대한내과학회지 : 제 86 권제 5 호 2014 http://dx.doi.org/10.3904/kjm.2014.86.5.537 특집 (Special Review) - 중환자의학의최신지견 인공호흡기연관폐렴의예방과치료 전북대학교의과대학내과학교실, 임상의학연구소 박승용 이흥범 Prevention and Management of Ventilator-Associated Pneumonia Seung Yong Park and Heung Bum Lee Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea Mechanical ventilation is currently an indispensable element within a hospital s intensive care unit (ICU). Regrettably, mechanical ventilation is also strongly associated with the risk of contracting ventilator-associated pneumonia (VAP), which is one of the most common causes of mortality and morbidity within the ICU, and has been for many years. The incidence of VAP has decreased in the last 10 years, from 14 to 9-10 cases per 1,000 days of mechanical ventilation. This has been an important achievement; however, hospital-acquired pneumonia and VAP still carry very high rates of morbidity and mortality, not to mention high financial costs as well. This comprehensive review explores our current understanding of the etiology and pathogenesis of VAP and proposes a strategy for its treatment and prevention. (Korean J Med 2014;86:537-545) Keywords: Ventilator-associated pneumonia; Prevention; Treatment 서론인공호흡기연관폐렴 (Ventilator-associated pneumonia, VAP) 은기계환기중인중환자실환자에서가장흔한감염질환중의하나로 [1], 기계환기시작시점에는폐렴이나혹은폐렴의잠복기에있지않은환자가기관삽관이나기계환기를시작한후 48시간이후에폐렴이발생한경우로정의한다 [1]. 연구에의하면 VAP은기관삽관환자의약 9-27% 정도에서발생하고, 그빈도는기계호흡기간에비례한다 [2]. 그러나 VAP 과관련된역학적연구는진단방법등에서표준화되어있지않을뿐만아니라연구자들간에적용한폐렴의진단기준 이다른실정이다. 더욱이각센터마다중환자실의특성이나병원의특성이다르므로발생빈도와위험인자등의역학자료는연구마다다른양상을보인다 [1]. 더불어인공호흡기연관폐렴의경우에있어서는이에대한명확한진단방법이나치료및예방전략등에관한표준화된진료지침은없는상태이다. 본종설에서는인공호흡기연관폐렴의예방과치료법에대한최신지견을알아보고자하였다. 인공호흡기연관폐렴의진단 VAP을비롯한병원연관폐렴 (hospital-acquired pneumonia, Correspondence to Heung Bum Lee, M.D., Ph.D. Department of Internal Medicine, Chonbuk National University Medical School, 20 Geonji-ro, Deokjin-gu, Jeonju 561-180, Korea Tel: +82-63-250-1685, Fax: +82-63-250-1609, E-mail: lhbmd@jbnu.ac.kr Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 537 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- The Korean Journal of Medicine: Vol. 86, No. 5, 2014 - HAP) 의진단에있어서임상적인증상과증후등은비특이적이기때문에폐렴의발생에관해서는항상그가능성을고려하는것이필요하다 [3-5]. 특히 38 C 이상의고열이나화농성객담, 백혈구증가증 (> 11,000/mm 3 ) 이나백혈구감소증 (< 4,000/mm 3 ), 산소포화도가떨어지는등의임상소견과함께흉부방사선촬영결과새로운병변이발생하거나악화되는경우에는반드시폐렴을고려해야한다. 임상적진단의한계를보완하기위해서하부기도검체를이용한여러가지미생물학적진단이인공호흡기연관폐렴의진단에이용되고있다. 