| Background:Intensive rehabilitation care unit is a place for early and reasonable rehabilitation intervention for patients with acute stage,difficult and severe cases,complicated diseases and injuries.The patients who received treatment are in the stage of transition from severe acute phase to recovery phase.The patient's condition is not completely stable,and dysfunction is serious.Due to long-term hospitalization,invasive operation and impaired immune function,it is easy to take the hospital acquired infection of lower respiratory tract.The common clinical separation pathogenic bacteria of this type of infection are mainly gram-negative bacteria.Most of the clinical isolates are opportunistic pathogens,which have a variety of complex resistance mechanisms.Combined with long-term use of broad-spectrum antibacterial agents induced resistance and antibiotic selective pressure resistance,the resistance even the multidrug-resistance status of clinical isolates becomes more and more serious.So it's difficult to treat.Therefore,the treatment of lower respiratory tract infection in critical patients is mainly treated with multidrug-resistant bacteria.The earlier empirical therapy of antibacterial agents is especially important due to the delay of the pathogeny culture and drugs sensitivity test results.So it's necessary to explore the distribution and antimicrobial resistance of the bacterial strains isolated from lower respiratory tract of critical patient in the intensive rehabilitation care unit.To investigate the influence of variables on hospital-acquired pneumonia and take targeted interventions in clinical work have contributed to reduce the incidence of hospital-acquired pneumonia,reduce the use of broad-spectrum antibacterial agents,control the growth of drug-resistant strains,improve the prognosis of patients,and reduce the waste of medical resources.Objective:1.To explore the distribution and antimicrobial resistance of the bacterial strains isolated from lower respiratory tract of critical patient in the intensive rehabilitation care unit,so as to provide guidance for empiric therapy of antibacterial agents.2.To investigate the influence of variables on hospital-acquired pneumonia of critical patient in the intensive rehabilitation care unit,so as to guide the selection of pneumonia prevention and control measures.Methods:1.A retrospective study was carried out on the distribution,antimicrobial resistance and variation trend of the bacterial strains isolated from lower respiratory tract of 368 patients in intensive rehabilitation care unit of Nanfang Hospital from January 2013 to December 2016.Besides,a total of 108 inpatients in intensive rehabilitation care unit of Nanfang Hospital were selected from October 2015 to October 2016 to investigate the influence of variables on hospital-acquired pneumonia.2.All of the strains were isolated from the lower respiratory tract by artificial airway attraction,fiberoptic bronchoscopy or bronchoalveolar lavage from the critical patients in intensive rehabilitation care unit.The sputum specimen was screened by smear.3.Bacterial isolation and identification were in accordance with National Guide To Clinical Laboratory Procedures(4th edition).Bacteria were identified with an automatic bacteria identification system of Becton,Dickinson and Company.Antibiotic susceptibility test was performed by Kirby-Bauer disk diffusion method and MIC susceptibility testing.Bacteria were confirmed by using standard of National Commitee for Clinical Laboratory Standards into sensitive,resistant,and intermediate.Multidrug-resistant bacteria,extensively drug-resistant bacteria,pandrug-resistant bacteria were confirmed by using an international expert proposal for interim standard definitions for acquired resistance.4.Diagnosis of hospital-acquired pneumonia was in accordance with Diagnostic Criteria For Nosocomial Infections(proposed).5.According to whether hospital-acquired pneumonia happened in the first 4 weeks in intensive rehabilitation care unit,all patients were divided into the pneumonia group and the non-pneumonia group.The clinical characteristics of all patients,including:general conditions,basic diseases,laboratory