与耐甲氧西林金黄色葡萄球菌阴性医院获得性肺炎降阶梯治疗相关的结果。
Outcomes Associated With De-escalating Therapy for Methicillin-Resistant Staphylococcus aureus in Culture-Negative Nosocomial Pneumonia.
机构信息
Barnes-Jewish Hospital, Saint Louis, MO.
Barnes-Jewish Hospital, Saint Louis, MO; Saint Louis College of Pharmacy, Saint Louis, MO.
出版信息
Chest. 2019 Jan;155(1):53-59. doi: 10.1016/j.chest.2018.10.014. Epub 2018 Oct 25.
BACKGROUND
In culture-positive nosocomial pneumonia, de-escalation (DE) from broad-spectrum empirical antimicrobials to narrower-spectrum agents has shown to decrease broad-spectrum antibiotic use without compromising patient outcomes. However, uncertainty exists regarding the safety of anti-methicillin-resistant Staphylococcus aureus (MRSA) agent DE in culture-negative nosocomial pneumonia. This study aimed to determine if anti-MRSA agent DE in culture-negative nosocomial pneumonia affects 28-day and hospital mortality, ICU and hospital length of stay (LOS), treatment failure, and safety.
METHODS
This single-center retrospective cohort study included adult patients admitted from 2012 to 2017 with nosocomial pneumonia and a negative respiratory culture. DE was defined as anti-MRSA agent discontinuation within 4 days of initiation. Secondary outcomes included hospital mortality, hospital and ICU LOS, treatment failure, and occurrence of acute kidney injury (AKI).
RESULTS
Of 279 patients included, 92 were in the DE group and 187 were in the no DE (NDE) group. Patients who were not de-escalated received 5 more days of MRSA coverage than patients who were de-escalated; however, there was no difference in 28-day mortality (NDE group, 28% vs DE group, 23%; difference, -5.5%; 95% CI, -16.1 to 6.5). Patients who were de-escalated had shorter hospital (DE group, 15 days vs NDE group, 20 days; difference, 3.2 days; 95% CI, 0.1-6.4) and ICU (DE group, 10 days vs NDE group, 13 days; difference, 2.2 days; 95% CI, -0.3 to 4.9) LOSs after the index date. The incidence of AKI was significantly higher in patients who were not de-escalated (DE group, 36% vs NDE group, 50%; difference, -13.8%; 95% CI, -26.9 to -0.4).
CONCLUSIONS
Although anti-MRSA agent DE in culture-negative nosocomial pneumonia did not affect 28-day mortality, it was associated with a shorter hospital LOS and lower incidence of AKI.
背景
在培养阳性的医院获得性肺炎中，从广谱经验性抗菌药物降阶梯（DE）为窄谱药物已被证明可减少广谱抗生素的使用，同时不影响患者的预后。然而，对于培养阴性的医院获得性肺炎中抗耐甲氧西林金黄色葡萄球菌（MRSA）药物 DE 的安全性仍存在不确定性。本研究旨在确定培养阴性的医院获得性肺炎中抗-MRSA 药物 DE 是否会影响 28 天死亡率和院内死亡率、重症监护病房（ICU）和医院住院时间（LOS）、治疗失败和安全性。
方法
这项单中心回顾性队列研究纳入了 2012 年至 2017 年期间因医院获得性肺炎和呼吸道培养阴性而入院的成年患者。DE 定义为在开始使用抗-MRSA 药物的 4 天内停用该药物。次要结局包括院内死亡率、医院和 ICU LOS、治疗失败和急性肾损伤（AKI）的发生。
结果
在 279 例患者中，92 例患者在 DE 组，187 例患者在非 DE（NDE）组。未进行降阶梯治疗的患者接受了 5 天以上的 MRSA 覆盖治疗，而进行降阶梯治疗的患者则没有；然而，28 天死亡率没有差异（NDE 组为 28%，DE 组为 23%；差异，-5.5%；95%CI，-16.1 至 6.5）。与 NDE 组相比，进行降阶梯治疗的患者的医院（DE 组为 15 天，NDE 组为 20 天；差异，3.2 天；95%CI，0.1-6.4）和 ICU（DE 组为 10 天，NDE 组为 13 天；差异，2.2 天；95%CI，-0.3 至 4.9）住院时间更短。未进行降阶梯治疗的患者 AKI 的发生率明显更高（DE 组为 36%，NDE 组为 50%；差异，-13.8%；95%CI，-26.9 至-0.4）。
结论
尽管培养阴性的医院获得性肺炎中抗-MRSA 药物 DE 不会影响 28 天死亡率，但它与较短的医院 LOS 和较低的 AKI 发生率有关。
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