Girou E, Stephan F, Novara A, Safar M, Fagon J Y
Service de Réanimation Médicale and Département de Médecine Interne, Hôpital Broussais, Paris, France.
Am J Respir Crit Care Med. 1998 Apr;157(4 Pt 1):1151-8. doi: 10.1164/ajrccm.157.4.9701129.
Intensive-care-unit (ICU) patients are at risk for both acquiring nosocomial infection and dying, and require a high level of therapy whether infection occurs or not. The objective of the present study was to precisely define the interrelationships between underlying disease, severity of illness, therapeutic activity, and nosocomial infections in ICU patients, and their respective influences on these patients' outcome. In a 10-bed medical ICU, we conducted a case-control study with matching for initial severity of illness, with daily monitoring of severity of illness and therapeutic activity scores, and with analysis of the contribution of nosocomial infections to patients' outcomes. Forty-one cases of patients who developed nosocomial infections during a 1-yr period were paired with 41 controls without nosocomial infection according to three criteria: age (+/- 5 yr), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (+/- 5 points), and duration of exposure to risk. Successful matching was achieved for 118 of 123 (96%) variables. Neurologic failure on the third day after ICU admission was the sole independent risk factor for nosocomial infection (adjusted odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.09 to 1.64; p = 0.007). Unlike control patients, case patients showed no clinical improvement and required a high level of therapeutic activity between ICU admission and the day of infection. Mortality attributable to nosocomial infection was 44%. Excess length of stay and duration of antibiotic treatment attributable to nosocomial infection were 14 d and 10 d, respectively. Attributable therapeutic activity as measured with the Therapeutic Intervention Scoring System (TISS) and Omega score was 368 and 233 points, respectively. Such consequences were observed in patients who developed multiple infections. These findings suggest that a persistent high level of therapeutic activity and persistent impaired consciousness are risk factors for nosocomial infections in ICU patients. These infections are responsible for excess mortality, prolongation of stay, and excess therapeutic activity resulting in important cost overruns for health-care systems.
重症监护病房（ICU）患者有发生医院感染和死亡的风险，无论是否发生感染都需要高水平的治疗。本研究的目的是精确界定ICU患者基础疾病、疾病严重程度、治疗活动和医院感染之间的相互关系，以及它们各自对这些患者预后的影响。在一个有10张床位的内科ICU中，我们进行了一项病例对照研究，匹配初始疾病严重程度，每日监测疾病严重程度和治疗活动评分，并分析医院感染对患者预后的影响。在1年期间发生医院感染的41例患者与41例未发生医院感染的对照患者根据三个标准进行配对：年龄（±5岁）、急性生理与慢性健康状况评价II（APACHE II）评分（±5分）和暴露于风险的持续时间。123个变量中的118个（96%）成功匹配。ICU入院后第三天的神经功能衰竭是医院感染的唯一独立危险因素（调整优势比[OR]：1.34；95%置信区间[CI]：1.09至1.64；p = 0.007）。与对照患者不同，病例患者在ICU入院至感染当天之间没有临床改善，并且需要高水平的治疗活动。医院感染导致的死亡率为44%。医院感染导致的住院时间延长和抗生素治疗持续时间分别为14天和10天。用治疗干预评分系统（TISS）和欧米茄评分衡量的归因治疗活动分别为368分和233分。在发生多重感染的患者中观察到了此类后果。这些发现表明，持续高水平的治疗活动和持续意识障碍是ICU患者发生医院感染的危险因素。这些感染导致额外的死亡率、住院时间延长和额外的治疗活动，给医疗保健系统带来了重要的成本超支。
