某區域醫院不同經驗性抗生素對急性住院成人肺炎的治療失敗率比較：回溯性研究

The Comparisons Empiric Antibiotics for the Treatment of Patients Admitted with Pneumonia in a Regional Hospital in Taiwan: A Retrospective Study

梁哲嘉(Che-Chia Liang)

指導教授 ： 林英琦

高雄醫學大學/藥學院/藥學系碩士在職專班/碩士(2019年)

摘要

研究背景：住院的肺炎患者未確定真正的致病菌前，臨床醫師會先進行經驗性抗生素的投予，而台灣住院 (非加護病房) 經驗性抗生素的選擇對預後影響研究甚少，故作者展開自己醫院的抗生素研究。
研究目標：本研究為病歷回溯性研究，依經驗性抗生素選擇分組，試圖比較不同經驗性抗生素的治療失敗率 (treatment failure rate) ，同時分析該地區肺炎的來源菌種，期望能給予該醫院對於經驗性抗生素選擇之建議。
研究方法：回溯性分析2015年至2017年3月中部某區域醫院病歷資料，篩選因肺炎診斷碼自急診住院之患者且診斷臨床標準 (Diagnostic clinical criteria) ≧ 2分，納入年齡≧ 20歲，依醫療照護相關危險因子分成醫療照護相關肺炎及社區性肺炎，將經驗性抗生素之選擇分組比較治療失敗率、死亡率、住院天數等預後。資料以SPSS 20.0進行描述性統計、T檢定、ANOVA及卡方檢定。(人體試驗編號HP180012)
研究結果：共收得1062位急診肺炎住院患者，排除與本研究設計不符之患者417位後，剩下645位，排除直接入住ICU患者61位後剩下243位社區性肺炎患者及341位醫療照護相關肺炎患者。社區性肺炎組治療失敗率為18.9%，醫療照護相關肺炎組治療失敗率為40.8%，來源菌種統計中，社區性肺炎前三名菌種為S. pneumoniae、 M. pneumoniae、 H. influenzae、 S. aureus；比較社區性肺炎組beta-lactam ± macrolide組及fluoroquinolone組的治療失敗率 (15.9% vs. 17.6% , P = 0.762)、治療失敗時天數雖有統計意義(6.9 vs. 5.4 , P<0.001)，但於住院天數(9.0 vs. 9.4, P = 0.926)、靜脈抗生素天數 (7.4 vs. 6.9, P = 0.712)、死亡率 (8.7% vs. 3.6% , P = 0.110) 於統計學上皆無顯著意義。比較醫療照護相關肺炎組不同抗生素的預後，於antipseudo beta-lactam 組的疾病嚴重度較高，故死亡率較高，但比較住院天數、治療失敗率及死亡率皆無統計學上之差異。
結論：本研究觀察到不同經驗性抗生素選擇之預後不管在治療失敗率、死亡率或住院天數皆無統計學上之差異，在臨床無特殊考量下可以額外考慮其他因素 (藥費、頻次等)。

關鍵字

社區性肺炎 ； 醫療照護相關肺炎 ； 治療失敗率

並列摘要

Background: Research on the effectiveness of empirical antibiotics in patients with pneumonia in non-intensive care units (non-ICUs) in Taiwan is scarce.
Aims: This study aimed to investigate the effectiveness (treatment failure rate) of empirical antibiotics in patients with pneumonia in a regional hospital in central Taiwan.
Methods: Retrospective analysis of hospital medical records from January 2015 to March 2017, screening for hospitalized patients diagnosed with pneumonia from the emergency department. The patients should fulfill Diagnostic clinical criteria ≧ 2 points, and age ≧ 20 years old. According to the risk factors related to healthcare-associated, they are divided into healthcare-associated pneumonia and community-acquired pneumonia. The association between empirical different antibiotics and compared to the prognosis of treatment failure rate, mortality, hospitalization days. SPSS 20.0 was utilized for descriptive statistics, chi-square tests and risk analysis.
Results: A total of 1062 patients admitted to emergency due to pneumonia were screened. 417 patients who were incompatible with the study were excluded, leaving 645, including 243 patients with CAP and 341 patients with HCAP, were included after excluding 61 patients were directly admitted to ICU. The treatment failure rate was 18.9% in the CAP group. There were no statistically significant differences in length of in-hospital stay (9.0 vs. 9.4, P = 0.926), intravenous antibiotic days (7.4 vs. 6.9, P = 0.712), treatment failure rates (15.9% vs. 17.6% , P = 0.762), and mortality (8.7% vs. 3.6%, P = 0.110) in the CAP group between Beta-lactam ± macrolide and fluoroquinolone, respectively. In CAP groups, Streptococcus pneumoniae was the pathogen detected most frequently (in 13.73% of all pathogens), followed by Mycoplasma pneumoniae (in 13.73%). In HCAP group, the treatment failure rates were 36.8%, 40.5%, 45.9% (P =0.394) and the mortality rate were 17.1%, 11.1%, and 16.3% (P = 0.509) for antipseudomonal-beta-lactams, fluoroquinolones, and non-antipseudomonal beta-lactams, respectively.
Discussion and conclusions: No statistical differences in treatment failure rate and mortality rate among empirical antibiotics in CAP and HCAP groups were observed. In cases where no special clinical considerations are needed, the choice of treatment may consider other selection factors (like Cost、interval).

並列關鍵字

community-acquired pneumonia ； healthcare-associated pneumonia ； treatment failure rate

參考文獻

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