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  • 學位論文

急診敗血症病患經驗性抗生素投予與病患預後及危險因子的關聯性分析

Correlation between risk factors and outcome of empirical antibiotic treatment in patients with septicemia in an emergency room

指導教授 : 盧敏吉

摘要


中文摘要 目的 : 敗血症常常導致病患死亡,尤其是在加護病房的病患因為多重潛在性疾病,敗血症致死率更是驚人。臨床上第一時間投予有效的抗生素對於嚴重感染併敗血症病人是重要的。在敗血症拯救計劃強烈建議於一小時內投予有效的抗生素來治療嚴重敗血症之病人。然而敗血症仍舊是造成病人死亡的主要因素。吾人想了解急診室敗血症之病人之經驗性抗生素治療與病患預後及危險因子的關係。 研究方法與材料 : 本研究是一回溯性收集在99年七月至100年六月於急診室治療的敗血症病人。收集病人的標準為(1)血液培養陽性(2)符合全身性發炎反應症候群兩種以上標準; (3) 年齡大於20歲;排除病人收集的標準為:需立即外科手術的病人。每位病人在一入急診室時均紀錄每位病人基本資料(年齡、性別、身高、體重)理學檢查發現(生命徵象及APACHE分數)實驗室資料(紅血球、白血球、血小板、腎功能、肝功能、黃疸指數等生化資料) 微生物培養(血液),第一時間及後續使用的抗生素種類,結果及30天之死亡率。 結果與發現 : 在本研究對象中,共有238 例是適當投予經驗性抗生素的族群,約佔全部病例的82.6 %。有 50例被歸類是不適當投予經驗性抗生素的族群,約佔全部病例的17.4 % 。在嚴重的敗血症病例使用血管昇壓劑方面,p 值< 0.05 ,達到統計上的意義,兩族群有明顯差異。亦即嚴重的敗血症病例使用血管昇壓劑及適當投予經驗性抗生素的比率較多。全部死亡的病例,共計44 例,約佔15.3 % 。吾人發現若分離出綠膿桿菌 (Pseudomonas aeruginosa ) 或抗藥性金黃色葡萄球( Methicillin resistant Staphylococcus aureus ) 在兩族群之病人死亡率較高。針對是否造成死亡的結果作多元邏輯斯迴歸分析發現使用血管增壓劑是容易造成死亡危險的相關因子;另外疾病嚴重度APACHE分數是比較接近造成死亡危險的相關因子。 結論 : 急診敗血症病患經驗性抗生素投予與病患預後及危險因子的關聯性分析 中發現大部分病患接受投予適當經驗性抗生素,病患的死亡率為15.3 %。皮膚感染或血液透析病患不適當投予經驗性抗生素機率較高。在急診室使用血管增壓劑病患是容易造成死亡危險的相關因子,而疾病嚴重度APACHE分數高的病患是比較接近造成死亡危險的相關因子。

並列摘要


Abstract Objective : A prompt institution of antimicrobial therapy that is active against the causative pathogen(s) is crucial for the treatment of patients with severe infections and sepsis. In fact, the Surviving Sepsis Campaign strongly recommends initiating empirical antibiotic therapy within the first hour of recognition of severe sepsis, after suitable cultures have been obtained. Our main objective was to determine whether the administration of inadequate empirical antimicrobial therapy and to assess the risk factors of the use of empirical antibiotic therapy on survival of patients with bacteraemia and sepsis in an emergency room . Materials and methods: We enrolled retrospectively of patients who was admitted and treated for sepsis from an emergency room during July 2010 through June 2011. Eligible patients meet the following criterias: (1) positive blood culture ; (2) two or more systemic inflammatory response syndrome (SIRS) criteria . (3) age more than 20 years old ; excluded patients who required immediate surgical intervention .Variables of each case record at baseline and during follow-up include patients’ demographics, physical examination findings (vital signs and APACHE score ) , laboratory measurements ( biochemistry and microbiological cultures ) , suspected source of infection, initial empirical antibiotic use, outcome and mortality during 30 days . Results : In this study , total 288 patients were enrolled . There were 238 cases were classified to appropriated empiric antibiotic treatment , about for 82.6 % of total cases. There were 50 cases was inappropriated empiric treatment group, about 17.4 % of total cases . The useage of vessopressin in severe septicemia patients was significant ( p < 0.05 ) , it was also that there was more portions of appropriated empiric antibiotic treatment in useage of vessopressin and severe septicemia patients . The total motality cases were 44 patients , about 15.3 % of total cases . The motality rate was higher if there was isolated with Pseudomonas aeruginosa or Methicillin resistant Staphylococcus aureus .Multiple logistic regression analysis identified that useage of vassoprssin was the only risk factor for fatal outcome ; the higher of APACHE scores of patients was closer of the risk factor for fatal outcome . Conclusion : The majority of patients were administrated with appropriated empiric antibiotic treatment for whom with septicemia in an Emergency room . The total motality rate was 15.3 % . The useage of vassoprssin was the only risk factor for fatal outcome ; the higher of APACHE scores of patients was closer of the risk factor for fatal outcome .

並列關鍵字

Septicemia empiric antibiotic Emergency room

參考文獻


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