中国九城市成人医院获得性肺炎微生物学与临床特点调查
중국구성시성인의원획득성폐염미생물학여림상특점조사
Adult hospital acquired pneumonia: a multicenter study on microbiology and clinical characteristics of patients from 9 Chinese cities
  • 万方数据
    中华结核和呼吸杂志 중화결핵화호흡잡지
    Chinese Journal of Tuberculosis and Respiratory Diseases
    2012年 10期 739-746 ,共8页

    刘又宁%曹彬%王辉%陈良安%佘丹阳%赵铁梅%梁志欣%孙铁英%李燕明%童朝晖%王臻%贺蓓%杨薇%瞿介明%李向阳%陈荣昌%叶枫%康健%李尔然%陈萍%郑岩%马忠森%任锦%施毅%孙文逵%冯玉麟%范红%姜淑娟%张嵩%熊盛道%左鹏%王占伟

    류우저%조빈%왕휘%진량안%사단양%조철매%량지흔%손철영%리연명%동조휘%왕진%하배%양미%구개명%리향양%진영창%협풍%강건%리이연%진평%정암%마충삼%임금%시의%손문규%풍옥린%범홍%강숙연%장숭%웅성도%좌붕%왕점위

    医院获得性肺炎%病原%流行病学%耐药性 醫院穫得性肺炎%病原%流行病學%耐藥性
    의원획득성폐염%병원%류행병학%내약성
    Hospital acquired pneumonia%Noxae%Epidemiology%Resistance
    目的 探讨我国医院获得性肺炎(HAP)的临床与致病微生物特点,为临床合理治疗提供依据.方法 在中国不同城市的13家教学医院进行HAP多中心、前瞻性调查研究.入选2008年8月至2010年12月国内13家大型教学医院呼吸科病房和呼吸科监护病房(RICU)所有确诊为HAP的患者.收集入选患者的临床资料,留取痰或气管吸引物及发热患者的血标本进行常规细菌培养及药敏试验,留取间隔2周以上的双份血清检测军团菌血清抗体,留取尿液检测尿液中肺炎链球菌抗原水平.结果 610例HAP患者中,93.9％(573例)合并一种或多种基础疾病,HAP总发生率为1.4％(610/42 877),其中呼吸科普通病房的发生率为0.9％ (362/41 261),RICU的发生率为15.3％(248/1616).610例中91.0％(555例)的患者在发生HAP前90天内使用过抗菌药物.HAP患者中79.8％(487/610)的患者检测到病原体,首位是鲍曼不动杆菌,占30.0％ (183/610),其次为铜绿假单胞菌(22.0％,134/610)、金黄色葡萄球菌(13.4％,82/610)及肺炎克雷伯菌(9.7％,59/610)；18例(3.0％)分离到苛养菌.呼吸机相关肺炎(VAP)中鲍曼不动杆菌和金黄色葡萄球菌的分离率为50.5％(97/192)和21.4％ (41/192),显著高于非VAP患者[分别为20.6％(86/418)和9.8％(41/418),均P＜0.01].急性生理学及慢性健康状况评分Ⅱ(APACHEⅡ)评分≥20的患者中,鲍曼不动杆菌和金黄色葡萄球菌的分离率分别为45.7％ (69/151)和20.5％ (31/151),显著高于APACHEⅡ评分＜20的患者[分别为24.8％(114/459)和11.1％(51/459),均P＜0.01].鲍曼不动杆菌对碳青霉烯的耐药率高达76.8％(109/142),对头孢哌酮舒巴坦的敏感度为40.8％(58/142),多黏菌素的敏感度为99.3％(141/142),替加环素的敏感度为95.8％(136/142).铜绿假单胞菌对美罗培南、亚胺培南的耐药率分别为48.8％(40/82)和70.7％(58/82).金黄色葡萄球菌中甲氧西林耐药的金黄色葡萄球菌(MRSA)占87.8％ (43/49).HAP的平均全因病死率为22.3％(135/605),其中VAP为34.5％ (61/177),显著高于平均全因病死率(P＜0.05).HAP患者的平均住院时间为(23.8±20.5)d,显著高于同期所有住院患者的平均住院时间(13.2±13.6) d(t=18.7498,P＜0.01).HAP患者总住院治疗费用平均为(108 950±116 608)元,显著高于同期呼吸科住院患者平均住院费用(17 999 ±33 364)元.结论 HAP是我国大型教学医院常见的医院内感染,全因病死率较高,可导致住院时间显著延长及住院总费用增高.HAP常见的致病菌主要为鲍曼不动杆菌、铜绿假单胞菌、金黄色葡萄球菌及肺炎克雷伯菌.我国教学医院HAP常见致病菌的耐药情况严重,值得关注.
    목적 탐토아국의원획득성폐염(HAP)적림상여치병미생물특점,위림상합리치료제공의거.방법 재중국불동성시적13가교학의원진행HAP다중심、전첨성조사연구.입선2008년8월지2010년12월국내13가대형교학의원호흡과병방화호흡과감호병방(RICU)소유학진위HAP적환자.수집입선환자적림상자료,류취담혹기관흡인물급발열환자적혈표본진행상규세균배양급약민시험,류취간격2주이상적쌍빈혈청검측군단균혈청항체,류취뇨액검측뇨액중폐염련구균항원수평.결과 610례HAP환자중,93.9％(573례)합병일충혹다충기출질병,HAP총발생솔위1.4％(610/42 877),기중호흡과보통병방적발생솔위0.9％ (362/41 261),RICU적발생솔위15.3％(248/1616).610례중91.0％(555례)적환자재발생HAP전90천내사용과항균약물.HAP환자중79.8％(487/610)적환자검측도병원체,수위시포만불동간균,점30.0％ (183/610),기차위동록가단포균(22.0％,134/610)、금황색포도구균(13.4％,82/610)급폐염극뢰백균(9.7％,59/610)；18례(3.0％)분리도가양균.호흡궤상관폐염(VAP)중포만불동간균화금황색포도구균적분리솔위50.5％(97/192)화21.4％ (41/192),현저고우비VAP환자[분별위20.6％(86/418)화9.8％(41/418),균P＜0.01].급성생이학급만성건강상황평분Ⅱ(APACHEⅡ)평분≥20적환자중,포만불동간균화금황색포도구균적분리솔분별위45.7％ (69/151)화20.5％ (31/151),현저고우APACHEⅡ평분＜20적환자[분별위24.8％(114/459)화11.1％(51/459),균P＜0.01].포만불동간균대탄청매희적내약솔고체76.8％(109/142),대두포고동서파탄적민감도위40.8％(58/142),다점균소적민감도위99.3％(141/142),체가배소적민감도위95.8％(136/142).동록가단포균대미라배남、아알배남적내약솔분별위48.8％(40/82)화70.7％(58/82).금황색포도구균중갑양서림내약적금황색포도구균(MRSA)점87.8％ (43/49).HAP적평균전인병사솔위22.3％(135/605),기중VAP위34.5％ (61/177),현저고우평균전인병사솔(P＜0.05).HAP환자적평균주원시간위(23.8±20.5)d,현저고우동기소유주원환자적평균주원시간(13.2±13.6) d(t=18.7498,P＜0.01).HAP환자총주원치료비용평균위(108 950±116 608)원,현저고우동기호흡과주원환자평균주원비용(17 999 ±33 364)원.결론 HAP시아국대형교학의원상견적의원내감염,전인병사솔교고,가도치주원시간현저연장급주원총비용증고.HAP상견적치병균주요위포만불동간균、동록가단포균、금황색포도구균급폐염극뢰백균.아국교학의원HAP상견치병균적내약정황엄중,치득관주.