이는폐렴을진단하는것은물론적합한배양검사를통해초기에적절한항균제치료를시작함과동시에사용중인항균제의점감 (de-escalation) 에유용하다. 그러나최근의메타분석결과는기관지폐포세척술 (bronchoalveolar lavage, BAL) 이나 protected sheath brushing (PSB) 을이용한침습적진단방법과기관경유흡인 (endotracheal aspiration) 을이용한비침습적미생물학적진단을비교하였으나예상과달리큰차이를보이지않았고, 결과적으로사망률감소에도기여하지못하였다 [6]. 또한이후에시행된 28개중환자실을대상으로한비교임상시험에서도 BAL을이용한침습적진단법 이나기관경유흡인을이용한진단에서 28일사망률과항생제사용기간의차이를보이지않았다 [7]. 때문에인공호흡기연관폐렴의미생물학적진단에있어기관지내시경을통한침습적 BAL 또는 PSB가반드시필요하지는않으며, 비교적간단하고쉽게시행할수있는기관경유흡인을이용한미생물검사도유용하다고하겠다. 2014년미국질병관리본부 (Center for Disease Control and Prevention, CDC) 에서는흉부방사선소견, 임상적증상및징후, 그리고미생물검사결과를바탕으로인공호흡기연관폐렴의진단에적용할수있는임상적진단기준을마련하였고이를일부변환하여요약하였다 (Table 1) [8]. 결론적으로현재까지 VAP에대한표준화된진단기준에는논란이있는실정으로 [9-11] VAP 의진단을위해서는임상증상이나징후의변화, 방사선소견의변화, 갑작스런산소포화도의감소등과같은인자에대해서항상 VAP을포함하여고려하는것이중요하겠다. 또한미국흉부학회 / 미국감염학회 (ATS/IDSA) 의지침및및권고에따른침습적또는비침습적하기도검체를통한미생물검사를시행하고, 우선경험적항생제치료를시작하며 2-3일뒤항생제치료의효 Table 1. Specific site algorithms for clinically defined pneumonia Radiology Signs/Symptoms/ Laboratory Threshold values for cultured specimens used in the diagnosis of pneumonia Two or more serial chest radiographs with at least one of the following - 538 - New or progressive and persistent infiltrate Consolidation Cavitation For ANY PATIENT, at least one of the following: At least two of the following: Fever (> 38 C or > 100.4 F) New onset of purulent sputum, or change in character Leukopenia (< 4,000 WBC/mm 3 ) or leukocytosis of sputum, or increased respiratory secretions, or (> 12,000 WBC/mm 3 ) increased suctioning requirements For adults > 70 years old, altered mental status with New onset or worsening cough, or dyspnea, or no other recognized cause tachypnea Rales or bronchial breath sounds Worsening gas exchange (e.g., O 2 desaturations (e.g., PaO 2/FiO 2 < 240), increased oxygen requirements, or increased ventilator demand) Specimen collection/technique Lung parenchyma Bronchoscopically obtained Bronchoalveolar lavage Protected BAL Protected specimen brushing Nonbronchoscopically obtained NB-BAL NB-PSB Values > 10 4 CFU/g tissue > 10 4 CFU/g tissue > 10 4 CFU/g tissue > 10 3 CFU/mL > 10 4 CFU/g tissue > 10 3 CFU/mL
