床旁优化痰涂片检查对呼吸机相关性肺炎早期诊治的价值  

Value of optimization of bedside Gram staining of sputum smear in the early diagnosis and treatment of ventilator-associated pneumonia

作　　者：廖鑫燕[1] 冉宇[1] 边士昌[1] 王超[1] 徐磊[2] 

机构地区：[1]天津市第四中心医院重症医学科,300140 [2]天津市第三中心医院重症医学科,300170

出　　处：《中华危重病急救医学》2014年第12期879-883,共5页Chinese Critical Care Medicine

基　　金：基金项目：天津市卫生行业重点攻关项目（12KG106）

摘　　要：目的 探讨床旁优化痰涂片检查对呼吸机相关性肺炎（VAP）早期临床诊治的应用价值。方法 回顾性分析天津市第四中心医院重症医学科2009年6月至2014年6月收治的机械通气超过48 h且临床诊断为VAP患者的临床资料。根据有无设立床旁快速痰涂片检查实验室将研究对象分为两组。所有VAP患者每日采用气管导管内吸引术（ETA）收集下呼吸道痰标本，抗菌药物经验治疗组（2009年6月至2011年12月，43例）根据VAP发生时间、本院重症监护病房（ICU）细菌流行病学监测资料以及是否存在多重耐药病原菌感染高危因素选择抗菌药物；抗菌药物目标治疗组（2012年1月至2014年6月，43例）在经验治疗组的基础上结合床旁快速痰涂片革兰染色镜检结果选择初始抗菌药物。分析入选患者痰涂片与痰培养结果的相关性，监测应用抗菌药物当日（1 d）及治疗3 d时患者的体温、外周血白细胞计数（WBC）、降钙素原（PCT）、超敏C-反应蛋白（hs-CRP）等指标；记录两组抗菌药物使用时间、机械通气时间、ICU住院时间。结果 痰培养合格痰标本512份、检出病原菌336株，痰涂片镜检合格痰标本512份、检出病原菌358株，痰涂片革兰镜检结果与痰培养结果的符合率为78.32%（401/512），诊断敏感度为85.42%（287/336），特异度为64.77%（114/176），阳性预测值为80.17%（287/358），阴性预测值为74.03%（114/154）。初始应用抗菌药物时两组患者各项感染指标差异均无统计学意义，治疗3 d时各指标均明显改善，且目标治疗组患者体温、WBC、PCT、hs-CRP明显低于经验治疗组〔体温（℃）：36.83±0.69比37.64±0.71，WBC（×109/L）：7.91±2.75比9.66±3.39，PCT（μg/L）：7.14±3.89比10.14±4.32，hs-CRP（mg/L）：12.24±6.28比15.54±5.94，P＜0.05或P＜0.01〕。与经验治疗组比较，目标治疗组患者抗菌药物使用时间（d：6.00±2.55比9.20±3.Objective To investigate the significance of optimization of bedside Gram staining of sputum smear in the early diagnosis and antimicrobial treatment for ventilator-associated pneumonia（VAP）patients. Methods The data of patients with VAP undergoing mechanical ventilation over 48 hours in the Department of Critical Care Medicine of Tianjin Fourth Central Hospital from June 2009 to June 2014 were analyzed. The patients were divided into two groups according to whether or not bedside Gram staining of sputum smear was used or not. The sputum samples from lower respiratory tract of all VAP patients were collected daily with tracheal catheter. In empirical examination group（from June 2009 to December 2011,n=43）,the patients received antibiotics at the time of onset of VAP, selection of antibiotics depended on the information of bacterial epidemiology of the intensive care unit（ICU）,and also existence of high risk factors of multi-drug resistant bacteria. In target treatment group（from January 2012 to June 2014,n=43）,the patients received antibiotics according to the results of bedside instant sputum smear examination and empirical antibiotic regime. The correlation between the results of sputum smear examination and culture result was analyzed. The levels of body temperature,white blood cell（WBC）count,procalcitonin（PCT）level,and high sensitivity C-reactive protein（hs-CRP）were measured on the 1st day and 3rd day. The length of antibiotics treatment, duration of mechanical ventilation,and the time of ICU stay were recorded for both groups. Results There were 512 qualified sputum specimens for culture,from which 336 pathogens were found,and 358 strains of pathogenic bacteria were found from microscopic examination of 512 qualified sputum smear. The coincidence rate of results of bedside examination of sputum smear and that of sputum culture was 78.32%（401/512）. The diagnostic acumen of the former was 85.42%（287/336）,specificity was 64.77%（114/176）,positive predictive value was 80.17

关 键 词：呼吸机相关性肺炎 痰涂片 革兰染色 

分 类 号：R563.1[医药卫生—呼吸系统]