الفهرس يوجد فقط 14 صفحة متاحة للعرض العام
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المستخلص
Pneumonia continues to be a major clinical problem in term of morbidity, mortality and use of hospital resources. It is well recognized that a delay in making the diagnosis and instituting appropriate antibiotic treatment is associated with an increased mortality. Diagnosis of pneumonia is easily made in the presence of typical symptoms, physical signs and radiological features. However, the clinical picture may not be so well defined in the presence of co-existing lung disease or if the patient presents in the early stages before radiological picture becomes apparent. In addition, other traditional markers may not be elevated. If making the diagnosis has not been easy, then assessing treatment response is likely to be difficult.
Ventilator-associated pneumonia (VAP) is the main cause of nosocomial infection in an intensive-care setting. VAP diagnosis is difficult, due both to the lack of well-defined clinical criteria and the overlap of symptoms with those of nosocomial pneumonia. American medical literature states that the mean incidence rate of VAP is 7 cases per 1,000 days of mechanical ventilation, ranging from 1 to over 20 cases per 1,000 days of mechanical ventilation.
Though an etiological investigation, composed of quantitative cultures from VAP patients (bronchoalveolar lavage fluid obtained through bronchoscopy with or without a protected catheter or simply collected by tracheal aspiration) is important for the optimization of antibiotic use, this recommendation is not universally accepted due to the lack of objective studies that demonstrate the benefit of these procedures.
Mini-BAL sampling in the previous literature usually depends on using a prepackaged dedicated catheters that is not available in the developing countries and if imported it would be extremely expensive. Therefore, this study employed a new, cheap method in acquiring mini-BAL samples in the diagnosis of VAP.
The aim of this work was to assess the incidence of different pathogens causing pneumonia and their antibiotic sensitivity in patients admitted to the respiratory intensive care unit in Ain Shams University Hospital during the period from 1/12/2009 to 31/5/2010.
The present study included 110 patients of which fifty patients were mechanically ventilated representing (Group A), thirty two of them were males and eighteen were females. Sixty patients with lower respiratory tract infection acquired during the ICU admission representing (Group B), thirty five of them were males and twenty five of them were females. Patients in group (A&B) were admitted at the respiratory Intensive Care Unit of Ain Shams University Hospitals in the period between 1\12\2009 and 31\5\2010.
Patients in group (A) and (B) were subjected to the following on first clinical presentation:
Full history taking
Thorough general examination and local chest examination.
Liver function tests.
Kidney function tests.
Complete blood picture.
Erythrocyte sedimentation rate.
Electrocardiography.
Chest X- ray postero-anterior view.
For patients in group (A), Mini-BAL technique was used for collection of bronchial aspirate which was then examined by conventional culture and sensitivity.
For patients in group (B), sputum sample was collected in a sterile container and was sent for conventional culture and sensitivity.
The results of the present study showed that the most frequently isolated organism causing pneumonia in non-mechanically ventilated patients was Klebsiella spp. 35.1% followed by E. coli in 21.6% , MSS in 16.2% , MRSA in 13.5% , Pseudomonas spp. in 10.8%.the least isolated organism in non-mechanically ventilated patients was Acinetobacter spp. in 2.7%.
Also it showed that the most common cause of VAP was Acinetobacter spp. in 32% followed by MRSA in 22% then Klebsiella spp. in 14% then Pseudomonas spp. in 12% and the least organisms isolated were MSS and E. coli which were isolated only in 10% of mechanically ventilated patients.
In this study we found that 23.5% of the isolated Acinetobacter spp. were sensitive to levofloxacin, then 17.6% were sensitive to imipenem, also we found that most of them (35.3%) were multi-drug resistant (MDR).
As regards Klebsiella spp., we found that 40% of the isolated Klebsiella spp. were sensitive to amikacin, followed by levofloxacin in 25% then imipenem in 20%. We found also that 20% of the isolated strains were resistant to broad spectrum penicillins followed by ceftriaxone, ciprofloxacin and azithromycin which were resistant in 15% each. This study also revealed that 5% of the isolated Klebsiella spp. were multi-drug resistant.
We found in the current study that the most potent antibiotic was imipenem in 19.5% of all the isolated organisms followed by levofloxacin 17.2% then amikacin 16.1% then broad spectrum penicillins 11.5% then vancomycin 10.3%, also it shows that trimeth.\ sulf., linezolid, ciprofloxacin and meropenem were the least effective antibiotics only in 1.1%.
In the current study, we found that the highest mortality rate was associated with MRSA infections in 37% out of all the dead patients followed by Acinetobacter spp. infections in 25.9% then infection with Klebsiella spp. and Pseudomonas spp. which accounted for 14.8% each from the dead patients.