Department of Infectious Diseases, Sindh Institute of Urology and Transplantation, Karachi, Pakistan.
Int J Infect Dis. 2021 May;106:171-175. doi: 10.1016/j.ijid.2021.03.004. Epub 2021 Mar 8.
Polymyxins (colistin) have emerged for the treatment of carbapenem resistant (CR) gram-negative infections. There is a paucity of data on treatment outcomes and adverse effects of high-dose colistin treatment in Pakistan. The aim of this study was to determine the efficacy and toxicity of colistin in CR bacteremia, including patients with renal failure and on hemodialysis, and to determine patient outcomes.
This prospective cohort study was performed from May to December 2017 at Sindh Institute of Urology and Transplantation, Karachi, Pakistan. Patients aged >18 years with documented gram-negative bacteremia were included. Data were compared between those who received colistin and those who did not, including risk factors for CR bacteremia, bacterial clearance, adverse effects, and all-cause mortality up to 14 days of follow-up.
The study included 137 patients, 73 (53.3%) in the colistin group and 64 (46.7%) in the non-colistin group. Patients in the colistin group were 1.47 times more likely to have died by day 14 of follow-up as compared to those in the non-colistin group (19.2% vs 7.8%; relative risk 1.47, p= 0.05). Patients in both groups achieved more than 80% bacteriological clearance. The colistin group patients were less likely to have received appropriate empirical antibiotics as compared to the non-colistin group patients (4.1% vs 62.5%; relative risk 0.09, p< 0.001). Factors significantly associated with mortality were inappropriate empirical antibiotics and acute renal failure. Of the 73 patients in the colistin group, 27 (37.0%) developed reversible neurological adverse effects. Patients with renal insufficiency, not on hemodialysis, were evaluated for colistin nephrotoxicity. Creatinine decreased from 8.08 mg/dl at baseline to 4.85 mg/dl on day 7 in the colistin group, and from 6.5 mg/dl to 3.9 mg/dl in the non-colistin group. Patients with normal renal function had no significant rise in serum creatinine.
Colistin is efficacious in clearing bacteremia even in patients with impaired renal function. The adverse effects were found to be minimal and reversible. We recommend the use of colistin in combination with carbapenems for CR gram-negative bacteria in renal failure. Most importantly, however, this study highlights the role of empirical colistin treatment in patients with risk factors for CR bacteremia.
多黏菌素（黏菌素）已被用于治疗碳青霉烯类耐药（CR）革兰氏阴性感染。在巴基斯坦，关于高剂量黏菌素治疗的治疗结果和不良反应的数据很少。本研究的目的是确定多黏菌素在 CR 菌血症中的疗效和毒性，包括肾功能衰竭和血液透析患者，并确定患者的预后。
这是一项前瞻性队列研究，于 2017 年 5 月至 12 月在巴基斯坦卡拉奇的信德省泌尿科和移植研究所进行。纳入年龄> 18 岁且有革兰氏阴性菌血症记录的患者。比较了接受黏菌素治疗和未接受黏菌素治疗的患者之间的风险因素、细菌清除率、不良反应以及 14 天随访期间的全因死亡率。
研究纳入了 137 名患者，其中 73 名（53.3%）在黏菌素组，64 名（46.7%）在非黏菌素组。与非黏菌素组相比，黏菌素组患者在随访第 14 天的死亡率更高（19.2% vs 7.8%；相对风险 1.47，p=0.05）。两组患者的细菌学清除率均超过 80%。与非黏菌素组患者相比，黏菌素组患者接受适当经验性抗生素治疗的可能性较小（4.1% vs 62.5%；相对风险 0.09，p< 0.001）。与死亡率显著相关的因素是经验性抗生素治疗不当和急性肾功能衰竭。在 73 名黏菌素组患者中，有 27 名（37.0%）出现可逆性神经不良反应。对肾功能不全但未行血液透析的患者进行了黏菌素肾毒性评估。黏菌素组患者的肌酐从基线时的 8.08 mg/dl 降至第 7 天时的 4.85 mg/dl，而非黏菌素组患者的肌酐从 6.5 mg/dl 降至 3.9 mg/dl。肾功能正常的患者的血清肌酐没有明显升高。
黏菌素对清除菌血症有效，即使在肾功能受损的患者中也是如此。不良反应发现是最小的且是可逆的。我们建议在肾功能衰竭的 CR 革兰氏阴性菌中使用黏菌素联合碳青霉烯类药物。然而，最重要的是，本研究强调了在 CR 菌血症风险因素患者中经验性黏菌素治疗的作用。
