中国九城市成人医院获得性肺炎微生物学与临床特点调查

摘要

目的 探讨我国医院获得性肺炎(HAP)的临床与致病微生物特点,为临床合理治疗提供依据.方法 在中国不同城市的13家教学医院进行HAP多中心、前瞻性调查研究.入选2008年8月至2010年12月国内13家大型教学医院呼吸科病房和呼吸科监护病房(RICU)所有确诊为HAP的患者.收集入选患者的临床资料,留取痰或气管吸引物及发热患者的血标本进行常规细菌培养及药敏试验,留取间隔2周以上的双份血清检测军团菌血清抗体,留取尿液检测尿液中肺炎链球菌抗原水平.结果 610例HAP患者中,93.9％(573例)合并一种或多种基础疾病,HAP总发生率为1.4％(610/42 877),其中呼吸科普通病房的发生率为0.9％ (362/41 261),RICU的发生率为15.3％(248/1616).610例中91.0％(555例)的患者在发生HAP前90天内使用过抗菌药物.HAP患者中79.8％(487/610)的患者检测到病原体,首位是鲍曼不动杆菌,占30.0％ (183/610),其次为铜绿假单胞菌(22.0％,134/610)、金黄色葡萄球菌(13.4％,82/610)及肺炎克雷伯菌(9.7％,59/610)；18例(3.0％)分离到苛养菌.呼吸机相关肺炎(VAP)中鲍曼不动杆菌和金黄色葡萄球菌的分离率为50.5％(97/192)和21.4％ (41/192),显著高于非VAP患者[分别为20.6％(86/418)和9.8％(41/418),均P＜0.01].急性生理学及慢性健康状况评分Ⅱ(APACHEⅡ)评分≥20的患者中,鲍曼不动杆菌和金黄色葡萄球菌的分离率分别为45.7％ (69/151)和20.5％ (31/151),显著高于APACHEⅡ评分＜20的患者[分别为24.8％(114/459)和11.1％(51/459),均P＜0.01].鲍曼不动杆菌对碳青霉烯的耐药率高达76.8％(109/142),对头孢哌酮舒巴坦的敏感度为40.8％(58/142),多黏菌素的敏感度为99.3％(141/142),替加环素的敏感度为95.8％(136/142).铜绿假单胞菌对美罗培南、亚胺培南的耐药率分别为48.8％(40/82)和70.7％(58/82).金黄色葡萄球菌中甲氧西林耐药的金黄色葡萄球菌(MRSA)占87.8％ (43/49).HAP的平均全因病死率为22.3％(135/605),其中VAP为34.5％ (61/177),显著高于平均全因病死率(P＜0.05).HAP患者的平均住院时间为(23.8±20.5)d,显著高于同期所有住院患者的平均住院时间(13.2±13.6) d(t=18.7498,P＜0.01).HAP患者总住院治疗费用平均为(108 950±116 608)元,显著高于同期呼吸科住院患者平均住院费用(17 999 ±33 364)元.结论 HAP是我国大型教学医院常见的医院内感染,全因病死率较高,可导致住院时间显著延长及住院总费用增高.HAP常见的致病菌主要为鲍曼不动杆菌、铜绿假单胞菌、金黄色葡萄球菌及肺炎克雷伯菌.我国教学医院HAP常见致病菌的耐药情况严重,值得关注.%Objective To investigate the etiology and clinical characteristics of hospital-acquired pneumonia (HAP) in China and to provide evidence for appropriate therapy.Methods We performed a prospective multicenter study in 13 Chinese urban tertiary hospitals.All HAP cases diagnosed at respiratory general ward and respiratory intensive care unit (RICU) from August 2008 to December 2010 were studied.Epidemiological data,etiology and clinical characteristics of enrolled patients were collected.Sputum or tracheal aspirate and blood cultures,Legionella antibodies and Streptococcus pneunoniae urinary antigen tests were performed.Bacteria to antimicrobial susceptibility test was performed.Results A total of 610 cases of HAP were diagnosed during the study,with an overall incidence of 1.4％ among 42 877 hospitalized patients,while the incidence was 0.9％ (362/41 261) in respiratory general ward and 15.4％ (248/1616)in RICU.93.9％ (573 cases) of patients had at least one underlying disease,and 91.0％ (555 cases) had exposure to at least one antimicrobial agent within 90 days prior to HAP diagnosis.Pathogens were identified in 487 patients,with Acinetobacter baumannii [30.0％ (183/610)],Pseudomonas aeruginosa [22.0％(134/610)],Staphylococcus aureus [13.4％ (82/610)] and Klebsiella pneumonia [9.7％ (59/610)]being the most common pathogens.Eighteen patients (3.0％) had infection with fastidious bacteria.A.baumannii and S.aureus were the more frequent pathogens in the ventilator-associated pneumonia (VAP)cases [50.5％ (97/192) and 21.4％ (41/192)] as compared to non-VAP cases [20.6％ (86/418) and 9.8％ (41/418),P ＜ 0.01].A.baumannii and S.aureus were also frequent pathogens in cases with a score of more than 20 by the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scoring [45.7％ (69/151)and 20.5％ (31/151)],as compared to cases with a score of less than 20 of APACHE Ⅱ [24.8％(114/459) and 11.1％ (51/459),P＜0.01].A.baumannii showed high resistance rates to carbapenems [more than 70％ (109/142)],and the susceptibility to cefoperazone/sulbactam,polymyxin B and tigecycline were 40.8％ (58/142),99.3 ％ (141/142) and 95.8％ (136/142) respectively.Resistance rates of P.aeruginosa to meropenem and imipenem were 48.8％ (40/82)and 70.7％ (58/82) respectively.Methicillin-resistant S.aureus (MRSA) accounted for 87.8％ (43/49)in all strains of S.aureus.Mortality rate of VAP cases was 34.5％ (61/177),significantly more than that of HAP patients [22.3％ (135/605),P ＜0.05].The average hospital stay of patients with HAP was (23.8 ±20.5) days,significantly more than that of the average for inpatients [(13.2 ± 13.6) days,P ＜0.01] during the study period.Mean costs of HAP were (108 950 ± 116 608) yuan,significantly higher than the average hospital costs of respiratory inpatients (17 999 ± 33 364) yuan.Conclusions Among Chinese patients hospitalized in urban tertiary medical centers,HAP incidence and mortality rate were high,which increased the patients' hospital stay and the medical costs.Common pathogens were A.baumannii,P.aeruginosa,S.aureus and K.pneumonia.The common bacteria of HAP in China showed high resistance rates to antibiotics.