Title

老人在社區及長照機構細菌感染抗藥性的實證研究

Translated Titles

An evidence-based research of the elderly in the community acquired and long term care institutions bacterial infections resistant to differences

DOI

10.6833/CJCU.2013.00002

Authors

劉秀娟

Key Words

老人感染 ; 社區老人感染 ; 長期照護機構感染 ; 細菌抗藥性 ; Elderly infection ; community acquired elderly infection ; long term care infection ; antibiotic resistance

PublicationName

長榮大學醫務管理學系(所)學位論文

Volume or Term/Year and Month of Publication

2013年

Academic Degree Category

碩士

Advisor

張晴翔

Content Language

繁體中文

Chinese Abstract

一、研究背景與動機 感染症經常是導致老年人急性住院的主要原因之一,一旦發生感染症時,老年人也較年輕人有較高的死亡率。許多研究指出長期照護機構的住民所感染的菌種其抗藥性明顯高於一般社區感染,目前針對長照機構感染及其抗藥性相關研究,大多是國外的研究,台灣較少相關研究,希望經由本篇的研究能提供臨床醫師的用藥參考。 二、研究目的 本研究目的為探討長期照護機構的住民與一般社區老人感染菌種及抗藥性的差異,以期在急性感染時提供臨床醫師在臨床治療使用抗生素的參考,讓病人能得到較佳的治療,避免治療失敗及細菌抗藥性的產生。 三、研究方法 本研究利用實證醫學的架構,針對老人在長照機構與一般社區的感染菌種及抗藥性是否有差異的實證研究,尋找研讀相關文獻,綜合整理比對。 利用回溯性研究(Retrospective Study)的方式進行收集資料,收集自98年7月至99年6月,檢視南部某區域教學醫院急診就醫並大於65歲以上病歷。進一步針對入院48小時內曾進行細菌培養檢查(包含尿液培養、痰液培養、血液培養)之個案,區分成長照機構群組(882人次)及一般社區群組(1202人次),共開立細菌培養1277件,結果為陽性者進行統計分析,將統計結果和文獻比對是否有異同之處。 四、結果: 1. 長照機構和一般社區老人其尿液培養陽性率分別77.2%與58.0%、痰液培養陽性率53.9%與36.3%、血液培養陽性率21.0%與16.4%。 2. 菌種分離率: (1) 尿液培養:長照機構老人與一般社區老人菌種分離率前三名依序為:大腸桿菌40.6%與44.8%、克雷伯氏肺炎桿菌13.3%與11.9%、綠膿桿菌13.1%與10.7%。 (2) 痰液培養:長照機構老人與一般社區老人菌種分離率前三名依序為:綠膿桿菌23.1%與26.5%、克雷伯氏肺炎桿菌17.3%與26.5%、鮑氏不動桿菌 17.3%與10.2%。 (3) 血液培養:長照機構老人與一般社區老人菌種分離率前三名依序為:大腸桿菌41.6%與36.2%、金黃色葡萄球菌16.9%與19.1%、克雷伯氏肺炎桿菌10.1%與13.8%。 3. 抗藥性分析: (1) 腸內桿菌(包含大腸桿菌、克雷伯氏肺炎桿菌、變形桿菌……等):除了Piperacillin/Tazobactam、Ertapenem、Impemen/ Meropenem無明顯差異外,其餘藥物長照機構老人的抗藥性明顯高於社區老人。 (2) 綠膿桿菌:除了Gentamicin和Ciprofloxacin這二種藥物的抗藥性長照機構明顯高於一般社區外,其餘藥物抗藥性差異不大。 (3) 陽性球菌:所有的藥物在長照機構和一般社區老人的抗藥性並無差異。 五、結果討論: 1.在尿道感染菌種分離率的相關文獻,台灣馬偕醫院於2002~2004對其護理之家的研究,綠膿桿菌分離率(15.2%)高於其他國家長照機構的相關研究(2.6%~8.4%),本研究結果13.1%與台灣馬偕的研究相似。在一般社區的研究,本研究綠膿桿菌分離率10.7%遠高於國外的相關研究(1.8%~4.0%),由此顯示台灣的綠膿桿菌盛行率高於其他國家,值得探討。 2.在下呼吸道感染菌種分離率的相關文獻,本研究的肺炎鏈球菌分離率6.3%遠低於國外的相關研究(13%~33%),推測可能台灣推動肺炎鏈球菌疫苗有其效果,但需進一步驗證。 3.和血流感染菌種分離率的相關文獻比較,本研究的變形桿菌分離率2.7%遠低於與國外的相關研究(6%~21%)。 4.和國家衛生研究院同期對全國門急診的研究比較發現,本研究老人的腸內桿菌(如大腸桿菌、克雷伯氏肺炎桿菌)的抗藥性,高於全國不分年齡的門急診患者的抗藥性,且長照機構老人的抗藥性更是遠高於國衛院的研究。由此結果更可說明長照構老人在腸內桿菌感染時的抗藥性遠高一般社區其他年齡的感染,可供臨床醫師用藥的參考。