- Seung Yong Park, et al. Prevention and management of VAP - 과등인공호흡기연관폐렴의진단에대해다시평가할것이필요하겠다 [12]. 인공호흡기연관폐렴의예방전략 VAP을포함한 HAP의발생은하부기도에침입한미생물의양과병원성, 그리고숙주의반응과관련된다. 폐침범은구인두기관혹은드물지만소화기관에상재하는미생물의미세흡인 (microaspiration) 이주된경로이며입원환자의상재균은주변환경및기저질환과관련되어있다 [13]. 2008년 the Society of Healthcare Epidemiology 와 infectious Diseases Society of America (IDSA) 는 VAP의예방을위한지침서를발간하였다 (Table 2) [14]. 지침서는기계환기기간을최소화함을물론미세흡인을최대한줄이기위한전략외에도상부기도와소화기관에상주하는균을줄이는방법 (decontamination) 을포함하고있다. 그러나여러전략들중에서실제로 VAP를줄인다는연구결 과는구강위생 (orophayngeal and/or digestive decontamination) 관리가유일한방법이다 [15]. 앙와위 (supine position) 에비해반와위 (semi-recumbent position) 가구인두, 비인두및위식도내용물의미세흡인을줄인다는많은연구결과들이있으며 [16,17], 이후시행된 RCT에서도앙와위에비해반와위는 HAP의발생을줄인다는중간보고결과로인해조기종료되었다 [18]. 그러나실제임상에서 45도각도를유지하는동안에마찰에의한등쪽피부손상등이발생될수있어주의가필요하기때문에일반적으로 10-30도를적용하기도한다. 성문하흡인 (Subglottic drainage) 과관련된연구를메타분석한결과성문하흡인군에서대조군에비해 VAP의발생률및중환자실재원기간, 기계환기기간등을감소시켰다. 그럼에도불구하고중환자실사망률이나원내사망률에는큰영향을미치지못하였다 [19]. 최근국내에서도지속적으로성문하흡인이가능하도록특별히제작된기도삽관튜브 (hi-lo Evac, Mallinckrodt Inc; Athlon, Ireland) 가사용되고있다. Table 2. Strategies to prevent ventilator-associated pneumonia in acute care hospitals General strategies that have been found to influence the risk of VAP Conduct active surveillance for VAP Adhere to hand hygiene guidelines published by the Centers for Disease Control and Prevention or the World Health ganization. Use noninvasive ventilation whenever possible. Minimize the duration of ventilation. Perform daily assessments of readiness to wean and use weaning protocols. Educate healthcare personnel who care for patients undergoing ventilation about VAP. Strategies to prevent aspiration Maintain patients in a semirecumbent position (30-45 elevation of the head of the bed) unless there are contraindications Avoid gastric overdistention. Avoid unplanned extubation and reintubation. Use a cuffed endotracheal tube with in-line or subglottic suctioning. Maintain an endotracheal cuff pressure of at least 20 cm H2O. Strategies to reduce colonization of the aerodigestive tract otracheal intubation is preferable to nasotracheal intubation. Avoid histamine receptor 2 (H2)-blocking agents and proton pump inhibitors for patients who are not at high risk for developing a stress ulcer or stress gastritis. Perform regular oral care with an antiseptic solution. The optimal frequency for oral care is unresolved. Strategies to minimize contamination of equipment used to care for patients receiving mechanical ventilation Remove condensate from ventilatory circuits. Keep the ventilatory circuit closed during condensate removal. Change the ventilatory circuit only when visibly soiled or malfunctioning. Store and disinfect respiratory therapy equipment properly. - 539 -
