老年患者医院获得性肺炎的危险因素分析

目的探讨老年患者医院获得性肺炎（HAP）的危险因素,为临床预防和治疗疾病提供依据。方法回顾性分析60例老年患者,依据是否合并HAP分为研究组（合并HAP）和对照组（未合并HAP）各30例,采用非条件Logistic回归分析方法分析发生HAP的危险因素。结果研究组较对照组患有基础疾病种类多、留置胃管率高、应用抑酸药物率高、白蛋白水平偏低、动静脉插管率高（P〈0.05）,多因素分析显示脑血管疾病、使用抑酸剂、留置胃管、白蛋白水平偏低是发生HAP的独立危险因素。结论老年HAP患者具有的危险因素多,积极采取综合防范措施,减少危险因素,是降低HAP发生率的关键。     

ICU患者分类管理对医院获得性肺炎发病率的影响

目的 探讨重症监护病房(ICU)患者分类管理对医院获得性肺炎(HAP)发病率的影响.方法 将2005-2011年入住ICU且时间＞48 h的2 077例患者按入院时间分为2组,2005-2009年未实施ICU患者分类管理的患者(1471例)为第1组,2010-2011年实施ICU患者分类管理后的患者(606例)为第2组.对2005-2011年ICU HAP发病率和多重耐药菌感染情况进行统计分析,比较2组HAP发病率与多重耐药菌感染率.结果 第2组HAP发病率及多重耐药菌感染率均较第1组明显下降(均P＜0.01).结论 实施ICU患者分类管理可有效地降低HAP发病率及多重耐药菌感染率.     

Effectiveness of a hospital-wide selective screening programme for methicillin-resistant Staphylococcus aureus (MRSA) carriers at hospital admission to prevent hospital-acquired MRSA infections

Screening of potential MRSA-positive patients at hospital admission is recommended in German and international guidelines. This policy has been shown to be effective in reducing the frequency of nosocomial MRSA transmissions in the event of an outbreak, but the influence of screening on reducing hospital-acquired MRSA infections in a hospital setting where MRSA is endemic is not yet well-documented. This study describes the effect of hospital-wide screening of defined risk groups in a 700-bed acute care hospital during a period of 19 months. In a cohort study with a 19-month control period, the frequencies of hospital-acquired MRSA infections were compared with and without screening. In the control period, there were 119 MRSA-positive patients, of whom 48 had a hospital-acquired MRSA infection. On the basis of this frequency, a predicted total of 73.2 hospital-acquired MRSA infections was calculated for the screening period, but only 52% of the expected number (38 hospital-acquired MRSA infections) were observed, i.e., 48% of the predicted number of hospital-acquired MRSA infections were prevented by the screening programme. The screening programme was performed with minimal effort and can therefore be recommended as an effective measure to help prevent hospital-acquired MRSA infections.     

老年患者医院获得性肺炎风险评估模型的构建

目的构建老年患者医院获得性肺炎(HAP)风险因素评估模型,筛选HAP的老年高危人群。方法采用logistic回归分析,进行危险因素识别,建立HAP风险因素评估体系;根据β值对各危险因素进行赋值,建立感染风险因素评估模型。结果年龄≥70岁、神经系统疾病、恶性肿瘤、血液病、曾住ICU、本次住院手术次数≥3次以及先前使用抗菌药物是HAP的独立危险因素,HAP风险评估模型在建模组和验证组数据中受试者工作特征(ROC)曲线的曲线下面积(AUC)分别为0.73和0.77。结论老年患者HAP的风险评估模型具有较好的风险识别效度,可对老年患者中HAP的高危人群进行有效识 别。     

