免疫功能低下的重症细菌性肺炎和感染性休克患者使用氨基糖苷类药物：一项前瞻性多中心多国队列的事后分析

Aminoglycosides in Immunocompromised Critically Ill Patients With Bacterial Pneumonia and Septic Shock: A Post-Hoc Analysis of a Prospective Multicenter Multinational Cohort.

作者信息

Lopez René, Rello Jordi, Taccone Fabio Silvio, Salem Omar Ben Hadj, Bauer Philippe R, Séguin Amélie, van de Louw Andry, Metaxa Victoria, Klouche Kada, Martin Loeches Ignacio, Montini Luca, Mehta Sangeeta, Bruneel Fabrice, Lisboa T, Viana William, Pickkers Peter, Russell Lene, Rusinova Katerina, Kouatchet Achille, Barbier François, Mokart Djamel, Azoulay Elie, Darmon Michael

机构信息

Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France.

Centro de Investigación Biomédica en Red en enfermedades respiratorias (Ciberes), Instituto Salud Carlos III, Barcelona, Spain.

出版信息

Shock. 2020 Dec;54(6):731-737. doi: 10.1097/SHK.0000000000001553.

DOI:10.1097/SHK.0000000000001553

PMID:32496415

Abstract

BACKGROUND

The routine use of empiric combination therapy with aminoglycosides during critical illness is associated with uncertain benefit and increased risk of acute kidney injury. This study aimed to assess the benefits of aminoglycosides in immunocompromised patients with suspected bacterial pneumonia and sepsis.

METHODS

Secondary analysis of a prospective multicenter study. Adult immunocompromised patients with suspected bacterial pneumonia and sepsis or septic shock were included. Primary outcome was hospital mortality. Secondary outcomes were needed for renal replacement therapy (RRT). Mortality was also assessed in neutropenic patients and in those with confirmed bacterial pneumonia. Results were further analyzed in a cohort matched on risk of receiving aminoglycosides combination.

RESULTS

Five hundred thirty-five patients were included in this analysis, of whom 187 (35%) received aminoglycosides in addition to another antibiotic effective against gram-negative bacteria. Overall hospital mortality was 59.6% (58.3% vs. 60.3% in patients receiving and not receiving combination therapy; P = 0.71). Lack of association between mortality and aminoglycosides was confirmed after adjustment for confounders and center effect (adjusted OR 1.14 [0.69-1.89]) and in a propensity matched cohort (adjusted OR = 0.89 [0.49-1.61]). No association was found between aminoglycosides and need for RRT (adjusted OR = 0.83 [0.49-1.39], P = 0.477), nor between aminoglycoside use and outcome in neutropenic patients or in patients with confirmed bacterial pneumonia (adjusted OR 0.66 [0.23-1.85] and 1.25 [0.61-2.57], respectively).

CONCLUSION

Aminoglycoside combination therapy was not associated with hospital mortality or need for renal replacement therapy in immunocompromised patients with pulmonary sepsis.

摘要

背景

在危重病期间常规使用氨基糖苷类药物进行经验性联合治疗，其获益尚不明确，且急性肾损伤风险增加。本研究旨在评估氨基糖苷类药物对疑似细菌性肺炎和脓毒症的免疫功能低下患者的疗效。

方法

对一项前瞻性多中心研究进行二次分析。纳入疑似细菌性肺炎和脓毒症或脓毒性休克的成年免疫功能低下患者。主要结局为住院死亡率。次要结局为肾脏替代治疗（RRT）的必要性。还对中性粒细胞减少患者和确诊细菌性肺炎患者的死亡率进行了评估。在根据接受氨基糖苷类联合治疗的风险进行匹配的队列中对结果进行了进一步分析。

结果

本分析纳入了535例患者，其中187例（35%）除接受另一种有效抗革兰氏阴性菌的抗生素外还接受了氨基糖苷类药物治疗。总体住院死亡率为59.6%（接受和未接受联合治疗的患者分别为58.3%和60.3%；P = 0.71）。在对混杂因素和中心效应进行校正后（校正比值比1.14 [0.69 - 1.89]）以及在倾向匹配队列中（校正比值比 = 0.89 [0.49 - 1.61]），均证实死亡率与氨基糖苷类药物之间无关联。未发现氨基糖苷类药物与RRT必要性之间存在关联（校正比值比 = 0.83 [0.49 - 1.39]，P = 0.477），在中性粒细胞减少患者或确诊细菌性肺炎患者中，氨基糖苷类药物的使用与结局之间也无关联（校正比值比分别为0.66 [0.23 - 1.85]和1.25 [0.61 - 2.57]）。