Yoğun Bakım Ünitesindeki Bakteriyemik Hastalarda Antibiyotik Direncinin ve Uygunsuz Ampirik Antibiyotik Tedavisinin 3 Günlük ve 28 Günlük Mortalite Üzerine Etkisi: 5 Yıllık Retrospektif Analiz

Yıl 2022, Cilt: 24 Sayı: 2, 187 - 192, 30.08.2022

İlker Ödemiş , Tuğba Arslan Gülen

https://doi.org/10.18678/dtfd.1069393

Öz

Amaç: Bu çalışmanın amacı, kan dolaşımı enfeksiyonu tanılı hastalarda antibiyotik direnci, ampirik antibiyotik tedavisi ve komorbid hastalıkların 3 günlük ve 28 günlük mortalite üzerine etkisinin incelenmesidir.
Gereç ve Yöntemler: 1 Ocak 2015 ile 1 Ocak 2020 tarihleri arasında pozitif kan kültürü sonucu olan hastaların dosyaları geriye dönük olarak analiz edildi. Birincil sonlanım noktası 3 günlük mortalite ve ikincil sonlanım noktası 28 günlük mortalite idi.
Bulgular: Çalışmaya, 208 (%40,4) kadın ve 307 (%59,6) erkek, toplam 515 hasta dahil edildi. Hastaların ortanca yaşı 73 (aralık, 18-95) yıl idi. 233 gram pozitif bakterinin 8’inde (%3,4) vankomisin direnci saptandı. 282 gram negatif bakterinin üçüncü kuşak sefalosporin, meropenem ve kolistin direnç oranları sırasıyla %72,7 (n=205), %53,2 (n=150) ve %9,9 (n=28) bulundu. 3 günlük ve 28 günlük mortalite oranları sırasıyla %14,4 (n=74) ve %64,3 (n=331) idi. Charlson komorbidite indeks skoru (Charlson comorbidity index score, CCIS) (p=0.001) ve akut fizyoloji ve kronik sağlık değerlendirmesi (acute physiology and chronic health evaluation, APACHE) skoru (p=0,019) 3 günlük mortalite için risk faktörleri olarak saptandı. 28 günlük mortalite için yaş (p<0,001), CCIS (p<0,001), APACHE II skoru (p=0,001), kronik obstrüktif akciğer hastalığı (p=0,007), hastane kaynaklı enfeksiyon (p=0,033) ve uygunsuz antibiyotik tedavisi (p<0,001) risk faktörleri idi.
Sonuç: Antibiyotik direnci ile mortalite arasında bir ilişki yoktu, ancak uygunsuz antibiyotik tedavisinin 28 günlük mortalite riskini artırdığı saptandı. Ayrıca yüksek CCIS ve APACHE II skorları hem 3 günlük hem de 28 günlük mortalite riskini arttırdığı için, bu skorlama sistemlerinin dikkate alınmasının mortalite riskini azaltacağını düşünüyoruz.

Anahtar Kelimeler

Mortalite, sepsis, yoğun bakım, bakteriyemi, antibiyotik, direnç

The Effect of Antibiotic Resistance and Inappropriate Empirical Antibiotic Therapy on 3-Day and 28-Day Mortality in Bacteremic Patients in the Intensive Care Unit: 5-Year Retrospective Analysis

Öz

Aim: The aim of this study was to examine the effects of antibiotic resistance, empirical antibiotic therapy, and comorbid diseases on 3-day and 28-day mortality in patients with bloodstream infections.
Material and Methods: Files of the patients with positive blood cultures results, between January 1st, 2015, and January 1st, 2020 were analyzed retrospectively. The primary outcome was 3-day mortality and the secondary outcome was 28-day mortality.
Results: A total of 515 patients, 208 (40.4%) female and 307 (59.6%) male, were included in the study. The median age of the patients was 73 (range, 18-95) years. Vancomycin resistance was detected in 8 (3.4%) of 233 gram-positive bacteria. Third-generation cephalosporin, meropenem, and colistin resistance rates of the 282 gram-negative bacteria were found to be 72.7% (n=205), 53.2% (n=150), and 9.9% (n=28), respectively. The 3-day and 28-day mortality rates were 14.4% (n=74) and 64.3% (n=331), respectively. Charlson comorbidity index score (CCIS) (p=0.001) and acute physiology and chronic health evaluation (APACHE) II score (p=0.019) were found to be risk factors for 3-day mortality. Risk factors for 28-day mortality were; age (p<0.001), CCIS (p<0.001), APACHE II score (p=0.001), chronic obstructive pulmonary disease (p=0.007), hospital-acquired infection (p=0.033), and inappropriate antibiotic therapy (p<0.001).
Conclusion: There was no association between antibiotic resistance and mortality, but inappropriate antibiotic treatment was found to increase the risk of 28-day mortality. In addition, since high CCIS and APACHE II scores increase the risk of both 3-day and 28-day mortality, we think that considering these scoring systems will reduce the risk of mortality.

