重症医学科呼吸机相关肺炎的病原学特点分析

目的:分析重症医学科呼吸机相关肺炎(ventilator-associated pneumonia,VAP)的病原学特点及细菌对抗生素的敏感性,为临床选择抗生素提供依据。方法:回顾分析2012年1月—2013年12月苏州大学附属第三医院重症医学科收治的32例VAP的细菌感染情况及细菌对抗生素的敏感性。结果:32例VAP中检出110株菌,其中革兰阴性杆菌48株(43.6%),以鲍曼不动杆菌、肺炎克雷伯菌、铜绿假单胞菌和大肠埃希菌为主;革兰阳性球菌43株(39.1%),以肠球菌、金黄色葡萄球菌、表皮葡萄球菌和溶血葡萄球菌为主;真菌19株(17.3%),以白色念珠菌为主。药敏试验结果显示,鲍曼不动杆菌、肺炎克雷伯菌和大肠埃希菌对碳青霉烯类的敏感率较其他抗生素高,未发现对万古霉素和利奈唑胺耐药的肠球菌和葡萄球菌。结论:重症医学科VAP患者感染革兰阴性杆菌比例稍高于革兰阳性球菌。临床上应根据细菌病原学及对抗生素的敏感性,合理选择抗生素来控制重症医学科内感染的发生,减少耐药菌株的出现。     

Ventilator-associated pneumonia: caveats for benchmarking

Objective To determine the influence of using different denominators on risk estimates of ventilator-associated pneumonia (VAP).Design and setting Prospective cohort study in the medical ICU of a large teaching hospital.Patients All consecutive patients admitted for more than 48 h between October 1995 and November 1997.Measurements and results We recorded all ICU-acquired infections using modified CDC criteria. VAP rates were reported per 1,000 patient-days, patient-days at risk, ventilator-days, and ventilator-days at risk. Of the 1,068 patients admitted, VAP developed in 106 (23.5%) of those mechanically ventilated. The incidence of the first episode of VAP was 22.8 per 1,000 patient-days (95% CI 18.7–27.6), 29.6 per 1,000 patient-days at risk (24.2–35.8), 35.7 per 1,000 ventilator-days (29.2–43.2), and 44.0 per 1,000 ventilator-days at risk (36.0–53.2). When considering all episodes of VAP (n=127), infection rates were 27.3 episodes per 1,000 ICU patient-days (95% CI 22.6–32.1) and 42.8 episodes per 1,000 ventilator-days (35.3–50.2).Conclusions The method of reporting VAP rates has a significant impact on risk estimates. Accordingly, clinicians and hospital management in charge of patient-care policies should be aware of how to read and compare nosocomial infection rates.Partially funded by a grant provided by the Department of Internal Medicine, University of Geneva Hospitals "Comité directeur des Laboratoires de Recherche clinique et Groupe de Recherche en Analyse des Systèmes de santé du Département de Médecine interne" (S.H) and a grant from G and L Hirsch, Geneva, Switzerland (P.E.).     

新生儿呼吸机相关性肺炎的临床分析

目的：分析新生儿呼吸机相关性肺炎（ventilator-associated pneumonia,VAP）的高危因素、病原菌,探讨临床降低VAP发生率的策略。方法：回顾分析2004年3月—2009年12月97例行机械通气的新生儿临床资料,其中并发VAP42例,比较胎龄,出生体质量,上机时间,以及分析病原学检测结果。结果：VAP发生率43.3%;VAP组上机时间明显多于非VAP组：不同胎龄、出生体质量的VAP的发生率有显著差异,致病病原菌以肺炎克雷伯菌、阴沟肠杆菌、大肠埃希菌、铜绿假单胞菌多见。结论：VAP是多因素综合作用的结果,必须重视并预防VAP,采取综合措施减少VAP的发生。     

Contamination of antimicrobial-resistant bacteria on toothbrushes used with mechanically ventilated patients: A cross sectional study

ObjectiveThe purpose of this study was to determine pathogenic and antimicrobial-resistant bacteria on used toothbrushes of mechanically ventilated patients.Research methodologyA cross-sectional study was conducted by collecting toothbrushes used with mechanically ventilated patients. The total bacterial count on each toothbrush was assessed by culturing on Trypticase soy agar (TSA). Gram stain and biochemical testing were used to identify bacterial species. Antibiotic susceptibility of pathogenic bacteria was assessed by the Kirby-Bauer disk diffusion method.ResultsThirty-five toothbrushes (97%) had bacterial contamination, 27 toothbrushes had at least two bacterial species, and 13 toothbrushes harboured antimicrobial-resistant bacteria. The most commonly isolated bacteria were Klebsiella spp. (21%), followed by Acinetobacter baumannii (18%). Five isolates of A. baumannii, six isolates of K. pneumoniae, and two isolates of Enterobacter cloacae were multidrug-resistant (MDR) strains. Four isolates of K. pneumoniae were identified as extended-spectrum beta-lactamase (ESBL) producing strains, and two isolates of P. aeruginosa were extensively drug-resistant (XDR). The average total bacterial count was 10⁴–10⁵ CFU/toothbrush head.ConclusionsAntimicrobial-resistant bacteria were detected on toothbrushes. Therefore, practice of toothbrush care should be reconsidered in associated to maintaining the oral hygiene of mechanically ventilated patients to prevent ventilator-associated pneumonia (VAP).     

