重症脑卒中后呼吸机相关肺炎临床及病原学特点

Clinical and pathogenic characteristics of ventilator-associated pneumonia after severe stroke

目的分析重症脑卒中后呼吸机相关肺炎(VAP)的临床和病原学特点。方法收集上海市普陀区中心医院重症监护病房2018年1月至2023年1月收治的121例重症脑卒中机械通气患者,按照是否发生VAP分成VAP组(53例)和非VAP组(68例),分析VAP的临床特点和危险因素、不同机械通气时间VAP发生率及VAP的病原学分布和药敏特点。计量资料采用独立样本t检验或U检验,计数资料比较采用Pearson卡方检验或Fisher’s确切概率法。采用单因素分析和多因素Logistic回归分析进行VAP发病相关危险因素研究。结果121例机械通气患者发生VAP共53例,其发病率为43.8%(53/121)。VAP与非VAP组患者性别、卒中类型、气管插管方式、胃管留置率和并发症差异无统计学意义(P均>0.05);两组患者年龄、卒中严重程度、机械通气时间、住院时间、医疗费用、良好预后率及院内病死率差异有统计学意义(P均<0.05)。多因素Logistic回归分析显示,年龄(OR=2.092、95%CI:1.507~2.905、P<0.001)和格拉斯哥昏迷量表(GCS)评分(OR=0.248、95%CI:0.103~0.599、P=0.002)均为VAP发生的独立危险因素。机械通气使用时间1~7 d的患者VAP发生率为28.3%(17/60),机械通气使用时间8~14 d的患者VAP发生率为49.0%(24/49),差异有统计学意义(χ^(2)=4.900、P=0.027);机械通气时间超过14 d的患者VAP发生率为100%(12/12),与机械通气8~14 d患者VAP发生率(49.0%,24/49)比较,差异有统计学意义(P=0.001)。VAP病原学分布:53例VAP患者痰中分离出病原菌95株,其中革兰阴性杆菌占75.8%(72/95),革兰阳性球菌占16.8%(16/95),真菌占7.4%(7/95)。革兰阴性杆菌中鲍曼不动杆菌占比最高,达34.7%(25/72)。革兰阳性菌中金黄色葡萄球菌占比最高,达56.3%(9/16)。VAP药敏特点:VAP耐药现象严重,鲍曼不动杆菌、肺炎克雷伯菌、铜绿假单胞菌和大肠埃希菌是最为重要的4种革兰阴性耐药菌,仅对多黏菌素、替加环素和美罗培南等药物敏感。金黄色葡萄球菌是最主要的革兰阳性耐药菌[9(56.3%)],除对万古霉素[1(11.1%)]、利奈唑胺[1(11.1%)]和替考拉宁[1(11.1%)]耐药率较低外,对其他多种抗菌药物均存在广泛耐药。结论重症卒中患者具有较高的VAP发病率,年龄和卒中严重程度是VAP独立危险因素;VAP耐药现象严重,鲍曼不动杆菌和金黄色葡萄球菌分别是耐药率最高的革兰阴性和阳性菌株;VAP对卒中预后产生严重的不良影响,需要采取积极措施减少VAP的发生。

Objective To investigate the clinical and pathogenic characteristics of ventilator-associated pneumonia(VAP)after severe stroke.Methods Total of 121 mechanically ventilated patients with severe stroke admitted to the intensive care unit of Shanghai Putuo District Central Hospital from January 2018 to January 2023 were divided into VAP group(53 cases)and non-VAP group(68 cases)according to whether complicated with VAP.The clinical characteristics and risk factors of VAP,incidence of VAP at different mechanical ventilation times,and etiological distribution and drug susceptibility characteristics of VAP were analyzed.Measurement data were measured by independent sample t-test or U test and count data were compared by Pearson Chi-square test or Fisher’s exact probability.The risk factors associated with VAP were analyzed by Univariate analysis and multivariate binary Logistic regression analysis.Results There were 53 VAP cases in 121 mechanically ventilated patients,and the incidence rate was 43.8%(53/121).The gender,stroke types,the way of endotracheal intubation,rate of gastric tube retention and complications between VAP and non-VAP groups were without significant differences(all P>0.05),but age,stroke severity,mechanical ventilation duration,length of hospitalization,medical cost,good prognosis and hospital mortality between the two groups were with significant differences(all P<0.05).Multivariate Logistic regression analysis showed that age(OR=2.092,95%CI:1.507-2.905,P<0.001)and Glasgow Coma Scale score(OR=0.248,95%CI:0.103-0.599,P=0.002)were both independent risk factors for VAP.The incidence of VAP was 28.3%(17/60)among patients for 1-7 d,and the incidence of VAP among patients for 8-14 d was 49.0%(24/49),with significant difference(χ^(2)=4.900,P=0.027).Compared with patients with mechanical ventilation for 8-14 d(49.0%,24/49),the incidence of VAP among patients with mechanical ventilation over 14 d was 100%(12/12),with significant difference(P=0.001).The pathogen distribution of VAP:total of 95 strains of pathogenic bacteria were isolated from the sputum of 53 patients with VAP,including 75.8%(72/95)of Gram-negative bacteria,16.8%(16/95)of Gram-positive cocci,and 7.4%(7/95)of fungi.Acinetobacter baumannii accounted for the highest proportion of Gram-negative bacteria up to 34.7%(25/72).Gram-positive bacteria were mainly Staphylococcus aureus[56.3(9/16)].The drug susceptibility test results showed that the phenomenon of VAP drug-resistance was severe,with Acinetobacter baumannii,Klebsiella pneumoniae,Pseudomonas aeruginosa and Escherichia coli being the four most important Gram-negative resistant bacteria,only sensitive to polymyxin,tigecycline and meropenem.Staphylococcus aureus was the leading Gram-positive resistant bacteria[9(56.3%)],with extensive resistance to many other antibiotics,except for the low resistance rate to vancomycin[1(11.1%)],linezolid[1(11.1%)]and teicoplanin[1(11.1%)].Conclusions Patients with severe stroke had a high incidence of VAP,and age and stroke severity were independent risk factors for VAP,and Acinetobacter baumannii and Staphylococcus aureus were the Gram-negative and positive strains with the highest resistance rate,respectively.VAP has serious adverse effects on stroke prognosis,and aggressive measures are needed to reduce the occurrence of VAP.