摘要
目的对严重烧伤血流感染患者病原菌分布、耐药性进行分析，为此类患者的临床治疗提供参考。方法收集笔者单位烧伤ICU2011年1月--2014年12月收治的162例严重烧伤（含特重度烧伤120例）血流感染患者的血液标本，采用全自动血培养仪进行病原菌培养，API细菌鉴定板条进行病原菌鉴定。采用K—B纸片扩散法检测主要革兰阴性菌、革兰阳性菌对氨苄西林、哌拉西林、替考拉宁等37种抗生素的耐药情况（万古霉素采用E试验检测），以及真菌对伏立康唑、两性霉素B等5种抗生素的耐药情况。采用改良Hodge试验进一步确认亚胺培南、美罗培南耐药肺炎克雷伯菌，采用D试验检测金黄色葡萄球菌对红霉素诱导克林霉素耐药情况。用WHONET5．5软件统计病原菌分布及常见病原菌耐药率、特重度烧伤患者和非特重度烧伤患者的病死率及感染病原菌种类。对数据行Wilcoxon秩和检验。结果（1）4年中共送检血液标本1658份，检出病原菌339株（20．4％），其中革兰阴性菌、革兰阳性菌、真菌的检出率分别为68．4％（232／339）、24．5％（83／339）、7．1％（24／339）。检出率居于前3位的病原菌从高到低依次为鲍氏不动杆菌、金黄色葡萄球菌和铜绿似单胞菌。（2）鲍氏不动杆菌除对米诺环素和多黏菌素B耐药率较低外，对其余抗生素耐药率均较高，为81．0％-100．0％。铜绿假单胞菌对多黏菌素B不耐药，对其余抗生素的耐药率为57．7％～100．0％。阴沟肠杆菌对亚胺培南、美罗培南不耐药，对环丙沙星、左氧氟沙星、头孢哌酮／舒巴坦、头孢吡肟、哌抟西林／他唑巴坦耐药率为25．0％～49．0％，对其余抗生素耐药率为66．7％～100．0％。肺炎克雷伯菌对头孢哌N／舒巴坦、亚胺培南、美罗培南耐药率低，为5．9％～15．6％（2株亚胺培南及美罗培南耐药株经改良Hodge试验进一步确认）；对阿莫西林／克拉维酸、哌拉西林／他唑巴坦、头孢吡肟、头孢西丁、阿米卡星、左氧氟沙星耐药率为35．3％～47．1％；对其余抗生素耐药率为50．O％～100．0％。（3）抗甲氧西林金黄色葡萄球菌（MRSA）对大部分抗生素的耐药率高于甲氧西林敏感金黄色葡萄球菌（MSSA）。MRSA对利奈唑胺、万古霉素、替考拉宁不耐药，对复方磺胺甲噁唑、克林霉素、米诺环素、红霉素耐药率为5．3％～31．6％，对其余抗生素耐药率为81．6％～100．0％。MSSA菌株除了对青霉素G、四环素完全耐药外，对其余抗生素不耐药。14株金黄色葡萄球菌出现对红霉素诱导克林霉素耐药现象。肠球菌对万古霉素、替考拉宁不耐药；对利奈唑胺、氯霉素、呋喃妥因、高单位庆大霉素耐药率较低，为10．0％～30．0％；对环丙沙星、红霉素、米诺环素、氨苄西林的耐药率较高，为60．0％～80．0％；对利福平完全耐药。（4）真菌对两性霉素B不耐药，对伏立康唑、氟康唑、伊曲康唑、酮康唑的耐药率为7．2％～12．5％。（5）特重度烧伤患者病死率高于非特重度烧伤患者。特重度烧伤患者感染病原菌种类明显多于非特重度烧伤患者（Z=-2．985，P=0．005）。结论严重烧伤血流感染患者病原菌种类广泛，以鲍氏不动杆菌、金黄色葡萄球菌及铜绿假单胞菌为主，且耐药情况严峻。特重度烧伤血流感染患者病原菌种类更为复杂，其病死率高于非特重度烧伤患者。
Objective To analyze the distribution and drug resistance of pathogen isolated from severely burned patients with bloodstream infection, so as to provide reference for the clinical treatment of these patients. Methods Blood samples of 162 severely burned patients （including 120 patients with extremely severe burn） with bloodstream infection admitted into our burn ICU from January 2011 to December 2014 were collected. Pathogens were cultured by fully automatic blood culture system, and API bacteria identification panels were used to identify pathogen. Kirby-Bauer paper disk diffusion method was used to detect the drug resistance of major Gram-negative and -positive bacteria to 37 antibiotics including ampicillin, piperacillin and teicoplanin, etc. （resistance to vancomycin was detected by E test） , and drug resistance of fungi to 5 antibiotics including voriconazole and amphotericin B, etc. Modified Hodge test was used to further identify imipenem and meropenem resistant Klebsiella pneumonia. D test was used to detect erythromycin-induced clindamycin resistant Staphylococcus aureus. The pathogen distribution and drug resistance rate were analyzed by WHONET 5.5. Mortality rate and infected pathogens of patients with extremely severe burn and patients with non-extremely severe burn were recorded. Data were processed with Wilcoxon rank sum test. Results （1） Totally 1 658 blood samples were collected during the four years, and 339 （20.4%） strains of pathogens were isolated. The isolation rate of Gram-negative bacteria, Gram-positive bacteria, and fungi were 68.4% （232/339） , 24.5% （83/339） , and 7. 