老年医疗保健相关性肺炎89例临床分析

Health care associated pneumonia in the elderly： clinical analysis of 89 cases

目的分析老年医疗保健相关性肺炎（HCAP）的临床特点及预后不良的独立危险因素。方法采用队列研究方法，回顾性分析了89例老年HCAP的临床资料，对比存活病例与死亡病例在流行病学、临床表现、病原学及治疗方面的差异，logistic回归法分析老年HCAP预后不良的独立危险因素。结果89例老年HCAP患者分为存活组61例（68．5％）及死亡组28例（31．5％）。死亡组脑血管病及慢性肾病较存活组多见；死亡组呼吸频率≥30次／min、心率≥100次／min、收缩压〈90mmHg及神志改变的发生率均高于存活组，而发热、咳嗽及咳痰在两组间无显著差异；死亡组及存活组均以铜绿假单胞菌、金黄色葡萄球菌及鲍曼不动杆菌等耐药性强的细菌感染多见；死亡组经验性抗感染治疗失败率高于存活组；logistic回归分析显示呼吸频率≥30次／min、收缩压〈90mmHg、肺炎严重指数5级、慢性肾病及多肺叶、段炎症浸润为老年HCAP预后不良的独立危险因素。结论老年HCAP症状不典型、病原复杂、耐药性强、病情严重且治疗困难，应进一步加强老年HCAP的诊治研究。

Objective Health care associated pneumonia （HCAP） has been proposed as a new category of pneumonia. This study aimed to analyze the clinical characteristics and risk factors for poor prognesis of HCAP in the elderly. Methods We conducted a retrospective observational study on 89 elderly HCAP patients. We compared the baseline characteristics, comorbidities, pathogen distribution, antibiotics, and clinical outcomes between survival and dead patients. Multivariate logistic regression analysis was used to identify the risk factors for treatment failure of HCAP. Results A total of 89 HCAP patients were divided into survival group（61 patients, 68.5%） and death group （28 patients, 31.5%）. The incidences of cerebrovascular diseases and chronic kidney diseases were higher in death patients than in survival patients. There were more patients with respiratory rate t〉30 breaths/min, heart rate I〉 100 beats/rain, systolic blood pressure 〈 90mmHg and altered mental station in death group than in survival group. There was no difference in fever, cough and expectoration. The most common causative organisms in both groups were pseudomonas aeruginosa, staphylococcus aureus and acinetobacter baumannii. Initial inappropriate antibiotics administration were more frequent in dead patients than in survival patients. Based on multivariate logistic analysis, respiratory rate~〉 30 breaths/min, systolic blood pressure〈90mmHg, class 5 pneumonia severity index（PSI）, chronic kidney diseases, and inflammatory infiltration of two or more lobes of lungs were independent risk factors for treatment failure of HCAP in elderly patients. Conclusions HCAP in elderly patients is characterized by atypical symptoms, complex pathogens, high drug resistance, severe condition, and treatment difficulty. Its treatment and diagnosis need to be strengthened by further studies.