- 대한내과학회지 : 제 86 권제 5 호통권제 645 호 2014 - 장관영양지원동안장관영양액의역류는최대약 80% 까지발생할수있다. 이러한흡인은급식관의위치에따른차이는없는것으로알려져있으며환자의체위를약 30-45도정도로반와위를유지함을물론주기적으로위잔여량을측정하여평가해야한다. 지속주입을공급받는환자는매 4시간마다, 간헐주입을공급받는환자는매급식전에위잔여량을측정하여 150-250 ml 이상이면부적응증상등평가가필요하다 [20-22]. 또한역류에의한흡인을감소시키기위해서는영양액의지속적주입방법을택하거나비위장급식보다는소장급식을시행하는것이권장된다 [23]. 그러나최근의연구결과에서는정기적인잔여위내용물을확인 (gastric volume monitoring) 하는것은 VAP의발생률에큰차이를보이지않으며 [24], 오히려적절한영양공급에방해가될수있다고보고하고있다 [20,25,26]. 때문에역류나저류등이의심되는환자에한해서선택적으로위내용물을확인하는것을고려하는것이좋을듯하다. Silver-coated endotracheal tube가 VAP의발생을감소시킬수있다는연구결과중 NASCENT study 는 silver-coated tube 가대조군에비하여유의한미생물학적으로확진된 VAP의비율과 VAP이발생하기까지의기간의감소를보였다 [27]. 그러나기관삽관기간이나중환자실재원기간, 그리고사망률에는유의한차이를보이지않았다. 기타스트레스상황에서적절한용량의 glucocorticoid가 HAP의발생을예방할수방법이라고제안된이후, 중증외상환자를대상으로한연구에서적절한 hydrocortisone을투여받은군에서대조군에비해 HAP에발생이낮은결과를보였고 (hazard ratio 0/47, 95% CI 0.25-0.86) [28], 기계호흡의기간과저나트륨혈증의발생을감소시켰으나사망률에서는큰차이를보이지않았다. 그러나외상성뇌손상환자들을대상으로한다른연구에서는 HAP의발생을줄이지못했고오히려사망률을증가시킨다는결과도있어향후이에대한대규모연구가필요하리라사료된다. 앞에서언급한것처럼 VAP의예방을위해서는포괄적이고통합적인환자관리가필요한데이러한방법으로묶음전략 (bundle approach) 을시행하고있다. Berenholtz 등 [29] 이제시한기계환기치료묶음 (ventilator bundle) 은침상머리올리기, 매일진정과기계환기이탈시도 (spontaneous awakening trial, SAT/spontaneous breathing trial, SBT), 스트레스궤양의예방, 심부정맥혈전의예방등다섯가지항목을포함하고있다. 이러한묶음전략이후 112개의중환자실에서 550,800일동안의기계환기기간동안 VAP의발생이현저히감소하였다 (5.5 cases to 0 cases/1,000 ventilator-days). 이외에도손위생, 위생장갑과위생가운의착용, 침상머리올리기, chlorhexidine 을이용한구강위생, 기관내튜브커프의압력조절 (> 20 cm H 2O), 경비관보다는경구를이용한영양공급튜브, 잔여위내용물확인, 불필요한기도흡인삼가등여덟가지항목으로이루어진묶음치료로 VAP의발생을줄였다는연구도있다 (23 to 13 VAP episodes/1,000 ventilator days) [30]. 그러나이러한치료묶음의효과에대해서는단순히 bundle 시행전 후의결과를비교한관찰연구라는한계가있어예방효과에대한결정적인효과라는데에는아직불충분하다고볼수있다 [26]. VAP의예방을위해서는이밖에도매일진정제투여를중단하고, 자발호흡및발관을시도함으로써기계호흡기간을최소화하고발관후재삽관을줄이고필요한경우비침습적환기 (non-invasive ventilation) 를시도해보는것이권장되며열-습기교환기 (heat moisture exchanger) 의사용, 적절한중환자실의인력, Polyurethane 재질의커프가있는튜브사용등을시도해볼수있겠다. 그러나잦은인공호흡기회로 (circuit) 의교체나조기 tracheostomy, 흉부물리치료등은추천되지않는다 [31]. 인공호흡기연관폐렴의치료적절한초기항균제투여는 VAP을비롯한 HAP의생존율을향상시키며부적절한항균제는반대로높은사망률과관련이있으므로 [32-34] 원칙적으로는초기의경험적항생제는가능성있는인공호흡기연관폐렴의주요원인균주에대하여모두효과적이어야만한다. 그러나앞서언급한바와같이인공호흡기연관폐렴에대한확실한진단이쉽지않기때문에확진이전에임상적의심만으로치료를시작한경우에는중복감염 (superinfection) 이나항균제의독성, 그리고향후내성균출현의위험성이따른다. 따라서경험적항균제투여후 48-72시간이지난뒤에는환자의임상상태와검사실결과를종합하여항균제변경이나중단등을고려하여야한다. 의료시설관련폐렴 (healthcare-associated pneumonia, HCAP) 이나 HAP의경우에서처럼임상적으로 VAP이의심되어항 - 540 -
