【www.zhangdahai.com--教学心得体会】
[摘要] 目的:探讨ICU鲍氏不动杆菌肺炎患者预后及危险因素。方法:2007年6月1日至2008年5月�31日入住东南大学附属中大医院ICU的鲍氏不动杆菌肺炎患者纳入观察,记录患者一般情况、抗生素的使用和病原菌药敏结果等,并记录患者28 d病死率及60 d病死率等临床指标,对可能影响鲍氏不动杆菌肺炎患者预后的危险因素进行分析。结果:观察期内入中大医院ICU的426例患者中医院获得性鲍氏不动杆菌肺炎患者52例,鲍氏不动杆菌肺炎发生率为12.2%。患者28 d病死率为32.7%,60 d病死率为34.6%。生存组患者确诊鲍氏不动杆菌肺炎时GCS评分和平均动脉压均明显高于死亡组,而确诊前合并真菌感染及病程中发生休克的比例均明显低于死亡组。Logistic多元回归分析结果显示确诊鲍氏不动杆菌肺炎时GCS评分低,确诊前合并真菌感染以及病程中发生休克是鲍氏不动杆菌肺炎患者死亡的独立危险因素。结论:ICU鲍氏不动杆菌肺炎患者确诊前合并真菌感染以及病程中发生休克提示患者预后不良。�
[关键词] 鲍曼不动杆菌; 肺炎; 预后�
[中图分类号] R563.1[文献标识码] A[文章编号] 1671-7562(2010)01-0006-05�
doi:10.3969/j.issn.1671-7562.2010.01.002��
Prognosis and risk factor of patients with pneumonia caused �
by Acinetobacter baumannii in ICU��
LI Jia, LIU Ling, YANG Yi
(Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing 210009, China)��
[Abstract] Objective: To investigate the prognosis and risk factor of the patients with pneumoniacaused by Acinetobacter baumannii in ICU. Methods: Fifty-two patients with pneumonia caused by Acinetobacter baumannii from June in 2007 to May in 2008 were enrolled in this study and were divided into two groups based on the prognosis. The following parameters of the patients were recorded: baseline characteristics of patients, the use of antibiotic, the sensitivity of Acinetobacter baumannii, 28-day mortality and 60-day mortality. Results: Fifty-two patients met the criteria for pneumoniacaused by Acinetobacter baumannii in the total 426 patients. The incidence of pneumoniacaused by Acinetobacter baumannii in this study was 12.2%, the 28-day mortality was 32.7% and the 60-day mortality was 34.6%. GCS score and MAP at enrollment of survivals were much higher than nonsurvivals, and the rates of superinfection by fungi before enrollment and shock during the course of disease were much lower. With the multivariate analysis, a lower GCS score at enrollment, superinfection by fungi before enrollment and a higher shock rate were independent risk factors of the death in patients with pneumonia caused by Acinetobacter �baumannii. Conclusion: Superinfection by fungi before enrollment and shock were valuable in predicting the prognosis of the pneumonia caused by Acinetobacter baumannii in ICU.�
[Key words] Acinetobacter baumannii; pneumonia; prognosis�
鲍氏不动杆菌是自然界常见的革兰阴性需氧杆菌,近年来它是院内感染的重要病原菌,而ICU的危重病患者为其易感人群[1-2]。鲍氏不动杆菌对抗生素的耐药率极高,导致临床治疗困难,病死率高达40%左右[3]。本研究拟探讨影响鲍氏不动杆菌肺炎预后的危险因素,以期为更好地治疗鲍氏不动杆菌肺炎提供参考。�
1 对象与方法�
1.1 病例选择�
2007年6月1日至2008年5月31日期间入住东南大学附属中大医院ICU,符合下述标准的患者纳入研究:(1) 临床表现符合中华医学会呼吸病学会拟定的医院获得性肺炎的诊断标准[4]。(2) 痰细菌培养结果提示鲍氏不动杆菌阳性连续两次:人工气道患者采用一次性痰液收集器直接从下呼吸道中收集痰标本;无人工气道患者清洁口咽后,深部咳痰留于无菌容器中送检。�
