Medical ICU, La Source Hospital, CHR Orléans, Orléans, France.
UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, Paris Diderot, Sorbonne Paris Cité University, Paris, France.
Intensive Care Med. 2018 May;44(5):616-626. doi: 10.1007/s00134-018-5154-4. Epub 2018 Apr 16.
To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE).
Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997-2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration > 48 h and ≥ 1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented.
The 318 enrolled ESBLE carriers (median age 68 years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3 days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05-0.6; P < 0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P = 0.43).
IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.
研究与感染相关的呼吸机相关性并发症（IVAC）的临床意义及其对产超广谱β-内酰胺酶肠杆菌科（ESBLE）定植机械通气（MV）患者碳青霉烯类药物消耗的影响。
这是一项来自法国前瞻性多中心 OUTCOMEREA 数据库的病例队列研究（17 个 ICU，1997-2015 年），纳入所有 ESBLE 定植者（入院时系统直肠拭子采集，随后每周采集，或尿或浅表手术部位定植），MV 时间>48 h，定植后有≥1 次 IVAC 发作。所有 ICU 获得性感染均进行了微生物学诊断。
318 例 ESBLE 定植者纳入研究（中位年龄 68 岁；男性 67%；内科就诊 68%；院内定植 53%）共发生 576 次 IVAC，其中 361 次（63%）无感染证据，124 次（21%）与呼吸机相关性肺炎（VAP）以外的感染相关，73 次（13%）与非 ESBLE VAP 相关，18 次（3%）与 ESBLE VAP 相关。总体而言，ESBLE 感染仅占 43 例（7%）。定植前 3 天内使用碳青霉烯类药物是 ESBLE 感染作为 IVAC 致病事件的唯一独立预测因素，具有保护作用（校正比值比 0.2，95%置信区间 0.05-0.6；P<0.01）。9%的无感染 IVAC、15%的非 VAP 感染相关 IVAC、42%的非 ESBLE VAP 相关 IVAC和 56%的 ESBLE VAP 相关 IVAC（ESBLE VAP 与非 ESBLE VAP：P=0.43）起始了碳青霉烯类药物治疗。
ESBLE 定植者的 IVAC 主要反映非感染性事件，但作为经验性碳青霉烯类药物消耗的强烈驱动因素。ESBLE 感染虽少见，但难以预测，这加强了对新型诊断方法和碳青霉烯类药物节约替代方案的需求。
