严重血流感染肠杆菌科所致感染患者的早期抗生素降阶梯治疗：一项前瞻性多中心队列的事后分析。

Early antibiotic de-escalation in patients with severe infections due to bloodstream infection by enterobacterales: A post hoc analysis of a prospective multicentre cohort.

机构信息

Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL (Institut d´Investigació Biomèdica de Bellvitge), University of Barcelona, Barcelona, Spain.

Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; Hospital Universitario Virgen Macarena, and Departamento de Medicina, Universidad de Sevilla, Seville, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain.

出版信息

Int J Antimicrob Agents. 2024 Nov;64(5):107317. doi: 10.1016/j.ijantimicag.2024.107317. Epub 2024 Sep 2.

DOI:10.1016/j.ijantimicag.2024.107317

PMID:39233214

Abstract

BACKGROUND

Data about antibiotic de-escalation in sepsis associated with the bloodstream and caused by Enterobacterales are scarce. The objectives of this study are to identify factors associated with early de-escalation and to analyse the impact of de-escalation on mortality in patients with Enterobacterales bloodstream infection (BSI) with a Sequential Organ Failure Assessment (SOFA) score ≥ 2.

METHODS

A prospective, multicentre cohort study was performed including episodes of BSI due to Enterobacterales and a SOFA score ≥ 2 who were receiving an active antipseudomonal β-lactam; the isolate should be susceptible to at least 1 narrower-spectrum antibiotic. Variables associated with de-escalation were identified using logistic binary regression. The association of de-escalation with 30-day mortality was investigated. Confounding was controlled by calculating a propensity score used as covariate, as matching variable, and for inverse probability treatment weighting.

RESULTS

Of the 582 patients included, de-escalation was performed in 311 (53.4%). Neutropenia (adjusted odds ratio [aOR] = 0.37; 95% confidence interval [95% CI] = 0.18-0.75), central venous catheter (aOR = 0.52; 95% CI = 0.32-0.83), and extended-spectrum β-lactamase (ESBL)-producing isolate (aOR = 0.28; 95% CI = 0.17-0.48) were negatively associated with de-escalation, and urinary tract source was positively associated (aOR = 2.27; 95% CI = 1.56-3.33). The 30-day mortality was 6.8% (21 patients) in de-escalated patients and 14.4% (39) in not de-escalated patients (relative risk, 0.63; 95% CI = 0.44-0.89). In multivariate analysis including the propensity score, de-escalation was not associated with mortality (AOR = 0.98; 95% CI = 0.39-2.47) and was protective in the case of urinary or biliary tract source (AOR = 0.31, 95% CI = 0.09-1.06). Matched and inverse probability treatment weighting analysis showed similar results.

CONCLUSIONS

These results suggest that early de-escalation from antipseudomonal β-lactams is safe in patients with Enterobacterales bacteremia and SOFA ≥ 2.

摘要

背景

关于与血流相关的由肠杆菌科引起的败血症中抗生素降阶梯治疗的数据很少。本研究的目的是确定与早期降阶梯相关的因素，并分析降阶梯对 SOFA 评分≥2 的肠杆菌科血流感染（BSI）患者死亡率的影响。

方法

进行了一项前瞻性、多中心队列研究，包括由肠杆菌科引起的 BSI 病例和 SOFA 评分≥2 的患者，他们正在接受活性抗假单胞菌β-内酰胺治疗；分离株应至少对 1 种窄谱抗生素敏感。使用逻辑二元回归确定与降阶梯相关的变量。研究了降阶梯与 30 天死亡率的关系。通过计算作为协变量、匹配变量和逆概率治疗加权的倾向评分来控制混杂。

结果

在 582 例患者中，311 例（53.4%）进行了降阶梯治疗。中性粒细胞减少症（调整后的优势比[aOR] = 0.37；95%置信区间[95%CI] = 0.18-0.75）、中央静脉导管（aOR = 0.52；95%CI = 0.32-0.83）和产超广谱β-内酰胺酶（ESBL）的分离株（aOR = 0.28；95%CI = 0.17-0.48）与降阶梯呈负相关，而尿路感染源呈正相关（aOR = 2.27；95%CI = 1.56-3.33）。降阶梯组 30 天死亡率为 6.8%（21 例），未降阶梯组为 14.4%（39 例）（相对风险，0.63；95%CI = 0.44-0.89）。在包括倾向评分的多变量分析中，降阶梯与死亡率无关（aOR = 0.98；95%CI = 0.39-2.47），对于尿路感染或胆道源，降阶梯是保护因素（aOR = 0.31，95%CI = 0.09-1.06）。匹配和逆概率治疗加权分析显示了类似的结果。