呼吸道感染在感染性疾病中占有重要地位，细菌性肺炎是呼吸道感染中的主要代表性疾病，最重要的治疗措施是抗菌治疗，用药选择及方法正确与否直接影响治疗的成败。同时如何降低医疗费用也是临床医生需要考虑的棘手问题。据国外文献报道在英国每年约有5亿张以上的抗微生物药物处方，其中住院处方中约40％为静脉制剂，而我国住院静脉制剂的处方比例则更高。医疗费用的增加部分与静脉用药过多有关。为寻求解决临床治疗与医疗费用之间的矛盾，选择高效、低毒、廉价的抗菌药物，1987年Quintiliani等[1]首先提出了抗生素序贯疗法（sequential therapy）的概念，即在经过相对短疗程（48～72 h）静脉抗菌药物治疗，临床症状基本稳定或改善后，改为口服抗菌药物治疗。口服的抗菌药物可以是与前者完全相同的口服剂型，也可以是同一类或抗菌谱相似的同一级药物，后也有人称之为"转换治疗"（switch therapy）、"降级治疗"（step-down therapy）。据国外文献报道，住院的社区获得性肺炎（CAP）应用序贯疗法者因早期出院每位患者节约费用293~1393美元[2-4]。
【摘要】 目的 分析ICU患者院内下呼吸道感染的细菌分布情况,为临床用药提供依据。方法 对成都市第六人民医院2006年1月—2009年6月566例ICU院内下呼吸道感染患者的痰培养标本结果进行回顾性调查分析。结果 共分离出371株病原菌,其中革兰阴性杆菌235株,占63.34%;革兰阳性球菌62株,占16.71%;真菌74株,占19.95%。药敏结果显示,对常规青霉素类基本耐药,亚胺培南—西司他丁、美罗培南耐药菌株少见,对万古霉素耐药菌株尚未出现。结论 加强ICU呼吸道感染的病原菌监测极为必要,对临床抗生素的合理使用具有指导意义。
Objective To assess the effectiveness and safety of Shuangjie Capsule (Piece) in the treatment of acute upper respiratory tract infection. Methods The multiple center, double-blinded, double-dummy and randomized controlled method was adopted to observe 770 patients who were divided into the treatment group A (n=330, treated with Shuangjie Capsule 3 pieces tid), treatment group B (n=330, treated with Shuangjie Piece 3 pieces tid) and the control group (n=110, treated with Chaihuang Piece 3 pieces tid). The therapeutic course for three groups was 5 days. Results Among 770 included patients, 724 and 718 were screened for intention to treat (ITT) and per-protocol population set (PPS) analysis, respectively. For the effectiveness on upper respiratory tract infection, in treatment group A, the markedly effective rate were 83.60% (ITT) and 84.69% (PPS) respectively, and effective rate were 98.39% (ITT) and 99.02% (PPS) respectively; in treatment group B, the markedly effective rate were 83.28% (ITT) and 83.22% (PPS) respectively, and effective rate were 99.04% (ITT) and 99.03% (PPS) respectively; while in the control group the markedly effective rate were 68.62% and 69.30% respectively, and effective rate were 98.04% and 99.01% respectively. The effectiveness of treatment group were significantly better than that of control group (Plt;0.05). For effects on TCM syndrome, in treatment group A, the markedly effective rate were 83.92% (ITT) and 85.02% (PPS), and effective rate were 98.07% (ITT) and 98.70% (PPS); in treatment group B, the markedly effective rate were 83.92% (ITT) and 83.87% (PPS), and effective rate were 99.36% (ITT) and 99.35% (PPS); while in the control group the markedly effective rate were 74.51% (ITT) and 75.24% (PPS), and effective rate was 98.04% (ITT) and 98.02% (PPS). It also showed a statistical significance between treatment and control group (Plt;0.05). ITT and PP analysis have the same results. No major adverse effect was found in the observation.Conclusion Shuangjie Capsule (Piece) shows a definite effect with no obvious toxic-adverse effects.
