重症医学科多重耐药菌致HAP的危险因素及治疗情况分析

Risk factors and treatment of hospital-acquired pneumonia due to multidrug-resistant organisms in intensive care unit

目的分析重症监护病房(ICU)多重耐药菌(MDRO)致医院获得性肺炎(HAP)的危险因素及其抗菌药物使用情况,进行风险评估并指导抗菌药物使用。方法对2012年1月—2013年12月ICU HAP患者进行回顾性队列研究,分析发生多重耐药(MDR)-HAP的危险因素,以及抗菌药物使用的合理性。结果ICU发生HAP110例,其中MDR-HAP63例(占57.27%)。logistic回归分析结果显示,近期住院时间≥5 d(OR=19.94)、直接从其他医疗机构转入(OR=19.33)、感染类型为晚发HAP(OR=7.98)、近90 d接受抗菌药物治疗(OR=3.42)是发生MDR-HAP的独立危险因素。初始经验性抗感染治疗:MDR-HAP组与非MDR-HAP组在临床诊断24 h内给药时机、抗菌药物品种选择合理率比较,差异无统计学意义(均P>0.05);MDR-HAP组病原菌覆盖率为73.02%,低于非MDR-HAP组的91.49%(P<0.05)。抗菌药物目标性治疗:两组品种选择,剂量、频次合理率比较,差异无统计学意义(均P>0.05);MDR-HAP组抗菌药物使用疗程合理率高于非MDR-HAP组,联合用药合理率略低于后者(均P<0.05)。结论 ICU应对患者进行MDR-HAP危险因素评估,并制定相应的预防与控制策略,以降低MDR-HAP的发生率,医务人员应以此为依据规范初始经验性抗感染治疗。

Objective To analyze risk factors and antimicrobial use for hospital-acquired pneumonia（HAP）due to multidrug-resistant organisms（MDROs）in an intensive care unit（ICU）,so as to perform risk assessment and guide antimicrobial use.Methods From January 2012 to December 2013,HAP patients were conducted retrospective cohort study,risk factors for MDRO-HAP and rationality of antimicrobial use were analyzed.Results A total of 110 cases of HAP occurred in ICU,63 cases（57.27%）were MDR-HAP.Logistic regression analysis revealed that recent hospital stay≥5 days（OR=19.94）,transference from other hospitals（OR=19.33）,infection type of lateonset HAP（OR=7.98）,and antimicrobial use in recent 90 days（OR=3.42）were independent risk factors for MDR-HAP.Initial empirical anti-infective treatment revealed that there were no significant difference in timing of antimicrobial administration within 24 hours after clinical diagnosis was confirmed,and rationality of antimicrobial selection between MDR-HAP group and non-MDR-HAP group（both P〉0.05）;The isolation rate of pathogens in MDR-HAP group was lower than non-MDR-HAP group（73.02% vs 91.49% P〈0.05）.Targeted antimicrobial therapy revealed that there were no significant difference in selection,dosage,and frequency of antimicrobial use between two groups（all P〉0.05）;the rationality rate of therapy course in MDR-HAP group was higher than noMDR-HAP group,but rationality rate of combination use of antimicrobial agents was slightly lower than the latter（both P〈 0.05）.Conclusion Patients in ICU should be conducted risk factor assessment,and according prevention and control measures should be formulated,so as to reduce the occurrence of MDR-HAP,health care workers should standardized the initial empirical anti-infective treatment.