CAJ | 학술논문

目的对沧州地区呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)的病原菌分布、耐药情况及预后进行临床研究,以期指导临床治疗.方法对2008年1～12月在沧州市3家三级甲等医院261例行机械通气治疗患者中发生VAP的106例患者进行临床病例的统计,对致病菌进行细菌鉴定,采用纸片扩散法检测其耐药性,采用单因素分析方法进行预后分析.结果 VAP平均发病时间为机械通气后7 d,VAP发生率41.0%,病死率35.0%.106例VAP患者呼吸道分泌物中分离出病原菌共126株.其中革兰阴性细菌103株(81.7%),革兰阳性细菌18株(14.3%),真菌5株(4.0%).铜绿假单胞菌37株(29.3%),鲍曼不动杆菌26株(20.6%),肺炎克雷伯菌18株(14.3%),洋葱假单胞菌9株(7.2%),大肠埃希菌9株(7.2%).嗜麦芽窄食单胞菌6株(4.8%),阴沟肠杆菌2株(1.6%),脑膜脓毒性黄杆菌2株(1.6%),金黄色葡萄球菌9株(7.1%),凝固酶阴性葡萄球菌5株(3.9%),肠球菌3株(2.4%),依次为沧州地区VAP患者最常见的病原菌.致病菌仍以细菌尤其是革兰阴性杆菌为主,铜绿假单胞菌居首位.革兰阴性细菌对头孢菌素等各种常见抗菌药物耐药情况均十分严重.本研究中VAP大多数病例为迟发性VAP.机械通气时间>7 d的VAP发生率显著高于<7 d组.>60岁患者发生VAP明显高于≤60岁患者.应用H2受体阻滞剂组的VAP发生率较未用组高.气管插管VAP发生率显著低于气管切开.VAP总病死率为35%,其中严重低白蛋白血症,肾功能衰竭合并葡萄球菌感染和抗生素治疗不当为预后不良的危险因素.结论沧州地区VAP病原菌耐药严重,病死率高,须加强预防及合理进行经验性抗生素治疗.
목적 대창주지구호흡궤상관성폐염(ventilator-associated pneumonia,VAP)적병원균분포、내약정황급예후진행림상연구,이기지도림상치료.방법 대2008년1～12월재창주시3가삼급갑등의원261례행궤계통기치료환자중발생VAP적106례환자진행림상병례적통계,대치병균진행세균감정,채용지편확산법검측기내약성,채용단인소분석방법 진행예후분석.결과 VAP평균발병시간위궤계통기후7 d,VAP발생솔41.0%,병사솔35.0%.106례VAP환자호흡도분비물중분리출병원균공126주.기중혁란음성세균103주(81.7%),혁란양성세균18주(14.3%),진균5주(4.0%).동록가단포균37주(29.3%),포만불동간균26주(20.6%),폐염극뢰백균18주(14.3%),양총가단포균9주(7.2%),대장애희균9주(7.2%).기맥아착식단포균6주(4.8%),음구장간균2주(1.6%),뇌막농독성황간균2주(1.6%),금황색포도구균9주(7.1%),응고매음성포도구균5주(3.9%),장구균3주(2.4%),의차위창주지구VAP환자최상견적병원균.치병균잉이세균우기시혁란음성간균위주,동록가단포균거수위.혁란음성세균대두포균소등각충상견항균약물내약정황균십분엄중.본연구중VAP대다수병례위지발성VAP.궤계통기시간>7 d적VAP발생솔현저고우<7 d조.>60세환자발생VAP명현고우≤60세환자.응용H2수체조체제조적VAP발생솔교미용조고.기관삽관VAP발생솔현저저우기관절개.VAP총병사솔위35%,기중엄중저백단백혈증,신공능쇠갈합병포도구균감염화항생소치료불당위예후불량적위험인소.결론 창주지구VAP병원균내약엄중,병사솔고,수가강예방급합리진행경험성항생소치료.
Objective To analyze the clinical and etiological characteristics and bacterial susceptibility in the patients with ventilato-assoeiated pneunionia(VAP) in Cangzhou area. Methods A retrospective study was conducted on VAP patients in three 3-A hospitals of Cangzhou from Jan 2008 to Dec 2008. Totally 261 patients were enrolled in this study, whose flora was identified and tested by Kirby Bauer disk diffusion susceptibility test. The univariate analysis method was used to analyze the prognostic parameters. Results The average onset time of VAP was 7 days after mechanical ventilation with a morbility rate of 41.0% and mortality rate of 35.0%. The proportion of gram-negative bacilli, gram-positive cocci and eumyeete was 81.7%, 14.3% and 4.0%. The most common pathogens were Pseudomonas aeruginosa ( 29.3% ), Acinetobacter baumannii (20. 6% ), Stenotrophomonas maltophilia ( 14.3% ), Burkholderia cepacia ( 7. 2% ), Pseudomonas cepacia and Aerobacter cloacae (7.2% ) ; Enterobacter cloacae ( 1.6% ), Staphylococcus aureus (7.1%). These were resistant to most common antibacterials including cephalosporin and imipenem in Cangzhou area. Multi-drug resistance bacteria were found in tardive VAP in the study. Gram-negative bacilli were the dominant pathogens of VAP separated from the patients receiving mechanical ventilation in comprehensive ICU,and these pathogens showed high drug-resistance rates to commonly used antibiotics.The study showed a significant higher incidence rate of VAP when mechanical ventilation longer than 7 days compared to 7 days less. The higher incidence rate of VAP was shown in 60 years old compared to that of 60 years less. A higher incidence rate of VAP tracheal intubation than incision of trachea after mechanical ventilation. Severity renal failure and staphylococcosis and in-propriety antibiotics the risk factors of bad prognosis. Conclusions The antibiotic resistance of VAP related pathogens in Cangzhou is very serious with high mortality. It is important to reinforce the prevention and treatment of VAP.