医院获得性肺炎、呼吸机相关性肺炎、卫生保健相关性肺炎的最新治疗进展

尽管目前有很好的抗生素治疗,对症支持治疗和预防,但是医院获得性肺炎(HAP)、呼吸机相关性肺炎(VAP)和卫生保健相关性肺炎(HCAP)仍是导致患者发病和死亡的重要原因,本文对 HAP,VAP 和 HCAP 的最新治疗进展将在此作一综述。     

医院获得性肺炎的治疗及预防进展

医院获得性肺炎(hospital-acquired pneumonia,HAP)是一种下呼吸道感染性肺炎,未接受有创机械通气的患者在入院后48 h以上发生[1]。呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)是气管插管或气管切开患者在接受机械通气48 h后,或撤机、或拔管后48 h内出现的肺炎[2]。2018年,我国发布了《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)》,明确规定VAP属于HAP的特殊类型,HAP和VAP的关键区别在于是医院获得性感染和机械通气的应用。HAP是我国最常见的医院获得性感染,HAP延长患者住院时间,导致患者病死率升高,加重了国家和家庭的医疗经济负担。HAP的全球发病率为每1000例住院患者中有5~20例[3]。在我国,住院患者中HAP的发生率为3.22%~5.22%。HAP患者占ICU患者近25%,非ICU患者HAP患病率也在增加[3-6]。目前HAP致死率仍旧很高,尚且没有明确的临床诊断和特别有效的治疗方法。本文对HAP的治疗、预防进行综述。     

医疗保健相关性肺炎的经验性治疗

医疗保健相关性肺炎(HCAP)是美国胸科学会与感染病学会(ATS/IDSA)2005年发布的成人医院获得性肺炎(HAP)、呼吸机相关性肺炎(VAP)和医疗保健相关性肺炎治疗指南中提出的新概念。本文主要从治疗场所的选择、治疗策略以及初始经验性抗菌药物选择等方面简要综述了HCAP的经验性治疗推荐,并介绍几种可能会成为治疗HCAP的新选择的抗菌药物,以期为临床医生治疗HCAP患者提供有益的借鉴。     

呼吸机相关肺炎的诊治难题和临床研究方向刍议

呼吸机相关肺炎(Ventilator-associated pneu-monia，VAP)是医院获得性肺炎(hospital—acquired pneumonia，HAP)中最常见和最严重的类型，是ICU患者的最主要死因，累积发病率15％～60％，病死率25％～76%。由于患者存在严重基础疾病、免疫防御机制损害以及ICU的特殊环境(相对封闭性、高医院感染率、抗生素高使用率和高耐药率)，加之VAP固有的特点,其诊断治疗存在诸多难题。     

老年人呼吸机相关性肺炎的危险因素及其防治策略

医院获得性肺炎(hospital acquired pneumoma，HAP)是指入院48小时后发生的肺炎。呼吸机相关性肺炎ventilator-associated pneumonia，VAP)是指应用呼吸机辅助机械通气48小时后发生的肺炎，是机械通气的常见并发症，也是医院获得性肺炎的一个重要组成部分。     

社区获得性肺炎和医院获得性肺炎国外指南评析

自2005年以来,美国、欧洲和日本分别对社区获得性肺炎(CAP)和医院获得性肺炎(HAP)的诊治指南进行了更新.新的CAP指南建议根据肺炎严重程度评分确定治疗地点,门诊患者不推荐常规进行病原学检查,并对抗菌药物应用的时机、疗程、联合用药进行了规范.新的HAP指南中预防仍是关注焦点,建议持续声门下分泌物吸引、维持合适的导管气囊内压以降低吸入风险.经支气管镜与盲取下呼吸道分泌物进行病原学培养相比,并不增加诊断价值.新的HAP指南还推荐了对多重耐药菌感染的治疗方案.     

VAP患者感染病原菌的调查和PCT、CRP水平的变化及诊断价值

目的 调查呼吸机相关性肺炎(VAP)患者感染病原菌的分布,探讨PCT、CRP水平的变化及其诊断价值。方法 2019年6月-2021年6月于我院行机械通气治疗的328例患者,根据是否发生VAP分为VAP组、非VAP组。采用全自动细菌鉴定仪检测VAP患者痰液或支气管液等标本的病原菌,分析VAP患者病原菌特点。检测并比较两组患者的血清PCT、CRP炎症因子的水平,采用ROC曲线分析血清PCT、CRP诊断VAP的效能。结果 328例患者中VAP患者144例(43.90%),共检查出188株病原菌,其中革兰阴性菌130株(69.15%),革兰阳性菌48株(25.53%),真菌10株(5.32%)。主要感染病原菌为鲍曼不动杆菌(40株)、肺炎克雷伯菌(31株)、大肠埃希菌(23株)。VAP组的血清PCT(5.16±1.52)ng/ml、CRP(18.76±5.23)mg/L水平以及CPIS评分(6.36±0.73)分明显高于非VAP组血清PCT(0.44±0.13)ng/ml、CRP(5.42±1.53)mg/L水平以及CPIS评分(3.82±0.58)分,差异有统计学意义(均P<0.05)...     

