Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients.
Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients.
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DOI：
10.7759/cureus.2917
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发表时间：
2018-07-03
期刊：
影响因子：
--
通讯作者：
Seifert CF
中科院分区：
文献类型：
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作者：
Rambaran KA;Alzghari SK;Seifert CF
血管通路感染是血液透析（HD）患者发病率和死亡率的主要原因之一。关于 HD 人群中万古霉素的使用缺乏共识指南。本研究的主要目的是确定万古霉素血清浓度是否与患有革兰氏阳性菌血症的 HD 患者的阳性结果相关。回顾性队列研究于2010年1月1日至2016年1月1日在一家拥有443个床位的三级教学县医院进行。对年龄为 18-89 岁、因血液透析而患有慢性肾功能衰竭、血液培养革兰氏阳性菌呈阳性并接受静脉注射万古霉素至少 24 小时的患者进行了评估。采用多变量分析比较与结果相关的因素，包括简化急性生理学评分 II (SAPS II)、负荷剂量、30 天死亡率和万古霉素血清浓度。总共获得了 139 名患者，其中 90 名患者记录了透析前血清万古霉素浓度。多变量分析显示，SAPS II 评分较低 [OR 1.220 (95% CI: 1.086-1.370，p < 0.0001)]，负荷剂量/kg 较高 [OR 0.7911 (0.6302-0.9929，p = 0.0239)]，透析前浓度在 15 至 20 mcg/mL 之间[0.05437 (95% CI: 0.0033-0.8891, p = 0.0099)] 与死亡率降低相关（总体多变量模型，p < 0.0001）。当考虑到患者的病情严重程度和负荷剂量时，透析前万古霉素血清浓度在 15 至 20 mcg/mL 之间与革兰氏阳性菌血症间歇性 HD 患者死亡率降低相关。需要进一步的前瞻性研究来评估将透析前血清万古霉素浓度设定为 15-20 mcg/mL 是否可以降低死亡率。
Vascular access infection is one of the major contributors to hemodialysis (HD) patient morbidity and mortality. There is a paucity of consensus guidelines on vancomycin use in the HD population. The primary objective of this study was to determine if vancomycin serum concentrations were associated with positive outcomes in HD patients with Gram-positive bacteremia. A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from January 1, 2010 to January 1, 2016 was performed. Patients aged 18-89, with chronic renal failure on hemodialysis who presented with positive blood cultures with Gram-positive bacteria and received intravenous vancomycin for at least 24 hours were evaluated. A multivariate analysis was utilized comparing factors related to outcomes including Simplified Acute Physiology Score II (SAPS II), loading dose, 30-day mortality and vancomycin serum concentrations. A total of 139 patients were obtained, 90 of whom had documented pre-dialysis serum vancomycin concentrations. A multivariate analysis showed that a lower SAPS II score [OR 1.220 (95% CI: 1.086-1.370, p < 0.0001)], a higher loading dose/kg [OR 0.7911 (0.6302-0.9929, p = 0.0239)], and pre-dialysis concentrations between 15 and 20 mcg/mL [0.05437 (95% CI: 0.0033-0.8891, p = 0.0099)] were associated with decreased mortality (overall multivariate model, p < 0.0001). When patient acuity and loading dosing are taken into account, pre-dialysis vancomycin serum concentrations between 15 and 20 mcg/mL were associated with decreased mortality in Gram-positive bacteremic intermittent HD patients. Further prospective studies are needed to assess whether targeting a pre-dialysis serum vancomycin concentration of 15-20 mcg/mL can improve mortality.