呼吸机相关性肺炎主要致病菌调查及护理对策

目的总结呼吸机相关性肺炎（VAP）的主要致病茵及其耐药率，为预防性护理提供依据。方法对206例VAP患者的痰标本进行病原茵及其主要抗生素耐药率的检测。结果VAP患者的病原茵以铜绿假单孢茵、金黄色葡萄球菌、肺炎克雷伯杆菌和阴沟肠杆菌为主，其耐药率的药物排位与我国细菌耐药监测研究组的监测结果基本一致,但细菌耐药率均高于监测结果。结论预防性护理对于切断VAP感染途径和减少感染率尤为重要。     

呼吸机相关性肺炎主要致病菌调查及护理对策

目的总结呼吸机相关性肺炎(VAP)的主要致病菌及其耐药率,为预防性护理提供依据。方法对206例VAP患者的痰标本进行病原菌及其主要抗生素耐药率的检测。结果VAP患者的病原菌以铜绿假单孢菌、金黄色葡萄球菌、肺炎克雷伯杆菌和阴沟肠杆菌为主,其耐药率的药物排位与我国细菌耐药监测研究组的监测结果基本一致,但细菌耐药率均高于监测结果。结论预防性护理对于切断VAP感染途径和减少感染率尤为重要。     

新生儿呼吸机相关肺炎的病原菌分析

目的探讨新生儿呼吸机相关性肺炎的病原学和药物敏感情况,指导临床用药。方法对2009年4月～2011年4月笔者所在医院NICU符合VAP诊断标准的61例患儿在停用呼吸机前作气道分泌物培养和药物敏感试验。结果 34例痰培养阳性,检出细菌46株,其中革兰氏阴性杆菌24株,球菌12株,霉菌10株,混合感染11例。肺炎克雷伯氏菌、阴沟肠杆菌对常用抗生素的耐药率高,亚胺硫霉素对大多数杆菌敏感。革兰氏球菌耐药率高,但对万古霉素均敏感。结论 VAP的病原菌以革兰氏阴性菌为主,对亚胺硫霉素较敏感。混合感染和多重耐药是呼吸机相关肺炎的病原学特点。上机时间越长,气道分泌物培养阳性率越高。     

ICU呼吸机相关性肺炎病原菌的构成及耐药性分析

目的;分析医院综合ICU呼吸机相关性肺炎（VAP）病原菌的分布特点及其耐药性。为vAP治疗提供合理用药参考。方法：回顾性分析210例VAP患者的下呼吸道分泌物细菌培养及药敏结果。结果：210例VAP患者下呼吸道分泌物培养如瘸原菌394株．革兰阴性杆菌占784％．革兰阳性球菌占12.6％．真菌感染9．0％：各类病原燕混台感染者占83．8％：常见病原菌为鲍曼不动杆菌20,3％,铜绿假单胞菌188％。肺炎克雷伯菌16．2％,金黄色葡萄菌8,1％,耐甲氧西林金黄色葡萄球菌（MRSA）检出率87．5％,白色念珠菌7．6％。鲍曼不动杆菌仅对头孢碾酮／舒巴坦敏感,铜绿假单胞菌仅对头孢哌酮／舒巴垣和碳膏酶烯类药物敏感,肺炎克雷伯菌和大肠埃希菌对碳青酶烯类药物敏感,金黄色葡萄球菊耐药现象严重．对万古霉素和替考拉宁敏感,白色念珠菌对氟康唑、伊曲康瞪、伏立康唑敏感。结论：VAP的主要瘸原菌以革兰阴性杆菌为主,耐药现象严鬣．多数为混合感染。治疗困难。进行细菌培养和药物敏感性试验．对合理选用抗菌药物治疗VAP具有重要意义。     

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内镜超声引导下细针穿刺(endoscopic ultrasonography guided fine needle aspiration,EUS.FNA)是指在内镜超声(EUS)的引导下将穿刺细针或切割针通过内镜管道穿刺人目标组织,获取目标的细胞和组织用于病理学诊断的方法.     