气囊上滞留物间歇吸引降低呼吸机相关肺炎的发病率

目的研究气囊上滞留物间歇吸引降低机械通气患者早期呼吸机相关肺炎（ventilator-associated pneumonia,VAP）的作用。方法选择机械通气超过48h的患者58例,随机分为气囊上滞留物间歇吸引组（观察组,n=28）和普通人工气道护理组（对照组,n=30）。比较两组患者VAP的发生率和气囊上滞留物的含菌量。结果观察组气囊上滞留物含菌量显著低于对照组（P〈0．05）;观察组1周内VAP发生率（7．1％）低于对照组（33．3％）,差异有统计学意义（P〈0．05）。结论气囊上滞留物间歇吸引可降低声门下气囊上区含菌量,降低早期VAP的发生率。     

ICU患者分类管理对医院获得性肺炎发病率的影响

目的 探讨重症监护病房(ICU)患者分类管理对医院获得性肺炎(HAP)发病率的影响.方法 将2005-2011年入住ICU且时间＞48 h的2 077例患者按入院时间分为2组,2005-2009年未实施ICU患者分类管理的患者(1471例)为第1组,2010-2011年实施ICU患者分类管理后的患者(606例)为第2组.对2005-2011年ICU HAP发病率和多重耐药菌感染情况进行统计分析,比较2组HAP发病率与多重耐药菌感染率.结果 第2组HAP发病率及多重耐药菌感染率均较第1组明显下降(均P＜0.01).结论 实施ICU患者分类管理可有效地降低HAP发病率及多重耐药菌感染率.     

Incidence and risk factors for ventilator-associated pneumonia after major heart surgery

Purpose  Major heart surgery (MHS) patients are a particularly high-risk population for nosocomial infections. Our objective was to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing MHS. Methods  Prospective study including 1,844 patients operated from 2003 to 2006. Results  Overall 106 patients (140 episodes) developed one or more episodes of VAP (5.7%, 22.2 episodes per 1,000 days of mechanical ventilation). VAP incidence was 45.9% in those patients requiring more than 48 h of MV. Enterobacteriaceae (32.8), Pseudomonas aeruginosa (28.6%) and Staphylococcus aureus (27.1%, of which 65.8% were methicillin resistant) were the principal microorganisms causing VAP. The independent risk factors for VAP were: age >70, perioperative transfusions, days of mechanical ventilation, reintubation, previous cardiac surgery, emergent surgery and intraoperative inotropic support. Median length of stay in the ICU for patients who developed VAP or not was, respectively, 25.5 versus 3 days (P < 0.001), and mortality was, respectively, 45.7 versus 2.8% in both populations (P < 0.001). We developed a predictive preoperative score with a sensitivity of 93% and a specificity of 40%. Conclusions  VAP is common in patients undergoing MHS that require more than 48 h of MV. In that “high-risk” population, innovative preventive measures should be developed and applied. This article is discussed in the editorial available at: doi:.     

重症监护病房呼吸机相关肺炎的集束干预效果观察

目的观察集束干预措施对于重症监护病房（ICU）呼吸机相关肺炎（VAP）发病率的影响。方法选取2011年6月-8月ICU使用呼吸机的患者作为基线调查对象,2011年9月-2012年5月实施集束干预措施后每3个月评估1次VAP发病率。结果呼吸机使用率由干预前的26．5％降至干预实施6个月后的24．6％和9个月后的22．6％,VAP发病率由61．2‰降至34．9‰、22．7‰,速干手消毒剂的用量由每床日32．6mL增至58．8、54．4mL。结论集束干预措施对于预防VAP效果明显,人员培训、床旁督导及监测反馈能有效促进干预措施执行。     

