雾化吸入氨基糖苷类抗菌药物治疗呼吸机相关性肺炎的meta分析
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摘要
目的通过meta分析研究雾化吸入氨基糖苷类抗菌药物在呼吸机相关性肺炎(ventilatorassociated pneumonia,VAP)患者中的疗效。方法计算机检索PubMed、Embase、中国知网、维普数据库和万方数据库,查找2018年5月前发表的有关雾化吸入氨基糖苷类抗菌药物治疗VAP的中英文文献,进行数据提取和质量评价后,应用RevMan 5.2软件进行meta分析。结果符合入选标准的共有9项随机对照试验,共计543例患者。meta分析结果显示:与非雾化吸入氨基糖苷类抗菌药物治疗的患者相比,雾化吸入阿米卡星可显著提高VAP患者的临床治愈率[比值比(odds ratio,OR)=2.37,95%置信区间(confidence interval,CI)=(1.50,3.75),P=0.000 2],雾化吸入妥布霉素[OR=2.30,95%CI(0.92,5.78),P=0.08]和2种及以上抗菌药物[OR=2.00,95%CI(0.62,6.46),P=0.25]对VAP患者的临床治愈率无显著影响;雾化吸入氨基糖苷类抗菌药物对VAP患者的病死率[OR=1.17,95%CI(0.66,2.07),P=0.59]、气管痉挛率[OR=2.39,95%CI(0.94,6.11),P=0.07]及肾功能损伤率[OR=0.62,95%CI(0.32,1.21),P=0.16]均无显著影响。结论雾化吸入阿米卡星可显著提高VAP患者的临床治愈率,但未能降低患者的病死率,雾化吸入氨基糖苷类抗菌药物安全性好,未增加VAP患者气管痉挛及肾功能损伤的发生风险。
Objective To evaluate the efficacy of aerosolized aminoglycoside antibiotics in patients with ventilator-associated pneumonia(VAP) by meta-analysis. Methods We searched PubMed, Embase, China National Knowledge Infrastructure, VIP and Wanfang Data for the Chinese and English literature on aerosolized aminoglycoside antibiotics for VAP until May, 2018. After data extraction and quality evaluation, RevMan 5.2 software was performed for meta-analysis. Results A total of 9 randomized controlled trials and a total of 543 patients were included in this study.Compared with patients treated with non-atomized inhaled aminoglycoside antibiotics, meta-analysis showed that aerosol inhalation of amikacin significantly improved the clinical cure rate of patients with VAP [odds ratio(OR)=2.37, 95%confidence interval(CI)(1.50, 3.75), P=0.000 2], nebulized tobramycin [OR=2.30, 95%CI(0.92, 5.78), P=0.08] and two or more antibiotics [OR=2.00, 95%CI(0.62, 6.46), P=0.25] had no significant effect on the clinical cure rate of patients with VAP; aerosolized aminoglycoside antibiotics had no significant effect on mortality of patients [OR=1.17, 95%CI(0.66,2.07), P=0.59] and tracheal spasm rate [OR=2.39, 95%CI(0.94, 6.11), P=0.07] and renal dysfunction rate [OR=0.62,95%CI(0.32, 1.21), P=0.16] in patients with VAP. Conclusion Inhalation of amikacin can significantly improve the clinical cure rate of patients with VAP, but it can not reduce the mortality rate of patients; the safety of aerosolized aminoglycoside antibiotics is good, and the risk of tracheal spasm and renal function damage in patients with VAP is not increased.