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目前,乳腺癌保留乳房治疗(BCT)已成为欧美国家临床早期乳腺癌的规范治疗,多项研究认为保留乳房治疗与改良根治术具有相同的疗效.王永胜等自1985年开展乳腺癌BCT的临床研究,证实选择部分Ⅰ、Ⅱ期乳腺癌病例行BCT足可行的[1].     

呼吸机相关性肺炎患者下呼吸道和胃液分离菌的分布特点及耐药性分析

目的 监测呼吸内科重症监护病房(ICU)中呼吸机相关性肺炎(VAP)患者下呼吸道、肺部及胃液标本病原菌的分布，测定其药敏，为临床治疗VAP提供选药依据。方法 采集患者的痰、下呼吸道分泌物、保护性毛刷刷检物(PSB)、肺泡灌洗液(BAL)、气囊上滞留物和胃液标本，分离菌应用棚细菌鉴定系统鉴定，药敏检测应用Kirby-Bauer纸片扩散法，统计软件应用WHONET5．1软件。结果 呼吸道标本共分离出513株病原菌，革兰阴性杆菌416株．占总分离菌的81．1％，其中以铜绿假单胞菌和鲍曼不动杆菌居多，分别占31．4％和25．7％，革兰阳性球菌32株，以金黄色葡萄球菌居多，占3．5％。酵母样真菌65株，白色念珠菌居多，占5．1％。胃液标本共分离出病原菌120株，其中革兰阴性杆菌73株(60．8％)，革兰阳性球菌15株(12．5％)，酵母样真菌32株(26．7％)。铜绿假单胞菌对氨苄西林(AMK)较敏感，耐药率为11．9％，其次是头孢吡肟(FEP)、亚胺培南(IMP)和头孢他啶(CAZ)，耐药率分别为23．4％、29．8％和36．4％。鲍曼不动杆菌对亚胺培南较敏感，耐药率为13．8％，对其他抗菌药物的耐药率多在80％以上。大肠埃希菌对亚胺培南和美洛培南(ME)较敏感，耐药率分别为0和2、7％。金黄色葡萄球菌对万古霉素(VAN)100％敏感，对苯唑西林(OXA)的耐药率已达55．6％。白色念珠菌对两性霉素B(AMPHO)和氟胞嘧啶(FLUl)较敏感，耐药率均为4．5％，所有分离的酵母样真菌对灰黄霉素(GRIS)的耐药率较高，在83％以上。结论 ICU中呼吸机相关性肺炎患者的感染菌多为多重耐药菌，一旦怀疑感染．则应立即经验性应用足量的广谱抗菌药物，以降低感染的死亡率。     

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随着肝脏外科诊断水平的提高和手术技术的日臻完善，肝癌的手术切除率有了很大的提高。但在临床上，中晚期病人虽可切除肿瘤，却因全身状况、肝功能、肿瘤位置和大小以及经济等多种原因而不能手术切除的病人仍占很大比例，对这些病人采用微创疗法，如血管介入、局部注射、热毁损、冷冻、近距离放射、电化学疗法等，仍可取得较好疗效。复习近年文献将上述疗法综述如下。     

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??Probiotics in the application of inflammatory bowel disease QIN Huan-long*??CHEN Hong-qi. *Department of General Surgery, Shanghai Tenth People’s Hospital, Shanghai 200072, China
Corresponding author ??QIN Huan-long??E-mail??hlqin@sjtu.edu.cn
Abstract Probiotic treatment of inflammatory bowel disease (IBD) has gradually become the hot issue in recent years. A growing number of experimental studies provide the important theoretical support for the application of probiotics in IBD, and achieved significant clinical effectiveness. Some probiotics have been recommended for maintenance of remission in mild to moderate UC patients and preventing and maintaining remission of pouchitis in UC patients pouch inflammation of postoperative UC patients. This paper will combine the latest results to evaluate the clinical efficacy in the treatment of UC, CD and postoperative patients with probiotics, and propose directions for future research, looking forward to more strictly large-scale clinical trials to further verify the efficacy and safety of probiotics in the treatment of IBD, and to guide clinical application of probiotics.     

