Duke University, Durham, NC.
Duke Clinical Research Institute, Durham, NC.
Chest. 2020 Dec;158(6):2370-2380. doi: 10.1016/j.chest.2020.06.034. Epub 2020 Jun 29.
Pneumonia is the leading infection-related cause of death. The use of simple clinical criteria and contemporary epidemiology to identify patients at high risk of nosocomial pneumonia should enhance prevention efforts and facilitate development of new treatments in clinical trials.
What are the clinical criteria and contemporary epidemiology trends that are helpful in the identification of patients at high risk of nosocomial pneumonia?
Within the ICUs of 28 US hospitals, we conducted a prospective cohort study among adults who had been hospitalized >48 hours and were considered high risk for pneumonia (defined as treatment with invasive or noninvasive ventilatory support or high levels of supplemental oxygen). We estimated the proportion of high-risk patients who experienced the development of nosocomial pneumonia. Using multivariable logistic regression, we identified patient characteristics and treatment exposures that are associated with increased risk of pneumonia development during the ICU admission.
Between February 6, 2016, and October 7, 2016, 4,613 high-risk patients were enrolled. Among 1,464 high-risk patients (32%) who were treated for possible nosocomial pneumonia, 537 (37%) met the study pneumonia definition. Among high-risk patients, a multivariable logistic model was developed to identify key patient characteristics and treatment exposures that are associated with increased risk of nosocomial pneumonia development (c-statistic, 0.709; 95% CI, 0.686-0.731). Key factors associated with increased odds of nosocomial pneumonia included an admission diagnosis of trauma or cerebrovascular accident, receipt of enteral nutrition, documented aspiration risk, and receipt of systemic antibacterials within the preceding 90 days.
Treatment for nosocomial pneumonia is common among patients in the ICU who are receiving high levels of respiratory support, yet more than one-half of patients who are treated do not fulfill standard diagnostic criteria for pneumonia. Application of simple clinical criteria may improve the feasibility of clinical trials of pneumonia prevention and treatment by facilitating prospective identification of patients at highest risk.
肺炎是感染相关死亡的主要原因。使用简单的临床标准和当代流行病学知识来识别发生医院获得性肺炎风险高的患者，应能增强预防措施，并有助于在临床试验中开发新的治疗方法。
有助于识别发生医院获得性肺炎风险高的患者的临床标准和当代流行病学趋势有哪些？
我们在美国 28 家医院的 ICU 中开展了一项前瞻性队列研究，纳入的患者为住院时间超过 48 小时且存在肺炎高危因素（定义为接受有创或无创通气支持或高浓度补充氧治疗）的成年人。我们估计了经历医院获得性肺炎发展的高危患者比例。采用多变量逻辑回归，我们确定了与 ICU 住院期间肺炎发生风险增加相关的患者特征和治疗暴露因素。
在 2016 年 2 月 6 日至 2016 年 10 月 7 日期间，纳入了 4613 名高危患者。在 1464 名（32%）接受疑似医院获得性肺炎治疗的高危患者中，有 537 名（37%）符合研究肺炎定义。在高危患者中，建立了一个多变量逻辑模型来识别与医院获得性肺炎发生风险增加相关的关键患者特征和治疗暴露因素（C 统计量为 0.709；95%CI，0.686-0.731）。与医院获得性肺炎发生几率增加相关的主要因素包括创伤或脑血管意外的入院诊断、接受肠内营养、有明确的吸入风险以及在过去 90 天内接受全身性抗菌药物治疗。
在接受高水平呼吸支持的 ICU 患者中，治疗医院获得性肺炎很常见，但接受治疗的患者中超过一半不符合肺炎的标准诊断标准。应用简单的临床标准可能通过促进对风险最高的患者进行前瞻性识别，从而提高肺炎预防和治疗临床试验的可行性。
