ICU呼吸机相关性肺炎患者...测对死亡风险的预测价值探讨_戚莲萍.pdf

现代生物医学进展Progress in Modern Biomedicine Vol.23NO.2JAN.2023doi:10.13241/ki.pmb.2023.02.011 临床研究 ICU 呼吸机相关性肺炎患者病原菌分布及 NLR、血清磷、PCT 联合检测对死亡风险的预测价值探讨*戚莲萍周兴梅盛怡费凯红庄燕萍（上海市第一人民医院重症监护室 上海 201600）摘要 目的：研究重症监护室（ICU）呼吸机相关性肺炎（VAP）患者病原菌分布及中性粒细胞与淋巴细胞计数比值（NLR）、血清磷、降钙素原（PCT）联合检测对死亡风险的预测价值。方法：选取上海市第一人民医院于 2020 年 1 月2022 年 1 月收治的 60 例VAP 患者。采集所有患者呼吸道分泌物并进行细菌培养。此外，将其按照预后的不同分为死亡组 21 例以及存活组 39 例，比较两组 NLR、血清磷及 PCT 水平。以单因素及多因素 Logistic 分析 VAP 患者死亡的危险因素，并通过受试者工作特征（ROC）曲线分析 NLR、血清磷及 PCT 预测死亡的效能。结果：60 例 VAP 患者呼吸道分泌物检出病原菌共 82 株，以革兰阴性菌占比最高，共检出革兰阴性菌 75.61%、革兰阳性菌 21.95%、真菌 2.44%。按照占比从高到低的顺序分别为鲍氏不动杆菌 20.73%，铜绿假单胞菌18.29%，肺炎克雷伯菌 17.07%，金黄色葡萄球菌 13.41%，大肠埃希菌 12.20%，其他革兰阴性菌 7.32%，表皮葡萄球菌 4.88%，肠球菌属 3.66%，真菌 2.44%。死亡组 NLR 及 PCT 水平均高于存活组，而血清磷水平低于存活组（P0.05）。单因素分析结果显示：急性生理与慢性健康评分（APACHE）评分及有创机械通气时间均和 VAP 患者死亡有关（P0.05）。多因素 Logistic 回归分析显示：APACHE评分较高、有创机械通气时间较长与 NLR、PCT 水平较高均是 VAP 患者死亡危险因素，血清磷水平较高是 VAP患者死亡的保护因素（P0.05）。ROC 曲线分析显示：NLR、血清磷及 PCT 联合预测 VAP 患者死亡的效能优于上述三项指标单独预测。结论：VAP 患者主要病原菌为革兰阴性菌，临床应合理选用抗菌药物治疗，NLR、血清磷及 PCT 均和患者死亡有关，联合检测对死亡风险的预测价值较高。关键词：呼吸机相关性肺炎；病原菌；中性粒细胞与淋巴细胞计数比值；血清磷；降钙素原中图分类号：R563.1文献标识码：A文章编号：1673-6273（2023）02-263-05Predictive Value Discussion of Combined Detection on Mortality Risk ofPathogenic Bacteria Distribution,Neutrophil to Lymphocyte Count Ratio,Serum Phosphorus and Procalcitonin in Patients with Ventilator AssociatedPneumonia in ICU*QI Lian-ping,ZHOU Xing-mei,SHENG Yi,FEI Kai-hong,ZHUANG Yan-ping(Department of Intensive Care Unit,Shanghai First Peoples Hospital,Shanghai,201600,China)ABSTRACT Objective:To study the pathogenic bacteria distribution and the predictive value of combined detection on mortalityrisk of neutrophil to lymphocyte count ratio(NLR),serum phosphorus and procalcitonin(PCT)in patients with ventilator associatedpneumonia(VAP)in intensive care unit(ICU).Methods:60 patients with VAP who were admitted to Shanghai First Peoples Hospitalfrom January 2020 to January 2022 were selected.Respiratory secretions were collected from all patients and bacterial culture was per-formed.In addition,according to the different prognosis,they were divided into death group with 21 cases and survival group with 39cases.The levels of NLR,serum phosphorus and PCT were compared between the two groups.Univariate and multivariate Logistic anal-ysis were used to analyze the risk factors for death in patients with VAP.Receiver operating characteristic(ROC)curve was used to ana-lyze the efficacy of NLR,serum phosphorus and PCT in predicting death.Results:82 strains of