重症监护病房呼吸机相关肺炎临床与病原学分析

Clinical and etiological analysis of ventilator-associated pneumonia in intensive care unit

目的分析重症监护病房(ICU)呼吸机相关肺炎(VAP)的临床、病原学和耐药特点。方法以复旦大学附属中山医院ICU行气管插管或气管切开患者为对象,采用前瞻性队列研究,分析VAP患者的临床资料、病原菌构成及药敏试验结果。结果98例人工气道机械通气患者中52例发生VAP,VAP发生率为53·1%;VAP发病为每1000插管日32·4例。慢性阻塞性肺疾病(COPD)史、H2-受体阻断剂、抗生素应用种类及时间、肠饲营养、APACHEⅡ评分、机械通气时间、胃液pH值、低蛋白血症、气管切开、重复气管插管、口咽部革兰阴性杆菌定植、意识障碍均与VAP发病有关。外科重症监护病房VAP最常见的病原体为鲍曼不动杆菌(18·6%),其次为铜绿假单胞菌(15·7%)和金黄色葡萄球菌(12·9%)。早发性VAP病原体以革兰阳性球菌为主,晚发性VAP以革兰阴性杆菌特别是非发酵菌为主,细菌耐药率高。结论明确VAP的发病因素和致病菌,有利于合理使用抗生素和防治VAP。

Objective To analyze the clinical and etiological characteristics and bacterial susceptibility in patients with ventilator-associated pneumonia(VAP)in intensive care unit (ICU).Methods A prospective cohort study was conducted on VAP in trachea-intubed or tracheotomized patients in ICU of Zhongshan hospital affiliated to Fudan university.Results Totally 98 patients were enrolled in this study,of which 52 were diagnosed as VAP,and 46 as no VAP.The VAP incidence of 53.1% meant 32.4 cases per 1 000 intubation days.Risk analysis shows that the risk factor related to VAP included history of chronic obstructive pulmonary disease(COPD),use of H2-receptor antagonist,the days during which antibiotics were used,the types of antibiotics,enteral feeding,APACHEⅡscores,the duration of mechanic ventilator,pH of gastric juice,hypoalbuminemia,tracheotomy,re-intubation,colonization of gram negative bacilli (GNB) in oropharynx,and conscious disturbance.The most common pathogen in ICU was acinetobacter baumanii(18.6%),the second and the third were pseudomonas aeruginosa(15.7%) and staphylococcus aureus(12.9%),respectively.The major pathogens of early-onset VAP were GNB,particularly nonzymophytes.The major pathogens of late-onset VAP were gram positive coccus (GPC).Conclusion Considering the risk factors and pathogens of VAP,cautious use of antibiotics are essential to prevent and treat VAP.