Dong Yi, Heng Gang, Zhang Jianxin, Shen Yanbing, Lan Zhen, Wei Kunchen, Jin Weidong
Department of General Surgery, General Hospital of Central Theater Command, Wuhan, China.
The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
Front Med (Lausanne). 2023 Nov 6;10:1276181. doi: 10.3389/fmed.2023.1276181. eCollection 2023.
Although corticosteroids are recommended in the 2021 Surviving Sepsis Campaign (SSC) guidelines, evidence with respect to their effects on short-term mortality remains conflicting. We conducted this study to identify whether corticosteroids alter 28-day mortality in septic shock patients with gram-negative bacterial infection.
A total of 621 patients with septic shock and gram-negative bacterial culture results were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Propensity score matching (PSM) was performed, and Kaplan-Meier survival curve analyses with log-rank tests were used to determine the relationship between corticosteroid use and the risk of 28-day mortality. Subgroup analyses were conducted to assess whether the conclusions were stable and reliable.
Corticosteroid administration was associated with increased 28-day mortality in septic shock patients with gram-negative bacterial infection (log-rank test = 0.028). The incidence of Stage 2 or 3 AKI and the rate of hospital mortality were higher among patients who received corticosteroids. The incidence of Stage 2 or 3 AKI in the early period significantly mediated the relationship between corticosteroid use and 28-day mortality [ =0.046 for the average causal mediation effect (ACME)]. Interaction tests indicated that the effect of corticosteroid use was maintained in patients with a neutrophil-to-lymphocyte ratio (NLR) of <20 (-value for interaction = 0.027).
Systemic corticosteroid use could be harmful in septic shock patients with gram-negative bacterial infection, especially in patients with relatively low NLR.
尽管2021年拯救脓毒症运动（SSC）指南推荐使用皮质类固醇，但关于其对短期死亡率影响的证据仍存在矛盾。我们开展这项研究以确定皮质类固醇是否会改变革兰氏阴性菌感染的脓毒症休克患者的28天死亡率。
从重症监护医学信息数据库IV（MIMIC-IV）中识别出总共621例有脓毒症休克且有革兰氏阴性菌培养结果的患者。进行倾向评分匹配（PSM），并使用带有对数秩检验的Kaplan-Meier生存曲线分析来确定皮质类固醇使用与28天死亡风险之间的关系。进行亚组分析以评估结论是否稳定可靠。
在革兰氏阴性菌感染的脓毒症休克患者中，使用皮质类固醇与28天死亡率增加相关（对数秩检验=0.028）。接受皮质类固醇治疗的患者中，2期或3期急性肾损伤的发生率和医院死亡率更高。早期2期或3期急性肾损伤的发生率显著介导了皮质类固醇使用与28天死亡率之间的关系[平均因果中介效应（ACME）为0.046]。交互检验表明，在中性粒细胞与淋巴细胞比率（NLR）<20的患者中，使用皮质类固醇的效果得以维持（交互P值=0.027）。
全身性使用皮质类固醇可能对革兰氏阴性菌感染的脓毒症休克患者有害，尤其是在NLR相对较低的患者中。
