呼吸机相关肺炎下呼吸道真菌定植的危险因素及意义

Risk Factors and Clinical Significance of Low Respiratory Tract Fungal Colonization in Patients with Ventilator Associated Pneumonia

目的调查分析呼吸机相关肺炎 (VAP)下呼吸道真菌定植的危险因素及临床意义。方法调查1999年 1月至 2 0 0 0年 12月本科收治的 5 3例VAP患者下呼吸道真菌定植的流行病学情况 ,根据真菌培养结果 ,将患者分为真菌定植组与非真菌定植组 ,对比分析其危险因素和对VAP患者结局的影响。结果5 3例患者中 ,共 30例患者在下呼吸道培养分离出 4 9株真菌 ,占VAP患者的 5 6 .6 % (30 / 5 3) ,其中念珠菌属占 98.0 % ,白色念珠菌占 5 1%。真菌定植组与非真菌定植组在前期是否使用强力广谱抗生素上有非常显著差异(P =0 .0 0 6 ) ,而在年龄、性别、APACHEⅡ评分、SAPSⅡ评分、前期是否使用激素和抑酸剂方面未发现有统计学显著差异。两组在死亡率和呼吸机使用天数上没有显著差异。结论在VAP患者中下呼吸道真菌定植很普遍 ,前期使用强力广谱抗生素是主要的危险因素之一。下呼吸道真菌定植对VAP患者的主要结局没有显著影响。对于没有免疫缺陷的VAP患者 ,没有必要根据下呼吸道真菌定植的结果来启动抗真菌治疗 。

ObjectivesTo survey the risk factors and clinical significance of low respiratory tract fungal colonization (LRTFC) in ventilator associated pneumonia (VAP).MethodsThe epidemiological data of LRTFC were collected from fifty three VAP patients who were admitted and treated in our ICU during Jan.1999～Dec.2000. They were divided into fungal colonization group and non fungal colonization group according to results of fungi culture. Risk factors and their effects on the outcome of VAP patients were compared and analyzed between both groups.ResultsForty nine strains of fungi were isolated from the LRT in 30 out of 53 patients, accounting for 56.6% (30/53) of VAP patients ; 98% of the isolates were Candida species, in which 51% belonged to Candida albicans. There was statistically significant difference in whether potent antibiotics with broad spectrum had been used at prior stage between fungal colonization group and non fungal colonization group (P=0.006), while no statistically significant differences were found in age, sex, APACHE Ⅱ scores, SAPS Ⅱ scores and whether glucocorticosteroid and antiacid were administered previously. No significant difference also existed in hospital mortality and number of days required for respirator application between both groups.ConclusionLRTFC is quite prevalent in VAP patients. Prior administration of potent antibiotics with broad spectrum is one of main risk factors. LRTFC exerts no distinct effect on essential outcomes of the patients. As for VAP patients without immunodeficiency, it is unnecessary to initiate antifungal therapy based on the results of LRTFC. Judgment made from other risk factors of invasive fungal infection and clinical manifestation should be emphasized.