Anahtar Kelimeler

Mortality, sepsis, critical care, bacteraemia, antibiotic, resistance

Kaynakça

• Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global incidence and mortality of hospital-treated sepsis current estimates and limitations. Am J Respir Crit Care Med. 2016;193(3):259-72.
• Evans RN, Pike K, Rogers CA, Reynolds R, Stoddart M, Howe R, et al. Modifiable healthcare factors affecting 28-day survival in bloodstream infection: A prospective cohort study. BMC Infect Dis. 2020;20(1):545.
• Hattori H, Maeda M, Nagatomo Y, Takuma T, Niki Y, Naito Y, et al. Epidemiology and risk factors for mortality in bloodstream infections: A single-center retrospective study in Japan. Am J Infect Control. 2018;46(12):e75-9.
• Lim SJ, Choi JY, Lee SJ, Cho YJ, Jeong YY, Kim HC, et al. Intensive care unit-acquired blood stream infections: a 5-year retrospective analysis of a single tertiary care hospital in Korea. Infection. 2014;42(5):875-81.
• Yamaga S, Shime N. Association between appropriate empiric antimicrobial therapy and mortality from bloodstream infections in the intensive care unit. J Infect Chemother. 2018;24(4):267-71.
• The Organisation for Economic Co-operation and Development. Stemming the superbug tide: just a few dollars more, OECD health policy studies. Paris: OECD Publishing; 2018. doi: 10.1787/9789264307599-en.
• Versporten A, Bolokhovets G, Ghazaryan L, Abilova V, Pyshnik G, Spasojevic T, et al. Antibiotic use in Eastern Europe: A cross-national database study in coordination with the WHO Regional Office for Europe. Lancet Infect Dis. 2014;14(5):381-7.
• Wang W, Jiang T, Zhang W, Li C, Chen J, Xiang D, et al. Predictors of mortality in bloodstream infections caused by multidrug-resistant gram-negative bacteria: 4 years of collection. Am J Infect Control. 2017;45(1):59-64.
• Brooks D, Polubothu P, Young D, Booth MG, Smith A. Sepsis caused by bloodstream infection in patients in the intensive care unit: the impact of inactive empiric antimicrobial therapy on outcome. J Hosp Infect. 2018;98(4):369-74.
• American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;101(6):864-74.
• eucast.org [Internet]. European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 9.0, 2019. [Cited: 2022 July 26]. Available from: https://www.eucast.org/fileadmin/src/media/ PDFs/EUCAST_files/Breakpoint_tables/v_9.0_Breakpoint_Tables.pdf.
• Papadimitriou-Olivgeris M, Psychogiou R, Garessus J, Camaret A, Fourre N, Kanagaratnam S, et al. Predictors of mortality of bloodstream infections among internal medicine patients in a Swiss Hospital: Role of quick Sequential Organ Failure Assessment. Eur J Intern Med. 2019;65:86-92.
• Delle Rose D, Sordillo P, Gini S, Cerva C, Boros S, Rezza G, et al. Microbiologic characteristics and predictors of mortality in bloodstream infections in intensive care unit patients: A 1-year, large, prospective surveillance study in 5 Italian hospitals. Am J Infect Control. 2015;43(11):1178-83.
• Capsoni N, Bellone P, Aliberti S, Sotgiu G, Pavanello D, Visintin B, et al. Prevalence, risk factors and outcomes of patients coming from the community with sepsis due to multidrug-resistant bacteria. Multidiscip Respir Med. 2019;14:23.
• Ergönül, Aydin M, Azap A, Başaran S, Tekin S, Kaya Ş, et al. Healthcare-associated gram-negative bloodstream infections: antibiotic resistance and predictors of mortality. J Hosp Infect. 2016;94(4):381-5.
• Mitsuboshi S, Tsuruma N, Watanabe K, Takahashi S, Ito A, Nakashita M, et al. Advanced age is not a risk factor for mortality in patients with bacteremia caused by extended-spectrum β-lactamase-producing organisms: a multicenter cohort study. Jpn J Infect Dis. 2020;73(4):288-92.
• Gerver SM, Mihalkova M, Bion JF, Wilson APR, Chudasama D, Johnson AP, et al. Surveillance of bloodstream infections in intensive care units in England, May 2016-April 2017: epidemiology and ecology. J Hosp Infect. 2020;106(1):1-9.
• Vucelić V, Klobučar I, Đuras-Cuculić B, Gverić Grginić A, Prohaska-Potočnik C, Jajić I, et al. Sepsis and septic shock - an observational study of the incidence, management, and mortality predictors in a medical intensive care unit. Croat Med J. 2020;61(5):429-39.
• Schuttevaer R, Alsma J, Brink A, van Dijk W, de Steenwinkel JEM, Lingsma HF, et al. Appropriate empirical antibiotic therapy and mortality: Conflicting data explained by residual confounding. PLoS One. 2019;14(11):e0225478.
• akilciilac.gov.tr [Internet]. Republic of Türkiye Ministry of Health. Akılcı ilaç kullanımı ulusal eylem planı 2014-2017. [Cited: 2022 July 26]. Available from: http://www.akilciilac.gov.tr/wp-content/uploads /2014/11/aik-ulusal-eylem-plani.pdf.