延迟适当抗生素治疗对严重细菌感染患者结局影响的系统评价。

A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Outcomes of Patients With Severe Bacterial Infections.

机构信息

Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA.

Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy.

出版信息

Chest. 2020 Sep;158(3):929-938. doi: 10.1016/j.chest.2020.03.087. Epub 2020 May 22.

DOI:10.1016/j.chest.2020.03.087

PMID:32446623

Abstract

BACKGROUND

Patients with severe bacterial infections often experience delay in receiving appropriate treatment. Consolidated evidence of the impact of delayed appropriate treatment is needed to guide treatment and improve outcomes.

RESEARCH QUESTION

What is the impact of delayed appropriate antibacterial therapy on clinical outcomes in patients with severe bacterial infections?

STUDY DESIGN AND METHODS

Literature searches of MEDLINE and Embase, conducted on July 24, 2018, identified studies published after 2007 reporting the impact of delayed appropriate therapy on clinical outcomes for hospitalized adult patients with bacterial infections. Where appropriate, results were pooled and analyzed with delayed therapy modeled three ways: delay vs no delay in receiving appropriate therapy; duration of delay; and inappropriate vs appropriate initial therapy. This article reports meta-analyses on the effect of delay and duration of delay.

RESULTS

The eligibility criteria were met by 145 studies, of which 37 contributed data to analyses of effect of delay. Mortality was significantly lower in patients receiving appropriate therapy without delay compared with those experiencing delay (OR, 0.57; 95% CI, 0.45-0.72). Mortality was also lower in the no-delay group compared with the delay group in subgroups of studies reporting mortality at 20 to 30 days, during ICU stay, or in patients with bacteremia (OR, 0.57 [95% CI, 0.43-0.76]; OR, 0.47 [95% CI, 0.27-0.80]; and OR, 0.54 [95% CI, 0.40-0.75], respectively). No difference was found in time to appropriate therapy between those who died and those who survived (P = .09), but heterogeneity between studies was high.

INTERPRETATION

Avoiding delayed appropriate therapy is essential to reduce mortality in patients with severe bacterial infections.

CLINICAL TRIAL REGISTRATION

PROSPERO; No.: CRD42018104669; URL: www.crd.york.ac.uk/prospero/.

摘要

背景

患有严重细菌感染的患者通常会延迟接受适当的治疗。为了指导治疗和改善预后，需要综合评估延迟适当治疗对严重细菌感染患者临床结局的影响。

研究问题

延迟适当的抗菌治疗对严重细菌感染住院患者的临床结局有何影响？

研究设计与方法

2018 年 7 月 24 日对 MEDLINE 和 Embase 进行文献检索，检索了 2007 年后发表的评估细菌感染住院成年患者接受适当治疗的延迟与临床结局关系的研究。如果合适，将结果汇总并分析，延迟治疗以三种方式建模：接受适当治疗的延迟与无延迟；延迟时间；以及初始治疗不适当与适当。本文报告了关于延迟和延迟时间影响的荟萃分析。

结果

符合纳入标准的研究有 145 项，其中 37 项研究的数据用于分析延迟的影响。与延迟接受适当治疗的患者相比，无延迟接受适当治疗的患者死亡率显著降低（OR，0.57；95%CI，0.45-0.72）。在报告 20-30 天死亡率、入住 ICU 期间死亡率或菌血症患者死亡率的亚组研究中，无延迟组患者的死亡率也低于延迟组（OR，0.57[95%CI，0.43-0.76]；OR，0.47[95%CI，0.27-0.80]；OR，0.54[95%CI，0.40-0.75]）。死亡患者和存活患者接受适当治疗的时间无差异（P=0.09），但研究间存在高度异质性。