Objective To evaluate the clinical effect and safety of Gankeshuangqing capsule in the treatment of acute upper respiratory infection (AURI).Methods A total of 144 patients with wind-heat syndrome (acute upper respiratory infection) were recruited and randomized into the Gankeshuangqing group (administered with Gankeshuangqing capsule and symptomatic treatment for 3 days) and the ribavirin group (administered with ribavirin tablets and symptomatic treatment for 3 days). And the severity scores of pathogenetic conditions, efficacy rates and adverse drug reaction were estimated at the end of the experiment. Results A total of 144 patients (72 in the Gankeshuangqing group, 72 in the ribavirin group) were enrolled in this trial, of whom 9 were dropped out (3 from the Gankeshuangqing group, 6 from the ribavirin group) and 11 were excluded (4 from the Gankeshuangqing group, 7 from the ribavirin group). A significant difference was observed in the rates of cure and excellence: 85.51% (59/69) for the Gankeshuangqing group, and 66.67% (44/66) for the ribavirin group, respectively (Plt;0.05) (FAS data set). A significant difference was observed in the rates of cure in fervescence, pharyngodynia and pars nasalis catarrhus symptome: 70.00%, 78.26%, 56.90% in the Gankeshuangqing group, and 40.38%, 51.52%, 36.21% in the ribavirin group, respectively (Plt;0.05) (FAS data set). There was no significant difference in the rates of cure in tussis between the two groups: 32.08% for the Gankeshuangqing group, and 34.00% for the ribavirin group, respectively (Pgt;0.05) (FAS data set). There were 2 adverse drug reactions observed in the ribavirin group, whose white blood cell count was decreased, but in the Gankeshuangqing group, no adverse drug reaction was found. Conclusion The results indicate that Gankeshuangqing Capsule shows a definite effect on wind-heat syndrome (acute upper respiratory infection) with good safety.
Objective To explore the application value of Mycoplasma pneumoniae （MP） rapid culture technique for diagnosis of lower respiratory tract infections （LRTIs ） inpatients. Methods 120 LRTIs inpatients in respiratory ward，Anzhen hospital from January 1，2010 to December 31，2010，were recruited in this study. Their pharynx swabs were obtained for rapid MP culture and the serum antibody detection of MP was performed by Gelatin particle agglutination method. Results There were 33 positive yields in 120 LRTIs patients by rapid culture method and 24 positive yields by serological assay. The positive rates were 27.5% and 20.0% respectively. There was no significant difference in the two detecting methods （Pgt;0.05）. Conclusions MP rapid culture method is a better early diagnostic method at the present. MP rapid culture method combined with serological detection can improve the positive yield and avoid missed diagnosis.
Objective To investigate the clinical features of lower respiratory tract infection caused by hypermastigote. Methods The clinical manifestations, chest imaging characteristics, fiber bronchoscopic and etiological test results were analyzed in 16 patients with hypermastigote infection in lower respiratory tract. Results In 16 patients with hypermastigote infection in lower respiratory tract, fever were present in all the cases, cough in 15 cases, night sweat in 12 cases, wheezing in 3 cases, and eosinophilia in 3 cases.Alive hypermastigotes were found in respiratory tract secretion in all the 16 cases. Bacterial culture of respiratory tract secretion yielded positive results in 8 of 16 cases. Chest imaging showed infiltrations in several lobes and segments or a large opacity with fuzzy patches. Bronchoscopy showed an acute inflammation in the respiratory tract lumen. Prognosis was good with the therapy of Metronidazole. Conclusions Detection of hypermastigote infection in lower respiratory tract have a definite clinical significance in Shenzhen area. Mixed infection is common in hypermastigote infection of lower respiratory tract.
