近日，法国利摩日综合康复处的Bruno François
据悉，院外可电击心律心脏停搏的患者，接受靶向温度管理后发生呼吸机相关性肺炎的风险增加。而预防性短期抗生素治疗的益处尚未明确。
研究组进行了一项多中心、双盲、随机、安慰剂对照试验，招募重症监护病房（ICU）中的成年患者，这些患者在院外发生可电击心律的心脏停搏，对其进行32-34℃的靶向温度管理后，行机械通气。之后将患者随机分配，在心脏停搏6小时后，分别静脉注射阿莫西林-克拉维酸或安慰剂，连续治疗2天。
研究组共招募了198名患者，有194名完成试验。共有60例患者确诊呼吸机相关性肺炎，其中早期呼吸机相关性肺炎（住院前7天）51例。抗生素组的早期呼吸机相关性肺炎的发生率为19%，显著低于对照组（34%）。两组中晚期呼吸机相关性肺炎发生率、无呼吸机天数、ICU住院时间、第28天的死亡率和严重不良反应等指标均无显著性差异。治疗第7天，未发现耐药菌增加。
总之，对于初始可电击心律的院外心脏停博后接受32-34℃靶向温度管理的患者，连续2天阿莫西林-克拉维酸的抗生素疗法相较于安慰剂可明显降低早期通气相关肺炎的发生率，而其他关键临床变量则无显著差异。
附：英文原文
Title: Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest
Author: Bruno Franois, M.D.,, Alain Cariou, M.D., Ph.D.,, Raphal Clere-Jehl, M.D.,, Pierre-Franois Dequin, M.D., Ph.D.,, Franoise Renon-Carron, Pharm.D.,, Thomas Daix, M.D.,, Christophe Guitton, M.D., Ph.D.,, Nicolas Deye, M.D., Ph.D.,, Stéphane Legriel, M.D.,, Gatan 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.
Issue&Volume: 2019-11-06
Abstract:
Background
Patients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.
Methods
We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin–clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.
Results
A total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.
Conclusions
A 2-day course of antibiotic therapy with amoxicillin–clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28.
DOI: 10.1056/NEJMoa1812379
Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1812379
The New England Journal of Medicine：《新英格兰医学杂志》，创刊于1812年。隶属于美国麻省医学协会，最新IF：176.079
官方网址：http://www.nejm.org/
投稿链接：http://www.nejm.org/page/author-center/home
本期文章：《新英格兰医学杂志》：Online/在线发表
