不同碳青霉烯类耐药革兰氏阴性杆菌引起的血流感染所致死亡率：来自意大利全国性研究（ALARICO 网络）的结果。
Mortality Attributable to Bloodstream Infections Caused by Different Carbapenem-Resistant Gram-Negative Bacilli: Results From a Nationwide Study in Italy (ALARICO Network).
机构信息
Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro," Bari, Italy.
出版信息
Clin Infect Dis. 2023 Jun 16;76(12):2059-2069. doi: 10.1093/cid/ciad100.
BACKGROUND
Our aim was to analyze mortality attributable to carbapenem-resistant (CR) gram-negative bacilli (GNB) in patients with bloodstream infections (BSIs).
METHODS
Prospective multicentric study including patients with GNB-BSI from 19 Italian hospitals (June 2018-January 2020). Patients were followed-up to 30 days. Primary outcomes were 30-day mortality and attributable mortality. Attributable mortality was calculated in the following groups: Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales, metallo-β-lactamases (MBL)-producing Enterobacterales, CR-Pseudomonas aeruginosa (CRPA), CR-Acinetobacter baumannii (CRAB). A multivariable analysis with hospital fixed-effect was built to identify factors associated with 30-day mortality. Adjusted OR (aORs) were reported. Attributable mortality was calculated according to the DRIVE-AB Consortium.
RESULTS
Overall, 1276 patients with monomicrobial GNB BSI were included: 723/1276 (56.7%) carbapenem-susceptible (CS)-GNB, 304/1276 (23.8%) KPC-, 77/1276 (6%) MBL-producing CRE, 61/1276 (4.8%) CRPA, and 111/1276 (8.7%) CRAB BSI. Thirty-day mortality in patients with CS-GNB BSI was 13.7% compared to 26.6%, 36.4%, 32.8% and 43.2% in patients with BSI by KPC-CRE, MBL-CRE, CRPA and CRAB, respectively (P < .001). On multivariable analysis, age, ward of hospitalization, SOFA score, and Charlson Index were factors associated with 30-day mortality, while urinary source of infection and early appropriate therapy resulted protective factors. Compared to CS-GNB, MBL-producing CRE (aOR 5.86, 95% CI 2.72-12.76), CRPA (aOR 1.99, 95% CI 1.48-5.95) and CRAB (aOR 2.65, 95% CI 1.52-4.61) were significantly associated with 30-day mortality. Attributable mortality rates were 5% for KPC-, 35% for MBL, 19% for CRPA, and 16% for CRAB.
CONCLUSIONS
In patients with BSIs, carbapenem-resistance is associated with an excess of mortality, with MBL-producing CRE carrying the highest risk of death.
背景
本研究旨在分析血流感染（BSI）患者中碳青霉烯类耐药（CR）革兰氏阴性菌（GNB）所致的死亡率。
方法
这是一项前瞻性多中心研究，纳入了来自意大利 19 家医院的 1276 例 GNB-BSI 患者（2018 年 6 月至 2020 年 1 月）。患者随访至 30 天。主要结局为 30 天死亡率和归因死亡率。归因死亡率在以下组别中进行计算：产 KPC 肠杆菌科细菌、产金属β-内酰胺酶（MBL）肠杆菌科细菌、CR 铜绿假单胞菌（CRPA）、CR 鲍曼不动杆菌（CRAB）。建立了包含医院固定效应的多变量分析，以确定与 30 天死亡率相关的因素。报告了校正后的比值比（aOR）。根据 DRIVE-AB 联合会的方法计算归因死亡率。
结果
共纳入 1276 例单一致病菌 GNB BSI 患者：723/1276（56.7%）为碳青霉烯敏感（CS）-GNB，304/1276（23.8%）为产 KPC 肠杆菌科细菌，77/1276（6%）为产 MBL 肠杆菌科 CRE，61/1276（4.8%）为 CRPA，111/1276（8.7%）为 CRAB BSI。CS-GNB BSI 患者的 30 天死亡率为 13.7%，而产 KPC-CRE、MBL-CRE、CRPA 和 CRAB 患者的 30 天死亡率分别为 26.6%、36.4%、32.8%和 43.2%（P<0.001）。多变量分析显示，年龄、住院科室、SOFA 评分和 Charlson 指数是与 30 天死亡率相关的因素，而尿路感染和早期适当治疗是保护性因素。与 CS-GNB 相比，产 MBL 的 CRE（aOR 5.86，95%CI 2.72-12.76）、CRPA（aOR 1.99，95%CI 1.48-5.95）和 CRAB（aOR 2.65，95%CI 1.52-4.61）与 30 天死亡率显著相关。归因死亡率分别为 KPC-5%、MBL-35%、CRPA-19%和 CRAB-16%。
结论
在 BSI 患者中，碳青霉烯类耐药与死亡率增加相关，产 MBL 的 CRE 具有最高的死亡风险。
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