万古霉素血药谷浓度和临床结局相关性的系统评价和Meta分析（英文）

Relationship Between Vancomycin Trough Serum Concentrations and Clinical Outcomes:A Systematic Review and Meta-Analysis

目的:研究万古霉素血药谷浓度与死亡率、治疗失败率和肾毒性之间的关系。方法:系统检索Pub Med、Embase、Cochrane图书馆和三个中文数据库(CNKI、CBM和万方数据),检索时间范围均为建库到2014年1月16日。纳入所有研究万古霉素谷浓度与临床结局相关性的文章,由两位研究者独立提取数据,并采用Newcastle-Ottawa评分评价观察性研究的质量,二分类变量结果选用相对危险比(RRs)和95%可信区间(95%CI)表示,如无统计学异质性则采用固定效应模型。主要终点结局是死亡率和治疗失败率,次要终点结局是肾毒性。结果:共纳入40个队列研究。与万古霉素谷浓度<15 mg·L^(-1)的患者相比,谷浓度≥15 mg·L^(-1)的患者的治疗失败率更低(RR=0.83,95%CI:0.70~0.97,P=0.02),肾毒性发生率更高(RR=1.99,95%CI:1.56~2.53,P<0.000 01);与万古霉素谷浓度<10 mg·L^(-1)或<20 mg·L^(-1)相比,万古霉素谷浓度≥10 mg·L^(-1)或≥20 mg·L^(-1)与肾毒性发生率增加明显相关;万古霉素谷浓度与死亡率不相关。结论:与万古霉素谷浓度<15 mg·L^(-1)相比,万古霉素谷浓度≥15 mg·L^(-1)与降低治疗失败率和肾毒性发生率增加明显相关。当患者的万古霉素谷浓度≥15 mg·L^(-1)时,应注意患者增加的肾毒性发生风险。

Objective：Certain studies have shown that treatment failure is not significantly altered when the vancomycin trough serum concentrations are maintained above 15 mg·L^（-1）. The purpose of this review was to examine the relationships between the vancomycin trough serum concentrations and mortality,treatment failure,and nephrotoxicity. Methods：Pub Med,Embase,the Cochrane Library and three Chinese literature databases（ CNKI,CBM,and Wan Fang） were searched through Jan 16,2014. All studies pertaining to the relationship between the vancomycin trough concentrations and clinical outcomes were included. Two authors（ Ye ZK and Chen K） independently extracted data and assessed the quality of the studies. The quality of the observational studies was assessed using the Newcastle-Ottawa scale. Risk ratios（ RRs）and 95% confidence intervals（ CIs） were calculated for the categorical variables using fixed-effects models if no significant heterogeneity in these variables was detected. The primary outcomes were mortality and treatment failure. The secondary outcome was vancomycin-associated nephrotoxicity. Results：Forty cohort studies were included in this Meta-analysis. Compared with the patients who displayed vancomycin trough concentrations of 〈15 mg · L^（-1）,those displaying vancomycin trough concentrations of ≥ 15 mg·L^（-1）exhibited a lower rate of treatment failure（ RR = 0. 83,95% CI： 0. 70-0. 97,P= 0. 02） and a higher incidence of nephrotoxicity（ RR = 1. 99,95% CI： 1. 56-2. 53,P 〈0. 000 01）. Compared with vancomycin trough levels of 〈10 or 20 mg·L^（-1）,vancomycin trough levels of ≥ 10 or 20 mg·L^（-1）,respectively,were associated with a higher incidence of nephrotoxicity. However,the vancomycin trough concentrations were not associated with mortality. Conclusion：Compared with vancomycin trough levels of 〈15 mg·L^（-1）,vancomycin trough levels of ≥ 15mg·L^（-1）were associated with a reduced rate of treatment failure and an increased incidence of nephrotoxicity. The increased risk of nephrotoxicity in patients with vancomycin trough serum concentrations greater than 15 mg·L^（-1） should be considered.