1% （24/339） , respectively. The top three pathogens with isolation rate from high to low were Acinetobacter baumannii , Staphylococcus aureus , and Pseudomonas aeruginosa in turn. （2） Except for the low drug resistance rate to polymyxin B and minocycline, drug resistance rate ofAcinetobacter baumannii to the other antibiotics were relatively high （81.0% - 100.0% ）. Pseudomonas aeruginosa was sensitive to polymyxin B but highly resistant to other antibiotics （57.7% - 100.0% ）. Enterobaeter cloacae was sensitive to imipenem and meropenem, while its drug resistance rates to eiprofloxacin, levofloxaein, eefoperazone/sulbactam, cefepime, piperacillin/tazobaetam were 25.0% - 49. 0% , and those to the other antibiotics were 66. 7% - 100. 0%. Drug resistance rates of Klebsiella pneumoniae to eefoperazone/sulbaetam, imipenem, and meropenem were low （5.9% - 15.6% , two imipenem- and meropenem-resistant strains were identified by modified Hodge test） , while its drug resistance rates to amoxieillin/clavulanic acid, piperacillin/tazobactam, cefepime, cefoxitin, amikaein, levofloxacin were 35.3% -47.1% , and those to the other antibiotics were 50.0% - 100.0% . （3） Drug resistanee rates of methieillin-resistant Staphylococcus aureus （MRSA） to most of the antibiotics were higher than those of the methicillin-sensitive Staphylococcus aureus （MSSA）. MRSA was sensitive to linezolid, vaneomycin, and teieoplanin, while its drug resistance rates to compound sulfamethoxazole, clindamyein, minocycline, and erythromycin were 5.3% - 31.6% , and those to the other antibiotics were 81.6% - 100.0%. Except for totally resistant to penicillin G and tetracycline, MSSA was sensitive to the other antibiotics. Fourteen Staphylococcus aureus strains were resistant to erythromycin-induced clindamyein. Enterococcus was sensitive to vaneomycin and teicoplanin, while its drug resistance rates to linezolid, chloramphenicol, nitrofurantoin, and high unit gentamiein were low （10.0% -30.0% ） , and those to ciprofloxaein, erythromycin, minocycline, and ampicillin were high （60.0% -80.0% ）. Enterococeus was fully resistant to rifampiein. （4） Fungi was sensitive to amphoteriein B, and drug resistance rates of fungi to voriconazole, fluconazole, itraconazole, and ketoeonazole were 7.2% -12.5%. （5） The mortality of patients with extremely severe burn was higher than that of patients with non-extremely severe burn. The variety of infected pathogens in patients with extremely severe burn significantly outnumbered that in patients with non-extremely severe burn （ Z = - 2. 985, P = 0. 005 ）. Conclusions The variety of pathogen in severely burned patients with bloodstream infection is wide, with the main pathogens as Acinetobacter baumaunii , Staphylococcus aureus , and Pseudomonas aeruginosa , and the drug resistance situation is grim. The types of infected pathogen in patients with extremely severe burn are more complex, and the mortality of these patients is higher when compared with that of patients with non-extremely severe burn.
出处
《中华烧伤杂志》
CAS
CSCD
北大核心
2016年第9期529-535,共7页
Chinese Journal of Burns
基金
国家自然科学基金（81571896）
关键词
烧伤
感染
细菌
真菌
抗药性
Burns
Infection
Bacteria
Fungi
Drug resistance
