泛耐药鲍曼不动杆菌呼吸机相关肺炎巢式病例对照研究
发布时间：2018-12-13 01:44
【摘要】：背景:目前,有创机械通气技术正在被广泛应用于重症医学领域。临床中主要用于抢救急慢性呼吸衰竭危重患者,但应用过程中并发症较多,其中呼吸机相关性肺(VAP)是机械通气患者最常见的感染性疾病之一。国外报道,VAP发病率为6%~52%或(1.6-52.7)例/1000机械通气日,病死率为14%-50%;若病原菌是多重耐药菌或泛耐药菌,病死率可达76%,归因死亡率为20%-30%。在我国,VAP发病率在4.7%-55.8%或(8.4-49.3)例/1000机械通气日,病死率为19.4%-51.6%。发生VAP患者机械通气时间延长5.4-14.5 d,ICU留治时间延长6.1-17.6d,住院时间延长11-12.5d。呼吸机相关肺炎感染的致病菌中以革兰阴性杆菌为主,其中以铜绿假单胞菌和鲍曼不动杆菌最为常见。鲍曼不动杆菌(Ab)属于条件致病菌,广泛分布于自然环境、医疗场所以及人体皮肤黏膜中。因其可以通过多种途径获得耐药性且克隆传播的能力非常强,目前多重耐药、广泛耐药、全耐药鲍曼不动杆菌正呈世界性流行趋势,已成为我国医院感染最重要的致病菌之一。有创机械性通气患者病情危重、常伴有多种基础疾病、免疫功能低下、广谱抗菌药物的使用、住院时间长等多种因素极易发生泛耐药鲍曼不动杆菌感染。巢式病例对照研究起源于美国流行病学家Mantel在1973年提出的综合式病例对照研究设计,Miettinen于1982年正式提出。它是将传统的病例对照研究和队列研究的一些要素进行重新组合后形成的一种新的研究方法,即在对一个事先确定好的队列研究的基础上,再应用病例对照研究的设计思路进行研究分析。目前该方法在国内外被广泛地应用于医学科研领域。采用巢式病例对照研究的方法,对泛耐药鲍曼不动杆菌导致呼吸机相关肺炎的危险因素进行探索的优点是收集资料在先,选择、调查偏倚较小;研究样本较队列研究小,节约人力物力;符合因果推论要求,论证度强。目的:本研究通过采用巢式病例对照研究的方法,探索泛耐药鲍曼不动杆菌呼吸机相关肺炎的危险因素,为医疗机构预防与控制该类感染及合理使用抗菌药物提供科学依据。方法:将2014年1月份至2014年12月份,我院急诊ICU、重症医学科收治的建立人工气道(气管插管或气管切开)并接受机械通气≥48 h的患者作为观察队列。排除年龄18周岁者;气管插管(或切开)留置时间48 h者;行气管插管(或切开)3 d内死亡者;严重多系统功能障碍的患者。设计前瞻性目标性监测调查表,对接受机械通气48h的患者,全面收集患者基本信息及临床特征(生命体征、既往史、个人史、家族史、临床体征)。收集实验室结果,逐个填写个案调查表,记录基本资料、原发疾病、住院时间、住院次数、IUC内住院时间、机械通气时间、临床症状和体征、用药情况和实验室检查结果等指标。根据中华医学会呼吸病学分会制定的《医院获得性肺炎诊断和治疗指南》(1999年草案)VAP的诊断标准诊断是否为呼吸机相关肺炎。从诊断的呼吸机相关肺炎的病例中,选择病原学诊断为泛耐药鲍曼不动杆菌感染病例为泛耐药组,同时按同科室、入院时间相隔1周、性别相同、年龄相近(±5岁)、临床病情分类等级相同或相近的条件,按照1:1选择非泛耐药鲍曼不动杆菌感染病例为对照组。统计学处理选用SPSS17.0软件,计数资料采用χ2检验,对危险因素进行单因素分析及多因素Logistic回归分析;所有统计学处理以P0.05认为差异有统计学意义。结果:共调查泛耐药鲍曼不动杆菌致呼吸机相关性肺炎例118。单因素分析显示,泛耐药鲍曼不动杆菌呼吸机相关性肺炎的发生与住院时间、机械通气时间、昏迷、使用碳青霉烯类抗菌药物、抗菌药物联合应用、吸烟、恶性肿瘤、合并慢性肺部疾病等8种因素有关(P0.05);Logistic回归分析发现,住院时间30天、机械通气7天、昏迷、使用碳青霉烯类抗菌药物、抗菌药物联合应用≥3种、吸烟、合并慢性肺部疾病是泛耐药鲍曼不动杆菌致呼吸机相关性肺炎的独立危险因素(P0.05)。结论:巢式病例对照研究的方法,可对目标性监测开始后出现的新的病因假设进行研究,且具有论证度强、节约人力物力的优点。住院时间30天、机械通气7天、昏迷、使用碳青霉烯类抗菌药物、抗菌药物联合应用≥3种、吸烟、合并慢性肺部疾病是我院机械通气患者,发生泛耐药鲍曼不动杆菌呼吸机相关肺炎的独立危险因素。
[Abstract]:BACKGROUND: At present, invasive mechanical ventilation is widely used in the field of severe medicine. The clinical application is mainly used to rescue the critical patients with acute and chronic respiratory failure, but there are more complications during the application, and the ventilator-related lung (VAP) is one of the most common infectious diseases in the patients with mechanical ventilation. The incidence of VAP was 6% ~ 52% or (1.6-52.7)/ 1000 mechanical ventilation days, and the case fatality rate was 14%-50%. The case fatality rate was 76% and the attributable mortality was 20%-30%. In China, the incidence of VAP was in the range of 4. 7% to 55. 8% or (8.4 to 49. 3). The case fatality rate was 19. 4% to 51. 6%. The time of mechanical ventilation in patients with VAP was prolonged by 5. 4-14. 5 d, and the retention time in the ICU was prolonged by 6.1-17. 6d, and the hospital stay was prolonged by 11-12. 5d. The pathogenic bacteria of ventilator-associated pneumonia were dominated by Gram-negative bacilli, which were the most common with P. aeruginosa and Abalanobacter baumannii. It is widely distributed in the natural environment, the medical site and the human skin mucosa. Because of its ability to get drug resistance through a variety of ways and the ability to clone and spread is very strong, the multi-drug resistance, wide drug resistance and all-drug-resistant Bowman's bacillus is becoming a worldwide trend, and has become one of the most important pathogenic bacteria of the hospital infection in our country. There are many basic diseases, such as low immune function, broad-spectrum antibiotic resistance, long hospital stay, and so on. The nested case-control study originated in the comprehensive case-control study of Mantel, an epidemiologist in the United States, in 1973, and Miettinen was formally presented in 1982. It is a new research method that combines the traditional case-control research and some elements of the