English Abstract

Background Infectious disease is a major cause of hospitalization in the elderly. Event of Infectious Diseases, the elderly have a higher mortality rate than younger people. Many studies have pointed out that the bacteria resistance of long-term care facility (LTCF) residents was significantly higher than the general community-acquired(CA). Infections and their resistance associated research for long term care institutions, mostly foreign, Taiwan less research and hope that through this study provide clinicians drug reference. Objective The purpose of this study is to investigate the differences in pathogen and resistant rate between the elderly in LTCF and the CA which can provide clinicians antibiotic suggestion in old hospitalized patient with acute infection. Methods An evidence-based research of the elderly in the community acquired and long term care institutions bacterial infections resistant to differences. Retrospective study to collect data, collected from 2009 July to 2010 June, in the southern teaching hospital emergency medical treatment elderly(>65years), the subjects were divided into a long term care institutions residents and the general community residents of two groups, the patients admitted to hospital within 48 hours, urine, sputum, blood bacterial culture test result is positive for statistical analysis.. Results 1. LTCF and the CA for the elderly in their urine culture positive rate of 77.2% and 58.0%, respectively, sputum culture positive rate of 53.9% and 36.3%, blood culture positive rate of 21.0% and 16.4%. 2. Pathogen culture rate: (1) For urine culture: From the LTCF elderly, most of the pathogen yielded was E. coli (40.6%), followed by Klebsiella pneumoniae (KP)(13.3%); Pseudomonas aeruginosa(PA) (13.1%). Among elderly from community, the most isolates is E.coli (44.8%), followed by KP (11.9%); PA (10.7%). (2) For sputum culture: From the LTCF elderly, most of the pathogen yielded was PA (23.1%), followed by KP(17.3%); Acinetobacter.baumannii(A.B) (17.3%). Among elderly from community, the most isolates is KP (26.5%), followed by PA(22.4%); E.coli(10.7%). (3) For blood culture: From the LTCF elderly, most of the pathogen yielded was E. coli (41.6%), followed by Staphylococcus aureus(SA)(17.3%); KP(10.1%). Among elderly from community, the most isolates is E. coli (36.2%), followed by SA(19.1%); KP(13.8%). 3. Antibiotic Resistance: (1) Enterobacteriae(inclusion E.coli、KP、Proteus mirabilis、Serratia marcescens……et al.):In addition to Piperacillin / Tazobactam, Ertapenem, Impemen / Meropenem was no significant difference, the resistance of the rest of the drug's LTCF for the elderly is significantly higher than the CA. (2) For PA:In addition to Gentamicin and Ciprofloxacin was significantly higher t resistance than CA,the remaining drug resistance was no significant difference (3) For Gram Positive cocci:There is no difference between all the drugs in the LTCF and the CA resistance to the elderly. Conclusion (1) Establish local epidemiological is very important. (2) Elderly enterobacteriae antibiotic resistant higher than young, and the LTCF of elderly, resistance is far higher than CA young.

