预防策略的实施、多重耐药菌定植及抗菌药物使用对早发和晚发呼吸机相关性肺炎风险的各自影响：OUTCOMEREA网络分析
Respective impact of implementation of prevention strategies, colonization with multiresistant bacteria and antimicrobial use on the risk of early- and late-onset VAP: An analysis of the OUTCOMEREA network.
作者信息
Ibn Saied Wafa, Souweine Bertrand, Garrouste-Orgeas Maité, Ruckly Stéphane, Darmon Michael, Bailly Sébastien, Cohen Yves, Azoulay Elie, Schwebel Carole, Radjou Aguila, Kallel Hatem, Adrie Christophe, Dumenil Anne-Sylvie, Argaud Laurent, Marcotte Guillaume, Jamali Samir, Papazian Laurent, Goldgran-Toledano Dany, Bouadma Lila, Timsit Jean-Francois
机构信息
UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, control and care, Inserm/ Paris Diderot University, Sorbonne Paris Cité, Paris, France.
Medical Intensive care unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France.
出版信息
PLoS One. 2017 Nov 29;12(11):e0187791. doi: 10.1371/journal.pone.0187791. eCollection 2017.
RATIONALE
The impact of prevention strategies and risk factors for early-onset (EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still debated.
OBJECTIVES
To evaluate, in a multicenter cohort, the risk factors for EOP and LOP, as the evolution of prevention strategies.
METHODS
7,784 patients with mechanical ventilation (MV) for at least 48 hours were selected into the multicenter prospective OUTCOMEREA database (1997-2016). VAP occurring between the 3rd and 6th day of MV defined EOP, while those occurring after defined LOPs. We used a Fine and Gray subdistribution model to take the successful extubation into account as a competing event.
MEASUREMENTS AND MAIN RESULTS
Overall, 1,234 included patients developed VAP (EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and LOP. Factors specifically associated with EOP were admission for respiratory distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa, chest tube and enteral feeding within the first 2 days of MV. Antimicrobials administrated within the first 2 days of MV were all protective of EOP. ICU admission for COPD exacerbation or pneumonia were early risk factors for LOP, while imidazole and vancomycin use within the first 2 days of MV were protective factors. Late risk factors (between the 3rd and the 6th day of MV) were the intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known colonization with methicillin-resistant Staphylococcus aureus. Among the antimicrobials administered between the 3rd and the 6th day, fluoroquinolones were the solely protective one.Contrarily to LOP, the risk of EOP decreased across the study time periods, concomitantly with an increase in the compliance with bundle of prevention measures.
CONCLUSION
VAP risk factors are mostly different according to the pneumonia time of onset, which should lead to differentiated prevention strategies.
原理
早发性（EOP）与晚发性（LOP）呼吸机相关性肺炎（VAP）的预防策略及风险因素的影响仍存在争议。
目的
在多中心队列中评估EOP和LOP的风险因素以及预防策略的演变情况。
方法
将7784例接受机械通气（MV）至少48小时的患者纳入多中心前瞻性OUTCOMEREA数据库（1997 - 2016年）。MV第3天至第6天发生的VAP定义为EOP，而在这之后发生的定义为LOP。我们使用Fine和Gray亚分布模型将成功拔管作为竞争事件纳入考虑。
测量指标及主要结果
总体而言，1234例纳入患者发生了VAP（EOP：445例（36%）；LOP：789例（64%））。男性是EOP和LOP的风险因素。与EOP具体相关的因素包括因呼吸窘迫入院、既往有多重耐药铜绿假单胞菌定植、胸管置入以及MV前2天内进行肠内喂养。MV前2天内使用抗菌药物对EOP均有保护作用。因慢性阻塞性肺疾病（COPD）急性加重或肺炎入住重症监护病房（ICU）是LOP的早期风险因素，而MV前2天内使用咪唑类和万古霉素是保护因素。晚期风险因素（MV第3天至第6天之间）包括院内转运、动脉血氧分压与吸入氧分数值（PAO2 - FIO2）<200 mmHg、使用血管活性药物以及已知有耐甲氧西林金黄色葡萄球菌定植。在第3天至第6天使用的抗菌药物中，氟喹诺酮类是唯一具有保护作用的药物。与LOP不同，EOP的风险在研究时间段内有所下降，同时预防措施集束的依从性有所提高。
结论
VAP的风险因素大多因肺炎发病时间不同而有所差异，这应导致采取差异化的预防策略。
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