菌血症对呼吸机相关性肺炎临床特征及预后影响
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摘要
目的研究菌血症对呼吸机相关性肺炎(VAP)的临床特征及预后有无影响。方法选择2012年6月至2017年6月,在本院ICU接受机械通气治疗的VAP患者。分为菌血症组和对照组。采用急性生理与慢性健康(APACHE)Ⅱ评分系统评估病情的严重程度,比较两组患者的临床特征及28天的死亡率。结果163例VAP患者中,有32例存在菌血症(19. 6%)。呼吸道及血培养物结果显示,金黄色葡萄球菌是最常见引起菌血症的病原微生物(46. 8%和43. 8%)。菌血症组APACHEⅡ评分和28天的死亡率明显高于对照组,差异有统计学意义(P <0. 05)。多因素Logistic回归分析显示,呼吸道培养物MRSA感染、近期使用广谱抗生素是菌血症的独立危险因素。结论菌血症可增加VAP患者的死亡率,呼吸道培养物MRSA感染、近期使用广谱抗生素是引起菌血症的独立危险因素。
Objective To study the effect of bacteremia on the clinical features and prognosis of ventilatorassociated pneumonia( VAP). Methods Patients with VAP received mechanical ventilation in ICU were selected and divided into the bacteremia group and the control group from June 2012 to June 2017. The acute Physiological Assessment and Chronic Health Evaluation Ⅱ score( APACHE Ⅱ score) was used to evaluate the severity of the VAP. The general clinical data of VAP patients and 28-day mortality were evaluated respectively between the two groups. Results 32 patient( 19. 6%) were diagnosed with bacteremia in 163 cases of VAP. Staphylococcus aureus was the most common pathogenic microorganism causing bacteremia( 46. 8% and 43. 8%) in the test of respiratory tract and blood culture. The APACHE Ⅱ score and 28 day mortality were higher in the bacteremia group than the control group( P < 0. 05). Multivariate Logistic regression analysis showed that MRSA infection in respiratory tract culture and the recent use of broad-spectrum antibiotics were independent risk factors for bacteremia. Conclusion Bacteremia can increase the mortality of VAP patients,and MRSA infection and the recent use of broad-spectrum antibiotics are independent risk factors for bacteremia.
Objective To study the effect of bacteremia on the clinical features and prognosis of ventilatorassociated pneumonia( VAP). Methods Patients with VAP received mechanical ventilation in ICU were selected and divided into the bacteremia group and the control group from June 2012 to June 2017. The acute Physiological Assessment and Chronic Health Evaluation Ⅱ score( APACHE Ⅱ score) was used to evaluate the severity of the VAP. The general clinical data of VAP patients and 28-day mortality were evaluated respectively between the two groups. Results 32 patient( 19. 6%) were diagnosed with bacteremia in 163 cases of VAP. Staphylococcus aureus was the most common pathogenic microorganism causing bacteremia( 46. 8% and 43. 8%) in the test of respiratory tract and blood culture. The APACHE Ⅱ score and 28 day mortality were higher in the bacteremia group than the control group( P < 0. 05). Multivariate Logistic regression analysis showed that MRSA infection in respiratory tract culture and the recent use of broad-spectrum antibiotics were independent risk factors for bacteremia. Conclusion Bacteremia can increase the mortality of VAP patients,and MRSA infection and the recent use of broad-spectrum antibiotics are independent risk factors for bacteremia.
引文
[1]MELSEN W G,ROVERS M M,GROENWOLD R H,et al.Attributable mortality of ventilator-associated pneumonia:a meta-analysis of individual patient data from randomised prevention studies[J].Lancet Infect Dis,2013,13(8):665-671.
[2]JU M H,YAO Y L,DU C L,et al.Subsequent multidrug-resistant bacteremia is a risk factor for short-term mortality of patients with ventilator-associated pneumonia caused by Acinetobacter baumannii in intensive care unit:a multicenter experience[J].Chin Med J(Engl),2018,131(3):361-363.
[3]中华医学会呼吸病学分会感染学组.中国成人医院获得性肺炎与呼吸机相关性肺炎诊断和治疗指南(2018年版)[S].中华结核和呼吸杂志,2018,41(4):255-280.
[4]中华人民共和国卫生部.医院感染诊断标准(试行)[S].中华医学杂志,2001,81(5):314-320.
[5]KUNAC A,SIFRI Z C,MOHR A M,et al.Bacteremia and ventilator-associated pneumonia:a marker for contemporaneous extra-pulmonic infection[J].Surg Infect(Larchmt),2014,15(2):77-83.
[6]HURLEY J C.Unusually high incidences of staphylococcus aureus infection within studies of ventilator associated pneumonia prevention using topical antibiotics:benchmarking the evidence base[J].Microorganisms,2018,6(1):E2.
[7]SCHREIBER M P,CHAN C M,SHORR A F.Bacteremia in Staphylococcus aureus pneumonia:outcomes and epidemiology[J].JCrit Care,2011,26(4):395-401.
[8]HELMICK R A,KNOFSKY M L,BRAXTON C C,et al.Mandated self-reporting of?ventilator-associated pneumonia?bundle and catheter-related bloodstream infection bundle compliance and infection rates[J].JAMA Surg,2014,149(10):1003-1007.
[9]WU H S,KUO S C,CHEN L Y,et al.Comparison between patients under hemodialysis with community-onset bacteremia caused by community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus strains[J].J Microbiol Immunol Infect,2013,46(2):96-103.
