万古霉素敏感性程度并不能准确预测MRSA死亡风险
2012-06-16 23:31:49 来源：
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Among patients with methicillin-resistant Staphylococcus aureus(MRSA) bacteremia, vancomycin susceptibility is not as significant a factor inpredicting risk for death as are advanced age, living in a nursing home,severity of bacteremia, and impaired organ function.
甲氧西林抗性金黄色葡萄球菌(MRSA)菌血症患者中，万古霉素敏感性并非如高龄、居住在养老院、菌血症的严重程度以及器官功能受损等作为重要因素预测死亡危险。
In the current study, published online June 13 in Emerging Infectious Diseases,Mina Pastagia, MD, from the Rockefeller University, New York, New York, andcolleagues, retrospectively examined data from 699 episodes of MRSA bacteremiainvolving 603 patients. The researchers found that the 90-day all-causemortality rate was 31.5% for the 603 patients and that the MRSA strain type wasnot associated with risk for death.
现在发表于6月13日的《新兴传染病（EmergingInfectious Diseases）》网络版上的一项研究中，位于纽约州纽约市洛克菲勒大学的MinaPastagia医学博士及其同事，回顾性研究了603例患者的699份MRSA菌血病发作资料。研究人员发现，603例患者的90日全因死亡率为31.5%，MRSA菌株类型与死亡风险无关。
Residence in a nursing home, older age, severe bacteremia, andorgan dysfunction (such as cirrhosis or renal impairment) were independentlyassociated with an increased risk for death, and each factor increased the riskfor death by 4% to 15%. Consultation with an infectious disease specialist, onthe other hand, decreased the risk for death by 11%. The researchers also foundthat patients with diabetes mellitus actually had a lower risk for death.
居住于养老院、高龄、严重菌血症以及器官功能障碍（如肝硬化或肾功能损伤）与死亡风险增加独立性相关，各因素增加死亡风险4%至15%。另一方面，与传染疾病专家会诊可降低死亡风险11%。研究人员同时发现糖尿病患者实际死亡风险更低一些。
"The idealized model for the treatment of patients with infectiousdiseases incorporates the triad of host, organism, and drug. Organisms anddrugs are more easily classified and hence more accessible for systematicstudy," write Dr. Pastagia and colleagues. "Our study of the 5-yearexperience with MRSA infections in adults at a major New York City medicalcenter illustrates why such a dyadic approach might be insufficient."
“治疗传染疾病患者的理想化模型包括宿主、病原生物和药物三要素。病原生物和药物更易分类，因而更便于进行系统性研究，” Pastagia博士及其同事写道。“我们5年来对纽约市主要医疗中心成人感染MRSA进行的研究经验表明，该二元途径可能存在不足。”
Assessing Risk Beyond the MIC
风险评估远不止最低抑菌浓度（MIC）
Patients included in the analysis were admitted between 2002 and2007 to an academic medical center in New York City. Researchers compareddemographic and clinical characteristics of adult patients with MRSAbacteremia, which included concurrent illnesses, place of residence beforehospitalization (facility vs community), the severity of bacteremia, and previoushealthcare exposures.
该分析中的患者于2002年至2007年入院至纽约市一家学术医学中心。研究人员对MRSA菌血症成人患者的人口统计学和临床特征进行了对比，包括并发疾病、入院前居住场所（设施vs社区）、菌血症严重程度以及既往治疗接触史。
MRSA infections were classified as vancomycin susceptible, vancomycinintermediate S aureus (VISA), or heteroresistant vancomycin intermediate Saureus (hVISA). The vancomycin minimum inhibitory concentrations (MICs) were 2μg/mL or less for all isolates, and some isolates were sent to an outsidelaboratory for blinded testing and retesting. No discrepancies were notedbetween in-house and outside testing.
MRSA感染被分为万古霉素敏感型、万古霉素中度金黄色葡萄球菌(VISA)或异种抗性万古霉素中度金黄色葡萄球菌(hVISA)。对于所有分离菌株，万古霉素最低抑菌浓度（MIC）为2 μg/mL或更低，某些分离菌株被送往外部其他实验室进行盲法检测与复测。内部与外部检测之间未发现差异。
The researchers found that patients with VISA were more likely to have had arecent vancomycin exposure (62%; 95% confidence interval [CI], 47.7% - 65.3%)than patients with hVISA (42%; 95% CI, 29.4% - 59%) or other MRSA strains (47%;95% CI, 41.3% - 49.7%).
研究人员发现VISA患者更可能有过近期万古霉素接触(62%;95% 置信区间[CI], 47.7% - 65.3%)，这比hVISA (42%; 95% CI, 29.4% - 59%) 或其他 MRSA 菌株患者 (47%;95% CI, 41.3% - 49.7%)可能性更高。
The researchers found that in a subanalysis of vancomycin MICsamong patients who died in the hospital, the mean MIC was 1.7 μg/mL; thecurrent breakpoint for vancomycin susceptibility is 2 μg/mL. This findingsupports findings from several other studies that vancomycin MIC is not anaccurate predictor of death.