Objective To evaluate the efficacy of aerosolized aminoglycoside antibiotics in patients with ventilator-associated pneumonia(VAP) by meta-analysis. Methods We searched PubMed, Embase, China National Knowledge Infrastructure, VIP and Wanfang Data for the Chinese and English literature on aerosolized aminoglycoside antibiotics for VAP until May, 2018. After data extraction and quality evaluation, RevMan 5.2 software was performed for meta-analysis. Results A total of 9 randomized controlled trials and a total of 543 patients were included in this study.Compared with patients treated with non-atomized inhaled aminoglycoside antibiotics, meta-analysis showed that aerosol inhalation of amikacin significantly improved the clinical cure rate of patients with VAP [odds ratio(OR)=2.37, 95%confidence interval(CI)(1.50, 3.75), P=0.000 2], nebulized tobramycin [OR=2.30, 95%CI(0.92, 5.78), P=0.08] and two or more antibiotics [OR=2.00, 95%CI(0.62, 6.46), P=0.25] had no significant effect on the clinical cure rate of patients with VAP; aerosolized aminoglycoside antibiotics had no significant effect on mortality of patients [OR=1.17, 95%CI(0.66,2.07), P=0.59] and tracheal spasm rate [OR=2.39, 95%CI(0.94, 6.11), P=0.07] and renal dysfunction rate [OR=0.62,95%CI(0.32, 1.21), P=0.16] in patients with VAP. Conclusion Inhalation of amikacin can significantly improve the clinical cure rate of patients with VAP, but it can not reduce the mortality rate of patients; the safety of aerosolized aminoglycoside antibiotics is good, and the risk of tracheal spasm and renal function damage in patients with VAP is not increased.
引文
1Kalanuria AA, Ziai W, Mirski M. Ventilator-associated pneumonia in the ICU. Critical Care, 2014, 18(2):208.
2Barbier F, Andremont A, Wolff M, et al. Hospital-acquired pneumonia and ventilator-associated pneumonia:recent advances in epidemiology and management. Curr Opin Pulm Med, 2013,19(3):216-228.
3Afify MH, Shaheen EA, El-Dahdouh SS, et al. Comparison between bronchoscopic BAL and non-bronchoscopic BAL in patients with VAP. Egypt J Chest Dis Tuberc, 2016, 65(1):113-119.
4Flume PA, VanDevanter DR. Clinical applications of pulmonary delivery of antibiotics. Adv Drug Deliv Rev, 2015, 85:1-6.
5李虎,杨春辉,薛杨勇,等.雾化吸入阿米卡星治疗铜绿假单胞菌引起的呼吸机相关性肺炎的临床观察.内科急危重症杂志,2016, 22(5):335-337.
6Liu C, Zhang YT, Peng ZY, et al. Aerosolized amikacin as adjunctive therapy of ventilator-associated pneumonia caused by multidrug-resistant gram-negative bacteria:a single-center randomized controlled trial. Chin Med J(Engl), 2017, 130(10):1196-1201.
7岳新召.雾化吸入阿米卡星治疗呼吸机相关性肺炎的疗效及可行性研究.临床合理用药杂志, 2016, 9(15):38-39, 42.
8王昕华,赵弘卿.抗生素不同给药方式治疗呼吸机相关性肺炎的临床观察.中国药业, 2015, 24(23):46-48.
9李虎,杨春辉,薛杨勇,等.雾化吸入抗生素治疗呼吸机相关性肺炎的临床疗效观察.中国呼吸与危重监护杂志, 2015, 14(3):273-277.
10刘建民,郭奕芬.雾化吸入妥布霉素联合静脉使用抗生素治疗呼吸机相关性肺炎的疗效.实用临床医学, 2015, 16(9):20-21.
11Niederman MS, Chastre J, Corkery K, et al. BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with gram-negative pneumonia.Intensive Care Medicine, 2012, 38(2):263-271.
12Hallal A, Cohn SM, Namias N, et al. Aerosolized tobramycin in the treatment of ventilator-associated pneumonia:a pilot study. Surg Infect(Larchmt), 2007, 8(1):73-82.
13Le Conte P, Potel G, Clémenti E, et al. Administration of tobramycin aerosols in patients with nosocomial pneumonia:a preliminary study. Presse Médicale, 2000, 29(2):76-78.
14Kalil AC, Metersky ML, Klompas M, et al. Executive summary:management of adults with hospital-acquired and ventilatorassociated pneumonia:2016 clinical practice guidelines by the infectious diseases society of America and the American Thoracic Society. Clin Infect Dis, 2016, 63(5):575-582.
