外科重症监护室中限制性使用三代头孢菌素的临床研究

 目的 分析外科重症监护室（surgical intensive care unit，SICU）中限制性使用三代头孢菌素的临床疗效。方法 回顾性对照研究门收集复旦大学附属中山医院SICU自2004年4月至2005年3月（Ⅱ组-对照组）和2005年4月至2006年3月（Ⅰ组-干预组）收治的患者，对Ⅱ组实施限制性使用三代头孢菌素策略。比较两组SICU中临床诊断为肺部感染患者的痰培养结果，了解该策略对革兰阴性杆菌、革兰阳性球菌、真菌检出率的影响；对照两组间治疗性抗革兰阳性球菌和抗真菌药物的累计使用数量；统计两组总体死亡率和感染相关死亡率。结果 两组的一般情况，包括患者的性别构成、平均年龄、APACHEⅡ评分、以及SICU治疗时间方面均无统计学差异。两组中肺部感染患者痰标本中革兰阴性多重耐药菌的检出率分别为23.1%和20.2%（P = 0.192）；耐甲氧西林的金黄色葡萄球菌（methicillin-resistant staphylococcus aureus，MRSA）的检出率分别为24.8%和15.9%（P = 0.000）；真菌的检出率分别为10.0%和4.8%（P = 0.000）；治疗性抗革兰阳性球菌及抗真菌药物用量明显降低；Ⅱ组中患者的感染相关病死率显著低于Ⅰ组。结论 SICU中限制性使用三代头孢菌素策略未能显著降低肺部感染患者多重耐药革兰阴性杆菌在痰标本中的检出率，但有助于减少MRSA和真菌引起的感染，降低临床感染相关病死率，改善预后。

Clinical study of strategic restriction of third-generation cephalosporin usage in surgical intensive care unit

Objective To analyze the clinical outcome of restriction of third-generation cephalosporin in surgical intensive care unit(SICU). Methods A retrospective before-after comparative study. All patients were from SICU of Shanghai Zhongshan Hospital, Fudan university. GcroupⅠ (control group) admitted from April 1^st, 2004 to March 31^st, 2005. Group Ⅱ (intervention group) admitted from April 1^st, 2005 to March 31^st, 2006, during which strategic restriction of third-generation cephalosporin was implemented. We compared the sputum culture results of patients clinically diagnosed with pulmonary infection in two groups to judge whether the strategy had effect on the detection rate of gram negative bacilli (GNB), gram positive coccus (GYC) and fungi. We analyzed the amount of therapeutic anti-GYC agents and anti-fungal agents in two groups，and compared the overall mortality and infection-related mortality between two groups. Results There were no significant differences between the patients of two groups in terms of gender, age, APACHE Ⅱ score or length of ICU stay. The detection rate of multiply-drug resistant gram negative bacilli (MDR-GNB) in sputum collected from patients clinically diagnosed of pulmonary infection of group Ⅰ and group Ⅱ was 23.1% and 20.2% (P = 0.192). The detection rate of MRSA in two groups was 24.8% and 15.9% (P = 0.000) and the detection rate of fungi in two groups was 10.0% and 4.8% (P = 0.000). The amount of therapeutic anti-GYC agents and anti-fungal agents was significantly decreased in group Ⅱ than in group Ⅰ. The infection-related mortality was significantly lower in group Ⅱ than in group Ⅰ. Conclusions Strategic restriction of third generation cephalosporin in SICU has no significant influence on the detection rate of MDR-GNB in sputum collected from patients suffered from pulmonary infection. But it can help to decrease the infection of MRSl1 and fungi，and reduce infection-related mortality and improve clinical outcome.