Inyumoniya ye-Nosocomial iyisifo esivame kakhulu futhi esibucayi se-nosocomial, lapho inyumoniya ehambisana ne-ventilator (VAP) yenza ama-40%. I-VAP ebangelwa amagciwane e-refractory kuseyinkinga enzima yomtholampilo. Sekuyiminyaka, iziqondiso zitusa ukungenelela okuhlukahlukene (njengokupholisa okuhlosiwe, ukuphakama kwekhanda) ukuvimbela i-VAP, kodwa i-VAP yenzeke ku-40% weziguli ezine-tracheal intubation, okuholela ekuhlaleni isikhathi eside esibhedlela, ukwanda kokusetshenziswa kwama-antibiotics, nokufa. Abantu bahlale befuna izindlela zokuvimbela ezisebenza kangcono.
I-Ventilator-associated pneumonia (VAP) iwukuqala okusha kwenyumoniya eba khona emahoreni angama-48 ngemva kokuthonywa koqhoqhoqho futhi iyisifo esivame kakhulu nesibulalayo se-nosocomial egunjini labagula kakhulu (ICU). I-American Society of Infectious Diseases Guidelines ka-2016 ihlukanise i-VAP encazelweni ye-pneumonia etholwe esibhedlela (HAP) (i-HAP ibhekisela kuphela ku-pneumonia eyenzeka ngemva kokulaliswa esibhedlela ngaphandle kwe-tracheal tube futhi ayihlobene nokungena komoya ngomshini; i-VAP i-pneumonia ngemva kokufaka uqhoqho kanye nokuphefumula umoya), futhi i-European Society ne-HAP iseyi-3 uhlobo lwe-VAP3]
Ezigulini ezithola ukungena komoya ngomshini, izehlakalo ze-VAP zisukela ku-9% ziye ku-27%, izinga lokufa lilinganiselwa ku-13%, futhi kungaholela ekwenyukeni kokusetshenziswa kwama-antibiotic esistimu, ukungena komoya isikhathi eside ngomshini, ukuhlala isikhathi eside kwe-ICU, kanye nezindleko ezikhulayo [4-6]. I-HAP/VAP ezigulini ezingezona i-immunodeficient ngokuvamile ibangelwa ukutheleleka kwebhaktheriya, futhi ukusatshalaliswa kwamagciwane avamile kanye nezici zabo zokumelana kuyahlukahluka ngesifunda, isigaba sasesibhedlela, inani lesiguli, kanye nokuchayeka kwama-antibiotic, nokushintsha ngokuhamba kwesikhathi. I-Pseudomonas aeruginosa yayibusa amagciwane ahlobene ne-VAP eYurophu naseMelika, kuyilapho i-Acinetobacter baumannii eyengeziwe yahlukaniswa yodwa ezibhedlela zemfundo ephakeme e-China. Ingxenye eyodwa kwezintathu kuya kwengxenye yazo zonke ukufa okuhlobene ne-VAP kubangelwa ngokuqondile ukutheleleka, kanti izinga lokufa kwamacala abangelwa i-Pseudomonas aeruginosa kanye ne-acinetobacter ephakeme [7,8].
Ngenxa ye-heterogeneity eqinile ye-VAP, ukucaciswa kokuxilonga kokubonakaliswa kwayo kwemitholampilo, ukuhlolwa kwe-imaging kanye ne-laboratory kuphansi, futhi ububanzi bokuxilongwa okuhlukile bukhulu, okwenza kube nzima ukuxilonga i-VAP ngesikhathi. Ngesikhathi esifanayo, ukumelana namagciwane kubangela inselele enkulu ekwelashweni kwe-VAP. Kulinganiselwa ukuthi ingozi yokuthuthukisa i-VAP ingu-3% ngosuku phakathi nezinsuku zokuqala ezingu-5 zokusebenzisa umoya omncane, u-2% ngosuku phakathi kwezinsuku ezi-5 neziyi-10, kanye no-1% ngosuku kuze kuphele isikhathi. Isigameko esiphezulu ngokuvamile senzeka ngemva kwezinsuku ezingu-7 zokungenisa umoya, ngakho-ke kukhona iwindi lapho ukutheleleka kungavinjelwa khona kusenesikhathi [9,10]. Ucwaningo oluningi luye lwabheka ukuvimbela i-VAP, kodwa naphezu kwamashumi eminyaka yocwaningo kanye nemizamo yokuvimbela i-VAP (njengokugwema ukungena ngaphakathi, ukuvimbela ukuphindaphinda kwe-intubation, ukunciphisa i-sedation, ukuphakamisa ikhanda lombhede ngo-30 ° kuya ku-45 °, nokunakekelwa komlomo), isigameko asibonakali sinciphile futhi umthwalo wezokwelapha ohambisana nawo uhlala uphakeme kakhulu.
