血流感染病原菌耐药性和血流感染预后分析

doi:10.3969/j.issn.1004-583X.2021.08.010

摘要/Abstract

摘要：

目的研究重症医学科(ICU)内血流感染病原菌耐药性,分析血流感染预后的影响因素,为早期抗菌治疗提供参考。方法采用回顾性研究方法统计2014年1月至2020年12月清华大学附属垂杨柳医院ICU确诊为血流感染患者的临床资料,对血培养阳性病原菌构成特点及耐药情况进行分析。根据住院期间存活和死亡,分为存活组和非存活组,收集性别、年龄、是否医院感染、基础疾病、血培养阳性报警时间、血流感染发生时间等,将单变量分析中差异有统计学意义的因素纳入Logistic回归分析,进一步分析影响患者预后的因素。结果病例资料完整的血流感染患者80例,共分离出病原菌84株。血流感染病原菌依次为凝固酶阴性葡萄球菌、金黄色葡萄球菌、大肠埃希菌、不动杆菌、肺炎克雷伯菌。67.86%病原菌为多重耐药菌株。未发现对万古霉素、利奈唑胺、替考拉宁耐药革兰阳性菌株。产ESBLs肺炎克雷伯菌和大肠埃希菌对头孢噻肟、头孢吡肟、氨曲南、环丙沙星、左氧氟沙星、莫西沙星、四环素、氯霉素耐药率高。单因素分析显示,血培养同时生长2种致病菌与血流感染预后有关(P<0.05),多因素Logistic回归分析未发现与血流感染预后相关的危险因素。结论不同地区和医院,血流感染病原菌分布差异较大,本院ICU血流感染病原菌以革兰阳性菌为主,主要为耐甲氧西林葡萄球菌。重症患者血流感染病情复杂,影响预后因素较多,需要大样本、多中心研究。

关键词: 血流感染, 血培养, 病原菌, 耐药

Abstract:

Objective To study the pathogenic bacteria resistance in patients with bloodstream infections in intensive care unit(ICU), to analyze the prognostic factors for bloodstream infection, and to provide references for early antibacterial treatment. Methods Retrospective research method was used to count the clinical data of patients diagnosed with bloodstream infection in the Department of ICU of Chui Yang Liu Hospital Affiliated to Tsinghua University from January 2014 to December 2020, and the constitute and resistance of blood culture-positive pathogens were analyzed. The patients were divided into survival and non-survival groups according to the survival and death during the hospitalization period. The gender, age, hospital infection, underlying disease, time-to-positivity of blood culture, occurrence time of bloodstream infection, etc. were collected. Factors in which the differences were statistically significant in univariate analysis were included in Logistic regression analysis to further analyze the factors affecting patients' prognosis. Results There were 80 cases of bloodstream infection patients with complete case data, and a total of 84 strains of pathogens were isolated. Pathogens of bloodstream infections were coagulase-negative staphylococci, staphylococcus aureus, escherichia coli, acinetobacter, and klebsiella pneumoniae in turn. Pathogens with the percent of 67.86% are multi-drug resistant strains. No gram-positive strains resistant to vancomycin, linezolid and teicoplanin were found. ESBLs-producing Klebsiella pneumoniae and Escherichia coli had high resistance rates to cefotaxime, cefepime, aztreonam, ciprofloxacin, levofloxacin, moxifloxacin, tetracycline, and chloramphenicol. Univariate analysis showed that two pathogenic bacteria simultaneously growing in the blood culture were related to the prognosis of bloodstream infection(P<0.05), and no risk factor related to the prognosis of bloodstream infection was found in multivariate logistic regression analysis.Conclusion The distribution of bloodstream infection pathogens varies greatly in different regions and hospitals. Main pathogens of bloodstream infections in the Department of ICU in this hospital are dominated by Gram-positive bacteria, and its mainly composed methicillin-resistant Staphylococcus. The condition of severely ill patients with bloodstream infection is complex, there are many factors influencing the prognosis, great samples and multicenter studies are required.

Key words: bloodstream infection, blood culture, pathogen, drug resistance

中图分类号:

R519.5

彭振丽, 姜尧, 贾丽娟, 王燕新, 薛唯潇, 史慧婷. 血流感染病原菌耐药性和血流感染预后分析[J]. 临床荟萃, 2021, 36(8): 724-729.

Peng Zhenli, Jiang Yao, Jia Lijuan, Wang Yanxin, Xue Weixiao, Shi Huiting. Analysis of pathogenic bacteria resistance and prognosis of bloodstream infection[J]. Clinical Focus, 2021, 36(8): 724-729.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2021.08.010

https://huicui.hebmu.edu.cn/CN/Y2021/V36/I8/724

图/表 5

参考文献 26

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抗菌药物	MRSA(n=9)		MSSA(n=1)		MRCNS(n=36)		MSCNS(n=4)
抗菌药物	耐药率	敏感率	耐药率	敏感率	耐药率	敏感率	耐药率	敏感率
万古霉素	0	100	0	100	0	100	0	100
替考拉宁	0	100	0	100	0	100	0	100
利奈唑胺	0	100	0	100	0	100	0	100
利福平	44.44	55.56	0	100	11.11	88.89	0	100
环丙沙星	22.22	77.78	0	100	80.56	19.44	25.00	75.00
庆大霉素	12.50	7.78	50.00	50.00	20.00	80.00	75.00	25.00
甲氧苄啶-磺胺甲噁唑	0	100	0	100	33.33	66.667	75.00	25.00
红霉素	11.11	88.89	100	0	100	0	75.00	25.00
克林霉素	66.67	33.33	0	100	30.56	69.44	25.00	75.00
四环素	77.78	22.22	0	100	83.33	91.67	25.00	75.00
青霉素G	100	0	100	0	100	0	100	0
苯唑西林	100	0	0	100	100	0	75.00	25.00

