Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia
Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia
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DOI：
10.1097/ccm.0b013e318243168e
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发表时间：
2012-05-01
影响因子：
8.8
通讯作者：
Lynch, John B.
中科院分区：
文献类型：
--
作者：
Chan, Jeannie D.;Dellit, Timothy H.;Lynch, John B.
目的：呼吸机相关性肺炎是重症监护病房最常见的感染之一，耐甲氧西林金黄色葡萄球菌已成为呼吸机相关性肺炎的常见原因。我们试图研究每周一次主动监测培养耐甲氧西林沙门氏菌的性能特点。金黄色葡萄球菌定植预测耐甲氧西林的发展。金黄色葡萄球菌呼吸机相关性肺炎。设计：前瞻性观察研究。设置：一所大学附属城市教学医院和一级创伤和烧伤中心的89张外科和内科重症监护病房。患者：所有患者>= 16岁，入住重症监护室接受机械通气>= 48小时，符合呼吸机诊断标准-包括2008年1月至2010年10月期间通过支气管镜肺泡灌洗或刷检标本获得的定量下呼吸道培养的相关性肺炎。干预措施：无。测量和主要结果：对924例疑似呼吸机相关性肺炎进行了评估，纳入了388例经支气管肺泡灌洗证实的呼吸机相关性肺炎患者。从鼻孔、口咽或气管以及任何开放性伤口常规采集监测培养物，包括入住重症监护室时、之后每7天以及重症监护室出院时。在388例患者中，37例（9.5%）存在耐甲氧西林S。金黄色葡萄球菌呼吸机相关性肺炎54例（13.9%）;在发生呼吸机相关性肺炎之前，通过主动监测培养记录了金黄色葡萄球菌定植。对既往耐甲氧西林链球菌的敏感性和特异性进行了研究。金黄色葡萄球菌定植作为耐甲氧西林链球菌的预测因子。金黄色葡萄球菌呼吸机相关性肺炎的发生率分别为70.3%（95%置信区间[CI] 52.8-83.6）和92.0%（95% CI 88.5-94.5）。阳性和阴性预测值分别为48.1%（95%CI 34.5-62.0）和96.7%（95%CI 94.0-98.3）。每周一次主动监测培养确定的金黄色葡萄球菌定植产生高特异性和阴性预测值，表明阴性主动监测培养可以准确排除耐甲氧西林的金黄色葡萄球菌。金黄色葡萄球菌是大多数呼吸机相关性肺炎患者的病原体，可能减少对经验性耐甲氧西林金黄色葡萄球菌的需求。疑似呼吸机相关性肺炎患者的金黄色葡萄球菌覆盖率。(Crit Care Med 2012; 40：1437-1442）
Objective: Ventilator-associated pneumonia is one of the most common infections in the intensive care unit and methicillin-resistant Staphylococcus aureus has emerged as a common cause of ventilator-associated pneumonia. We sought to study the performance characteristics of once weekly active surveillance culture of methicillin-resistant S. aureus colonization in predicting the development of methicillin-resistant S. aureus ventilator-associated pneumonia.Design: Prospective observational study.Setting: Eighty-nine-bed surgical and medical intensive care units in a university-affiliated urban teaching hospital and level I trauma and burn center.Patients: All patients >= 16 yrs old admitted to the intensive care unit on mechanical ventilation >= 48 hrs who met diagnostic criteria for ventilator-associated pneumonia by quantitative lower respiratory tract cultures obtained through bronchoscopic alveolar lavage or brush specimen between January 2008 and October 2010 were included.Interventions: None.Measurements and Main Results: Nine hundred twenty-four episodes of suspected ventilator-associated pneumonia were evaluated, and 388 patients with bronchoalveolar lavage-confirmed ventilator-associated pneumonia were included. Surveillance cultures were taken from the nares, oropharynx or trachea, and any open wound routinely on admission to the intensive care unit, every 7 days afterward, and at intensive care unit discharge. Of the 388 patients, 37 (9.5%) had methicillin-resistant S. aureus ventilator-associated pneumonia and 54 (13.9%) had methicillin-resistant S. aureus colonization documented by active surveillance culture before the development of ventilator-associated pneumonia. The sensitivity and specificity of prior methicillin-resistant S. aureus colonization as a predictor for methicillin-resistant S. aureus ventilator-associated pneumonia are 70.3% (95% confidence interval [CI] 52.8-83.6) and 92.0% (95% CI 88.5-94.5), respectively. The positive and negative predictive values are 48.1% (95% CI 34.5-62.0) and 96.7% (95% CI 94.0-98.3).Conclusions: In our study, prior methicillin-resistant S. aureus colonization as ascertained by once-weekly active surveillance culture yielded high specificity and negative predictive value, suggesting that negative active surveillance culture can accurately exclude methicillin-resistant S. aureus as an etiology in most patients with ventilator-associated pneumonia and may decrease the need for empirical methicillin-resistant S. aureus coverage in patients with suspected ventilator-associated pneumonia. (Crit Care Med 2012; 40: 1437-1442)