Effect of appropriate combination therapy on mortality of patients with bloodstream infections due to carbapenemase-producing Enterobacteriaceae (INCREMENT): a retrospective cohort study.
2017年4月 Lancet Infect Dis に報告された、10カ国の26施設によるCPE血流感染患者に対しする抗菌薬併用療法の効果を検討したのレトロスペクティブ研究。
- Effect of appropriate combination therapy on mortality of patients with bloodstream infections due to carbapenemase-producing Enterobacteriaceae (INCREMENT): a retrospective cohort study.
P : patients with clinically significant monomicrobial BSIs due to CPE
E : combinationtherapy (more than one)
C : monotherapy (only one active drug)
Overall mortality was not different between those receiving combination therapy or monotherapy (47 [35%] of 135 vs 85 [41%] of 208; adjusted HR 1·63 [95% CI 0·67-3·91]; p=0·28).
However, combination therapy was associated with lower mortality than was monotherapy in the high-mortality-score stratum (30 [48%] of 63 vs 64 [62%] of 103; adjusted HR 0·56 [0·34-0·91]; p=0·02), but not in the low-mortality-score stratum (17 [24%] of 72 vs 21 [20%] of 105; adjusted odds ratio 1·21 [0·56-2·56]; p=0·62).
T : retrospective cohort study
INCREMENT-CPE mortality score
- severe sepsis or shock at presentation ( five points)
- a Pitt bacteraemia score of at least 6 (four points)
- a Charlson comorbidity index score of at least 2 (three points)
- a source of BSI other than urinary or biliary tract (three points)
- inappropriate empirical and early targeted therapy (two points; we did not consider this factor since we speci cally assessed therapy as a predictor)
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This study has limitations, including its observational nature, so that an e ect of unmeasured variables and residual confounding cannot be discarded.
Also, despite being, to our knowledge, the biggest cohort to date, the statistical power in some strata was low. We could not provide estimations of the e cacy of speci c combinations, an intrinsic problem in CPE since the scarce available options might be heterogeneous among isolates.
We did not collect information about timing of source control.
We included patients until December, 2013; therefore, subsequent changes in management should be considered.
Finally, local laboratories might have used di erent procedures despite all of them being experienced in detection of carbapenemases. Some strengths of this analysis are inclusion of patients from di erent countries, the large number of patients, inclusion of di erent Enterobacteriaceae and carbapenemases, and use of strict denitions and advanced methods in controlling for confounders.