Topic Category 醫藥衛生 > 醫院管理與醫事行政
健康科學學院 > 醫務管理學系(所)
社會科學 > 管理學
Reference
  1. 2.張家銘、盧豐華、柯文謙(2005).老年人的感染症緒論.台灣老年醫學雜誌.1(2),51-60。
    連結:
  2. 4.曲佩芬、李聰明(2002).長期照護機構之重要一環-院內感染控制.台北,感控雜誌,12(2),202-204。
    連結:
  3. 6.陳鼎達、黃麗卿、鍾嫈嫈、張家銘(2005).護理之家住民因泌尿道感染而住院之調查研究.台灣,台灣老年醫學雜誌,1(2),65-77
    連結:
  4. 7.謝美芬、顏兆熊(2010).老人之泌尿道感染.當代醫學,436,120-124。
    連結:
  5. 8.林詩淳、徐明洲、蔡坤維(2010).老人常之泌尿道感染.志維護理,9(5),66-70
    連結:
  6. 12.許清曉(1996).抗微生物藥劑臨床使用的新教學法.院內感染控雜誌,6,306-314。
    連結:
  7. 13.李至恭(2005).院內感染及社區感染菌種分布性的差異.感控雜誌,15(4),247-250。
    連結:
  8. 14.張上淳、王昱蒼、周偉惠等(2011).2011年台灣院內感染監視資訊系統分析報告.22(6),301-307。
    連結:
  9. 15.張上淳、王昱蒼、周偉惠等(2012).2010~2011 年台灣院內感染監視系統分析報告:實驗室通報常見致病菌臨床菌株之抗生素感受性統計資料分析.22(6),308-314。
    連結:
  10. 16.衛生署疾病管制局(2011).醫院感染管制查核作業查核基準說明.2012年12月取自疾管局網頁http://www.cdc.gov.tw/professional/
    連結:
  11. 19.台灣長期照護專業協會(2012).認識台灣長期照護服務模式. 2012年7月1日取自http://www.ltcpa.org.tw/public/choose_01.html.
    連結:
  12. 20.賴惠雯、李文生、王炯中等(2010).北部某醫學中心急診室及病房血液培養菌種之比較與分析,台灣,感控雜誌,20(4),205-14。
    連結:
  13. 21.楊采菱(2005).全國微生物抗藥性監測計劃(Taiwan Surveillance of Antimicrobial Resistance; TSAR).感控雜誌,15(5)。
    連結:
  14. 23.Marcus E-L, Clarfield MA, Moses AE. Ethical issues relating to the use of antimicrobial therapy in older adults. Clin Infect Dis 2001;33:1697-705.
    連結:
  15. 25.William M. Valenti, M.D, Randall G, Trudell B.S, et al. Factors Predisposing to Oropharyngeal Colonization with Gram-Negative Bacilli in the Aged. New England Journal of Med 1978; 298:1108-1111.
    連結:
  16. 26.Charles P. Mouton, Oralia V. Bazaldua. Common Infections in Older Adults. Am Fam Physician 2001; 63: 257-68.
    連結:
  17. 27.Yoshikawa TT. Epidemiology and unique aspects of aging and infectious diseases. Clin Infect Dis. 2000;30:931-3.
    連結:
  18. 28.Nicolle LE. Infection control in long-term care facilities. Clin Infect Dis .2000;31:752-6.
    連結:
  19. 29.Nicolle LE, Strausbaugh LJ,Garibalsi RA. Infection and antibiotic resistance in nursing homes, Cli microbiology review. 1996; 9(1):1-17.
    連結:
  20. 31.Heyland DK, Cook DJ, Griffith L, et al. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian critical trials group. Am JRespir Crit Care Med. 1999;159:1249-56.
    連結:
  21. 32.Barre-t SP, Savage MA ,Rebec MP,et al. Antibiotic sensitivity of bacteria associated with community-acquired urinary tract in fection in Britain. Joury of Antimicrobial chemotherapy. 1999;44:359-365.
    連結:
  22. 33.Rituparna Das, MD, Eleanor Perrelli, MSN, Virginia Towle,et al. Antimicrobial Susceptibility of Bacteria Isolated from Urine Samples Obtained from Nursing Home Residents. Infect Control Hosp Epidemiol. 2009 November ; 30(11): 1116–1119.
    連結:
  23. 34.Mohammed Akram1, Mohammed Shahid2 and Asad U Khan. Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in J N M C Hospital Aligarh, India. Annals of Clinical Microbiology and Antimicrobials. 2007; 6:4.
    連結:
  24. 36.Marin H. Kollef, Andrew Shorr, Ying P. Tabak, Vikas Gupta, Larry Z. Liu, R. S. Johannes. Epidemiology and Outcomes of Health-care-Associated Pneumonia : Results From a Large US Database of Culture-Positive Pneumonia. Chest. 2005;128;3854-3862.
    連結:
