大面积脑卒中患者VAP临床特点及免疫功能分析

Clinical characteristics and immune function in large-area stroke patients with VAP

目的探究大面积脑卒中患者呼吸机相关性肺炎(Ventilator-associated pneumonia,VAP)医院感染的病原菌分布特点,并对其免疫功能的改变进行分析。方法选择2011年3月-2017年10月在医院行机械通气的大面积脑卒中患者124例为研究对象。采集患者呼吸道的分泌物和静脉血液,进行病原菌分析和药敏实验,对患者外周血中的CD_4^+%、CD8+%和CD_4^+/CD8+的比值进行检测,对IgA、IgG和IgM等免疫球蛋白进行检测。结果124例在医院行机械通气的大面积脑卒中患者,其中6例患者在入院治疗的24h内因原发病加重而导致死亡,顾在本次研究中排除,纳入118例,其中31例患者发生VAP,VAP的发生率为26.27%;31例发生VAP的患者共分离出病原菌57株,其中革兰阴性菌占63.16%,革兰阳性菌占31.58%,真菌占5.26%;主要革兰阴性菌和革兰阳性菌对目前临床常用抗菌药物均存在一定的耐药性,其中革兰阴性菌对哌拉西林/他唑巴坦和氨苄西林的耐药株数分别为17株和13株;而革兰阳性菌金黄色葡萄球菌对青霉素和克拉霉素的耐药株均为10株;感染组患者的IgM、IgG、CD_4^+%、CD8+%及CD_4^+/CD8+水平较非感染组患者低(P<0.05)。结论大面积脑卒中VAP的病原菌感染主要以革兰阴性菌为主、对于临床上常用的抗菌药物均有一定的耐药性,且患者免疫功能严重下降,因此在治疗上一定要依据其病原菌耐药性,给予患者选择合理抗菌药物,同时加强患者营养提高机体免疫力,这对于提高大面积脑卒中患者VAP临床治疗效果和改善患者预后有着重要意义。

OBJECTIVE To investigate the distribution of pathogens in nosocomial infection of ventilator-associated pneumonia (VAP) among patients with large-area stroke and to analyze the changes of immune function in patients with VAP. METHODS 124 patients with large-area stroke who received mechanical ventilation in the hospital from Mar. 2011 to Oct. 2017 were selected as the subjects. The secretion of respiratory tract and venous blood were collected, and the pathogens were analyzed. The drug sensitivity test was carried out. The values of CD4^+%, CD8^+% and CD4 ^+/CD8^ 4+ ratio in peripheral blood were detected, and the immunoglobulins such as IgA, IgG and IgM were detected. RESULTS Among 124 patients with large-area stroke undergoing mechanical ventilation in the hospital, 6 patients died of exacerbation of primary disease within 24 hours after admission and were therefore excluded. In the 118 patients included in this study, the incidence of VAP was 26.27%(31/118). A total of 57 strains of pathogens were isolated from the 31 patients with VAP. Gram-negative bacteria accounted for 63.16 %, gram-positive bacteria accounted for 31.58%, and fungi accounted for 5.26%. The main gram-positive bacteria and gram-negative bacteria showed resistance to the microbial agents commonly used in clinic. The number of Gramnegative bacteria resistant to piperacillin-tazobactam and ampicillin was 17 and 13 respectively. 10 strains of grampositive Staphylococcus aureus were resistant to penicillin and clarithromycin. The levels of IgM, IgG, CD4^+%, CD8^+% and CD4 ^+/CD8^+ in the infected group were significantly lower than those in the non-infccted group (P<0.05). CONCLUSION Gram-negative bacteria are the main pathogens of VAP in large-area stroke patients. They are all resistant to antimicrobial agents commonly used in clinic, and the immune function of the patients is severely decreased. Therefore, the treatment must be based on the drug resistance of the pathogens, giving patients a reasonable choice of antibiotics, while strengthening the patients nutrition to improve the body's immunity. It is of great significance to improve the clinical therapeutic effect and prognosis of large-area stroke patients with VAP.