产非碳青霉烯酶碳青霉烯类耐药肺炎克雷伯菌血症的治疗转归：碳青霉烯类联合治疗的作用。
Treatment Outcome of Bacteremia Due to Non-Carbapenemase-producing Carbapenem-Resistant Klebsiella pneumoniae Bacteremia: Role of Carbapenem Combination Therapy.
机构信息
Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University Tainan, Tainan, Taiwan.
Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan.
出版信息
Clin Ther. 2020 Mar;42(3):e33-e44. doi: 10.1016/j.clinthera.2020.01.004. Epub 2020 Feb 12.
PURPOSE
Infections caused by carbapenemase-producing Klebsiella pneumoniae are emerging causes of morbidity and mortality worldwide. Optimal treatment for non-carbapenemase-producing carbapenem-resistant K pneumoniae (nCP-CRKP) bacteremia remains undefined. The goal of this study was to assess the clinical outcome, predictors of mortality, and therapeutic strategy of carbapenems for nCP-CRKP bacteremia.
METHODS
A retrospective study of monomicrobial bacteremia caused by nCP-CRKP, at a medical center between 2010 and 2015 was conducted. CRKP which was defined as a minimum inhibitory concentration (MIC) of ≥ 2 for ertapenem or ≥ 4 mg/L for meropenem, or imipenem. Multiplex polymerase chain was applied to detect carbapenemase genes. The patients definitively treated with combination therapy were compared with monotherapy using a propensity score-matched analysis to assess therapeutic effectiveness. The primary end point was the 30-day crude mortality and clinical prognostic factors were assessed.
FINDINGS
Overall 171 patients met criteria were eligible for the study and their overall 30-day mortality rate was 38.6%. The multivariate logistic regression analysis showed that combination therapy was associated with a lower 30-day mortality rate (adjusted odds ratio [aOR], 0.11; 95% CI, 0.03-0.43; P = 0.001) and less clinical (aOR, 0.21; 95% CI, 0.08-0.58; P = 0.003) and microbiologic (aOR, 0.36; 95% CI, 0.19-0.71; P = 0.003) failure. However, the 30-day mortality rate in the cases infected by a pathogen with a meropenem MIC ≤8 mg/L receiving carbapenem-containing or carbapenem-sparing combination regimens was similar (15 of 58 [25.9%] vs 5 of 20 [23.3%]; P = 1.0).
IMPLICATIONS
Combination therapy, regardless of carbapenem-containing or carbapenem-sparing, with one or more active agents improved survival more than monotherapy and was more effective in patients with critical illness. (Clin Ther. 2020; 42:XXX-XXX) © 2020 Elsevier HS Journals, Inc.
目的
产碳青霉烯酶肺炎克雷伯菌引起的感染是全球发病率和死亡率上升的原因。非产碳青霉烯酶碳青霉烯耐药肺炎克雷伯菌（nCP-CRKP）菌血症的最佳治疗方法仍未确定。本研究旨在评估碳青霉烯类药物治疗 nCP-CRKP 菌血症的临床结局、死亡率预测因素和治疗策略。
方法
对 2010 年至 2015 年期间在一家医疗中心发生的单一致病菌血症患者进行回顾性研究。CRKP 定义为美罗培南最小抑菌浓度（MIC）≥2 或亚胺培南≥4 mg/L。采用多重聚合酶链反应检测碳青霉烯酶基因。使用倾向评分匹配分析比较明确接受联合治疗的患者与单药治疗的患者，以评估治疗效果。主要终点是 30 天的粗死亡率和临床预后因素。
结果
共有 171 例患者符合条件，总 30 天死亡率为 38.6%。多变量逻辑回归分析显示，联合治疗与较低的 30 天死亡率相关（调整优势比[aOR]，0.11；95%CI，0.03-0.43；P=0.001），临床（aOR，0.21；95%CI，0.08-0.58；P=0.003）和微生物学（aOR，0.36；95%CI，0.19-0.71；P=0.003）失败的发生率更低。然而，接受美罗培南 MIC≤8mg/L 病原体感染的患者中，接受含碳青霉烯或碳青霉烯节约联合方案治疗的 30 天死亡率相似（58 例中有 15 例[25.9%]与 20 例中有 5 例[23.3%]；P=1.0）。
结论
联合治疗，无论是否包含碳青霉烯类药物，联合一种或多种活性药物，比单药治疗更能提高生存率，对重症患者更有效。（临床治疗。2020；42：XXX-XXX）©2020 Elsevier HS 期刊，Inc.
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