呼吸机相关肺炎的经验性抗生素选择和治疗结果

The relevance of empirical antibiotic option with outcomes of ventilator-associated pneumonia

目的 探讨呼吸机相关肺炎 (VAP)初始经验性抗生素治疗中降阶梯治疗策略的应用对临床治疗结果的影响。方法 1999年 6月～ 2 0 0 2年 12月前瞻性研究了 10 3例机械通气患者 2 37例次VAP的初始经验性抗生素治疗 ,将VAP发病分为治疗组和对照组 ,治疗组患者的最初经验性抗生素治疗由本课题研究组决定 ,按照“全面覆盖推测病原菌”原则和降阶梯治疗策略选择抗生素 ;对照组患者由经治医生自行决定处方和调整。对比分析两组患者的临床治疗结果。结果 治疗组和对照组的初治方案均以单药处方为主 (5 7 8%和 6 3 7% ) ;治疗组多选择有抗假单胞菌活性的抗生素 (83 0 %比 6 1 7% ) ,治疗组的不适当初治明显低于对照组 (2 7 4 %比 4 3 1% ,P <0 0 1) ,对照组中抗菌谱未覆盖病原谱明显高于治疗组 (45 8%比 10 4 % ,P <0 0 1) ;两组初治方案调整分别为4 9 6 %和 5 7 8% ,调整方案以单用升级和单用改联合为主 ,治疗组简化方案 2 5例次 (37 3% ) ;治疗组有效率明显高于对照组 (71 9%比 5 8 9% ,P <0 0 5 ) ;两组病死率无明显差异 ,总病死率为 2 4 5 %(5 8/ 2 37)。结论 VAP的单用或联合初治方案应以具有抗假单胞菌活性的广谱抗生素为核心 ,尽早开始并根据病原学结果进行维持或调整 ;

Objective To evaluate the impact of empiric de-escalation antibiotic therapy at the initial stage on the outcomes of ventilator-associated pneumonia(VAP).Methods A prospective controlled clinical trial in 237 cases of VAP in 103 patients receiving mechanical ventilation was underwent between June 1999 and December 2002.VAP cases were assigned to the treatment group (135 cases) and the control group (102 cases),respectively.The initial antibiotic empiric therapy was given according to the strategy covering most likely pathogens and de-escalated modified for the treatment group whereas antibiotics were chosen by attending physicians of their own for the control group.The clinical outcomes of VAP in the two groups were compared.ResultsSingle antibiotic was the predominant choice in the initial therapy (57.8% and 63.7%) in the treatment group and control groups,though antibiotics with antipseudomonal activity were adopted more frequently in the treatment group (83.0% vs. 61.7%).The percentage of modifying the initial therapy according to the results of culture and sensitivity was 49.6% and 57.8% for the treatment and control groups,respectively.The effective rates were 71.9% and 58.9% (P<0.05) for the treatment and control groups,respectively.There were no differences with regard to mortality when compared the treatment group with the control group.The overall mortality of the two groups was 24.5%.Conclusions The broad-spectrum antibiotics with antipseudomonal activity should be considered for the initial empiric monotherapy or combined therapy of VAP as the core agents.The initial therapy should be promptly mandated and maintained or modified based on microbiological results.De-escalation therapy reduces the inappropriate initial therapy and raises the effective rate.