Department of Surgery, Weill Medical College of Cornell University, 525 E. 68th St., New York, NY 10021, USA.
Surg Infect (Larchmt). 2010 Feb;11(1):13-20. doi: 10.1089/sur.2008.025.
Ventilator-associated pneumonia (VAP) is one of the leading causes of morbidity in critically ill surgical patients. Certain pathogens (e.g., methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa) have been associated with an excess mortality rate from sepsis in several studies, but not in the surgical setting specifically or when protocol-driven antibiotic therapy is administered.
We sought to determine which factors and, in particular, whether the individual pathogen affected the mortality rate in our surgical intensive care unit (ICU), where a rotational antibiotic system has been employed continuously since 1997. We hypothesized that the type of pathogen and illness severity were the primary influences on the mortality rate of patients with VAP.
A total of 198 consecutive patients from a university surgical ICU, with clinical signs of VAP confirmed by quantified isolation of significant numbers of a pathogen (> or =10(4) colony-forming units [cfu]/mL) from bronchoalveolar (BAL) fluid obtained by fiberoptic bronchoscopy, were identified prospectively from January 2001 to November 2004. The data collected were age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) III score, multiple organ dysfunction score, unit day of diagnosis, time (h) to antibiotic administration (TTA), appropriateness of initial therapy (AIT), unit and hospital length of stay, and mortality rate. Pathogens were classified as non-lactose-fermenting gram-negative bacilli (NGNB), lactose-fermenting gram-negative bacilli (LGNB), methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, yeast, community-acquired pneumonia (e.g., Streptococcus pneumoniae), or other pathogens. Patients with a polymicrobial isolate were placed in the "other" category.
The overall mortality rate was 32.3% vs. 55% as predicted by APACHE III normative data. The overall AIT was 92%. The mortality rate for NGNB infections was 35.6% vs. 29.4% for LGNB infections (p = NS). By logistic regression, neither TTA, AIT, nor pathogen influenced the mortality rate.
The type of pathogen does not influence death in surgical ICU patients with VAP diagnosed rigorously and treated by a rotational antibiotic system. The high proportion of AIT as a result of the rotational antibiotic administration system optimizes bacterial killing and negates the impact of bacterial resistance, contributing to better outcomes.
呼吸机相关性肺炎（VAP）是危重病患者发病率的主要原因之一。在几项研究中，某些病原体（例如耐甲氧西林金黄色葡萄球菌，铜绿假单胞菌）与败血症的死亡率过高有关，但在外科环境中却没有具体的研究，或者当实施基于方案的抗生素治疗时也没有具体的研究。
我们试图确定哪些因素，特别是病原体的类型是否会影响我们的外科重症监护病房（ICU）患者的死亡率，在该病房中，自 1997 年以来一直连续使用旋转抗生素系统。我们假设病原体的类型和疾病严重程度是影响 VAP 患者死亡率的主要因素。
我们前瞻性地确定了 2001 年 1 月至 2004 年 11 月期间来自大学外科 ICU 的 198 例连续患者，这些患者通过纤维支气管镜从支气管肺泡（BAL）液中定量分离出大量病原体（>或= 10（4）菌落形成单位[cfu]/mL），临床诊断为 VAP，并通过定量分离出大量病原体（>或= 10（4）菌落形成单位[cfu]/mL）进行临床诊断。收集的数据包括年龄，性别，急性生理学和慢性健康评估（APACHE）III 评分，多器官功能障碍评分，入住 ICU 的天数，抗生素治疗开始时间（TTA），初始治疗的适当性（AIT），入住 ICU 和住院时间以及死亡率。病原体分为非乳糖发酵革兰氏阴性杆菌（NGNB），乳糖发酵革兰氏阴性杆菌（LGNB），甲氧西林敏感金黄色葡萄球菌，耐甲氧西林金黄色葡萄球菌，酵母，社区获得性肺炎（例如肺炎链球菌）或其他病原体。分离出多种病原体的患者被归入“其他”类别。
总体死亡率为 32.3％，而 APACHE III 规范数据预测的死亡率为 55％。总体 AIT 为 92％。NGNB 感染的死亡率为 35.6％，而 LGNB 感染的死亡率为 29.4％（p = NS）。通过逻辑回归，TTA，AIT 或病原体均未影响死亡率。
严格诊断和采用旋转抗生素系统治疗的外科 ICU 患者中 VAP 的病原体类型不会影响死亡。由于旋转抗生素管理系统，AIT 的比例很高，可以优化细菌杀伤作用，并消除细菌耐药性的影响，从而改善预后。
