Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, Unidade de Tratamento Intensivo, São Paulo, SP, Brazil.
Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil.
Braz J Anesthesiol. 2024 May-Jun;74(3):744431. doi: 10.1016/j.bjane.2023.03.003. Epub 2023 Mar 23.
Systemic inflammatory responses mimicking infectious complications are often present in surgical patients.
The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion.
Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37).
Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.
手术患者常出现模拟感染并发症的全身炎症反应。
本研究旨在评估在回顾性危重外科患者队列中，对于疑似医院获得性感染但无明确感染源的非脓毒症患者，在调查其他诊断时延迟开始早期抗菌治疗与较差结局之间的相关性。在感染疑似后 24 小时内开始抗生素治疗定义为早期经验性抗生素策略（EEA）组，在 24 小时后开始或未开处方定义为保守抗生素策略（CA）组。主要结局是 14 天内复合：死亡、脓毒症或脓毒性休克。主要排除标准是纳入时存在脓毒症或明显的感染源。
340 例患者符合纳入标准（74%为创伤患者）。两组之间的年龄、性别、住院原因、SAPS3 评分、SOFA 评分以及血管加压素或机械通气的使用无差异。在纳入后 14 天内，100%（130/130）的 EEA 患者接受了抗生素治疗，而 CA 组为 57%（120/210）。在调整混杂变量后，主要结局与两组之间无关联。在后验亚组分析中，仅包括经微生物培养后确认感染的患者，延迟开始适当的抗菌治疗与主要结局独立相关（延迟 1 天的优势比为 1.19；95%CI 为 1.05-1.37）。
在无明显感染源的疑似医院获得性感染但非脓毒症的外科患者中，延迟开始早期经验性抗生素治疗与 14 天内器官功能障碍进展无关。
