重症患者应用万古霉素联合不同β-内酰胺类抗菌药物治疗的急性肾损伤风险比较

Acute kidney injury risks in critically ill patients receiving vancomycin and concomitant beta-lactam antibiotics

目的探究重症患者应用万古霉素联合哌拉西林他唑巴坦(VPT)与万古霉素联合美罗培南(VM)、万古霉素联合氨曲南(VA)、万古霉素联合头孢哌酮舒巴坦(VCS)之间急性肾损伤(AKI)发生率及临床预后的差异。方法回顾性研究2017年9月至2020年4月接受VPT、VM、VA、VCS联合治疗至少48 h的重症患者病例,按联合使用的β-内酰胺类抗菌药物进行分组,收集各组临床资料,比较AKI发生率和临床预后。应用多因素Logistic回归对AKI发生的危险因素进行分析。结果共纳入133例病例,其中VPT组32例、VM组64例、VA+VCS组37例。AKI总发生率为22.56%。VPT组、VM组、VA+VCS组间AKI发生率差异有统计学意义(40.63% vs 17.19% vs 16.22%,P<0.05)。三组间肾脏替代治疗率、院内病死率差异无统计学意义(P>0.05)。多因素Logistic回归分析发现,应用VPT(OR=3.324,95%CI:1.266~8.733,P=0.015)、万古霉素谷浓度增加(OR=1.066,95%CI:1.018~1.116,P=0.006)和急性生理与慢性健康评估Ⅱ(APACHE-Ⅱ)评分升高(OR=1.110,95%CI:1.027~1.200,P=0.009),是重症患者发生AKI的独立危险因素。结论重症患者应用万古霉素联合VPT治疗出现AKI风险高于联合VM、VA与VCS,需要谨慎用药。

Objective To determine the difference in the incidences of acute kidney injury (AKI) and clinical outcomes in critically ill patients receiving vancomycin and concomitant piperacillin-tazobactam (VPT),meropenem (VM),aztreonam (VA),or cefoperazone-sulbactam (VCS).Methods A retrospective study was conducted on critically ill patients who received at least 48 h of combination therapy with VPT,VM,VA or VCS from September,2017 to April,2020.The patients were grouped by beta-lactam antibiotics administered concomitantly.The clinical data of all patients were obtained to compare the incidences of AKI and clinical outcomes in different groups.Multivariate Logistic regression was used to evaluate the independent risk factors associated with AKI.Results Totally 133 critically ill patients were included in the study:32 patients in the VPT group,64 in the VM group,and 37 in the VA+VCS group.AKI occurred in 30 out of the 133 patients (22.56%).There was a significant difference in the incidence of AKI in the VPT group,VM group and VA+VCS group (40.63% vs 17.19% vs 16.22%,P<0.05).No significant difference was found in the proportion of renal replacement therapy and hospital mortality (P>0.05).In the multivariate Logistic regression,the use of VPT (OR=3.324,95%CI:1.266-8.733,P=0.015),vancomycin trough levels increased (OR=1.066,95%CI:1.018-1.116,P=0.006),and APACHE-Ⅱ score (OR=1.110,95%CI:1.027-1.200,P=0.009) were the 3 independent risk factors of AKI.Conclusion Critically ill patients treated with VPT have higher risk of AKI as compared with VM,VA or VCS,which should be used with caution.