Kim Insu, Kim Won-Young, Jeoung Eun Suk, Lee Kwangha
Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.
Acute Crit Care. 2018 May;33(2):73-82. doi: 10.4266/acc.2017.00591. Epub 2018 Apr 26.
We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia.
One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant , extended-spectrum β-lactamase-producing gram-negative bacteria ( and ), carbapenem-resistant gram-negative rods ( and ), and vancomycin-resistant Enterococcus faecium.
Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden's index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P < 0.001) based on multivariate Cox regression analysis.
An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28-day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.
我们评估了感染性疾病会诊（IDC）在多重耐药（MDR）菌血症通气患者中的现状及对生存的影响。
在5年期间，纳入了一家三级医疗中心的161例连续患者。纳入至少患有以下六种MDR菌血症之一的患者：耐甲氧西林、产超广谱β-内酰胺酶的革兰阴性菌（和）、耐碳青霉烯类革兰阴性杆菌（和）以及耐万古霉素屎肠球菌。
患者中位年龄为66岁（范围18至95岁），57.8%的受试者为男性。血培养当天后的28天死亡率为52.2%。基于血培养阳性，96例患者（59.6%）被要求进行IDC。未进行IDC的患者合并血液肿瘤疾病的比例显著更高（36.9%对11.5%，P<0.001）。未进行IDC的患者在血培养当天的急性生理与慢性健康状况评估（APACHE）II评分更高（中位数20；范围8至38对中位数16；范围5至34，P<0.001）和序贯器官衰竭评估（SOFA）评分更高（中位数9；范围2至17对中位数7；范围2至20；P = 0.020），且28天死亡率更高（72.3%对38.5%，P<0.001）。在血培养当天SOFA≥9（基于约登指数的截断水平）且为革兰阴性菌血症的患者中，基于多因素Cox回归分析，IDC也与较低的28天死亡率显著相关（风险比[HR]，0.298；95%置信区间[CI]，0.167至0.532以及HR，0.180；95%CI，0.097至0.333；所有P<0.001）。
对于疾病严重程度更高且采血后28天死亡率更高的通气MDR菌血症患者，要求进行IDC的情况较少。在血培养当天SOFA≥9且为革兰阴性菌血症的患者中，IDC与采血培养后28天生存率的改善相关。