    Objective To investigate the etiology and clinical characteristics of hospital-acquired pneumonia (HAP) in China and to provide evidence for appropriate therapy.Methods We performed a prospective multicenter study in 13 Chinese urban tertiary hospitals.All HAP cases diagnosed at respiratory general ward and respiratory intensive care unit (RICU) from August 2008 to December 2010 were studied.Epidemiological data,etiology and clinical characteristics of enrolled patients were collected.Sputum or tracheal aspirate and blood cultures,Legionella antibodies and Streptococcus pneunoniae urinary antigen tests were performed.Bacteria to antimicrobial susceptibility test was performed.Results A total of 610 cases of HAP were diagnosed during the study,with an overall incidence of 1.4％ among 42 877 hospitalized patients,while the incidence was 0.9％ (362/41 261) in respiratory general ward and 15.4％ (248/1616)in RICU.93.9％ (573 cases) of patients had at least one underlying disease,and 91.0％ (555 cases) had exposure to at least one antimicrobial agent within 90 days prior to HAP diagnosis.Pathogens were identified in 487 patients,with Acinetobacter baumannii [30.0％ (183/610)],Pseudomonas aeruginosa [22.0％(134/610)],Staphylococcus aureus [13.4％ (82/610)] and Klebsiella pneumonia [9.7％ (59/610)]being the most common pathogens.Eighteen patients (3.0％) had infection with fastidious bacteria.A.baumannii and S.aureus were the more frequent pathogens in the ventilator-associated pneumonia (VAP)cases [50.5％ (97/192) and 21.4％ (41/192)] as compared to non-VAP cases [20.6％ (86/418) and 9.8％ (41/418),P ＜ 0.01].A.baumannii and S.aureus were also frequent pathogens in cases with a score of more than 20 by the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scoring [45.7％ (69/151)and 20.5％ (31/151)],as compared to cases with a score of less than 20 of APACHE Ⅱ [24.8％(114/459) and 11.1％ (51/459),P＜0.01].A.baumannii showed high resistance rates to carbapenems [more than 70％ (109/142)],and the susceptibility to cefoperazone/sulbactam,polymyxin B and tigecycline were 40.8％ (58/142),99.3 ％ (141/142) and 95.8％ (136/142) respectively.Resistance rates of P.aeruginosa to meropenem and imipenem were 48.8％ (40/82)and 70.7％ (58/82) respectively.Methicillin-resistant S.aureus (MRSA) accounted for 87.8％ (43/49)in all strains of S.aureus.Mortality rate of VAP cases was 34.5％ (61/177),significantly more than that of HAP patients [22.3％ (135/605),P ＜0.05].The average hospital stay of patients with HAP was (23.8 ±20.5) days,significantly more than that of the average for inpatients [(13.2 ± 13.6) days,P ＜0.01] during the study period.Mean costs of HAP were (108 950 ± 116 608) yuan,significantly higher than the average hospital costs of respiratory inpatients (17 999 ± 33 364) yuan.Conclusions Among Chinese patients hospitalized in urban tertiary medical centers,HAP incidence and mortality rate were high,which increased the patients' hospital stay and the medical costs.Common pathogens were A.baumannii,P.aeruginosa,S.aureus and K.pneumonia.The common bacteria of HAP in China showed high resistance rates to antibiotics.
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