1.2 临床观察�
记录患者入ICU时性别、年龄、诊断、GCS评分、APACHEⅡ评分、血乳酸水平、器官衰竭个数。记录患者确诊鲍氏不动杆菌肺炎时(即入组时,指第2次培养阳性的送检痰培养的时间)体温、心率、平均动脉压(MAP)、动脉血氧合指数、乳酸水平、GCS评分、APACHEⅡ评分、外周血白细胞和血小板计数。记录患者确诊前住院时间及合并感染,病程中机械通气时间、休克持续时间以及是否气管切开。�
1.3 细菌学培养及抗生素应用情况�
记录患者病程中细菌学培养结果及药敏试验结果。如首次培养鲍氏不动杆菌仅对一代头孢耐药对其他抗生素敏感,记为敏感菌;仅对碳氢酶烯类抗生素敏感,对其他药物均耐药,记为多药耐药菌;对所有药物均耐药为全耐药菌。记录病程中抗生素应用情况及经验性抗生素治疗是否准确。�
1.4 预后�
以确诊鲍氏不动杆菌肺炎后60 d患者生存情况作为预后判断指标,分为生存组和死亡组。记录28 d病死率和60 d病死率。�
1.5 统计学处理�
实验数据采用SPSS 15.0软件进行统计学分析。正态分布参数以±s表示,非正态分布参数用中位数(四分位间距)表示。均数比较先进行方差齐性检验,方差齐时采用单因素方差分析,组间方差不齐时采用秩和检验。组间率比较采用χ2检验。P0.05�
图1 不同敏感性病原菌感染患者预后的生存分析�
Fig 1 Kaplan-Meier analysis of probability of survival of patients infected by pathogenic bacteria with different sensibility
表5 确诊前患者合并感染对患者预后的影响例�
Tab 5 Influences of infection by other microorganismscases�
组 别n合并其它细菌感染合并真菌感染
生存组3417(50.0)9(26.5)
死亡组1813(72.2)10(55.6)
P值0.1510.046
注:括弧中为所占百分比
鲍氏不动杆菌肺炎患者确诊前经验性抗生素治疗的准确率为19.2%,经验性抗生素治疗准确患者的�60 d病死率为40.0%,不准确的为33.3%。上述两者的60 d病死率差异无统计学意义。�
2.5 鲍氏不动杆菌肺炎患者预后的独立危险因素�
单因素分析中生存组和死亡组患者比较有统计学差异的指标:确诊鲍氏不动杆菌肺炎时GCS评分、MAP、确诊前合并真菌感染、病程中发生休克,纳入Logistic多元回归模型,结果显示确诊时GCS评分低、确诊前合并真菌感染以及病程中发生休克是鲍氏不动杆菌肺炎患者死亡的独立危险因素(表6)。
表6 Logistic多元回归分析鲍氏不动杆菌肺炎患者死亡的独立危险因素�
Tab 6 Independent risk factors of death in patients infected by Acinetobacter baumannii�
因 素χ2OR95%可信区间P值
值确诊时GCS评分5.7930.5900.384～0.9070.016
确诊时MAP2.7490.8890.773～1.0220.097
确诊前合并真菌感染5.06321.6671.487～315.7930.024
病程中发生休克5.904247.4462.903～21 092.1410.015�
3 讨论�
鲍氏不动杆菌作为一种条件致病菌广泛存在于水、土壤等自然环境,同时也存在于医院环境及人体皮肤,待机体抵抗力下降时引发感染成为病原菌,近年来其在院内感染的发病率也越来越高,偶可引起大流行[5-8]。鲍氏不动杆菌耐药率的不断攀升,使得该病原菌感染的患者病情更为复杂难治,病死率高,住院费用大大增加。因此,鲍氏不动杆菌的院内感染是不容忽视的问题。本研究显示ICU鲍氏不动杆菌肺炎患者发生率高达12.2%,28 d病死率达32.7%,60 d病死率达34.6%。国外有研究提示鲍氏不动杆菌感染的烧伤患者ICU病死率为33.3%,与本研究基本相符[5]。�
鲍氏不动杆菌肺炎患者的预后受多因素影响。国内外研究显示,患者原发病、基础疾病严重程度以及抗生素的滥用均与鲍氏不动杆菌感染患者的预后相关[7,9]。本研究显示,确诊鲍氏不动杆菌肺炎前合并真菌感染、病程中发生休克以及确诊时GCS评分低是鲍氏不动杆菌肺炎患者死亡的独立危险因素。�
合并真菌感染是鲍氏不动杆菌肺炎患者死亡的独立危险因素。本研究中,死亡组患者确诊前发生真菌感染的比例明显增高,Logistic多元回归分析显示其OR值高达21.667,强烈提示合并真菌感染对判断鲍氏不动杆菌肺炎的危重病患者预后不良有重要价值。因此,对于鲍氏不动杆菌肺炎的高危患者积极预防及治疗真菌感染可能可以改善预后。�
合并休克的鲍氏不动杆菌肺炎患者预后不良。Logistic多元回归分析提示鲍氏不动杆菌肺炎患者病程中发生休克的OR值为247.446。国内研究提示感染性休克影响鲍氏不动杆菌血流感染患者预后,其结论与本实验结果相符[7]。而患者发生休克即提示感染严重,导致血流动力学不稳定,一旦发生休克则病死率高,因此必须密切关注患者循环状态,进行积极预防,对于已发生休克的患者也应积极治疗纠正休克,以期改善患者病情和预后。�
患者的意识状态可能是影响鲍氏不动杆菌肺炎患者预后的重要因素。本研究中Logistic多元回归分析结果显示,患者确诊鲍氏不动杆菌肺炎时GCS评分低是患者死亡的危险因素。意识不清可能导致患者自主呛咳反射减弱,呼吸道分泌物不易排出,可加重肺部感染,导致病情恶化,影响预后。因此对于意识不清的患者,我们更应做好呼吸道清洁和管理,保持呼吸道通畅,加强气道湿化促进排痰、必要时开放人工气道,同时病程中应注意保持半卧位防止返流误吸,以期达到改善患者病情的效果[10]。�
