ARDS患者并发VAP的危险因素分析及病原菌检测

Analysis of risk factors for ventilator-associated pneumonia in patients with acute respiratory distress syndrome and pathogen detection

目的分析急性呼吸窘迫综合征(ARDS)患者并发呼吸机相关性肺炎(VAP)的危险因素及病原菌分布。方法回顾性分析西安国际医学中心医院2020年1月至2023年1月收治的ARDS患者118例的临床资料,根据是否并发VAP将患者分为VAP组(n=38)与Non-VAP组(n=80)。比较两组血清学指标、血气分析指标、呼吸机参数等,分析影响VAP发生的危险因素,并对患者痰液中的病原菌进行检测。结果118例患者中,男79例,女39例;年龄(53.1±9.6)岁。ARDS主要的原发病包括慢性阻塞性肺疾病49例(41.53%)、脓毒血症20例(16.95%)、重症肺炎17例(14.41%)、大面积脑卒中16例(13.56%)。单因素分析结果显示:与Non-VAP组相比,VAP组的ARDS严重程度明显较重(Z=-4.73,P<0.05),白蛋白、血小板及降钙素原水平显著较低(t=13.75、3.11、2.27,均P<0.05),超敏C反应蛋白、转化生长因子β、血管紧张素Ⅱ水平显著较高(t=2.51、26.63、27.50,均P<0.05);VAP组发生昏迷、接受气管切开、使用2种以上抗生素的比例显著较高(χ^(2)=14.84、19.04、11.22,均P<0.05),抗生素使用天数也明显延长(t=6.88,P<0.05)。多因素分析显示,白蛋白(OR=2.632,95%CI:1.398~3.749)、超敏C反应蛋白(OR=2.358,95%CI:1.534~4.036)、昏迷(OR=3.035,95%CI:2.034~3.834)、使用抗生素>2种(OR=2.005,95%CI:1.363~2.846)是影响ARDS患者并发VAP的独立性危险因素(均P<0.05)。38例VAP患者的痰液中共分离出病原菌63株,80例Non-VAP患者的痰液中共分离出病原菌128株。最常见的病原菌依次为铜绿假单胞菌、肺炎克雷伯菌、鲍曼不动杆菌、金黄色葡萄球菌。VAP组、Non-VAP组检测出单一病原菌分别为16例(42.11%)、51例(63.75%),2种病原菌分别为14例(36.84%)、25例(31.25%),3种及以上病原菌分别为8例(21.05%)、4例(5.00%)。VAP组、Non-VAP组生存率分别为57.9%(22/38)、85.0%(68/80),Non-VAP组的生存率明显较好(χ^(2)=22.67,P<0.001)。结论ARDS患者并发VAP的风险较高,且以双重或多重病原菌感染为主,应加强临床干预。

Objective To analyze the risk factors and pathogen distribution of ventilator-associated pneumonia(VAP)in patients with acute respiratory distress syndrome(ARDS).Methods A retrospective analysis was conducted on the clinical data of 118 patients with ARDS who received treatment at Xi'an International Medical Center Hospital from January 2020 to January 2023.The patients were divided into two groups:the VAP group(n=38)and the non-VAP group(n=80),based on the presence of concurrent VAP.Serological indicators,blood gas analysis parameters,and ventilator settings were compared between the two groups to identify the risk factors associated with the occurrence of VAP.Pathogenic bacteria in the patients'sputum were also detected.Results Among the 118 patients,there were 79 males and 39 females,with an average age of(53.1±9.6)years.The primary underlying conditions leading to ARDS included chronic obstructive pulmonary disease in 49 cases(41.53%),sepsis in 20 cases(16.95%),severe pneumonia in 17 cases(14.41%),and extensive stroke in 16 cases(13.56%).Univariate analysis revealed that,compared with the non-VAP group,the VAP group had significantly more severe ARDS(Z=-4.73,P<0.05).Compared with the non-VAP group,the levels of albumin,platelets,and procalcitonin in the VAP group were significantly lower(t=13.75,3.11,2.27,all P<0.05),while levels of high-sensitivity C-reactive protein,transforming growth factor beta(TGF-β),and angiotensinⅡin the VAP group were significantly higher(t=2.51,26.63,27.50,all P<0.05).The VAP group had a significantly higher proportion of patients who experienced coma,underwent tracheostomy,and received more than two types of antibiotics(χ^(2)=14.84,19.04,11.22,all P<0.05).The VAP group also had significantly longer duration of antibiotic use compared with the non-VAP group(t=6.88,P<0.05).Multivariate analysis showed that albumin(OR=2.632,95%CI:1.398-3.749),high-sensitivity C-reactive protein(OR=2.358,95%CI:1.534-4.036),coma(OR=3.035,95%CI:2.034-3.834),and use of more than two types of antibiotics(OR=2.005,95%CI:1.363-2.846)were independent risk factors for the occurrence of VAP in patients with ARDS(all P<0.05).In 38 patients with VAP,63 pathogenic strains were isolated from sputum,while in 80 patients with non-VAP,128 pathogenic strains were isolated.The most common pathogens identified were Pseudomonas aeruginosa,Klebsiella pneumoniae,Acinetobacter baumannii,and Staphylococcus aureus.In the VAP group,a single pathogen was identified in 16 cases(42.11%),whereas in the non-VAP group,a single pathogen was identified in 51 cases(63.75%).Two types of pathogens were found in 14 cases(36.84%)of the VAP group and 25 cases(31.25%)of the non-VAP group,while three or more pathogens were detected in 8 cases(21.05%)of the VAP group and 4 cases(5.00%)of the non-VAP group.The survival rates for the VAP and non-VAP groups were 57.9%(22/38)and 85.0%(68/80),respectively,with the non-VAP group showing a significantly higher survival rate(χ^(2)=22.67,P<0.001).Conclusion The risk of VAP in patients with ARDS is high,with two or more pathogen infections being predominant.Clinical interventions should be strengthened.