- 박승용외 1 인. 인공호흡기연관폐렴의예방과치료 - 균제투여를결정하였다면경험적항균제선택에있어다제내성균에대한위험도를평가하여야한다. 일반적으로다제내성균에의한폐렴의위험성이높은환자측인자로는 1) 최근 90일이내항균제를투여받은경우, 2) 최근 5일이상입원하였거나, 3) 그지역사회나특정병원에서항균제내성빈도가높은경우, 4) 면역력이저하된자나혹은면역억제치료를받고있는경우, 5) 최근 90일이내에 2일이상입원치료를받은경험이있거나장기요양시설수용자, 항균제를포함한자가치료를받은경우, 최근 30일이내에혈액투석이나창상치료를받은경우와같은여러위험인자를가진경우이다. 또한중증의만성기저질환이있는환자의경우에도다제내성균의위험도는높아진다 [12]. 미국에서시행된 24개의연구에서보고된인공호흡기연관폐렴의주요원인균주로는 Pseudomonas aeruginosa가가장많았으며 (24%), 그뒤로 Staphylococcus aureus가 20% 를보였다 [1]. 그외에 Enterobacteriaceae 14%, Hemophilus spp. 10%, Strepcoccus spp. 8%, Acinetobacter spp. 8% 순이었다. 그러나이러한분포는인공호흡기연관폐렴의발생시점에따라다소차이를보였다 (Table 3). 또한아시아국가를대상으로한연구에서는 Acinetobacter spp. 의빈도가아주높으며 (16-38%), S. aureus의경우대부분메티실린내성균 (methicillinresistant S. aureus, MRSA) 으로서구에비해내성균의빈도가상대적으로높은것으로보고되고있다 [35]. 우리나라의전국병원감염감시체계 (Korean Nosocomial Infection Surveillance System, KONIS) 자료에따르면 S. aureus 가 39% 로가장빈도가높고, A. baumanii 22%, K. pneumoniae 11%, P. aeruginosa 10% 정도로보고되고있으나이역시인공호흡기연관폐렴의진단기준이다양하며병원마다또한중환자실마다가지고있는각각의특성과최근항균제치료를받았던환자의분포와같은지역적특성에영향을받기때문에항균제치료에있어서는지역적, 센터별특정감수성 패턴을감안하여적절한초기항균제를선택하는것이매우중요하다 [36]. 다제내성의위험성이높지않은경우에는지역사회획득폐렴에서처럼원인이될만한주요원인균에대한항균제로 ceftriaxone 또는 respiratory fluoroquinolones, Ampicillin/sulbactam 또는 ertapenem과같은항균제중한가지를선택하여단독으로우선투여한다. 그러나다제내성균의위험성이있는경우에는광범위, 복합항균제로시작하여야하고이후배양검사및감수성검사결과에따라항균제범위를좁혀나가야한다. 다제내성균인 P. aeruginosa, K. pneumoniae, Acinetobacter spp. 에대해서는 antipseudomonal cephalosporin (cefepime, ceftazidime) 또는 antipseudomonal carbepenem (imipenem 또는 meropenem) 또는 ß-Lactam/ß-lactamase inhibitor (piperacillin-tazobactam) 에 antipseudomonal fluoroquinolone (ciprofloxacin 또는 levofloxacin) 또는 aminoglycoside (amikacin, gentamicin 또는 tobramycin) 를병합하고, 만약 MRSA가흔한병원감염균이라면 linezolid 또는 vancomycin 을반드시추가하여야한다 (Table 4). 항균제의치료기간은일반적으로임상적반응에따라달라진다. 프랑스에서시행된대규모전향적무작위비교연구에서적절한초기경험적항생제치료를받은인공호흡기연관폐렴의경우 8일단기치료와 15일장기치료간에사망률, 기계환기기간및중환자실체류기간에서차이가없었다 [37]. 또한항생제사용기간이짧은군에서다제내성균의발생빈도가더욱낮게보고되었다. 때문에과거인공호흡기연관폐렴의경우최소 14-21일동안치료할것이권장되었으나 [38] 최근의추세는치료효과는물론안전성등에문제가없고새로운내성균의출현을염려하여단기간인 7-10일정도를추천한다 [12]. 그러나 P. aeruginosa, A. baumanii, S. maltophilia 같은유당비분해 (nonfermenting) 그람음성균의경우에는단기간의치료군에서재발률이의미있게높아이러한경우에는보다장기간의치료가필요할것으로사료된다. Table 3. Classification of ventilator-associated pneumonia Early onset: developed within < 5 days Late onset: developed within 5 days Antibiotic sensitive bacteria Multidrug-resistant (MDR) pathogens Strepcoccus pneumoniae Pseudomonas aeruginosa Hemophilus influenzie Acinetobacter spp. Staphylococcus aureus Methicillin-resistant S. aureus Better prognosis Associated increased mortality and morbidity - 541 -
