本篇研究的目標在於分析成人加護病房、呼吸照護中心與呼吸照護病房所整合的呼吸照護系統中的院內感染的發生率、感染部位、致病微生物的種類與其比率。研究的資料來自中台灣某大學附設醫院的醫院院內感染管制監測系統，研究的期間為2003年到2006年，而收案的定義是使用被許多國家採用的美國疾病管制局（Centers for Disease Control and Prevention）的標準與方法。成人加護病房的院內感染發生率（incidence）是14.0/1000 patient-days，呼吸照護中心為10.3/1000 patient-days，而呼吸照護病房為5.0/1000 patient-days。在三個單位中最常見的感染型態分別是泌尿道感染、血流感染與肺炎。在加護病房當中最常被分離培養出來的致病微生物為非發酵性格蘭氏陰性桿菌（nonfermentative gram-negative bacilli, 33.0%）、腸內菌科（Enterobacteriaceae, 26.5%）、念珠菌屬（Candida spp., 18.2%）、金黃色葡萄球菌（Staphylococcus aureus, 8.9%）、凝固酵素陰性葡萄球菌（coagulase-negative Staphylococci, 4.9%）以及腸球菌屬（Enterococci, 4.5%）。雖然呼吸照護中心與呼吸照護病房的院內感染致病微生物的主要種類與加護病房的結果相類似，但是分佈的型態是不一樣的。若是呼吸照護病房與加護病房比較，金黃色葡萄球菌在呼吸照護病房的院內感染比例是高於加護病房（odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7），並且腸球菌屬（OR 2.2; 95% CI, 1.4 to 3.5）與腸內菌科（OR 2.2; 95% CI, 1.7 to 2.8）也是比較容易在呼吸照護病房當中得到。但是凝固酵素陰性葡萄球菌（OR 0.3; 95% CI, 0.1 to 0.8）、非發酵性格蘭氏桿菌（OR 0.5; 95% CI, 0.4 to 0.7）與念珠菌屬（OR 0.2; 95% CI, 0.1 to 0.3）則在呼吸照護病房中的院內感染比例較低。此外，具有抗藥性的細菌在呼吸照護病房當中也相當嚴重的，其中methicillin抗藥性金黃色葡萄球菌（OR 4.9; 95% CI, 1.1 to 22.0）與產生extended-spectrum β-lactamase的腸內菌科（OR 4.1; 95% CI, 2.2 to 7.5）均證實呼吸照護病房比加護病房中更容易得到。這個研究的結果顯示呼吸照護中心的感染型態與致病微生物的分佈是接近加護病房的，但是呼吸照護病房中的院內感染特色是內源性的細菌的浮現以及抗藥性菌種比例的增多，然而感染的密度是在呼吸照護系統中最低且接近一般病房，不過反覆發生的院內感染是被注意到的問題。這也顯示當我們面對在此一呼吸照護系統中的院內感染時，選擇經驗性抗生素療法是受到許多的侷限。

The objectives of this study were to investigates the incidence of nosocomial infections (NIs) and the distribution of resistant nosocomial pathogens in critical and long-term care respiratory care units, including adult intensive care units (ICUs), respiratory care center (RCC) and respiratory care ward (RCW). The Centers for Disease Control and Prevention’s definitions and methods were used to collect the NIs data in adult ICUs, RCC and RCW at an 1100-bed university-affiliated hospital from 2003 to 2006. The overall NI incidences were 14.0, 10.3 and 5.0 per 1000 patient-days for adult ICUs, RCC and RCW, respectively. Urinary tract infections, bloodstream infections and pneumonias most commonly occurred. The frequently reported micro-organisms in adult ICUs were nonfermentative gram-negative bacilli (33.0%), Enterobacteriaceae (26.5%), Candida spp. (18.2%), Staphylococcus aureus (8.9%), coagulase-negative Staphylococci (4.9%) and Enterococci (4.5%). As compared with ICUs patients, RCW patients had a higher proportion of NIs caused by S. aureus (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7), Enterococci ( OR 2.2; 95% CI, 1.4 to 3.5) and Enterobacteriaceae ( OR 2.2; 95% CI, 1.7 to 2.8), at the same time, a lower proportion of coagulase-negative Staphylococci (OR 0.3; 95% CI, 0.1 to 0.8), nonfermentative gram-negative bacilli ( OR 0.5; 95% CI, 0.4 to 0.7) and Candida spp. ( OR 0.2; 95% CI, 0.1 to 0.3). Additionally, RCW patients had higher chances of infection caused by methicillin-resistant S. aureus (OR 4.9; 95% CI, 1.1 to 22.0) and extended-spectrum β-lactamase Enterobacteriaceae (OR 4.1; 95% CI, 2.2 to 7.5) when compared with ICU patients. Limited options for treating RCW patients with NIs have been a challenge due to a high prevalence of multidrug-resistant organisms. These pathogens were often endogenous and associated with decreased host defenses and broad-spectrum antibiotic uses during the period of prior prolonged hospitalization.

目 錄……………………………………………………………………1
中文摘要 ………………………………………………………………3
英文摘要 ………………………………………………………………5
第 壹 章 緒 論………………………………………………………7
第一節前言………………………………………………………………7
第二節 名詞解釋………………………………………………………9
第三節 研究架構………………………………………………………15
第貳章 材料和方法 …………………………………………………18
第一節 研究對象 ……………………………………………………18
第二節 院內感染收案方法 …………………………………………19
第三節 細菌學試驗 …………………………………………………21
第四節 資料分析 ……………………………………………………22
第參章結果……………………………………………………………23
第一節 院內感染率的結果……………………………………………23
第二節 不同院內感染部位所佔比率之比較…………………………24
第三節 各單位病房內的院內感染致病微生物分佈…………………25
第四節 各單位病房院內感染致病微生物的比較……………………28
第五節 院內感染致病微生物之抗藥性………………………………31
第肆章 討論……………………………………………………………34
第一節 院內感染發生率逐步下降但感染率逐步上升………………35
第二節泌尿道感染是最常見的感染部位，其次是血流感染與肺炎…38
第三節 加護病房院內感染致病微生物分佈與國外研究有所不同……39
第四節 呼吸照護中心的院內感染致病微生物分佈相近於加護病房…42
第五節 隨著患者由加護病房下轉至呼吸照護病房而浮現內源性致病微生物的重要性與致病微生物的抗藥性……………………………43
第伍章 結論與建議……………………………………………………47
參考文獻 ………………………………………………………………49
圖表及其他附錄 ………………………………………………………63
表1: 各單位的院內感染發生率………………………………………63
表2：依照感染部位分類之院內感染分佈……………………………64
表3：院內感染致病微生物的分佈……………………………………65
表4：院內感染致病微生物的分佈……………………………………66
表5：各單位病房指標性高抗藥性致病微生物的比較………………67

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