多药耐药革兰氏阴性菌对静脉-静脉体外膜肺氧合的回顾性分析。多中心 RANGER 研究。
Retrospective ANalysis of multi-drug resistant Gram-nEgative bacteRia on veno-venous extracorporeal membrane oxygenation. The multicenter RANGER STUDY.
机构信息
Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy.
Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy.
出版信息
Crit Care. 2024 Aug 27;28(1):279. doi: 10.1186/s13054-024-05068-x.
BACKGROUND
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a rapidly expanding life-support technique worldwide. The most common indications are severe hypoxemia and/or hypercapnia, unresponsive to conventional treatments, primarily in cases of acute respiratory distress syndrome. Concerning potential contraindications, there is no mention of microbiological history, especially related to multi-drug resistant (MDR) bacteria isolated before V-V ECMO placement. Our study aims to investigate: (i) the prevalence and incidence of MDR Gram-negative (GN) bacteria in a cohort of V-V ECMOs; (ii) the risk of 1-year mortality, especially in the case of predetected MDR GN bacteria; and (iii) the impact of annual hospital V-V ECMO volume on the probability of acquiring MDR GN bacteria.
METHODS
All consecutive adults admitted to the Intensive Care Units of 5 Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records, survival < 24 h after V-V ECMO. A standard protocol of microbiological surveillance was applied and MDR profiles were identified using in vitro susceptibility tests. Cox-proportional hazards models were applied for investigating mortality.
RESULTS
Two hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall MDR GN bacteria percentage was 50%: 21% (n.59) detected before and 29% (n.80) after V-V ECMO placement. The overall 1-year mortality was 42%, with a higher risk observed in predetected patients (aHR 2.14 [1.33-3.47], p value 0.002), while not in 'V-V ECMO-acquired MDR GN bacteria' group (aHR 1.51 [0.94-2.42], p value 0.090), as compared to 'non-MDR GN bacteria' group (reference). Same findings were found considering only infections. A larger annual hospital V-V ECMO volume was associated with a lower probability of acquiring MDR GN bacteria during V-V ECMO course (aOR 0.91 [0.86-0.97], p value 0.002).
CONCLUSIONS
21% of MDR GN bacteria were detected before; while 29% after V-V ECMO connection. A history of MDR GN bacteria, isolated before V-V ECMO, was an independent risk factor for mortality. The annual hospital V-V ECMO volume affected the probability of acquiring MDR GN bacteria. Trial Registration ClinicalTrial.gov Registration Number NCTNCT06199141, date 12.26.2023.
背景
静脉-静脉体外膜肺氧合（V-V ECMO）是一种在全球范围内迅速发展的生命支持技术。最常见的适应证是严重的低氧血症和/或高碳酸血症，对常规治疗无反应，主要发生在急性呼吸窘迫综合征病例中。关于潜在的禁忌证，没有提到微生物学史，特别是与 V-V ECMO 放置前分离的多药耐药（MDR）细菌有关。我们的研究旨在调查：（i）V-V ECMO 患者队列中 MDR 革兰氏阴性（GN）细菌的流行率和发生率；（ii）1 年死亡率的风险，特别是在预先检测到 MDR GN 细菌的情况下；（iii）医院每年 V-V ECMO 量对获得 MDR GN 细菌的概率的影响。
方法
对 5 家意大利大学附属医院的重症监护病房收治的所有连续成年 V-V ECMO 患者进行筛查。排除标准为年龄<18 岁、妊娠、静脉-动脉或混合 ECMO 配置、记录不完整、V-V ECMO 后生存时间<24 小时。应用标准的微生物监测方案，并使用体外药敏试验确定 MDR 特征。应用 Cox 比例风险模型调查死亡率。
结果
共纳入 279 例 V-V ECMO 患者（72%为男性）。总体 MDR GN 细菌百分比为 50%：21%（n=59）在 V-V ECMO 前检出，29%（n=80）在 V-V ECMO 后检出。总的 1 年死亡率为 42%，在预先检测到的患者中风险更高（aHR 2.14[1.33-3.47]，p 值=0.002），而在“V-V ECMO 获得性 MDR GN 细菌”组中则没有（aHR 1.51[0.94-2.42]，p 值=0.090），与“非 MDR GN 细菌”组（参考）相比。同样的发现也适用于仅考虑感染的情况。较大的医院每年 V-V ECMO 量与 V-V ECMO 过程中获得 MDR GN 细菌的概率较低相关（aOR 0.91[0.86-0.97]，p 值=0.002）。
结论
21%的 MDR GN 细菌在 V-V ECMO 前检出；而在 V-V ECMO 连接后检出 29%。V-V ECMO 前分离的 MDR GN 细菌史是死亡的独立危险因素。医院每年 V-V ECMO 量影响获得 MDR GN 细菌的概率。
临床试验注册
ClinicalTrials.gov 注册号 NCT06199141，注册日期 2023 年 12 月 26 日。
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