Treatment outcomes of patients with non-bacteremic pneumonia caused by extensively drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex isolates: Is there any benefit of adding tigecycline to aerosolized colistimethate sodium?
Treatment outcomes of patients with non-bacteremic pneumonia caused by extensively drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex isolates: Is there any benefit of adding tigecycline to aerosolized colistimethate sodium?
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DOI：
10.1097/md.0000000000012278
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发表时间：
2018-09
期刊：
影响因子：
1.6
通讯作者：
Lam C
中科院分区：
文献类型：
--
作者：
Jean SS;Hsieh TC;Lee WS;Hsueh PR;Hsu CW;Lam C
对于广泛耐药醋酸钙不动杆菌-鲍曼不动杆菌（XDR-Acb）复合菌株引起的各种感染，包括肺炎，几乎没有治疗选择。本研究探讨了雾化多粘菌素E甲磺酸钠（AS-CMS，200万单位，每日三次）单独治疗或联合标准剂量替加环素（TGC）治疗XDR-Acb所致非菌血症性肺炎患者的临床疗效，并探讨了影响患者30天死亡率的因素。1：1例（n = 106; 2014年1月至2016年12月，在台湾一家医疗中心的非菌血症XDR-Acb复合型肺炎成人患者中进行了一项观察性研究。回顾性记录临床相关数据。主要终点为30天病死率。次要终点研究了合并症、XDR-A.鲍曼不动杆菌作为肺炎病原体、治疗相关因素或耐粘菌素Acb的气道定植对入选患者的14天临床状况产生负面影响。接受联合治疗组的30天死亡率较高（34.0% vs 22.6%; P = 0.17）。 ≥7天的AS-CMS治疗成功根除了> 90%的气道XDR-Acb分离株。然而，10例（6.4% [10/156]）患者的随访痰液标本定植有粘菌素耐药Acb分离株。在通过多变量logistic分析校正条件因素后，唯一独立预测30天病死率的因素是14天时治疗XDR-Acb肺炎失败（校正比值比[aOR]= 38.2; 95%置信区间[CI]= 9.96-142.29; P <0.001）。 考克斯比例回归分析发现，慢性阻塞性肺疾病（COPD）（校正风险比[aHR]= 2.08; 95% CI = 1.05-4.10; P = 0.035）、慢性肾衰竭（aHR = 3.00; 95% CI = 1.52-5.90; P = 0.002）、无创通气使用（aHR = 2.68; 95% CI = 1.37-5.25; P = 0.004）和缺乏TGC治疗（aHR = 0.52; 95% CI = 0.27-1.00; P = 0.049）对14天临床结局产生不利影响。 相反，在随访痰液样本中出现粘菌素耐药Acb分离株与治愈或改善XDR-Acb肺炎无统计学显著相关性。总之，积极的肺部卫生护理，TGC的添加和皮质类固醇剂量逐渐减少有利于改善14天患者的结局。
Few therapeutic options exist for various infections caused by extensively drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (XDR-Acb) complex isolates, including pneumonia. This study investigated the clinical efficacy between aerosolized colistimethate sodium (AS-CMS, 2 million units thrice a day) treatment alone or in combination with standard-dose tigecycline (TGC) in patients with non-bacteremic pneumonia due to XDR-Acb, and explored the factors influencing patients’ 30-day mortality. A 1:1 case (n = 106; receiving TGC plus AS-CMS) control (receiving AS-CMS alone with matching scores) observational study was conducted among adult patients with non-bacteremic XDR-Acb complex pneumonia in a Taiwanese medical center from January 2014 through December 2016. The clinically relevant data were retrospectively recorded. The primary endpoint was 30-day case fatality. Secondary endpoints investigated that if the co-morbidities, XDR-A. baumannii as a pneumonic pathogen, therapy-related factors, or airway colonization with colistin-resistant Acb negatively influenced the 14-day clinical condition of enrolled patients. A higher 30-day mortality rate was noted among the group receiving combination therapy (34.0% vs 22.6%; P = .17). The ≥7-day AS-CMS therapy successfully eradicated > 90% of airway XDR-Acb isolates. Nevertheless, follow-up sputum specimens from 10 (6.4% [10/156]) patients were colonized with colistin-resistant Acb isolates. After the conditional factors were adjusted by multivariate logistic analysis, the only factor independently predicting the 30-day case-fatality was the failure of treating XDR-Acb pneumonia at 14 days (adjusted odds ratio [aOR] = 38.2; 95% confidence interval [CI] = 9.96–142.29; P < .001). Cox proportional regression analysis found that chronic obstructive pulmonary disease (COPD) (adjusted hazard ratio [aHR] = 2.08; 95% CI = 1.05–4.10; P = .035), chronic renal failure (aHR = 3.00; 95% CI = 1.52–5.90; P = .002), non-invasive ventilation use (aHR = 2.68; 95% CI = 1.37–5.25; P = .004), and lack of TGC therapy (aHR = 0.52; 95% CI = 0.27–1.00; P = .049) adversely influenced the 14-day clinical outcomes. Conversely, the emergence of colistin-resistant Acb isolates in the follow-up sputum samples was not statistically significantly associated with curing or improving XDR-Acb pneumonia. In conclusion, aggressive pulmonary hygiene care, the addition of TGC, and corticosteroid dose tapering were beneficial in improving the 14-day patients’ outcomes.