目的 了解1995-2004年北京大学第三医院(简称本院)呼吸重症监护病房(RICU)呼吸机相关性肺炎(VAP)病原菌的变化特点及其影响因素.方法 回顾性分析1995-2004年在本院RICU住院并使用机械通气的VAP患者137例,其中1995-1999年47例;2000-2004年90例.VAP的诊断符合以下标准:肺炎出现在气管插管48 h后,影像学表现为新发现的或进展性浸润阴影,且至少有以下2种临床表现:(1)体温>38.0℃或<35.5℃;(2)白细胞>10×109/L或<4×109/L;(3)有脓性分泌物,同时细菌培养阳性(气管插管取标本).使用SPSS 11.5软件分析数据,定量资料用x±s表示,独立样本采用t检验,定性资料采用χ2检验.对于各个统计变量采用logistic多元回归分析以确定特殊病原菌VAP的易患因素.结果 (1)1995-2004年本院RICU中VAP总发病率为17.9%(137/765);1995-1999年47例,平均发病率为16.2%(3.1%～29.8%);2000-2004年90例,平均发病率为19.6%(12.4%～27.7%).(2)1995-1999年检出的病原菌中居前4位的分别为嗜麦芽黄窄食单胞菌(15株,23.4%)、铜绿假单胞菌(12株,18.8%)、阴沟肠杆菌(8株,12.5%)及鲍曼不动杆菌(7株,10.9%).2000-2004年居前4位的病原菌为鲍曼不动杆菌(40株,34.2%)、铜绿假单胞菌(32株,27.4%)、金黄色葡萄球菌(24株,20.5%)及嗜麦芽黄窄食单胞菌(8株,6.8%).1995-1999年金黄色葡萄球菌感染2株(2/64,3.1%),均为耐甲氧西林的金黄色葡萄球菌(MRSA),2000-2004年24株金黄色葡萄球菌感染中21株(21/117,17.9%)为MRSA.(3)1995-1999年中心静脉置管11例(11/47,23.4%),2000-2004年为45例(45/90,50.0%);雾化吸入时间分别为(46±55)和(28±30)d;使用二代头孢类抗生素为12例(12/47,25.5%)和7例(7/90,7.8%),使用青霉素类抗生素为13例(13/47,27.7%)和10例(10/90,11.1%),使用喹诺酮类抗生素为10例(10/47,21.3%)和46例(46/90,51.1%).(4)金黄色葡萄球菌性VAP的发生可能与同期住院患者的相互传播有关(Wald值=16.690,P<0.01,OR=9.212);嗜麦芽黄窄食单胞菌性VAP的发生与雾化吸入时间有关(Wald值=7.852,P<0.01,OR=1.021);鲍曼不动杆菌性VAP的发生与使用三代头孢类抗生素有关(Wald值=5.553,P<0.05,OR=3.461).结论 10年来本院RICU中VAP的发病率未增加;鲍曼不动杆菌和金黄色葡萄球菌及MRSA明显增多;RICU病原菌的变迁可能与雾化吸入时间下降、经验性使用抗生素种类不同及同期患者院内传播有关.
