Czosnowski Quinn A, Wood G Christopher, Magnotti Louis J, Croce Martin A, Swanson Joseph M, Boucher Bradley A, Fabian Timothy C
Department of Pharmacy Practice and Administration, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, Pennsylvania 19104, USA.
Pharmacotherapy. 2009 Sep;29(9):1054-60. doi: 10.1592/phco.29.9.1054.
To determine clinical and microbiologic success in patients receiving adjunctive aerosolized antibiotics for the treatment of ventilator-associated pneumonia (VAP).
Retrospective medical record review.
Level I trauma intensive care unit of a large academic medical center.
Forty-nine patients (mean +/- SD age 42 +/- 19 yrs) who received aerosolized antibiotics for the treatment of a total of 60 episodes of VAP caused by Pseudomonas aeruginosa and/or Acinetobacter baumannii between January 2001 and July 2007.
Patients were identified by using an existing database of patients with documented VAP at the study center. To receive a diagnosis of VAP, patients had to have bacterial growth of 10(5) or more colony-forming units/ml from a bronchoscopic bronchoalveolar lavage and new or changing infiltrate on chest radiograph, plus at least two of the following: abnormal body temperature (> 38 degrees C or < 36 degrees C), abnormal white blood cell count (> 10 or < 4 x 10(3)/mm(3), or > 10% immature bands), or macroscopically purulent sputum. By reviewing patient data, we evaluated clinical and microbiologic success using standard definitions. The median (interquartile range) Injury Severity Score and admission Acute Physiology and Chronic Health Evaluation II score were 40 (29-45) and 17 (9-21), respectively. Pseudomonas aeruginosa, A. baumannii, or both were isolated in 45, 14, and 1 episode(s), respectively. Eighteen VAP episodes included additional bacteria. Aerosolized tobramycin, amikacin, and colistimethate were used in 44, 9, and 9 episodes, respectively. Systemic antibiotics were used in 59 (98%) of the 60 episodes. Clinical success was achieved in 36 (73%) of the 49 first episodes of VAP, 8 (73%) of 11 subsequent episodes, 17 (85%) of 20 episodes that were failing intravenous monotherapy, and 30 (79%) of 38 episodes with multidrug-resistant P. aeruginosa or A. baumannii. Microbiologic success was achieved in 29 (71%) of 41 evaluable episodes. Six patients died from VAP.
Treatment with adjunctive aerosolized antibiotics was associated with a good response rate in critically ill trauma patients with VAP due to nonfermenting gram-negative bacilli. It is noteworthy that episodes of VAP that followed intravenous therapy failure and/or that were due to multidrug-resistant organisms responded well.
确定接受雾化吸入抗生素辅助治疗呼吸机相关性肺炎（VAP）患者的临床及微生物学治疗成功率。
回顾性病历审查。
某大型学术医疗中心的一级创伤重症监护病房。
49例患者（平均年龄±标准差42±19岁），2001年1月至2007年7月期间，共接受雾化吸入抗生素治疗60例由铜绿假单胞菌和/或鲍曼不动杆菌引起的VAP。
通过研究中心现有的VAP确诊患者数据库识别患者。要确诊为VAP，患者支气管镜支气管肺泡灌洗的细菌生长量须达到10⁵或更多菌落形成单位/毫升，且胸部X光片有新的或变化的浸润影，另外还需满足以下至少两项：体温异常（>38℃或<36℃）、白细胞计数异常（>10或<4×10³/mm³，或未成熟带>10%）或肉眼可见脓性痰。通过回顾患者数据，我们采用标准定义评估临床及微生物学治疗成功率。损伤严重度评分中位数（四分位间距）和入院时急性生理与慢性健康状况评分II分别为40（29 - 45）和17（9 - 21）。分别有45例、14例和1例分离出铜绿假单胞菌、鲍曼不动杆菌或两者。18例VAP发作还分离出其他细菌。分别有44例、9例和9例发作使用了雾化妥布霉素、阿米卡星和多粘菌素甲磺酸钠。60例发作中有59例（98%）使用了全身抗生素。49例首次VAP发作中有36例（73%）取得临床成功，11例后续发作中有8例（73%）成功，20例静脉单一疗法治疗失败的发作中有17例（85%）成功，38例耐多药铜绿假单胞菌或鲍曼不动杆菌发作中有30例（79%）成功。41例可评估发作中有29例（71%）取得微生物学成功。6例患者死于VAP。
对于因非发酵革兰阴性杆菌导致VAP的重症创伤患者，雾化吸入抗生素辅助治疗有较好的反应率。值得注意的是，静脉治疗失败后发生的VAP发作以及由耐多药菌引起的发作反应良好。