cohort study, that is, on the basis of a pre-determined cohort study, the design thinking of the case-control study is analyzed and analyzed. At present, the method is widely applied to the field of medical science and research at home and abroad. The method of using the nest type case-control study has the advantages that the risk factors of ventilator-related pneumonia caused by the universal drug-resistant Bowman's bacillus are explored, the data is collected, the selection is small, the investigation bias is small, the study sample is smaller in the cohort study, the manpower and material resources are saved, the cause and effect inference requirements are met, The demonstration is strong. Objective: To study the risk factors of universal drug-resistant Bowman's ventilator-associated pneumonia by using a nested case-control study, and to provide scientific basis for the prevention and control of this kind of infection and the rational use of anti-bacterial drugs in medical institutions. Methods: From January 2014 to December 2014, an artificial airway (tracheal intubation or tracheotomy) was established in the emergency and intensive care unit of our hospital, and the patients with mechanical ventilation for 48 hours were treated as observation cohort. Patients with age 18 excluded; endotracheal tube (or cut) dwell time of 48 h; tracheal intubation (or cut) 3d internal death; patients with severe multi-system dysfunction. A prospective, objective monitoring questionnaire was designed to fully collect the patient's basic information and clinical features (vital signs, previous history, personal history, family history, clinical signs) for patients receiving mechanical ventilation for 48h. Collect laboratory results, fill in case questionnaire one by one, record basic data, primary disease, hospital stay, number of hospitalizations, hospitalization time in IUC, mechanical ventilation time, clinical symptoms and signs, medication conditions and laboratory test results. The diagnostic criteria for the VAP are diagnosed as ventilator-associated pneumonia in accordance with the Diagnostic and Therapeutic Guidelines for Hospital-acquired Pneumonia (Draft 1999) developed by the Society for Respiratory Disease of the Chinese Medical Association. In the case of the diagnosis of ventilator-related pneumonia, the case of the etiological diagnosis of the drug-resistant Bowman's infection was selected as the panresistance group, and at the same time, according to the same department, the hospital admission time was 1 week, the gender was the same, and the age was similar (the age of 5 years). Under the condition of the same or similar clinical condition, the non-drug-resistant Bowman's infection case was selected as the control group according to 1: 1. The software of SPSS17.0 was selected for statistical processing. The data of the count data were analyzed by a two-factor method, and the single-factor analysis and multi-factor logistic regression analysis were performed on the risk factors, and all the statistical treatments were considered to be statistically significant with the difference of P0.05. Results: A total of 118 cases of ventilator-associated pneumonia were investigated. The single factor analysis shows that the occurrence and the hospitalization time, the mechanical ventilation time, the coma, the use of carbapenem antibacterial drugs, the combination of the antibacterial drugs, the smoking, the malignant tumor, 8 factors (P0.05) were related to the combination of chronic pulmonary disease (P0.05); the logistic regression analysis found that the hospitalization time was 30 days, the mechanical ventilation was 7 days, the coma, the carbapenem-based antibacterial drugs and the antibacterial drugs were used in combination with the other three types, smoking, The combined