【作者】 陈兰；

【导师】 王导新；

【作者基本信息】 重庆医科大学 ， 内科学， 2015， 硕士

【摘要】 目的：探讨重庆地区重症监护病房(Intensive Care Unit, ICU)呼吸机相关性肺炎(Ventilator-associated Pneumonia, VAP)病原菌构成及预后相关因素分析,为临床预防和诊治提供参考。方法：对重庆市三家医院2011年1月-2014年10月重症监护病房962例机械通气患者,回顾性分析307例VAP患者的病原菌分布特点,并收集其年龄、性别、吸烟史、VAP发生时间、侵袭性操作次数、插管次数、气管切开、APACHE Ⅱ评分、CPIS评分、CHALSON评分及预后等资料。对预后相关因素采用单因素分析,若P<0.05,再采用多因素Logistic回归分析。结果：962例机械通气患者中确诊为VAP 307例,其中,COPD 112例、颅脑疾患或术后102例、脓毒血症或休克65例、心肺复苏13例、重症胰腺炎或消化道出血8例、重度哮喘7例。痰培养共分离出病原菌367株,其中G-菌78.26%、G+菌10.30%、真菌11.44%；G-菌为主要致病菌,前3位依次为鲍曼不动杆菌、铜绿假单孢菌、肺炎克雷伯,G+菌以金黄色葡萄球菌为主,真菌感染率呈逐年上升趋势,以念珠菌为主,其次为曲霉菌。病原菌药敏试验结果显示多重耐药菌株(Multidrug resistant, MDR)为主,占78.5%,敏感菌株占18.28%,泛耐药菌株3.22%。经验性抗生素治疗72小时内缓解率为7.52%,其中首选氨基糖苷类、氟喹诺酮类、碳青霉烯类单独或联合使用80%以上。本组研究中VAP发生率为31.91%,死亡率为62.54%。VAP预后相关的因素有年龄、吸烟史、APACHE Ⅱ、CPIS、CHALSON及气管切开等,其中APACHE Ⅱ、CPIS相关性最高,而性别、VAP发生时间、插管次数、侵袭性操作次数对预后无显著意义。针对本组VAP死亡率较高,真菌感染增加的现象,主要考虑与患者的基础疾病、免疫、营养及感染严重程度相关。因此,针对性使用敏感抗生素、增强免疫、加强营养等综合治疗,同时加强手卫生及目标监测,提早预防、早期诊断及合适治疗,从而减少VAP发生、改善预后。结论：VAP发生率为31.91%,死亡率为62.54%。病原菌分布以G-菌为主,真菌感染呈逐年上升趋势。病原菌药敏试验提示以MDR菌株为主,经验性抗生素治疗缓解率较低,常需联合用药。VAP预后相关因素有年龄、吸烟史、APACHE Ⅱ、CPIS、CHALSON及气管切开等,主要与患者基础疾病、感染严重程度密切相关。采取综合治疗、监测管理,同时加强预防、早期诊断及合适治疗是临床防治VAP的关键。更多还原

【Abstract】 Objective:To explore the distribution of pathogenic bacteria and prognostic analysis of ventilator-associated pneumonia in intensive care units in Chongqing area, so as to provide reference for clinical prevention and treatment.Methods:A retrospective study was conducted in Chongqing three hospitals. The subjects were 962 patients consecutively admitted to the intensive care unit from January 2011 to October 2014. Collect the basic data of the patients who developed ventilator-associated pneumonia during the duration of the mechanical ventilation, including pathogenic bacteria, age, sex, smoking, onset of VAP, the frequency of intubation and invasion, tracheotomy, the sore of acute physiology and chronic health evaluation、 clinical pulmonary inflammation score、CHALSON complication index, prognosis and so on. First, take univariate analysis of factors associated with prognosis, if P<0.05, then take multivariate Logistic regression analysis.Results:Among the 962 mechanical ventilated patients,307 cases were firmly diagnosed as VAP. Among the patients, chronic obstructive pulmonary disease 112 cases、brain-injury disease or postoperation 102 cases、sepsis or shock 65 case、cardiopulmonary resuscitation 13 cases、 severe pancreatitis or gastrointestinal hemorrhage 8 cases、severe asthma 7 cases. The pathogenic bacteria isolated from sputum culture were 367 strains, Gram-negative bacteria (78.26%), followed by fungi (11.44%) and Gram-positive bacteria(10.30%). Among Gram-negative bacteria, the top 3 pathogens were acinetobacter baumannii, pseudomonas aeruginosa, and klebsiella pneumonia, respectively. Staphylococcus aureus was the main Gram-positive bacteria. There was an increase in fungal infection, mainly candida, followed by aspergillus. The factors associated with prognosis of ventilator-associated pneumonia included age, sex, APACHE Ⅱ, CPIS, CHALSON and tracheotomy. Pathogenic bacteria drug sensitive test showed that the multiple drug resistant strains (MDR) took the most part, accounting for 78.5%, sensitive strains 18.28%, pan drug resistant strains 3.22%. The relief rate of empiric antibiotic therapy in 72hours was 7.52%. More than 80% preferred choice was aminoglycoside, fluoroquinolone, carbon penicillin alkene alone or combined.In this report, the incidence of VAP was 31.91% and the mortality was 62.54%. The factors associated with outcome included age, smoking, APACHE II, CPIS, CHALSON and tracheotomy, especially APACHE II and CPIS made the most significant point. While sex, onset of VAP, frequency of intubation and invasion made no significant point in outcome of VAP.Underlying condition、immune、nutrition and infection severity were considered as the cause for high mortality and increasing fungi infection. Therefore, it was the key to take measures to adopt comprehensive therapy such as sensitive antibiotics、immune and nutrition improvement, strengthen hand hygiene and target monitoring and enhance prevention、early diagnosis and appropriate treatment, in order to decrease the incidence of VAP and improve the outcome.Conclusion:The incidence of VAP was 31.91% and the mortality was 62.54%. The pathogens distribution presented mainly multiple drug resistant gram-negative bacteria and an increase in fungi infection year by year. Drug-sensitive test mainly showed multiple drug resistant bacteria. The empirical antibiotic administration gained a low relief rate, therefore it was urgent to combine antibiotic use. The factors associated with outcome included age, smoking, APACHE II, CPIS, CHALSON and tracheotomy, which was closely related with underlying condition and severe infection. The prevention、early diagnosis and proper treatment of VAP should be enhanced in clinical practice. Meanwhile, it was the key to take measures to comprehensive therapy、strengthen hand hygiene and target monitoring and enhance prevention、early diagnosis and appropriate treatment to achieve the clinical prevention and treatment.更多还原