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Analiza faktora rizika za smrtni ishod i troškova lečenja kod pacijenata na mehaničkoj ventilaciji sa pneumonijom

Analysis of predictors of mortality and treatment costs in patients with ventilator associated pneumonia

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Author
Injac, Vlada
Mentor
Janković, Slobodan
Committee members
Petrović, Marina
Radonjić, Vesela
Mikov, Momir
Jevđić, Jasna
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Abstract
Izvod: Pneumonija kod pacijenata na mehaničkoj ventilaciji (VAP) povezana je sa visokim mortalitetom. Cilj ovog rada bio je da identifikuje faktore rizika za smrtni ishod kod pacijenata sa VAP-om, da analizira uzročnike VAP-a i njihovu rezistenciju na primenjenu antibiotsku terapiju, da proceni da li postoji razlika u uzročnicima kod ranog i kasnog VAP-a i da prikaže direktne troškove lečenja VAP-a i da ih analizira u odnosu na mortalitet i adekvatnost primenjene antibiotske terapije. Retrospektivno kohortno ispitivanje bilo je sprovedeno u medicinskoj jedinici intenzivne nege (JIN) na Institutu za plućne bolesti u Sremskoj Kamenici, u periodu od 2009. do 2014. godine. Ukupno je bilo uključeno 122 pacijenta sa mikrobiološki potvrđenim VAP-om. Nezavisni faktori rizika za smrtni ishod bili su: egzacerbacija hronične opstruktivne bolesti pluća na prijemu u JIN (OR = 3,758; r = 0,040), APACHE II skor prvog dana VAP-a (OR = 1,147; r ˂ 0,001) i trećeg dana VAP-a (OR = 1,175; r ˂ 0,001); SAP...S II skor 1 dana VAP-a (OR: 1,060; r < 0,001), SOFA skor prvog dana (OR: 1,343; r = 0,001), trećeg dana (OR: 1,336; r < 0,001) i 7 dana VAP-a (OR = 1,503; r ˂ 0,001); septički šok prvog dana VAP-a (OR = 3,610; p = 0,017), akutna bubrežna insuficijencija u toku boravka u JIN (OR = 2,497; r = 0,039), kardioverzija u toku boravka u JIN (OR = 2,635; r = 0,038), neurađena traheostoma (OR = 0,178; r ˂ 0,001). Postojala je statistički značajna razlika u preživljavanju pacijenata u zavisnosti od adekvatnosti primenjene empirijske antibiotske terapije (χ2= 10,031; r < 0,001). Najčešće izolovani uzročnici bili su XDR (sojevi sa proširenom rezistencijom) Acinetobacter spp (89%). Postojao je statistički značajan porast Klebsiella pneumoniae (8,9% vs 25,6%, r = 0,013). XDR Acinetobacter spp je bio osetljiv na tigeciklin i kolistin uz statistički značajan porast rezistencije na ampicilin/sulbaktam (30,2% vs 58,6%; r = 0,012). Nije bilo statistički značajne razlike u uzročnicima ranog i kasnog VAP-a. Troškovi po danu lečenja kod umrlih pacijenata bili su statistički značajno veći u poređenju sa preživelim pacijentima sa VAP-om (412,91 ± 189,63 EU vs 235,80 ± 94,17 EU; r < 0,001). Dnevni troškovi kod pacijenata lečenih adekvatnom i neadekvatnom empirijskom antibiotskom terapijom nisu bili statistički značajno različiti.

Abstract: Ventilator-associated pneumonia (VAP) is associated with high mortality in critically ill subjects. The objective of our study was to identify predictors of mortality in subjects with VAP, to evaluate etiology and antimicrobial resistance to pathogens causing VAP, to examine whether there were differences between pathogens in early-onset and late-onset VAP and to determine direct hospital treatment costs of VAP and to analyze them in regards to mortality and equivalency of applied empirical antibiotic therapy. A retrospective cohort study was conducted in a respiratory Intensive care unit (ICU) at the Institute for Pulmonary Diseases in Sremska Kamenica between 2009 and 2014. A total of 122 subjects with microbiologically confirmed VAP were included. Independent predictors of mortality in subjects with VAP were chronic obstructive pulmonary disease (COPD) exacerbation at the admission (ОR = 3.758; P = 0.040), APACHE II score 1st day (ОR = 1.147; P ˂ 0.001) and 3rd day of VA...P (ОR = 1.175; P ˂ 0.001); SAPS II score 1st day of VAP (ОR: 1.060; P < 0.001), SOFA score 1st day (ОR: 1.343; P = 0.001), 3rd day (ОR: 1.336; P < 0.001) and 7th day of VAP (ОR = 1.503; P ˂ 0.001); septic shock 1st day of VAP (ОR = 3.610; P = 0.017), acute renal failure during hospitalization in ICU (ОR = 2.497; P = 0.039), cardioversion during hospitalization in ICU (ОR = 2.635; P = 0.038), non-performed tracheostomy (ОR = 0.178; P ˂ 0.001). There was a statistically significant difference in the survival concerning the appropriateness of the obtained empirical antibiotic therapy (chi-square = 10.031; P < 0.001). The most commonly isolated were extensively drug-resistant (XDR) strains of Acinetobacter spp (89%). There was statistically significant increase in incidence of infection with Klebsiella pneumoniae (8.9% vs 25.6%, P = 0.013). XDR Acinetobacter spp was susceptible to tigecycline and colistin with a significant increase in resistance to ampicillin/sulbactam (30.2% vs 58.6%; P = 0.012). Patients with early- and late-onset VAP have the same pathogens. Daily costs in dead patients are statistically significantly higher in comparison to surviving VAP patients (412.91±189.63 EU vs 235.80 ± 94.17 EU; P < 0.001). Daily costs in patients treated with an adequate and inadequate therapy weren’t statistically significantly different.

Faculty:
Универзитет у Крагујевцу, Факултет медицинских наука
Date:
06-07-2017
Keywords:
pneumonija / pneumonia / faktori rizika / smrtni ishod / mehanička ventilacija / troškovi lečenja / predictors of mortality / mechanical ventilation / treatment costs
[ Google Scholar ]
Handle
https://hdl.handle.net/21.15107/rcub_nardus_8526
URI
https://nardus.mpn.gov.rs/handle/123456789/8526
http://eteze.kg.ac.rs/application/showtheses?thesesId=5216
https://fedorani.ni.ac.rs/fedora/get/o:804/bdef:Content/download

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