chronic pulmonary disease is an independent risk factor for ventilator-associated pneumonia (P <0.05). Conclusion: The method of nest-type case-control study can be used to study the new cause hypothesis after the start of the target monitoring, and has the advantages of strong demonstration degree and saving manpower and material resources. The duration of the hospital was 30 days, the mechanical ventilation was 7 days, the comatose, the carbapenem antibacterial drugs and the anti-bacterial drugs were used in combination with the other three types, smoking, and the combined chronic pulmonary disease was the independent risk factor of the ventilator-related pneumonia in the patients with mechanical ventilation in our hospital.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R563.1
本文编号：2375644
[Abstract]:BACKGROUND: At present, invasive mechanical ventilation is widely used in the field of severe medicine. The clinical application is mainly used to rescue the critical patients with acute and chronic respiratory failure, but there are more complications during the application, and the ventilator-related lung (VAP) is one of the most common infectious diseases in the patients with mechanical ventilation. The incidence of VAP was 6% ~ 52% or (1.6-52.7)/ 1000 mechanical ventilation days, and the case fatality rate was 14%-50%. The case fatality rate was 76% and the attributable mortality was 20%-30%. In China, the incidence of VAP was in the range of 4. 7% to 55. 8% or (8.4 to 49. 3). The case fatality rate was 19. 4% to 51. 6%. The time of mechanical ventilation in patients with VAP was prolonged by 5. 4-14. 5 d, and the retention time in the ICU was prolonged by 6.1-17. 6d, and the hospital stay was prolonged by 11-12. 5d. The pathogenic bacteria of ventilator-associated pneumonia were dominated by Gram-negative bacilli, which were the most common with P. aeruginosa and Abalanobacter baumannii. It is widely distributed in the natural environment, the medical site and the human skin mucosa. Because of its ability to get drug resistance through a variety of ways and the ability to clone and spread is very strong, the multi-drug resistance, wide drug resistance and all-drug-resistant Bowman's bacillus is becoming a worldwide trend, and has become one of the most important pathogenic bacteria of the hospital infection in our country. There are many basic diseases, such as low immune function, broad-spectrum antibiotic resistance, long hospital stay, and so on. The nested case-control study originated in the comprehensive case-control study of Mantel, an epidemiologist in the United States, in 1973, and Miettinen was formally presented in 1982. It is a new research method that combines the traditional case-control research and some elements of the cohort study, that is, on the basis of a pre-determined cohort study, the design thinking of the case-control study is analyzed and analyzed. At present, the method is widely applied to the field of medical science and research at home and abroad. The method of using the nest type case-control study has the advantages that the risk factors of ventilator-related pneumonia caused by the universal drug-resistant Bowman's bacillus are explored, the data is collected, the selection is small, the investigation bias is small, the study sample is smaller in the cohort study, the manpower and material resources are saved, the cause and effect inference requirements are met, The demonstration is strong. Objective: To study the risk factors of universal drug-resistant Bowman's ventilator-associated pneumonia by using a nested case-control study, and to provide scientific basis for the prevention and control of this kind of infection and the rational use of anti-bacterial drugs in medical institutions. Methods: From January 2014 to December 