目的 瞭解1995-2004年北京大學第三醫院(簡稱本院)呼吸重癥鑑護病房(RICU)呼吸機相關性肺炎(VAP)病原菌的變化特點及其影響因素.方法 迴顧性分析1995-2004年在本院RICU住院併使用機械通氣的VAP患者137例,其中1995-1999年47例;2000-2004年90例.VAP的診斷符閤以下標準:肺炎齣現在氣管插管48 h後,影像學錶現為新髮現的或進展性浸潤陰影,且至少有以下2種臨床錶現:(1)體溫>38.0℃或<35.5℃;(2)白細胞>10×109/L或<4×109/L;(3)有膿性分泌物,同時細菌培養暘性(氣管插管取標本).使用SPSS 11.5軟件分析數據,定量資料用x±s錶示,獨立樣本採用t檢驗,定性資料採用χ2檢驗.對于各箇統計變量採用logistic多元迴歸分析以確定特殊病原菌VAP的易患因素.結果 (1)1995-2004年本院RICU中VAP總髮病率為17.9%(137/765);1995-1999年47例,平均髮病率為16.2%(3.1%～29.8%);2000-2004年90例,平均髮病率為19.6%(12.4%～27.7%).(2)1995-1999年檢齣的病原菌中居前4位的分彆為嗜麥芽黃窄食單胞菌(15株,23.4%)、銅綠假單胞菌(12株,18.8%)、陰溝腸桿菌(8株,12.5%)及鮑曼不動桿菌(7株,10.9%).2000-2004年居前4位的病原菌為鮑曼不動桿菌(40株,34.2%)、銅綠假單胞菌(32株,27.4%)、金黃色葡萄毬菌(24株,20.5%)及嗜麥芽黃窄食單胞菌(8株,6.8%).1995-1999年金黃色葡萄毬菌感染2株(2/64,3.1%),均為耐甲氧西林的金黃色葡萄毬菌(MRSA),2000-2004年24株金黃色葡萄毬菌感染中21株(21/117,17.9%)為MRSA.(3)1995-1999年中心靜脈置管11例(11/47,23.4%),2000-2004年為45例(45/90,50.0%);霧化吸入時間分彆為(46±55)和(28±30)d;使用二代頭孢類抗生素為12例(12/47,25.5%)和7例(7/90,7.8%),使用青黴素類抗生素為13例(13/47,27.7%)和10例(10/90,11.1%),使用喹諾酮類抗生素為10例(10/47,21.3%)和46例(46/90,51.1%).(4)金黃色葡萄毬菌性VAP的髮生可能與同期住院患者的相互傳播有關(Wald值=16.690,P<0.01,OR=9.212);嗜麥芽黃窄食單胞菌性VAP的髮生與霧化吸入時間有關(Wald值=7.852,P<0.01,OR=1.021);鮑曼不動桿菌性VAP的髮生與使用三代頭孢類抗生素有關(Wald值=5.553,P<0.05,OR=3.461).結論 10年來本院RICU中VAP的髮病率未增加;鮑曼不動桿菌和金黃色葡萄毬菌及MRSA明顯增多;RICU病原菌的變遷可能與霧化吸入時間下降、經驗性使用抗生素種類不同及同期患者院內傳播有關.
목적 료해1995-2004년북경대학제삼의원(간칭본원)호흡중증감호병방(RICU)호흡궤상관성폐염(VAP)병원균적변화특점급기영향인소.방법 회고성분석1995-2004년재본원RICU주원병사용궤계통기적VAP환자137례,기중1995-1999년47례;2000-2004년90례.VAP적진단부합이하표준:폐염출현재기관삽관48 h후,영상학표현위신발현적혹진전성침윤음영,차지소유이하2충림상표현:(1)체온>38.0℃혹<35.5℃;(2)백세포>10×109/L혹<4×109/L;(3)유농성분비물,동시세균배양양성(기관삽관취표본).사용SPSS 11.5연건분석수거,정량자료용x±s표시,독립양본채용t검험,정성자료채용χ2검험.대우각개통계변량채용logistic다원회귀분석이학정특수병원균VAP적역환인소.결과 (1)1995-2004년본원RICU중VAP총발병솔위17.9%(137/765);1995-1999년47례,평균발병솔위16.2%(3.1%～29.8%);2000-2004년90례,평균발병솔위19.6%(12.4%～27.7%).(2)1995-1999년검출적병원균중거전4위적분별위기맥아황착식단포균(15주,23.4%)、동록가단포균(12주,18.8%)、음구장간균(8주,12.5%)급포만불동간균(7주,10.9%).2000-2004년거전4위적병원균위포만불동간균(40주,34.2%)、동록가단포균(32주,27.4%)、금황색포도구균(24주,20.5%)급기맥아황착식단포균(8주,6.8%).1995-1999년금황색포도구균감염2주(2/64,3.1%),균위내갑양서림적금황색포도구균(MRSA),2000-2004년24주금황색포도구균감염중21주(21/117,17.9%)위MRSA.(3)1995-1999년중심정맥치관11례(11/47,23.4%),2000-2004년위45례(45/90,50.0%);무화흡입시간분별위(46±55)화(28±30)d;사용이대두포류항생소위12례(12/47,25.5%)화7례(7/90,7.8%),사용청매소류항생소위13례(13/47,27.7%)화10례(10/90,11.1%),사용규낙동류항생소위10례(10/47,21.3%)화46례(46/90,51.1%).(4)금황색포도구균성VAP적발생가능여동기주원환자적상호전파유관(Wald치=16.690,P<0.01,OR=9.212);기맥아황착식단포균성VAP적발생여무화흡입시간유관(Wald치=7.852,P<0.01,OR=1.021);포만불동간균성VAP적발생여사용삼대두포류항생소유관(Wald치=5.553,P<0.05,OR=3.461).결론 10년래본원RICU중VAP적발병솔미증가;포만불동간균화금황색포도구균급MRSA명현증다;RICU병원균적변천가능여무화흡입시간하강、경험성사용항생소충류불동급동기환자원내전파유관.
