中东呼吸综合征危重症患者：一项多中心回顾性队列研究

Critically Ill Patients With the Middle East Respiratory Syndrome: A Multicenter Retrospective Cohort Study.

作者信息

Arabi Yaseen M, Al-Omari Awad, Mandourah Yasser, Al-Hameed Fahad, Sindi Anees A, Alraddadi Basem, Shalhoub Sarah, Almotairi Abdullah, Al Khatib Kasim, Abdulmomen Ahmed, Qushmaq Ismael, Mady Ahmed, Solaiman Othman, Al-Aithan Abdulsalam M, Al-Raddadi Rajaa, Ragab Ahmed, Al Mekhlafi Ghaleb A, Al Harthy Abdulrahman, Kharaba Ayman, Ahmadi Mashael Al, Sadat Musharaf, Mutairi Hanan Al, Qasim Eman Al, Jose Jesna, Nasim Maliha, Al-Dawood Abdulaziz, Merson Laura, Fowler Robert, Hayden Frederick G, Balkhy Hanan H

机构信息

1College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. 2Intensive Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia. 3College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. 4Department of Intensive Care, Dr Sulaiman Al-Habib Group Hospitals, Riyadh, Saudi Arabia. 5Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia. 6Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia. 7Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. 8Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. 9Division of Infectious Diseases, Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. 10Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia. 11Intensive Care Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia. 12Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia. 13Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia. 14Tanta University Hospitals, Tanta, Egypt. 15King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. 16Intensive Care Department, King Abdulaziz Hospital, Al Ahsa, Saudi Arabia. 17Department of Research, Ministry of Health, Jeddah, Saudi Arabia. 18Intensive Care Department, King Fahd Hospital, Jeddah, Saudi Arabia. 19Department of Critical Care, King Fahad Hospital, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia. 20International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Infectious Diseases Data Observatory, Oxford University, Oxford, United Kingdom. 21AMR Infection Control and Publications AIP/PED/HSE/HQ, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada. 22Department of Critical Care Medicine and Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 23International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA. 24Department of Infection Prevention and Control, King Abdulaziz Medical City National Guard Health Affairs, Riyadh, Saudi Arabia.

出版信息

Crit Care Med. 2017 Oct;45(10):1683-1695. doi: 10.1097/CCM.0000000000002621.

DOI:10.1097/CCM.0000000000002621

PMID:28787295

Abstract

OBJECTIVES

To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies.

DESIGN

Retrospective cohort study.

SETTING

Patients admitted to ICUs in 14 Saudi Arabian hospitals.

PATIENTS

Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (n = 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of non-Middle East respiratory syndrome etiology (non-Middle East respiratory syndrome severe acute respiratory infection) (n = 222).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with non-Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78]; p < 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252]; p < 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7]; p = 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%; p < 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%; p = 0.003), vasopressor support (79.4% vs 55.0%; p < 0.001), and renal replacement therapy (48.8% vs 22.1%; p < 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to non-Middle East respiratory syndrome severe acute respiratory infection (adjusted odds ratio, 5.87; 95% CI, 4.02-8.56; p < 0.001).

CONCLUSIONS

Substantial overlap exists in the clinical presentation and comorbidities among patients with Middle East respiratory syndrome severe acute respiratory infection from other etiologies; therefore, a high index of suspicion combined with diagnostic testing is essential component of severe acute respiratory infection investigation for at-risk patients. The lack of distinguishing clinical features, the need to rely on real-time reverse transcription polymerase chain reaction from respiratory samples, variability in viral shedding duration, lack of effective therapy, and high mortality represent substantial clinical challenges and help guide ongoing clinical research efforts.

摘要

目的

描述中东呼吸综合征重症急性呼吸道感染危重症患者的特征、临床表现、疾病进程（包括病毒复制模式）及转归，并将这些特征与其他病因所致重症急性呼吸道感染患者进行比较。

设计

回顾性队列研究。

地点

沙特阿拉伯14家医院的重症监护病房收治的患者。

患者

将2012年9月至2015年10月期间收治的实验室确诊的中东呼吸综合征重症急性呼吸道感染危重症患者（n = 330）与连续收治的非中东呼吸综合征病因的社区获得性重症急性呼吸道感染危重症患者（非中东呼吸综合征重症急性呼吸道感染）（n = 222）进行比较。

干预措施

无。

测量指标及主要结果

尽管中东呼吸综合征重症急性呼吸道感染患者比非中东呼吸综合征重症急性呼吸道感染患者年轻（中位数[四分位数1，四分位数3] 58岁[44，69]对70岁[52，78]；p < 0.001），但其临床表现和合并症有很大重叠。中东呼吸综合征重症急性呼吸道感染患者有更严重的低氧性呼吸衰竭（动脉血氧分压/吸入氧分数值：106 [66，160]对176 [104，252]；p < 0.001）和更频繁的非呼吸器官衰竭（非呼吸序贯器官衰竭评估评分：6 [4，9]对5 [3，7]；p = 0.002），因此更频繁地需要有创机械通气（85.2%对73.0%；p < 0.001）、氧疗救援措施（体外膜肺氧合5.8%对0.9%；p = 0.003）、血管活性药物支持（79.4%对55.0%；p < 0.001）及肾脏替代治疗（48.8%对22.1%；p < 0.001）。在对潜在混杂因素进行校正后，与非中东呼吸综合征重症急性呼吸道感染相比，中东呼吸综合征与死亡独立相关（校正比值比，为5.87；95%可信区间，4.02 - 8.56；p < 0.001）。

结论

中东呼吸综合征重症急性呼吸道感染患者与其他病因患者的临床表现和合并症存在大量重叠；因此，对于高危患者，高度怀疑并结合诊断检测是重症急性呼吸道感染调查的重要组成部分。缺乏可区分的临床特征、需要依赖呼吸道样本的实时逆转录聚合酶链反应、病毒脱落持续时间的变异性、缺乏有效治疗方法以及高死亡率构成了重大临床挑战，并有助于指导正在进行的临床研究工作。