遵循经验性抗菌方案可改善复杂性腹腔内感染的预后：一项前瞻性观察研究。
Compliance with an empirical antimicrobial protocol improves the outcome of complicated intra-abdominal infections: a prospective observational study.
机构信息
Department of Anaesthesiology and Critical Medicine.
Department of Anaesthesiology and Critical Medicine INSERM UMR 1088, Jules Verne University Picardy, Amiens, France.
出版信息
Br J Anaesth. 2016 Jul;117(1):66-72. doi: 10.1093/bja/aew117.
BACKGROUND
Despite improvements in medical and surgical care, mortality attributed to complicated intra-abdominal infections (cIAI) remains high. Appropriate initial antimicrobial therapy (ABT) is key to successful management. The main causes of non-compliance with empirical protocols have not been clearly described.
METHODS
An empirical ABT protocol was designed according to guidelines, validated in the institution and widely disseminated. All patients with cIAI (2009-2011) were then prospectively studied to evaluate compliance with this protocol and its impact on outcome. Patients were classified into two groups according to whether or not they received ABT in compliance with the protocol.
RESULTS
310 patients were included: 223 (71.9%) with community-acquired and 87 (28.1%) with healthcare-associated cIAI [mean age 60(17-97) yr, mean SAPS II score 24(16)]. Empirical ABT complied with the protocol in 52.3% of patients. The appropriateness of empirical ABT to target the bacteria isolated was 80%. Independent factors associated with non-compliance with the protocol were the anaesthetist's age ≥36 yr [OR 2.1; 95%CI (1.3-3.4)] and the presence of risk factors for multidrug-resistant bacteria (MDRB) [OR 5.4; 95%CI (3.0-9.5)]. Non-compliance with the protocol was associated with higher mortality (14.9 vs 5.6%, P=0.011) and morbidity: relaparotomy (P=0.047), haemodynamic failure (P=0.001), postoperative pneumonia (P=0.025), longer duration of mechanical ventilation (P<0.001), longer ICU stay (P<0.001) and longer hospital stay (P=0.002). On multivariate logistic regression analysis, non-compliance with the ABT protocol was independently associated with mortality [OR 2.4; 95% CI (1.1-5.7), P=0.04].
CONCLUSIONS
Non-compliance with empirical ABT guidelines in cIAI is associated with increased morbidity and mortality. Information campaigns should target older anaesthetists and risk factors for MDRB.
背景
尽管在医疗和外科治疗方面有所进步，但归因于复杂的腹腔内感染（cIAI）的死亡率仍然很高。适当的初始抗菌治疗（ABT）是成功治疗的关键。不符合经验性方案的主要原因尚未明确描述。
方法
根据指南设计了经验性 ABT 方案，在机构中进行了验证并广泛传播。然后对所有患有 cIAI（2009-2011 年）的患者进行前瞻性研究，以评估对该方案的依从性及其对结局的影响。根据是否按照方案接受 ABT，将患者分为两组。
结果
共纳入 310 例患者：223 例（71.9%）为社区获得性感染，87 例（28.1%）为医疗保健相关感染[平均年龄 60（17-97）岁，平均 SAPS II 评分 24（16）]。经验性 ABT 符合方案的患者占 52.3%。经验性 ABT 对分离出的细菌的适当性为 80%。与不遵守方案相关的独立因素是麻醉师年龄≥36 岁[比值比 2.1；95%置信区间（1.3-3.4）]和存在耐多药细菌（MDRB）的危险因素[比值比 5.4；95%置信区间（3.0-9.5）]。不遵守方案与更高的死亡率（14.9% vs 5.6%，P=0.011）和发病率相关：再次剖腹手术（P=0.047）、血流动力学衰竭（P=0.001）、术后肺炎（P=0.025）、机械通气时间延长（P<0.001）、ICU 住院时间延长（P<0.001）和住院时间延长（P=0.002）。多变量逻辑回归分析显示，不遵守 ABT 方案与死亡率独立相关[比值比 2.4；95%置信区间（1.1-5.7），P=0.04]。
结论
cIAI 中不符合经验性 ABT 指南与发病率和死亡率增加有关。信息宣传活动应针对年龄较大的麻醉师和 MDRB 的危险因素。
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