降钙素原对呼吸机相关性肺炎诊断价值的系统评价

目的系统评价降钙素原（PCT）对呼吸机相关性肺炎（VAP）的诊断价值。方法计算机检索MEDLINE（1996～2010.1）、EMbase（1974～2010.1）、e Cochrane Library（2010年第1期）、CBM（1978～2010.1）和BIOSIS（1995～2010.1）数据库,并手检纳入研究的参考文献,全面收集使用PCT诊断VAP的相关研究。按照QUADAS标准评价纳入研究质量后采用Meta-Disk1.4软件对敏感性、特异性、阳性似然比（＋LR）、阴性似然比（–LR）进行合并分析和异质性检验,并绘制综合受试者特征曲线（SROC）。结果从103篇文献中共筛选出5个合格研究,这些研究间存在明显异质性（I2〉50%）,其总的敏感性为0.70[95%CI（0.62,0.77）],特异性为0.76[95%CI（0.69,0.82）]。＋LR为5.651[95%CI（1.237,25.810）],–LR为0.349[95%CI（0.155,0.784）]。SROC曲线下面积（AUC）为0.884[诊断比值比（DOR）=19.416,95%CI（2.473,152.47）]。结论 PCT用于VAP的诊断只有中等程度的敏感性和特异性,虽然总的诊断准确性较高,但各研究间存在较大差异,期待开展更多高质量的研究。其次,单独使用PCT来诊断VAP存在局限,使用PCT诊断VAP仍需结合具体的临床情况。     

重症监护病房中选择性消化道脱污染对院内获得性肺炎的临床价值

目的探讨在重症监护病房（intonsive cane tmit,ICU）行选择性消化道脱污染（selective digestivedecontamination,SDD）的临床实用价值。方法选取2007年1月～2010年1月危重症患者376例,随机分为两组,对照组予常规口腔护理治疗,治疗组予选择性消化道脱污染治疗,比较两组患者病情疗效的参数。结果治疗组院内获得性肺炎发生率为18.4%、院内获得性肺炎发生时间（7.2±3.2）d、人工气道（气管插管/切开）保留天数（10.5±3.8）d、机械通气天数（8.4±3.1）d、入住ICU天数（14.7±4.8）d、病死率11.6%;对照组院内获得性肺炎发生率为30.1%、院内获得性肺炎发生时间（5.6±3.6）d、人工气道（气管插管/切开）保留天数（12.5±4.6）d、机械通气天数（10.2±4.2）d、入住ICU天数（17.2±6.2）d、病死率19.4%;两组比较差异均有统计学意义（P〈0.05）。结论在ICU内行选择性消化道脱污染可有效控制院内获得性肺炎,改善患者病情,减少住院天数,降低病死率。     

重症监护病房呼吸机相关性肺炎目标监测分析

目的观察重症监护病房（ICU）呼吸机相关性肺炎（VAP）目标监测效果,分析其危险因素,采取有效措施,减少VAP的发生。方法对2013年1月-7月使用呼吸机的患者（观察组）进行目标监测,并与2012年1月-7月实施全面综合性监测患者（对照组）进行比较,观察两组患者VAP的发生情况。结果观察组VAP感染率21.73‰,对照组VAP感染率53.33‰;两组患者差异有统计学意义（P〈0.05）。结论对ICU机械通气患者,进行目标监测能掌握VAP的危险因素及感染率,及时调整干预措施,降低VAP的发生率,提高患者的治愈率。     

综合重症监护病房呼吸机相关性肺炎监测分析

目的了解综合重症监护病房(ICU)呼吸机相关性肺炎(VAP)感染率、危险因素、病原菌分布及其耐药情况,探讨有针对性的预防控制措施。方法 2009年1月-12月综合ICU共收治患者447例,采用主动监测方法,由ICU医务人员和专职人员每日对综合ICU病房住院时间≥48 h且撤停机械通气后48 h内的患者进行VAP监测。结果 447例患者中住院时间≥48 h的患者168例,96例患者使用呼吸机,使用呼吸机时间182 d,ICU住院总日数1 339 d,发生VAP 17例,呼吸机使用率13.59%,VAP感染率93.4例/1 000机械通气日,根据平均病情严重程度(ASIS法)调整后的VAP感染率为2.38%。呼吸机使用方式与VAP发生有关联。检出病原菌18株,全部为Gˉ杆菌,其中鲍曼不动杆菌4株,对包括硫霉素、氨曲南在内的多种抗菌药物耐药。结论综合ICU病房VAP感染率为2.38%,呼吸机使用不当是VAP的危险因素,VAP致病菌为Gˉ杆菌,其中鲍曼不动杆菌耐药率达100%,并呈多重耐药性;抗生素使用时间过长,预防性使用不当是致病菌产生多重耐药的重要原因。     

