局部应用抗生素对 ICU 患者中第三代头孢菌素和碳青霉烯类耐药革兰氏阴性菌的清除和获得的影响；一项多中心集群随机试验的事后分析。
The effects of topical antibiotics on eradication and acquisition of third-generation cephalosporin and carbapenem-resistant Gram-negative bacteria in ICU patients; a post hoc analysis from a multicentre cluster-randomized trial.
机构信息
Department of Medical Microbiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands.
Intensive Care Centre, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands.
出版信息
Clin Microbiol Infect. 2020 Apr;26(4):485-491. doi: 10.1016/j.cmi.2019.08.001. Epub 2019 Aug 14.
OBJECTIVES
The aim was to quantify the effects of selective digestive tract decontamination (SDD) consisting of a mouth paste and gastro-enteral suspension, selective oropharyngeal decontamination with a mouth paste (SOD) and 1-2% chlorhexidine (CHX) mouthwash on eradication and acquisition of carriage of third-generation cephalosporin-resistant Enterobacterales (3GCR-E) and carbapenem-resistant Gram-negative bacteria (CR-GNB) in Intensive Care Unit (ICU) patients.
METHODS
This was a nested cohort study within a cluster-randomized cross-over trial in six European countries and 13 ICUs with 8665 patients. Eradication and acquisition during ICU stay of 3GCR-E and CR-GNB were investigated separately in the rectum and respiratory tract for the three interventions and compared with standard care (SC) using Cox-regression competing events analyses.
RESULTS
Adjusted cause specific hazard ratios (CSHR) for eradication of rectal carriage for SDD were 1.76 (95% CI 1.31-2.36) for 3GCR-E and 3.17 (95% CI 1.60-6.29) for CR-GNB compared with SC. For the respiratory tract, adjusted CSHR for eradication of 3GCR-E were 1.47 (0.98-2.20) for SDD and 1.38 (0.92-2.06) for SOD compared with SC, and for eradication of CR-GNB these were 0.77 (0.41- 1.45) for SDD and 0.81 (0.44-1.51) for SOD, compared with SC. Adjusted CSHRs for acquisition of rectal carriage during SDD (compared with SC) were 0.51 (0.40-0.64) for 3GCR-E and of 0.56 (0.40-0.78) for CR-GNB. Adjusted CSHRs for acquiring respiratory tract carriage with 3GCR-E compared with SC were 0.38 (0.28-0.50) for SDD and 0.55 (0.42-0.71) for SOD, and for CR-GNB 0.46 (0.33-0.64) during SDD and 0.60 (0.44-0.81) during SOD, respectively. SOD was not associated with eradication or acquisition of 3GCR-E and CR-GNB in the rectum.
CONCLUSIONS
Among mechanically ventilated ICU patients, SDD was associated with more eradication and less acquisition of 3GCR-E and CR-GNB in the rectum than SC. SDD and SOD were associated with less acquisition of both 3GCR-E and CR-GNB than SC in the respiratory tract.
目的
定量评估选择性消化道去定植（SDD）方案（含口腔糊剂和胃肠混悬液）、选择性口腔去定植（SOD）加口腔糊剂（含 1-2%洗必泰）、以及含 2%氯己定（CHX）的口腔冲洗液对重症监护病房（ICU）患者第三代头孢菌素耐药肠杆菌科细菌（3GCR-E）和耐碳青霉烯类革兰阴性菌（CR-GNB）的定植清除和获得的影响。
方法
这是一项嵌套队列研究，纳入了在欧洲 6 个国家的 13 家 ICU 进行的一项随机交叉试验，共纳入 8665 例患者。分别在直肠和呼吸道中研究三种干预措施对 3GCR-E 和 CR-GNB 定植的清除和获得情况，并与标准护理（SC）进行比较，采用 Cox 回归竞争事件分析。
结果
与 SC 相比，SDD 对 3GCR-E 的直肠定植清除的校正病因特异性危险比（CSHR）为 1.76（95%CI 1.31-2.36），对 CR-GNB 的 CSHR 为 3.17（95%CI 1.60-6.29）。对于呼吸道，SDD 对 3GCR-E 的清除校正 CSHR 为 1.47（0.98-2.20），SOD 为 1.38（0.92-2.06），与 SC 相比，SDD 对 CR-GNB 的清除校正 CSHR 为 0.77（0.41-1.45），SOD 为 0.81（0.44-1.51）。与 SC 相比，SDD 对直肠定植获得的校正 CSHR 为 0.51（0.40-0.64），对 CR-GNB 的 CSHR 为 0.56（0.40-0.78）。与 SC 相比，SDD 对呼吸道 3GCR-E 定植的校正 CSHR 为 0.38（0.28-0.50），SOD 为 0.55（0.42-0.71），对 CR-GNB 的 CSHR 为 0.46（0.33-0.64），SOD 为 0.60（0.44-0.81）。SOD 与直肠 3GCR-E 和 CR-GNB 的清除或获得均无相关性。
结论
在机械通气的 ICU 患者中，与 SC 相比，SDD 可更有效地清除直肠内的 3GCR-E 和 CR-GNB，定植获得率也更低。与 SC 相比，SDD 和 SOD 均能降低呼吸道内 3GCR-E 和 CR-GNB 的定植获得率。
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