【作者】 陈灿；

【导师】 李其皓； 柴燕玲；

【作者基本信息】 昆明医学院 ， 内科学， 2008， 硕士

【摘要】 目的分析社区获得性肺炎(community-acquired pneumonia,CAP)患者在昆明医学院第二附属医院呼吸科的治疗情况,阐明CAP治疗的合理性问题。方法以2002年01月01日至2006年12月31日在昆明医学院第二附属医院呼吸科住院的417例CAP患者为研究对象,通过回顾性研究,应用SPSS13.0统计分析软件,分析患者的住院情况、首剂抗生素使用情况、痰培养阳性率及病死率,了解我科CAP患者的治疗情况并进一步了解我国CAP指南在我科的执行情况。结果1、(1)按我国CAP病情评估标准,我科社区获得性肺炎符合住院标准患者为80.6%,不符合住院标准患者为19.4%,与Fine评分之间无统计学差别(P=0.094);(2)2002年～2006年入院治疗符合率之间无统计学差异(P=0.473);2、(1)平均住院时间(15±10)天,与薛晓艳研究组的(14±6)天无差别(F=5.02,P＞0.05);(2)5年的平均住院时间未见明显变化(F=1.958,P=0.1)。3、痰培养的阳性率为12.8%。肺炎链球菌是最常见的病原菌,占47%。4、(1)2002年～2006年首剂抗生素治疗除2例外,均在诊断为CAP后4小时以内;(2)首剂抗生素治疗选择中β-内酰胺类抗生素使用居第一位(64.8%),其次为喹诺酮类(17.3%)、林可霉素类(8.6%)、大环内酯类(5.0%)。在联合用药方面,头孢类药物与其他类药物联合居首位(92.3%);(3)2002年～2006年首剂抗生素的使用遵循我国CAP诊疗指南的为68.8%(287/417),5年的年遵循率未见明显变化(P=0.577);(4)首剂抗生素治疗失败87例(20.86%),其中β-内酰胺类抗生素的使用占79.31%。①首剂抗生素失败率最高的是头孢类联合喹诺酮类,其余依次为β-内酰胺类、头孢类联合大环内酯类、林可霉素类、喹诺酮类、大环内酯类。通过x~2检验,P=0.064,说明各类首剂抗生素治疗的失败率之间无差别。②87例患者中,首剂抗生素选择未遵循指南者37例。首剂抗生素选择遵循指南者50例,其中14例治疗失败原因不明,其余36例治疗失败与病情重(PSI＞130分)、年龄≥65岁及痰培养出CAP非常见病原菌有关。③5年间首剂抗生素治疗的失败率未见明显变化(P=0.913);(5)死亡39例,β-内酰胺类为其常用的首剂抗生素。①首剂抗生素治疗的病死率,以喹诺酮类最低;②5年的病死率为9.4%(39/417),并且5年的病死率未见明显变化(P=0.624);③首剂抗生素选择遵循指南的病死率为4.9%(14/287),未遵循指南的病死率为19.2%(25/130),后者的病死率明显高于前者(P=0.000);结论1、根据我国CAP病情评估标准及PSI标准,住院CAP患者中有19.42%～30.0%的患者可以安全接受门诊治疗,从而造成医疗资源的浪费。2、我科痰培养结果阳性率12.8%,以肺炎链球菌、流感嗜血杆菌为主。虽然阳性率低于国内的其他地区,但细菌的分布相似。非典型病原体抗体的检测有待开展。3、我科CAP患者平均住院时间(15±10)天,与国内报道相似。4、我科CAP治疗首剂抗生素选择以β-内酰胺类抗生素居首位,其次为喹诺酮类;在联合用药方面,也以β-内酰胺类联合喹诺酮类为主。5、我科首剂抗生素选择遵循指南的患者占68.8%(287/417),首剂抗生素治疗失败率20.86%(87/287),其中遵循指南治疗的失败率为17.42%(50/287),未遵循指南治疗的失败率为28.46%(37/130),通过x~2检验,P=0.013,表明遵循指南选择首剂抗生素治疗能够降低失败率。6、我科CAP患者病死率为9.4%(39/417),与国外报道相符。其中首剂抗生素选择遵循指南的患者的病死率为4.9%(14/287),未遵循指南的患者的病死率为19.2%(25/130),通过x~2检验,P=0.000,表明首剂抗生素选择遵循指南能够明显的降低CAP患者的病死率。7、5年间未见指南对患者的治疗(包括治疗地点、住院时间、首剂抗生素使用及治疗情况、病死率)有明显影响。因此,为提高CAP的治疗水平,重视指南、严格遵循指南的意识需进一步增强。更多还原

