Corticosteroid Treatment in Critically Ill Patients with Pandemic Influenza A/H1N1 2009 Infection Analytic Strategy Using Propensity Scores
Corticosteroid Treatment in Critically Ill Patients with Pandemic Influenza A/H1N1 2009 Infection Analytic Strategy Using Propensity Scores
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DOI：
10.1164/rccm.201101-0110oc
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发表时间：
2011-05-01
影响因子：
24.7
通讯作者：
Koh, Younsuck
中科院分区：
文献类型：
--
作者：
Kim, Sung-Han;Hong, Sang-Bum;Koh, Younsuck
基本原理：对2009年甲型H1N1流感（pH 1 N1）患者给予辅助皮质类固醇可以减少炎症并改善预后。目的：评估辅助皮质类固醇治疗对pH 1 N1感染的危重患者预后的影响。方法：入选了2009年9月至2010年2月期间在韩国28家医院重症监护室住院的所有确诊pH 1 N1的成人患者。通过两种危险分层模型对接受和未接受辅助皮质类固醇治疗的患者进行回顾性比较：（1）一项回顾性队列研究，使用倾向评分分析调整治疗分配的混杂因素;（2）一项倾向匹配的病例对照研究。共245例患者入组队列研究，其中107例（44%）接受了辅助类固醇治疗。在队列研究中，使用类固醇的患者的90天死亡率（58%，62/107）显著高于未使用类固醇的患者（27%，37/138）（P < 0.001）。类固醇组更容易发生二重感染，如继发性细菌性肺炎或侵袭性真菌感染，并且比无类固醇组有更长的重症监护时间。多变量分析表明，当考虑90天死亡率和倾向评分的独立预测因素时，类固醇治疗与90天死亡率增加相关（校正比值比，2.20; 95%置信区间，1.03-4.71）。在病例对照研究中，类固醇组的90天死亡率为54%（35/65），无类固醇组的90天死亡率为31%（20/65）（McNemar检验，P = 0.004）。
Rationale: Administration of adjuvant corticosteroids to patients with pandemic influenza A/H1N1 2009 (pH1N1) may reduce inflammation and improve outcomes.Objectives: To assess the effect of adjuvant corticosteroid treatment on the outcome of critically ill patients with pH1N1 infection.Methods: All adult patients with confirmed pH1N1 admitted to the intensive care unit of 28 hospitals in South Korea from September 2009 to February 2010 were enrolled. Patients with and without adjuvant corticosteroid treatment were retrospectively compared by two risk stratification models: (1) a retrospective cohort study that used propensity score analysis to adjust for confounding by treatment assignment and (2) a propensity-matched case-control study.Measurements and Main Results: A total of 245 patients were enrolled in the cohort study, 107 of whom (44%) received adjuvant steroid treatment. In the cohort study, the 90-day mortality rate of patients given steroids (58%, 62 of 107) was significantly higher than that of those not given steroids (27%, 37 of 138) (P < 0.001). The steroid group was more likely to have superinfection such as secondary bacterial pneumonia or invasive fungal infection, and had more prolonged intensive care unit stays than the no-steroid group. Multivariate analysis indicated that steroid treatment was associated with increased 90-day mortality when independent predictors for 90-day mortality and propensity score were considered (adjusted odds ratio, 2.20; 95% confidence interval, 1.03-4.71). In the case-control study, the 90-day mortality rate in the steroid group was 54% (35 of 65) and 31% (20 of 65) in the no-steroid group (McNemar test, P = 0.004).Conclusions: Adjuvant corticosteroids were significantly associated with higher mortality in critically ill patients with pH1N1 infection.