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[Lancet Infect Dis在线发表]:感染科会诊对念珠菌血症患者病死率及治疗的影响:一项回顾性队列研究
2019年11月21日 时讯速递, 进展交流 暂无评论

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Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study

Carlos Mejia-Chew, Jane A O'Halloran, Margaret A Olsen, et al.

Lancet Infect Dis September 24, 2019 DOI:https://doi.org/10.1016/S1473-3099(19)30405-0

Summary

Background 背景

Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections.

念珠菌血症患者病死率很高。感染科会诊能够改善某些感染( 包括金黄色葡萄球菌和隐球菌,多重耐药菌)的预后。我们旨在验证感染性疾病会诊与治疗差异及念珠菌血症病死率之间的相关性。

Methods 方法

In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management.

在这项回顾性、单中心队列研究中,我们回顾了2002年至2015年Barnes-Jewish医院收治的所有患者的病历。入选标准为18岁以上成人且罹患念珠菌血症。我们收集了人口统计学、合并症、致病因素、全因死亡、抗真菌药物使用、拔除中心静脉导管及眼科与心脏超声等资料,以评估感染科会诊与未会诊患者的90天全因病死率。我们采用倾向性评分逆加权,根据Cox比例风险模型进行生存分析,评估感染科会诊对病死率及治疗差异的影响。

Findings 结果

Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p<0·0001). In the model with inverse weighting by the propensity score, infectious disease consultation was associated with a hazard ratio of 0·81 (95% CI 0·73–0·91; p<0·0001) for mortality. In the consultation group, median duration of antifungal therapy was longer (18 [IQR 14–35] vs 14 [6–20] days; p<0·0001) and central-line removal (587 [76%] of 776 vs 538 [59%] of 915; p<0·0001), echocardiography use (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001), and ophthalmological examination (412 [53%] of 776 vs160 [17%] of 915; p<0·0001) were more frequently done. Fewer patients in the infectious disease consultation group were not treated (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001).

2002年1月1日至2015年12月31日间,共有1794名患者符合入选标准,我们对1691名念珠菌血症患者进行了分析;776名患者 (45·9%) 接受了感染科会诊,其余915名患者 (54·1%) 未接受感染科会诊。所有1691名患者均纳入最后分析,没有数据丢失。多数基础疾病在两组间分布均衡。感染科会诊组患者90天病死率低于非会诊组 (29% [222/776] vs 51% [468/915]; p<0·0001)。根据倾向性评分逆加权模型,感染科会诊的死亡风险比为 0·81 (95% CI 0·73–0·91; p<0·0001)。会诊组患者抗真菌药物疗程更长(18 [IQR 14–35] vs 14 [6–20] 天; p<0·0001),中心静脉导管拔除比例更高(587 [76%] of 776 vs 538 [59%] of 915; p<0·0001),心脏超声 (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001) 和眼科检查 (412 [53%] of 776 vs160 [17%] of 915; p<0·0001) 更多。感染科会诊组中更少患者未接受治疗 (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001)。

Interpretation 结论

Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection.

接受感染科会诊的念珠菌血症患者病死率更低。造成这一结果的原因可能包括这些患者接受更多基于循证的非药物性治疗,且更少患者未接受治疗。这些数据提示,感染科会诊应当成为念珠菌血症患者临床治疗的重要组成部分。

Funding 资助

Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

评论[仅代表个人观点]

  • 这个研究仍来自于Marin Kollef及其同事,证明了专业性的重要
  • 抗感染治疗是一个大家对于权威性和专业性缺乏尊重的领域。任何年资的医生,任何专科的医生都不会承认自己其实不懂抗生素的使用
  • 然而,国内部分感染科老师也只是沉溺于重症感染的“全覆盖”策略(先覆盖耐药革兰阴性感染,然后是耐药革兰阳性球菌,之后是真菌),缺乏对病情特点的分析和判断。这样的会诊其实不要也罢

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