  25. 37.Jordi Carratalà, MD, PhD; Analía Mykietiuk, MD; Núria Fernández-Sabé, MD, et al. Health Care–Associated Pneumonia Requiring Hospital Admission pidemiology, Antibiotic Therapy, and Clinical Outcomes. Arch Intern Med. 2007;167(13):1393-1399.
    連結:
  26. 38.Yuichiro Shindo, Shinji Sato, Eiichi Maruyama, Takamasa Ohashi,et al. Health-Care-Associated Pneumonia AmongHospitalized Patients in a Japanese Community Hospital. Chest. 2009;135;633-640.
    連結:
  27. 39.Yardena Siegman-Igra, Boaz Fourer, Ruth Orni-Wasserlauf,et al. Reappraisal of Community-Acquired Bacteremia: A Proposal of a New Classification for the Spectrum of Acquisition of Bacteremia. Clinical Infectious Diseases. 2002; 34:1431–9.
    連結:
  28. 40.Joseph M. Mylotte, Ammar Tayara, and Susan Goodnough. Epidemiology of Bloodstream Infection in Nursing Home Residents: Evaluation in a Large Cohort from Multiple Homes. Clinical Infectious Diseases. 2002; 35:1484–90.
    連結:
  29. 41.Dae Won Park, Byung Chul Chun, June Myung Kim,et al. Epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock: A prospective observational study in 12 university hospitals in Korea,J Korean Med Sci. 2012;27:1308-1314.
    連結:
  30. 42.Valenti WM, Trudell RG, Bentley DW. Factors predisposing to oropharyngeal colonization with gram-negative bacilli in the aged, N Engl J Med. 1978;298(20):1108.
    連結:
  31. 43.Kang Y, Crogan N. L. An evidencebased review of infectious disease, Geriatric Nursing. 2009; 30 (4): 272-286.
    連結:
  32. 44.Hutt, E., Ecord, M., Eilertsen, T. B., Frederickson, E., & Kramer, A.M. Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents. Journal of the American Geriatrics Society.2002; 50(2): 223-229.
    連結:
  33. 45.Maki, D. G., Crnich, C. J., & Safdar, N. Nosocomial infection in the intensive care unit. In J. E. Parrillo, & Dellinger, R. P. (Eds). Critical Care Medicine (pp 1041). Philadelphia: Mobsy.2008
    連結:
  34. 46.Thomas Fekete, MD. Urinary tract associated with indwelling bladder catheters . Retrieved July 2009 from UpToDate online textbook: http://www.uptodate.com.
    連結:
  35. 48.Maki, D. G., Crnich, C. J., & Safdar, N. Nosocomial infection in the intensive care unit. In J. E. Parrillo, & Dellinger, R. P. (Eds). Critical Care Medicine (pp 1041). Philadelphia: Mobsy.2008.
    連結:
  36. 49.Aurora, Pop-Vicas, MD, MPH., Susan, L. Mitcbell, MD et.al. Multidrug Resistant Gram-Negative Bacteria in a Long-Term Care Facility: Prevalence and Risk Factors. The American Geriatrics Society. 2008;56,1276-1280.
    連結:
  37. 50.Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Van Ness PH, Quagliarello V. Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing homeresidents. J Am Geriatr Soc. 2007;55(7):1072-1077.
    連結:
  38. 51.Magaziner, J., J. H. Tenney, B. DeForge, R. Hebel, H. L. Muncie, and J. W.Warren. Prevalence and characteristics of nursing home-acquired infections in the aged. J. Am. Geriatr. Soc.1991; 39:1071–1078.
    連結:
  39. 52.Eriksen H. M., Iversen B. G., & Aavitsland P. Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003. J Hosp Infect. 2004; 57(4), 316-20.
    連結:
  40. 53.Pettersson E, Vernby A, Mölstad S, & Lundborg CS. Infections and antibiotic prescribing in Swedish nursing homes: a cross-sectional study. Scand J Infect Dis. 2008; 40(5), 393-8.
    連結:
