基質輔助雷射脫附游離飛行時間式質譜儀於急診抗生素使用之影響

The Clinical Impact of Matrix-Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry in Emergency Medicine Antibiotics Therapy

呂育碩(Yu-Shuo Lu)

指導教授 ： 許國堂

共同指導教授 ： 李原地(an-Ti Lee)

中山醫學大學/醫學院/醫學研究所/碩士(2020年)

https://doi.org/10.6834/csmu202000231

摘要

研究目的： 菌血症仍是造成敗血症及臨床主要死亡原因之一，但獲得正式血液細菌培養結果仍有速度及敏感性的限制。觀察中山醫學大學附設醫院導入基質輔助雷射脫附游離飛行時間式質譜儀(Matrix-assisted laser desorption ionization time-of-flight mass spectrometry，MALDI-TOFS)前後，敗血症病人於急診抗生素使用情形，並探討是否影響行醫模式或預後影響。

研究方法及資料：本文採回溯性觀察研究，收集2018年五月至十一月在急診採檢的陽性血液細菌培養報告進入研究，並分析其在MALDI-TOFS導入前後的差異性，首要觀察目標為抗生素使用適當率及其首次更改抗生素的行醫模式變化，研究採用統計學工具為PASW Statistics 18的套裝軟體進行「t檢定」、「卡方檢定」及「曼．惠特尼檢定」，p值若小於0.05為明顯統計學上意義。

研究結果： 於2018年六個月期間總計納入343位病人，其中182和141位分別為MALDI-TOFS介入前和後的個案數，發現抗生素使用適當率(75.3% vs 76.6%)與更改的時間(25.46 vs 31.46小時)無統計學意義。但分別有32.4%和24.8%個案於細菌培養尚未呈現陽性前即更改抗生素，進一步分析發現在初步血液培養報告前先改變抗生素 對於quick sepsis-related organ failure assessment (qSOFA)分數 >2及敗血性休克死亡率有統計學意義(p<0.001)，且死亡率和住院天數明顯較高(p=0.04 和 0.02)

結論與建議： 細菌培養系統中的MALDI-TOFS導入，在急診室血液培養陽性病人上無明顯提升抗生素使用適當率或抗生素更改速度。仍需更多前瞻性研究及實驗室流程改善來證實其臨床意義。

關鍵字

台灣 ； 急診 ； 抗生素使用 ； 敗血症 ； 菌血症 ； 基質輔助雷射脫附游離飛行時間式質譜儀

並列摘要

Objective：Bacteremia and subsequent sepsis still remains leading cause of death but blood culture yield limited speed and sensitivity to identify the causative organism. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOFS) were recently introduced in Chung Shan Medical University Hsopital (CSMUH) . Clinical impact comparism could be made in emergency department regard antimicrobital therapy.between before and after MALDI-TOFS analysis.

Methods and Materials：Retrospective case-control study of blood culture positive cases were enrolled from May to Nov in 2018. First three month with conventional method were compared with MALDI-TOFS ones. Primary goal were appropriate antibiotics therapy after blood culture showed positivity and secondary one were first antibiotics switch pattern. Data were collected via CSMUH electronic system and defined by Emergency Medicine and Infectology physician. Statistics method included Student’ T-test , Chi-squre and Mann-Whiney test, significance was p <0.05 and calculated by PASW Statistics 18.

Results：Totally 343 positive blood cultures were included from during six month period, in which 182 were examed by conventional method and 141 cases were examined by MALDI-TOFS application. Appropriate antibiotics therapy percentage were 75.3% vs 76.6% respectively, and its first switch time (25.46 vs 31.46 hours)were found without major difference. However, 32.4% and 24.8% cases were noticed that, antibiotics had been switched before blood culture even showed positivity. Thus, Sub-analysis were performed, which demonstrated high association with qSOFA>2 and septic shock, also, significant higher mortality and length of stay (p =0.04 and 0.02)

Conclusion and Suggestion： MALDI-TOFS analysis showed no obvious better or faster appropriated antibiotics therapy or switch time in positive blood culture cases withdrawn from Emergency Medicine Department. More prostepctic studies or laboratory setting improvement shoulde be done to vertify its clinical efficacy.

並列關鍵字

MALDI-TOFS ； Taiwan ； Emergency Medicine ； Antimicrobial Therapy ； Sepsis ； Bacteremia

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