神经外科重症监护病房出血性脑损伤患者肺部感染的细菌学分析

Bacteriological analysis of pulmonary infection in hemorrhagic brain injury patients from neurosurgical intensive care unit

目的研究神经外科重症监护病房（NICU）出血性脑损伤患者并发肺部感染的病原菌分布及耐药特点。方法回顾性分析2013年3月—2014年9月入住N1CU的234例出血性脑损伤患者的临床资料，根据患者是否发生肺部感染分为肺部感染组和非肺部感染组。对两组患者入院时GCS评分、性别、年龄、吸烟史、昏迷时间、呼吸机使用时间、住NICU时间等进行评估，并对肺部感染组患者的病原菌分布及耐药情况进行分析。结果肺部感染组158例（67．5％），非肺部感染组76例（32．5％）。发生多重感染61例（38．6％），其中合并2种病原菌感染26例（16．5％），合并3种病原菌感染19例（12．0％），≥4种病原菌感染16例（10．1％）。肺部感染组年龄（P〈0．05）、吸烟率（P〈0．05）均高于非肺部感染组。肺部感染组昏迷时间、呼吸机使用时间及住NICU时间均较非肺部感染组明显延长（P〈0．05）。肺部感染组患者标本共分离出219株病原菌，其中革兰阴性菌193株（88．1％），革兰阳性菌13株（5．9％），真菌13株（5．9％）。肺炎克雷伯菌、铜绿假单胞菌、鲍曼不动杆菌对亚胺培南、哌拉西林-他唑巴坦、左氧氟沙星耐药率低。金黄色葡萄球菌对万古霉素、利奈唑胺、替加环素完全敏感，对青霉素完全耐药。真菌对伏立康唑、伊曲康唑、酮康唑、氟康唑、两性霉素B均无耐药性。结论NICU出血性脑损伤患者肺部感染率高，病原菌种类多样，以革兰阴性菌为主。多重耐药菌株发生率高，结合药敏试验合理选择抗生素是关键。

Objective To investigate the characteristics of pathogen distribution and drug resistance of pulmonary infection in hemorrhagic brain injury patients from neurosurgical intensive care unit （NICU）. Methods Clinical data of 234 patients with hemorrhagic brain injury hospitalized in NICU from March 2013 to September 2014 were retrospectively analyzed. According to the incidence of pulmonary infection, the patients were divided into pulmonary infection group and non-pulmonary infection group. Parameters estimated were admission GCS, sex, age, history of smoking, time of coma, duration of mechanical ventilation, NICU length of stay. Patients in pulmonary infection group were analyzed on the distribution of pathogens and incidence of drug resistance. Results A total of 158 patients （67.5%） had pulmonary infection. Among them 60 cases （38. 6% ） were found to be co-infected including infection with two pathogens in 26 cases （ 16.5% ） , three pathogens in 19 cases （ 12. 0% ） , and four and more pathogens in 16 cases （ 10. 1% ）. Age and smoking increased the incidence of pulmonary infection （ P 〈 0.05 ）. Time of coma, duration of mechanical ventilation, and NICU length of stay were prolonged in pulmonary infection group than in non-pulmonary infection group （ P 〈 0. 05 ）. A total of 219 strains of pathogens were isolated from the patients in pulmonary infection group. Specifically, there were 193 strains of gram negative bacteria （88.1% ）, 13 strains of gram positive bacteria （5.9%）, and 13 strains of fungi （5.9%）. Gram negative were sensitive to amikacin, imipenem, cefoperazone/ sulbactam and ciprofloxacin. Staphylococcus aureus isolated were 100% sensitive to vancomycin, linezolid and teicoplanin, and were completely penicillin resistant. Fungi were not resistant to voriconazole, itraconazole, ketoconazole, fluconazol, and amphotericin B. Conclusions High incidence of pulmonary infection is noted among the hemorrhagic brain injury patients in NICU, and the pathogens are diverse dominated by Gram negative bacteria. Incidence of multi-drug resistant pulmonary infection is high, indicating that the key point is to choose antibiotics rationally based on drug sensitivity test.