- The Korean Journal of Medicine: Vol. 86, No. 5, 2014 - Table 4. Recommendations for initial, broad-spectrum, empiric therapy for MDR pathogens Potential MDR pathogens Initial, broad-spectrum, combination antibiotic therapy MDR G (-) bacilli P.aeruginosa K.pneumoniae E.coli ESBL (+) K.pneumoniae Acinetobacter species Non-MDR G (-) bacilli L.pneumophilia MDR G (+) cocci MRSA Anti-pseudomonal cephalosporin (cefepime, ceftazidime) Anti-pseudomonal carbapenem (imipenem or meropenem) Anti-pseudomonal penicillin (piperacillin-tazobactam) Plus Anti-pseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) Aminoglycoside (amikacin, gentamicin, or tobramycin) Carbapenem Carbapenem + Aminoglycoside Fluoroquinolone (ciprofloxacin or levofloxacin) Macrolide (azithromycin) Add linezolid or vancomycin (if MRSA is suspected or there is a high incidence locally) Figure 1. Recommendations for assessing response to initial antibiotic therapy as well as its de-escalation and termination. 약제내성균들의출현을낮추기위해서는경험적항균제투여후에는초기항균제시작 72시간후환자상태를평가하여항균제를중단하거나또는배양및감수성검사에근거하여점감하여항균제노출을최소화하여야한다 (Fig. 1). 폐렴의원인균이동정된경우감수성결과에맞게항균제를점감 (de-escalation) 하여총 7일간유지하고 P. aeruginosa 등그람음성균이동정되었다면총 15일이상유지할것을권장한다 [38]. 만약임상적으로는호전되었으나원인균이규명되지못한경우에는 Pseudomonas spp. 와 MRSA 에대한항균제를중단하여항균범위가좁은항균제로유지하고 72시간후 에도임상적으로호전이없으면서내성균이동정된경우에는배양및감수성결과에따라항균제를변경하면서폐외의다른감염원이나감별해야할다른질환은없는지, 폐렴의합병증이생겼는지등에대한평가가필요하며같은종류의항균제중보다폐조직에대한투과력이좋은항생제로의교체를고려한다 MRSA 의표준치료요법으로흔히사용되는 vancomycin, linezolid, teicoplanin 중어느것이치료효과에있어월등히우월하다는연구결과는없는실정이다 [39-43]. 때문에 2005년 ATS/IDSA 지침서나 2011년 IDSA 지침서에서 MRSA 감염에대해 linezolid 혹은 vancomycin을모두권고하고있다. Vancomycin을사용하는경우최저혈중농도 (trough level) 는 14-20 mcg/ml 를유지하도록추천하고있으며, 신기능장애 (renal insufficiency) 가우려되거나 vancomycin MIC > 2 mcg/ml의경우에는초기치료로 linezolid 사용을고려한다 [12,44]. 최근발표된 ATTAIN study [45] 결과를토대로미국식품의약국 (Food and Drug Administration, FDA) 에서승인된 telavancin의경우에는 vancomycin에비하여치료율은높으나, 신장기능이저하된 (Creatinine clearance < 50 ml/min) 환자의경우에는오히려 vancomycin 치료군에비하여사망률이높았다. 때문에기존의 MRSA 감염치료제를사용할수없거나사용함에도불구하고효과가미미한경우에만사용하도록추천하고 - 542 -
- Seung Yong Park, et al. Prevention and management of VAP - 있다. 이밖에도 tigecycline, daptomycin, quinupristin-dalfopristin, ceftaroline 등 MRSA infection에효과가입증된약제들이있으나, 아직까지 MRSA 로인한 HAP (VAP 포함 ) 의치료제로는추천되고있지않다 [46-51]. Extended-spectrum β-lactamase (ESBL) 양성 K. pneumoniae와 Acinetobacter spp. 에대해서는 3세대 cephalosporin 단독사용은피해야한다. 이러한경우 carbapenem이우선적으로추천되는데, 임상에서는흔히 fluoroquinolone이나 aminoglycoside 병합요법을사용하지만실제로는 carbapenem 단독요법에비해뛰어나다는연구결과는아직까지없는실정이다 [52,53]. 