新生儿呼吸机相关性肺炎病原学及不良预后高危因素分析

Analysis of pathogen and high risk factors for poor prognosis in newborns with ventilator-associated pneumonia

目的探讨新生儿重症监护病房(NICU)呼吸机相关性肺炎(VAP)病原菌及不良预后发生的高危因素。方法回顾性分析苏州大学附属儿童医院新生儿科2012年8月至2019年8月NICU诊治的236例VAP患儿的临床资料。根据预后情况将患儿分为预后良好组和预后不良组,比较两组患儿临床特征及病原学情况,分析不良预后发生的高危因素。结果(1)236例VAP患儿预后良好组182例,预后不良组54例;两组气道分泌物共培养出病原菌258株,以革兰阴性菌为主240株(93.02%);两组病原菌均以肺炎克雷伯杆菌、嗜麦芽窄食单胞菌、鲍曼不动杆菌、阴沟肠杆菌及铜绿假单胞菌为主,其中肺炎克雷伯杆菌为预后良好组检出最多的病原菌,鲍曼不动杆菌为预后不良组检出最多的病原菌。(2)两组临床资料对比显示预后不良组患儿上机时长>5 d、上机或撤机后再恶化、发热、低钾血症、低钠血症、低氯血症、肺不张、肺出血及机械通气时最低血清白蛋白≤30 g/L发生率显著高于预后良好组(P<0.05)。(3)Logistic多因素逐步回归分析显示上机或撤机后再次恶化、低钠血症、低氯血症及机械通气时最低血清白蛋白≤30 g/L为预后不良发生的独立高危因素。结论NICU中预后不良的VAP患儿以鲍曼不动杆菌为主要致病菌;减少上机或撤机后再次恶化次数、及时纠正电解质紊乱及增加营养储备可改善VAP患儿预后情况。

ObjectiveTo analyze the pathogen and high risk factors for poor prognosis in newborns with ventilator-associated pneumonia(VAP)in Neonatal Intensive Care Unit(NICU).MethodsThe clinical data of 236 newborns with VAP admitted from August 2012 to August 2019 to the NICU,Children’s Hospital of Soochow University,were analyzed retrospectively.According to the prognosis,the patients were divided into the group with good prognosis and the group with poor prognosis.The clinical characteristics and pathogen of the two groups were compared,and the risk factors for poor prognosis were analyzed.Results(1)Among the 236 children with VAP,182 were in the good prognosis group and 54 were in the bad prognosis group.A total of 258 strains of pathogenic bacteria were cultured from the airway secretions of the two groups,and 240 strains(93.02%)were gram-negative bacteria.Klebsiella pneumoniae,Stenotrophomonas maltophilia,Acinetobacter baumannii,Enterobacter cloacae and Pseudomonas aeruginosa were the main pathogens in the two groups.Klebsiella pneumoniae was the most common pathogen in the group with good prognosis,and Acinetobacter baumannii was the most common pathogen in the group with poor prognosis.(2)The incidence of invasive ventilator use time>5 d,relapse after using ventilator or withdrawing ventilator,fever,hypokalemia,hyponatremia,hypochloridemia,atelectasis,pulmonary hemorrhage and the minimum serum albumin≤30 g/L during mechanical ventilation in the group with poor prognosis was significantly higher than that of the other group(P<0.05).(3)Multivariate Logistic regression analysis showed that relapse after using ventilator or withdrawing ventilator,hyponatremia,hypochloridemia and the minimum serum albumin≤30 g/L during mechanical ventilation were independent high risk factors for poor prognosis.ConclusionAcinetobacter baumannii is the main pathogen in VAP neonates with poor prognosis.The prognosis of children with VAP can be improved by reducing relapse after using ventilator or withdrawing ventilator,correcting electrolyte disorders in time and increasing nutritional reserves.