抗生素治疗与系统性皮质类固醇治疗哮喘加重住院患者结局的关系
2019/02/19
摘要
背景：虽然专业协会指南不鼓励使用经验性抗生素治疗哮喘急性发作，但美国和其他地方已经记录了高抗生素处方率。本文旨在确定抗生素治疗与哮喘住院患者和皮质类固醇激素治疗患者预后的关系。
方法：回顾性队列研究了2015年1月1日至2016年12月31日期间在美国542家急诊医院哮喘急性加重和接受全身性皮质类固醇治疗的19 811名成人的数据。早期抗生素治疗，定义为在住院的前2天开始使用至少2天的抗生素治疗。主要结果指标是住院时间。其他措施包括出院后30天内治疗失败（开始机械通气，在住院第2天后转入重症监护室，住院死亡率或哮喘再入院），住院费用和抗生素相关性腹泻。多变量调整，倾向评分匹配，倾向加权和工具变量分析用于评估抗生素治疗与结果的相关性。
结果：在19811名患者中，年龄中位数（四分位距 [IQR]）为46（34-59）岁，14389名（72.6％）为女性，8771名（44.3％）为白种人，5120（25.8％）名医疗保险是主要的健康保险形式。8788名患者开出了抗生素（44.4％）。与未接受抗生素治疗的患者相比，接受治疗的患者年龄较大（中位[IQR]年龄，48 [36-61] vs 45 [32-57]岁），白种人（48.6％对40.9％），吸烟者（ 6.6％vs 5.3％）和合并症的数量较多（例如，充血性心力衰竭，6.2％对5.8％）。接受抗生素治疗的患者住院时间明显延长（中位[IQR]，4 [3-5]对3 [2-4]天）和相似的治疗失败率（5.4％对5.8％）。在倾向评分匹配分析中，接受抗生素与住院时间延长29％（住院时间长度比例为1.29; 95％CI，1.27-1.31）和住院费用增加（中位数[IQR]成本，$4776 [$3219 - $ 7373] vs $ 3641 [$ 2346- $ 5942]）相关，但治疗失败的风险没有差异（倾向评分匹配OR，0.95; 95％CI，0.82-1.11）。多变量调整，倾向评分加权和仪器变量分析以及几种灵敏度分析得出的结果相似。
结论：抗生素治疗可能与更长的住院时间，更高的住院费用和类似的治疗失败风险相关。这些结果强调了在哮喘住院患者中减少不适当的抗生素处方的必要性。
Association of Antibiotic Treatment With Outcomes in Patients Hospitalized for an Asthma Exacerbation Treated With Systemic Corticosteroids.
Stefan MS, Shieh MS, Spitzer KA, Pekow PS, Krishnan JA, Au DH, Lindenauer PK.
Abstract
BACKGROUND:Although professional society guidelines discourage use of empirical antibiotics in the treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere. To determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids.
METHODS:Retrospective cohort study of data of 19 811 adults hospitalized for asthma exacerbation and treated with systemic corticosteroids in 542 US acute care hospitals from January 1, 2015, through December 31, 2016. Early antibiotic treatment, defined as an treatment with an antibiotic initiated during the first 2 days of hospitalization and prescribed for a minimum of 2 days. The primary outcome measure was hospital length of stay. Other measures were treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 2, in-hospital mortality, or readmission for asthma) within 30 days of discharge, hospital costs, and antibiotic-related diarrhea. Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes.
RESULTS:Of the 19 811 patients, the median (interquartile range [IQR]) age was 46 (34-59) years, 14 389 (72.6%) were women, 8771 (44.3%) were white, and Medicare was the primary form of health insurance for 5120 (25.8%). Antibiotics were prescribed for 8788 patients (44.4%). Compared with patients not treated with antibiotics, treated patients were older (median [IQR] age, 48 [36-61] vs 45 [32-57] years), more likely to be white (48.6% vs 40.9%) and smokers (6.6% vs 5.3%), and had a higher number of comorbidities (eg, congestive heart failure, 6.2% vs 5.8%). Those treated with antibiotics had a significantly longer hospital stay (median [IQR], 4 [3-5] vs 3 [2-4] days) and a similar rate of treatment failure (5.4% vs 5.8%). In propensity score-matched analysis, receipt of antibiotics was associated with a 29% longer hospital stay (length of stay ratio, 1.29; 95% CI, 1.27-1.31) and higher cost of hospitalization (median [IQR] cost, $4776 [$3219-$7373] vs $3641 [$2346-$5942]) but with no difference in the risk of treatment failure (propensity score-matched OR, 0.95; 95% CI, 0.82-1.11). Multivariable adjustment, propensity score weighting, and instrumental variable analysis as well as several sensitivity analyses yielded similar results.
CONCLUSIONS:Antibiotic therapy may be associated with a longer hospital length of stay, higher hospital cost, and similar risk of treatment failure. These results highlight the need to reduce inappropriate antibiotic prescribing among patients hospitalized for asthma.