呼吸机相关性肺炎患者下呼吸道病原菌分布及耐药性分析

目的分析重症监护病房（ICU）呼吸机相关性肺炎（VAP）患者下呼吸道分离病原菌的分布及耐药性。方法回顾性分析2008年7月—2011年12月温州市第三人民医院综合性ICU接受有创机械通气治疗的1324例患者的临床资料。根据患者发生VAP的时间将其分为早发性VAP（EOP,于气管插管后4d内发生）和晚发性VAP（LOP,气管插管4d后发生）。采用,检验和t检验比较2组患者下呼吸道分离的病原菌构成和药敏结果等。结果1324例患者中,552例发生VAP,发生率为41．7％,其中EOP患者74例（5．6％）,LOP患者382例（28．9％）,二者均发生96例（7．3％）。EOP患者分离前6位的病原菌分别为鲍曼不动杆菌（72株,22．6％）、铜绿假单胞菌（45株,14．1％）、肺炎克雷伯菌（32株,10．0％）、白假丝酵母菌（31株,9．7％）、洋葱伯克霍尔德菌（31株,9．7％）和金黄色葡萄球菌（28株,8．8％）;LOP患者分离前6位的病原菌分别为鲍曼不动杆菌（235株,21．2％）、白假丝酵母菌（201株,18．1％）、铜绿假单胞菌（111株,10．0％）、光滑假丝酵母菌（86株,7．8％）、肺炎克雷伯菌（81株,7．3％）和金黄色葡萄球菌（46株,4．2％）。其中,EOP患者金黄色葡萄球菌的分离率明显高于LOP患者（∥=10．780,P=0．002）,而白假丝酵母菌的分离率明显低于LOP患者（X2=12．907,P=0．000）。无论EOP还是LOP患者,革兰阴性杆菌（特别是鲍曼不动杆菌和铜绿假单胞菌）的耐药形势均较为严重;金黄色葡萄球菌中大部分为耐甲氧西林金黄色葡萄球菌（EOP患者：67．9％,19／28;LOP患者：63．o％,29／46）;真菌中的白假丝酵母菌和光滑假丝酵母菌对目前临床常用抗真菌药物的敏感性较好。结论EOP与LOP患者下呼吸道分离的菌株均以革兰阴性菌为主,菌株耐药形势不容乐观。     

氯己定擦浴预防ICU患者呼吸机相关性肺炎的Meta分析

目的系统评价氯己定擦浴预防ICU患者呼吸机相关性肺炎的效果。方法计算机检索Cochrane图书馆、PubMed、Ovid Medline、EMbase、中国生物医学文献服务系统(CBM)、维普数据库(VIP)、中国期刊全文数据库(CNKI)以及万方数据库中关于氯己定擦浴用于预防ICU患者呼吸机相关性肺炎的临床对照试验,检索时限均为从建库至2015年5月,并且筛选纳入研究的参考文献。由2名研究者对文献质量进行严格评价和资料提取,使用RevMan5.3软件进行Meta分析和亚组分析。结果共纳入9篇文献,3篇为随机对照试验研究,6篇临床对照试验。Meta分析结果显示:与对照组方法相比,氯己定擦浴可以降低呼吸机相关性肺炎的发生率[RR=0.82,95%CI(0.67,0.99)]。结论氯己定全身擦浴能够降低呼吸机相关性肺炎的发生率,然而考虑到文献质量及数量,有待高质量的研究予以验证。     

常规刷牙预防呼吸机相关性肺炎的效果观察

目的探讨常规刷牙在预防呼吸机相关性肺炎(VAP)中的作用,为寻找更为有效的口腔护理方法提供依据。方法将98例经口气管插管机械通气患者随机分为两组,对照组(48例)应用传统擦拭法进行口腔护理,观察组(50例)采用常规刷牙方法进行口腔护理;两组口腔护理后均给予口腔冲洗和咽部深吸引。比较两组机械通气1周后VAP发生率、机械通气时间及ICU住院时间。结果观察组机械通气1周后VAP发生率显著低于对照组(P<0.05),机械通气时间及ICU住院时间显著短于对照组(均P<0.01)。结论常规刷牙配合口腔冲洗及咽部深吸引能显著降低VAP的发生率,缩短机械通气及ICU住院的时间。     

