- 學位論文
內科加護病房綠膿桿菌肺炎:流行病學調查與不同抗生素治療組合之有效性探討
Pseudomonas aeruginosa Pneumonia in Critically Ill Patients: Epidemiology and Effectiveness of Different Antibiotic Strategies
摘要
研究背景:綠膿桿菌(Pseudomonas aeruginosa)是內科加護病房中常見菌種之一。除了回顧目前的抗生素治療指引仍無強力的證據支持以及確切的定論之外，根據2018年台灣院內感染監視資訊系統第二季監視季報，綠膿桿菌為醫學中心加護病房的肺炎最常見的感染菌種。因此，本研究的目的為：一、探究高醫體系三院的內科加護病房中影響綠膿桿菌肺炎的死亡因素；二、探討治療綠膿桿菌肺炎的各種抗生素組合的治療策略和其療效。 研究方法:本研究是回溯性的觀察性研究，利用高醫體系三院，包含高醫附院、大同醫院、小港醫院的內科加護病房的資料庫和病歷來蒐集資料，探討2011年到2017年間綠膿桿菌感染當中，綠膿桿菌肺炎的死亡風險因素。另一方面，探究關於綠膿桿菌肺炎的抗生素組合的治療策略，並以死亡率為主要分析的結果，以單變項和多變項的羅吉斯統計分析來分析關聯性。 研究結果:在研究期間 (2011-2017年)，共有342位病人曾經在內科加護病房感染綠膿桿菌肺炎，整體的死亡率為31.7％。在多變項羅吉斯統計分析中，預測加護病房死亡率的因子包括: 入加護病房後48小時內有使用呼吸器 (aOR=4.24, 95% CI=1.48-12.11)和肺炎初診日的SOFA score (aOR=1.35, 95% CI=1.15-1.58)、病人罹患癌症 (aOR=6.00, 95% CI=2.14-16.81)等顯著地增加死亡率。其他獨立的危險因子包含: 酒精濫用者 (aOR=4.98, 95% CI=1.53-16.25)以及病人對Ureido/carboxypenicillins組合產生抗藥性者(aOR=3.66, 95% CI=1.40-9.57)。 關於探究抗生素的療效，在多變項的羅吉斯統計分析中校正影響死亡率相關因素後，任一種抗生素組合在降低死亡率均無顯著差異。另外，在經驗性抗生素(aOR=0.60, 95% CI=0.15-2.43)和確定性抗生素使用單一或合併的抗生素(aOR=0.78 ,95% CI=0.22-2.81)在降低死亡率均無顯著差異。 結論:除了已知影響死亡率的因素以外，本研究發現酒精濫用者或病人對Ureido/carboxypenicillins組合產生抗藥性者也是影響死亡率的因素之一。至於在所有抗生素的分析中，在多變項分析校正後，經驗性和確定性抗生素使用單一或合併的抗生素治療，在降低死亡率均無顯著差異，但我們的研究結果與目前對於重症患者的主流治療建議一致，未來仍需要更多的研究來佐證結果。
並列摘要
Background: Pseudomonas aeruginosa is the most common pneumonic pathogen in both medical centers and regional hospitals. Due to the high mortality rate and antibiotic resistance, it's more difficult to treat clinically. Additionally, reviewing all guidelines from different countries around the world, important differences exist between recommendations of different societies and epidemiological data also varies by regions. Therefore, it’s still no strong evidence to inform the selection of appropriate antibiotic treatment so far. Therefore, the aims of our study are：1. to evaluate the risk factors for ICU mortality in P. aeruginosa pneumonia. 2. to assess the effectiveness of different antibiotic treatment strategies for patients with P. aeruginosa pneumonia who were admitted to ICU. Methods: From 2011 to 2017, we conducted a retrospective analysis of observational study using data prospectively to enter into multicenter database from three affiliated hospitals of Kaohsiung Medical University (KMU). All patients who met the inclusion criteria during the study period were being identified from the Research Database of KMU, other clinical data will be collected from the electronic medical records. Mortality was used as primary clinical outcome. In order to evaluate the risk factors of mortality and the different antibiotic regimen for patients with P. aeruginosa pneumonia, multivariate-adjusted odds ratios were acquired by logistic regressions analysis. Results: A total of 342 ICU P. aeruginosa pneumonia patients enrolled to final analysis in our study and the overall mortality was 31.7%. In multivariable analyses, independent predictors of ICU mortality included mechanical ventilation use within 48 hours on ICU admission (adjusted odds ratio [aOR]=4.24, 95% confidence interval [CI]=1.48-12.11), SOFA score on the initial diagnosis day of pneumonia (aOR=1.35, 95% CI=1.15-1.58), patients who were alcoholism (aOR=4.98, 95% CI=1.53-16.25), patients with malignancy (aOR=6.00, 95% CI=2.14-16.81), patients who resistant to Ureido/carboxypenicillins (aOR=3.66, 95% CI=1.40-9.57). For effectiveness of antibiotics, after adjusted with covariates in multivariate logistic regression, none of antibiotic-based groups were significantly associated with ICU mortality. Furthermore, monotherapy (as reference group) and combination therapy in both empiric (aOR=0.60, 95% CI=0.15-2.43) and definitive antibiotic phase (aOR=0.78, 95% CI=0.22-2.81) were no significant differences. Conclusion: In addition to several widely known risk factors, our findings highlight the importance of alcoholism and patients who resistant to Ureido/carboxypenicillins as independent risk factors. For effectiveness of antibiotic strategies, although monotherapy and combination therapy in both empiric and definitive antibiotic phase were no significant differences, our findings in line with recommendations for critically ill patients from current guidelines and studies. More studies are needed to convince this results in the future.
參考文獻
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