中臺灣某區域教學醫院菌血症抗生素降階治療的成效分析

Clinical Efficacy of De-escalation Therapy Versus Continuing Empirical Antibiotic Therapy in Patients with Bacteremia: An Analysis at a Regional Hospital in Central Taiwan

抗生素的選擇對於菌血症的治療成功率是關鍵的要素，在菌血症發生當下，經驗性抗生素選擇一般會以廣效性為原則，之後再根據細菌培養報告作調整。降階療法在抗生素管理計劃是被推薦的介入措施，但降階抗生素的治療，是否會影響病人的存活率，目前仍未定論。本研究的目的在於分析菌血症之病人，使用廣效性抗生素治療整個療程或者在檢驗報告出來對較窄效的抗生素有效時，降階抗生素，分析降階與未降階病人的存活率是否有差異。我們收錄了2019年1月到2021年3月間共119位發生菌血症的住院病人，59位執行降階治療、60位未降階，分析顯示未降階組有較多的重度患者（p = 0.006），同時有較低的七天及三十天存活率（p = 0.054 及 p = 0.003）。但在次族群分析中，在原發性菌血症、泌尿道感染及肺部感染引起之繼發性菌血症之病人，疾病嚴重度皆無統計學上的差異，降階治療對於病人七天及三十天存活率皆無統計學上差異。據此，臨床醫師針對此種情況，在周全性考量病人情況下，可以更有信心執行降階療法。

The optimal selection of antibiotics is key to the successful management of bacteremia. The principle of managing bacteremia involves the early administration of broad-spectrum empirical antibiotics followed by the de-escalation of antibiotics based on drug susceptibility test results. Despite the recommendation of de-escalation therapy by the antibiotic stewardship program (ASP), the patient survival rate in bacteremia cases upon changing the antibiotic to a narrow-spectrum antibiotic regimen remains uncertain. This study aimed to determine whether de-escalation therapy or continuing broad-spectrum empirical antibiotic therapy affects the survival rate of patients with bacteremia. We enrolled 119 patients who were admitted with bacteremia between January 2019 and March 2021. Of them, 59 underwent de-escalation therapy, while 60 continued broad-spectrum empirical antibiotic therapy. De-escalation did not increase short- or long-term mortality rates compared with non-de-escalation in cases of urosepsis, primary bacteremia, and bacteremia secondary to pneumonia. Therefore, physicians can more confidently provide de-escalation therapy in such cases upon performing a comprehensive assessment.