摘要
目的 探讨常规气管内抽吸（ETA）培养物在呼吸机相关性肺炎（VAP）中的临床价值.方法 选择40例ICU机械通气的患者,在建立人工气道后（气管插管或气管切开）,予常规ETA取样定量培养;每周2次进行常规微生物分析,直至除去气管内导管.怀疑VAP时,用纤维支气管镜进行检查并进行支气管肺泡灌洗（BAL）,同时取支气管肺泡灌洗液（BALF）定量培养,行支气管镜检查时,分别记录患者SOFA评分,体温,白细胞计数,C-反应蛋白水平,临床肺部感染评分值（CPIS）,通气时间和使用抗生素的情况.当BALF定量培养物中至少可见一种浓度≥104 cfu/mL的病原微生物生长时,患者VAP诊断才予确诊.结果 在40例BALF培养结果中,28例BALF培养物出现阳性结果,根据培养结果28例患者（70％）诊断为VAP.在28例患者VAP诊断明确前,常规ETA同样培养鉴定出了18例（64％）具有相同抗生素耐药性的相同微生物.对于19例迟发型VAP,ETA同样培养鉴定出了13例与BALF培养发现的相同微生物.鲍曼不动杆菌是BALF培养最常见的细菌（n=14,50％）;而VAP诊断前ETA培养物在诊断预测鲍曼不动杆菌引起的VAP中具有很好的价值（敏感性62％,特异性95％,阳性预测值88％,阴性预测值80％）.结论 VAP患者应按国际指南治疗,但在VAP诊断明确前常规ETA培养物如已鉴定出多重耐药病原体,则初始抗生素治疗应涵盖这些微生物.因此在诊断疑似患有肺炎的重症患者时,常规ETA定量培养是一种安全有效的非侵入性诊断工具,特别是在诊断VAP的情况下.
Objective To discuss the clinical value of routine endotracheal aspirate （ETA） cultures in ventilator-associated pneumonia. Methods 40 patients who were admitted to ICU with mechanical ventilation （MV） requirement were chosen. After establishing an artificial airway （tracheal intubation or tracheotomy）, routine ETA sampling was used to quantify the culture; Routine microbiological analysis was performed by ETA （pre-VAP ETA） twice weekly in all patients until the endotracheal tube was removed. When VAP was suspected, fiberoptic bronchoscopy examination with bronchoalveolar lavage （BAL） was performed. When BAL was performed, the SOFA score, temperature, leukocyte count, C-reactive protein levels, clinical pulmonary infection score value, length of MV, and presence of antimicrobiological treatments were recorded. A diagnosis of VAP was established when the BAL quantitative culture grew at least one microorganism at a concentration ≥104 cfu/mL. Results VAP was diagnosed in 28 （70%） of the 40 patients based on BAL culture results. Among 28 positive BAL cultures, preVAP ETA identified the same microorganism with the same antibiotics resistance pattern in 18 （64%） patients. Regarding only late-onset VAP, pre-VAP ETA identified the same microorganisms found by BAL culture in 13 of the 19 cases. Acinetobacter baumannii was the most frequently isolated microorganism from BAL cultures （n = 14, 50%）. The diagnostic value of pre-VAP ETA results in predicting Acinetobacter baumannii VAP documented with the following values （sensitivity： 62%; specificity： 95%, positive predictive value： 88%, negative predictive value： 80%）. Conclusion VAP patients should be treated with international guidelines, but if pre-VAP ETA cultures identify multidrug resistant pathogens, the initial antibiotic therapy should cover these microorganisms. Thus, quantitative ETA cultures are a useful noninvasive diagnostic tool in critically ill patients suspected of having pneumonia especially in the case of VAP.
作者
倪春华
杨燕
王琴
NI Chun-hua;YANG Yan;WANG Qin(Kunshan No.1 People＇ s Hospital,Kunshan,Jiangsu,215300,China)
出处
《中国血液流变学杂志》
CAS
2018年第1期39-43,共5页
Chinese Journal of Hemorheology
关键词
抗生素
常规气管内抽吸培养物
支气管肺泡灌洗
呼吸机相关性肺炎
antibiotics
routine endotracheal aspirate cultures
bronchoalveolar lavage
ventilator-associated pneumonia
作者简介
倪春华（1975-），男，江苏丹阳人，硕士研究生，副主任医师，研究方向：重症医学。
