抗菌药物降阶梯治疗对脓毒症患者临床结局及血清炎性因子水平影响

The effect of antibiotic descending step therapy on clinical outcome and serum inflammatory factor levels in patients with sepsis

目的:探讨抗菌药物降阶梯治疗对脓毒症患者临床结局及血清炎性因子水平影响。方法:选取2021年3月—2023年5月来本院治疗的脓毒症患者306例,采用区组随机化方法随机分为降阶梯组(n=156)和非降阶梯组(n=150)。非降阶梯组患者进入ICU后给予经验性抗菌药物治疗,采用第三代头孢类抗菌药物,治疗3 d后根据患者感染控制情况调整抗菌药物,如果控制不佳则升级为碳青霉烯类抗菌药物,或者根据细菌培养结果及药敏结果调整抗菌药物,在感染控制后继续目前抗菌药物治疗。降阶梯治疗组患者进入ICU后同样给予经验性抗菌药物治疗,采用第三代头孢类抗菌药物,在获取病原体培养和药敏结果后24 h内将抗菌药物更换为抗菌谱更窄的类型或减少抗菌药物的数量。比较两组进入ICU后、治疗7 d和治疗14 d时血清白细胞(WBC)、C反应蛋白(CRP)、降钙素原(PCT)水平变化,同时记录两组治疗期间出现呕吐、恶心、肝功能异常、肾损伤等不良反应发生率。结果:两组患者在年龄、性别、APACHEⅡ评分、SOFA评分等临床资料间具有临床可比性(P>0.05),治疗前和治疗7 d后两组血清CRP、PCT和WBC水平间差异无统计学意义(P>0.05),治疗14 d后降阶梯组血清CRP、PCT和WBC水平明显低于非降阶梯组(P<0.05);降阶梯组机械通气时间、MDRO抗菌药物使用时间和ICU住院时间明显低于非降阶梯组(P<0.05);两组再感染发生率和ICU死亡率间差异无统计学意义(P>0.05),治疗后降阶梯组不良反应发生率(18.59%)明显低于非降阶梯组(34.00%)(P<0.05)。结论:抗菌药物降阶梯治疗可明显改善脓毒症患者治疗结果,并且安全性较好。

Objective:To investigate the effects of antibiotic descending ladder therapy on clinical outcomes and serum inflammatory factor levels in patients with sepsis.Methods:A total of 306 patients with sepsis treated in our hospital from March 2021 to May 2023 were randomly divided into a descending ladder group(n=156)and a non-descending ladder group(n=150)using the block randomization method.Patients in the non-descending ladder group received empirical antimicrobial drug therapy with third-generation cephalosporins after admission to the ICU.Antibiotics were adjusted according to infection control after 3 days of treatment;if the infection was not well controlled,the patient was upgraded to carbapenem antibiotics,or the antibiotics were adjusted according to the results of bacterial culture and drug sensitivity tests.Patients in the de-escalation therapy group were treated with empiric antibiotics and third-generation cephalosporins after admission to the ICU.The antimicrobial drugs were adjusted to types with a narrower antimicrobial spectrum or to reduce the number of antimicrobial drugs within 24 h after pathogen culture,and susceptibility results were obtained.We compared the changes in serum white blood cell(WBC),C-reactive protein(CRP),and procalcitonin(PCT)levels in the two groups after admission to the ICU and 7 and 14 days of treatment,and recorded the incidence of adverse reactions,such as vomiting,nausea,abnormalities in liver function,and renal injury during the treatment period in the two groups.Results:The two groups of patients were clinically comparable in terms of age,gender,APACHE II score,and SOFA score(P>0.05).There was no statistically significant difference in serum CRP,PCT,or WBC levels between the two groups before and after 7 days of treatment(P>0.05).After 14 days of treatment,the serum CRP,PCT,and WBC levels in the descending step group were significantly lower than those in the non-descending step group(P<0.05).The duration of mechanical ventilation,MDRO antimicrobial drug use,and ICU hospitalization were significantly lower in the descending ladder group than in the non-descending ladder group(P<0.05).There was no statistically significant difference in the incidence of reinfection or ICU mortality between the two groups(P>0.05).The incidence of adverse reactions in the descending ladder group(18.59%)was significantly lower than that in the non-descending ladder group(34.00%)(P<0.05).Conclusions:Antibiotic descending ladder therapy significantly improves outcomes in patients with sepsis and has a favorable safety profile.