重症监护病房卒中相关性肺炎的危险因素及病原学分析

Analysis of risk factors and pathogens for stroke associated pneumonia in intensive care unit

目的 分析重症监护病房（ICU）中急性脑卒中患者伴发卒中相关性肺炎（SAP）的发生率、危险因素及病原学特点.方法 回顾性分析2012年1月至2013年12月合肥市第一人民医院综合ICU收治的142例脑卒中患者的临床资料,分析其基本资料、脑卒中情况、基础疾病、治疗情况、预后及感染病原菌,分别通过成组t检验、Mann-Whitney U检验、Pearson x2检验和多因素Logistic回归模型对SAP的发生风险进行单因素和多因素分析.结果 142例脑卒中患者发生SAP共94例,发生率为66.2％,其中54.3％为早发性肺炎.94例SAP患者菌群分析结果显示早发性肺炎组的致病菌主要为金黄色葡萄球菌和肺炎克雷伯杆菌;晚发性肺炎组致病菌以鲍曼不动杆菌、金黄色葡萄球菌和铜绿假单胞菌为主.多因素Logistic回归分析显示脑出血（OR=10.917,95％ CI：1.834～60.959）、既往卒中史（OR=15.223,95％ CI：1.947 ～ 96.969）、入科时高APACHEⅡ评分（OR=1.607,95％ CI：1.253 ～2.062）、存在吞咽障碍（OR=5.321,95％ CI：1.225 ～ 26.519）、机械通气时间长（OR=1.809,95％ CI：1.208～2.709）、ICU住院时间长（OR=1.391,95％CI：1.085～1.783）以及高血糖（OR=1.534,95％CI：1.101～2.138）是ICU中SAP发生的独立危险因素,血浆白蛋白水平与SAP的发生呈负相关（OR=0.809,95％ CI：0.674 ～0.971）.对SAP中早发性肺炎（EOP）和晚发性肺炎（LOP）分别分析,发现其共同危险因素为APACHEⅡ评分和机械通气时间,EOP的危险因素还有存在吞咽障碍（OR =4.331,95％CI：1.330～14.098）、既往卒中史（OR=13.690,95％CI：2.198～ 85.277）以及慢性支气管炎（OR=12.907,95％CI：1.203～138.542）,LOP的危险因素还有ICU住院时间长（OR=1.687,95％CI：1.131～2.517）、脑出血（OR=21.657,95％CI：1.559～ 106.752）,血浆白蛋白水平是LOP的保护因素（OR=0.782,95％CI：0.637 ～0.961）.EOP组与LOP组间病死率（49.0％vs.44.2％）差异无统计学意义（P＞0.05）,但明显高于非SAP组.结论 ICU中SAP发生率高,病死率高,针对SAP发生的相关危险因素,积极采取综合性预防措施是降低其发生率的关键.

Objective To analyze the incidence,risk factors and pathogens of stroke associated pneumonia （SAP） in patients with acute stroke in the intensive care unit （ICU）.Methods One hundred and forty-two patients with acute stroke admitted in ICU from January 2012 to December 2013 were retrospectively studied.The data of medical history of patients,treatment,prognosis,and pathogens of SAP were collected.Data were analyzed by t test,Mann-Whitney U test,Pearson x2 test and muhivariable logistic regression.Results Of 142 patients,94 （66.2%） were contracted SAP of which 54.3% were early-onset pneumonia （EOP≤72 h） and 45.7% were late-onset pneumonia （LOP 〉72 h）.The most common pathogens isolated from EOP were Staphylococcus aureus and Klebsiella pneumonia,while the most common pathogens isolated from LOP were Acinetobacter baumanii,Staphylococcus aureus and Pseudomonas aeruginosa.Multivariate logistic regression analysis demonstrated that hemorrhagic apoplexy,history of stroke,higher APACHE score,dysphagia,prolonged use of mechanical ventilation,prolonged stay in ICU,and hyperglycemia were the independent risk factors of SAP,and the odds ratios （OR） with 95% confidence intervals （CI） were 10.917 （1.834-60.959）,15.223 （1.947-96.969）,1.607 （1.253-2.062）,5.321 （1.225-26.519）,1.809 （1.208-2.709）,1.391 （1.085-1.783）,1.534 （1.l01-2.138）,respectively.While plasma albumin level was negatively associated with SAP （OR =0.809,95% CI：0.674-0.971）.The common risk factors of EOP and LOP were higher APACHE score and prolonged use of of mechanical ventilation.The independent risk factors of EOP were dysphagia （OR =4.331,95% CI：1.330-14.098）,history of stroke （OR =13.690,95% CI：2.198-85.277） and chronic bronchitis （OR =12.907,95% CI：1.203-138.542）,While those of LOP were prolonged stay in ICU （OR =1.687,95 % CI：1.131-2.517）,hemorrhagic apoplexy （OR =21.657,95% CI：1.559-106.752） and low plasma albumin level （OR =0.782,95% CI：0.637-0.961）.There was no significant difference in mortality between EOP （49%） and LOP （44.2%） （P 〉 0.05）,but the mortality of SAP was significantly higher than that of non-SAP group.Conclusions The incidence rate and mortality of SAP are quite high in ICU.The pathogens and risk factors are different between EOP and LOP.This observation results suggest it is important to identify high-risk stroke patients,and to develop a novel treatment strategy and prophylactic measures facilitating limiting the complications of stroke.