研究人员发现，对院内死亡患者万古霉素MIC次级分析中，平均MIC为1.7μg/mL;当前万古霉素敏感性断点为2μg/mL。该发现支持了数项其他研究的发现，即万古霉素MIC并非引起死亡的确切预测指标。
"Our findings can help clinicians estimate the risk that a patient withMRSA bacteremia will die. For example, an elderly patient with liver cirrhosisand MRSA bacteremia who lived in a nursing home before hospital admission wouldhave an extremely poor prognosis. Conversely, an otherwise healthy patient withdiabetes mellitus might have a better prognosis that could be improved evenmore by consultation with an infectious disease specialist," the studyauthors write.
“我们的发现可以帮助意识估计MRSA菌血症患者的死亡风险。比如，一位年老、入院前居住于养老院的肝硬化与MRSA菌血症患者，其预后会非常糟糕。相反的是，一位除糖尿病其他方面健康的患者可能会有一个较好的预后，而且如果与一位传染疾病专家会诊后，其预后会提高更多。”该研究作者写道。
Study limitations include the retrospective design, focus on a single academicinstitution, and derivation of MICs from microdilution.
研究局限性包括回顾性设计、关注点仅限于一家学术机构以及MIC微量稀释引起的偏差。
Individualized Treatment Is Key
个体化治疗是关键
In an interview with Medscape Medical News, William R. Jarvis, MD, from Jasonand Jarvis Associates, an infectious disease consulting firm, said, "Thisstudy shows that vancomycin susceptibility is not a significant factor whenappropriate antimicrobials are used for treatment. [The] study emphasizes theimportance of underlying diseases and shows that we should be individualizingthe treatment of patients depending upon their age and underlyingdiseases."
在医景医疗新闻（MedscapeMedical News）的一次采访中，一家传染疾病顾问公司Jason与Jarvis联合公司的WilliamR. Jarvis医学博士说，“该研究表明，治疗采用适当抗微生物措施的情况下，万古霉素敏感性并不是一个重要因素。该研究突出了潜在疾病的重要性，也表明我们应该根据年龄及潜在疾病对患者进行个体化治疗。”
"This study again documents that healthcare-associated MRSA infections area major cause of morbidity and mortality. This may lead to the more rapidassessment and implementation of appropriate therapy for patients with MRSA[bloodstream infections] and to lead to individualization of treatment forthose with specific underlying conditions, particularly renal and liverdisease," said Dr. Jarvis.
“该研究再一次证明，与健康相关的MRSA感染是发病率与死亡率的主要元凶。这可引入于更快速的评估方法以及实现对MRSA患者[血液感染]合适的疗法，并可以引入对特定潜在疾病，尤其是肾脏和肝脏疾病的患者的个体化治疗。” Jarvis博士说。
甲氧西林抗性金黄色葡萄球菌(MRSA)菌血症患者中，万古霉素敏感性并非如高龄、居住在养老院、菌血症的严重程度以及器官功能受损等作为重要因素预测死亡危险。
In the current study, published online June 13 in Emerging Infectious Diseases,Mina Pastagia, MD, from the Rockefeller University, New York, New York, andcolleagues, retrospectively examined data from 699 episodes of MRSA bacteremiainvolving 603 patients. The researchers found that the 90-day all-causemortality rate was 31.5% for the 603 patients and that the MRSA strain type wasnot associated with risk for death.
现在发表于6月13日的《新兴传染病（EmergingInfectious Diseases）》网络版上的一项研究中，位于纽约州纽约市洛克菲勒大学的MinaPastagia医学博士及其同事，回顾性研究了603例患者的699份MRSA菌血病发作资料。研究人员发现，603例患者的90日全因死亡率为31.5%，MRSA菌株类型与死亡风险无关。
Residence in a nursing home, older age, severe bacteremia, andorgan dysfunction (such as cirrhosis or renal impairment) were independentlyassociated with an increased risk for death, and each factor increased the riskfor death by 4% to 15%. Consultation with an infectious disease specialist, onthe other hand, decreased the risk for death by 11%. The researchers also foundthat patients with diabetes mellitus actually had a lower risk for death.
居住于养老院、高龄、严重菌血症以及器官功能障碍（如肝硬化或肾功能损伤）与死亡风险增加独立性相关，各因素增加死亡风险4%至15%。另一方面，与传染疾病专家会诊可降低死亡风险11%。研究人员同时发现糖尿病患者实际死亡风险更低一些。
"The idealized model for the treatment of patients with infectiousdiseases incorporates the triad of host, organism, and drug. Organisms anddrugs are more easily classified and hence more accessible for systematicstudy," write Dr. Pastagia and colleagues. "Our study of the 5-yearexperience with MRSA infections in adults at a major New York City medicalcenter illustrates why such a dyadic approach might be insufficient."