미국 FDA 는 VAP의치료에있어 carbapenem 중의하나인 doripenem 의사용을경고한바있다. 다른 carbapenem 계열약물에비해서 doripenem의높은항녹농균효과에도불구하고 doripenem군이 imipenem 군에비해 28일사망률이현저하게높고 (23% vs. 17%), 임상적인호전도낮아연구가조기종료된한무작위연구결과 [54] 에기초하고있는데, 이는두군간에약제의투여기간등방법에차이가있고조기에중단한 doripenem 종료후재발혹은재감염이되었을가능성등을배제할수없으며, aminoglycoside 병합치료등의기타혼란요소 (confounding factor) 가영향을미쳤을수도있다는점을고려할필요가있다. 앞에서언급한균주이외에도최근에는 colistin, tigecycline과일부 aminoglycoside에만감수성이있는광범위내성 (extensively drug-resistant, XDR) 그람음성균주들의빈도가점점증가되고있어이들에대한치료와예방에대한많은관심이필요할것으로사료된다. 결론인공적기계환기는급 만성호흡부전과급성호흡곤란증후군환자의치료에기본적인처치임에도불구하고기계환기자체로인한기계환기유발폐손상 (ventilator-induced lung injury) 외에도인공호흡기연관폐렴이동반될수있다. 이는중환자실환자의사망률과이환율의증가와직접적인관련이있는문제이다. 때문에기계환기중인환자에대해서는항상인공호흡기연관폐렴의예방을위한적극적인노력과 VAP 발생을고려하고, 발생한경우에있어서는센터별특성에맞는항균제를조기에투여함은물론면밀하게임상경과를관찰하고조기에폐렴의원인균이동정된경우감수성결과에맞게항균제로점감하여내성균의출현을최소화 하여야한다. 중심단어 : 인공호흡기연관폐렴 ; 예방 ; 치료 REFERENCES 1. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867-903. 2. Fagon JY, Chastre J, Hance AJ, et al. Detection of nosocomial lung infection in ventilated patients: use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis 1988;138:110-116. 3. Paterson DL. The epidemiological profile of infections with multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species. Clin Infect Dis 2006;43(Suppl 2):S43-48. 4. Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986;133:792-796. 5. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004; 32:1396-1405. 6. Shorr AF, Sherner JH, Jackson WL, Kollef MH. Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2005;33:46-53. 7. Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006;355:2619-2630. 8. Centers for Disease Control and Prevention (CDC). National Healthcare Safety Network. CDC Atlantan GA, [Internet]. CDC, c2014 [cited 2014 January 6], Available from: HYPERLINK www.cdc.gov/nhsn/pdfs/pscmanual/ 6pscVAPcurrent.pdf. 9. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA 2007;297:1583-1593. 10. Schurink CA, Van Nieuwenhoven CA, Jacobs JA, et al. Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability. Intensive Care Med 2004;30:217-224. 11. Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin Infect Dis 2010;51(Suppl 1): S131-135. 12. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171: 388-416. 13. Kollef MH. The prevention of ventilator-associated pneu- - 543 -
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