Kashuk Jeffry L, Moore Ernest E, Price Connie S, Zaw-Mon Christopher, Nino Theresa, Haenel James, Biffl Walter L, Burlew C Cothren, Johnson Jeffrey L
Department of Surgery, Division of Acute Care Surgery, Penn State Hershey Medical Center and College of Medicine, Hershey, PA 17033, USA.
J Trauma. 2010 Sep;69(3):519-22. doi: 10.1097/TA.0b013e3181c4521c.
Community-acquired methicillin-resistant Staphylococcal aureus (CA-MRSA) infection is approaching endemic proportions nationally, and it is a potential cause for early ventilator-associated pneumonia (VAP) in the acutely injured patient. We sought to determine the prevalence of early (≤4 days) and late (>4 days) MRSA pneumonia in ventilated multisystem trauma patients and to correlate findings with admission nasal swabs.
We performed a review of our prospective trauma and infectious disease data bases for all patients admitted to our surgical intensive care unit with early (≤4 days) and late (>4 days) VAP during a 4-year period. The diagnosis of pneumonia was established by clinical pulmonary infection score >6, bronchoalveolar lavage, and quantitative cultures showing >10 organisms. Nasal swabs for early identification of MRSA carriers were performed routinely at admission.
One hundred seventy-six patients were identified with S. aureus VAP. Patients with MRSA were compared with those with methicillin-susceptible S. aureus (MSSA). There were 47 (27%) early MSSA VAP and only 4 (2.2%) with early MRSA VAP. One hundred twenty-five patients were diagnosed with late VAP. Forty patients (23%) had MRSA VAP and 85 patients (64%) had MSSA VAP. None of the four patients with an early MRSA VAP had positive nasal swabs at admission.
Despite an increase of MRSA nationally, we found a low incidence of early and late MRSA VAP in trauma patients, which was not identified by nasal swab screening. On the basis of our results, we question the efficacy of empiric vancomycin therapy in early (≤4 days) S. aureus VAP. Furthermore, nasal swabs were not helpful in identifying patients at risk for MRSA VAP.
社区获得性耐甲氧西林金黄色葡萄球菌（CA-MRSA）感染在全国范围内正接近地方流行程度，并且它是急性受伤患者发生早期呼吸机相关性肺炎（VAP）的一个潜在原因。我们试图确定通气的多系统创伤患者中早期（≤4天）和晚期（>4天）MRSA肺炎的患病率，并将结果与入院时的鼻腔拭子检查结果相关联。
我们回顾了我们前瞻性创伤和传染病数据库中在4年期间入住我们外科重症监护病房且发生早期（≤4天）和晚期（>4天）VAP的所有患者的数据。肺炎的诊断依据临床肺部感染评分>6、支气管肺泡灌洗以及定量培养显示有>10个菌落形成单位。入院时常规进行鼻腔拭子检查以早期识别MRSA携带者。
共识别出176例金黄色葡萄球菌VAP患者。将MRSA患者与甲氧西林敏感金黄色葡萄球菌（MSSA）患者进行比较。有47例（27%）早期MSSA VAP，而仅有4例（2.2%）早期MRSA VAP。125例患者被诊断为晚期VAP。40例（23%）有MRSA VAP，85例（64%）有MSSA VAP。4例早期MRSA VAP患者在入院时鼻腔拭子检查均为阴性。
尽管全国范围内MRSA有所增加，但我们发现创伤患者中早期和晚期MRSA VAP的发生率较低，且通过鼻腔拭子筛查无法识别。基于我们的结果，我们质疑经验性万古霉素治疗在早期（≤4天）金黄色葡萄球菌VAP中的疗效。此外，鼻腔拭子检查无助于识别有MRSA VAP风险的患者。
