, China. 18Global Health, Population & Nutrition, Family Health International 360, Duke University, Durham, NC. 19China-Japan Friendship Hospital, Beijing, China.

出版信息

Crit Care Med. 2016 Jun;44(6):e318-28. doi: 10.1097/CCM.0000000000001616.

DOI:10.1097/CCM.0000000000001616

PMID:26934144

Abstract

OBJECTIVE

To determine the impact of adjuvant corticosteroids administered to patients hospitalized with influenza A (H7N9) viral pneumonia.

DESIGN

The effects of adjuvant corticosteroids on mortality were assessed using multivariate Cox regression and a propensity score-matched case-control study. Nosocomial infections and viral shedding were also compared.

SETTING

Hospitals with influenza A (H7N9) viral pneumonia patient admission in 84 cities and 16 provinces of Mainland China.

PATIENTS

Adolescent and Adult patients aged >14 yr with severe laboratory-confirmed influenza A (H7N9) virus infections were screened from April 2013 to March 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The study population comprised 288 cases who were hospitalized with influenza A (H7N9) viral pneumonia. The median age of the study population was 58 years, 69.8% of the cohort comprised male patients, and 51.4% had at least one type of underlying diseases. The in-hospital mortality was 31.9%. Two hundred and four patients (70.8%) received adjuvant corticosteroids; among them, 193 had hypoxemia and lung infiltrates, 11 had chronic obstructive pulmonary disease, and 11 had pneumonia only. Corticosteroids were initiated within 7 days (interquartile range, 5.0-9.4 d) of the onset of illness and the maximum dose administered was equivalent to 80-mg methylprednisolone (interquartile range, 40-120 mg). The patients were treated with corticosteroids for a median duration of 7 days (interquartile range, 4.0-11.3 d). Cox regression analysis showed that compared with the patients who did not receive corticosteroid, those who received corticosteroid had a significantly higher 60-day mortality (adjusted hazards ratio, 1.98; 95% CI, 1.03-3.79; p = 0.04). Subgroup analysis showed that high-dose corticosteroid therapy (> 150 mg/d methylprednisolone or equivalent) significantly increased both 30-day and 60-day mortality, whereas no significant impact was observed for low-to-moderate doses of corticosteroids (25-150 mg/d methylprednisolone or equivalent). The propensity score-matched case-control analysis showed that the median viral shedding time was much longer in the group that received high-dose corticosteroids (15 d), compared with patients who did not receive corticosteroids (13 d; p = 0.039).

CONCLUSIONS

High-dose corticosteroids were associated with increased mortality and longer viral shedding in patients with influenza A (H7N9) viral pneumonia.

摘要

目的

确定给予甲型H7N9流感病毒性肺炎住院患者辅助性皮质类固醇激素的影响。

设计

使用多变量Cox回归和倾向评分匹配病例对照研究评估辅助性皮质类固醇激素对死亡率的影响。还比较了医院感染和病毒脱落情况。

地点

中国大陆16个省份84个城市收治甲型H7N9流感病毒性肺炎患者的医院。

患者

2013年4月至2015年3月期间，对年龄>14岁、实验室确诊为重症甲型H7N9病毒感染的青少年及成年患者进行筛查。

干预措施

无。

测量指标及主要结果

研究人群包括288例甲型H7N9流感病毒性肺炎住院患者。研究人群的中位年龄为58岁，队列中69.8%为男性患者，51.4%至少有一种基础疾病。住院死亡率为31.9%。204例患者（70.8%）接受了辅助性皮质类固醇激素治疗；其中，193例有低氧血症和肺部浸润，11例有慢性阻塞性肺疾病，11例仅有肺炎。皮质类固醇激素在发病7天内（四分位间距，5.0 - 9.4天）开始使用，最大剂量相当于80mg甲泼尼龙（四分位间距，40 - 120mg）。患者接受皮质类固醇激素治疗的中位持续时间为7天（四分位间距，4.0 - 11.3天）。Cox回归分析显示，与未接受皮质类固醇激素治疗的患者相比，接受皮质类固醇激素治疗的患者60天死亡率显著更高（调整后风险比，1.98；95%置信区间，1.03 - 3.79；p = 0.04）。亚组分析显示，高剂量皮质类固醇激素治疗（>150mg/d甲泼尼龙或等效剂量）显著增加30天和60天死亡率，而低至中等剂量的皮质类固醇激素（25 - 150mg/d甲泼尼龙或等效剂量）未观察到显著影响。倾向评分匹配病例对照分析显示，接受高剂量皮质类固醇激素治疗的组（15天）病毒脱落中位时间比未接受皮质类固醇激素治疗的患者（13天）长得多（p = 0.039）。