老人在社區及長照機構細菌感染抗藥性的實證研究

劉秀娟

doi:10.6833/CJCU.2013.00002

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老人在社區及長照機構細菌感染抗藥性的實證研究

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

劉秀娟 , Masters　　Advisor：張晴翔　　

繁體中文 DOI： 10.6833/CJCU.2013.00002

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

Abstract │ Reference (65) │ Times Cited (2) │ Altmetrics

Abstract 〈TOP〉

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。

Parallel Abstract 〈TOP〉

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.

Reference ( 65 ) 〈TOP〉

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：
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：
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：
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：
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：

Times Cited (2) 〈TOP〉

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