NOSOCOMIAL PNEUMONIA IN PATIENTS RECEIVING CONTINUOUS MECHANICAL VENTILATION - PROSPECTIVE ANALYSIS OF 52 EPISODES WITH USE OF A PROTECTED SPECIMEN BRUSH AND QUANTITATIVE CULTURE TECHNIQUES
NOSOCOMIAL PNEUMONIA IN PATIENTS RECEIVING CONTINUOUS MECHANICAL VENTILATION - PROSPECTIVE ANALYSIS OF 52 EPISODES WITH USE OF A PROTECTED SPECIMEN BRUSH AND QUANTITATIVE CULTURE TECHNIQUES
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DOI：
10.1164/ajrccm/139.4.877
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发表时间：
1989-04-01
期刊：
影响因子：
--
通讯作者：
GIBERT, C
中科院分区：
文献类型：
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作者：
FAGON, JY;CHASTRE, J;GIBERT, C
需要机械通气的患者院内细菌性肺炎的流行病学研究受到限制，因为在这种情况下诊断程序的可靠性较差。为了确定呼吸机相关性肺炎（V-A）的预后和描述性因素，我们前瞻性研究了567例在我们单位接受机械通气超过3天的患者。由于存在新的肺浸润和脓性气管分泌物，对每例疑似肺炎的患者使用受保护的标本刷（PSB）进行纤维支气管镜检查。只有当PSB标本中至少一种微生物的含量> 103 cfu/ml时，才保留V-A肺炎的诊断，除非该结果在随访中被确定为假阳性结果。49例患者发生V-A肺炎，共52次发作（9%）。V-A肺炎的精算风险在通气10天时为6.5%，20天时为19%，30天时为28%。 与非肺炎患者相比，肺炎患者明显更老（65岁对57岁，p < 0.01），更常患有严重的基础疾病（24%对10%，p < 0.01）。从PSB标本中分离出显著浓度的共84种微生物（51种革兰氏阴性和33种革兰氏阳性）。铜绿假单胞菌和金黄色葡萄球菌分别占这些肺炎的31%和33%。40%的标本产生了一个多微生物植物群与一个以上的潜在病原体。既往抗菌治疗增加了铜绿假单胞菌或不动杆菌属引起的肺炎的发生率。(65葡萄球菌感染中甲氧西林耐药率分别为100%和33%，P < 0.05。V-A肺炎患者的总死亡率为71%，而非肺炎患者的总死亡率为29%（p < 0.01）。只有13%的肺炎患者由铜绿假单胞菌或不动杆菌属引起。而其他细菌性肺炎患者的存活率为31%（P < 0.01）。
Epidemiologic studies of nosocomial bacterial pneumonia in patients requiring mechanical ventilation have been limited because of the poor reliability of diagnosis procedures in this setting. To determine prognostic and descriptive factors of ventilator-associated (V-A)pneumonia, we prospectively studied 567 patients who had been receiving mechanical ventilation for more than 3 days in our unit. Fiberoptic bronchoscopy using a protected specimen brush (PSB) was performed on each patient suspected of having pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. The diagnosis of V-A pneumonia was retained only if PSB specimens yielded > 103 cfu/ml of at least one microorganism, unless this result was established to be a false positive result on follow-up. V-A pneumonia developed in 49 patients for a total of 52 episodes (9%). The actuarial risk of V-A pneumonia was 6.5% at 10 days, 19% at 20 days, and 28% at 30 days of ventilation. Patients with pneumonia were significantly older (65 versus 57 yr of age, p < 0.01) and more frequently had severe underlying illnesses (24 versus 10%, p < 0.01) than did patients without pneumonia. A total of 84 microorganisms (51 gram-negative and 33 gram- positive) were isolated in significant concentrations from PSB specimens. Pseudomonas aeruginosa and Staphylococcus aureus were involved in 31 and 33% of these pneumonias, respectively. Forty percent of all specimens yielded a polymicrobial flora with more than one potential pathogen. Prior antimicrobial therapy increased the rate of pneumonia caused by P. aeruginosa or Acinetobacter spp. (65 verus 19%, p < 0.01) and the frequency of methicillin resistance in staphylococcal infections (100 versus 33%, p < 0.05). Overall mortality in patients with V-A pneumonia was 71% compared with 29% in patients without pneumonia (p < 0.01). Only 13% of patients with pneumonia caused by P. aeruginosa or Acinetobacter spp. survived, whereas 31% of patients with pneumonia caused by other bacteria survived (p < 0.01).