急诊癌症发热性中性粒细胞减少症患者的抗生素处方和结局。
Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department.
机构信息
Emergency Department, Hôpital Saint-Louis, Paris, France.
Emergency Department, Hôpital Saint-Joseph, Paris, France.
出版信息
PLoS One. 2020 Feb 28;15(2):e0229828. doi: 10.1371/journal.pone.0229828. eCollection 2020.
INTRODUCTION
The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED.
METHODS
We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses.
RESULTS
We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28).
CONCLUSION
An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.
介绍
在急诊室（ED）减少中性粒细胞减少患者开始使用抗生素的时间的益处存在争议，而关于 ED 中遵循国际指南使用抗生素的影响的研究则很少。我们旨在研究发热性中性粒细胞减少症（FN）患者的抗生素时机和适当性对结局的影响，并评估 MASCC 风险指数在 ED 中对这类患者进行风险分层的效果。
方法
我们前瞻性地确定了就诊于 ED 的 FN 患者，并评估了他们的多国支持癌症治疗协会（MASCC）风险指数。回顾性提取了给予静脉抗生素的时间和根据国际指南的抗生素方案的适当性。通过灵敏度、特异性和接受者操作特征曲线（ROC）下的面积（AUC）评估 MASCC 风险指数预测无并发症的表现。我们通过逻辑回归分析研究了抗生素开始时间和抗生素方案的适当性对结局（入住 ICU 或死亡）的影响。
结果
我们纳入了 249 名患者。中位年龄为 60 岁，67.9%患有血液系统恶性肿瘤，26 名（10.4%）入住 ICU，23 名（9.8%）在住院期间死亡。在 MASCC 风险指数低危的 173 名患者中，有 56 名（32.4%）出现了至少一种并发症，包括 11 例死亡。MASCC 风险指数预测无并发症的灵敏度和特异性分别为 0.78%和 0.43%，AUC 为 0.67。调整表现状态和休克指数后，ED 中抗生素的开始时间与结局无关。相反，ED 抗生素方案不充分与住院期间 ICU 入住或死亡的风险增加相关（OR = 3.50；95%CI = 1.49 至 8.28）。
结论
FN 患者 ED 中抗生素方案不充分与住院期间 ICU 入住或死亡的风险增加显著相关。
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