经纤维支气管镜阿米卡星肺泡灌洗治疗多重耐药鲍曼不动杆菌呼吸机相关性肺炎的临床观察

Clinical Observation of Treatment on Multidrug-resistant Acinetobacter Baumannii Ventilator-associated Pneumonia with Amikacin by Fiberoptic Bronchoscopy Lavage

目的评估经纤维支气管镜阿米卡星肺泡灌洗治疗多重耐药治疗鲍曼不动杆菌(multidrug-resistant acinetobacter baumanii,MDRAb)呼吸机相关肺炎(ventilator-associated pneumonia,VAP)的效果和安全性。方法将42例多重耐药鲍曼不动杆菌呼吸机相关性肺炎的机械通气患者随机分为观察组和对照组,每组21例。两组均使用头孢哌酮舒巴坦钠3.0 g,1次/6小时并每日行支气管肺泡灌洗吸痰,观察组每日支气管肺泡灌洗治疗结束后用阿米卡星0.4 g加10 m L生理盐水灌洗,对照组使用阿米卡星7.5 mg/kg静脉滴注1次/天。记录治疗前后急性生理与慢性健康评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)、临床肺部感染评分(clinical pulmonary infection score,CPIS)、血清肌酐(Cr)、C-反应蛋白(CRP),比较两组治疗结束时支气管肺泡灌洗液细菌学检查转阴率、28 d病死率。结果与治疗前相比,两组APACHEⅡ评分、CPIS、CRP治疗后均有下降(P<0.05)。观察组患者治疗结束后其APACHEⅡ评分、CPIS、CRP下降均较对照组显著(P<0.05)。与治疗前比观察组Cr水平未见明显变化(P>0.05),而对照组Cr水平有显著升高(P<0.05)。治疗结束时,支气管肺泡灌洗液培养MDR-Ab转阴率观察组显著高于对照组[80.9%(17/21)vs 42.8%(9/21),P<0.05],随访28 d病死率两组未见差异[23.8%(5/21)vs 33.3%(7/21)(P>0.05)]。结论与静脉给药相比,经纤维支气管镜阿米卡星肺泡灌洗治疗多重耐药鲍曼不动杆菌呼吸机相关性肺炎效果较好且能达到更高的细菌清除率,同时有效减轻肾脏毒性。

Objective To evaluate the efficacy and safety of amikacin by fiberoptic bronchoscopy lavage treatment of multidrug-resistant acinetobacter baumannii （multidrug-resistant acinetobacter baumanii, MDR-Ab） ventilator-associated pneumonia （ventilator-associated pneumonia, VAP）. Methods The 42 patients in mechanical ventilation with multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia were randomly divided into observation group and control group, each group of 21 cases. Both groups use cefoperazone sulbactam 3.0 g intravenous infusion （every 6 hours） and bronchoalveolar lavage suction daily, after the end of the daily bronchoalveolar lavage observation group continue with amikacin 0.4 g in 10 mL of normal saline lavage, control group using amikacin 7.5 mg/kg inlravenous infusion （every day）. Record acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ ）, the clinical pulmonary infection score （CPIS）, serum ereatinine （Cr）, C-reactive protein （CRP） before and after treatment, also bronchial lavage fluid bacteriological examination negative rate, 28-day mortality were compared at the end of treatment. Results Compared with the previous treatment, APACHE Ⅱ score, CPIS, CRP were decreased in both groups（P〈0.05）. Compared with control group, APACHE Ⅱ score, CPIS, CRP in observation group decreased significantly after treatment （P〈0.05）. Cr levels did not change in observation group after treatment （P〉0.05）, while the control group has significantly higher levels of Cr than before treatment （P〈0.05）. At the end of the treatment, bronchoalveolar lavage fluid culture MDR-Ab negative rate in observation group was significantly higher than control group [80.9% （17/21） vs 42.8% （9/21）, P〈0.05], and 28-day mortality has no statistically significant difference in both groups [23.8% （5/21） vs 33.3% （7/21） （P〉0.05）]. Conclusion Treatment of multidrug-resistant acinetobacter baumannii ventilator-associated pneumonia by fiberoptic bronchoscopy lavage was better than intravenous administration of amikacin, and can achieve higher bacterial clearance rate, while effectively reducing nephrotoxicity.