Ama-antibiotics ahogelwe asetshenziselwe ukwelapha izifo ezingelapheki endleleni yomoya kusukela ngawo-1940. Ngenxa yokuthi ingakhuphula ukulethwa kwezidakamizwa endaweni okuhloswe ngayo ukutheleleka (okungukuthi endleleni yokuphefumula) futhi yehlise imiphumela emibi yesistimu, ibonise ukubaluleka kokusebenza okuhle ezifweni ezihlukahlukene. Ama-antibiotics ahogelwe manje asegunyazwe yi-US Food and Drug Administration (FDA) kanye ne-European Medicines Agency (EMA) ukuze asetshenziswe ku-cystic fibrosis. Ama-antibiotics aphefumulelwe anganciphisa kakhulu umthwalo webhaktheriya kanye nemvamisa yokwanda kwe-bronchiectasis ngaphandle kokwandisa izenzakalo ezimbi eziphelele, futhi iziqondiso zamanje ziye zazibona njengokwelashwa kokuqala kweziguli ezine-pseudomonas aeruginosa ukutheleleka kanye nokwanda okuvamile; Ama-antibiotics aphefumulelwe ngesikhathi se-perioperative yokufakelwa kwamaphaphu angasetshenziswa njengezidakamizwa ze-adjuvant noma ze-prophylactic [11,12]. Kodwa emiqondisweni ye-VAP ka-2016 yase-US, ochwepheshe babengenakho ukuzethemba ekusebenzeni kwe-adjuvant inhaled antibiotics ngenxa yokuntuleka kokuhlolwa okukhulu okulawulwa ngokungahleliwe. Uhlolo lweSigaba 3 (INHALE) olwanyatheliswa ngo-2020 nalo lwehlulekile ukuthola imiphumela emihle (ukuhogela i-amikacin yasiza ama-antibiotic e-Gram-negative amagciwane okubangelwa iziguli ze-VAP, izimpumputhe eziphindwe kabili, ezingahleliwe, ezilawulwa yi-placebos, isivivinyo sesigaba sesi-3 sokusebenza ngempumelelo, ingqikithi yeziguli ezingama-807, imithi yesistimu + esizwa ukuhogela izinsuku eziyi-10).
Kulo mongo, ithimba eliholwa abacwaningi abavela ku-Regional University Hospital Center of Tours (CHRU) e-France lamukele isu lokucwaninga elihlukile futhi lenza uphenyo oluqalwe ngumphenyi, olugxile ezintweni eziningi, olungaboni kabili, olulawulwa ngokungahleliwe (AMIKINHAL). I-amikacin ehogeliwe noma i-placebo yokuvimbela i-VAP yaqhathaniswa ku-19 icus eFrance [13].
Isamba seziguli ezikhulile ezingama-847 ezinomshini wokungenisa umoya ohlaselayo phakathi kwamahora angama-72 nangama-96 zabelwa ngokungahleliwe u-1:1 ekuhogeleni i-amikacin (N= 417,20 mg/kg isisindo somzimba esifanele, QD) noma ukuhogela i-placebo (N=430, 0.9% okulingana ne-sodium chloride) izinsuku ezi-3. Isiphetho esiyinhloko kwakuyisiqephu sokuqala se-VAP kusukela ekuqaleni komsebenzi ozokwenziwa ngokungahleliwe kuze kube usuku lwama-28.
Imiphumela yocwaningo ibonise ukuthi ezinsukwini ezingu-28, iziguli ezingu-62 (15%) eqenjini le-amikacin zakhiwe i-VAP kanye neziguli ezingu-95 (22%) eqenjini le-placebo zathuthukise i-VAP (umehluko olinganiselwe wokusinda we-VAP kwakuyizinsuku ezingu-1.5; 95% CI, 0.6 ~ 2.5; P = 0.004).
Mayelana nokuphepha, iziguli eziyisikhombisa (1.7%) eqenjini le-amikacin neziguli ezine (0.9%) eqenjini le-placebo zabhekana nezenzakalo ezimbi kakhulu ezihlobene nokuhlolwa. Phakathi kwalabo abangazange babe nokulimala okunamandla kwezinso ngesikhathi se-randomization, iziguli ze-11 (4%) eqenjini le-amikacin kanye neziguli ze-24 (8%) eqenjini le-placebo zazinokulimala kwezinso ezinzima ngosuku lwe-28 (HR, 0.47; 95% CI, 0.23 ~ 0.96).
