De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock
De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock
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DOI：
10.1007/s00134-013-3077-7
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发表时间：
2014-01-01
影响因子：
38.9
通讯作者：
Marquez-Vacaro, J. A.
中科院分区：
文献类型：
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作者：
Garnacho-Montero, J.;Gutierrez-Pizarraya, A.;Marquez-Vacaro, J. A.
我们着手评估入住 ICU 的严重脓毒症或感染性休克患者的抗生素降阶梯治疗的安全性以及对院内死亡率和 90 天死亡率的影响。我们开展了一项前瞻性观察性研究，纳入了入住 ICU 的严重脓毒症或感染性休克患者。降级被定义为一旦获得培养结果，就停止使用抗菌药物或将抗生素更换为谱较窄的抗生素。为了控制混杂变量，我们进行了传统的回归分析和倾向评分（PS）调整多变量分析。共有 712 名入住 ICU 的严重败血症或败血性休克患者接受了广谱抗生素的经验治疗。其中 628 人接受了评估（84 人在培养物获得之前死亡）。 219 名患者 (34.9%) 接受了降阶梯治疗。通过多变量分析，与院内死亡率独立相关的因素是感染性休克、培养结果当天的 SOFA 评分以及经验性抗菌治疗不足，而降阶梯治疗是一个保护因素 [比值比 (OR) 0.58； 95% 置信区间 (CI) 0.36-0.93）。对 403 名接受充分经验治疗的患者进行的分析显示，与死亡率相关的因素是培养结果当天的 SOFA 评分，而降阶梯治疗是一个保护因素（OR 0.54；95% CI 0.33-0.89）。 PS 调整后的逻辑回归模型证实，降阶梯治疗是两项分析中的保护因素。降阶梯治疗也是 90 天死亡率的保护因素。针对严重脓毒症和感染性休克的降阶梯治疗是一种安全策略，可降低死亡率。增加该策略频率的努力是完全合理的。
We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock.We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis.A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9 %). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95 % confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95 % CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality.De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.