Chen I-Ling, Lee Chen-Hsiang, Ting Shih-Wen, Wang Lily Yu-Chin
Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Infect Drug Resist. 2018 Mar 1;11:283-293. doi: 10.2147/IDR.S157200. eCollection 2018.
The increasing number of reports on infections due to carbapenem-resistant Gram-negative bacilli (GNB) has raised concerns, because they have complicated empiric or guided antibiotic therapy for critically ill patients. We aimed to develop a scoring system to predict nosocomial imipenem-resistant GNB (IR-GNB) septicemia among the critically ill patients.
The study included critically ill adult patients with nosocomial GNB septicemia at Kaohsiung Chang Gung Memorial Hospital (CGMH) in 2013-2015, and the scoring system for predicting IR-GNB septicemia was developed, followed by prospective validation conducted among patients at Linkou CGMH and Kaohsiung CGMH between January and June, 2016.
In the development of the scoring system, 748 patients were included. The independent factors associated with IR-GNB septicemia were prior exposure (days) to carbapenems (adjusted odds ratio [aOR] per 1-day increase, 1.1; 1-3 days: 2 points, 4-6 days: 5 points, 7-9 days: 8 points, and ≥10 days: 13 points), use of mechanical ventilation (aOR 3.7; 5 points), prior colonization with IR-GNB strains (aOR 3.5; 5 points) within 30 days before the onset of GNB septicemia, and comorbid condition with chronic kidney disease (aOR 2.1; 3 points). The internal validation showed an area under the receiver operating characteristic curve (ROC) of 0.75; and an external validation among 314 patients showed similarly good performance (ROC 0.77). Youden's index indicated the score of ≥6 as the best cutoff value with sensitivity of 75% and specificity of 79%.
This scoring system might help clinicians stratify the risk for developing IR-GNB septicemia among critically ill patients and combined antibiotics may be used until antimicrobial de-escalation/adjustment is clearly indicated by the subsequently identified GNB and its susceptibility profile.
耐碳青霉烯类革兰阴性杆菌（GNB）引起感染的报告数量不断增加，引发了人们的关注，因为这使重症患者的经验性或指导性抗生素治疗变得复杂。我们旨在开发一种评分系统，以预测重症患者医院获得性耐亚胺培南GNB（IR-GNB）败血症。
该研究纳入了2013 - 2015年高雄长庚纪念医院（CGMH）患有医院获得性GNB败血症的成年重症患者，并开发了预测IR-GNB败血症的评分系统，随后于2016年1月至6月在林口长庚纪念医院和高雄长庚纪念医院的患者中进行前瞻性验证。
在评分系统的开发过程中，纳入了748例患者。与IR-GNB败血症相关的独立因素包括先前使用碳青霉烯类药物的时间（天数）（每增加1天调整后的优势比[aOR]为1.1；1 - 3天：2分，4 - 6天：5分，7 - 9天：8分，≥10天：13分）、使用机械通气（aOR 3.7；5分）、在GNB败血症发作前30天内先前定植有IR-GNB菌株（aOR 3.5；5分）以及合并慢性肾病（aOR 2.1；3分）。内部验证显示受试者工作特征曲线（ROC）下面积为0.75；对314例患者的外部验证显示出类似的良好性能（ROC 0.77）。约登指数表明，≥6分为最佳截断值，敏感性为75%，特异性为79%。
该评分系统可能有助于临床医生对重症患者发生IR-GNB败血症的风险进行分层，并且在随后确定的GNB及其药敏谱明确表明需要进行抗菌药物降阶梯/调整之前，可联合使用抗生素。
