Антибактериальная терапия при сепсисе с диссеминированным внутрисосудистым свертыванием: аналитический обзор

Сепсис остаётся одной из ведущих причин летальности в отделениях интенсивной терапии, а его течение часто осложняется сепсис-индуцированной коагулопатией и диссеминированным внутрисосудистым свёртыванием, значимо ухудшающими прогноз. Цель обзора - систематизировать современные представления о роли антибактериальной терапии в комплексном ведении пациентов с сепсисом, осложнённым коагулопатией. Антибактериальная терапия рассматривается как обязательный компонент лечения, направленный на устранение инфекционного триггера тромбовоспаления. Наиболее обоснованным остаётся требование раннего инфекционного контроля при высокой вероятности бактериального сепсиса или септическом шоке, включая адекватную эмпирическую терапию и устранение источника инфекции. Вместе с тем степень влияния антибиотиков именно на динамику коагулопатии остаётся менее изученной, поскольку большинство исследований не стратифицирует пациентов по коагуляционному статусу и источнику инфекции. Обсуждается диагностическая роль биомаркеров: прокальцитонина, пресепсина, С-реактивного белка, внеклеточной свободной ДНК, показателей комплемента, активности антитромбина и фибриногена. Показано, что они могут помочь в оценке инфекционной нагрузки, риска диссеминированного внутрисосудистого свёртывания и прогноза, однако ни один из них не должен использоваться как автономный критерий назначения или отмены антибиотиков и антикоагулянтов. Органоспецифичность сепсис-ассоциированного диссеминированного внутрисосудистого свёртывания дополнительно демонстрирует, что источник инфекции влияет на прогноз, возможность контроля очага, исходную активность антитромбина и потенциальную применимость антикоагулянтных вмешательств. Сформулирована клиническая рамка, основанная на ранней адекватной антибактериальной терапии, параллельной оценке коагуляционного статуса, активном контроле источника инфекции, индивидуализации доз антибиотиков при органной дисфункции и экстракорпоральной поддержке, а также на рассмотрении антикоагулянтной терапии только после оценки коагуляционного фенотипа, источника инфекции и риска кровотечения. Подчёркивается необходимость проспективных исследований, стратифицированных по коагуляционному статусу и источнику инфекции, для уточнения оптимальных терапевтических стратегий.

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