【Abstract】 Objective To explore the current therapeutic strategy for community acquired pneumonia(CAP)in the second affiliated hospital of Kunming Medical University,and to illuminate the reasonable therapeutic strategy for CAP.Methods The data of 417 hospitalized CAP patients from January 1 st,2002 to December 31,2006 was documented retrospectively.The patient’s situation was scored by either Chinese CAP guideline or Fine’s risk classification.The data was analyzed with SPSS 13.0 to identify the patients’ hospital situation,the choice of the first dose antibiotics,the positive rate of sputum culture and the mortality,to explore the therapeutic conditions in the department,and in further,to explore the implementation of the Chinese CAP guideline in the department.Results 1(1)According to Chinese CAP guideline,80.6%of the 417 hospitalized CAP patients met the standard and 19.4%didn’t meet the standard.There was no significant statistical difference between Chinese CAP guideline and Fine’s risk classification(P=0.094).(2)The rate of hospitalization that met the Chinese CAP guideline had no significant statistical difference(P=0.473)in these five years.2(1)The average day of length of stay was(15±10),and there was no significant difference between ours and Xue Xiaoyan’(F=5.02,P＞0.05).(2)The average length of stay did not change obviously in the five years(F=1.958,P=0.1).3 The positive rate of sputum culture was 12.8%.Streptococcus pneumoniae was the most common causative organism,the percentage was 47%.4(1)From the year 2002 to 2006,all the first dose antibiotic treatment was administered within four hours except two.(2)In all the first dose antibiotics,theβ-lactam antibiotics ranked first(64.8%),followed by quinolones(17.3%),Lincomycin category(8.6%),macrolides(5.0%).In combination, Cephalosporin drugs combined with other types of antibiotics ranked first(92.3%).(3) The percentage that the first dose antibiotics used follow the Chinese CAP guideline was 68.8%(287/417).There was no significant difference in the percentage in five years(P=0.577).(4)The first dose antibiotic treatment was failed in 87 cases(20.86%), and among all the first dose antibiotics that were used in these 87 cases,β-lactam antibiotics accounted for 79.31%.①The treatment failure rate was the highest when the first dose antibiotic was cephalosporins plus quinolones,and followed byβ-lactams, cephalosporins plus macrolides,lincomycin,quinolones,macrolides.Through chi square test,P=0.064,it meaned that there was no difference among the various types of antibiotic in the treatment failure rate.②In 87 cases,the cases that the first dose antibiotics didn’t follow the Chinese CAP guideline was 37,50 cases followed.Among the 50 cases,the reason was unknown in 14 cases,the remaining 36 cases were related with the severity of the illnesses、age≥65y and atypical pathogens seen in the sputum culture.③There was no significant difference among the failure rate of the first dose antibiotic treatment(P=0.913).(5)The death cases was 39,and among all the first dose antibiotics that were used in these 39 cases,β-lactam antibiotics was the most common.①The mortality was the lowest when the first dose antibiotic treatment used quinolones.②The mortality was 9.4%(39/417)in five years,and there was no significant difference in mortality in five years(P=0.624).③The mortality was 4.9%(14/287)when the first dose antibiotics used follow the Chinese CAP guideline, and the mortality was 19.2%(25/130)when didn’t,the latter was obviously higher than the former(P=0.000).Conclusions 1 According to Chinese CAP guideline and PSI standards,some patients(19.42%～30.0%)could be safely treated as out-patients,and this condition results in the waste of medical resources.2 The positive rate of sputum culture was 12.8%,Streptococcus pneumoniae and Haemophilus influenzae were the common pathogens.Though the positive rate was lower than other regions in China,but the distribution of bacteria was similar with the other regions.Atypical pathogens antibody testing need to be undertaken.3 The average day of length of stay was(15±10),and it was similar with other reports in domestic.4 In all the first dose antibiotics, theβ-lactam antibiotics ranked first,followed by quinolones.In combination, Cephalosporin drugs combined with quinolones ranked first.5 The percentage that the first dose antibiotics used follow the Chinese CAP guideline was 68.8%(287/417).The first dose antibiotic treatment failure rate was 20.86%(87/287),and the failure rate was 17.42%(50/287)when the first dose antibiotics used follow the Chinese CAP guideline, and the failure rate was 28.46%(37/130)when didn’t,through chi square test,P=0.013, it meaned that the first dose antibiotics used follow the Chinese CAP guideline can reduce the treatment failure rate.6 The mortality was 9.4%(39/417)in five years,and it it was similar with other reports.The mortality was 4.9%(14/287)when the first dose antibiotics used follow Chinese CAP guideline,and the mortality was 19.2%(25/130) when didn’t,through chi square test,P=0.000,it meaned that the first dose antibiotics used follow the Chinese CAP guideline can reduce the mortality.7 No significant influence by the Chinese CAP guidelines on the therapy(the site,the length of stay,the mortality,the choice of the first dose antibiotics and its therapeutic conditions)of the CAP patients.Therefore,in order to raise the level of CAP therapy,the consciousness of strictly obey the Chinese CAP guideline for the management of CAP should be strengthened.更多还原