pathogenic bacteria were detected in res-piratory secretions of 60 cases of patients with VAP,and Gram-negative bacteria accounted for the highest proportion,with 75.61%ofGram-negative bacteria,21.95%of Gram-positive bacteria and 2.44%of fungi.According to the order of proportion from high to low,they were Acinetobacter baumannii 20.73%,Pseudomonas aeruginosa 18.29%,Klebsiella pneumoniae 17.07%,Staphylococcus aureus13.41%,Escherichia coli 12.20%,other Gram-negative bacteria 7.32%,Staphylococcus epidermidis 4.88%,Enterococcus 3.66%,Fungi*基金项目：上海市卫生计生系统重要薄弱学科建设计划项目（2018ZB0405）；上海市松江区科学技术攻关项目（2019SJKJ6602）作者简介：戚莲萍（1984-），女，硕士研究生，研究方向：呼吸重症，E-mail:通讯作者：庄燕萍（1990-），女，本科，主治医师，研究方向：呼吸重症，E-mail:（收稿日期：2022-06-10 接受日期：2022-07-06）263现代生物医学进展Progress in Modern Biomedicine Vol.23NO.2JAN.2023was 2.44%.The levels of NLR and PCT in the death group were higher than those in the survival group,while the level of serum phos-phorus was lower than that in the survival group(P0.05).Univariate analysis showed that acute physiology and chronic health score(APACHE)and invasive mechanical ventilation time were associated with death in patients with VAP(P0.05).Multivariate Logisticregression analysis showed that higher APACHE score,longer duration of invasive mechanical ventilation,higher levels of NLR andPCT were risk factors for death in patients with VAP,and higher serum phosphorus level was a protective factor for death in patientswith VAP(P0.05).ROC curve analysis showed that the combination of NLR,serum phosphorus and PCT in predicting the death ofpatients with VAP was better than the above three indicators alone.Conclusion:The main pathogenic bacteria in patients with VAP areGram-negative bacteria,and antibiotics should be used reasonably in clinical treatment.NLR,serum phosphorus and PCT are all relatedto the death of patients,and the combined detection has a high predictive value for the mortality risk.Key words:Ventilator-associated pneumonia;Pathogenic bacteria;Neutrophil to lymphocyte count ratio;Serum phosphorus;Procal-citoninChinese Library Classification(CLC):R563.1Document code:AArticle ID:1673-6273(2023)02-263-05前言呼吸机相关性肺炎（VAP）主要是指在机械通气 48 h 后拔管至 48 h 内发生的肺炎，属于重症监护室（ICU）患者行机械通气治疗后最为常见的一种并发症，具有较高的发病率以及死亡率1,2。ICU 患者一旦并发 VAP 会在一定程度上延长康复周期，增加患者家庭以及社会的经济负担。受医疗环境持续变化的影响，VAP 患者病原菌亦出现动态分布变化，对临床抗感染治疗方案的需求随之呈动态变化，从而导致经验性用药效果欠佳。因此，及时掌握病原菌变化情况，可能有利于医生制定并实施针对性干预措施3,4。此外，有效预测 VAP 患者预后亦是广大医务工作者亟待解决的难题之一。中性粒细胞与淋巴细胞计数比值（NLR）是近年来发现的反映机体炎症程度的新型指标，可能有利于评估 VAP 患者预后转归5,6。磷为机体内关键性元素之一，在机体能量代谢、维持酸碱平衡以及调控酶促反应等过程中起着