重症监护室机械通气相关性肺炎

Ventilator Associated Pneumonia in Surgical Intensive Care Unit

目的 研究外科重症监护室(SICU)患者机械通气相关性肺炎(VAP)发病与影响预后的危险因素,并了解VAP的病原体分布及细菌耐药性变化。方法 1994年1月～1996年12月3a期间本院SICU收治60例VAP为感染组,同期机械通气未产生VAP的24例为对照组。采用SAS统计软件包分别就影响VAP发病和预后的11项和10项可能因素进行单因素、多因素逐步Logistic回归分析。细菌的耐药性测定采用微量药敏稀释法。结果 (1)单变量分析显示胃管留置、H2受体阻断剂、利尿剂、糖皮质激素、多种抗生素、呼气末正压(PEEP)、重复气管插管、插管时间延长均与VAP发病有关。(2)多元逐步Logistic回归分析示多种抗生素应用、气管插管时间延长、重复气管插管、H2受体阻断剂具有显著意义(P<0.01)。(3)单因素分析示胸腹部联合手术、休克、肾功能减退、菌血症与VAP预后相关,而多元回归分析仅有胸腹部联合手术、菌血症在影响VAP预后方面具有显著意义(P<0.01)。(4)革兰阳性细菌占24.3%(23株),革兰阴性杆菌(GNB)占73.9%(71株),其中肠杆菌科细菌仅占23.8%,非发酵菌占50.1%,真菌占2.1%(2株)。(5)药敏测试结果示GNB对12种抗生素有不同程度耐药,尤其绿脓杆菌、其他假单胞菌、不动杆菌等非发酵菌的耐药率更高。结论 多种抗生素应用、气管插管时间延长。

To study the predisposing factors of incidence and mortality of ventilator aassociated pneumonia (VAP) in surgical intensive care unit (SICU),and to analyse the distribution of etiological agents and drug resistant rate to bacteria. Methods Sixty cases of VAP was assigned as an infectious group,and the other 24 cases of non VAP,as control group.The univariate and multivariate stepwise logistic regression statistics were done for studying the predisposing factors of incidence and mortality of VAP.Drug susceptibility test was measured according to microdilution method. Results ① Univariate analysis showed that the gastric tube,H 2 receptor blockers,diuretics,corticosteriods,reintubation,use of various antibiotics,PEEP were independently associated with the incidence of VAP.② Multiple stepwise logistic regression analysis indicated that the use of various antibiotics,duration expandation of tracheo intubation,reintubation,H 2 receptor blockers were significantly related to the VAP ( P <0.01).③ Univariate analysis expressed that thoraco abdominal operation,shock,decrease of renal function,bactermia were independently associated with the prognosis of VAP,however,the multivariate stepwise logistic regression analysis indicated that only the thoraco abdominal operation and bactermia were significantly related to the prognosis of VAP.④ The distribution of etiological agents of VAP was that the gram positive cocci,gram negative bacill and fungus accounted for 24.3%,73.9% and 2.1% respectively.⑤ The drug susceptibility test showed that there was obvious drug resistance to common antibiotics among 94 strains of bacteria(18.7%-100.0%),especially higher drug resistance rate in nonfermental bacteria such as pseudomonas aeruginosa,other pseudomonas spp,acinetobacter. Results ① Univariate analysis showed that the gastric tube,H 2 receptor blockers,diuretics,corticosteriods,reintubation,use of various antibiotics,PEEP were independently associated with the incidence of VAP.② Multiple stepwise logistic regression analysis indicated that the use of various antibiotics,duration expandation of tracheo intubation,reintubation,H 2 receptor blockers were significantly related to the VAP ( P <0.01).③ Univariate analysis expressed that thoraco abdominal operation,shock,decrease of renal function,bactermia were independently associated with the prognosis of VAP,however,the multivariate stepwise logistic regression analysis indicated that only the thoraco abdominal operation and bactermia were significantly related to the prognosis of VAP.④ The distribution of etiological agents of VAP was that the gram positive cocci,gram negative bacill and fungus accounted for 24.3%,73.9% and 2.1% respectively.⑤ The drug susceptibility test showed that there was obvious drug resistance to common antibiotics among 94 strains of bacteria(18.7%-100.0%),especially higher drug resistance rate in nonfermental bacteria such as pseudomonas aeruginosa,other pseudomonas spp,acinetobacter. Conclusions The use of various antibiotics,duration expandation of tracheo intubation,reintubation,H 2 receptor blockers were the risk factors of incidencce of VAP.Bactermia and thoraco abdominal operation were the influencing factors related to the prognosis of VAP.The nonfermental bacteria was the major agents in VAP,furthermore,it had higher resistance rate to antibiotics.