Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome
Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome
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DOI：
10.1164/rccm.201706-1172oc
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发表时间：
2018-03-15
影响因子：
24.7
通讯作者：
Fowler, Robert A.
中科院分区：
文献类型：
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作者：
Arabi, Yaseen M.;Mandourah, Yasser;Fowler, Robert A.
基本原理：皮质类固醇治疗常用于中东呼吸综合征（MERS）重症患者，但其对预后的影响尚不确定。观察性研究的分析通常不考虑患者在开始皮质类固醇治疗时的临床状况。Objectives：To investigate the association of corticosteroids therapy on mortality and on MERS coronavirus RNA clearance in critical ill patients with MERS.Methods：MERS的ICU患者在2012年9月至2015年10月期间来自14个沙特阿拉伯中心。我们进行边际结构建模，占基线和随时间变化的confersider. Measures和主要结果：309例患者中，151例接受皮质类固醇。从ICU入院后中位3.0天（四分位数1 [Q1]-Q3，1.0-7.0）开始使用皮质类固醇。接受糖皮质激素治疗的患者更可能接受有创通气（151例中的141例[93.4%] vs. 158例中的121例[76.6%]; P < 0.0001），90天粗死亡率更高（151例中的112例[74.2%] vs. 158例中的91例[57.6%]; P = 0.002）。使用边缘结构模型，皮质类固醇治疗与90天死亡率无显著相关性（校正比值比，0.75; 95%置信区间，0.52-1.07; P = 0.12），但与MERS冠状病毒RNA清除延迟相关结论：MERS患者的糖皮质激素治疗与校正时变混杂因素后的死亡率差异无关，但与MERS冠状病毒RNA清除延迟相关。这些发现强调了在使用观察性研究估计治疗的临床效果时调整基线和时变混杂因素的挑战和重要性。
Rationale: Corticosteroid therapy is commonly used among critically ill patients with Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients' clinical condition at the time of corticosteroid therapy initiation.Objectives: To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS.Methods: ICU patients with MERs were included from 14 Saudi Arabian centers between September 2012 and October 2015. We performed marginal structural modeling to account for baseline and time-varying confounders.Measurements and Main Results: Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (quartile 1 [Q1]-Q3, 1.0-7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141 of 151 [93.4%] vs. 121 of 158 [76.6%]; P < 0.0001) and had higher 90-day crude mortality (112 of 151 [74.2%] vs. 91 of 158 [57.6%]; P = 0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio, 0.75; 95% confidence interval, 0.52-1.07; P = 0.12) but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio, 0.35; 95% CI, 0.17-0.72; P = 0.005).Conclusions: Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.