Alvarez-Lerma F
Unidad de Cuidados Intensivos, Hospital del Mar, Universitat Autònoma de Barcelona, Spain.
Intensive Care Med. 1996 May;22(5):387-94. doi: 10.1007/BF01712153.
To assess the frequency of and the reasons for changing empiric antibiotics during the treatment of pneumonia acquired in the intensive care unit (ICU).
A prospective multicenter study of 1 year's duration.
Medical and surgical ICUs in 30 hospitals all over Spain.
Of a total of 16,872 patients initially enrolled into the study, 530 patients developed 565 episodes of pneumonia after admission to the ICU.
Empiric antibiotics were administered in 490 (86.7%) of the 565 episodes of pneumonia. The antimicrobials most frequently used were amikacin in 120 cases, tobramycin in 110, ceftazidime in 96, and cefotaxime in 96. Monotherapy was indicated in 135 (27.6%) of the 490 episodes, a combination of two antibiotics in 306 episodes (62.4%), and a combination of three antibiotics in 49 episodes (10%). The empiric antibiotic treatment was modified in 214 (43.7%) cases because of isolation of a microorganism not covered by treatment in 133 (62.1%) cases, lack of clinical response in 77 (36%), and development of resistance in 14 (6.6%). Individual factors associated with modification of empiric treatment identified in the multivariate analysis were microorganism not covered (relative risk (RR)) 22.02; 95% confidence interval (CI) 11.54 to 42.60; p < 0.0001), administration of more than one antimicrobial (RR 1.29; 95% CI 1.02 to 1.65; p = 0.021), and previous use of antibiotics (RR 1.22; 95% CI 1.08 to 1.39; p = 0.0018). Attributable mortality was 16.2% in patients with appropriate initial therapy and 24.7% in patients with inappropriate treatment (p = 0.034).
A high percentage of patients (43.7%) required modification of empiric antibiotic treatment for pneumonia acquired in the ICU. In 62.1% of cases the main reason for changing antibiotic treatment was inadequate antibiotic coverage of microorganisms. Attributable mortality was significantly higher in patients with inappropriate initial antibiotic therapy. Rapid and accurate diagnostic methods are needed to initiate appropriate antibiotic treatment as soon as pneumonia is suspected.
评估重症监护病房（ICU）获得性肺炎治疗期间经验性抗生素更换的频率及原因。
一项为期1年的前瞻性多中心研究。
西班牙各地30家医院的内科和外科ICU。
在最初纳入研究的16872例患者中，530例患者在入住ICU后发生了565次肺炎发作。
565次肺炎发作中有490次（86.7%）使用了经验性抗生素。最常用的抗菌药物为阿米卡星120例、妥布霉素110例、头孢他啶96例和头孢噻肟96例。490次发作中有135次（27.6%）采用单药治疗，306次发作（62.4%）采用两种抗生素联合治疗，49次发作（10%）采用三种抗生素联合治疗。214例（43.7%）患者的经验性抗生素治疗进行了调整，其中133例（62.1%）是因为分离出治疗未覆盖的微生物，77例（36%）是因为缺乏临床反应，14例（6.6%）是因为出现耐药。多变量分析确定的与经验性治疗调整相关的个体因素为微生物未被覆盖（相对危险度（RR）22.02；95%置信区间（CI）11.54至42.60；p<0.0001）、使用一种以上抗菌药物（RR 1.29；95%CI 1.02至1.65；p=0.021）以及既往使用过抗生素（RR 1.22；95%CI 1.08至1.39；p=0.0018）。初始治疗恰当的患者归因死亡率为16.2%，治疗不恰当的患者为24.7%（p=0.034）。
很高比例（43.7%）的ICU获得性肺炎患者需要调整经验性抗生素治疗。62.1%的病例中，更换抗生素治疗的主要原因是抗生素对微生物的覆盖不足。初始抗生素治疗不恰当的患者归因死亡率显著更高。需要快速准确的诊断方法，以便在怀疑肺炎时尽快开始恰当的抗生素治疗。