2014, an artificial airway (tracheal intubation or tracheotomy) was established in the emergency and intensive care unit of our hospital, and the patients with mechanical ventilation for 48 hours were treated as observation cohort. Patients with age 18 excluded; endotracheal tube (or cut) dwell time of 48 h; tracheal intubation (or cut) 3d internal death; patients with severe multi-system dysfunction. A prospective, objective monitoring questionnaire was designed to fully collect the patient's basic information and clinical features (vital signs, previous history, personal history, family history, clinical signs) for patients receiving mechanical ventilation for 48h. Collect laboratory results, fill in case questionnaire one by one, record basic data, primary disease, hospital stay, number of hospitalizations, hospitalization time in IUC, mechanical ventilation time, clinical symptoms and signs, medication conditions and laboratory test results. The diagnostic criteria for the VAP are diagnosed as ventilator-associated pneumonia in accordance with the Diagnostic and Therapeutic Guidelines for Hospital-acquired Pneumonia (Draft 1999) developed by the Society for Respiratory Disease of the Chinese Medical Association. In the case of the diagnosis of ventilator-related pneumonia, the case of the etiological diagnosis of the drug-resistant Bowman's infection was selected as the panresistance group, and at the same time, according to the same department, the hospital admission time was 1 week, the gender was the same, and the age was similar (the age of 5 years). Under the condition of the same or similar clinical condition, the non-drug-resistant Bowman's infection case was selected as the control group according to 1: 1. The software of SPSS17.0 was selected for statistical processing. The data of the count data were analyzed by a two-factor method, and the single-factor analysis and multi-factor logistic regression analysis were performed on the risk factors, and all the statistical treatments were considered to be statistically significant with the difference of P0.05. Results: A total of 118 cases of ventilator-associated pneumonia were investigated. The single factor analysis shows that the occurrence and the hospitalization time, the mechanical ventilation time, the coma, the use of carbapenem antibacterial drugs, the combination of the antibacterial drugs, the smoking, the malignant tumor, 8 factors (P0.05) were related to the combination of chronic pulmonary disease (P0.05); the logistic regression analysis found that the hospitalization time was 30 days, the mechanical ventilation was 7 days, the coma, the carbapenem-based antibacterial drugs and the antibacterial drugs were used in combination with the other three types, smoking, The combined chronic pulmonary disease is an independent risk factor for ventilator-associated pneumonia (P <0.05). Conclusion: The method of nest-type case-control study can be used to study the new cause hypothesis after the start of the target monitoring, and has the advantages of strong demonstration degree and saving manpower and material resources. The duration of the hospital was 30 days, the mechanical ventilation was 7 days, the comatose, the carbapenem antibacterial drugs and the anti-bacterial drugs were used in combination with the other three types, smoking, and the combined chronic pulmonary disease was the independent risk factor of the ventilator-related pneumonia in the patients with mechanical ventilation in our hospital.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R563.1
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相关期刊论文 前3条
1 谭薇;郭桂芳;王乐强;刘婷;于振刚;;早发性与晚发性呼吸机相关性肺炎病原学分析[J];中华医院感染学杂志;2007年05期
2 王贺;徐英春;陈民钧;;细菌质粒介导的喹诺酮类抗菌药物耐药机制研究进展[J];中华医院感染学杂志;2007年05期
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