背景：虽然专业协会指南不鼓励使用经验性抗生素治疗哮喘急性发作，但美国和其他地方已经记录了高抗生素处方率。本文旨在确定抗生素治疗与哮喘住院患者和皮质类固醇激素治疗患者预后的关系。
方法：回顾性队列研究了2015年1月1日至2016年12月31日期间在美国542家急诊医院哮喘急性加重和接受全身性皮质类固醇治疗的19 811名成人的数据。早期抗生素治疗，定义为在住院的前2天开始使用至少2天的抗生素治疗。主要结果指标是住院时间。其他措施包括出院后30天内治疗失败（开始机械通气，在住院第2天后转入重症监护室，住院死亡率或哮喘再入院），住院费用和抗生素相关性腹泻。多变量调整，倾向评分匹配，倾向加权和工具变量分析用于评估抗生素治疗与结果的相关性。
结果：在19811名患者中，年龄中位数（四分位距 [IQR]）为46（34-59）岁，14389名（72.6％）为女性，8771名（44.3％）为白种人，5120（25.8％）名医疗保险是主要的健康保险形式。8788名患者开出了抗生素（44.4％）。与未接受抗生素治疗的患者相比，接受治疗的患者年龄较大（中位[IQR]年龄，48 [36-61] vs 45 [32-57]岁），白种人（48.6％对40.9％），吸烟者（ 6.6％vs 5.3％）和合并症的数量较多（例如，充血性心力衰竭，6.2％对5.8％）。接受抗生素治疗的患者住院时间明显延长（中位[IQR]，4 [3-5]对3 [2-4]天）和相似的治疗失败率（5.4％对5.8％）。在倾向评分匹配分析中，接受抗生素与住院时间延长29％（住院时间长度比例为1.29; 95％CI，1.27-1.31）和住院费用增加（中位数[IQR]成本，$4776 [$3219 - $ 7373] vs $ 3641 [$ 2346- $ 5942]）相关，但治疗失败的风险没有差异（倾向评分匹配OR，0.95; 95％CI，0.82-1.11）。多变量调整，倾向评分加权和仪器变量分析以及几种灵敏度分析得出的结果相似。
结论：抗生素治疗可能与更长的住院时间，更高的住院费用和类似的治疗失败风险相关。这些结果强调了在哮喘住院患者中减少不适当的抗生素处方的必要性。
(中日友好医院呼吸与危重症医学科 王瑞茵 摘译 林江涛 审校)
(JAMA Intern Med. 2019 Jan 28. doi: 10.1001/jamainternmed.2018.5394. [Epub ahead of print])
(JAMA Intern Med. 2019 Jan 28. doi: 10.1001/jamainternmed.2018.5394. [Epub ahead of print])
Association of Antibiotic Treatment With Outcomes in Patients Hospitalized for an Asthma Exacerbation Treated With Systemic Corticosteroids.
Stefan MS, Shieh MS, Spitzer KA, Pekow PS, Krishnan JA, Au DH, Lindenauer PK.
Abstract
BACKGROUND:Although professional society guidelines discourage use of empirical antibiotics in the treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere. To determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids.
METHODS:Retrospective cohort study of data of 19 811 adults hospitalized for asthma exacerbation and treated with systemic corticosteroids in 542 US acute care hospitals from January 1, 2015, through December 31, 2016. Early antibiotic treatment, defined as an treatment with an antibiotic initiated during the first 2 days of hospitalization and prescribed for a minimum of 2 days. The primary outcome measure was hospital length of stay. Other measures were treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 2, in-hospital mortality, or readmission for asthma) within 30 days of discharge, hospital costs, and antibiotic-related diarrhea. Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes.
RESULTS:Of the 19 811 patients, the median (interquartile range [IQR]) age was 46 (34-59) years, 14 389 (72.6%) were women, 8771 (44.3%) were white, and Medicare was the primary form of health insurance for 5120 (25.8%). Antibiotics were prescribed for 8788 patients (44.4%). Compared with patients not treated with antibiotics, treated patients were older (median [IQR] age, 48 [36-61] vs 45 [32-57] years), more likely to be white (48.6% vs 40.9%) and smokers (6.6% vs 5.3%), and had a higher number of comorbidities (eg, congestive heart failure, 6.2% vs 5.8%). Those treated with antibiotics had a significantly longer hospital stay (median [IQR], 4 [3-5] vs 3 [2-4] days) and a similar rate of treatment failure (5.4% vs 5.8%). In propensity score-matched analysis, receipt of antibiotics was associated with a 29% longer hospital stay (length of stay ratio, 1.29; 95% CI, 1.27-1.31) and higher cost of hospitalization (median [IQR] cost, $4776 [$3219-$7373] vs $3641 [$2346-$5942]) but with no difference in the risk of treatment failure (propensity score-matched OR, 0.95; 95% CI, 0.82-1.11). Multivariable adjustment, propensity score weighting, and instrumental variable analysis as well as several sensitivity analyses yielded similar results.
CONCLUSIONS:Antibiotic therapy may be associated with a longer hospital length of stay, higher hospital cost, and similar risk of treatment failure. These results highlight the need to reduce inappropriate antibiotic prescribing among patients hospitalized for asthma.
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奥玛珠单抗对哮喘患者食物过敏的影响：一项真实世界研究
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蒸煮过的干草对患重症哮喘的马临床症状及气道免疫反应的影响
