Berlot Giorgio, Vassallo Michele Claudio, Busetto Nicola, Nieto Yabar Margarita, Istrati Tatiana, Baronio Silvia, Quarantotto Giada, Bixio Mattia, Barbati Giulia, Dattola Roberto, Longo Irene, Chillemi Antonino, Scamperle Alice, Iscra Fulvio, Tomasini Ariella
Department of Anesthesia, Resuscitation and Pain Therapy, Cattinara Hospital, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy.
Department of Anesthesia and Intensive Care, San Martino Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
Ann Intensive Care. 2018 Dec 10;8(1):122. doi: 10.1186/s13613-018-0466-7.
The administration of endovenous immunoglobulins in patients with septic shock could be beneficial and preparations enriched with IgA and IgM (ivIgGAM) seem to be more effective than those containing only IgG. In a previous study Berlot et al. demonstrated that early administration of ivIgGAM was associated with lower mortality rate. We studied a larger population of similar patients aiming either to confirm or not this finding considering also the subgroup of patients with septic shock by multidrug-resistant (MDR) pathogens.
Adult patients with septic shock in intensive care unit (ICU) treated with ivIgGAM from August 1999 to December 2016 were retrospectively examined. Collected data included the demographic characteristics of the patients, the diagnosis at admission, SOFA, SAPS II and Murray Lung Injury Score (LIS), characteristics of the primary infection, the adequacy of antimicrobial therapy, the delay of administration of ivIgGAM from the ICU admission and the outcome at the ICU discharge. Parametric and nonparametric tests and logistic regression were used for statistic analysis.
During the study period 107 (30%) of the 355 patients died in ICU. Survivors received the ivIgGAM earlier than nonsurvivors (median delay 12 vs 14 h), had significantly lower SAPS II, SOFA and LIS at admission and a lower rate of MDR- and fungal-related septic shock. The appropriateness of the administration of antibiotics was similar in survivors and nonsurvivors (84 vs 79%, respectively, p: n.s). The delay in the administration of ivIgGAM from the admission was associated with in-ICU mortality (odds ratio per 1-h increase = 1.0055, 95% CI 1.003-1.009, p < 0.001), independently of SAPS II, LIS, cultures positive for MDR pathogens or fungi and onset of septic shock. Only 46 patients (14%) had septic shock due to MDR pathogens; 21 of them (46%) died in ICU. Survivors had significantly lower SAPS II, SOFA at admission and delay in administration of ivIgGAM than nonsurvivors (median delay 18 vs 66 h). Even in this subgroup the delay in the administration of ivIgGAM from the admission was associated with an increased risk of in-ICU mortality (odds ratio 1.007, 95% CI 1.0006-1.014, p = 0.048), independently of SAPS II.
Earlier administration of ivIgGAM was associated with decreased risk of in-ICU mortality both in patients with septic shock caused by any pathogens and in patients with MDR-related septic shock.
对感染性休克患者静脉注射免疫球蛋白可能有益，富含IgA和IgM的制剂（静脉注射IgGAM）似乎比仅含IgG的制剂更有效。在之前的一项研究中，贝洛特等人证明早期给予静脉注射IgGAM与较低的死亡率相关。我们研究了更多类似患者，旨在确认或否定这一发现，同时也考虑了由多重耐药（MDR）病原体引起感染性休克的患者亚组。
对1999年8月至2016年12月在重症监护病房（ICU）接受静脉注射IgGAM治疗的成年感染性休克患者进行回顾性检查。收集的数据包括患者的人口统计学特征、入院诊断、序贯器官衰竭评估（SOFA）、简化急性生理学评分II（SAPS II）和默里肺损伤评分（LIS）；原发性感染的特征、抗菌治疗的充分性、从ICU入院到静脉注射IgGAM的延迟时间以及ICU出院时的结局。采用参数检验、非参数检验和逻辑回归进行统计分析。
在研究期间，355例患者中有107例（30%）在ICU死亡。存活者比非存活者更早接受静脉注射IgGAM（中位延迟时间分别为12小时和14小时），入院时SAPS II、SOFA和LIS显著更低，且多重耐药和真菌相关感染性休克的发生率更低。存活者和非存活者抗生素使用的适宜性相似（分别为84%和79%，p：无统计学意义）。从入院到静脉注射IgGAM的延迟与ICU内死亡率相关（每增加1小时的比值比=1.0055，95%置信区间1.003 - 1.009，p < 0.001），与SAPS II、LIS、多重耐药病原体或真菌培养阳性以及感染性休克的发作无关。只有46例患者（14%）因多重耐药病原体导致感染性休克；其中21例（46%）在ICU死亡。存活者入院时的SAPS II、SOFA显著更低，静脉注射IgGAM的延迟时间也比非存活者短（中位延迟时间分别为18小时和66小时）。即使在这个亚组中，从入院到静脉注射IgGAM的延迟也与ICU内死亡风险增加相关（比值比1.007，95%置信区间1.0006 - 1.014，p = 0.048），与SAPS II无关。
早期给予静脉注射IgGAM与任何病原体引起的感染性休克患者以及多重耐药相关感染性休克患者的ICU内死亡风险降低相关。
