Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia - A prospective multicenter study
Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia - A prospective multicenter study
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DOI：
10.7326/0003-4819-135-7-200110020-00007
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发表时间：
2001-10-02
影响因子：
39.2
通讯作者：
Muder, RR
中科院分区：
文献类型：
--
作者：
Vergis, EN;Hayden, MK;Muder, RR
背景：肠球菌属是医院感染的主要病原菌，且对万古霉素的耐药性日益增加。以前的研究还没有解决万古霉素耐药是否是肠球菌属侵袭性疾病患者死亡的独立危险因素，或者抗生素治疗是否改变肠球菌菌血症的结局。目的：确定万古霉素耐药是否是肠球菌菌血症患者死亡的独立预测因素，以及适当的抗菌治疗是否影响结局。设计：前瞻性观察性研究。设置：四个学术医疗中心和一家社区医院。患者：所有肠球菌菌血症患者。测量：人口统计学特征;基础疾病;急性生理学和慢性健康评估（APACHE）II评分;抗生素治疗，免疫抑制和发病前的程序;以及随后6周内的抗生素治疗。结果：398例中，60%由E.粪肠球菌（E. faecalis）占37%;屎室37%的分离株对万古霉素表现出耐药或中度敏感。22%的E.屎肠分离株显示出对奎奴普汀-达福普汀的敏感性降低。既往万古霉素使用（比值比[OR]，5.82 [95% CI，3.20 - 10.58]; P < 0.001），既往使用皮质类固醇（OR，2.43 [CI，1.22 - 4.86]; P = 0.01），和APACHE II总评分（OR，1.06/单位变化[CI，1.02 ~ 1.10/单位变化]; P = 0.003）与万古霉素耐药肠球菌菌血症相关。第14天时的死亡率为19%。恶性血液病（OR，3.83 [CI，1.56 - 9.39]; P = 0.003），万古霉素耐药（OR，2.10 [CI，1.14 - 3.88]; P = 0.02），和APACHE II评分（OR，1.10/单位变化[CI，1.05 ~ 1.14/单位变化]; P < 0.001）与14天死亡率相关。在单菌性肠球菌菌血症患者中，48小时内接受有效的抗菌治疗可独立预测生存率（死亡OR为0.21 [Cl，0.06 - 0.80]; P = 0.02）。结论：万古霉素耐药是肠球菌菌血症死亡的独立预测因子。早期有效的抗菌治疗与生存率的显著改善相关。
Background: Enterococcus species are major nosocomial pathogens and are exhibiting vancomycin resistance with increasing frequency. Previous studies have not resolved whether vancomycin resistance Is an independent risk factor for death in patients with invasive disease due to Enterococcus species or whether antibiotic therapy alters the outcome of enterococcal bacteremia.Objective: To determine whether vancomycin resistance is an independent predictor of death in patients with enterococcal bacteremia and whether appropriate antimicrobial therapy influences outcome.Design: Prospective observational study.Setting: Four academic medical centers and a community hospital.Patients: All patients with enterococcal bacteremia.Measurements: Demographic characteristics; underlying disease; Acute Physiology and Chronic Health Evaluation (APACHE) II scores; antibiotic therapy, immunosuppression, and procedures before onset; and antibiotic therapy during the ensuing 6 weeks. The major end point was 14-day survival.Results: Of 398 episodes, 60% were caused by E. faecalis and 37% were caused by E. faecium. Thirty-seven percent of isolates exhibited resistance or Intermediate susceptibility to vancomycin. Twenty-two percent of E. faecium isolates showed reduced susceptibility to quinupristin-dalfopristin. Previous vancomycin use (odds ratio [OR], 5.82 [95% Cl, 3.20 to 10.58]; P < 0.001), previous corticosteroid use (OR, 2.43 [Cl, 1.22 to 4.86]; P = 0.01), and total APACHE II score (OR, 1.06 per unit change [Cl, 1.02 to 1.10 per unit change]; P = 0.003) were associated with vancomycin-resistant enterococcal bacteremia. The mortality rate was 19% at 14 days. Hematologic malignancy (OR, 3.83 [Cl, 1.56 to 9.39]; P = 0.003), vancomycin resistance (OR, 2.10 [Cl, 1.14 to 3.88]; P = 0.02), and APACHE II score (OR, 1.10 per unit change [Cl, 1.05 to 1.14 per unit change]; P < 0.001) were associated with 14-day mortality. Among patients with monomicrobial enterococcal bacteremia, receipt of effective antimicrobial therapy within 48 hours independently predicted survival (OR for death, 0.21 [Cl, 0.06 to 0.80]; P = 0.02).Conclusions: vancomycin resistance is an independent predictor of death from enterococcal bacteremia. Early, effective antimicrobial therapy is associated with a significant improvement in survival.