tests results,auxiliary examination results,and medical intervention measures were recorded.Record the cumulative duration of intervention.6.All the data were analyzed by SPSS software 21.0 version.The enumeration data were represented by rate or constituent ratio.The measurement data were represented by mean±standard deviation(x±s).The drug resistance status was analyzed with X2 test(Pearson Chi-Square or Fisher's Exact Test).P<0.05 was a statistically significant difference.The relationship between possible affecting factors and pneumonia was analyzed by univariate analysis and multivariate analysis.In univariate analysis,the measurement data were analyzed with t test(equal variances assumed),or Satterthwaite estimation t test(equal variances not assumed);the enumeration data were analyzed with X2 test(Pearson Chi-Square or Fisher's Exact Test).P<0.05 was a statistically significant difference.On the basis of univariate analysis,the variables P<0.05 were analyzed with binary logistic regression analysis,and calculated adjusted odds ratio(OR)and 95%confidence interval(95%CI),so as to screening of independent risk factors or protective factors for hospital-acquired pneumonia in intensive rehabilitation care unit.Results:1.A total of 368 bacterial strains were isolated from January 2013 to December 2016,with 318 strains of Gram-negative bacteria and 50 strains of Gram-positive bacteria.The top three Gram-negative bacteria were Pseudomonas aeruginosae(181,49.2%),Acinetobacter baumannii(59,16.0%),Klebsiella pneumoniae(26,7.1%).The main Gram-positive cocci was Staphylococcus aureus(36,9.8%).2.A total of 63 strains of carbapenems-resistant Pseudomonas aeruginosae were found.The drug-resistance rates of Pseudomonas aeruginosae strains to common usable antibacterial agents:Aztreonam has the highest drug-resistance rate 48.8%,followed by imipenem 38.2%.The drug-resistance rates to cefepime,meropenem,levofloxacin,ceftazidime,ciprofloxacin,piperacillin/tazobaltan,cefoperazone/sulbatan,amikacin,were 31.3%,30.1%,27.0%,22.4%,22.4%,16.6%,12.4%,5.5%respectively.Polymyxin has the lowest drug-resistance rate 1.9%.Compared with 2013,the drug-resistance rates to imipenem,meropenem,levofloxacin was increasing in 2016(P<0.05).3.The drug-resistance of Acinetobacter baumannii was the most serious.A total of 38 strains of carbapenems-resistant Acinetobacter baumannii,2 strains of polymyxin-resistant Acinetobacter baumannii and 1 strain of pandrug-resistant Acinetobacter baumannii were found.The drug-resistance rates of Acinetobacter baumannii strains to common usable antibacterial agents:Tetracycline has the highest drug-resistance rate 89.8%,followed by cefepime 87.8%.The drug-resistance rates to ciprofloxacin,piperacillin/tazobartan,ampicillin/sulbatan,gentamicin,levofloxacin,ceftazidime,cefotaxime,trimethoprim/sulfamethoxazole,amikacin,meropenem,imipenem,were 86.0%,86.0%,85.7%,84.0%,84.0%,82.0%,81.6%,81.6%,80.0%,76.0%,75.5%respectively.Polymyxin has the lowest drug-resistance rate 4.2%.4.A total of 16 strains of Klebsiella pneumoniae producing extended-spectrum beta-lactamases and 1 strain of carbapenem-resistant Enterobacteriaceae were found.The drug-resistance rates of Klebsiella pneumoniae strains to common usable antibacterial agents:Cefazolin and ampicillin has the highest drug-resistance rates 100%,followed by trimethoprim/sulfamethoxazole 69.2%.The drug-resistance rates to cefotaxime,tetracycline,aztreonam,chloramphenicol,cefepime,ampicillin/sulbatan,ceftazidime,ciprofloxacin,gentamicin,piperacillin/tazobartan,amikacin,meropenem,imipenem,were 65.4%,65.4%,61.5%,61.5%,57.7%,53.8%,50.0%,50.0%,26.9%,23.1%,3.8%,3.8%,3.8%respectively.Klebsiella pneumoniae was not found to be resistant to polymyxin.5.A total of 16 strains of methicillin-resistant Staphylococcus aureus were found.The drug-resistance rates of Staphylococcus aureus strains to common usable antibacterial agents:Erythromycin and tetracycline has the highest drug-resistance rates 47.2%,followed by oxacillin 44.4%.The drug-resistance rates to ciprofloxacin,gentamicin,clindamycin,rifampicin,trimethoprim/sulfamethoxazole,quinupristin/dalfopristin syncercid,were 38.9%,36.1%,32.3%,16.7%,13.9%,2.8%respectively.Staphylococcus