| Summary: | 碩士 === 高雄醫學大學 === 藥學系臨床藥學碩士班 === 104 === Background:
Pneumonia is a leading cause of death in intensive care unit. Proper use of antibiotic to cover multiple drug resistant (MDR) pathogens is essential in reducing mortality in these critically ill patients. The classification of pneumonia in the IDSA guideline attempts to predict infection with MDR pathogen, but the precise of such prediction is unclear. Many scoring tools have been developed to predict MDR for patients with pneumonia. However none of them have been validated in Taiwan population as well as focusing on patients in the medical intensive care unit (MICU), who could have the higher mortality than patients in general wards.
Aims:
The object of this study was to identify the risk factors for multiple-drug resistant (MDR) aand to develop a new scoring tool for MICU patients with pneumonia in Taiwan.
Methods:
We conducted a retrospective cohort study on patients admitted to the MICU of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH) with pneumonia diagnosis between January 2012 and October 2013. Patient before admission and during this admission was collected from data base of KMUH and medical record review. Stepwise logistic regression and repeated random sub-sampling validation were used to identify the important independent risk factors. To create an easy to use scoring tool, we adapted coefficient-based scoring method to give each predictor an integer point score according to the association between independent risk factors and pneumonia with MDR pathogens. Finally, we calculated the total risk score by adding the individual scores for each predictor together and used receiver operating characteristic (ROC) curve analysis to assess the accuracy of this new scoring tool.
Result:
During the study period, about 300 episodes of pneumonia with positive culture were analyzed. The first three common pathogen were Klebsiella pneumonia (19.3%), Pseudomonas aeruginosa (16.3%) and Acinetobacter baumannii (10.7%). There were 95 pneumonia episode (31.7%) infected by multiple drug resistant (MDR) pathogen. The first four common pathogen with MDR were A. baumannii, of which MDR rate was 75.0%, followed by Stenotrophomonas maltophilia (33.3%), Staphylococcus aureus (38.1%) and P. aeruginosa (36.7%). In the logistic regression, patients from long term care (LTC) centers (OR=3.764, 95%CI=2.165-6.544, p<.0001), hospitalization for 25 days or more during the preceding 90 days (OR=2.768, 95%CI=1.382-5.545, p=0.0041) and patients with long term ventilator (OR=2.81, 95%CI=1.223-6.458, p=0.015) were independent risk factors. In the repeated random sub-sampling validation, these three were still the most important risk factors, which were selected 985(98.5%), 508(50.8%) and 558(55.8%) times as significant variable ,respectively, in training group and were selected 788(80.0%), 61(12.0%) and 33(5.9%) times individually in validation group. The relative importance of those risk factors were 78.8%, 6.1% and 3.3% ,respectively, and the odds ratio in the final model is 3.49 (95%CI=1.897-6.416, p<.0001), 2.47 (95%CI=1.141-5.364, p=0.0218) and 3.38 (95%CI=1.334-8.541, p=0.0102) individually. According to the association between independent risk factors and MDR pathogen, risk score of those three independent risk factors were all assigned 1 point and after calculated the total risk score by adding the individual scores, we found prevalence of MDR of the episodes with score of 0, 1 and 2 were 16.6%, 50.0%, 66.7% respectively. The AUC (area of under curve) of this scoring tool was 0.7117 (95%CI=0.6539-0.7694).
Conclusion:
This single center, retrospective, observational study identified the important risk factors of pneumonia with MDR pathogens in MICU patients. A new scoring tool was develped. The scoring system contains LTC, hospitalization for 25 days or more during the preceding 90 days and long term ventilator. This simple and feasible prediction tool can be used to facilitate appropriate selection of initial antibiotic treatment for patient with pneumonia in MICU.
|
|---|