Objective To investigate the viral etiology of acute lower respiratory tract infection in adult inpatients. Methods 192 adult inpatients suffering from community-acquired pneumonia, acute bronchitis, or acute exacerbation of chronic obstructive pulmonary disease, admitted from October 2007 to October 2008, were enrolled in the study. Swabs from the nasopharynxes were collected. Multiple polymerase chain reaction was employed to identify the 7 common species of respiratory virus ( including 11subspecies) . Serumspecific IgM against several viruses were detected by indirect immunofluorescence. 106 healthy volunteers were enrolled as control. Results Only 4 cases were found to be infected with virus in 106 healthy volunteers. Viruses were identified in 80 ( 41. 6% ) cases of 192 inpatients and 99 ( 51. 5% )viral strains were detected. The most common viruses identified in the inpatients were influenza virus A ( FluA) , rhinovirus ( RhV) , and parainfluenza virus 1 ( PIV1) . The ratio of the 3 virus strains to the all strains identified was 81. 8% ( 81/99) . Serumspecific IgM was positive in 61 ( 31. 7% ) inpatients and 73 ( 38. 0% ) viral strains were detected. The most common viruses identified in the inpatients were FluA, PIV1,and respiratory syncytial virus ( RSV) . When summing up the data from the swabs and serum, 91 ( 47. 3% )cases had viral infection in 192 inpatients and 110 ( 57. 2% ) viral strains were detected. Conclusion The rate of viral infection is relatively high in the adult inpatients with acute lower respiratory tract infection, and the most common species are FluA, RhV, and PIV1.
ObjectiveTo investigate clinical characteristics and influencing factors of lower respiratory tract infection of Acinetobacter baumannii (AB-LRTI) in respiratory intensive care unit (RICU).MethodsClinical data were collected from 204 RICU patients who were isolated Acinetobacter baumannii (AB). The bacteriological specimens were derived from sputum, bronchoscopic endotracheal aspiration, bronchoalveolar lavage fluid, pleural effusion and blood. The definition of bacterial colonization was based on the responsible criteria from Centers for Disease Control and Prevention/National Medical Safety Network (CDC/NHSN). The patients were divided into three groups as follows, AB colonization group (only AB was isolated, n=40); simple AB-LRTI group (only AB was isolated and defined as infection, n=63), AB with another bacteria LRTI group (AB and another pathogen were isolated simultaneously, n=101). The epidemiology, clinical characteristics and influencing factors of each group were analyzed and compared. ResultsCompared with the AB colonization group, the AB with another bacteria LRTI group had higher proportion of patients with immunosuppression, specimens from sputum and bronchoalveolar lavage fluid, more than 4 invasive procedures, 90-day mortality, white blood cell count >10×109/L (or <4×109/L), neutrophil percent >75% (or <40%), lymphocyte count <1.1×109/L, platelet count <100×109/L, albumin <30 g/L, high sensitivity C-reactive protein >10 mg/L, and neutrophil-to-lymphocyte ratio (NLR). The frequency of bronchoscopy and days of infusing carbapenem within 90 days before isolating AB, the Acute Physiology and Chronic Health Evaluation Ⅱ score, the proportion of patients with invasive mechanical ventilation and the duration of invasive mechanical ventilation in the AB with another pathogen LRTI group were higher than those in the AB colonization group (all P<0.05). Days of infusing carbapenem and β-lactams/β-lactamase inhibitors within 90 days before isolating AB, proportion of septic shock, NLR and 90-day mortality of the patients from the AB with another pathogen LRTI group were more than those in the simple AB-LRTI group (all P<0.05). After regression analysis, more than 4 invasive procedures, or immunosuppression, or with more days of infusing carbapenem within 90 days before isolating AB were all the independent risk factors for AB-LRTI.ConclusionsThere are significant differences in epidemiology, clinical symptoms and laboratory indicators between simple AB-LRTI, AB with another pathogen LRTI and AB colonization in RICU patients. For RICU patients, who suffered more than 4 invasive procedures, immunosuppression, or with more days of infusing carbapenem within 90 days before isolating AB, are more susceptible to AB-LRTI.
Objective To investigate the relations between the human beta defensin-2 (HBD-2) and systemic inflammatory responses in patients with lower respiratory tract infection（LRTI）. Methods Eighty-one patients with confirmed LRTI including community-acquired pneumonia，acute exacerbation of chronic obstructive pulmonary disease or concurrent lung infection，and bronchiectasis concurrent infection were enrolled，and twenty healthy volunteers were included as control. Plasma concentrations of HBD-2，IL-1β，and IL-8 were assayed with ELISA method in all patients and controls. Furthermore the patients were divided into three groups according to the onset of disease:,ie.group A （shorter than 7 days），group B （7 to 14 days），and group C （more than 14 days）. The differences between these groups were compared. Correlation between HBD-2 and IL-1β or IL-8 concentrations was analyzed. Results HBD-2，IL-1β，white blood cell （WBC） of the peripheral blood in the patients with LRTI were all significantly higher than those in the healthy controls. HBD-2 and IL-1β increased in group A and group B，and decreased in group C comparing to the control group （Plt;0.05 respectively）. There was no significant difference of IL-8 in group A，B and C. HBD-2 showed a positive linear correlation with IL-1β （r=0.313，P=0.030） and no correlation with IL-8（Pgt;0.05）. Conclusions The plasma HBD-2 concentration is increased in LRTI patients，which may be a biomarker of systemic inflammation in the early or relative early course of LRTI.
