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[Lancet Infect Dis在线发表]:碳青霉烯耐药对中低收入国家肠杆菌科细菌血行性感染患者预后的影响
2019年06月06日 时讯速递, 进展交流 暂无评论

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Effect of carbapenem resistance on outcomes of bloodstream infection caused by Enterobacteriaceae in low-income and middle-income countries (PANORAMA): a multinational prospective cohort study

Andrew J Stewardson, Kalisvar Marimuthu, Sharmila Sengupta, et al

Lancet Infect Dis Published: April 29, 2019

DOI:https://doi.org/10.1016/S1473-3099(18)30792-8

Summary

Background 背景

Low-income and middle-income countries (LMICs) are under-represented in reports on the burden of antimicrobial resistance. We aimed to quantify the clinical effect of carbapenem resistance on mortality and length of hospital stay among inpatients in LMICs with a bloodstream infection due to Enterobacteriaceae.

有关抗生素耐药负担的报告中很少有中低收入国家(LMICs)的数据。本研究旨在定量分析碳青霉烯耐药对于LMICs肠杆菌科细菌血行性感染的住院患者病死率及住院日的影响。

Methods 方法

The PANORAMA study was a multinational prospective cohort study at tertiary hospitals in Bangladesh, Colombia, Egypt, Ghana, India, Lebanon, Nepal, Nigeria, Pakistan, and Vietnam, recruiting consecutively diagnosed patients with carbapenem-susceptible Enterobacteriaceae (CSE) and carbapenem-resistant Entero-bacteriaceae (CRE) bloodstream infections. We excluded patients who had previously been enrolled in the study and those not treated with curative intent at the time of bloodstream infection onset. There were no age restrictions. Central laboratories in India and the UK did confirmatory testing and molecular characterisation, including strain typing. We applied proportional subdistribution hazard models with inverse probability weighting to estimate the effect of carbapenem resistance on probability of discharge alive and in-hospital death, and multistate modelling for excess length of stay in hospital. All patients were included in the analysis.

PANORAMA研究是一项多国前瞻队列研究,在孟加拉国、哥伦比亚、埃及、加纳、印度、黎巴嫩、尼泊尔、尼日利亚、巴基斯坦和越南的三级医院进行,入选连续诊断的碳青霉烯敏感(CSE)及耐药(CRE)肠杆菌科细菌血行性感染患者。我们排除了既往入选本研究的患者,以及发生血行性感染时未接受积极治疗者。入选患者没有年龄限制。印度及英国的中心实验室负责进行确证试验及分子特征研究,包括菌株分型。我们采用反概率加权进行比例次分布风险模型分析,估测碳青霉烯耐药对存活出院及住院期间死亡的影响,并采用多状态模型分析碳青霉烯耐药对住院日的影响。所有患者均纳入分析。

Findings 结果

Between Aug 1, 2014, and June 30, 2015, we recruited 297 patients from 16 sites in ten countries: 174 with CSE bloodstream infection and 123 with CRE bloodstream infection. Median age was 46 years (IQR 15–61). Crude mortality was 20% (35 of 174 patients) for patients with CSE bloodstream infection and 35% (43 of 123 patients) for patients with CRE bloodstream infection. Carbapenem resistance was associated with an increased length of hospital stay (3·7 days, 95% CI 0·3–6·9), increased probability of in-hospital mortality (adjusted subdistribution hazard ratio 1·75, 95% CI 1·04–2·94), and decreased probability of discharge alive (0·61, 0·45–0·83). Multilocus sequence typing showed various clades, with marginal overlap between strains in the CRE and CSE clades.

2014年8月1日至2015年7月30日,我们从10个国家16个中心共纳入297名患者:174名为CSE血行性感染,123名为CRE血行性感染。中位年龄为46岁(IQR 15–61)。CSE血行性感染患者粗病死率为20% (35/174),CRE血行性感染患者为35% (43/123)。碳青霉烯耐药伴随住院日延长(3·7天,95% CI 0·3–6·9),住院期间死亡概率增加(校正后次分布风险比 1·75, 95% CI 1·04–2·94),存活出院概率降低(0·61, 0·45–0·83)。多位点序列分型显示存在多个进化支,CSE和CRE菌株间仅有轻度重叠。

Interpretation 结论

Carbapenem resistance is associated with increased length of hospital stay and mortality in patients with bloodstream infections in LMICs. These data will inform global estimates of the burden of antimicrobial resistance and reinforce the need for better strategies to prevent, diagnose, and treat CRE infections in LMICs.

碳青霉烯耐药伴随LMICs的血行性感染患者住院日延长及病死率增加。这些数据为估计全球抗生素耐药负担提供资料,并且强调在LIMCs需要有更好策略预防、诊断及治疗CRE感染。

Funding 资助

bioMérieux.

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