老年患者医院获得性肺炎危险因素的研究进展

医院获得性肺炎(hospital-acquired pneumonia,HAP)是指患者在入院时未感染也未处于病原感染潜伏期,而于入院48 h后新发生的肺炎.广义上讲,HAP包括呼吸机相关肺炎(ventilator associated pneumonia,VAP),后者是HAP的特殊类型[1].HAP是最常见的医院获...     

老年革兰阴性杆菌肺炎43例临床特征分析

革兰阴性杆菌是医院获得性肺炎(HAP)、呼吸机相关性肺炎(VAP)的主要致病菌[1].但近年来老年人肺部革兰阴性杆菌感染率在社区获得性肺炎(CAP)感染中也呈上升趋势.本文回顾性探讨老年革兰阴性杆菌肺炎的临床表现特征、病程经过,以期提高对老年革兰阴性杆菌肺炎的认识及治疗水平.     

降钙素原联合临床肺部感染评分在呼吸机相关性肺炎诊断和预后的价值

目的:观察并探究降钙素原(PCT)联合临床肺部感染评分(CPIS)在呼吸机相关性肺炎(VAP)的诊断及预后中的价值。方法:选取接受机械通气超过48 h的患者为研究对象,其中48例为VAP患者,56例为非VAP患者。在诊断当天对两组患者的C-反应蛋白(CRP)、PCT及CPIS等差异进行比较;在诊断后的第28天对VAP组的存活患者及死亡患者上述指标间差异进行比较,并开展受试者工作特征曲线(ROC曲线)分析。结果:VAP患者的CRP、PCT及CPIS相比于非VAP患者发生明显升高;CRP的诊断准确性比较低,PCT及CPIS则具有中等准确性,在联合应用PCT与CPIS后,诊断特异度得到显著提高(P<0.05)。在VAP患者中,死亡患者的PCT与CPIS则显著高于存活患者;在联合应用PCT与CPIS后,诊断特异度提高至84.8%。结论:在诊治VAP患者过程中,联合应用PCT与CPIS可有效提高诊断的准确性及特异度,能很好地反映病情危重程度,具有很好的临床实用价值,值得推广应用。     

Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.     

血清降钙素原在呼吸机相关性肺炎的应用

呼吸机相关性肺炎（VAP）是ICU患者进行机械通气后病情加重甚至死亡的原因之一。传统预测感染的指标对VAP的诊断敏感性、特异性不高,其预测价值有限。血清降钙素原（PCT）检测在VAP预测中较传统的炎性指标具有较高的灵敏性和特异性。国外研究发现,当人体发生细菌感染以及发生脓毒症时血清PCT浓度升高,具有一定的诊断价值。监测PCT的变化可能有助于VAP的早期诊断以及及时调整抗生素的使用。本文就VAP的诊断、治疗及预后几方面,综述PCT在VAP患者中的应用。     

Prognosis of hospital‐acquired pneumonia/ventilator‐associated pneumonia with Stenotrophomonas maltophilia versus Klebsiella pneumoniae in intensive care unit: A retrospective cohort study

IntroductionWe collected data on ventilator‐associated pneumonia (VAP) and hospital‐acquired pneumonia (HAP) induced by Stenotrophomonas maltophilia (SM) and Klebsiella pneumoniae (KP) and compared differences between two bacteria in mortality, duration of ventilator use, length of hospital stay, and risk factors for infection.ObjectivesThis study aimed to evaluate the prognosis and to find risk factors of SM‐HAP/VAP versus KP‐HAP/VAP in the intensive care unit (ICU).MethodsThis retrospective cohort study included patients admitted to the ICU between June 2019 and June 2021 and diagnosed with SM‐HAP/VAP or KP‐HAP/VAP. The primary outcome was 28‐day mortality.ResultsNinety‐two HAP/VAP patients (48 with SM‐HAP/VAP and 44 with KP‐HAP/VAP) were included. The 28‐day mortality was 16.7% (8/48 patients) in SM‐HAP/VAP and 15.9% (7/44 patients) in KP‐HAP/VAP (P = 0.922). After adjustment for potential confounders, the hazard ratios for 28‐day mortality in SM‐HAP/VAP were 1.3 (95% CI:0.5–3.7), 1.0 (95% CI:0.4–3.0), 1.4 (95% CI:0.5–4.0), and 1.1 (95% CI:0.4–3.4), respectively.ConclusionSM‐HAP/VAP and KP‐HAP/VAP patients in ICU might have a similar prognosis in mortality, the total duration of the artificial airway and ventilator use, the total length of ICU stay, and hospital stay. The risk factors of SM‐HAP/VAP versus KP‐HAP/VAP might be the artificial airway, ventilator use, gastric tube placement, acid suppressant and antibiotics (especially carbapenem).     

