- 學位論文
加護病房肺炎病人抗生素使用與其治療結果的探討
Antibiotics use patterns and treatment outcomes in patients with pneumonia in the medical intensive care unit
摘要
研究背景 肺炎是一個死亡率很高的疾病，為世界排名第三大死因，尤其是在疾病嚴重程度較高的病人有更高的死亡率，而目前根據2005年ATS/IDSA的治療指引對於有多重抗藥性(MDR)感染風險的病人，建議應儘快給予廣效抗生素，然而在一些文獻中卻也發現按照IDSA治療指引來治療這些被IDSA治療指引指出可能有多重抗藥性風險的病人，其死亡率是上升的；而為了因應國情不同，我們在先前研究針對高醫內科加護病房的肺炎病人研發了一個量表來預測多重抗藥性，以便利能夠選擇廣效的經驗性抗生素，其預測能力已被驗證，但運用抗生素之後的臨床治療效果還未知。 研究目的 本研究欲探討目前IDSA治療指引運用在我們族群對於選擇經驗性抗生素治療後的臨床治療結果為何，同時去比較自行研發的量表的給藥模式的臨床治療結果，以期能夠將研發的預測量表應用到臨床。 研究方法 本研究回朔2012至2013年的高醫內科加護病房肺炎病人的資料，利用高醫院內資料庫與先前研究高醫電子病歷相關變項資料，以存活分析方式來看遵照IDSA治療指引給藥與遵照量表給藥的三十天死亡情形，並利用羅吉斯回歸(logistic regression)前向和逐步選取顯著的校正因子，計算三十天死亡的校正勝算比。 研究結果 遵照治療指引給藥組別比起沒有遵照治療指引給藥組別，其三十天死亡較高，且生存曲線(Kaplan-Meier curve)有顯著差別(log rank test=0.0144)，逐步挑選後的校正勝算比為1.43(95%信賴區間[CI]:0.96-2.14)，不具統計意義(p=0.0790);而遵照量表給藥組別比起沒有量表給藥組別，其三十天死亡沒有差別，且生存曲線(Kaplan-Meier curve)沒有達顯著差別(log rank test=0.4421)，逐步挑選後的校正勝算比為0.82(95%CI:0.56-1.19)，不具統計意義(p=0.2912)；此外，直接比較治療指引與量表使用的組別，遵照量表的組別比起遵照IDSA治療指引給藥組別，勝算比為0.48(95%CI:0.23-1.01,p=0.0538)。 結論 遵照量表給藥比起遵照IDSA治療指引給藥在三十天死亡率較低，雖然經過校正後沒有達到顯著差異，但可能使用量表在我們的群有潛在好處，而遵照IDSA治療指引給藥組別為什麼死亡率較高原因還需要去持續探討，而我們研發的預測量表對於實際的臨床運用可能還需要更大型與前瞻性的研究來驗證。
並列摘要
Background The mortality in pneumonia patients is very high, and especially those critically ill patients. Recently, the 2005 IDSA pneumonia guideline was criticized to their empirical antibiotics treatment for those potential multiple-drug resistant (MDR) pneumonia patient. Some studies found that guideline-concordant antimicrobial treatment for those MDR risk patients increased mortality. Previous study developed a prediction tool according the local cohort population. in the medical intensive care unit(ICU) in Kaohsiung medical university Chung-Ho memorial hospital(KMUH). The effectiveness of this predation tool selecting empirical antibiotics was not validate. Objectives This study wants to evaluate mortality of ATS/IDSA guidelines-concordant-antibiotics treatment (GCAT) on pneumonia patients in medical intensive care units and to compare the treatment outcome of GCAT and our prediction tool-concordant-antibiotics therapy (TCAT). Methods We retrospect observed 693 episodes with pneumonia in medical ICU. We classified GCAT versus non-GCAT groups and TCAT versus non-TCAT group in selection of empirical antibiotics to evaluate 30-day mortality. Results The 30-day mortality was increased in GCAT group comparing to non-GCAT group. The Kaplan-Meier curve showed that significant with log rank test was 0.0144. The association was not significance after adjusted (OR1.43, 95% confidence interval [CI] 0.96-1.24).TCAT group was not association with increased 30-day mortality (OR 0.82, 95% CI 0.56-1.19).; TCAT was association with decreased 30-day mortality direct comparing to GCAT (OR 0.48, 95% CI 0.23-1.01),although the result was not significant. Conclusion The perdition tool may more appropriate in our local population comparing to the 2005 guidelines. However, our results are limited by the retrospective cohort design. A prospective and good quality research are needed to identify the reality effectiveness of our prediction tool.
參考文獻
延伸閱讀
- 林麗梅（2010）。加護病房胃酸抑制藥物使用與發生院內感染型肺炎危險之相關性探討〔碩士論文，臺北醫學大學〕。華藝線上圖書館。https://doi.org/10.6831/TMU.2010.00188
- Wu, H. P., Huang, C. Y., Chu, C. M., Chieh, C., Hua, C. C., Yu, T. J., & Liu, Y. C. (2016). 嚴重革蘭氏陰性病菌健康照護相關／院內肺炎病人的聯合抗生素使用. 內科學誌, 27(2), 89-96. https://doi.org/10.6314/JIMT.2016.27(2).05
- Chen, Y. J. (2018). 內科加護病房克雷伯氏肺炎菌肺炎：流行病學調查與不同抗生素治療組合之有效性探討 [master's thesis, Kaohsiung Medical University]. Airiti Library. https://www.airitilibrary.com/Article/Detail?DocID=U0011-2708201815421600
- 許振東（2012）。遵循抗生素臨床指引與治療結果關係之研究-以肺炎治療性抗生素與手術預防性抗生素之使用為例〔博士論文，國立臺灣大學〕。華藝線上圖書館。https://doi.org/10.6342/NTU.2012.02483
- Adler, N. R., Weber, H. M., Gunadasa, I., Hughes, A. J., & Friedman, N. D. (2014). Adherence to Therapeutic Guidelines for Patients with Community-Acquired Pneumonia in Australian Hospitals. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, (2014), 17-20. https://doi.org/10.4137/CCRPM.S17978