Cost of a ventilator-associated pneumonia in a shock trauma intensive care unit

BACKGROUND: Nosocomial pneumonia and especially ventilator-associated pneumonia (VAP) are costly complications for the hospitalized patient. Nosocomial pneumonia has been estimated to cost $5,000 per episode, but the specific cost for a VAP has not been well estimated. As part of a successful performance improvement program in decreasing VAP from 10 VAPs/100 ICU admissions to 2.5 VAPs/100 ICU admissions, we examined the costs associated with VAP. METHODS: From January 1, 2002, through September 30, 2003, Shock Trauma Intensive Care Unit patients and charts were reviewed concurrently by an infection control practitioner for development of VAP as defined by National Nosocomial Infection Surveillance (NNIS) guidelines. Costs were obtained from the hospital's cost accounting software Transition Systems version 3.1.01 (TSI). All patients requiring greater than one day of mechanical ventilation were evaluated. Seventy patients with VAP and 70 patients without VAP were matched according to age and Injury Severity Score. Differences were compared using Kruskal-Wallis and two sample T-tests. Significance was considered for p < 0.05. RESULTS: The ICU cost difference was significant (p < 0.05) between the case-controlled patients with VAP ($82,195) and those without VAP ($25,037). There was also a significant increase in ICU length of stay (21.6 versus 6.4 days) and the number of ventilator days (17.7 versus 5.8; both, p < 0.05). Mortality was not different in the case-controlled population. A substantial portion of the increased cost of a VAP was from the increase in ICU length of stay ($1,861/day). Pharmacy, respiratory and "other" also accounted for the increases when cost distribution was analyzed. This translates into a cost avoidance of approximately $428,685 per 100 admissions to the ICU. CONCLUSIONS: Ventilator-associated pneumonia not only leads to a significant increase in ventilator days and ICU length of stay, but adds substantially to hospital costs. In our ICU, an episode of VAP costs $57,000 per occurrence.     

有创呼吸机管路系统更换时间对VAP发生的影响

目的探讨有创呼吸机管路系统更换时间对呼吸机相关性肺炎发生的影响,为医护人员临床实际操作提供参考。方法将神经内科、神经外科和呼吸科ICU进行有创机械通气的189例患者按入院时间分为对照1组59例,对照2组64例,观察组66例;对照组7d更换1次呼吸机管路,观察组仅在管路肉眼可见明显污染或功能障碍时予以更换。结果观察组和对照1组、2组患者机械通气期间呼吸机相关性肺炎发生率比较,差异无统计学意义(P0.05)。结论管路仅在出现肉眼可见污染或功能障碍时予以更换并不增加VAP发生率,同时可减少患者经济负担和人力、物力资源的消耗。     

Incidence and risk factors for the development of acute renal failure in patients with ventilator-associated pneumonia

AIM: Infections are one of the most important risk factors for the development of acute renal failure (ARF) and ventilator-associated pneumonia (VAP) has been reported as one of the most frequent infection in intensive care units (ICU). Sepsis, shock, multiorgan dysfunction syndrome (MODS), use of nephrotoxic antibiotics and mechanical ventilation are potential risk factors for development of ARF during VAP. The objective of the study was to evaluate the incidence of ARF in patients with VAP and the role of VAP-related potential risk factors in the development of ARF. METHODS: One hundred and eight patients who were admitted to the pulmonary ICU of a university hospital and developed VAP were included in this prospective observational cohort study. Only first episodes of VAP were studied. Diagnosis was based on microbiologically confirmed clinical findings. Potential outcome variables including responsible pathogens, recurrence, polymicrobial aetiology, bacteraemia, multidrug resistance of microorganisms, late/early VAP and sepsis and other known risk factors for development of ARF were evaluated. Risk factors were analysed by logistic regression analysis for significance. RESULTS: Incidence of ARF was 38% (n = 41). Pneumonia with multidrug resistant pathogens (odds ratio, (OR) 5; 95% confidence interval (95%CI), 1.5-18; P = 0.011), sepsis (OR, 5.6; 95%CI, 1.7-18; P = 0.005) and severity of admission disease (Acute Physiology and Chronic Health Evaluation II score: OR, 1.1; 95%CI, 1.02-1.3; P = 0.017) were independent risk factors for the development of ARF during VAP episodes in multivariate analysis. CONCLUSION: These results showed that the incidence of ARF is high during the VAP episodes and that VAP developed with multidrug resistant pathogens and sepsis have an independent effect on the development of ARF.     

