Loftus Tyler J, Brakenridge Scott C, Moore Frederick A, Lemon Stephen J, Nguyen Linda L, Voils Stacy A, Jordan Janeen R, Croft Chasen A, Smith R Stephen, Efron Phillip A, Mohr Alicia M
Department of Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine , Gainesville, Florida.
Surg Infect (Larchmt). 2016 Dec;17(6):766-772. doi: 10.1089/sur.2016.108. Epub 2016 Sep 16.
Despite the excellent negative predictive value of sterile respiratory cultures, antibiotics often are continued after negative endotracheal aspirate (ETA) or bronchoalveolar lavage (BAL) for critically ill trauma patients. We hypothesized that persistent elevation of the Clinical Pulmonary Infection Score (CPIS) would predict continued antibiotic therapy after a negative respiratory culture for intubated trauma patients, and that prolonged antibiotics would provide no benefit.
We performed a four-year retrospective cohort analysis (May 1, 2011-September 30, 2015), including patients from our trauma database with ETA or BAL, excluding patients with any infection other than pneumonia or bacteremia. Cultures with <2 organisms on gram stain and <2 or 10 organisms on culture were considered negative. The CPIS was assessed at the time of culture and five days later, when all cultures were final. Multiple logistic regression was used to identify predictors of long-term antibiotic therapy.
A series of 106 patients with negative cultures were included, of whom 61 had ≤5 d of antibiotics and 45 had >5 d of antibiotics. There were no differences in injury severity, head or chest trauma, initial CPIS, or subsequent culture results between the groups. Long-term antibiotic therapy did not affect intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, or death. Factors predicting long-term antibiotic therapy included development of a localized chest radiograph infiltrate (odds ratio [OR] 6.8; 95% confidence interval [CI] 1.7-28), CPIS >5 five days after culture (OR 6.1; 95% CI 1.2-32), and a colonized culture (OR 3.3; 95% CI 1.3-8.3).
Long-term antibiotic therapy for intubated trauma patients with negative respiratory cultures provided no benefit and was predicted by development of a localized chest radiograph infiltrate, persistently elevated CPIS, and a contaminated/colonized culture. Although long-term antibiotic use did not worsen outcomes, better strategies are needed to diagnose pneumonia accurately and ensure timely discontinuation of antibiotics when appropriate.
尽管无菌呼吸道培养具有出色的阴性预测价值，但对于重症创伤患者，在气管内吸出物（ETA）或支气管肺泡灌洗（BAL）结果为阴性后，抗生素通常仍会继续使用。我们假设，临床肺部感染评分（CPIS）持续升高可预测气管插管创伤患者呼吸道培养结果为阴性后仍需继续使用抗生素，且延长使用抗生素并无益处。
我们进行了一项为期四年的回顾性队列分析（2011年5月1日至2015年9月30日），纳入了创伤数据库中接受ETA或BAL检查的患者，排除患有除肺炎或菌血症以外任何感染的患者。革兰氏染色显示微生物数量<2个且培养显示微生物数量<2个或10个的培养结果被视为阴性。在培养时以及五天后所有培养结果确定时评估CPIS。采用多因素logistic回归分析来确定长期使用抗生素治疗的预测因素。
共纳入106例培养结果为阴性的患者，其中61例接受抗生素治疗≤5天，45例接受抗生素治疗>5天。两组在损伤严重程度、头部或胸部创伤、初始CPIS或后续培养结果方面无差异。长期使用抗生素治疗并未影响重症监护病房（ICU）住院时间（LOS）、机械通气天数、医院住院时间或死亡率。预测长期使用抗生素治疗的因素包括出现局部胸部X线浸润（比值比[OR] 6.8；95%置信区间[CI] 1.7 - 28）、培养五天后CPIS>5（OR 6.1；95% CI 1.2 - 32）以及培养结果为定植（OR 3.3；95% CI 1.3 - 8.3）。
对于呼吸道培养结果为阴性的气管插管创伤患者，长期使用抗生素并无益处，且可通过出现局部胸部X线浸润、CPIS持续升高以及培养结果为污染/定植来预测。虽然长期使用抗生素并未使预后恶化，但仍需要更好的策略来准确诊断肺炎，并确保在适当的时候及时停用抗生素。
