背景:广泛耐药的革兰氏阴性(XDRGN)杆菌引起的呼吸机相关性肺炎(VAP)的死亡率极高。这项研究的目的是比较吸入(IH)加静脉(IV)多粘菌素B与IV多粘菌素B在XDRGN杆菌VAP患者中的疗效和安全性。
方法:2018年1月1日至2020年1月1日在中国的8个ICU进行了一项回顾性多中心观察性队列研究。分析了用多粘菌素B治疗的所有患者的微生物学证实的VAP的数据。主要终点是VAP的临床治愈。良好的临床结果,微生物结果,住院期间VAP相关死亡率和全因死亡率,与多粘菌素B相关的副作用是次要终点。有利的临床结果包括临床治愈或临床改善。
结果:151例患者和46例患者接受了静脉多粘菌素B和IH加静脉多粘菌素B治疗,分别。XDR肺炎克雷伯菌是主要的分离病原体(n=83,42.1%)。年龄匹配后(±5岁),性别,感染性休克,多粘菌素B开始时的ApacheII评分(±4分),132名患者被纳入。44例患者同时接受IH加IV多粘菌素B,88例患者接受IV多粘菌素B。临床治愈率(43.2%vs27.3%,p=0.066),细菌根除(36.4%vs23.9%,p=0.132)以及与VAP相关的死亡率(27.3%vs34.1%,p=0.428),全因死亡率(34.1%vs42.0%,p=0.378)两组之间没有显着差异。然而,IH+IV多粘菌素B治疗与改善良好的临床结局相关(77.3%vs58.0%,p=0.029)。不同亚组的患者(因医学病因入院,感染肺炎克雷伯菌,没有菌血症,具有免疫抑制状态)的奇数比率(ORs)有利于联合治疗。没有患者因不良事件而需要停用多粘菌素B。额外使用IH多粘菌素B(aOR2.63,95%CI1.06,6.66,p=0.037)是与良好临床结局相关的独立因素。
结论:在低剂量IV多粘菌素B中添加低剂量IH多粘菌素B并不能提供有效的临床治愈和细菌根除XDRGN杆菌引起的VAP。关键点IH多粘菌素B的额外使用是良好临床结局的唯一独立危险因素。不同亚组的患者的HR基本上有利于额外使用IH多粘菌素B。没有患者由于不良事件而需要多粘菌素B停药。
BACKGROUND: The mortality of extensively drug-resistant Gram-negative (XDR GN) bacilli-induced ventilator-associated pneumonia (VAP) is extremely high. The purpose of this study was to compare the efficacy and safety of inhaled (IH) plus intravenous (IV) polymyxin B versus IV polymyxin B in XDR GN bacilli VAP patients.
METHODS: A retrospective multi-center observational cohort study was performed at eight ICUs between January 1st 2018, and January 1st 2020 in China. Data from all patients treated with polymyxin B for a microbiologically confirmed VAP were analyzed. The primary endpoint was the clinical cure of VAP. The favorable clinical outcome, microbiological outcome, VAP-related mortality and all-cause mortality during hospitalization, and side effects related with polymyxin B were secondary endpoints. Favorable clinical outcome included clinical cure or clinical improvement.
RESULTS: 151 patients and 46 patients were treated with IV polymyxin B and IH plus IV polymyxin B, respectively. XDR Klebsiella pneumoniae was the main isolated pathogen (n = 83, 42.1%). After matching on age (± 5 years), gender, septic shock, and Apache II score (± 4 points) when polymyxin B was started, 132 patients were included. 44 patients received simultaneous IH plus IV polymyxin B and 88 patients received IV polymyxin B. The rates of clinical cure (43.2% vs 27.3%, p = 0.066), bacterial eradication (36.4% vs 23.9%, p = 0.132) as well as VAP-related mortality (27.3% vs 34.1%, p = 0.428), all-cause mortality (34.1% vs 42.0%, p = 0.378) did not show any significant difference between the two groups. However, IH plus IV polymyxin B therapy was associated with improved favorable clinical outcome (77.3% vs 58.0%, p = 0.029). Patients in the different subgroups (admitted with medical etiology, infected with XDR K. pneumoniae, without bacteremia, with immunosuppressive status) were with odd ratios (ORs) in favor of the combined therapy. No patient required polymyxin B discontinuation due to adverse events. Additional use of IH polymyxin B (aOR 2.63, 95% CI 1.06, 6.66, p = 0.037) was an independent factor associated with favorable clinical outcome.
CONCLUSIONS: The addition of low-dose IH polymyxin B to low-dose IV polymyxin B did not provide efficient clinical cure and bacterial eradication in VAP caused by XDR GN bacilli. Keypoints Additional use of IH polymyxin B was the sole independent risk factor of favorable clinical outcome. Patients in the different subgroups were with HRs substantially favoring additional use of IH polymyxin B. No patients required polymyxin B discontinuation due to adverse events.