- 學位論文
多重抗藥性影響不動桿菌之院內感染菌血症的預後
Multidrug Resistance Influencing the Prognosis of Nosocomial Acinetobacter Bacteremia
摘要
本篇研究的目標，在於針對目前臨床上日益增加的不動桿菌(Acinetobacter species) 所造成的院內感染症，探討其嚴重程度與抗藥性快速增加的情形；並特別針對不動桿菌造成的院內感染菌血症，比較分析其臨床上致病的風險因子、潛在疾病、臨床特徵、抗生素敏感性及影響預後的因素等，最後強調多重抗藥性菌株造成治療上的困難和預後不佳。 研究的資料來自中台灣某大學附設醫院的院內感染管制監測系統，近年來的院內感染數據，以及2007至2008年間所收集到的不動桿菌院內感染菌血症的個案。研究的結果顯示，不動桿菌感染症已經成為全院和加護病房中，造成院內感染菌血症和肺炎最嚴重的病菌 (菌血症死亡率住院中三成四、二個月超過五成)。影響不動桿菌菌血症預後的因素，包括中央靜脈導管置放 (OR 51.4; p= 0.017)、原患有慢性阻塞性肺病(OR 29.5; p= 0.026)、對Carbapenem有抗藥性的菌株 (OR 26.1; p= 0.012)、加護病房內感染 (OR 25.9; p= 0.028)、曾經接受手術治療 (OR 19.0; p= 0.037) ，及感染時有較高的C-反應蛋白濃度 (OR 1.3; p= 0.019)；而如果感染到的不動桿菌菌株是對所有抗生素都有敏感性的，預後明顯較佳 (OR 0.01; p= 0.024)。 我們也發現，多重和非多重抗藥性菌血症患者的預後有明顯差異 (HR 11.5; p = 0.001)，可能是多重抗藥性菌株會影響抗生素選擇的適當性。推估住院患者較可能感染多重抗藥性不動桿菌的因素，包括臨床上出現敗血性休克 (OR 27.0; p= 0.004) 和曾接受氣管插管治療 (OR 10.2; p= 0.002)。如果在感染菌株已經確定後，仍存活的多重抗藥性不動桿菌菌血症患者，能更改至適當的抗生素治療，患者的預後也會改善；但若未更改至適當的抗生素治療，患者的死亡率高達九成。 另外，我們也記錄了內科加護病房中，於2008年施行加強環境清潔和消毒措施後的成果，確實部分改善了多重抗藥性不動桿菌感染症的嚴重度，但是每項措施實行幾個月後，抗藥性感染的比例又再慢慢增加。我們認為，良好的感染控制除了嚴密的環境清潔和消毒措施，所有醫護人員、醫事人員、甚至清潔人員的持續配合更為重要。 鑑於不動桿菌菌血症感染的預後不佳，但是發生率卻越來越高，且對抗生素的敏感性日益惡化，臨床上除了開發新藥之外，良好的感染控制、審慎而有效的抗生素管制和使用，以及適時的隔離移生與 感染多重抗藥性菌株的患者，以減少傳播感染，更是重要的課題。
並列摘要
The objective of this study was to assess the risk factors, clinical characteristics, antibiotic resistance and therapeutic prognosis of the bacteremic patients of nosocomial Acinetobacter infection at a university-affiliated hospital in mid-Taiwan from 2007 to 2008 year. The severity of the increasing incidences of nosocomial Acinetobacter infections and the worsening conditions of antibiotic resistance in this hospital were also evaluated. We found the Acinetobacter spp. was the most important pathogen related to nosocomial bacteremia and pneumonia in hospital and also in intensive care units (ICUs). The mortality rate of nosocomial Acinetobacter bacteremic patients was 34% from 79 episodes of bacteremic accidents. The factors influencing the poor prognosis included insertion of central lines (OR 51.4; p= 0.017), underlying chronic obstructive pulmonary disease (OR 29.5; p= 0.026), Carbapenem -resistance (OR 26.1; p= 0.012), ICU admission (OR 25.9; p= 0.028), ever receiving surgery (OR 19.0; p= 0.037), and higher C-reactive protein level (OR 1.3; p= 0.019). Better prognosis was also noted if the isolated Acinetobacter pathogen is sensitive to all antibiotics (OR 0.01; p= 0.024). Significant mortality difference was also noticed between the multidrug resistant (MDR) and non-MDR bacteremic patients (HR 11.5; p = 0.001). The predictive factors of MDR Acinetobacter bacteremia included clinical shock (OR 27.0; p= 0.004) and ever intubated by artificial airway (OR 10.2; p= 0.002). If appropriate antibiotics were prescribed after pathogens identified, the prognosis would be improved. We also described the effects of augmented environment clearing and disinfection at medical-ICU in 2008 year and emphasized the importance to operate in coordination for infection control. Because of the increasing prevalence, worsening antibiotic resistance and poor prognosis of the nosocomial Acinetobacter bacteremia, adherence to good infection control practices, prudent and effective antibiotic use, and isolating the colonized and infected MDR patients are very important topics other than developing new antibiotics.
參考文獻
延伸閱讀
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