Fisher Kristen, Trupka Tracy, Micek Scott T, Juang Paul, Kollef Marin H
1 Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine , St. Louis, Missouri.
2 Division of Pharmacy Practice, St. Louis College of Pharmacy , St. Louis, Missouri.
Surg Infect (Larchmt). 2017 Oct;18(7):827-833. doi: 10.1089/sur.2017.111. Epub 2017 Sep 7.
Pneumonia and respiratory failure are common problems in the intensive care unit (ICU) setting, often occurring together. The relative prevalence of pneumonia types (community acquired, hospital acquired, ventilator associated) and causative pathogens is not well described in patients with respiratory failure.
This was a prospective observational cohort study conducted in the medical ICU (34 beds) of Barnes-Jewish Hospital, an academic referral center of 1,300 beds from January 2016-December 2016. All patients who were prospectively adjudicated to have respiratory failure and pneumonia (RFP) regardless of pneumonia type were classified into one of four microbiologic categories: pathogen negative, antibiotic-susceptible pathogen (according to ceftriaxone susceptibility), antibiotic-resistant pathogen, and viruses. The primary outcomes assessed were the hospital mortality rate and inappropriate initial antibiotic therapy (IIAT) for non-viral pathogens.
Among 364 consecutive patients with RFP, 63 (17.3%) had organisms that were antibiotic susceptible, 104 (28.6%) had antibiotic-resistant organisms, 118 (32.4%) were pathogen negative, and 79 (21.7%) had viral infections. For these categories, IIAT occurred in 3.2%, 21.2%, 0.8%, and 0, respectively (p < 0.001). Vasopressor-requiring shock was present in 61.9%, 72.1%, 68.6%, and 67.1%, respectively (p = 0.585), and the hospital mortality rates were 27.0%, 48.1%, 31.4%, and 36.7%, respectively (p = 0.020). Multivariable logistic regression analysis identified IIAT as an independent predictor of in-hospital death (adjusted odds ratio 5.28; 95% confidence interval 2.72-10.22; p = 0.012). Male gender, increasing Acute Physiology and Chronic Health Evaluation (APACHE) II scores, greater age, and the presence of shock also predicted death.
Microbiologic categorization of patients with RFP suggests that antibiotic-resistant pathogens and viruses are associated with the highest mortality rates. Vasopressor-requiring shock was common regardless of the microbiologic categorization of RFP. Future development and use of rapid diagnostics and novel therapeutics targeting specific RFP pathogens may allow more timely administration of appropriate antimicrobial therapy and enhance antibiotic stewardship practices.
肺炎和呼吸衰竭是重症监护病房（ICU）常见的问题，常同时发生。呼吸衰竭患者中肺炎类型（社区获得性、医院获得性、呼吸机相关性）及致病病原体的相对患病率尚无充分描述。
这是一项前瞻性观察队列研究，于2016年1月至2016年12月在拥有1300张床位的学术转诊中心巴恩斯-犹太医院的内科ICU（34张床位）进行。所有经前瞻性判定患有呼吸衰竭和肺炎（RFP）的患者，无论肺炎类型如何，均被分为四类微生物学类别之一：病原体阴性、抗生素敏感病原体（根据头孢曲松敏感性）、抗生素耐药病原体和病毒。评估的主要结局为医院死亡率和非病毒病原体的不适当初始抗生素治疗（IIAT）。
在364例连续的RFP患者中，63例（17.3%）有抗生素敏感的微生物，104例（28.6%）有抗生素耐药的微生物，118例（32.4%）病原体阴性，79例（21.7%）有病毒感染。对于这些类别，IIAT分别发生在3.2%、21.2%、0.8%和0（p<0.001）。需要血管升压药的休克分别出现在61.9%、72.1%、68.6%和67.1%（p=0.585），医院死亡率分别为27.0%、48.1%、31.4%和36.7%（p=0.020）。多变量逻辑回归分析确定IIAT是院内死亡的独立预测因素（调整后的优势比为5.28；95%置信区间为2.72-10.22；p=0.012）。男性、急性生理与慢性健康状况评估（APACHE）II评分增加、年龄增大和休克的存在也预示着死亡。
RFP患者的微生物学分类表明，抗生素耐药病原体和病毒与最高死亡率相关。无论RFP的微生物学分类如何，需要血管升压药的休克都很常见。针对特定RFP病原体的快速诊断和新型治疗方法的未来开发和应用可能会使更及时地给予适当的抗菌治疗并加强抗生素管理实践。
