医院获得性肺炎北京协和医院 加强医疗科 杜斌HAP - 概况 定义 住院48小时后发生的肺炎 接受机械通气患者的7%至40% 收治ICU的患者较普通病房患者明显增高 气管插管进行机械通气的患者发生肺炎危险性增加数倍HAP - 概况 常见医院获得性感染的第一位 罹患率及病死率最高 40% to 80% 住院死亡患者中约15%直接与医院获 得性肺炎有关 1/3 to 1/2 = 归因死亡率ICU中HAP的患病率3,668名MICU 117: 1434-1442.HAP - 流行病学患病率 NNIS - 所有住院患者医院获得性下呼吸道 感染 0.6 例 / 100 住院患者 ICU患者8%至20% EPIC - 医院获得性肺炎 10038名ICU患者中967名= 9.6% 欧洲医院获得性肺炎协作组 肺炎粗患病率8.9%HAP - 流行病学 接受机械通气的ICU患者发生肺炎的危险明 显增加 作者比数比 Cross10 SENIC21 Celis 7 EPIC ? Chevret 3HAP - 流行病学HAP - 流行病学 23个意大利ICU进 行的前瞻性研究 长期接受机械通气 治疗( 72 hrs)的 724名患者 VAP平均患病率 = 23%HAP - 流行病学肺炎患病危险每日增加1%HAP - 流行病学 气管插管时间 = 发生HAP非常重要的 危险因素HAP - 病死率HAP - 病死率致病菌也是影响病死率的危险因素 革兰氏阴性杆菌肺炎较革兰氏阳性球 菌病死率更高 56% vs 24% (Graybill) 50% vs 5% (Stevens) 绿脓杆菌Pseudomonas aeruginosa 70% to 80%HAP - 病死率细菌耐药性-死亡的危险因素 迟发性肺炎(Kollef) 高危致病菌(P. aeruginosa, Acinetobacter spp., and S. maltophilia) 65% vs 31% MRSA vs MSSA (Rello) 85.7% vs 11.9% (RR = 20.72)HAP - 死亡的危险因素多因素回归分析 呼吸功能衰竭的恶化 存在最终致命性基础疾病 存在迅速致命性基础疾病 出现休克 不适当的抗生素治疗 ICU的种类 - by Torres et alHAP - 死亡的危险因素死亡的独立危险因素-多因素分析的结果HAP - 死亡的危险因素医院获得性肺炎的粗病死率与归因死亡率 -5项对照队列研究的结果HAP - 预后VAP - 预后医院获得性肺炎-额外的医疗费用 Pinner 1982$ 1,255 Beyt1985$ 2,863 Baker$40,000VAP - 致病菌医院获得性肺炎的主要7种致病菌 NNIS, 1985-1988 Staphylococcus aureus Pseudomonas aeruginosa Enterobacteriaceae Klebsiella spp. Escherichia coli Serratia marcescens Proteus spp.金黄色葡萄球菌引起的VAPRello, AJRCCM 1994HAP - 致病菌HAP - 危险因素 长期机械通气 (24 h) 再次气管插管 既往应用抗生素? 可证实的误吸 应用肌松剂 气管插管套囊压力过低 仰卧位HAP - 危险因素HAP的独立危险因素 逻辑回归分析结果 既往应用抗生素 器官功能衰竭 年龄超过60岁 平卧位 - by KollefHAP - 危险因素应激性溃疡的预防 -荟粹分析的结果 sucralfate vs H2 blockers9 studies sucralfate vs antacids 10 studies 应激性溃疡的预防 sucralfate = antacids H2 blockers 医院获得性肺炎发生率 sucralfate 38 C or 10,000 or 3,000) 脓性气管分泌物干预措施 在临床诊断VAP后或原有VAP侵润影进展后24小时内进行纤维支 气管镜下BAL 所有患者均应用抗生素，其中107在纤维支气管镜见检查前，25 名在纤维支气管镜检查后立即应用抗生素经验性抗生素治疗HAP - 经验性治疗* Excludes patients with immunosuppression.Patients with mild-to-moderate HAP, no unusual risk factors, onset any time or patients with severe hospital-acquired pneumonia with early onset*HAP - 经验性治疗* Excludes patients with immunosuppression. * Rifampin may be added if Legionella species is documented.Patients with mild-to-moderate hospital-acquired pneumonia with risk factors, onset any time*HAP - 经验性治疗* Excludes patients with immunosuppression. * Aztreonam efficacy is limited to enteric gram-negative bacilli and should not be used in combination with an aminoglycoside if gram- positive or Hemophilus influenzae infection is of concern.Patients with severe hospital-acquired pneumonia with risk factors, early onset or patients with severe HAP, late onset*HAP - 经验性治疗HAP - 经验性治疗HAP - 预防Mortality benefit unprovenASelective digestive tract decontaminationHypothetically beneficial, no supportive dataCPostpyloric position for enteral feeding tubeLess aspiration shown in intubated patients; however, raised head of bed might be a risk for pneumonia in extubated patients requiring reintubationCElevated head of bedRecent multicenter trial showed no differenceBNon-pH-altered peptic ulcer prophylaxisRecommendation based on 1 study with trend toward benefitBOral position of endotracheal tube instead of intranasal positionOf 5 randomized trials, only 1 demonstrated reduced pneumonia; the other 4 had favorable trending dataBKinetic bed therapyReports of increased frequency of endotracheal tube occlusion with heat and moisture exchangersBHeat and moisture exchangers instead of heated humidifiersRequires specific endotracheal tube suction systemAModified endotracheal tube allowing subglottic suctioning of secretionsMore frequent changes of no benefitAVentilator circuit changes no more than every 7 dCommentStrength of Evidence, GradeInterventionHAP - 预防传统的感染控制措施 University of Washington, Seattle 6张床位的开放式ICU，仅有2个洗手池 14张床位，独立隔离房间，有单独的洗手池 对细菌定植或感染总体发生率无影响HAP - 预防传统的感染控制措施 24%的医务人员接触患者后洗手 单纯改善环境不能有效降低感染 率 医务人员的态度和行为更为重要HAP - 预防Wash Hands Use GlovesFrom: Khatib M, et al. Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest 1999;116:172-5HAP - 预防结论 简单的标志可以有效提醒医务人员进行洗手 降低医院获得性肺炎的发病率？HAP - 预防教育课程的效果 肺炎发病率 4.0%1.6% by Britt et al PICU中使用简单的隔离措施 (disposable, nonwoven polypropylene gowns, nonsterile latex gloves) 每日感染率减半 首次感染发生延迟 8 20天 by Klein et alHAP - 预防Medical Devices Agency one report of MRSA being detected on the internal components of an ICU ventilator staff unaware that air filters inside the equipment need to be cleaned or replaced on a regular basis UK hospitals alerted to MRSA contaminationSept. 27, 2001HAP - 预防振动及旋转床 minimize complete immobilizationsHAP - 预防持续或间断吸引口咽部分泌物 气管插管具有单独的管腔，供每小时 清除套囊上方潴留的分泌物 145例机械通气患者 肺炎 12.8% vs 29.1% (p0.05) 肺炎发生延迟 16.2 vs 8.3 dHAP - 预防抗生素预防的效果HAP - 预防结论 降低VAP发生率及严重程度的有效抗 生素 需要包括 静脉(PCN G)以及 局部(genta/polymyxin B)HAP - 预防选择性胃肠道去污染, SDD