  41. 54.Irvine P. W., Van B. N., & Crossley K. Causes for hospitalization of nursing home residents: the role of infection. J Am Geriatr Soc.1984; 32(2), 103-7.
    連結:
  42. 55.Alessi CA, & Harker JO. A prospective study of acute illness in the nursing home. Aging. 1998; 10(6), 479-89.
    連結:
  43. 56.Jacobson, C., and L. Strausbaugh. Incidence and impact of infection in a nursing home care unit. Am. J. Infect. Control. 1990; 18:151–159.
    連結:
  44. 58.Castle SC. Clinical relevance of age-related immune dysfunction. Clin Infect Dis. 2000;31:578-85.
    連結:
  45. 59.Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age Aging. 1986;15:230-4.
    連結:
  46. 60.Castle SC, Norman DC, Yeh M, Miller D, Yoshikawa TT. Fever response in elderly nursing home residents: are the older truly colder? J Am Geriatr Soc. 1991;39:853-7.
    連結:
  47. 62.Norman DC. Fever in the elderly. Clin Infect Dis 2000;31:148-51.
    連結:
  48. 65.Fanh YH, Hsueh PR, HU JJ, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children in northern Taiwan. J Microbiol Immunol Infect 2004;37:29-34.
    連結:
  49. 66.Huang YC,Lin TY, Wang CH. Community-acquired Pseudomonas aeruginosa sepsis in previously healthy infants and children: analysis of forty-three episodes. Pediatr Infect DisJ.2002;1049-52.
    連結:
  50. 1.吳麗芬、沈樨等(2004).某醫院住院老年人常見的護理診斷及導因之初步探討.榮總護理,11(4),415-425。
  51. 3.內政部主計處(2011).內政統計通報。
  52. 5.劉靄宜(2009).北部某護理之家住民抗藥性菌株感染調查.台北,台大醫院北護分院五週年院慶特刊,30-43。
  53. 9.李逸文、張家銘(2002).導尿管引起之菌尿症的預防.台灣老年醫學學會會訊,48,10-14。
  54. 10.王任賢(2005).依症侯群之抗生素使用原則.2012年12月取自網頁http://www.stjoho.org.tw/department/control/content1.htm
  55. 11.吳天鳴、朱延和(2003).細菌的抗藥性.科學發展,364,64~73。
  56. 17.范淑玲(2004).護理之家住民長期照護服務使用情形及其相關因素探討,國立陽明大學碩士論文。
  57. 18.行政院衛生署(1995).我國長期照護需求與服務體系之政策分析. 台北:同作者.
  58. 22.盧朝勇、李麗娜、陳重華等.台灣肺炎診治指引.台灣胸腔暨重症加護醫學會、台灣感染症醫學會,2007。
  59. 外文部份
  60. 24.Yoshikawa TT. Infectious diseases, immunity and aging-perspectives and prospects. Immunity and Infections. Springer, New York. 1997:1-11.
  61. 30.Richard A, Brenda A. Infection in nursing in Nursing homes, John V. Bennett. Philip S. Branhman, etc. Hospital Infection 3th. United Stated
  62. 35.E Brabazon, M Carton, G Dornikova, D Bedford. Epidemiology and resistance patterns in urinary pathogens from long-term care facilities and GP populations. Ir Med J. 2012 Jun;105(6):177-80
  63. 47.Fekete, T. (2008/11/24):Urinary tract associated with indwelling bladder catheters . Retrieved Oct. 11, 2009, from http:// www. utdol. com/online/ content/ topic.do?topicKey=uti_infe/2922&selectedTitle=3...
  64. 57.Falsey AR. Infectious Disease. In: Pathy MSJ, ed. Principles and Practice of Geriatric Medicine. 3rd Ed. England: John Wiley & Sons Ltd. 1998;281-8.
  65. 61.Castle SC, Yeh M, Toledo S, Yoshikawa TT, Norman DC. Lowering the temperature criterion improves detection of infection in nursing home residents. Aging Immunol Infect Dis. 1993;4:67-76.
  66. 63.Ismail NH, Lieu PK, Lien CT, Ling ML. Bacteremia in the elderly. Ann Acad Med Singapore. 1997;26(5):593–8.
  67. 64.Chi CY Wong WW, Fung CP,et al. Epidermiology of Community-acquired Staphylococcus aureus bacteremia. J Microbiol Immunol Infect. 2004;37:16-23.
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