Service Anesthésie-Réanimation, Hôpital Guillaume et René Laennec, Boulevard Jacques Monod, 44800, Saint-Herblain, France,
Eur J Clin Microbiol Infect Dis. 2014 May;33(5):823-30. doi: 10.1007/s10096-013-2020-8. Epub 2013 Dec 10.
Ventilator-acquired pneumonia (VAP) is a common burden in intensive care unit (ICU) patients, but, to date, specific data are not available in patients with severe aneurysmal subarachnoid hemorrhage (SAH). A single neuro-ICU retrospective analysis of 193 patients with SAH requiring mechanical ventilation (MV) ≥48 h admitted from January 2005 to May 2010 was undertaken. The diagnosis of early VAP was prospectively upheld during a multidisciplinary staff meeting, according to the American Thoracic Society (ATS) 2005 guidelines with a threshold of 7 days after the onset of MV. Patients had a median age of 53 (44-62) years and 70 (36 %) were male. The median Glasgow coma scale (GCS) score before MV was 9 (5-14). 142 (74 %) patients had a World Federation of Neurosurgeons (WFNS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 162 (84 %) patients. 81 (48.7 %) patients declared an early VAP. On multivariate analysis, male sex (odds ratio [OR] 2.26, 95 % confidence interval [CI] [1.14-4.46]), use of mannitol before day 7 (OR 3.03, 95 % CI [1.54-5.95]), and achieving enteral nutrition ≥20 kcal kg(-1) day(-1) after day 7 (OR 2.91, 95 % CI [1.27-6.67]) remained independent risk factors of VAP. The main pathogens involved were methicillin-susceptible Staphylococcus aureus (MSSA) (34.9 %), Haemophilus influenzae (28.1 %), Streptococcus pneumoniae (15.5 %), and Enterobacteriaceae (10.7 %). Early VAP was associated with a longer duration of MV and ICU stay, but not with an excess of mortality. Early VAP bears significant morbidity in patients with severe SAH. Pathogens involved in early VAP are susceptible to antibiotics. Among modifiable risk factors of VAP, early enteral nutrition could be an easy and effective target.
呼吸机相关性肺炎（VAP）是重症监护病房（ICU）患者的常见负担，但迄今为止，在重症动脉瘤性蛛网膜下腔出血（SAH）患者中尚无具体数据。对 2005 年 1 月至 2010 年 5 月期间因机械通气（MV）≥48 小时而入住单一神经重症监护病房的 193 例需要 MV 的 SAH 患者进行了一项回顾性分析。根据美国胸科学会（ATS）2005 年的指南，在多学科工作人员会议上前瞻性地维持了早期 VAP 的诊断，MV 后 7 天的阈值为 7 天。患者的中位年龄为 53 岁（44-62 岁），70 例（36%）为男性。MV 前的中位格拉斯哥昏迷评分（GCS）为 9 分（5-14 分）。142 例（74%）患者的世界神经外科医生联合会（WFNS）评分≥III 级。162 例（84%）患者采用血管内线圈填塞术固定动脉瘤。81 例（48.7%）患者确诊为早期 VAP。多变量分析显示，男性（比值比[OR]2.26，95%置信区间[CI] [1.14-4.46]）、第 7 天前使用甘露醇（OR 3.03，95%CI [1.54-5.95]）和第 7 天后达到≥20 kcal kg(-1) day(-1)的肠内营养（OR 2.91，95%CI [1.27-6.67]）是 VAP 的独立危险因素。主要病原体包括耐甲氧西林金黄色葡萄球菌（MSSA）（34.9%）、流感嗜血杆菌（28.1%）、肺炎链球菌（15.5%）和肠杆菌科（10.7%）。早期 VAP 与 MV 和 ICU 住院时间延长有关，但与死亡率增加无关。早期 VAP 使重症 SAH 患者出现显著的发病率。早期 VAP 涉及的病原体对抗生素敏感。在 VAP 的可改变危险因素中，早期肠内营养可能是一个简单有效的目标。