鲍氏不动杆菌耐药率不断攀升,导致患者预后不良。国内外研究报道鲍氏不动杆菌碳氢酶烯类抗生素耐药率高达40%~80%[5,7,9,11]。本研究中的52例患者培养结果碳氢酶烯类抗生素耐药率为55.8%。鲍氏不动杆菌感染率居高不下,甚至呈上升态势的原因可能与抗生素的滥用以及细菌定植有关[12-16]。对于多药耐药甚至全耐药的鲍氏不动杆菌感染目前缺乏有效的治疗措施,因此,合理使用有效的抗生素,并积极寻找导致鲍氏不动杆菌耐药的其他原因势在必行。�
综上所述,ICU鲍氏不动杆菌肺炎发病率高,病原菌耐药率高,其患者预后不佳,病死率也高。而合并真菌感染以及病程中发生休克是ICU鲍氏不动杆菌肺炎患者死亡的独立危险因素。�
[参考文献]�
[1] MUNOZ-PRICE L S, WEINSTEIN R A. Acinetobacter infection[J]. N Engl J Med,2008,258:1271-1281.�
[2] SHORR A F. Review of studies of the impact on Gram-negative bacterial resistance on outcomes in the intensive care unit[J]. Crit Care Med,2009,37:1463-1469.�
[3] 冯加喜,林云,吕冬青.耐亚胺培南鲍氏不动杆菌医院获得性肺部感染危险因素及耐药性分析[J].中华医院感染学杂志,2006,16:1416-1418.�
[4] 中华医学会呼吸病学会.医院获得性肺炎诊断和治疗指南(草案)[J].中华结核呼吸杂志,1999,22:201-204.�
[5] TROTTIER V, SEGURA P G, NAMIAS N, et al. Outcomes of acinetobacter baumannii infection in critically Ⅲ burned patients[J]. J Burn Care Res,2007,28:248-254.�
[6] BLOSSOM D B, SRINIVASAN A. Drug-resistant acinetobacter baumannii calcoaceticus complex an emerging nosocomial pathogen with few treatment options[J]. Infect Dis Clin Pract,2008,16:1-3.�
[7] 沈宁,姚婉贞,刘振英.鲍曼不动杆菌血流感染临床分析[J].中国感染与化疗杂志,2008,8:126-129.�
[8] WANG F D, CHO W L, LIU C Y, et al. Risk factors for mortality in patients with Acinetobacter baumannii bloodstream infection with genotypic species identification[J]. J Microbiol Immunol Infect,2008,41:397-402.�
[9] BARAN G, ERBAY A, BODUR H, et al. Risk factors for nosocomial imipenem- resistant Acinetobacter baumannii infections[J]. J Infect Dis,2008,12:16-21.�
[10] 李卫光,王一兵,朱其凤,等.心外科重症监护病房鲍氏不动杆菌医院感染暴发流行调查[J].中华医院感染学杂志,2006,16:1108-1109.�
[11] 张玉萍.ICU铜绿假单胞菌与鲍曼不动杆菌[J].东南大学学报:医学版,2008,27(5):370-372.�
[12] SHIH M J, LEE N Y, LEE H C, et al. Risk factors of multidrug resistance in nosocomial bacteremia due to Acinetobacter baumannii: a case-control study[J]. J Microbiol Immunol Infect,2008,41:118-123.�
[13] ELSHAFIE S S, ALISHAQ M, GARCIA M L. Investigation of an outbreak of multidrug-resistant Acinetobacter baumannii in trauma intensive care unit[J]. J Hosp Infect,2004,56:101-105.�
[14] DENTON M, WILCOX M H, PARNELL P, et al. Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit[J]. Intensive and Critical Care Nursing,2005,21:94-98.�
[15] GRIFFITH M E, YUN H C, HORVATH L L, et al. Minocycline therapy for traumatic wound infections caused by the multidrug-resistant Acinetobacter baumannii-Acinetobacter calcoaceticus complex[J]. Infect Dis Clin Pract,2008,16:16-19.�
[16] SEGAL S C, ZAOUTIS T E, KAGEN J, et al. Epidemiology of and risk factors for Acinetobacter species bloodstream infection in children[J]. Pediatr Infect Dis J,2007,26:920-926.
