- 學位論文
甲氧芐氨嘧啶/磺胺甲惡唑於嗜麥芽寡養單胞菌感染治療評估–系統性回顧與統合分析及單一區域醫院病例系列分析
The Evaluations of Trimethoprim /Sulfamethoxazole in Stenotrophomonas maltophilia Infections : a Systematic Review and Meta-Analysis and Case-Series from a Regional Hospital
摘要
【研究目的】 嗜麥芽寡養單胞菌為高死亡率菌血症。嗜麥芽寡養單胞菌對Trimethoprim/ Sulfamethoxazole ( TMP/SMX Co-trimoxazole )抗藥性高時，臨床上於抗生素選擇仍有爭議。因此本研究的目的是希望能夠透過系統性回顧及病例系列分析了解TMP/SMX對比其他抗生素於探討嗜麥芽寡養單胞菌感染之療效。研究2009年1月至2018年12月台灣區域醫院嗜麥芽寡養單胞菌感染病人，進行病例系列(Case-Series)研究，觀察臨床治療策略。 【研究方法】: 本研究分兩個部分。第一部分為系統性文獻回顧。首先於Pubmed和Embase等電子資料庫進行系統性文獻搜尋任何探討嗜麥芽寡養單胞菌感染病人使用Trimethoprim / Sulfamethoxazole (TMP/SMX)比對其他抗生素造成死亡人數之觀察性研究。文章品質使用Risk Of Bias In Non-randomized Studies tool (ROBINS)進行文獻評讀，並以Review manager（版本5.3）統計分析。第二部分為利用南部某一區域醫院2009年1月至2018年12月之嗜麥芽寡養單胞菌感染病患的住院資料，包括年齡、性別、疾病史、用藥史、住院治療方式、住院天數、藥品用法用量來進行分析。 【研究結果】 於系統性回顧部份，此研究符合收納條件有16篇Cohort study及1 篇Case-Series，包括1082名和TMP/SMX、Fluoroquinolones(FQ類)及minocycline在內的17項研究進行統合分析，於嗜麥芽寡養單胞菌感染病人死亡人數統合分析顯示出TMP/SMX相比於FQ類有相當的死亡率(OR 0.82, 95% CI 0.15-1.30)，TMP/SMX相比於minocyclin也有相當的死亡率(OR 1.22, 95% CI 0.48-3.12)造成死亡。 於2009年1月至2018年12月，共收錄17名嗜麥芽寡養單胞菌感染病人，進行病例系列研究(Case-Series)，其中使用FQ類(levofloxacin)治療8名(47.06%)、minocycline治療有3名(17.65%)，使用cephalosporins或Beta-lactam治療為6名(35.29%)，未存活人數僅2名(11.76%)，選用抗生素治療為carbapenem類及cephalosporin類。 【結論】 統合分析結果顯示嗜麥芽寡養單胞菌感染死亡率，於使用治療抗生素中TMP/SMX、FQ類與minocycline相比沒有顯著差異，在病例系列研究也觀察到嗜麥芽寡養單胞菌感染病患，在選擇FQ類與minocycline時亦無觀察到差別，臨床上若病人使用TMP/SMX發生抗藥性或不良反應時，可使用替代抗生素FQ類或minocycline。
並列摘要
Purposes: Stenotrophomonas maltophilia (S. maltophilia ) bacteremia has high mortality. In cases when S. maltophilia is resistant to Trimethoprim / Sulfamethoxazole ( TMP / SMX ; Co-trimoxazole ) , the choice of antibiotics is still controversial. Therefore, the purpose of this study is to understand the efficacy of TMP/SMX versus other antibiotics in S. maltophilia infections through Systematic Review and Case-Series studies. Methods: This study is divided into two parts. The first part is a systematic review of the literature. Clinical trials with patients infected with S. maltophilia were searched through Pubmed and Embase databases and other electronic systematic literature search. The study should allow the comparisons between Trimethoprim /Sulfamethoxazole (TMP/SMX) and other antibiotics. The number of death and the quality of the article were reviewed and evaluated bythe Risk Of Bias In Non-randomized Studies tool (ROBINS) and Review manager (version 5.3). The second part is the case series. Data of the patients infected with S. maltophilia from January 2009 to December 2018 in a regional hospital were recorded. The data included gender, underlying disease, medication history, hospitalization, hospital stay, and medication dosage. Results: For the systematic review, 1082 patients treated with TMP/SMX and either Fluoroquinolones (FQs) or minocycline were included from 17 researches (which included 16 Cohort studies and 1 Case Series). The odds of death for patients treated with FQ was 0.82 (95% CI = 0.15, 1.30), compared to TMP/SMX. The odds ratio of death for patients treated with minocycline is 1.22(95% CI = 0.48, 3.12) compared to TMP/SMX. From January 2009 to December 2018, a total of 17 patients infected with S. maltophilia were in identified. Of which 8 patients (47.05%) were treated with FQs (Levofloxacin), 3 patients (17.64%) were treated with minocycline, 6 patients (35.29%) were treated with Cephalosporins or Beta-lactams. The 2 non-survivors (10.5%) were treated with antibiotic treatment chose for carbapenem and cephalosporin. Conclusion: The results of the integrated analysis showed no differences in mortality of S. maltophilia infections when comparing TMP/SMX to either FQs or minocycline. In the case series, no death was observed from patients infected with S. maltophilia treated with either FQs or minocycline. Clinically, if the patient was infected by TMP/SMX-resistant S. maltophilia or experience adverse reactions using TMP/SMX, FQs and minocycline may be good alternatives.