多黏菌素B治疗碳青霉烯耐药革兰阴性杆菌脓毒症的观察性研究  

An observational study of polymyxin B in the treatment of sepsis caused by carbapenem-resistant Gram-negative bacilli

作　　者：张晓娟[1] 祁绍艳[2] 刘韶华[1] 张瑞芳[1] 段晓光[1] 王海旭[1] 朱志强[3] 冯敏[4] 邢丽华[5] 孙同文[1] Zhang Xiaojuan;Qi Shaoyan;Liu Shaohua;Zhang Ruifang;Duan Xiaoguang;Wang Haixu;Zhu Zhiqiang;Feng Min;Xing Lihua;Sun Tongwen(Department of General ICU,the First Affiliated Hospital of Zhengzhou University,Henan Key Laboratory of Critical Care Medicine,Zhengzhou Key Laboratory of Sepsis,Henan Engineering Research Center for Critical Care Medicine,Zhengzhou 450052,China;Department of ICU,the Second Affiliated Hospital of Zhengzhou University,Zhengzhou 450003,China;Department of Emergency ICU,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China;Department of Surgical ICU,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China;Department of Respiratory ICU,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China)

机构地区：[1]郑州大学第一附属医院综合ICU,河南省重症医学重点、实验室,郑州市脓毒症重点实验室,河南省重症医学工程研究中心,郑州450052 [2]郑州大学第二附属医院ICU,郑州450003 [3]郑州大学第一附属医院急诊ICU,郑州450052 [4]郑州大学第一附属医院外科ICU,郑州450052 [5]郑州大学第一附属医院呼吸ICU,郑州450052

出　　处：《中华急诊医学杂志》2020年第12期1606-1612,共7页Chinese Journal of Emergency Medicine

基　　金：中原科技创新领军人才(194200510017);河南省医学科技攻关计划省部共建项目(SBGJ2018020);河南省卫生计生科技创新型人才“51282”工程(2016-32);郑州市科技惠民计划项目(2019KJHM0001);2019年河南省卫生科技英才海外研修工程(HWYX2019008)。

摘　　要：目的探讨多黏菌素B(Polymyxin B,PMB)对碳青霉烯耐药革兰阴性杆菌(Carbapenem-resistant Organism,CRO)引起脓毒症患者的有效性及安全性;方法观察性研究2018年10月1日至2019年6月30日河南省14家医院ICU中因CRO引起的脓毒症静脉应用PMB至少7 d的患者,进行28 d随访。根据诊断标准将患者分为脓毒性休克组和非休克组,比较两组患者的临床特征、感染指标、SOFA、APACHEⅡ、病原菌分布情况、抗感染治疗情况、不良反应及预后。结果共纳入98例患者,其中脓毒性休克48例。与非休克组相比,脓毒性休克组的机械通气患者比例更高(72.92%vs 32%,P<0.05),血小板低(74.63×109/L vs 139.10×109/L,P<0.05),SOFA评分(10.04 vs 5.72,P<0.05)和APACHEⅡ评分更高(20.81 vs 14.94,P<0.05)。脓毒性休克组与非休克组抗感染治疗方案差异无统计学意义,PMB联合碳青霉烯类(27.08%vs 34%,P>0.05)、PMB联合替加环素和碳青霉烯类(29.17%vs 24%,P>0.05)常见。入组患者中16.33%的患者出现了不良反应,肾毒性7.14%,神经毒性6.12%。脓毒性休克组和非休克组的不良反应发生率差异无统计学意义(22.92%vs 10%,P>0.05)。脓毒性休克组的28 d病死率远高于非休克组(64.58%vs 18%,P<0.05),ICU病死率(18.75%vs 6%,P>0.05)和住院病死率(22.92%vs 8%,P>0.05)差异无统计学意义。对28 d病死率进行Kaplan-Meier生存曲线,脓毒性休克组的PMB治疗至死亡的平均时间短(18.73 d vs 26.7 d,P<0.001)。结论对CRO的脓毒症患者,PMB抗感染治疗安全、有效,可尽早启动PMB治疗,一旦进展为脓毒性休克,病死率高。Objective To investigate the efficacy and safety of polymyxin B(PMB)in patients with sepsis caused by carbapenem-resistant organism(CRO).Methods This observational study enrolled patients with sepsis caused by CRO and treated with intravenous PMB for at least 7 days in the ICU of 14 hospitals in Henan Province from October 1,2018 to June 30,2019.All the patients were followed up for 28 days.The patients were divided into the septic shock group and non-septic shock group according to the diagnostic criteria.The clinical characteristics,infection indexes,SOFA,APACHEⅡ,pathogen,anti-infective therapeutic regimen,adverse reactions and prognosis were compared between the two groups.Results A total of 98 patients were enrolled,including 48 patients with septic shock.Compared with the non-septic shock group,there were more proportion of patients with mechanical ventilation(72.92%vs 32%,P<0.05),thrombocytopenia(74.63×109/L vs.139.10×109/L,P<0.05),higher SOFA score(10.04 vs.5.72,P<0.05)and APACHEⅡscore(20.81 vs.14.94,P<0.05)in the septic shock group.There was no significant difference in the anti-infective treatment between the septic shock group and the non-septic shock group.PMB combined with carbapenems(27.08%vs 34%,P>0.05),PMB combined with tigecycline and carbapenems(29.17%vs 24%,P>0.05)were the most common.Adverse reactions were found in 16.33%of patients(nephrotoxicity 7.14%and neurotoxicity 6.12%).The incidence of adverse reactions were not significantly different between the septic shock group and the non-septic shock group(22.92%vs.10%,P>0.05).The 28-day mortality rate was significantly higher in the septic shock group than the non-septic shock group(64.58%vs.18%,P<0.05),but the ICU mortality(18.75%vs.6%,P>0.05)and hospital mortality(22.92%vs.8%,P>0.05)did not differ between the two groups.Kaplan-Meier curves showed that the average time from PMB treatment to death was shorter in the septic shock group(18.73 days vs.26.7 days,P<0.001).Conclusions PMB is safe and effictive,so patients with sepsis caused by C

关 键 词：多黏菌素B 碳青霉烯耐药革兰阴性杆菌感染 脓毒症 脓毒性休克 安全性 疗效 

分 类 号：R446.5[医药卫生—诊断学] R459.7[医药卫生—临床医学]