【作者】 张永利；

【导师】 万献尧；

【作者基本信息】 大连医科大学 ， 内科学， 2004， 硕士

【摘要】 目的:呼吸机相关性肺炎(VAP)是重症监护病房(ICU)中最常见的院内感染,近几年由多重耐药菌引起的VAP逐渐增加,VAP延长了患者在ICU的留住时间、增加了医疗费用。探讨VAP的病原菌、耐药性及临床相关因素为防治VAP提供科学依据。方法:回顾性分析2002年7月至2003年12月我院中心ICU科收治的97例有创机械通气超过48h患者的临床资料,并将患者分为VAP组和非VAP组。对39例VAP患者的微生物学资料进行调查分析,用无菌吸痰管或经纤维支气管镜从下呼吸道采集分泌物进行细菌培养并做耐药试验。用软件统计包(SPSS11.5)先以单因素分析可能影响VAP预后的临床相关因素[包括年龄、性别、机械通气天数、ICU住院天数、休克、机械通气前48h内抗生素应用情况、慢性充血性心力衰竭、慢性阻塞性肺病(COPD)、急性肾功能衰竭、血糖、激素应用情况、创伤、手术、Glasgow昏迷评分、急性生理慢性健康评分Ⅲ(APACHEⅢ)]及发生VAP后对病死率的影响,再通过后退法多元逐步Logistic回归分析确定VAP的独立危险因素。结果:VAP的发生率为40.2%,病死率为61.5%。共分离出病原菌211株,其中革兰阴性菌占80.1%,铜绿假单胞菌居首位;革兰阳性球菌占9.5%;真菌占 10.4%;产超广谱β内酰胺酶菌集中于产气肠杆菌、肺炎克雷伯杆菌、阴沟肠杆菌、大肠埃希菌。革兰阴性杆菌对常用抗<WP=5>菌药物表现出较高的耐药率。单因素分析显示VAP与机械通气天数、ICU住院天数、机械通气前48h内抗生素应用情况、机械通气前激素应用情况、COPD、Glasgow昏迷评分、APACHEⅢ密切相关,病死率与VAP密切相关。回归分析提示机械通气天数、机械通气前48h内抗生素应用情况、APACHEⅢ为VAP的独立危险因素,其相对危险度及其95%可信区间分别为:1.158(1.072~1.251)、9.405(2.065~42.836)、1.032(1.011~1.052)。结论:中心ICU科中VAP病原菌以革兰阴性杆菌为主,并有多重耐药;VAP具有较高的发生率和病死率;VAP与多种临床因素密切相关;严密动态监测病原菌及避免VAP相关因素以达到有效控制VAP的目的。更多还原

【Abstract】 Objective:Ventilator-associated pneumonia(VAP) is the leading ICU infection, the frequency of VAP caused by multiantibiotic-resistant pathogens has increased in recent years, VAP has increased the length of ICU stay and costs of treatment. Pathogens, antibiotic resistance and clinically related factors in VAP were explored to provide the corresponding clinical prevention strategies. Methods: The clinical data of all the 97 mechanical ventilation(>48h) patients admitted to our comprehensive ICU from July 2002 to december 2003 were retrospectively investigated, and all the 97 patients were divided into two groups:VAP and non-VAP. The micro-organism data of all the 39 VAP patients was analysed. Aspsis tube or bronchofibroscope was used to obtain secretions from lower respiratory tract, The specimens were cultivated and examed drug-resistance . Using univariate analysis of a statistical software package(SPSS11.5) we first analysed the related prognostic factors of VAP( including age, sex, mechanical ventilation days, ICU stay, shock, antibiotic usage 48h before ventilation , corticosteroid usage, trauma, operation, Glasgow coma score, acute physiology and chronic health evaluation [APACHEⅢ] and the effect of VAP to mortality),then independent risk factors were determined with backward multivariate stepwise logistic regression analysis. Results: The morbidity of VAP was 40.2% and the mortality was <WP=7>61.5%, A total of 211 pathogens were identified. Among all the strains causing VAP, Gram-negative bacteria accounted for 80.1%, in which Pseudomonas aeruginosa was the major pathogen. Gram positive cocci occuping 9.5% and 10.4% were fungi. Extened-spectrum β-lactamases-producing strains were identified in Enterobacter aerogen, Klebsiella pneumoniae, Enterobacter cloacae and Escherichia coli. All these indicated high resistant rate to commonly used antibiotics in Gram-negative bacteria. Univarite analysis showed that the number of days of mechanical ventilation, ICU stay, antibiotic usage 48h before ventilation, COPD, corticosteroid usage, Glasgow coma score, APACHEⅢ were significant related with VAP and mortality is also connected with VAP. While mutivarite stepwise logistic regression analysis showed that mechanical ventilation days, antibiotic usage 48h before ventilation and APACHEⅢ were independent risk factors. The relative risk and 95% confidencial interval of mechanical ventilation days, antibiotic usage 48h before ventilation and APACHEⅢ were: 1.158(1.072~1.251), 9.405(2.065~42.836), 1.032(1.011~1.052) respectively. Conclusion: Gram-negative bacteria were the most common pathogens of VAP in central ICU , which presented to multi-drug resistant pattern. The morbidity and mortality of VAP were very high , VAP was related with many clinical factors. To effectively control VAP, extensive and dynamical monitoring of VAP pathogens and avoiding of related factors were advocated.更多还原