摘要
目的探讨新生儿呼吸机相关性肺炎（ventilator—associated pneumonia，VAP）的病原菌分布和耐药性变迁，以指导临床防治。方法收集复旦大学附属儿科医院新生儿重症监护病房（neonatal intensive care unit，NICU）采取综合感染防治措施前后3个不同阶段（2006年2月1日至2007年1月31日为第一阶段，2008年8月1日至2009年7月31日为第二阶段，2010年1月1日至2010年12月31日为第三阶段）使用气管插管机械通气≥48h，并在NICU住院≥5d的患儿的相关临床及实验室检查资料，对发生VAP患儿的下呼吸道分泌物标本进行病原菌检测，用琼脂扩散敏感试验法测定病原菌耐药性。采用两独立样本t检验、单因素方差分析或X^2检验进行统计学分析。结果3个阶段共纳入491例患儿，其中发生VAP共92例，VAP发生率为27．3／1000个呼吸机使用日。采取综合感染防治措施后新生儿VAP发生率逐渐下降，3个阶段VAP发生例数分别为38、22、32例，VAP发生率分别为48．8／1000个呼吸机使用日、25．7／1000个呼吸机使用日和18．5／1000个呼吸机使用日（X^2=26．19，P=0．000）。VAP病原菌以革兰阴性杆菌为主，占95．5％（63／66）。其中鲍曼不动杆菌是VAP最主要的致病菌，占65．2％（43／66）；其次是肺炎克雷伯菌，占15．2％（10／66）；大肠埃希菌及铜绿假单胞菌，各占6．1Voo（4／66）。3个阶段相比，第一阶段致VAP鲍曼不动杆菌对第三代头孢菌素全部耐药，对碳青霉烯类抗生素敏感率为57．9％，有8株多重耐药菌株；第二阶段分离到的病原菌对第三代头孢菌素敏感率上升至75．0％（X^2=16．39，P=0．000），且无耐碳青霉烯类菌株及多重耐药菌株；与第二阶段相比，第三阶段病原菌对头孢菌素及碳青霉烯类药物的敏感率分别下降至5．0％（X^2=11．76，P=0．001）和20．0％（X^2=6．72，P=0．01），出现10株多重耐种类逐年变迁。定期监测和分析NICU患儿VAP病原菌分布及其耐药性变迁，对临床合理使用抗菌药物及控制VAP发生具有重要指导意义。
Objective To investigate the distribution of pathogens and antibiotic sensitivity in neonates with ventilator-associated pneumonia （VAP） in a Chinese neonatal intensive care unit （NICU）, providing evidence for rational administration of antibiotics and nosocomial infection control. Methods The neonates admitted into NICU of Childrents Hospital, Fudan University subjected to tracheal intubation-mechanieal ventilation for ≥48 h and hospitalized for ≥5 d during three stages were selected in this study. The first stage was from February 1, 2006 to January 31, 2007; the second stage was from August 1, 2008 to July 31, 2009 and the third stage was from January 1, 2010 to December 31, 2010. Related clinical and laboratory information of these neonates was collected. Sputum specimens from the lower respiratory tract in VAP newborns were collected for the detection of pathogens. Antimicrobial susceptibility testing was carried out by Kirby-Bauer method according to the unified protocol. Continuous variables were summarized in mean± standard deviation （x^-±s）. Categorical variables were summarized using count and percentage. Categorical variables were evaluated using the Chi-square. Continuous variables were evaluated using t-test or one way ANOVA, as appropriate. Results The incidence of VAP was declined gradually after implement of a bundle of infection-control practices. There were 491 patients enrolled during three stages, and 92 VAP cases among them. The incidence of VAP was 27.3 per 1000 ventilated days. In three stages, there were 38, 22 and 32 VAP cases, and the incidence of VAP was 48.8, 25.7 and 18.5 per 1000 ventilated days respectively （X^2 = 26.19, P = 0. 000）. Gram-negative bacilli （63 strains, 95.5%） were the primary VAP microorganisms in all stages, and the most common organisms isolated for VAP during three periods were Acinetobacter baumannii （43 strains, 65.2 %）, Klebsiella pneumonia （10 strains, 15.2 %）, Escherichia coli and Pseudomonas aeruginosa （4 strains, 6.1% in each）. In the first stage, antimicrobial susceptibility test showed that all Acinetobacter baumannii were resistant to Cephalosporin, and antimicrobial susceptibility of Carbapenems was 57.9%. Eight multi-drug resistant bacterial strains were isolated. After implemented the infection control practices during the second stage, 75.0% Acinetobacter baumannii were sensitive to Cephalosporin （X^2 = 16.39, P = 0.000） and no multi-drug resistant or Carbapenem-resistant strains were isolated. However, compared with the second stage, the antimicrobial susceptibility to the third-generation Cephalosporin and Carbapenems in the third stage declined to 5.0% （X^2 =11.76,P=0. 001） and 20.0% （X^2 =6.72, P= 0.01） respectively. Additionally, 10 multi-drug-resistant strains were isolated. Conclusions Gram-negative bacilli were the primary VAP microorganisms in the NICU. Implement of a bundle of infection-control practices might reduce the incidence of VAP in NICU. While, pathogenrs species might change year by year. Regular analysis and monitoring of pathogen＇s species and variance of drug resistance in local patients with VAP might have important significance to guide the clinical use of antimicrobial agents and effective control of the incidence of VAP.
出处
《中华围产医学杂志》
CAS
北大核心
2012年第8期462-468,共7页
Chinese Journal of Perinatal Medicine
基金
上海市科委国际合作项目（09410705900）
关键词
肺炎
呼吸机相关性
革兰氏阴性菌
抗药性
细菌
微生物敏感性试验
Pneumonia, ventilator-associated
Gram-negative bacteria
Drug resistance, bacterial
Microbial sensitivity tests
