AJRCCM:新冠肺炎机械通气患者继发细菌性肺炎的患病率?

2021-10-20 小文子 MedSci原创

插管时基于指南的经验性抗生素管理导致抗生素过度使用。

目前指南建议重症新冠肺炎患者在证据不足的基础上,接受经验性抗生素治疗疑似细菌二重感染。在新冠肺炎患者的临床试验中,呼吸机相关肺炎(VAP)的发病率非常低。由于新冠肺炎和细菌性肺炎的临床体征和症状在很大程度上是重叠的,因此准确的微生物学诊断对确诊新冠肺炎插管患者的细菌二重感染性肺炎至关重要。通过BAL对肺泡腔取样是检测呼吸道病原体的金标准。

发表在American Journal of Respiratory and Critical Care Medicine杂志的一篇文章探索了重度新冠肺炎患者首次插管时细菌二重感染的发生率和病因,以及随后细菌性VAP的发生率和病因。研究人员对所有需要机械通气的新冠肺炎患者的支气管镜BAL样本进行定量培养和多重PCR分析。实际使用抗生素与指南推荐的治疗进行比较。

研究纳入美国西北大学纪念医院的新冠肺炎需机械通气患者179例,分析了386份BAL样本。21%的患者在插管后48小时内检测到细菌二重感染。早期插管后二重感染细菌性肺炎是社区获得性肺炎(CAP)的主要病因。链球菌属和对甲氧西林敏感的金黄色葡萄球菌占总病例的79%(22/28)。多种微生物感染常见,在28份早期BAL样本中检测到51种病原体。仅3例患者(既往均接受过抗生素治疗)的病原体对标准CAP抗生素耐药。72例患者(44.4%)至少发生一次VAP发作(VAP发生率=45.2/1000呼吸机日);15例(20.8%)初始VAP由难治性病原体引起。临床标准没有区分有无细菌二重感染的患者。与指南建议相比,基于BAL的管理与抗生素使用显著减少相关。

结果表明,在需要机械通气的新冠肺炎患者中,25%的患者在插管时发生细菌二重感染。插管时基于指南的经验性抗生素管理导致抗生素过度使用。插管时和早期VAP的二重感染细菌性肺炎通常由CAP相关病原体引起且对窄谱抗生素敏感。44%的患者出现细菌性VAP,但在没有对BAL进行微生物学分析的情况下无法准确鉴定。

原文出处:

Chiagozie O. Pickens, Catherine A. Gao, et al, Bacterial Superinfection Pneumonia in Patients Mechanically Ventilated for COVID-19 Pneumonia, American Journal of Respiratory and Critical Care Medicine,2021, https://doi.org/10.1164/rccm.202106-1354OC.

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    2022-08-01 feifers
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    2022-08-08 isabellayj
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