泛耐藥鮑曼不動桿菌呼吸機(jī)相關(guān)肺炎巢式病例對照研究
發(fā)布時間：2018-12-13 01:44
【摘要】：背景:目前,有創(chuàng)機(jī)械通氣技術(shù)正在被廣泛應(yīng)用于重癥醫(yī)學(xué)領(lǐng)域。臨床中主要用于搶救急慢性呼吸衰竭危重患者,但應(yīng)用過程中并發(fā)癥較多,其中呼吸機(jī)相關(guān)性肺(VAP)是機(jī)械通氣患者最常見的感染性疾病之一。國外報道,VAP發(fā)病率為6%~52%或(1.6-52.7)例/1000機(jī)械通氣日,病死率為14%-50%;若病原菌是多重耐藥菌或泛耐藥菌,病死率可達(dá)76%,歸因死亡率為20%-30%。在我國,VAP發(fā)病率在4.7%-55.8%或(8.4-49.3)例/1000機(jī)械通氣日,病死率為19.4%-51.6%。發(fā)生VAP患者機(jī)械通氣時間延長5.4-14.5 d,ICU留治時間延長6.1-17.6d,住院時間延長11-12.5d。呼吸機(jī)相關(guān)肺炎感染的致病菌中以革蘭陰性桿菌為主,其中以銅綠假單胞菌和鮑曼不動桿菌最為常見。鮑曼不動桿菌(Ab)屬于條件致病菌,廣泛分布于自然環(huán)境、醫(yī)療場所以及人體皮膚黏膜中。因其可以通過多種途徑獲得耐藥性且克隆傳播的能力非常強(qiáng),目前多重耐藥、廣泛耐藥、全耐藥鮑曼不動桿菌正呈世界性流行趨勢,已成為我國醫(yī)院感染最重要的致病菌之一。有創(chuàng)機(jī)械性通氣患者病情危重、常伴有多種基礎(chǔ)疾病、免疫功能低下、廣譜抗菌藥物的使用、住院時間長等多種因素極易發(fā)生泛耐藥鮑曼不動桿菌感染。巢式病例對照研究起源于美國流行病學(xué)家Mantel在1973年提出的綜合式病例對照研究設(shè)計,Miettinen于1982年正式提出。它是將傳統(tǒng)的病例對照研究和隊列研究的一些要素進(jìn)行重新組合后形成的一種新的研究方法,即在對一個事先確定好的隊列研究的基礎(chǔ)上,再應(yīng)用病例對照研究的設(shè)計思路進(jìn)行研究分析。目前該方法在國內(nèi)外被廣泛地應(yīng)用于醫(yī)學(xué)科研領(lǐng)域。采用巢式病例對照研究的方法,對泛耐藥鮑曼不動桿菌導(dǎo)致呼吸機(jī)相關(guān)肺炎的危險因素進(jìn)行探索的優(yōu)點是收集資料在先,選擇、調(diào)查偏倚較小;研究樣本較隊列研究小,節(jié)約人力物力;符合因果推論要求,論證度強(qiáng)。目的:本研究通過采用巢式病例對照研究的方法,探索泛耐藥鮑曼不動桿菌呼吸機(jī)相關(guān)肺炎的危險因素,為醫(yī)療機(jī)構(gòu)預(yù)防與控制該類感染及合理使用抗菌藥物提供科學(xué)依據(jù)。方法:將2014年1月份至2014年12月份,我院急診ICU、重癥醫(yī)學(xué)科收治的建立人工氣道(氣管插管或氣管切開)并接受機(jī)械通氣≥48 h的患者作為觀察隊列。排除年齡18周歲者;氣管插管(或切開)留置時間48 h者;行氣管插管(或切開)3 d內(nèi)死亡者;嚴(yán)重多系統(tǒng)功能障礙的患者。設(shè)計前瞻性目標(biāo)性監(jiān)測調(diào)查表,對接受機(jī)械通氣48h的患者,全面收集患者基本信息及臨床特征(生命體征、既往史、個人史、家族史、臨床體征)。收集實驗室結(jié)果,逐個填寫個案調(diào)查表,記錄基本資料、原發(fā)疾病、住院時間、住院次數(shù)、IUC內(nèi)住院時間、機(jī)械通氣時間、臨床癥狀和體征、用藥情況和實驗室檢查結(jié)果等指標(biāo)。根據(jù)中華醫(yī)學(xué)會呼吸病學(xué)分會制定的《醫(yī)院獲得性肺炎診斷和治療指南》(1999年草案)VAP的診斷標(biāo)準(zhǔn)診斷是否為呼吸機(jī)相關(guān)肺炎。從診斷的呼吸機(jī)相關(guān)肺炎的病例中,選擇病原學(xué)診斷為泛耐藥鮑曼不動桿菌感染病例為泛耐藥組,同時按同科室、入院時間相隔1周、性別相同、年齡相近(±5歲)、臨床病情分類等級相同或相近的條件,按照1:1選擇非泛耐藥鮑曼不動桿菌感染病例為對照組。統(tǒng)計學(xué)處理選用SPSS17.0軟件,計數(shù)資料采用χ2檢驗,對危險因素進(jìn)行單因素分析及多因素Logistic回歸分析;所有統(tǒng)計學(xué)處理以P0.05認(rèn)為差異有統(tǒng)計學(xué)意義。結(jié)果:共調(diào)查泛耐藥鮑曼不動桿菌致呼吸機(jī)相關(guān)性肺炎例118。單因素分析顯示,泛耐藥鮑曼不動桿菌呼吸機(jī)相關(guān)性肺炎的發(fā)生與住院時間、機(jī)械通氣時間、昏迷、使用碳青霉烯類抗菌藥物、抗菌藥物聯(lián)合應(yīng)用、吸煙、惡性腫瘤、合并慢性肺部疾病等8種因素有關(guān)(P0.05);Logistic回歸分析發(fā)現(xiàn),住院時間30天、機(jī)械通氣7天、昏迷、使用碳青霉烯類抗菌藥物、抗菌藥物聯(lián)合應(yīng)用≥3種、吸煙、合并慢性肺部疾病是泛耐藥鮑曼不動桿菌致呼吸機(jī)相關(guān)性肺炎的獨立危險因素(P0.05)。結(jié)論:巢式病例對照研究的方法,可對目標(biāo)性監(jiān)測開始后出現(xiàn)的新的病因假設(shè)進(jìn)行研究,且具有論證度強(qiáng)、節(jié)約人力物力的優(yōu)點。住院時間30天、機(jī)械通氣7天、昏迷、使用碳青霉烯類抗菌藥物、抗菌藥物聯(lián)合應(yīng)用≥3種、吸煙、合并慢性肺部疾病是我院機(jī)械通氣患者,發(fā)生泛耐藥鮑曼不動桿菌呼吸機(jī)相關(guān)肺炎的獨立危險因素。
[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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R563.1
本文編號：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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R563.1
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