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心脏停搏后早发性呼吸机相关性肺炎的预防
Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest


Bruno François ... 心脑血管疾病 呼吸系统疾病 • 2019.11.07

摘要


背景

在院外发生可电击复律的心脏停搏后,接受目标体温管理的患者发生呼吸机相关性肺炎的风险增加。目前尚未证明抗生素短期预防性用药的益处。

 

方法

我们开展了一项多中心、双盲、随机、安慰剂对照试验,本试验纳入在院外发生最初可电击复律的心脏停搏后,正在重症监护治疗病房(ICU)接受机械通气治疗,并且接受32~34℃目标体温管理的成人患者(>18岁)。正在接受抗生素治疗、有多药耐药细菌长期定植或处于濒死状态的患者被排除。患者发生心脏停搏后,我们于6小时内开始阿莫西林克拉维酸盐(剂量分别为1 g和200 mg)或安慰剂静脉用药,每日3次,为期2日。主要结局是早发性呼吸机相关性肺炎(住院后7日内)。独立裁定委员会对呼吸机相关性肺炎的诊断做出确认。

 

结果

共有198例患者被随机分组,194例被纳入分析。经裁定后,60例呼吸机相关性肺炎得到确认,包括51例早发性呼吸机相关性肺炎。抗生素预防组的早发性呼吸机相关性肺炎发生率低于安慰剂组(19例[19%] vs. 32例[34%];风险比,0.53;95%CI,0.31~0.92;P=0.03)。在晚发性呼吸机相关性肺炎发生率(分别为4%和5%)、不使用呼吸机的天数(21日和19日)、ICU停留时间(出院患者分别为5日和8日,死亡患者分别为7日和7日)和第28日时的死亡率(41%和37%)方面,抗生素组和对照组之间未观察到显著差异。第7日时,我们未发现耐药菌增多。两组的严重不良事件无显著差异。

 

结论

对于在院外发生最初可电击复律的心脏停搏后,接受32~34℃目标体温管理策略的患者,2日的阿莫西林克拉维酸盐抗生素疗程与安慰剂相比降低了早发性呼吸机相关性肺炎的发生率。在其他关键临床变量(如不使用呼吸机的天数和第28日时的死亡率)方面未观察到显著组间差异(由法国卫生部[French Ministry of Health]资助;ANTHARTIC在ClinicalTrials.gov注册号为NCT02186951)。





作者信息

Bruno François, M.D., Alain Cariou, M.D., Ph.D., Raphaël Clere-Jehl, M.D., Pierre-François Dequin, M.D., Ph.D., Françoise Renon-Carron, Pharm.D., Thomas Daix, M.D., Christophe Guitton, M.D., Ph.D., Nicolas Deye, M.D., Ph.D., Stéphane Legriel, M.D., Gaëtan Plantefève, M.D., Jean-Pierre Quenot, M.D., Arnaud Desachy, M.D., Toufik Kamel, M.D., Sandrine Bedon-Carte, M.D., Jean-Luc Diehl, M.D., Nicolas Chudeau, M.D., Elias Karam, M.D., Isabelle Durand-Zaleski, M.D., Ph.D., Bruno Giraudeau, Ph.D., Philippe Vignon, M.D., Ph.D., and Amélie Le Gouge, M.Sc. for the CRICS-TRIGGERSEP Network and the ANTHARTIC Study Group*
From Réanimation Polyvalente (B.F., T.D., P.V.), INSERM Centre d’Investigation Clinique (CIC) 1435 (B.F., T.D., P.V.), and Unité des Essais Cliniques, Pharmacie à Usage Intérieur (F.R.-C.), Centre Hospitalier Universitaire (CHU) Dupuytren, and INSERM Unité Mixte de Recherche (UMR) 1092, Faculté de Médecine, Université de Limoges (B.F., T.D., P.V.), Limoges, Médecine Intensive et Réanimation, Hôpitaux Universitaires Paris Centre (site Cochin), Assistance Publique–Hôpitaux de Paris (AP-HP) (A.C.), Université Paris Descartes (A.C.), Réanimation Médicale, CHU Lariboisière, AP-HP (N.D.), INSERM UMR S942, Université Paris Diderot (N.D.), Réanimation Médicale, Hôpital Européen Georges-Pompidou, AP-HP (J.-L.D.), INSERM UMR S1140, Université Paris Descartes (J.-L.D.), and AP-HP, Unité de Recherche Clinique en Économie de la Santé d’Ile de France and Hôpital Henri Mondor (I.D.-Z.), Paris, Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg (R.C.-J.), Médecine Intensive–Réanimation (P.-F.D.) and INSERM Unité 1100 (P.-F.D.), CHU Bretonneau, and INSERM CIC 1415, CHU de Tours (B.G., A.L.G.), Tours, Médecine Intensive et Réanimation, CHU de Nantes, and Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes (C.G.), Réanimation Médico-chirurgicale, Centre Hospitalier du Mans, Le Mans (C.G., N.C.), Réanimation Médico-chirurgicale, Centre Hospitalier André Mignot, Versailles (S.L.), Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil (G.P.), Médecine Intensive et Réanimation, CHU François Mitterrand, Lipness Team, Centre de Recherche INSERM Lipides, Nutrition, Cancer–UMR 1231, and INSERM CIC 1432, Epidémiologie Clinique, Université de Bourgogne, Dijon (J.-P.Q.), Réanimation Polyvalente, Centre Hospitalier d’Angoulême, Angoulême (A.D.), Médecine Intensive et Réanimation, Centre Hospitalier Régional d’Orléans, Orléans (T.K.), Réanimation Polyvalente, Centre Hospitalier de Périgueux, Périgueux (S.B.-C.), and Réanimation Polyvalente, Centre Hospitalier, Brive la Gaillarde (E.K.) — all in France. Address reprint requests to Dr. François at Réanimation Polyvalente, CHU de Limoges, 2 Ave. Martin Luther King, 87042 Limoges, CEDEX, France, or at b.francois@unilim.fr. *A list of investigators in the ANTHARTIC Study Group is provided in the Supplementary Appendix, available at NEJM.org.

 

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