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[MEDSCAPE]: 疑似VAP的抗生素治疗:何时短疗程更佳?
2017年06月16日 研究点评, 进展交流 暂无评论

Treatment of Suspected VAP: When Shorter Is Better

John A. Sellick, DO, MS

May 31, 2017

Which VAP Patients Don't Need a Full Course of Antibiotics? 哪些VAP患者无需接受完整疗程抗生素治疗?

Patients with suspected ventilator-associated pneumonia (VAP) are frequently started on empirical antibiotics, yet definitive diagnosis of VAP may not be made. Can antibiotics be safely discontinued early in some patients, and can ventilator settings be used to guide this decision? To find out, a recent study[1]compared outcomes among patients with suspected VAP and minimal and stable ventilator settings treated with 1-3 days versus more than 3 days of antibiotics.

尽管疑似呼吸机相关肺炎(VAP)的患者尚未确诊,但经常接受经验性抗生素治疗。某些患者能否安全的早期停用抗生素,呼吸机设置能否用于指导上述决策?为回答上述问题,近期一项研究对于呼吸机参数设置不高且稳定的疑似VAP患者,比较了1-3天抗生素疗程与3天以上抗生素疗程对预后的影响。

The study was a retrospective analysis of patients receiving mechanical ventilation over the course of 9 years at a single center. Possible VAP cases were identified using a broad clinical definition: patients from whom sputum cultures were obtained and in whom new antibiotics were started. From this group, patients with stable and minimal ventilator settings—daily minimum positive end-expiratory pressure ≤ 5 cm H2O and fraction of inspired oxygen ≤ 40%—were identified. Patients treated with antibiotics for 1-3 days were compared with those treated for more than 3 days, while controlling for a large number of demographic, clinical, and physiologic characteristics.

研究是对于单中心9年内接受机械通气患者的一项回顾性分析。采用较为宽泛的临床定义鉴别可能的VAP病例:留取痰培养且开始应用新的抗生素。在上述患者中,鉴别那些呼吸机设置稳定且条件不高的患者—每日最低PEEP ≤ 5 cm H2O,吸入氧浓度 ≤ 40%。作者将接受1-3天抗生素治疗的患者与接受3天以上抗生素治疗的患者进行比较,且针对很多人口统计学、临床及生理学指标进行校正。

Death while receiving mechanical ventilation, death during hospitalization, time to extubation, and time to discharge did not statistically significantly differ between the two groups. Likewise, propensity-matched pairs in the full group, patients with a discharge diagnosis of VAP, and those with purulent sputum containing potential pathogens showed no differences in these outcomes.

两组患者接受机械通气期间病死率,住院病死率,拔管时间及出院时间均无显著差异。同时,倾向性评分匹配分析,出院诊断为VAP的患者亚组,以及脓性痰中分离到可能致病菌的患者亚组分析均显示,上述预后指标在两组间并无差异。

Viewpoint 观点

This was not a randomized trial of VAP treatment, and there may be factors that naturally placed patients into the shorter treatment group but escaped quantification. That said, a shorter course of treatment appears to be appropriate for patients with suspected VAP on stable ventilator settings. The benefits for antimicrobial stewardship might be substantial, especially in busy units.

这并非一项VAP治疗的随机试验,可能存在部分因素造成患者更容易接受短疗程抗生素治疗,但并未纳入分析。然而,研究表明,对于呼吸机设置稳定的疑似VAP患者,短疗程抗生素可能是恰当的。这对于抗生素管理可能产生巨大影响,尤其是工作繁忙的单位。

References 参考文献

1. Klompas M, Li L, Menchaca JT, Gruber S; Centers for Disease Control and Prevention Epicenters Program. Ultra-short-course antibiotics for patients with suspected ventilator-associated pneumonia but minimal and stable ventilator settings. Clin Infect Dis. 2017;64:870-876. Abstract

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