Department of Anesthesiology and Critical Care Medicine, Hospices Civils de Lyon, Edouard Herriot Teaching Hospital, 5 place d'Arsonval, 69003, Lyon, France.
Polyvalent ICU, St Joseph Hospital, Paris, France.
Crit Care. 2019 Sep 6;23(1):307. doi: 10.1186/s13054-019-2581-8.
Enterococcus species are associated with an increased morbidity in intraabdominal infections (IAI). However, their impact on mortality remains uncertain. Moreover, the influence on outcome of the appropriate or inappropriate status of initial antimicrobial therapy (IAT) is subjected to debate, except in septic shock. The aim of our study was to evaluate whether an IAT that did not cover Enterococcus spp. was associated with 30-day mortality in ICU patients presenting with IAI growing with Enterococcus spp.
Retrospective analysis of French database OutcomeRea from 1997 to 2016. We included all patients with IAI with a peritoneal sample growing with Enterococcus. Primary endpoint was 30-day mortality.
Of the 1017 patients with IAI, 76 (8%) patients were included. Thirty-day mortality in patients with inadequate IAT against Enterococcus was higher (7/18 (39%) vs 10/58 (17%), p = 0.05); however, the incidence of postoperative complications was similar. Presence of Enterococcus spp. other than E. faecalis alone was associated with a significantly higher mortality, even greater when IAT was inadequate. Main risk factors for having an Enterococcus other than E. faecalis alone were as follows: SAPS score on day 0, ICU-acquired IAI, and antimicrobial therapy within 3 months prior to IAI especially with third-generation cephalosporins. Univariate analysis found a higher hazard ratio of death with an Enterococcus other than E. faecalis alone that had an inadequate IAT (HR = 4.4 [1.3-15.3], p = 0.019) versus an adequate IAT (HR = 3.1 [1.0-10.0], p = 0.053). However, after adjusting for confounders (i.e., SAPS II and septic shock at IAI diagnosis, ICU-acquired peritonitis, and adequacy of IAT for other germs), the impact of the adequacy of IAT was no longer significant in multivariate analysis. Septic shock at diagnosis and ICU-acquired IAI were prognostic factors.
An IAT which does not cover Enterococcus is associated with an increased 30-day mortality in ICU patients presenting with an IAI growing with Enterococcus, especially when it is not an E. faecalis alone. It seems reasonable to use an IAT active against Enterococcus in severe postoperative ICU-acquired IAI, especially when a third-generation cephalosporin has been used within 3 months.
肠球菌属与腹腔内感染（IAI）的发病率增加有关。然而，它们对死亡率的影响尚不确定。此外，除了感染性休克之外，初始抗菌治疗（IAT）的适当或不适当状态对预后的影响也存在争议。本研究的目的是评估在患有肠球菌生长的 IAI 的 ICU 患者中，未覆盖肠球菌属的 IAT 是否与 30 天死亡率相关。
回顾性分析了 1997 年至 2016 年法国数据库 OutcomeRea 中的数据。我们纳入了所有腹膜样本中生长有肠球菌的 IAI 患者。主要终点为 30 天死亡率。
在 1017 例 IAI 患者中，有 76 例（8%）患者被纳入研究。对肠球菌的 IAT 不足的患者 30 天死亡率更高（7/18（39%）vs 10/58（17%），p=0.05）；然而，术后并发症的发生率相似。除屎肠球菌外，肠球菌属的存在与更高的死亡率显著相关，而在 IAT 不足的情况下则更为显著。除屎肠球菌外，肠球菌属的其他肠球菌存在的主要危险因素如下：0 天 SAPS 评分、ICU 获得性 IAI 和 IAI 前 3 个月内的抗菌治疗，特别是第三代头孢菌素。单因素分析发现，与适当 IAT 相比，不适当 IAT 时除屎肠球菌外的肠球菌死亡风险更高（HR=4.4[1.3-15.3]，p=0.019）。然而，在调整混杂因素（即 IAI 诊断时 SAPS II 和感染性休克、ICU 获得性腹膜炎和其他细菌的 IAT 适当性）后，多因素分析中 IAT 适当性的影响不再显著。诊断时感染性休克和 ICU 获得性 IAI 是预后因素。
在 ICU 患者中，不覆盖肠球菌的 IAT 与患有肠球菌生长的 IAI 患者的 30 天死亡率增加相关，尤其是当它不是屎肠球菌时。在严重的术后 ICU 获得性 IAI 中，尤其是在 3 个月内使用第三代头孢菌素后，使用对肠球菌有效的 IAT 似乎是合理的。
