アミカシン吸入による人工呼吸器関連肺炎の予防

アミカシン吸入による人工呼吸器関連肺炎の予防(Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia)
N Engl J Med 2023; 389:2052-2062
DOI: 10.1056/NEJMoa2310307

・3日以上挿管管理をされた患者に3日間のアミカシン吸入により28日以内のVAP罹患率が減った。(18% VS 26%)
・アミカシン群とプラセボ群でICUや入院期間、死亡率については本研究では明確な差はなかった。
・VAPは重症挿管患者の5~40%で発生し、最大死亡率は13%とされ、発症により抗菌薬使用量や挿管期間、ICU滞在期間、治療費が増加する。

 

BACKGROUND

Whether preventive inhaled antibiotics may reduce the incidence of ventilator-associated pneumonia is unclear.

METHODS

In this investigator-initiated, multicenter, double-blind, randomized, controlled, superiority trial, we assigned critically ill adults who had been undergoing invasive mechanical ventilation for at least 72 hours to receive inhaled amikacin at a dose of 20 mg per kilogram of ideal body weight once daily or to receive placebo for 3 days. The primary outcome was a first episode of ventilator-associated pneumonia during 28 days of follow-up. Safety was assessed.

RESULTS

A total of 850 patients underwent randomization, and 847 were included in the analyses (417 assigned to the amikacin group and 430 to the placebo group). All three daily nebulizations were received by 337 patients (81%) in the amikacin group and 355 patients (83%) in the placebo group. At 28 days, ventilator-associated pneumonia had developed in 62 patients (15%) in the amikacin group and in 95 patients (22%) in the placebo group (difference in restricted mean survival time to ventilator-associated pneumonia, 1.5 days; 95% confidence interval [CI], 0.6 to 2.5; P=0.004). An infection-related ventilator-associated complication occurred in 74 patients (18%) in the amikacin group and in 111 patients (26%) in the placebo group (hazard ratio, 0.66; 95% CI, 0.50 to 0.89). Trial-related serious adverse effects were seen in 7 patients (1.7%) in the amikacin group and in 4 patients (0.9%) in the placebo group.

CONCLUSIONS

Among patients who had undergone mechanical ventilation for at least 3 days, a subsequent 3-day course of inhaled amikacin reduced the burden of ventilator-associated pneumonia during 28 days of follow-up. (Funded by the French Ministry of Health; AMIKINHAL ClinicalTrials.gov number, NCT03149640. opens in new tab; EUDRA Clinical Trials number, 2016-001054-17. opens in new tab.)