抗菌药物	MRSA(n=9)		MSSA(n=1)		MRCNS(n=36)		MSCNS(n=4)
抗菌药物	耐药率	敏感率	耐药率	敏感率	耐药率	敏感率	耐药率	敏感率
万古霉素	0	100	0	100	0	100	0	100
替考拉宁	0	100	0	100	0	100	0	100
利奈唑胺	0	100	0	100	0	100	0	100
利福平	44.44	55.56	0	100	11.11	88.89	0	100
环丙沙星	22.22	77.78	0	100	80.56	19.44	25.00	75.00
庆大霉素	12.50	7.78	50.00	50.00	20.00	80.00	75.00	25.00
甲氧苄啶-磺胺甲噁唑	0	100	0	100	33.33	66.667	75.00	25.00
红霉素	11.11	88.89	100	0	100	0	75.00	25.00
克林霉素	66.67	33.33	0	100	30.56	69.44	25.00	75.00
四环素	77.78	22.22	0	100	83.33	91.67	25.00	75.00
青霉素G	100	0	100	0	100	0	100	0
苯唑西林	100	0	0	100	100	0	75.00	25.00

抗菌药物	不动杆菌属(n=6)		铜绿假单胞菌(n=3)
抗菌药物	耐药率	敏感率	耐药率	敏感率
阿米卡星	33.33	66.67	0	100
庆大霉素	33.33	66.67	0	100
哌拉西林	33.33	66.67	0	100
哌拉西林-他唑巴坦	33.33	66.67	0	100
氨苄西林-舒巴坦	33.33	66.67	100	0
头孢噻肟	33.33	66.67	100	0
头孢他啶	50.00	50.00	0	100
头孢吡肟	33.33	66.67	33.33	66.67
氨曲南	100	0	33.33	66.67
亚胺培南	33.33	66.67	0	100
美罗培南	33.33	66.67	0	100
环丙沙星	50.00	50.00	0	100
左氧氟沙星	50.00	50.00	33.33	66.67
甲氧苄啶-磺胺甲噁唑	0	100	100	0
多黏菌素B	0	100	0	100

抗菌药物	不动杆菌属(n=6)		铜绿假单胞菌(n=3)
抗菌药物	耐药率	敏感率	耐药率	敏感率
阿米卡星	33.33	66.67	0	100
庆大霉素	33.33	66.67	0	100
哌拉西林	33.33	66.67	0	100
哌拉西林-他唑巴坦	33.33	66.67	0	100
氨苄西林-舒巴坦	33.33	66.67	100	0
头孢噻肟	33.33	66.67	100	0
头孢他啶	50.00	50.00	0	100
头孢吡肟	33.33	66.67	33.33	66.67
氨曲南	100	0	33.33	66.67
亚胺培南	33.33	66.67	0	100
美罗培南	33.33	66.67	0	100
环丙沙星	50.00	50.00	0	100
左氧氟沙星	50.00	50.00	33.33	66.67
甲氧苄啶-磺胺甲噁唑	0	100	100	0
多黏菌素B	0	100	0	100

指标	转归		Z/t/χ²值	P值
指标	好转	死亡	Z/t/χ²值	P值
性别[例(%)]
男女	21(39.6) 32(60.4)	12(44.4) 15(55.6)	0.172	0.679
年龄(岁)	71.79±15.92	77.93±11.04	-1.791	0.077
是否医院获得性感染[例(%)]
否是	13(24.5) 40(75.5)	8(29.6) 19(70.4)	0.240	0.624
院感发生于入ICU前[例(%)]
否是	48(90.6) 5(9.4)	23(85.2) 4(14.8)	0.120	0.729
院感发生于入ICU后[例(%)]
否是	18(34.0) 35(66.0)	12(44.4) 15(55.6)	0.839	0.360
感染部位[例(%)]
导管相关性血行感染	21(39.6)	12(44.4)
实体器官感染	17(32.1)	5(18.5)	3.760	0.289
手术或操作相关	5(9.4)	1(3.7)
原发菌血症	10(18.9)	9(33.3)
基础疾病[例(%)]
无	9(17.0)	6(22.2)
恶性肿瘤	2(3.8)	2(7.4)	1.526	0.679
糖尿病	19(35.8)	7(25.9)
其他	23(43.4)	12(44.4)
机械通气>72 h[例(%)]
否是	21(39.6) 32(60.4)	8(29.6) 19(70.4)	0.773	0.379
留置血管导管[例(%)]
否是	20(37.7) 33(62.3)	6(22.2) 21(77.8)	1.962	0.161
血液净化治疗[例(%)]
否是	42(79.2) 11(20.8)	21(77.8) 6(22.2)	0.023	0.879
手术[例(%)]
否是	32(60.4) 21(39.6)	22(81.5) 5(18.5)	3.632	0.057
同时生长两种菌[例(%)]
否是	53(100.0) 0	23(85.2) 4(14.8)	5.440	0.020
住ICU总天数(d)	17.00(7.00, 30.00)	15.00(7.00, 24.00)	-0.728	0.467
住院天数(d)	30.00(17.50, 50.50)	22.00(12.00, 35.00)	-1.842	0.065
血流感染发生时间(h)	4.00(0.50, 12.00)	3.00(0.00, 10.00)	-1.179	0.239
血培养阳性报警时间(h)	21.39(15.08, 26.50)	20.33(14.33, 30.50)	-0.122	0.903
血培养报警瓶数(瓶)	1.00(1.00, 2.00)	2.00(1.00, 3.00)	-1.803	0.071