研究目的:

为了评估感染的抗菌治疗不足（包括社区获得性和院内感染），并为需要入住ICU的患者住院死亡率之间的关系。

设计：

前瞻性队列研究。

设置:

巴恩斯 - 犹太医院，大学附属城市教学医院。

病人:

两千例患者需要住院医疗或外科ICU。

干预措施:

前瞻性病人监测和数据收集。

数据和结果：

169名(8.5%)感染患者对其感染的抗菌素治疗不足。这代表了655名被评估为社区获得性感染或院内感染的患者中的25.8%。抗菌药物治疗不足在医院感染患者中最为常见，发生于社区获得性感染治疗后(45.2%)，其次是单纯的医院感染(34.3%)和单纯的社区获得性感染(17.1%)(p < 0.001)。多因素logistic回归分析，仅使用感染患者队列(n = 655)，表明既往使用抗生素(调整优势比[OR]， 3.39;95%置信区间[CI]， 2.88 ~ 4.23;p < 0.001)，存在血流感染(调整OR, 1.88;95% CI, 1.52至2.32;p = 0.003)，增加急性生理和慢性健康评估(APACHE) II评分(调整OR, 1.04;95% CI, 1.03至1.05;p = 0.002)，并降低患者年龄(调整OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission.

结论：

需要入住ICU患者中感染治疗不彻底似乎是住院死亡率的重要决定因素。这些数据表明，旨在减少抗菌治疗不足的发生可以提高危重病人的预后是临床工作。此外，之前的抗生素治疗，应确认为ICU患者临床怀疑感染中抗菌治疗不彻底的管理的一个重要危险因素。