嗜麦芽寡养单胞菌医院获得性肺炎在重症监护病房的结局：一项全国性回顾性研究。
Outcomes of Stenotrophomonas maltophilia hospital-acquired pneumonia in intensive care unit: a nationwide retrospective study.
机构信息
Department of Anaesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy-Brabois, Vandoeuvre-Lès-Nancy, France.
INSERM U1116, Groupe Choc, University of Lorraine, Nancy, France.
出版信息
Crit Care. 2019 Nov 21;23(1):371. doi: 10.1186/s13054-019-2649-5.
BACKGROUND
There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy.
METHODS
This nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy.
RESULTS
Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5-18] days. The Simplified Acute Physiology Score II was 47 [36-63], and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively).
CONCLUSIONS
S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival.
TRIAL REGISTRATION
clinicaltrials.gov, NCT03506191.
背景
目前关于重症监护病房中嗜麦芽寡养单胞菌医院获得性肺炎（HAP）的描述性数据很少。最佳的抗菌治疗方式仍有待确定。我们的目的是描述嗜麦芽寡养单胞菌肺炎的流行病学和预后因素，重点关注抗菌治疗。
方法
这是一项全国性的回顾性研究，纳入了 2012 年至 2017 年期间在法国 25 家混合重症监护病房住院的重症监护病房中发生的嗜麦芽寡养单胞菌 HAP 的所有患者。主要终点是院内死亡时间。次要终点包括微生物学疗效以及抗菌治疗方式，如抗菌治疗的延迟、单药治疗与联合治疗、抗菌治疗的持续时间。
结果
在 282 名患者中，84%在诊断为嗜麦芽寡养单胞菌 HAP 时接受了气管插管，持续时间为 11[5-18]天。简化急性生理学评分 II 为 47[36-63]，院内死亡率为 49.7%。14.1%的患者存在慢性肺部合并症。根据药敏模式，只有 30%的患者经验性抗菌治疗被认为是有效的。然而，抗菌治疗的延迟对主要终点没有显著影响。生存分析显示，联合抗菌治疗（HR=1.27，95%CI[0.88;1.83]，p=0.20）或延长抗菌治疗超过 7 天（HR=1.06，95%CI[0.6;1.86]，p=0.84）均不能改善预后。在适当和及时的经验性抗菌治疗的情况下，无论嗜麦芽寡养单胞菌 HAP 是单一致病菌还是多致病菌，院内死亡率均无差异（p=0.273）。在诊断为嗜麦芽寡养单胞菌 HAP 之前，接受机械通气的时间和 ICU 住院时间在单一致病菌嗜麦芽寡养单胞菌 HAP 患者中较短（p=0.031 和 p=0.034）。
结论
嗜麦芽寡养单胞菌 HAP 发生于病情严重、长期入住重症监护病房、主要需要长时间有创通气的患者中。经验性抗菌治疗效果不佳，而抗菌治疗方式对住院生存率无显著影响。
试验注册
clinicaltrials.gov，NCT03506191。
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