【Cochrane简语概要】 成人重症监护患者医院获得性肺炎的短程与长疗程抗生素治疗

系统综述问题 

我们回顾了随机对照试验（RCT）的证据，该证据比较了短疗程抗生素和长疗程抗生素对医院获得性肺炎（HAP）重症监护患者的疗效。

背景 

医院获得性肺炎是重症监护病房（ICU）中发生院内感染的主要原因。有许多因素使危重症患者更有可能发展为肺炎，其中最重要的因素是气管插管配合机械通气操作；因此，大多数合并HAP的ICU患者患有呼吸机相关性肺炎（VAP）。

有人担心不必要的长期抗生素治疗可能会导致患者获得耐抗生素生物，当它们引起感染时可能更难以识别和治疗，并可能增加药物成本。另一方面，疗程太短又有治疗失败的风险。

（图片来源于网络）

研究特征 

证据截至2015年6月。我们确定了6项RCTs，涉及1088例患者。这些研究采用了截然不同的调查方法，我们发现只有一项研究探讨了患HAP但未进行机械通气的ICU患者的抗生素治疗时间。

主要结果 

对于VAP患者，我们的主要发现是，与10~15天的疗程相比，使用7或8天抗生素疗法可使抗生素使用量总体下降，并可减少由耐药菌引起的肺炎复发。此外，这对死亡率没有任何显着影响。然而，如果VAP是由于某种特定类型的微生物（“非发酵性革兰阴性杆菌”）导致的，这种微生物可能难以用抗生素根除，那么在短期治疗后，肺炎复发的风险似乎更高。

一项研究发现，对于可能发生（但可能性很小）HAP的患者，短期（三天）疗程似乎与获得耐药菌或因耐药菌引起的继发性感染机会降低有关。

证据质量 

主要结局指标的证据质量低到中等。质量不高的主要原因是，仅找到了少数研究，而且在患者群体、研究之间干预的性质以及所报告的结局均存在差异。

结论: 

基于少量研究并意识到缺乏统一的肺炎定义，我们得出结论，对于不是由NF-GNB引起的VAP患者，与延长疗程（10到15天）相比，一个短期、固定的疗程（七或八天）似乎不会增加不利临床后果的风险，并可能减少耐药生物的出现。然而，对于由NF-GNB导致的VAP患者，短程治疗后似乎有更高的复发风险。这些发现与我们先前的综述并无不同，并且与当前的指南基本一致。很少有RCT的数据比较未通气HAP患者的治疗时长，但仅根据一项研究，短期（3天）HAP治疗似乎与较差的临床结局无关，而且根据CPIS，当发生肺炎的可能性较低时，还可能降低继发性感染或耐药生物出现的风险。

译者：裴旭燕，重庆医科大学公共卫生与管理学院循证医学中心；审校：刘琴，重庆医科大学公共卫生与管理学院循证医学中心；编辑排版：张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】Short-course versus long-course antibiotic treatment for hospital-acquired pneumonia in adult intensive care patients

Review question 

We reviewed the evidence from randomised controlled trials (RCTs) that compared the effects of a short course of antibiotics with a long course for intensive care patients with hospital-acquired pneumonia (HAP).

Background 

Hospital-acquired pneumonia is the major cause of hospital-acquired infection in the intensive care unit (ICU). There are a number of factors that make the critically ill more likely to develop pneumonia, among which the most important is tracheal intubation performed in conjunction with mechanical ventilation; thus, the majority of ICU patients with HAP have what is termed ventilator-associated pneumonia (VAP).

There is concern that an unnecessarily long course of antibiotic therapy may lead to patients acquiring antibiotic-resistant organisms, which may be more difficult to recognise and treat when they cause infection and may increase drug costs. On the other hand, too short a course risks the treatment failing.

Study characteristics 

The evidence was current as of June 2015. We identified six RCTs, which had enrolled 1088 patients. The studies took quite different approaches to their investigations, and we found only one study that had explored the duration of antibiotic therapy for ICU patients who had HAP, but were not mechanically ventilated.

Key results 

For patients with VAP, our main finding was that a course of seven or eight days of antibiotics was associated with an overall decrease in antibiotic administration and reduced the recurrence of pneumonia due to resistant organisms when compared with a 10- to 15-day course. Furthermore, this was achieved without any significant effect on mortality. Nevertheless, in cases when VAP was due to a particular type of organism ('non-fermenting Gram-negative bacillus'), which can be difficult to eradicate with antibiotics, the risk of pneumonia recurring appeared higher after a short course of treatment.

One study found that for patients with possible (but low probability) HAP a short (three-day) course of therapy seemed to be associated with a lower chance of acquiring resistant organisms or of subsequent infections being due to a resistant organism.

Quality of evidence 

The quality of evidence for the main outcome measures was low to moderate. The main reasons that the quality was not high were that only a small number of studies were identified, and that there were differences in patient populations, in the nature of the interventions between studies and in the reported outcomes.

Authors' conclusions: 

On the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.

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