青年急性缺血性卒中患者卒中相关性肺炎：微生物学资料、危险因素和对转归的影响

Stroke-associated pneumonia in young patients with acute ischemic stroke： the microbiological data, risk factors, and effect on outcomes

目的探讨青年急性缺血性卒中患者卒中相关性肺炎（stroke-associated pneumonia, SAP）的微生物学、危险因素以及对转归的影响。 方法前瞻性纳入青年急性缺血性卒中患者，明确SAP的微生物学资料和危险因素。在发病90 d时应用改良Rankin量表进行转归评价，〉2分定义为转归不良。比较人口统计学和基线临床特征，采用多变量logistic回归分析确定SAP对转归的影响。 结果共纳入418例青年缺血性卒中患者，其中SAP组108例（25.84%），非SAP组310例（74.16%）；16例失访，转归不良组146例（36.32%），转归良好组256例（63.68%）。SAP组病原学检查结果提示阳性率为52.78%，19.30%为混合感染。主要为社区获得性病原菌（如金黄色葡萄球菌、肺炎链球菌、肺炎克雷伯杆菌），其次为具有多重耐药性的院内病原菌（如铜绿假单胞菌、鲍曼不动杆菌、耐甲氧西林金葡菌）。多变量logistic回归分析显示，吸烟[优势比（odds ratio, OR） 4.328，95%可信区间（confidence interval, CI） 2.847～6.442；P＝0.014]、慢性阻塞性肺疾病（OR 3.927，95% CI 2.419～5.253；P＝0.017）、吞咽困难（OR 6.782，95% CI 4.378～9.553；P＝0.003）、气管插管或机械通气（OR 7.632，95% CI 5.394～12.376；P＝0.001）、降钙素原（OR 2.980，95% CI 2.234～4.118；P＝0.027）、抗生素（OR 6.321，95% CI 4.362～8.376；P＝0.007）是SAP的独立危险因素，年龄〈35岁是SAP的独立保护因素（OR 0.582，95% CI 0.329～0.719；P＝0.028）；既往卒中或短暂性脑缺血发作史（OR 3.854，95% CI 2.645～5.023；P＝0.014）、气管插管或机械通气（OR 3.501，95% CI 2.329～4.614；P＝0.016）、大动脉粥样硬化（OR 5.274，95% CI 3.342～7.246；P＝0.006）、基线美国国立卫生研究院卒中量表评分（OR 2.248，95% CI 1.482～2.821；P＝0.031）、发病至入院时间（OR 1.245，95% CI 1.184～1.698；P＝0.048）、SAP（OR 3.347，95% CI 2.275～4.338；P＝0.018）是转归不良的独立危险因素，年龄〈35岁（OR 0.340，95% CI 0.147～0.420；P＝0.042）和溶栓治疗（OR 0.582，95% CI 0.329～0.719；P＝0.028）是转归良好的独立保护因素。 结论青年急性缺血性卒中患者中SAP较为常见，且在微生物学资料和危险因素方面具有自身的特点。SAP与转归不良密切相关。

ObjectiveTo investigate the microbiology, risk factors, and impact on outcomes of stroke-associated pneumonia （SAP） in young patients with acute ischemic stroke. MethodsYoung patients with acute ischemic stroke were enrolled prospectively. Their microbiological data and risk factors for SAP were identified. The outcomes at 90 d after onset were evaluated with the modified Rankin Scale （mRS） scores, and mRS 〉2 was defined as poor outcome. The demography and baseline clinical characteristics were compared. Multivariate logistic regression analysis was used to identify the effect of SAP on the outcomes. ResultsA total of 418 young patients with ischemic stroke were enrolled, including 108 （25.84%） in the SAP group and 310 （74.16%） in the non-SAP group; 16 were lost to follow-up, 146 （36.32%） were in the poor outcome group and 256 （63.68%） were in the good outcome group. The results of pathogen test showed that the positive rate was 52.78% and 19.30% was mixed infection. The main pathogens were community-acquired pathogens （such as Staphylococcus aureus, Streptococcus pneumoniae and Klebsiella pneumoniae）, followed by multidrug-resistant nosocomial pathogens （such as Pseudomonas aeruginosa, Acinetobacter Baumanii, and methicillin-resistant Staphylococcus aureus）. Multivariate logistic regression analysis showed that smoking （odds ratio [OR]4.328, 95% confidence interval [CI]2.847-6.442; P=0.014）, chronic obstructive pulmonary disease （OR 3.927, 95% CI 2.419-5.253; P=0.017）, dysphagia （OR 6.782, 95% CI 4.378-9.553; P=0.003）, tracheal intubation or mechanical ventilation （OR 7.632, 95% CI 5.394-12.376; P=0.001）, procalcitonin （OR 2.980, 95% CI 2.234-4.118; P=0.027）, antibiotics （OR 6.321, 95% CI 4.362-8.376; P=0.007） were the independent risk factors for SAP, and age 〈35 years old was an independent protective factor of SAP （OR 0.582, 95% CI 0.329-0.719; P=0.028）; history of previous stroke or transient ischemic attack （OR 3.854, 95% CI 2.645-5.023; P=0.014）, tracheal intubation and mechanical ventilation （OR 3.501, 95% CI 2.329-4.614; P=0.016）, large artery atherosclerosis （OR 5.274, 95% CI 3.342-7.246; P=0.006）, baseline National Institutes of Health Stroke Scale score （OR 2.248, 95% CI 1.482-2.821; P=0.031）, onset to admission time （OR 1.245, 95% CI 1.184-1.698; P=0.048）, SAP （OR 3.347, 95% CI 2.275-4.338; P=0.018） were the independent risk factors for poor outcomes, and age 〈35 years old （OR 0.340, 95% CI 0.147-0.420; P=0.042） and thrombolytic therapy （OR 0.582, 95% CI 0.329-0.719; P=0.028） were the independent protective factors of good outcomes. ConclusionSAP was more common in young patients with acute ischemic stroke, and had its own characteristics in microbiological data and risk factors. SAP was closely associated with poor outcomes.