[10]STRYJEWSKI M E,BARRIERE S L,RUBINSTEIN E,et al.Telavancin versus vancomycin for bacteraemic hospital-acquired pneumonia[J].Int J Antimicrob Agents,2013,42(4):367-369.
[11]DUNCAN L R,SMART J I,FLAMM R K,et al.Telavancin activity tested against a collection of Staphylococcus aureus isolates causing pneumonia in hospitalized patients in the United States(2013-2014)[J].Diagn Microbiol Infect Dis,2016,86(3):300-302.
[12]COREY G R,KOLLEF M H,SHORR A F,et al.Telavancin for hospital-acquired pneumonia:clinical response and 28-day survival[J].Antimicrob Agents Chemother,2014,58(4):2030-2037.
[13]RUIZ-RAMOS J,VIDAL-CORTS P,DAZ-LAMAS A,et al.Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus:do minimum inhibitory concentrations to vancomycin and daptomycin matter[J].Eur J Clin Microbiol Infect Dis,2017,36(9):1569-1575.
[14]BARUAH M,LYNGDOH C,LYNGDOH W V,et al.Noncatheterrelated bacteraemia due to Chryseobacterium indologenes in an immunocompetent patient[J].Indian J Med Microbiol,2016,34(3):380-381.
[15]BROTFAIN E,BORER A,KOYFMAN L,et al.Multidrug resistance Acinetobacter bacteremia secondary to ventilator-associated pneumonia:risk factors and outcome[J].J Intensive Care Med,2017,32(9):528-534.
[16]DE LA CALLE C,MORATA L,COBOS-TRIGUEROS N,et al.Staphylococcus aureus bacteremic pneumonia[J].Eur J Clin Microbiol Infect Dis,2016,35(3):497-502.
[2]JU M H,YAO Y L,DU C L,et al.Subsequent multidrug-resistant bacteremia is a risk factor for short-term mortality of patients with ventilator-associated pneumonia caused by Acinetobacter baumannii in intensive care unit:a multicenter experience[J].Chin Med J(Engl),2018,131(3):361-363.
[3]中华医学会呼吸病学分会感染学组.中国成人医院获得性肺炎与呼吸机相关性肺炎诊断和治疗指南(2018年版)[S].中华结核和呼吸杂志,2018,41(4):255-280.
[4]中华人民共和国卫生部.医院感染诊断标准(试行)[S].中华医学杂志,2001,81(5):314-320.
[5]KUNAC A,SIFRI Z C,MOHR A M,et al.Bacteremia and ventilator-associated pneumonia:a marker for contemporaneous extra-pulmonic infection[J].Surg Infect(Larchmt),2014,15(2):77-83.
[6]HURLEY J C.Unusually high incidences of staphylococcus aureus infection within studies of ventilator associated pneumonia prevention using topical antibiotics:benchmarking the evidence base[J].Microorganisms,2018,6(1):E2.
[7]SCHREIBER M P,CHAN C M,SHORR A F.Bacteremia in Staphylococcus aureus pneumonia:outcomes and epidemiology[J].JCrit Care,2011,26(4):395-401.
[8]HELMICK R A,KNOFSKY M L,BRAXTON C C,et al.Mandated self-reporting of?ventilator-associated pneumonia?bundle and catheter-related bloodstream infection bundle compliance and infection rates[J].JAMA Surg,2014,149(10):1003-1007.
[9]WU H S,KUO S C,CHEN L Y,et al.Comparison between patients under hemodialysis with community-onset bacteremia caused by community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus strains[J].J Microbiol Immunol Infect,2013,46(2):96-103.
[10]STRYJEWSKI M E,BARRIERE S L,RUBINSTEIN E,et al.Telavancin versus vancomycin for bacteraemic hospital-acquired pneumonia[J].Int J Antimicrob Agents,2013,42(4):367-369.
[11]DUNCAN L R,SMART J I,FLAMM R K,et al.Telavancin activity tested against a collection of Staphylococcus aureus isolates causing pneumonia in hospitalized patients in the United States(2013-2014)[J].Diagn Microbiol Infect Dis,2016,86(3):300-302.
[12]COREY G R,KOLLEF M H,SHORR A F,et al.Telavancin for hospital-acquired pneumonia:clinical response and 28-day survival[J].Antimicrob Agents Chemother,2014,58(4):2030-2037.
[13]RUIZ-RAMOS J,VIDAL-CORTS P,DAZ-LAMAS A,et al.Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus:do minimum inhibitory concentrations to vancomycin and daptomycin matter[J].Eur J Clin Microbiol Infect Dis,2017,36(9):1569-1575.
[14]BARUAH M,LYNGDOH C,LYNGDOH W V,et al.Noncatheterrelated bacteraemia due to Chryseobacterium indologenes in an immunocompetent patient[J].Indian J Med Microbiol,2016,34(3):380-381.
[15]BROTFAIN E,BORER A,KOYFMAN L,et al.Multidrug resistance Acinetobacter bacteremia secondary to ventilator-associated pneumonia:risk factors and outcome[J].J Intensive Care Med,2017,32(9):528-534.
[16]DE LA CALLE C,MORATA L,COBOS-TRIGUEROS N,et al.Staphylococcus aureus bacteremic pneumonia[J].Eur J Clin Microbiol Infect Dis,2016,35(3):497-502.