口腔卫生护理的Cochrane系统评价证据

目的总结有关口腔卫生护理的Cochrane系统评价证据。方法计算机检索Cochrane Library（2008年第3期）中有关口腔卫生护理的系统评价,并进行分析。结果共检索到4篇系统评价,内容涉及：手动与电动牙刷对维护口腔卫生的效果比较,应用牙问隙刷保持固定矫治患者口腔卫生的效果评价,初级121腔卫生护理的复诊间隔的选择,刮舌预防口臭的效果。结论目前缺乏高强度证据来支持牙间隙刷等口腔卫生护理的疗效。其他口腔护理方法的疗效如漱口水等尚需通过进一步的试验来评估。现有口腔卫生护理的系统评价纳入随机对照试验的方法学质量普遍较低,部分研究存在随机方法描述不清、无隐蔽分组、无样本量计算,以及无意向治疗分析等缺陷。建议推行临床试验透明化,实施临床试验注册制度,按照CONSORT声明规范报道随机对照试验,以便总结口腔卫生护理的临床证据,提高口腔卫生护理临床水平。     

Oral intake evaluation in patients following critical illness: an ICU cohort study

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post‐critical illness was observed during a 1‐month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1–2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post‐critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post‐critical illness to oral nutrition.     

国内部分三甲医院危重疾病患者口腔护理情况调查

目的了解国内三甲医院重症监护室危重疾病患者口腔护理情况,为提高危重疾病患者口腔护理水平提供依据和建议。方法采用信访、向危重病人口腔护理专家咨询和走访等调查方式,获得国内危重疾病患者口腔护理现状信息。结果本次调查共发放调查问卷184份,回收有效问卷79份,有效回收率42.93%。所有回复者均认为口腔护理对于危重疾病患者很重要,有98.7%的重症监护室采取了不同的方式进行护理前评估,包括检查口腔基本情况及口腔分泌物提取,评估实施者主要为床旁责任护士（63.3%）。目前使用最多的口腔护理方式为棉球擦洗法（62.5%）,护理频率每日2～3次,每次平均时间9.1±5.1min,主要使用的口腔护理液有生理盐水（76.0%）、碳酸氢钠（22.8%）、呋喃西林（13.9%）、双氧水（13.9%）等。结论目前国内口腔护理水平相差较大,应加强针对循证口腔护理的培训,有必要建立危重疾病患者口腔护理的全国统一规范。     

Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial

Background

Ventilator associated pneumonia remains an important concern in the intensive care unit (ICU). An increasing body of evidence shows that mortality and morbidity can be reduced by implementing a range of preventive strategies, including optimizing oral hygiene.

Aim

The aim of this feasibility study was to test two oral hygiene strategies on the effects of microbial colonization of dental plaque with respiratory pathogens (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome).

Methods

A single blind randomised comparative study was conducted in a 20-bed adult intensive care unit in a university hospital. Patients with an expected duration of mechanical ventilation more than 48 h were eligible. Patients were randomised to one of three study regimens (Group A control, second hourly oral rinse with sterile water, Group B sodium bicarbonate mouth wash second hourly, and Group C twice daily irrigations with chlorhexidine 0.2% aqueous oral rinse and second hourly irrigations with sterile water). All study options included cleaning with a toothbrush and non foaming toothpaste.

Results

Data from a total of 109 patients were analyzed. Group A 43, Group B 33 and Group C 33 (mean age: 58 ± 17 years, simplified acute physiology score II: 44 ± 14 points). On admission no significant differences were found between groups for all clinical data. While Group B showed a greater trend to reduction in bacterial colonization no significant differences could be demonstrated at Day 4 of admission (p = 0.302). The incidence of ventilator associated pneumonia was evenly spread between Groups B and C (5%) while Group A was only 1%.

Conclusions

While a number of studies have advocated the use of various mouth rinses in reducing colonization of dental plaque a standardized oral hygiene protocol which includes the use of mechanical cleaning with a toothbrush may be a factor in the reduction of colonization of dental plaque with respiratory pathogens. This feasibility study provides data to inform future adequately powered studies.     

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BackgroundVentilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.ObjectivesThe objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).MethodsThis was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.Results:No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).ConclusionThe use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria.ClinicalTrials.gov IdentifierNCT04527276.     

质子泵抑制剂和重症患者的医院获得性肺炎之间的关系

目的研究质子泵抑制剂（PPI）是否为危重患者发生医院获得性肺炎的危险因素。方法收集2002年6月-2009年6月收治的198例重症患者资料,分为使用PPI组（96例）和未使用PPI组（102例）。采用logistic回归分析PPI使用情况和医院获得性肺炎的关系。结果使用PPI组肺炎的发生率较高（26.9%）,尤其是PPI使用时间超过7d者（37.5%）。在不同的多变量logistic回归模型中,分别用APACHEⅡ评分和入住重症监护室原因校正后,使用PPI以及使用天数均是医院获得性肺炎发生的危险因素（P=0.031,OR=2.230,95%CI：1.957～2.947;P=0.002,OR=1.824,95%CI：1.457～2.242）。结论长时间应用PPI可能是增加ICU患者发生医院获得性肺炎的一种风险因素。