至2002年6月,有关上呼吸道感染治疗的临床证据如下:①止痛剂/抗炎药用于缓解症状:1个系统评价发现与安慰剂比较止痛剂或抗炎药在1～5 d时显著减轻咽喉炎症状;1个RCT发现在服用抗生素的急性鼻窦炎患者,激素鼻喷剂较安慰剂明显改善症状,持续21 d.②抗生素用于预防β溶血链球菌咽炎的少见并发症:1个系统评价发现抗生素可预防β溶血链球菌咽炎的非化脓性并发症,但在工业化国家该并发症少见.③抗生素能缩短流感嗜血杆菌、卡他莫拉菌或肺炎链球菌感染的康复时间,在少部分患者中其上呼吸道感染由流感嗜血杆菌,卡他莫拉菌或肺炎链球菌引起.1个RCT发现抗生素较安慰剂明显增加这些患者在5 d时的康复.但目前尚无简捷的方法将此亚组患者从众多鼻咽培养阴性的患者中甄别出来.④抗生素缩短急性支气管炎、咽喉炎和鼻窦炎的康复时间:系统评价发现抗生素能轻度改善症状.与安慰剂比较,使用抗生素常出现副作用(恶心、呕吐、头痛、皮疹、阴道炎).⑤抗生素在感冒患者中的作用:2个系统评价发现,在患感冒6～14 d时使用抗生素在治愈率或全身改善方面与安慰剂没有差异.⑥抗组胺药用于流涕和喷嚏:1个系统评价发现,使用抗组胺药2 d后流涕和喷嚏明显减轻,但临床获益较小.⑦β受体激动剂缩短成人支气管高反应性、喘息或气流受限患者咳嗽的持续时间:1个系统评价发现,与安慰剂或红霉素比较,在7 d时β受体激动剂可减轻成人咳嗽症状,但亚组分析表明此种获益仅限于伴有支气管高反应性、喘息或气流受限者.β受体激动剂明显增加手抖、震颤和神经过敏的发生比例.儿童中进行的2个小样本RCTs发现在7 d时咳嗽症状在β受体激动剂和安慰剂间没有显著差异.但是,这些RCTs规模太小,故不能检出临床上重要的差异.⑧减充血剂用于充血症状的长期缓解:1个系统评价发现,无证据支持数天中反复使用减充血剂.1个病例对照研究发现,有微弱证据支持去甲麻黄碱可能增加出血性中风的风险.⑨减充血剂用于充血症状的短期缓解:1个系统评价发现,与安慰剂比较单剂减充血剂显著减轻鼻充血,持续3～10h.⑩紫锥花属用于预防:1个系统评价发现与不干预比较,紫锥花属显著减少一次感染发作的人数,但与安慰剂比较,无有效证据支持紫锥花属的作用.(11)紫锥花属制剂:2个系统评价发现有限证据支持紫锥花属的某些制剂在改善症状方面优于安慰剂,但我们未发现有效证据支持任何特定产品的疗效.(12)蒸汽吸入:1个系统评价发现,无证据支持蒸汽吸入的作用.(13)维生素C:1个系统评价发现与安慰剂比较维生素C可轻度缩短感冒症状持续时间,但该作用较小且可能是发表偏倚.(14)锌(鼻内锌胶或锭剂):2个RCTs发现,与安慰剂比较鼻内锌胶缩短感冒症状的平均持续时间,但仅有1个RCT发现差异有显著性.2个系统评价发现,与安慰剂比较葡萄糖酸锌或醋酸盐锌锭剂在7d时减轻症状的持续.