Impact of Initial Appropriate Antibiotics on the Outcomes of Patients with Community-Acquired and Non-Community-Acquired Sepsis in Intensive Care Units

內科加護病房敗血症患者依臨床分類對適當抗生素的衝擊及病情預後的影響

蘇文麟(Wen-Lin Su) ； 吳燿光(Yao-Kuang Wu) ； 鐘雪文(Hsueh-Wen Chung) ； 楊美貞(Mei-Chen Yang) ； 黃國良(Kuo-Liang Huang) ； 陳欣怡(Xin-Yi Chen) ； 藍冑進(Chou-Chin Lan) ； 黃俊耀(Chun-Yao Huang) ； 黃奕智(Yi-Chih Huang) ； 蘇秋萍(Chiu-Ping Su) ； 顏鴻欽(Horng-Chin Yan)

《胸腔醫學》 31卷6期 (2016/12) Pp. 323-334

摘要

前言：回顧性研究調查來源不同的敗血症病人（社區型、非社區型），對初始抗生素治療適當性的衝擊以及對患者存活率的影響。方法：回顧性世代研究2014 年台北慈濟醫院的內科加護病房（ICU）敗血症病人，符合細菌培養陽性。細菌的藥物敏感性試驗結果作為初始抗生素適當性的判斷依據。適當的初始抗生素治療與其他風險因子共同分析對敗血症患者的生存影響，由單因素和多因素Cox 回歸分析進行評估。結果：非社區型敗血症患者有較多合併症，更長的ICU 住院天數以及較高的28 天ICU 死亡率和90天住院死亡率（p ≤ 0.002）。雖然社區型敗血症患者入住ICU 前接受適當抗生素給藥比率較高但不影響存活率（p ≤ 0.015），然而在非社區型敗血症在入住ICU 前接受適當抗生素給藥存活率顯著較高（p 值=0.010）。多因素分析顯示，死亡的危險性與急性生理和慢性健康評估II（APACHE II）嚴重度有關，社區型敗血症（HR=1.14，p=0.008），非社區型敗血症（HR=1.18，p=0.014）。結論：敗血症重症病患入住內科加護病房除了評估APACHE II 分數，並且快速分辨病人來源，以慎選適當的抗生素治療，以降低非社區型敗血症的死亡率。

關鍵字

社區型 ； 敗血症 ； 存活率

並列摘要

Introduction: This retrospective study was conducted to investigate the impact of initial antimicrobial therapy on the survival of patients with culture-positive community-acquired and non-community-acquired (healthcare-associated and hospital-acquired) sepsis. Methods: All patients admitted to the intensive care unit (ICU) of Taipei Tzu Chi Hospital throughout 2014 who had culture-positive sepsis were retrospectively identified. The administration of antibiotics to which the recovered pathogens were susceptible was considered appropriate. The impact of initial appropriate antimicrobial therapy and other risk factors on the survival of patients with sepsis was assessed in univariate and multivariate Cox regression analyses. Results: Patients with non-community-acquired sepsis had more comorbidities, significantly longer length of stay in the ICU, and greater 28-day ICU mortality and 90- day mortality (p≤0.002). While a greater proportion of subjects with community-acquired sepsis received initial appropriate antibiotics before admission to the ICU (p≤0.015), initial appropriate antibiotic administration was significantly associated with improved survival only in patients with non-community-acquired sepsis (p=0.010), and not in those with community-acquired sepsis. Multivariate analysis showed that the risk of death increased with increasing Acute Physiology and Chronic Health Evaluation II (APACHE II) scores in both patients with community-acquired sepsis (HR=1.14, p=0.008) and those with non-community-acquired sepsis, (HR=1.18, p=0.014). Conclusions: Thus, appropriate empirical antimicrobial therapy is particularly important for lowering the risk of mortality of patients with non-community-acquired sepsis.

並列關鍵字

community-acquired ； healthcare-associated ； hospital-acquired ； sepsis ； survival