“治疗传染疾病患者的理想化模型包括宿主、病原生物和药物三要素。病原生物和药物更易分类，因而更便于进行系统性研究，” Pastagia博士及其同事写道。“我们5年来对纽约市主要医疗中心成人感染MRSA进行的研究经验表明，该二元途径可能存在不足。”
Assessing Risk Beyond the MIC
风险评估远不止最低抑菌浓度（MIC）
Patients included in the analysis were admitted between 2002 and2007 to an academic medical center in New York City. Researchers compareddemographic and clinical characteristics of adult patients with MRSAbacteremia, which included concurrent illnesses, place of residence beforehospitalization (facility vs community), the severity of bacteremia, and previoushealthcare exposures.
该分析中的患者于2002年至2007年入院至纽约市一家学术医学中心。研究人员对MRSA菌血症成人患者的人口统计学和临床特征进行了对比，包括并发疾病、入院前居住场所（设施vs社区）、菌血症严重程度以及既往治疗接触史。
MRSA infections were classified as vancomycin susceptible, vancomycinintermediate S aureus (VISA), or heteroresistant vancomycin intermediate Saureus (hVISA). The vancomycin minimum inhibitory concentrations (MICs) were 2μg/mL or less for all isolates, and some isolates were sent to an outsidelaboratory for blinded testing and retesting. No discrepancies were notedbetween in-house and outside testing.
MRSA感染被分为万古霉素敏感型、万古霉素中度金黄色葡萄球菌(VISA)或异种抗性万古霉素中度金黄色葡萄球菌(hVISA)。对于所有分离菌株，万古霉素最低抑菌浓度（MIC）为2 μg/mL或更低，某些分离菌株被送往外部其他实验室进行盲法检测与复测。内部与外部检测之间未发现差异。
The researchers found that patients with VISA were more likely to have had arecent vancomycin exposure (62%; 95% confidence interval [CI], 47.7% - 65.3%)than patients with hVISA (42%; 95% CI, 29.4% - 59%) or other MRSA strains (47%;95% CI, 41.3% - 49.7%).
研究人员发现VISA患者更可能有过近期万古霉素接触(62%;95% 置信区间[CI], 47.7% - 65.3%)，这比hVISA (42%; 95% CI, 29.4% - 59%) 或其他 MRSA 菌株患者 (47%;95% CI, 41.3% - 49.7%)可能性更高。
The researchers found that in a subanalysis of vancomycin MICsamong patients who died in the hospital, the mean MIC was 1.7 μg/mL; thecurrent breakpoint for vancomycin susceptibility is 2 μg/mL. This findingsupports findings from several other studies that vancomycin MIC is not anaccurate predictor of death.
研究人员发现，对院内死亡患者万古霉素MIC次级分析中，平均MIC为1.7μg/mL;当前万古霉素敏感性断点为2μg/mL。该发现支持了数项其他研究的发现，即万古霉素MIC并非引起死亡的确切预测指标。
"Our findings can help clinicians estimate the risk that a patient withMRSA bacteremia will die. For example, an elderly patient with liver cirrhosisand MRSA bacteremia who lived in a nursing home before hospital admission wouldhave an extremely poor prognosis. Conversely, an otherwise healthy patient withdiabetes mellitus might have a better prognosis that could be improved evenmore by consultation with an infectious disease specialist," the studyauthors write.
“我们的发现可以帮助意识估计MRSA菌血症患者的死亡风险。比如，一位年老、入院前居住于养老院的肝硬化与MRSA菌血症患者，其预后会非常糟糕。相反的是，一位除糖尿病其他方面健康的患者可能会有一个较好的预后，而且如果与一位传染疾病专家会诊后，其预后会提高更多。”该研究作者写道。
Study limitations include the retrospective design, focus on a single academicinstitution, and derivation of MICs from microdilution.
研究局限性包括回顾性设计、关注点仅限于一家学术机构以及MIC微量稀释引起的偏差。
Individualized Treatment Is Key
个体化治疗是关键
In an interview with Medscape Medical News, William R. Jarvis, MD, from Jasonand Jarvis Associates, an infectious disease consulting firm, said, "Thisstudy shows that vancomycin susceptibility is not a significant factor whenappropriate antimicrobials are used for treatment. [The] study emphasizes theimportance of underlying diseases and shows that we should be individualizingthe treatment of patients depending upon their age and underlyingdiseases."
在医景医疗新闻（MedscapeMedical News）的一次采访中，一家传染疾病顾问公司Jason与Jarvis联合公司的WilliamR. Jarvis医学博士说，“该研究表明，治疗采用适当抗微生物措施的情况下，万古霉素敏感性并不是一个重要因素。该研究突出了潜在疾病的重要性，也表明我们应该根据年龄及潜在疾病对患者进行个体化治疗。”
"This study again documents that healthcare-associated MRSA infections area major cause of morbidity and mortality. This may lead to the more rapidassessment and implementation of appropriate therapy for patients with MRSA[bloodstream infections] and to lead to individualization of treatment forthose with specific underlying conditions, particularly renal and liverdisease," said Dr. Jarvis.
“该研究再一次证明，与健康相关的MRSA感染是发病率与死亡率的主要元凶。这可引入于更快速的评估方法以及实现对MRSA患者[血液感染]合适的疗法，并可以引入对特定潜在疾病，尤其是肾脏和肝脏疾病的患者的个体化治疗。” Jarvis博士说。
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