Colonization with methicillin-resistant Staphylococcus aureus in ICU patients:: Morbidity, mortality, and glycopeptide use
Colonization with methicillin-resistant Staphylococcus aureus in ICU patients:: Morbidity, mortality, and glycopeptide use
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DOI：
10.1086/501846
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发表时间：
2001-11-01
影响因子：
4.5
通讯作者：
Carlet, J
中科院分区：
文献类型：
--
作者：
Garrouste-Orgeas, M;Timsit, JF;Carlet, J
目的：探讨耐甲氧西林金黄色葡萄球菌（MRSA）定植对重症监护病房（ICU）患者金黄色葡萄球菌感染（甲氧西林耐药和甲氧西林敏感）发生、糖肽使用和预后的影响。设计：前瞻性观察队列调查。环境：这是一所拥有460张床位的大学附属三级医疗医院，是一间内科外科重症监护室，有10间单人床。患者：1995年7月1日至1998年7月1日对1044例ICU患者进行MRSA定植检测。方法：采用所有患者的鼻腔样本和外科患者的伤口样本，在入院48小时内或ICU前48小时内以及之后每周检测MRSA定植。MRSA感染的定义采用疾病控制与预防中心的标准定义，但呼吸机相关性肺炎和导管相关性感染除外，后者通过定量远端培养样本来定义。结果：共纳入1444例患者，其中医学患者占70%。平均年龄61±18岁；简化急性生理评分（SAPS）平均为36.4+/-20；ICU住院时间中位数为4天（范围1 ~ 193天）。231例（22%）患者在ICU死亡。54例患者（5.1%）入院时MRSA定植，1044例患者中52例（4.9%）在ICU获得MRSA定植。35例患者共发生42例金黄色葡萄球菌感染（32例MRSA， 10例甲氧西林敏感）。在多变量Cox模型（SAPS II bbb36：危险比[HR]， 1.64； P=.09；男性：HR， 2.2； P=.05）中调整与金黄色葡萄球菌感染相关的因素后，MRSA定殖增加了金黄色葡萄球菌感染的风险（HP, 3.84； P=.0003）。MRSA定殖不影响ICU死亡率（HP, 1.01； P= 0.94）， 11.4%的患者（119/ 1044）使用糖肽治疗，中位持续时间为5天。对于未定植、入院时MRSA定植和icu获得性MRSA定植的患者，每1000个住院日糖肽使用量分别为37.7、235.2和118.3天。与非MRSA定殖患者相比，即使在MRSA感染未被证实的情况下，MRSA定殖患者糖肽的使用本身也增加了3.3倍。结论：在我们的病房，MRSA定殖大大增加了金黄色葡萄球菌感染的风险以及定殖和非定殖患者使用糖肽的风险，但不影响ICU的死亡率。即使没有MRSA感染，MRSA定植也会影响糖肽的使用；因此，在革兰氏阳性球菌中，MRSA控制程序有必要减少万古霉素的使用并限制糖肽耐药性。
OBJECTIVE: To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization on the occurrence of S aureus infections (methicillin-resistant and methicillin-suseeptible), the use of glycopeptides, and outcome among intensive care unit (ICU) patients.DESIGN: Prospective observational cohort survey.SETTING: A medical-surgical ICU with 10 single-bed rooms in a 460-bed, tertiary-care, university-affiliated hospital.PATIENTS: A total of 1,044 ICU patients were followed for the detection of MRSA colonization from July 1, 1995, to July, 1 1998.METHODS: MRSA colonization was detected using nasal samples in all patients plus wound samples in surgical patients within 48 hours of admission or within the first 48 hours of ICU stay and weekly thereafter. MRSA infections were defined using Centers for Disease Control and Prevention standard definitions, except for ventilator-associated pneumonia and catheter-related infections, which were defined by quantitative distal culture samples.RESULTS: One thousand forty-four patients (70% medical patients) were included in the analysis. Mean age was 61+/-18 years; mean Simplified Acute Physiologic Score (SAPS) II was 36.4+/-20; and median ICU stay was 4 (range, 1-193) days. Two hundred thirty-one patients (22%) died in the ICU. Fifty-four patients (5.1%) were colonized with MRSA on admission, and 52 (4.9%) of 1,044 acquired MRSA colonization in the ICU. Thirty-five patients developed a total of 42 S aureus infections (32 MRSA, 10 methicillin-susceptible). After factors associated with the development of an S aureus infection were adjusted for in a multivariate Cox model (SAPS II >36: hazard ratio [HR], 1.64; P=.09; male gender: HR, 2.2; P=.05), MRSA colonization increased the risk of S aureus infection (HP, 3.84; P=.0003). MRSA colonization did not influence ICU mortality (HP, 1.01; P=.94), Glycopeptides were used in 11.4% of the patients (119/1,044) for a median duration of 5 days. For patients with no colonization, MRSA colonization on admission, and ICU-acquired MRSA colonization, respectively, glycopeptide use per 1,000 hospital days was 37.7, 235.2, and 118.3 days. MRSA colonization per se increased by 3.3-fold the use of glycopeptides in MRSA-colonized patients, even when an MRSA infection was not demonstrated, compared to non-colonized patients.CONCLUSIONS: In our unit, MRSA colonization greatly increased the risk of S aureus infection and of glycopeptide use in colonized and non-colonized patients, without influencing ICU mortality. MRSA colonization influenced glycopeptide use even if an MRSA infection was not demonstrated; thus, an MRSA control program is warranted to decrease vancomycin use and to limit glycopeptide resistance in gram-positive cocci.