多重耐药鲍曼不动杆菌医院获得性肺炎的危险因素及预后分析

Risk factors and prognosis of hospital-acquired pneumonia due to multidrugresistant Acinetobacter baumannii

目的分析多重耐药鲍曼不动杆菌(MDRAB)医院获得性肺炎(HAP)患者的危险因素及死亡预后因素,以期指导临床工作,减少多重耐药菌的发生及降低病死率。方法采用病例对照的研究方法,回顾性分析2009年1月—2012年12月中山大学附属江门市中心医院MDRAB HAP84例,并选取同时期非MDRAB HAP153例作为对照组,应用单因素分析(t检验和χ2检验)及多因素Logistic回归分析MDRAB HAP的危险因素。将84例MDRAB HAP患者分为死亡组21例和存活组63例,应用上述方法分析MDRAB HAP死亡的预后因素。结果单因素分析发现,MDRAB HAP的危险因素包括:合并其他细菌感染、机械通气≥7 d、气管插管/切开、感染前使用舒巴坦合剂、感染前使用碳青霉烯类、感染前使用抗菌药物≥3种以及感染时APACHEⅡ评分≥20分等。再进行Logistic多因素回归分析,结果显示感染时APACHEⅡ评分≥20分(OR=4.10)、机械通气≥7 d(OR=3.03)、感染前使用碳青霉烯类(OR=2.34)是MDRAB HAP的独立危险因素。预后因素单因素分析,MDRAB HAP死亡的危险因素包括:感染前使用抗菌药物≥3种、感染时APACHEⅡ评分≥20分、治疗3 d后临床肺部感染评分(CPIS)升高、细菌(鲍曼不动杆菌)未清除、治疗后转为泛耐药菌等。再进行Logistic多因素回归分析发现,感染时APACHEⅡ评分≥20分(OR=2.14)、治疗3 d后CPIS升高(OR=1.87)、细菌未清除(OR=5.37)及治疗后转为泛耐药菌(OR=1.79)是导致MDRAB HAP死亡的预后因素。结论感染时APACHEⅡ评分≥20分、机械通气≥7 d、感染前使用碳青霉烯类是感染MDRAB HAP的独立危险因素;感染时APACHEⅡ评分≥20分、治疗3 d后CPIS升高、细菌未清除及治疗后转为泛耐药菌是MDRAB HAP死亡的预后因素。

Objective To analyze the risk factors and prognosis of hospital-acquired pneumonia due to multidrug-resistant Acinetobacter baumannii（MDRAB）for better prevention and control of such infections.Methods A total of 84 cases of hospital-acquired pneumonia caused by MDRAB were treated in Jiangmen Central Hospital during the period from January 2009 to December 2012.The clinical data of these patients were reviewed retrospectively.Additional 153 cases of hospital-acquired pneumonia caused by non-multidrug-resistant A.baumannii were included as control group.Univariate and multivariate logistic analysis were used to examine the risk factors of MDRAB pneumonia.The prognostic factors for the 84 cases of hospitalacquired pneumonia due to MDRAB were analyzed similarly by comparing the relevant factors between the 21 deaths and63 survivals.Results Univariate analysis found that the risk factors for MDRAB hospital-acquired pneumonia included mixed bacterial infection,mechanical ventilation≥7 days,endotracheal intubation/tracheotomy, use of sulbactambased therapies,carbapenems,or at least 3 antibiotics prior to infection,and APACHE II score≥20 at time of infection.Subsequent multivariate logistic analysis showed that APACHE II score≥20 at time of infection（OR=4.10）,mechanical ventilation≥7 days（OR=3.03）,use of carbapenems prior to infection（OR=2.34）were independent risk factors for MDRAB pneumonia.Univariate analysis revealed that the death of patients with hospital-acquired pneumonia was associated with use of at least 3 antibiotics prior to infection,APACHE II≥20 at time of infection,higher clinical pulmonary infection score（CPIS）after treatment for 3 days,persistent A.baumannii infection,extensively drug resistant A.baumannii.Multivariate logistic analysis found that APACHE II≥20 at time of infection（OR=2.14）,higher CPIS after treatment for 3days（OR=1.87）,persistent A.baumannii infection（OR=5.37）,and extensively drug resistant A.baumannii（OR=1.79）were independent risk factors of death in patients with hospital-acquired pneumonia due to MDRAB.Conclusions APACHE II score≥20 at time of infection,mechanical ventilation≥7 days,and use of carbapenems prior to infection are independent risk factors for hospital-acquired pneumonia caused by MDRAB.APACHE II≥20 at time of infection,higher CPIS after treatment for 3 days,persistent A.baumannii infection,and extensively drug resistant A.baumannii are independent risk factors of patient death.