重症内科患者抗生素使用的混合策略与循环策略评估：对耐药微生物获得及临床结局的影响
Evaluation of a Mixing versus a Cycling Strategy of Antibiotic Use in Critically-Ill Medical Patients: Impact on Acquisition of Resistant Microorganisms and Clinical Outcomes.
作者信息
Cobos-Trigueros Nazaret, Solé Mar, Castro Pedro, Torres Jorge Luis, Rinaudo Mariano, De Lazzari Elisa, Morata Laura, Hernández Cristina, Fernández Sara, Soriano Alex, Nicolás José María, Mensa Josep, Vila Jordi, Martínez José Antonio
机构信息
Department of Infectious Diseases, Hospital Clínic, IDIBAPS, Barcelona University, Barcelona, Spain.
ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic - University of Barcelona, Barcelona, Spain.
出版信息
PLoS One. 2016 Mar 16;11(3):e0150274. doi: 10.1371/journal.pone.0150274. eCollection 2016.
OBJECTIVE
To compare the effect of two strategies of antibiotic use (mixing vs. cycling) on the acquisition of resistant microorganisms, infections and other clinical outcomes.
METHODS
Prospective cohort study in an 8-bed intensive care unit during 35- months in which a mixing-cycling policy of antipseudomonal beta-lactams (meropenem, ceftazidime/piperacillin-tazobactam) and fluoroquinolones was operative. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48h of admission and thrice weekly thereafter. Target microorganisms included methicillin-resistant S. aureus, vancomycin-resistant enterococci, third-generation cephalosporin-resistant Enterobacteriaceae and non-fermenters.
RESULTS
A total of 409 (42%) patients were included in mixing and 560 (58%) in cycling. Exposure to ceftazidime/piperacillin-tazobactam and fluoroquinolones was significantly higher in mixing while exposure to meropenem was higher in cycling, although overall use of antipseudomonals was not significantly different (37.5/100 patient-days vs. 38.1/100 patient-days). There was a barely higher acquisition rate of microorganisms during mixing, but this difference lost its significance when the cases due to an exogenous Burkholderia cepacia outbreak were excluded (19.3% vs. 15.4%, OR 0.8, CI 0.5-1.1). Acquisition of Pseudomonas aeruginosa resistant to the intervention antibiotics or with multiple-drug resistance was similar. There were no significant differences between mixing and cycling in the proportion of patients acquiring any infection (16.6% vs. 14.5%, OR 0.9, CI 0.6-1.2), any infection due to target microorganisms (5.9% vs. 5.2%, OR 0.9, CI 0.5-1.5), length of stay (median 5 d for both groups) or mortality (13.9 vs. 14.3%, OR 1.03, CI 0.7-1.3).
CONCLUSIONS
A cycling strategy of antibiotic use with a 6-week cycle duration is similar to mixing in terms of acquisition of resistant microorganisms, infections, length of stay and mortality.
目的
比较两种抗生素使用策略（混合使用与轮换使用）对耐药微生物的获得、感染及其他临床结局的影响。
方法
在一家拥有8张床位的重症监护病房进行为期35个月的前瞻性队列研究，在此期间实施抗假单胞菌β-内酰胺类抗生素（美罗培南、头孢他啶/哌拉西林-他唑巴坦）和氟喹诺酮类药物的混合-轮换策略。入院后48小时内采集鼻咽拭子、直肠拭子及呼吸道分泌物，此后每周采集三次。目标微生物包括耐甲氧西林金黄色葡萄球菌、耐万古霉素肠球菌、对第三代头孢菌素耐药的肠杆菌科细菌及非发酵菌。
结果
共有409例（42%）患者采用混合使用策略，560例（58%）患者采用轮换使用策略。混合使用时头孢他啶/哌拉西林-他唑巴坦和氟喹诺酮类药物的暴露量显著更高，而轮换使用时美罗培南的暴露量更高，尽管抗假单胞菌药物的总体使用量无显著差异（37.5/100患者日 vs. 38.1/100患者日）。混合使用时微生物的获得率略高，但排除因洋葱伯克霍尔德菌外源性暴发导致的病例后，这种差异失去了统计学意义（19.3% vs. 15.4%，OR 0.8，CI 0.5-1.1）。对干预抗生素耐药或具有多重耐药性的铜绿假单胞菌的获得情况相似。在获得任何感染的患者比例（16.6% vs. 14.5%，OR 0.9，CI 0.6-1.2）、因目标微生物导致的任何感染（5.9% vs. 5.2%，OR 0.9，CI 0.5-1.5）、住院时间（两组中位数均为5天）或死亡率（13.9% vs. 14.3%，OR 1.03，CI 0.7-1.3）方面，混合使用与轮换使用之间无显著差异。
结论
为期6周的抗生素轮换使用策略在耐药微生物的获得、感染、住院时间和死亡率方面与混合使用策略相似。
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