呼吸器相關肺炎不同診斷方法之比較

呼吸器相關肺炎診斷不易，臨床診斷過於寬鬆，侵入性採檢法能減少對疑似肺炎病例使用廣效性抗生素，降低加護病房抗藥菌增生，並減少抗生素治療費用。為了解不同侵入性診斷方法之差異，吾等自1999年7月至2000年12月收集院內感染呼吸器相關肺炎病例，依診斷方法分為PSB(protected sheath brushing)及BAL(bronchoalveolar lavage)兩組。PSB組21人，採檢時呼吸器使用平均天數14.5±26.9天（中間數為6）,平均住院天數45.9±47.5天（中間數為30），採檢前72小時內使用抗生素者20人(95.2%)，因採檢結果改抗生素者15人(71.4%)，因改抗生素而肺炎改善者8人(38.1%)，雖改抗生素但反應不佳者7人(33.3%)，其中7人死亡(33.3%)。細菌種類以Pseudomonas aeruginosa最多(68.2%)，其次是Stenotrophomonas maltophilia及Serratia marsecens(9%)，由菌落數判定確定感染者8人(38%)。BAL組19人，採檢時呼吸器使用平均天數15.6±9.2天（中間數為15），平均住院天數42.7±22.4天（中間數為38），採檢前72小時內使用抗生素者18人(94.7%)，因採檢結果改抗生素者14人(73.7%)，因改抗生素而肺炎改善者8人(42.1%)，雖改抗生素但反應不佳者6人(31.6%)，其中5人死亡(26.3%)，細菌種類以Pseudomonas aeruginosa最多(45%)，其次是Acinetobacter baumannii(18%)，由菌落數判定確定感染者14人(73.6%)。PSB及BAL兩組不同診斷方法中，其相關因素及使用抗生素後成效之比較分析，結果無顯著差異。故PSB及BAL兩種診斷方法，對診斷結果及疾病預後並無顯著差別。

關鍵字

呼吸器相關肺炎；保護性套管刷取；支氣管肺泡灌洗術

並列摘要

The diagnosis of ventilator-associated pneumonia is difficult. The clinical approach frequently leads to over-diagnosis. Invasive sampling of deep bronchial secretions may make an accurate bacteriologic diagnosis and preclude the need for broad spectrum antibiotic coverage for all patients with suspected pneumonia; thus it may reduce the risk of emergence of resistant microorganisms in the ICU, and lower the cost of antibiotic treatment. To elucidate the clinical usefulness of different diagnostic methods, we collected cases with nosocomial pneumonia from July, 1999, to December, 2000. The diagnostic methods employed were protected sheath brushing (PSB) and bronchoalveolar lavage (BAL). There were 21 patients in the PSB group and 19 in the BAL group. The age, the range of WBC, the duration of ventilator use before sampling, and the average hospital stay before the sampling were generally comparable between the two groups. Twenty of the 21(95.2%) patients in the PSB group received antibiotic therapy within 72 hours prior to the microbial investigation. The antibiotics were adjusted after culture results were available in 15 patients (71.4%), and 8 of them (38.1%) improved after the changes in the antibiotics. The remaining 7(33.3%) had clinical deterioration despite the changes in the drugs. Seven patients (33.3%) died, 4 of them from the pneumonia despite the changes in the antibiotics, 3 from the infection without changes in the drugs. Eight cases had definite microbiologic diagnosis of infection by the colony counts. Pseudomonas aeruginosa (68.2%) was the most common pathogen. Eighteen of the 19 patients in the BAL group (94.7%) received antimicrobials within 72 hours prior to the investigation. In 14 of the 19 (73.7%) patients, the drugs were adjusted after the culture results were available, and there was clinical improvement in 8 (42.1%). Of the remaining 6 patients (31.6%) who clinically did worse. Five patients (26.3%) died, 3 of them from the pneumonia despite the changes in the antibiotics, 2 from the infection without changes in the drugs. Fourteen patients had definite microbiologic diagnosis. Pseudomonas aeruginosa was again the most commonly isolated. Comparing the two methods, there appear to be a difference in the rate of pathogen isolation. However, the difference was statistically not significant. The end results of treatment were also similar. Further analysis of antibiotic usage suggested that early administration of appropriate antibiotics as soon as the pneumonia was suspected saved more patients; and the late use of proper antibiotics after the identification of the pathogens did not reduce the mortality. Either PSB or BAL did not have any influence on the prognosis of the illness. However, they may be useful in deleting some antibiotics used in the initial broad-spectrum coverage of all potential pathogens.

並列關鍵字

ventilator-associated pneumonia ； protected sheath brushing ； bronchoalveolar lavage

國際替代計量

呼吸器相關肺炎不同診斷方法之比較

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