aureus was not found to be resistant to teicoplanin,vancomycin,linezolid and fusidic acid.Compared with 2013,the drug-resistance rates to half of the antibacterial agents was increasing in 2016(P>0.05).6.Among the main separation pathogenic bacteria mentioned above,a total of 89 strains of multidrug-resistant bacteria,52 strains of extensively drug-resistant bacteria and 1 strain of pandrug-resistant bacteria were found.The proportion of MDR/XDR/PDR in Acinetobacter baumannii was the highest,more than 80%over the years,mostly XDR,and 1 strain of PDR was found in 2014.The proportion of MDR/XDR in Pseudomonas aeruginosae was 20%-46.3%over the years,and no PDR was found in all the years.The proportion of MDR/XDR in Klebsiella pneumoniae was 50%-100%over the years,and no PDR was found in all the years.The proportion of MDR in Staphylococcus aureus was 33.3%-75.0%over the years,and no XDR/PDR was found in all the years.Compared with 2013,the proportion of MDR/XDR/PDR in Pseudomonas aeruginosae and Staphylococcus aureus was increasing in 2016(P>0.05).7.Among the 108 hospitalized patients of intensive rehabilitation care unit from October 2015 to October 2016,59 cases had hospital-acquired pneumonia.8.Univariate analysis showed that the levels of serum albumin(t=-5.006,P=0.000),the levels of consciousness(X2=6.584,P=0.010),tracheal cannula with subglottic attracting(X2=6.438,P=0.011),nasal feeding tube(P=0.045),pulmonary inflation&discharging sputum with vibration(X2=7.521,P=0.006)between the pneumonia group and the non-pneumonia group was statistically significant(P<0.05).The factors mentioned above affected the incidence of hospital-acquired pneumonia in intensive rehabilitation care unit.9.Binary logistic regression analysis showed that high levels of consciousness(OR=0.222,95%CI 0.065~0.757,P=0.016),pulmonary inflation&discharging sputum with vibration(OR=0.263,95%CI 0.100-0.689,P=0.007),high levels of serum albumin(OR=0.776,95%CO 0.684~0.879,P=0.000)were the protective factors for hospital-acquired pneumonia in intensive rehabilitation care unit.Conclusions:1.The bacterial strains isolated from lower respiratory tract of critical patient in the intensive rehabilitation care unit were mainly Gram-negative bacteria.Pseudomonas aeruginosae was an absolute advantage.Most of these bacterial strains showed severe multidrug resistance.2.The drug-resistance rates of Pseudomonas aeruginosae strains to aztreonam was the highest,while polymyxin was the lowest.The drug-resistance rates to imipenem,meropenem,levofloxacin was increasing.More than one third of Pseudomonas aeruginosae was carbapenems-resistant.3.The drug-resistance of Acinetobacter baumannii was the most serious.Tetracycline has the highest drug-resistance rate,while polymyxin has the lowest.More than 3/4 of Acinetobacter baumannii was carbapenems-resistant.Pandrug-resistant Acinetobacter baumannii had been found.4.The drug-resistance rates of Klebsiella pneumoniae strains to Cefazolin and ampicillin were 100%.Klebsiella pneumoniae was not found to be resistant to polymyxin.More than half of Klebsiella pneumoniae produced extended-spectrum beta-lactamases.Carbapenem-resistant Klebsiella pneumoniae had been found.5.The drug-resistance rates of Staphylococcus aureus strains to erythromycin and tetracycline were the highest.Staphylococcus aureus was not found to be resistant to teicoplanin,vancomycin,linezolid and fusidic acid.More than one third of Staphylococcus aureus was methicillin-resistant.6.MDR and XDR were common in most major clinical separation pathogenic bacteria.The proportion of MDR/XDR/PDR in Acinetobacter baumannii was the highest.7.The levels of serum albumin,the levels of consciousness,tracheal cannula with subglottic attracting,nasal feeding tube,pulmonary inflation&discharging sputum with vibration affected the incidence of hospital-acquired pneumonia in intensive rehabilitation care unit.8.High levels of consciousness,pulmonary inflation&discharging sputum with vibration,high levels of serum albumin were the protective factors for hospital-acquired pneumonia in intensive rehabilitation care unit. |
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