髓系细胞触发受体-1、降钙素原分别联合临床肺部感染评分对呼吸机相关性肺炎的诊断价值

目的探讨TREM-1、PCT分别联合CPIS在VAP中的诊断价值。方法选取2020年1月5月我院ICU收治的气管插管或气管切开接受有创机械通气治疗的住院患者156例,根据病情分为VAP组(66例)和非VAP组(90例),比较两组患者在机械通气后第1 d、3 d、7 d的血清TREM-1、PCT及CPIS间的差异。绘制ROC曲线评估血清TREM-1、PCT分别联合CPIS诊断VAP的应用价值。结果对两组患者TREM-1、PCT、CPIS进行重复测量方差分析显示:①TREM-1的时间效应、处理效应和交互效应均有统计学意义(F_时间=135.684,P<0.001;F_处理=577.117,P<0.001;F_交互=62.408,P<0.001);②PCT的时间效应、处理效应和交互效应均有统计学意义(F_时间=35.129,P<0.001;F_处理=158.284,P<0.001;F_交互=31.220,P<0.001);③CPIS的时间效应、处理效应和交互效应均有统计学意义(F_时间=14.445,P<0.001;F_处理=148.629,P<0.001;F_交互=4.968,P=0.008)。血清TREM-1、PCT和CPIS诊断VAP的AUC分别为0.977、0.907和0.922。而TREM-1+CPIS评分和PCT+CPIS评分联合诊断VAP的AUC分别为0.976和0.944,均明显高于3项指标的单独应用。结论TREM-1尤其是TREM-1+CPIS评分对机械通气患者早期诊断VAP具有优势,TREM-1+CPIS评分对评估VAP具有更高的诊断效能。     

不同类型老年吸入性肺炎的病原学、抗生素应用及临床转归

目的 比较老年社区获得性吸入性肺炎(CAP)、医疗相关性吸入性肺炎(HCAP)及医院获得性吸入性肺炎(HAP,包括呼吸机相关性吸入性肺炎)三者病原学、抗生素应用及治疗转归的关系.方法 收集2005年1月一2010年12月北京二炮总医院呼吸科住院的216例老年吸人性肺炎患者病例,分析其病原学结果、抗生素应用的及治疗转归.结果 三种吸入性肺炎的病原学有显著差异,与CAP和HCAP相比,HAP患者G-杆菌的感染比例明显增多(P<0.001);抗生素应用方案有明显差异,CAP组病人未调整抗生素应用比率明显高于HCAP组与HAP组(P<0.001);抗生素应用策略不同,所致死亡率有明显差异,以升阶梯方案为最高,以降阶梯治疗为最低(P=0.03).结论 三种吸入性肺炎在感染病原菌种类、抗生素应用策略及治疗转归上有明显差异,应根据不同类型的老年吸入性肺炎特点合理经验性使用抗菌药物.     

呼吸机相关肺炎的研究进展

呼吸机相关肺炎（VAP）是机械通气患者常见且较特殊的医院内获得性肺炎，发病率及病死率较高。临床预防、早期诊断、病原学诊断和临床抗菌药物治疗仍然是VAP重症患者救治领域的难点，现将近年来VAP的研究进展做一综述。     

血清PCT、CRP联合检测对老年肺炎病情诊疗及预后的价值探究

目的观察并探讨联合检测血清降钙素原(Procalcitonin,PCT)和C反应蛋白(C-reactive protein,CRP)对老年肺炎患者诊断及预后评价探究。方法选择自2013年2月至2015年4月在本院接受诊断和治疗的老年肺炎患者56例,作为观察组;选取同期入院并排除细菌感染的健康老年人56例,作为对照组。利用化学发光法检测两组的PCT和CRP水平。观察组患者接受治疗后1周,根据病情好转分为改善组32例和未改善组24例,比较两组PCT、CRP水平。结果观察组PCT、CRP水平分别为(2.62±0.34)ng/ml和(34.24±4.82)mg/ml,对照组为(0.05±0.01)ng/ml和(4.71±0.18)mg/ml,观察组PCT、CRP水平明显高于对照组(P0.05);CRP诊断老年肺炎的敏感性和特异性分别为96.4%(54/56)和67.8%(38/56),PCT的敏感性和特异性分别为92.9%(52/56)和76.8%(43/56),而两者联合的敏感性和特异性分别为94.6%(53/56)和89.2%(50/56),联合诊断特异性明显更高(P0.05);改善组与未改善组相比,PCT、CRP水平及急性生理与慢性健康评分(APACHE II)明显更低(P0.05)。结论老年肺炎患者的PCT和CRP水平均显著上升,PCT和CRP可作为老年肺炎诊断的灵敏指标,对于PCT和CRP的动态监测有助于老年肺炎预后判断。     