15Ekren PK, Ranzani OT, Ceccato A, et al. Evaluation of the 2016Infectious Diseases Society of America/American Thoracic Society Guideline Criteria for Risk of Multidrug-Resistant Pathogens in Patients with Hospital-acquired and Ventilator-associated Pneumonia in the ICU. Am J Respir Crit Care Med, 2018, 197(6):826-830.
16杨春辉,李虎,薛杨勇,等.雾化吸入阿米卡星气道分泌物及血药动力学特点.内科急危重症杂志, 2013, 19(3):165-167.
2Barbier F, Andremont A, Wolff M, et al. Hospital-acquired pneumonia and ventilator-associated pneumonia:recent advances in epidemiology and management. Curr Opin Pulm Med, 2013,19(3):216-228.
3Afify MH, Shaheen EA, El-Dahdouh SS, et al. Comparison between bronchoscopic BAL and non-bronchoscopic BAL in patients with VAP. Egypt J Chest Dis Tuberc, 2016, 65(1):113-119.
4Flume PA, VanDevanter DR. Clinical applications of pulmonary delivery of antibiotics. Adv Drug Deliv Rev, 2015, 85:1-6.
5李虎,杨春辉,薛杨勇,等.雾化吸入阿米卡星治疗铜绿假单胞菌引起的呼吸机相关性肺炎的临床观察.内科急危重症杂志,2016, 22(5):335-337.
6Liu C, Zhang YT, Peng ZY, et al. Aerosolized amikacin as adjunctive therapy of ventilator-associated pneumonia caused by multidrug-resistant gram-negative bacteria:a single-center randomized controlled trial. Chin Med J(Engl), 2017, 130(10):1196-1201.
7岳新召.雾化吸入阿米卡星治疗呼吸机相关性肺炎的疗效及可行性研究.临床合理用药杂志, 2016, 9(15):38-39, 42.
8王昕华,赵弘卿.抗生素不同给药方式治疗呼吸机相关性肺炎的临床观察.中国药业, 2015, 24(23):46-48.
9李虎,杨春辉,薛杨勇,等.雾化吸入抗生素治疗呼吸机相关性肺炎的临床疗效观察.中国呼吸与危重监护杂志, 2015, 14(3):273-277.
10刘建民,郭奕芬.雾化吸入妥布霉素联合静脉使用抗生素治疗呼吸机相关性肺炎的疗效.实用临床医学, 2015, 16(9):20-21.
11Niederman MS, Chastre J, Corkery K, et al. BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with gram-negative pneumonia.Intensive Care Medicine, 2012, 38(2):263-271.
12Hallal A, Cohn SM, Namias N, et al. Aerosolized tobramycin in the treatment of ventilator-associated pneumonia:a pilot study. Surg Infect(Larchmt), 2007, 8(1):73-82.
13Le Conte P, Potel G, Clémenti E, et al. Administration of tobramycin aerosols in patients with nosocomial pneumonia:a preliminary study. Presse Médicale, 2000, 29(2):76-78.
14Kalil AC, Metersky ML, Klompas M, et al. Executive summary:management of adults with hospital-acquired and ventilatorassociated pneumonia:2016 clinical practice guidelines by the infectious diseases society of America and the American Thoracic Society. Clin Infect Dis, 2016, 63(5):575-582.
15Ekren PK, Ranzani OT, Ceccato A, et al. Evaluation of the 2016Infectious Diseases Society of America/American Thoracic Society Guideline Criteria for Risk of Multidrug-Resistant Pathogens in Patients with Hospital-acquired and Ventilator-associated Pneumonia in the ICU. Am J Respir Crit Care Med, 2018, 197(6):826-830.
16杨春辉,李虎,薛杨勇,等.雾化吸入阿米卡星气道分泌物及血药动力学特点.内科急危重症杂志, 2013, 19(3):165-167.