恶性肿瘤患者医院获得性真菌感染的病原学分布与耐药性分析

目的了解恶性肿瘤患者医院获得性真菌感染的菌种分布,诱发真菌感染的危险因素及对常用抗真菌药物的耐药性,为临床治疗真菌感染提供依据。方法对2012年1月至2013年12月送检的324例恶性肿瘤患者标本进行真菌培养及药敏试验。结果 324例恶性肿瘤患者标本中共检出真菌96株,感染率为29.6%。其中以呼吸道感染最多,占74.0%;菌种以白假丝酵母菌为首,占67.7%,其次是热带假丝酵母菌,占14.6%。抗菌药物的滥用、大量激素的使用及侵入性操作等是真菌感染的危险因素。5种假丝酵母菌对伊曲康唑的耐药率最高,对5-氟胞嘧啶和两性霉素B全敏感。结论常见假丝酵母菌属对常用抗真菌药物已具有一定的耐药性,临床应加强监测与控制,并根据药敏试验结果合理选用抗真菌药物。     

Mechanisms of antimicrobial resistance among hospital-associated pathogens

Introduction: The introduction of antibiotics revolutionized medicine in the 20th-century permitting the treatment of once incurable infections. Widespread use of antibiotics, however, has led to the development of resistant organisms, particularly in the healthcare setting. Today, the clinician is often faced with pathogens carrying a cadre of resistance determinants that severely limit therapeutic options. The genetic plasticity of microbes allows them to adapt to stressors via genetic mutations, acquisition or sharing of genetic material and modulation of genetic expression leading to resistance to virtually any antimicrobial used in clinical practice.

Areas covered: This is a comprehensive review that outlines major mechanisms of resistance in the most common hospital-associated pathogens including bacteria and fungi.

Expert commentary: Understanding the genetic and biochemical mechanisms of such antimicrobial adaptation is crucial to tackling the rapid spread of resistance, can expose unconventional therapeutic targets to combat multidrug resistant pathogens and lead to more accurate prediction of antimicrobial susceptibility using rapid molecular diagnostics. Clinicians making treatment decisions based on the molecular basis of resistance may design therapeutic strategies that include de-escalation of broad spectrum antimicrobial usage, more focused therapies or combination therapies. These strategies are likely to improve patient outcomes and decrease the risk of resistance in hospital settings.     

Appropriate Antibiotic Administration in Critically Ill Patients with Pneumonia

Inappropriate initial antibiotics for pneumonia infection are usually linked to extended intensive care unit stay and are associated with an increased risk of mortality. This study evaluates the impact of inappropriate initial antibiotics on the length of intensive care unit stay, risk of mortality and the co-predictors that influences these outcomes. This retrospective study was conducted in an intensive care unit of a teaching hospital. The types of pneumonia investigated were hospital-acquired pneumonia and ventilator-associated pneumonia. Three different time points were defined as the initiation of appropriate antibiotics at 24 h, between 24 to 48 h and at more than 48 h after obtaining a culture. Patients had either hospital-acquired pneumonia (59.1%) or ventilator-associated pneumonia (40.9%). The length of intensive care unit stay ranged from 1 to 52 days (mean; 9.78±10.02 days). Patients who received appropriate antibiotic agent at 24 h had a significantly shorter length of intensive care unit stay (5.62 d, P<0.001). The co-predictors that contributed to an extended intensive care unit stay were the time of availability of susceptibility results and concomitant diseases, namely cancer and sepsis. The only predictor of intensive care unit death was cancer. The results support the need for early appropriate initial antibiotic therapy in hospital-acquired pneumonia and ventilator-associated pneumonia infections.     

乌司他丁在超高龄老年重症医院内获得性肺部感染患者中的作用

目的探讨乌司他丁对超高龄老年重症医院内获得性肺部感染（SHLI）患者的治疗作用。方法将130例超高龄老年SHLI患者随机分为对照组和乌司他丁（UTI）组,在相同基础治疗的同时,UTI组加用乌司他丁治疗,比较两组患者的治愈率、总有效率、病死率,以及治疗前、治疗后第3、7、14d的炎性标志物C-反应蛋白（CRP）、前白蛋白（PA）及白介素-6（IL-6）的变化。结果与对照组比较,UTI组的治愈率、总有效率均明显提高（P〈0.05）,病死率明显降低（P〈0.01）,CRP及IL-6浓度均明显降低（P〈0.01）,PA的浓度明显升高（P〈0.01）。结论乌司他丁能够有效缓解高龄老年SHLI患者病情,改善相关炎性反应因子指标,提高治愈率和总有效率,降低病死率。