影响重症肺炎预后的多个因素分析

Analysis on Risk Factors of affecting Prognosis of Severe Pneumonia

目的:探讨重症肺炎的流行病学,各辅助检查,治疗情况及其与预后的关系。方法:收集2005-2008年2月在湘雅医院诊断为重症肺炎的病例90份,所有病例均符合2001年美国胸科学会(ATS)对重症肺炎判定的定义从一般情况、临床表现、影像学资料、病原学资料及治疗情况各方面进行回顾性研究,采用四格表x^2检验,P<0.05有统计学意义,分析影响其预后的危险因素。结果:(1)重症肺炎好发于有基础疾病患者,无任何基础疾病的患者仅占0.6%。(2)重症肺炎的首要致病菌为铜绿假单胞菌,其次为鲍曼不动杆菌和葡萄球菌,而几乎所有的细菌都对三种及三种以上的抗生素耐药。对铜绿假单胞杆菌敏感的抗生素依次有:头孢吡圬,头孢哌酮/舒巴坦,美罗培南,环丙沙星敏感,敏感率为66.7%～80%。其中鲍曼不动杆菌耐药率最高,仅对美罗培南敏感,敏感率为58.3%。对葡萄球菌敏感的有万古霉素,美罗培南,氯霉素,敏感率为90.9%～72.7%。而真菌及病毒的感染也不容忽视,尤其是当细菌感染合并真菌感染时,患者的死亡率显著增高。(3)重症肺炎的死亡率为42.2%,肺部有基础病变或出现多器官功能损害可显著升高重症肺炎的死亡率。结论:重症肺炎的病原菌以革兰阴性杆菌为主,耐药率高,细菌合并真菌感染、肺部有基础疾病及出现多器官功能损害是影响预后的危险因素。

Objective： To investigate the epidemiology, examination and therapy of the severe pneumonia, and its relation to mortality rate. Methods： 90 cases with severe pneumonia were collected in Xiangya hospital between 2005-2008. The general data, clinical performance, x-ray information, pathogen results and therapy of the patients were retrospectively studied and analysed. Results： （1）Most severe pneumonia occurred in patients with basic diseases. Patients without any disease accounted for only 0.6%. （2）In the 90 cases, the first pathogen was Pseudomonas aeruginosa, the second and the third were baumanii and staphylococci. Almost all of the bacteria were resistant to more than three antibiotic. Pseudomonas aeruginosa were sensitive to such antibiotics as cephalosporins topiramate masonry, cefoperazone/Sulbactam, meropenem, ciprofloxacin sensitive, with a sensitive rate of 66.7% to 80%. Drug resistance ofbaumanii was upmost. It was sensitive only to Meropenem, and the sensitive rates was 58.3%. Staphylococcus aureus were sensitive to vancomycin, meropenem, chloramphenicol, with a sensitive rate of 90.9% to 72.7%. However, the infection of fungi and virus were also important in clinic. Especially when bacterial infection combined with fungal infection, the patient mortality was significantly higher. （3）Mortality of the severe pneumonia was 42.4%. The basic disease of pulmonary or a multiple organ dysfunction increased the mortality significantly. Conclusions： The gram negative bacilli were the major pathgen of severe pneumonia. Besides, high drug resistance, bacterial infection combined with fungal infection, pulmonary basic disease and a multiple organ dysfunction are the independent risk factors affecting the prognosis of severe pneumonia.