Ukuhlolwa komtholampilo kube nezinto ezintathu ezibalulekile. Okokuqala, mayelana nomklamo wocwaningo, uhlolo lwe-AMIKINHAL ludonsela ocwaningweni lwe-IASIS (uhlolo olungahleliwe, olungaboni kabili, olulawulwa yi-placebo, oluhambisana nesigaba sesi-2 esibandakanya iziguli eziyi-143). Ukuhlola ukuphepha nokusebenza kwe-amikacin - i-fosfomycin inhalation systemic treatment of gram-negative bacterial infection okubangelwa i-VAP) kanye nokuhlolwa kwe-INHALE ukuze kuphele ngemiphumela engemihle izifundo ezifundiwe, ezigxile ekuvimbeleni i-VAP, futhi kwathola imiphumela emihle uma kuqhathaniswa. Ngenxa yezici zokufa okuphezulu nokuhlala isikhathi eside esibhedlela ezigulini ezinokuphefumula kwemishini kanye ne-VAP, uma i-amikacin inhalation ingafinyelela imiphumela ehluke kakhulu ekunciphiseni ukufa nokuhlala esibhedlela kulezi ziguli, kuyoba usizo kakhulu ekusebenzeni komtholampilo. Kodwa-ke, uma kubhekwa ukuhlukahluka kokwelashwa nokunakekelwa sekwephuzile esigulini ngasinye kanye nesikhungo ngasinye, kunezici eziningi ezididayo ezingaphazamisa ucwaningo, ngakho kungase kube nzima futhi ukuthola umphumela omuhle obangelwa ama-antibiotics ahogelwe. Ngakho-ke, isifundo somtholampilo esiphumelelayo asidingi nje ukuklama okuhle kakhulu kocwaningo, kodwa futhi nokukhethwa kweziphetho ezifanele eziyinhloko.
Okwesibili, nakuba ama-antibiotic e-aminoglycoside enganconywa njengesidakamizwa esisodwa emiqondisweni ehlukahlukene ye-VAP, ama-antibiotic e-aminoglycoside angakwazi ukumboza amagciwane avamile ezigulini ze-VAP (kuhlanganise ne-pseudomonas aeruginosa, i-acinetobacter, njll.), nangenxa yokumuncwa kwawo okulinganiselwe kumaseli e-epithelial yamaphaphu, ukugxila okuphezulu endaweni yesistimu yokutheleleka, nobuthi obuphansi. Ama-antibiotic e-Aminoglycoside athandwa kakhulu phakathi kwama-antibiotics aphefumulelwe. Leli phepha lihambisana nesilinganiso esibanzi sobukhulu bomphumela wokuphathwa kwe-intracheal ye-gentamicin kumasampuli amancane ashicilelwe ngaphambili, okubonisa ngokuhlanganyela umphumela wama-antibiotic e-aminoglycoside ehogeliwe ekuvimbeleni i-VAP. Kufanele futhi kuqashelwe ukuthi izilawuli eziningi ze-placebo ezikhethiwe ocwaningweni oluhlobene nemithi elwa namagciwane ehogeliwe iwusawoti ojwayelekile. Kodwa-ke, uma kucatshangelwa ukuthi ukuhogela okune-athomu kasawoti ovamile ngokwako kungadlala indima ethile ekuhlambululeni isikhwehlela nokusiza i-expectorant, usawoti ovamile ungabangela ukuphazamiseka okuthile ekuhlaziyweni kwemiphumela yocwaningo, okufanele kucatshangelwe ngokugcwele ocwaningweni.
Ngaphezu kwalokho, ukuzijwayeza kwendawo kwemithi ye-HAP/VAP kubalulekile, njengoba kufanele i-antibiotic prophylaxis. Ngesikhathi esifanayo, kungakhathaliseki ubude besikhathi sokufakwa kwe-intubation, i-ecology ye-ICU yendawo iyisici esibaluleke kakhulu sobungozi bokutheleleka ngamabhaktheriya amelana nezidakamizwa eziningi. Ngakho-ke, ukwelashwa okunamandla kufanele kubhekisele kudatha ye-microbiology yezibhedlela zendawo ngangokunokwenzeka, futhi ayikwazi ukubhekisela ngokuphuphuthekile kuzinkombandlela noma ulwazi lwezibhedlela zemfundo ephakeme. Ngesikhathi esifanayo, iziguli ezigula kakhulu ezidinga umoya omncane wemishini zivame ukuhlanganiswa nezifo eziningi zesistimu, futhi ngaphansi kwesenzo esihlangene sezici eziningi ezifana nesimo sokucindezeleka, kungase kube khona isenzakalo se-intestinal microbes crosstalk kuya emaphashini. I-heterogeneity ephezulu yezifo ezibangelwa i-superposition yangaphakathi nangaphandle futhi inquma ukuthi ukukhuthazwa komtholampilo okukhulu kokungenelela okusha kuyindlela ende okufanele yenziwe.
Isikhathi sokuthumela: Dec-02-2023