十年间重症监护病房呼吸机相关性肺炎耐药菌的临床分析

Drug-resistance bacteria in patients with ventilator-associated pneumonia in intensive care unit between 2001 and 2010

目的探寻防治呼吸机相关性肺炎(VAP)耐药菌爆发的综合措施。方法收集2001年1月—2010年12月间上海长征医院急救科重症监护病房(ICU)收治的需行机械通气患者的临床资料,按照入院时间分为2001—2005年组和2006—2010年组,回顾性分析患者的临床资料,比较两组患者的一般资料、VAP发病率、病死率、带管时间、ICU停留时间、住院天数及治疗措施,分析VAP患者耐药菌发生的变化规律。结果 2006—2010年组VAP发病率、病死率分别为9.65%(293/3037)和21.16%(62/293),均显著低于2001—2005年组的28.19%(391/1387)和43.22%(169/391,P值分别<0.01、0.05)。2001—2005年组患者的带管时间、ICU停留时间和住院天数分别为(35.41±10.25)、(41.53±9.26)和(49.77±11.42)d,均显著长于2006―2010年组的(21.56±9.36)、(27.37±8.71)和(35.81±7.29)d(P值均<0.05)。两组患者VAP致病菌检出率排序不同,但前3位均为鲍曼不动杆菌、铜绿假单胞菌和肺炎克雷伯菌。2006―2010年组真菌及革兰阳性菌的检出率分别为17.41%(51/293)和12.63%(37/293),均较2001―2005年组的9.46%(37/391)和7.42%(29/391)显著上升(P值分别<0.05和0.01)。2006―2010年组肠球菌对万古霉素和庆大霉素的耐药率均显著高于2001—2005年组(P值均<0.05),对替考拉宁的耐药率显著低于2001―2005年组(P<0.05)。结论 10年来ICU内VAP耐药菌具有高发病率和高病死率的特点,耐药菌对药物耐药的比例上升,通过实施防治VAP耐药菌爆发的综合措施,ICU内患者VAP的发病率、病死率均显著下降,患者带管时间、ICU停留时间及住院天数也明显缩短。

Objective To explore effective therapies for prevention and cure of out-burst of drug- resistance bacteria in patients with ventilator-associated pneumia （VAP）. Methods Clinical data of critical patients who needed mechanical ventilation in intensive care unit （ICU） of Shanghai Changzheng Hospital from January 2001 to December 2010 were retrospectively analyzed. The patients were divided into group A （from 2001 to 2005） and group B （from 2006 to 2010） according to the time when they were admitted to hospital. General condition, morbidity and mortality of VAP, the duration of intubation, ICU stay, hospital stay and therapitic measures were compared between the two groups. Results The morbidity and mortality of VAP were 28. 19% （391/1 387） and 43.22% （169/391） in groupA, 9.65% （293/3 037） and 21. 16% （62/293） in group B. The morbidity and mortality of VAP in group B were significantly lower than that in group A （P〈0.01, 0.05）. The durations of intubation were （35.41 ± 10.25） d and （21.56 ± 9.36） d in group A and group B, respectively （P〈 0.05）. ICU stay were （41.53±9,26） d and （27.37±8.71） d in group A and group B （P〈0.05）. Hospital stay were （49.77 ± 11.42） d and （35.81 ± 7.29） d in group A and group B （P〈0.05）. The first three pathogenic bacteria were baumanii, Pseudomonas aeruginosa and Klebsiella pneumoniae in both groups. There were 37 patients （9.46%） with fungous infection in group A, and 51 （17.41%） in group B （P〈0.05）. There were 29 patients （7.42%） wtih Gram-positive bacteria infection in group A, and 37 （ 12.63% ） in group B （P〈0.05）. The drug-resistance of enterococci to vancomycin and gentamycin in group B was significantly higher than group A （ P〈 0.05）. The drug-resistance rate of enterococci to teicoplanin in group B was significantly lower than group A （ P〈 0.05）. Conclusion The clinical characteristic of VAP is high morbidity and mortality within ten years in our ICU. The ratio of drug-resistance bacteria to antibiotics is increasing. The morbidity and mortality of VAP sigfnificantly decrease, and the duration of intubation, ICU stay and hospital stay are significantly shortened by comprehensive treatment.