Prognostic role of clinical and laboratory criteria to identify early ventilator-associated pneumonia in brain injury

BACKGROUND: We investigated the role of the clinical pulmonary infection score (CPIS), serum levels of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in the detection of patients with early ventilator-associated pneumonia (VAP). METHODS: Observational study in a university hospital. In 58 patients with severe brain injury receiving mechanical ventilation, CPIS, PCT, CRP and SAA were evaluated at ICU entry and at days 3 to 4 of hospital stay for VAP diagnosis (confirmed by endotracheal aspirate or BAL cultures). RESULTS: We found the following: (1) PCT at entry was increased in patients who later had early VAP develop (25 patients) compared to no VAP (median, 1.4 ng/mL; 25-75 percentiles, 0.14-0.78; vs median, 0.2 ng/mL; 25-75 percentiles, 0.76-2.4, p<0.001; sensitivity, 76%; and specificity, 75%); (2) CPIS increased at the day of VAP diagnosis, compared to entry (median, 6.6+/-1.1 vs 1.5+/-1.1, p<0.001; sensitivity, 97%; specificity, 100%), while other serum inflammatory markers did not change; and (3) deterioration in oxygenation and changes in tracheal secretions were the main determinants of CPIS changes. CONCLUSIONS: PCT may be a useful marker to predict which patients subsequently have early VAP. The CPIS could help as an early way to detect the patients with early VAP and who need further diagnostic testing.     

Ventilator-associated pneumonia complicating the acute respiratory distress syndrome

Pulmonary infections span a wide spectrum, ranging from self-limited processes (e.g., tracheobronchitis) to life-threatening infections including both community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Together, pneumonia and influenza rank as the sixth leading cause of death in the United States and lead all other infectious diseases in this respect. Pneumonia is the second-most-common hospital-acquired infection in the United States, accounting for 17.8% of all hospital-acquired infections and 40,000 to 70,000 deaths per year. HAP is the most common nosocomial infection occurring in patients requiring mechanical ventilation, developing in 6.5% of patients after 10 days and in 28% of patients after 30 days of ventilatory support. Patients acquiring HAP have a greater risk of mortality than comparably ill ventilated patients who do not develop pneumonia. Ventilator-associated pneumonia (VAP) specifically refers to a bacterial pneumonia developing in patients with acute respiratory failure who have been receiving mechanical ventilation for at least 48 hours. The etiologic bacteriologic agents associated with VAP typically differ based on the timing of the occurrence of the infection relative to the start of mechanical ventilation. VAP occurring within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-sensitive bacteria that colonize the patient prior to hospital admission (e.g., Streptococcus pneumoniae, Haemophilus influenza, oxacillin-sensitive Staphylococcus aureus). VAP developing after 96 hours of ventilatory support is more often associated with antibiotic-resistant bacteria including oxacillin-resistant Staphylococcus aureus, Acinetobacter species and Pseudomonas aeruginosa. However, more recent data suggest that hospitalization and exposure to antibiotics prior to the start of mechanical ventilation are important risk factors for the occurrence of VAP attributed to antibiotic-resistant bacteria. Therefore, these risk factors should be considered when deciding on an appropriate empiric antibiotic regimen regardless of the onset of VAP. VAP and catheter-associated bloodstream infections are the leading causes of infection acquired in the intensive care unit (ICU) setting. Patients in the ICU have rates of HAP that are as much as five to ten times higher than the rates in general hospital wards. Additionally, like nosocomial bloodstream infections, VAP is associated with an attributable mortality beyond that accounted for by patients' severity of illness. The attributable mortality associated with VAP appears to be greatest for "high-risk' antibiotic-resistant bacteria including Pseudomonas aeruginosa and oxacillin-resistant Staphylococcus aureus. The greater hospital mortality associated with these "high-risk' pathogens has been attributed to the virulence of these bacteria and the increased occurrence of inadequate initial antibiotic treatment of VAP due to the presence of antibiotic resistance. This review provides an overview of the clinical importance of VAP. We then describe how this nosocomial infection influences the management and outcomes of patients with the acute respiratory distress syndrome (ARDS).