以非抗綠膿桿菌抗生素治療養護機構相關性肺炎失敗之危險因子分析

Risk Factors of Treatment Failure of Non-antipseudomonal Antibiotic Therapy in Nursing Home-Associated Pneumonia

蔡慶宏(Chin-Hung Tsai)

指導教授 ： 李孟智

中山醫學大學/醫學院/醫學研究所/碩士(2011年)

https://doi.org/10.6834/CSMU.2011.00089

摘要

研究背景：
養護機構相關性肺炎的患者隨著老年人口比例逐年增加而增加，美國在2005年制定了醫療照護相關性肺炎的診療指引，建議以抗綠膿桿菌之組合用藥治療養護機構相關性肺炎。然而，有些患者使用社區性肺炎抗生素治療亦足夠。台灣關於此部份的資料極少，菌種分布及治療方式亦無明確之證據指引。
研究目的：
評估以非抗綠膿桿菌抗生素治療養護機構相關性肺炎時的治療結果，並辨別導致治療失敗的危險因子以供臨床治療參考，期望以此改善病患的預後並降低不必要的抗生素過度使用。
研究設計與對象：
本研究採單中心、回溯性病歷回顧分析研究。於西元2008年12月31日至2010年12月31日期間，於台灣中部區域級教學醫院，收錄因養護機構相關性肺炎住院，被施以非抗綠膿桿菌抗生素之病患。
研究方法：
藉由病歷回顧的方式收集病人的基本資料與臨床相關數據。研究相關變項以病患住院時的臨床表徵、合併症、菌種、醫療處置、併發症、原來之安養機構的種類以及抗生素治療等為主。主要依變項為非抗綠膿桿菌抗生素治療成功或失敗。以此分類，再以全部收集之資料進行統計分析。統計分析包括單變項分析及多變項羅吉斯迴歸分析，尋找可能導致治療失敗的危險因子。
研究結果：
研究期間共收案120人，使用非抗綠膿桿菌抗生素者共88人，其中治療成功者有52人(59%)，治療失敗者則有36人(41%)。整體院內死亡率為13.6%。單變項分析的結果顯示以非抗綠膿桿菌抗生素治療失敗有關的因子包括有代表疾病嚴重度的CURB-65分數(1.5± 1.0 vs. 2.0± 1.1，p=0.038)、年齡(p=0.006)、具有人工呼吸道(p=0.012)，臨床表徵如到院時的呼吸速率每分鐘大於30次(p=0.029)、到院之胸部X光有肋膜積水(p=0.047)。而多變項羅吉斯迴歸分析的結果則顯示年齡 (勝算比1.07，p=0.014)、具有人工呼吸道 (勝算比0.37，p=0.05)，與病人在住院時之C反應蛋白 (勝算比1.10，p=0.033) 為可能造成治療失敗的獨立危險因子。
結論：
若養護機構相關性肺炎患者入院時CURB-65分數較高、呼吸較急促、具有人工呼吸道且有肋膜積水，則以非抗綠膿桿菌抗生素治療的失敗風險較高。而具有人工呼吸道及較高的C反應蛋白更是治療失敗的獨立危險因子，此時需考慮使用對抗抗藥性菌種之用藥組合。

關鍵字

醫療照護相關肺炎 ； 養護機構相關性肺炎 ； 長期照護機構 ； 抗生素 ； 死亡率 ； 抗藥性病原菌

並列摘要

Background:
Nursing home associated pneumonia (NHAP) was categorized into healthcare-associated pneumonia (HCAP) in 2005 ATS/IDSA pneumonia guideline, which suggests treatment with antibiotics against multidrug-resistant pathogens. However, there is a proportion of patients experiencing successful treatment under antibiotics used for community-acquired pneumonia (CAP).
Objective:
To evaluate risk factors of treatment failure with non-antipseudomonal agents in nursing home associated pneumonia.
Design：
A single center, retrospective, chart-review study
Setting:
Tungs’ Taichung MetroHarbor Hospital, a community teaching hospital in central Taiwan.
Patients:
88 patients, who were hospitalized with nursing home associated pneumonia (NHAP) and initially received non-antipseudomonal agents between January 1, 2009 and January 1, 2011, were included.
Methods:
Medical records were reviewed for patients’ demographic data and clinical information. Underlying diseases, bacterial infection, clinical and radiographic manifestations, comorbidities, invasive procedures, and antibiotic therapy were collected. Univariate analysis and multivariate logistic regression analysis were used to identify risk factors for treatment failure.
Results:
During the study period, 88 patients met criteria for inclusion. Among them, 52(59%) patients gained favorable outcome and 36(41%) patients failed under treatment of non-antipseudomonal agents. The overall in-hospital mortality rate was 13.6%. The clinical characteristics (eg, co-morbidities) were comparable between treatment successful and treatment failure group except for age (p=0.027) and the severity of illness (CURB-65 score 1.5±1.0 vs. 2.0±1.1，p=0.038). No significant difference of in-hospital mortality rate between the two groups. Aetiology was defined in 48 cases (55%). The most common isolates were Acinetobacter species (13.6%), Proteus mirabilis (10.2%), Pseudomonas aeruginosa (9.0%). Univariate analysis showed that the risk factors for treatment failure included: artificial airway (p=0.012), respiratory rate more than 30/min (0.029), and pleural effusion (p=0.047). Multivariate logistic regression analysis showed that age (odds ratio 1.07, P=0.014), artificial airway (odds ratio 0.37, P=0.05), and CRP (odds ratio 1.10, P=0.033) were independent factors for treatment failure.
Conclusions:
Non-antipseudomonal agents were more likely to fail when used in patients who were elderly, with higher CURB-65 score, or had artificial airway, respiratory rate ≧ 30/min, and pleural effusion. Age, artificial airway, and higher CRP were independent factors for treatment failure.

並列關鍵字

Nursing home-associated pneumonia ； Health care-associated pneumonia ； long-term care facility ； antibiotics ； mortality ； multi-drug resistance pathogens

參考文獻

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