浙江省某院5年来老年社区获得性肺炎的病原体变迁及危险因素分析

Pathogen Changes and Risk Factor Analysis of Community-acquired Pneumonia in the Elderly of A Hospital in Zhejiang Province in Recent 5 Years

目的了解我院老年社区获得性肺炎(CAP)的病原体和耐药性变迁,分析CAP发病的高危因素,为老年CAP的预防和治疗提供指导意见。方法回顾性分析2008—2012年的315例老年CAP患者的资料,对痰标本进行培养、分离和鉴定,药敏试验采用K-B法。对相关危险因素进行单因素和多因素Logistic回归分析。结果 315份痰标本病原体培养阳性113份,阳性率为35.9%,2008—2012年各年阳性率分别为36.2%(21/58)、33.9%(19/56)、36.1%(22/61)、36.4%(24/66)和36.5%(27/74),差异无统计学意义(χ2=0.574,P>0.05);共分离出130株病原体,革兰阳性菌43株(占33.1%),革兰阴性菌51株(占39.2%),非典型病原体36株(占27.7%)。其中分布最多的4种病原体为肺炎链球菌、肺炎支原体、流感嗜血杆菌和肺炎克雷伯菌,分别占23.9%、20.8%、15.4%和14.6%。2008—2012年肺炎链球菌(由34.8%下降至18.8%)和流感嗜血杆菌(由26.1%下降至9.4%)的比重逐年下降,肺炎克雷伯菌(由8.7%上升至18.8%)和肺炎支原体(由13.0%上升至31.3%)逐年上升;肺炎链球菌对青霉素的耐药率在5年都很高,且在后2年达到100%。多因素Logistic回归分析显示年龄、吸烟史、烟龄、慢性阻塞性肺疾病(COPD)、哮喘、慢性支气管炎、肺结核、支气管扩张和肺癌是CAP的独立危险因素(P<0.05)。结论本地区老年CAP的病原体构成和耐药性均发生了明显变迁,由以往以肺炎链球菌为主,逐渐变为以肺炎支原体为主,耐药性增强且呈多重耐药特点;吸烟和呼吸道疾病是老年CAP的高危因素。

Objective To explore the pathogen changes and drug-resistance evolution of community-acquired pneumonia（ CAP） in the elderly,and to analyze the risk factors related to CAP,in order to to provide guidance for the prevention and treatment of CAP in the elderly. Methods 315 elderly cases with CAP were reviewed during 2008 ～ 2012 years. The sputum specimens were cultured,isolated and indentified. The drug sensitive was tested by K-B method. The related risk factors were analyzed by single factor and multi-factor logistic test. Results 113 specimens were cultured positively,and the positive rate was 35. 9%,and in 2008 ~ 2012 years it was 36. 2%（ 21 /58） 、33. 9%（ 19 /56） 、36. 1%（ 22 /61） 、36. 4%（ 24 /66） and 36. 5%（ 27 /74） respectively; the difference was not significant（ χ^2= 0. 574,P〈0. 05）. A total of 130 pathogens were isolated with 43 strains of Gram-positive bacteria（ 33. 1%）,51 strains of Gram-negative bacteria（ 39. 2%） and 36 strains of atypical pathogen（ 27. 7%）. The four most common pathogens were Streptococcus pneumoniae,Mycoplasma pneumoniae,Haemophilus influenzae and Klebsiella pneumoniae,accounting for 23. 9%,20. 8%,15. 4% and 14. 6%,respectively. From 2008 to 2012,the proportions of Streptococcus pneumoniae and Haemophilus influenzae were dropped from 34. 8%（ 26. 1%） to 18. 8%（ 9. 4%）,while the proportions of Mycoplasma pneumoniae and Klebsiella pneumoniae increased year by year from 8. 7%（ 13. 0%） to 18. 8%（ 31. 3%）. The resistance rate of Streptococcus pneumoniae to penicillin were high in five years, and up to 100% in the last two years. Logistic regression analysis showed that age,smoking,smoke age,COPD,asthma, chronic bronchitis,tuberculosis, bronchiectasis and lung cancer were the independent risk factors for CAP（ P〈0. 05）.Conclusion The pathogen changes and drug-resistance evolution are both obvious in the elderly with CAP in our region. The main pathogen is changed from Streptococcus pneumoniae in the past to Mycoplasma pneumoniae nearly,and Streptococcus pneumoniae gives multiple drug resistance characteristics. Smoking and respiratory diseases are high risk factors for CAP.