多黏菌素B治疗危重患者泛耐药革兰阴性菌感染的疗效和影响因素分析

Analysis of efficacy and influencing factors of polymyxin B in the treatment of critically ill patients with extensively drug-resistant Gram-negative bacterial infection

目的:通过分析多黏菌素B治疗危重患者泛耐药革兰阴性菌感染的疗效及其影响因素,为多黏菌素B的合理应用提供参考依据。方法:回顾性收集2018年1月至2019年12月期间在中山大学附属第一医院重症监护病房住院感染泛耐药革兰阴性菌,且使用多黏菌素B治疗≥3 d的患者资料,观察患者使用多黏菌素B的疗效,并对相关的影响因素进行统计学分析。结果:共纳入患者91例,平均年龄为(56.76±18.57)岁,多黏菌素B平均给药剂量为(118.04±32.23)mg·d,给药疗程中位和四分位数间距为11(7,16)d,患者细菌清除率为40.7%(37/91),临床有效率为52.8%(48/91),30 d死亡率为48.4%(44/91),住院死亡率为60.4%(55/91);多因素logistic回归分析显示患者接受连续性肾脏替代治疗(OR=0.32,95%CI:0.12~0.82,P=0.018)及给药时机(OR=0.28,95%CI:0.10~0.77,P=0.013)是影响多黏菌素B临床疗效的独立危险因素;序贯器官衰竭评分(OR=1.30,95%CI:1.12~1.51,P=0.001)及血流感染(OR=10.49,95%CI:2.35~46.93,P=0.002)是患者在多黏菌素B治疗期间30 d内死亡的独立危险因素。结论:对于多黏菌素B应用于危重患者泛耐药革兰阴性菌感染,恰当的给药时机是治疗成功的关键因素,而接受连续性肾脏替代治疗是临床疗效的独立影响因素,患者器官功能的衰竭程度以及伴随血流感染是治疗预后不良的独立危险因素。

OBJECTIVE To analyze the efficacy and influencing factors for the treatment of polymyxin B(PMB)in critically ill patients with extensively drug-resistant gram-negative bacterial(XDR-GNB)infection and provide rational reference for clinical application of PMB.METHODS The data of patients hospitalized in the intensive care unit(ICU)of First Affiliated Hospital of Sun Yat sen University from January 2018 to December 2019 infected with XDR-GNB and treated with PMB≥3 days were collected retrospectively.The efficacy and the relevant influencing factors of PMB were statistically analyzed.RESULTS A total of 91 patients were included,with an average age of(56.76±18.57)years,the average PMB dosage at(118.04±32.23)mg·d,and treatment course of 11(7,16)days.The bacterial clearance rate was 40.7%(37/91),the clinical effective rate was 52.8%(48/91),the 30-day mortality was 48.4%(44/91),and the hospitalization mortality was 60.4%(55/91).Multivariate logistic regression analysis showed that the patients receiving continuous renal replacement therapy(CRRT)(OR=0.32,95%CI:0.12-0.82,P=0.018)and timing of administration(OR=0.28,95%CI:0.10-0.77,P=0.013)were independent related factors for the clinical efficacy of PMB;the sepsis-related organ failure assessment(SOFA)score(OR=1.30,95%CI:1.12-1.51,P=0.001)and bloodstream infection(OR=10.49,95%CI:2.35-46.93,P=0.002)were independent risk factors for the 30-day mortality.CONCLUSION The appropriate timing of PMB administration is the key factor for the successful treatment of XDR-GNB infection in critically ill patients,and patients receiving CRRT is an independent factor affecting the clinical efficacy.The degree of organ failure and bloodstream infection are independent risk factors for poor prognosis in the treatment of PMB.