Claeys Kimberly C, Zasowski Evan J, Trinh Trang D, Lagnf Abdalhamid M, Davis Susan L, Rybak Michael J
University of Maryland School of Pharmacy, Baltimore, MD, USA.
Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
Infect Dis Ther. 2018 Mar;7(1):135-146. doi: 10.1007/s40121-017-0179-5. Epub 2017 Nov 21.
Lower respiratory tract infections (LRTIs) are a major cause of morbidity and death. Because of changes in how LRTIs are defined coupled with the increasing prevalence of drug resistance, there is a gap in knowledge regarding the current burden of antimicrobial use for Centers for Disease Control and Prevention (CDC)-defined LRTIs. We describe the infection characteristics, antibiotic consumption, and clinical and economic outcomes of patients with Gram-negative (GN) LRTIs treated in intensive care units (ICUs).
This was a retrospective, observational, cross-sectional study of adult patients treated in ICUs at two large academic medical centers in metropolitan Detroit, Michigan, from October 2013 to October 2015. To meet the inclusion criteria, patients must have had CDC-defined LRTI caused by a GN pathogen during ICU stay. Microbiological assessment of available Pseudomonas aeruginosa isolates included minimum inhibitory concentrations for key antimicrobial agents.
Four hundred and seventy-two patients, primarily from the community (346, 73.3%), were treated in medical ICUs (272, 57.6%). Clinically defined pneumonia was common (264, 55.9%). Six hundred and nineteen GN organisms were identified from index respiratory cultures: P. aeruginosa was common (224, 36.2%), with 21.6% of these isolates being multidrug resistant. Cefepime (213, 45.1%) and piperacillin/tazobactam (174, 36.8%) were the most frequent empiric GN therapies. Empiric GN therapy was inappropriate in 44.6% of cases. Lack of in vitro susceptibility (80.1%) was the most common reason for inappropriateness. Patients with inappropriate empiric GN therapy had longer overall stay, which translated to a median total cost of care of $79,800 (interquartile range $48,775 to $129,600) versus $68,000 (interquartile range $38,400 to $116,175), p = 0.013. Clinical failure (31.5% vs 30.0%, p = 0.912) and in-hospital all-cause mortality (26.4% vs 25.9%, p = 0.814) were not different.
Drug-resistant pathogens were frequently found and empiric GN therapy was inappropriate in nearly 50% of cases. Inappropriate therapy led to increased lengths of stay and was associated with higher costs of care.
下呼吸道感染（LRTIs）是发病和死亡的主要原因。由于LRTIs定义的变化以及耐药性的日益普遍，疾病控制与预防中心（CDC）定义的LRTIs目前抗菌药物使用负担方面存在知识空白。我们描述了在重症监护病房（ICU）接受治疗的革兰氏阴性（GN）LRTIs患者的感染特征、抗生素使用情况以及临床和经济结果。
这是一项对2013年10月至2015年10月在密歇根州底特律市两个大型学术医疗中心的ICU接受治疗的成年患者进行的回顾性、观察性横断面研究。为符合纳入标准，患者在ICU住院期间必须患有由GN病原体引起的CDC定义的LRTI。对可用的铜绿假单胞菌分离株进行微生物学评估，包括关键抗菌药物的最低抑菌浓度。
472例患者主要来自社区（346例，73.3%），在医疗ICU接受治疗（272例，57.6%）。临床诊断的肺炎很常见（264例，55.9%）。从初始呼吸道培养物中鉴定出619种GN微生物：铜绿假单胞菌很常见（224例，36.2%），其中21.6%的分离株对多种药物耐药。头孢吡肟（213例，45.1%）和哌拉西林/他唑巴坦（174例，36.8%）是最常用的经验性GN治疗药物。44.6%的病例经验性GN治疗不恰当。缺乏体外敏感性（80.1%）是最常见的不恰当原因。经验性GN治疗不恰当的患者住院总时间更长，这导致护理总费用中位数为79,800美元（四分位间距48,775美元至129,600美元），而恰当治疗的患者为68,000美元（四分位间距38,400美元至116,175美元），p = 0.013。临床失败率（31.5%对30.0%，p = 0.912）和院内全因死亡率（26.4%对25.9%，p = 0.814）无差异。
经常发现耐药病原体，近50%的病例经验性GN治疗不恰当。不恰当的治疗导致住院时间延长，并与更高的护理费用相关。
