Influence of Empiric Therapy with a β-Lactam Alone or Combined with an Aminoglycoside on Prognosis of Bacteremia Due to Gram-Negative Microorganisms
Influence of Empiric Therapy with a β-Lactam Alone or Combined with an Aminoglycoside on Prognosis of Bacteremia Due to Gram-Negative Microorganisms
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DOI：
10.1128/aac.00115-10
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发表时间：
2010-09-01
影响因子：
4.9
通讯作者：
Mensa, J.
中科院分区：
文献类型：
--
作者：
Martinez, J. A.;Cobos-Trigueros, N.;Mensa, J.
支持氨基糖苷类与β-内酰胺类联合治疗革兰氏阴性菌血症的证据尚不确定。我们通过回顾性分析一系列由需氧菌或兼性革兰氏阴性菌引起的菌血症发作，探讨了经验性β-内酰胺单药治疗与β-内酰胺-氨基糖苷类联合治疗对生存率的影响。结果变量为30天死亡率。预后因素采用Logistic回归分析。共评估了4，863次发作，其中678次（14%）接受了联合治疗，467次（10%）为致死性发作。与死亡率独立相关的因素包括年龄大于65岁（比值比[OR]，2; 95%置信区间[CI]，1.6 - 2.6），医院获得（OR，1.5; 95% CI，1.2 - 1.9），快速或最终致死的基础疾病（OR，2.5; 95% CI，2 - 3.2），肝硬化（OR，1.9; 95% CI，1.4 - 2.6），既往皮质类固醇（OR，1.5; 95% CI，1.1 - 2），就诊时休克（OR，8.8; 95% CI，7 - 11），肺炎（OR，2.8; 95% CI，1.9 - 4）和不适当的经验性治疗（OR，1.8; 95% CI，1.3 - 2.5）。亚组分析显示，联合治疗是出现休克（OR，0.6; 95% CI，0.4 - 0.9）或中性粒细胞减少（OR，0.5; 95% CI，0.3 - 0.9）的独立保护因素。联合治疗改善了经验性治疗对产超广谱β-内酰胺酶（ESBL）或AmpC的肠杆菌科和铜绿假单胞菌的适应性。在革兰阴性菌血症患者中，我们没有发现经验性β-内酰胺-氨基糖苷类联合治疗与预后之间的总体相关性。然而，对于表现为休克或中性粒细胞减少症的发作，不能放弃生存优势，因此在这些情况下，使用联合治疗仍然是合理的。对于有感染耐药微生物风险的患者，即使只是为了增加经验性治疗的适当性，也应该考虑联合治疗。
Evidence supporting the combination of aminoglycosides with beta-lactams for Gram-negative bacteremia is inconclusive. We have explored the influence on survival of empirical therapy with a beta-lactam alone versus that with a beta-lactam-aminoglycoside combination by retrospectively analyzing a series of bacteremic episodes due to aerobic or facultative Gram-negative microorganisms treated with single or combination therapy. The outcome variable was a 30-day mortality. Prognostic factors were selected by regression logistic analysis. A total of 4,863 episodes were assessed, of which 678 (14%) received combination therapy and 467 (10%) were fatal. Factors independently associated with mortality included age greater than 65 (odds ratio [OR], 2; 95% confidence interval [CI], 1.6 to 2.6), hospital acquisition (OR, 1.5; 95% CI, 1.2 to 1.9), a rapidly or ultimately fatal underlying disease (OR, 2.5; 95% CI, 2 to 3.2), cirrhosis (OR, 1.9; 95% CI, 1.4 to 2.6), prior corticosteroids (OR, 1.5; 95% CI, 1.1 to 2), shock on presentation (OR, 8.8; 95% CI, 7 to 11), pneumonia (OR, 2.8; 95% CI, 1.9 to 4), and inappropriate empirical therapy (OR, 1.8; 95% CI, 1.3 to 2.5). Subgroup analysis revealed that combination therapy was an independent protective factor in episodes presenting shock (OR, 0.6; 95% CI, 0.4 to 0.9) or neutropenia (OR, 0.5; 95% CI, 0.3 to 0.9). Combination therapy improved the appropriateness of empirical therapy in episodes due to extended-spectrum beta-lactamase (ESBL)- or AmpC-producing Enterobacteriaceae and Pseudomonas aeruginosa. In patients with Gram-negative bacteremia, we could not find an overall association between empirical beta-lactam-aminoglycoside combination therapy and prognosis. However, a survival advantage cannot be discarded for episodes presenting shock or neutropenia, hence in these situations the use of combination therapy may still be justified. Combination therapy also should be considered for patients at risk of being infected with resistant organisms, if only to increase the appropriateness of empirical therapy.