重新发明轮子：抗生素暴露时间延长对创伤患者多重耐药呼吸机相关性肺炎的影响。

Reinventing the wheel: Impact of prolonged antibiotic exposure on multidrug-resistant ventilator-associated pneumonia in trauma patients.

机构信息

From the Department of Surgery (R.H.L., J.P.S., J.M.S., T.C.F., M.A.C., L.J.M.), University of Tennessee Health Science Center, Memphis, Tennessee.

出版信息

J Trauma Acute Care Surg. 2018 Aug;85(2):256-262. doi: 10.1097/TA.0000000000001936.

DOI:10.1097/TA.0000000000001936

PMID:29664891

Abstract

BACKGROUND

Multidrug-resistant (MDR) strains of both Acinetobacter baumannii (AB) and Pseudomonas aeruginosa (PA) as causative ventilator-associated pneumonia (VAP) pathogens are becoming increasingly common. Still, the risk factors associated with this increased resistance have yet to be elucidated. The purpose of this study was to examine the changing sensitivity patterns of these pathogens over time and determine which risk factors predict MDR in trauma patients with VAP.

METHODS

Patients with either AB or PA VAP over 10 years were stratified by pathogen sensitivity (sensitive [SEN] and MDR), age, severity of shock, and injury severity. Prophylactic and empiric antibiotic days, risk factors for severe VAP, and mortality were compared. Multivariable logistic regression was performed to determine which risk factors were independent predictors of MDR.

RESULTS

Three hundred ninety-seven patients were identified with AB or PA VAP. There were 173 episodes of AB (91 SEN and 82 MDR) and 224 episodes of PA (170 SEN and 54 MDR). The incidence of MDR VAP did not change over the study (p = 0.633). Groups were clinically similar with the exception of 24-hour transfusions (14 vs. 19 units, p = 0.009) and extremity Abbreviated Injury Scale (AIS) score (1 vs. 3, p < 0.001), both significantly increased in the MDR group. Antibiotic exposure as well as multiple episodes of inadequate empiric antibiotic therapy (mIEAT) (63% vs. 81%, p < 0.001) were significantly increased in the MDR group. Multivariable logistic regression identified prophylactic antibiotic days (odds ratio, 23.1; 95% confidence interval, 16.7-28, p < 0.001) and mIEAT (odds ratio, 18.1; 95% confidence interval, 12.2-26.1, p = 0.001) as independent predictors of MDR after adjusting for severity of shock, injury severity, severity of VAP, and antibiotic exposure.

CONCLUSION

Prolonged exposure to unnecessary antibiotics remains one of the strongest predictors for the development of antibiotic resistance. Multivariable logistic regression identified prophylactic antibiotic days and mIEAT an independent risk factors for MDR VAP. Thus, limiting prophylactic antibiotic days is the only potentially modifiable risk factor for the development of MDR VAP in trauma patients.

LEVEL OF EVIDENCE

Level IV Therapeutic; level III Prognostic.

摘要

背景

鲍曼不动杆菌（AB）和铜绿假单胞菌（PA）的多药耐药（MDR）菌株作为导致呼吸机相关性肺炎（VAP）的病原体越来越常见。然而，与这种耐药性增加相关的危险因素尚未阐明。本研究的目的是研究这些病原体随时间的变化敏感性模式，并确定哪些危险因素可预测创伤患者 VAP 中的 MDR。

方法

将 10 年内发生 AB 或 PA VAP 的患者按病原体敏感性（敏感[SEN]和 MDR）、年龄、休克严重程度和损伤严重程度分层。比较预防性和经验性抗生素天数、严重 VAP 的危险因素和死亡率。采用多变量逻辑回归确定哪些危险因素是 MDR 的独立预测因素。

结果

共确定了 397 例 AB 或 PA VAP 患者。AB 有 173 例（91 例 SEN 和 82 例 MDR），PA 有 224 例（170 例 SEN 和 54 例 MDR）。研究期间，MDR VAP 的发生率没有变化（p = 0.633）。除 24 小时输血（14 与 19 单位，p = 0.009）和四肢损伤严重程度评分（AIS）（1 与 3，p < 0.001）外，两组患者在临床特征上无明显差异，且 MDR 组显著增加。MDR 组抗生素暴露以及多次经验性抗生素治疗不足（mIEAT）（63%与 81%，p < 0.001）显著增加。多变量逻辑回归发现预防性抗生素天数（优势比，23.1；95%置信区间，16.7-28，p < 0.001）和 mIEAT（优势比，18.1；95%置信区间，12.2-26.1，p = 0.001）是调整休克严重程度、损伤严重程度、VAP 严重程度和抗生素暴露后 MDR 的独立预测因素。