Time Is of the Essence: The Impact of Delayed Antibiotic Therapy on Patient Outcomes in Hospital-Onset Enterococcal Bloodstream Infections
Time Is of the Essence: The Impact of Delayed Antibiotic Therapy on Patient Outcomes in Hospital-Onset Enterococcal Bloodstream Infections
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DOI：
10.1093/cid/ciw110
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发表时间：
2016-05-15
影响因子：
11.8
通讯作者：
Rybak, Michael J.
中科院分区：
文献类型：
--
作者：
Zasowski, Evan J.;Claeys, Kimberly C.;Rybak, Michael J.
背景。随着万古霉素耐药肠球菌（VRE）患病率的增加，肠球菌血流感染（EBSI）的适当抗生素治疗可能会延迟。关于延迟治疗对EBSI结果的影响的数据是相互矛盾的，并且与不良结果最密切相关的时间延迟尚未确定。这是一项单中心、回顾性队列研究，研究对象为2010年至2014年住院的非中性粒细胞减少的成人EBSI患者。采用分类和回归树（CART）分析确定最能预测30天死亡率的适当治疗延迟。适当的治疗被定义为肠球菌和病原体敏感的抗生素治疗。结果和临床特征比较接受早期或延迟治疗的患者，由CART时间点定义。使用泊松回归来确定延迟治疗与30天死亡率和延迟治疗预测因子的独立关联。总共纳入190例患者。适当治疗的断点确定为48.1小时，30天死亡率大幅增加（14.6% vs 45.3%; P < 0.001）。48.1小时后接受适当治疗的患者也有更高的住院死亡率和更长的EBSI持续时间。在调整疾病严重程度和合并症后，延迟治疗>= 48.1小时与30天死亡率增加3倍相关（风险比为3.16[95%可信区间，1.96-5.09]）。万古霉素耐药是延迟治疗的唯一独立预测因素。在医院发病的EBSI患者中，在最初48小时内接受适当治疗与死亡率降低相关，这强调了快速诊断检测对早期识别VRE的潜在作用。
Background. With increasing prevalence of vancomycin-resistant enterococci (VRE), appropriate antibiotic therapy for enterococcal bloodstream infections (EBSI) can be delayed. Data regarding the impact of delayed therapy on EBSI outcomes are conflicting, and the time delay most strongly associated with poor outcomes has not been defined.Methods. This was a single-center, retrospective cohort study of adult, nonneutropenic patients with hospital-onset EBSI from 2010 to 2014. Classification and regression tree (CART) analysis was used to determine the delay in appropriate therapy most predictive of 30-day mortality. Appropriate therapy was defined as antibiotic therapy to which the enterococci and copathogen, where applicable, were susceptible. Outcomes and clinical characteristics were compared between patients receiving early or delayed therapy, defined by CART timepoint. Poisson regression was employed to determine the independent association of delayed therapy on 30-day mortality and predictors of delayed therapy.Results. Overall, 190 patients were included. A breakpoint in time to appropriate therapy was identified at 48.1 hours, where 30-day mortality was substantially increased (14.6% vs 45.3%; P < .001). Patients receiving appropriate therapy after 48.1 hours also experienced higher in-hospital mortality and longer EBSI duration. After adjustment for severity of illness and comorbidity, delayed therapy >= 48.1 hours was associated with a 3-fold increase in 30-day mortality (risk ratio, 3.16 [95% confidence interval, 1.96-5.09]). Vancomycin resistance was the only independent predictor of delayed therapy.Conclusions. In patients with hospital-onset EBSI, receipt of appropriate therapy within the first 48 hours was associated with reduced mortality, underscoring the potential role of rapid diagnostic testing for early identification of VRE.