集束化干预对综合ICU呼吸机相关性肺炎的防控效果

目的探讨集束化干预措施对综合ICU呼吸机相关性肺炎预防控制的效果。方法由医院感染管理科人员对ICU医护人员进行呼吸机相关性肺炎集束化干预措施专题培训,并督导集束化干预的实施,比较实施前(2013年、2014年)与实施后(2015年、2016年)使用呼吸机患者呼吸机相关性肺炎发生率。结果 2013、2014、2015及2016年呼吸机相关性肺炎感染率分别为24.60‰、19.74‰、17.28‰及15.09‰,呈逐年减少趋势。结论集束化干预措施可有效降低呼吸机相关性肺炎发生率。     

Role of L-selectin in the development of ventilator-associated pneumonia in patients after major surgery

BACKGROUND: The circulating level of soluble L-selectin (sL-selectin) has been reported to be low in adult respiratory distress syndrome and acute lung injury. This study explores the role of L-selectin in the development of ventilator-associated pneumonia (VAP) in patients undergoing major surgery. PATIENTS AND METHODS: Thirty-four patients who underwent esophagectomy were maintained by mechanical ventilation in a surgical intensive care unit. Fourteen patients developed VAP by postoperative day (POD) 7, while 20 patients did not. The plasma levels of soluble adhesion molecules and elastase were measured serially by ELISA or EIA. The expression of L-selectin on polymorphonuclear neutrophils (PMNs) was analyzed by flow cytometry. RESULTS: In multiple logistic regression analysis, only the preoperative plasma level of sL-selectin was significantly associated with VAP. The plasma sL-selectin level before surgery was significantly lower in the patients who developed VAP compared with the patients who did not develop VAP. After surgery, the level of sL-selectin did not change. The plasma level of soluble intercellular adhesion molecule-1 increased in the patients with and without VAP. The plasma level of soluble vascular cell adhesion molecule-1 was significantly higher in the patients with VAP. L-selectin expression on PMNs showed a peak on POD 2 in the patients without VAP, whereas it was impaired in the patients with VAP. CONCLUSIONS: Determination of the preoperative plasma level of sL-selectin may help to identify patients at high risk for VAP after esophagectomy.     

重症监护病房耐甲氧西林金黄色葡萄球菌耐药性及基因分型研究

目的 对重症监护病房（ICU）耐甲氧西林金黄色葡萄球菌（MRSA）感染进行分子流行病学调查,探讨临床分离菌株的同源性,为预防和控制医院感染提供参考.方法 采用药敏纸片法（K-B法）、葡萄球菌染色体mec盒基因（SCCmec）分型及葡萄球菌蛋白质A（spa）基因分型技术对2009年11月24日-12月3日宁夏医科大学附属医院ICU、急诊ICU、烧伤ICU、呼吸ICU的MRSA感染患者、医护人员携带及周围环境中的MRSA进行药物敏感性试验和同源性分析.结果 440份样本中共分离出78株金黄色葡萄球菌,其中MRSA 62株（79.48%）,主要分离于烧伤ICU（22/62,35.48%）.SCCmec分型结果显示,50株为医院获得性MRSA（SCCmecⅢ型43株、SCCmec Ⅰ型4株、SCCmecⅡ型3株）,未分型12株.进行spa分型研究的37株MRSA中,28株医院获得性MRSA为SCCmecⅢ-t030,呈现高度的克隆一致性.结论 MRSA菌株具有多药耐药的特征,SCCmecⅢ-t030型是其主要型别,MRSA 临床株与环境株可能具有同源性.