Objective To investigate the changing patterns and associated factors of microbial pathogens which caused ventilator-associated pneumonia (VAP) in our respiratory intensive care unit (RICU) from 1995 to 2004. Methods Cases of VAP in our RICU from 1995 to 2004 (n=137) were retrospectively analyzed, 47 cases from 1995 to 1999 and 90 cases from 2000 to 2004. YAP was diagnosed according to the following criteria: pneumonia occurred 48 hours after tracheal intubatioas; new or progressive infiltrative opacities on chest X ray film; and at least two of the following clinical features: (1) Temperature > 38. 0 ℃ or < 35. 5 ℃, (2)WBC > 10×109/L or < 4×109/L, (3)purulent airway secretions; and positive bacterial cultures (the samples obtained through endotracheal intubations). The data were analyzed using statistical software SPSS version 11.5. Continuous data were expressed as x±s. T-test and χ2-test were used for continuous and categorical data, respectively. Logistic regression analysis was used to determine the risk factors for special pathogens. Results The mean incidence of VAP was 17. 9% from 1995 to 2004 (137/765), 16. 2% from 1995 to 1999 (n = 47, 3.1% - 29. 8%) and 19.6% from 2000 to 2004 (n =90, 12. 4% -27. 7%). From 1995 to 1999, common pathogens were Stenotrophomonas maltophilia (n =15, 23.4%), Pseudomonas aeruginosa (n = 12, 18.8%), Aerobacter cloacae (n = 8, 12.5%) and Acinetobacter baumanii (n = 7, 10. 9%). From 2000 to 2004, common pathogens were Acinetobacter baumanii (n =40, 34. 2%), Pseudomonus aeruginosa (n =32, 27.4%), Staphylococcus aureus (n =24,20. 5%) and Stenotrophomonus maltophilia (n =8, 6. 8%). There were 2 cases (2/64,3.1%) caused by Staphylococcus aureus from 1995 to 1999, and both were caused by Methicillin-resistant Staphylococcus aureus (MRSA) ; there were 24 cases caused by Staphylococcus aureus from 2000 to 2004 , and 21 cases (21/117,17.9%) were caused by MRSA. There were 11 (11/47,23.4%) and 45 (45/90,50. 0%) cases with central intravenous catheters in the period of 1995 to 1999 and 2000 to 2004, respectively. In the period of 1995 to 1999 and 2000 to 2004, durations of aerosolized therapy were (46±55) and(28±30) days. There were 12 patients (12/47,25.5%) using second-generation cephalosporin before VAP occurred in the period of 1995 to 1999 and 7 patients(7/90,7. 8%) in the period of 2000 to 2004. There were 13 patients (13/47,27. 7%) using penicillin before VAP in the period of 1995 to 1999 and 10 patients (10/90,11.1%) in the period of 2000 to 2004. There were 10 patients (10/47,21.3 %) using quinolones before VAP in the period of 1995 to 1999 and 46 patients (46/90,51.1%) in the period of 2000 to 2004. The occurrence of Staphylococcus aureus VAP may be related to the cross-infection between inpatients (Wald =16. 690,P <0. 01, OR = 9. 212). VAP caused by Stenotrophomonas maltophilia was positively related to duration of aerosolized therapy (Wald = 7. 852, P < 0.01, OR = 1. 021). VAP caused by Acinetobacter baumanii was positively related to third-generation cephalosporin usage (Wald = 5. 553, P < 0. 05, OR =3.461). Conclusions The incidence of VAP was not increased in the recent 10 years in our RICU, but the incidence of VAP caused by Acinetobocter baumanii. Staphylococcus aureus and MRSA increased significantly, may be related to the decrease of duration of aerosolized therapy, the usage of different kinds of antibiotics and cross-infection between inpatients.
