万古霉素最低抑菌浓度较高时万古霉素敏感金黄色葡萄球菌感染患者死亡率较高

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万古霉素最低抑菌浓度较高时万古霉素敏感金黄色葡萄球菌感染患者死亡率较高
（Int J Antimicrob Agents. 2012 Dec;40(6):496-509）

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	万古霉素最低抑菌浓度较高时万古霉素敏感金黄色葡萄球菌感染患者死亡率较高（Int J Antimicrob Agents. 2012 Dec;40(6):496-509）      关键词： 万古霉素，最低抑菌浓度，万古霉素敏感金黄色葡萄球菌感染

题目：万古霉素最低抑菌浓度对万古霉素敏感的金黄色葡萄球菌感染患者临床结局的影响：一项Meta分析和Meta回归分析（Impact of vancomycin minimum inhibitory concentration on clinical outcomes of patients with vancomycin-susceptible Staphylococcus aureus infections: a meta-analysis and meta-regression）
尽管万古霉素最低抑菌浓度（VMIC）对金黄色葡萄球菌的敏感截点目前被降低到≤2 mg/L，但分离菌株在敏感菌范围内，但MIC值较高的患者临床预后较差。本文通过一项系统评价和Meta分析，比较金黄色葡萄球菌感染者分离菌株"万古霉素最低抑菌浓度较高"（惯例定义为VMIC＞1 mg/L而≤2 mg/L）和"万古霉素最低抑菌浓度较低"（VMIC≤1 mg/L）患者的临床结局（全因死亡率和治疗失败）。通过单变量Meta回归分析，评估潜在混杂的影响。共纳入33项研究（6210例患者）。大部分研究为回顾性研究（28/33），使用Etest项（22/33），涉及耐甲氧西林金黄色葡萄球菌（MRSA）感染项（26/33）和菌血症项（23/33）。不考虑万古霉素最低抑菌浓度的检测方法、甲氧西林耐药和感染部位，万古霉素最低抑菌浓度较高组比万古霉素最低抑菌浓度较低组的死亡率高（相对危险度（RR）=1.21（95% 置信区间（CI）1.03-1.43；4612例患者），治疗失败也更多（RR=1.67（1.26-2.21）；2049例患者）。结果不受潜在混杂因素的影响，并在耐甲氧西林金黄色葡萄球菌感染亚族患者中能够再现（死亡率, RR=1.19（1.02-1.40）， 2956例患者；治疗失败， RR=1.69（1.26-2.25），1793 例患者）。
总的来说，与VMIC≤1 mg/L 相比，VMIC＞1 mg/L的万古霉素敏感金黄色葡萄球菌感染与更高的死亡率相关。需要进一步的研究来验证该结果并评估万古霉素最低抑菌浓度对耐甲氧西林金黄色葡萄球菌感染的影响。选择替代的抗菌药物似乎是合理的。

  http://www.ncbi.nlm.nih.gov/pubmed/23068600  

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Int J Antimicrob Agents. 2012 Dec;40(6):496-509. doi: 10.1016/j.ijantimicag.2012.07.023. Epub 2012 Oct 12.
Impact of vancomycin minimum inhibitory concentration on clinical outcomes of patients with vancomycin-susceptible Staphylococcus aureus infections: a meta-analysis and meta-regression.
Mavros MN, Tansarli GS, Vardakas KZ, Rafailidis PI, Karageorgopoulos DE, Falagas ME.
SourceAlfa Institute of Biomedical Sciences (AIBS), Athens, Greece; Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.

Abstract
Although the vancomycin minimum inhibitory concentration (VMIC) susceptibility breakpoint for Staphylococcus aureus was recently lowered to ≤2mg/L, it is argued that isolates in the higher levels of the susceptible range may bear adverse clinical outcomes. Clinical outcomes (all-cause mortality and treatment failure) of patients with S. aureus infections by 'high-VMIC' (conventionally defined as VMIC >1mg/L but ≤2mg/L) and 'low-VMIC' (VMIC≤1mg/L) isolates were compared by performing a systematic review and meta-analysis. The effect of potential confounders was assessed by univariate meta-regression analyses. In total, 33 studies (6210 patients) were included. Most studies were retrospective (28/33), used the Etest (22/33) and referred to meticillin-resistant S. aureus (MRSA) infections (26/33) and bacteraemia (23/33). Irrespective of VMIC testing method, meticillin resistance and site of infection, the high-VMIC group had higher mortality [relative risk (RR)=1.21 (95% confidence interval 1.03-1.43); 4612 patients] and more treatment failures [RR=1.67 (1.26-2.21); 2049 patients] than the low-VMIC group. The results were not affected by the potential confounders and were reproduced in the subset of patients with MRSA infections [mortality, RR=1.19 (1.02-1.40), 2956 patients; treatment failure, RR=1.69 (1.26-2.25), 1793 patients]. In conclusion, infection by vancomycin-susceptible S. aureus with VMIC>1mg/L appears to be associated with higher mortality than VMIC≤1mg/L. Further research is warranted to verify these results and to assess the impact of VMIC on meticillin-susceptible S. aureus infections. Evaluation of alternative antimicrobial agents also appears justified.