某医院临床鲍曼不动杆菌耐药性调查与抗菌药物使用分析

发布时间：2018-01-08 04:22

本文关键词：某医院临床鲍曼不动杆菌耐药性调查与抗菌药物使用分析　出处：《中国人民解放军军事医学科学院》2017年硕士论文　论文类型：学位论文

【摘要】：鲍曼不动杆菌(Acinetobacter baumannii,AB)属于非发酵革兰阴性杆菌,广泛存在于自然界的水及土壤中,同时在医院环境与人体皮肤、呼吸道、消化道和泌尿道也可检测到,属于条件致病菌。该菌在医院环境中分布很广并可以长期存活,是医院感染最常见病原体之一,主要引起呼吸道感染,也可引发泌尿系感染、菌血症、手术部位感染、继发性脑膜炎等。近年来其对常用抗菌药物的耐药性呈现快速上升趋势,引起临床医生和和公共卫生专家的密切关注。AB极易出现多重耐药成为多重耐药鲍曼不动杆菌(Multidrug-resistant Acinetobacter baumannii,MDR-AB),而且耐药株的检出率不断增加,给临床治疗带来了较大困难。合理的选择抗菌药物进行针对性治疗,对改善感染患者预后具有重要意义。目前国内外针对AB开展的多是流行传播规律及监测研究,对医院内针对MDR-AB治疗的抗菌药物使用的现状和临床意义关注不多;有部分研究关注了MDR-AB所致菌血症患者的预后和影响因素,而对MDR-AB所致呼吸道感染以及抗菌药物治疗效果评价相关研究较少,尤其缺乏抗菌药物使用对MDR-AB感染患者临床结局影响方面的研究。针对上述问题,我们进行了两个部分研究:一.临床分离鲍曼不动杆菌抗菌药物耐药性的调查分析为了解鲍曼不动杆菌目前的感染现状,首先于2014年对北京某三甲医院进行了一次现患率调查,结果显示,调查日当天实际调查1447例患者,实查率为100.00%;医院感染患者87例,现患率为6.01%;87例医院感染病例中,发生下呼吸道感染45例,占总感染例数的51.72%;引起感染的病原菌中,鲍曼不动杆菌的检出率为6.00%。由此横断面调查结果我们了解到了医院感染类型中下呼吸道感染占医院感染的比重较大,鲍曼不动杆菌是引起感染的病原菌之一。进一步我们对该三甲医院2007年至2013年从痰液、肺泡灌洗液、血液、伤口、脓液、尿液等标本中分离鉴定出的鲍曼不动杆菌数据进行了系统回顾性分析,主要包括不同科室的AB检出率、重症监护病房、呼吸内科及神经内科三个重点科室的抗菌药物的耐药性变化等。结果显示,这三个科室收治患者中重症及危重患者居多,AB分离率从2007年至2013年呈现上升趋势,其中重症监护病房的检出率呈明显上升态势,而AB对抗菌药物的耐药性变化趋势在重症监护病房表现为逐年增高。另一方面,本研究还发现在呼吸内科与神经内科这类收治中重度患者较多的科室中,AB的分离率低于重症监护病房,但总体仍然呈现上升态势,可见AB已成为医院感染的重要病原菌,需要临床引起高度注意。另外,该医院临床分离的AB对碳青霉烯类、头孢菌素类和青霉素类等抗菌药物的耐药性均呈显著上升趋势,其中对碳青霉烯类药物的耐药性在2012年、2013年均已高于80.00%;氟喹诺酮类和氨基糖苷类抗菌药物的耐药率也呈上升趋势,而对头孢哌酮/舒巴坦的耐药率相对较低。二.多重耐药鲍曼不动杆菌致呼吸道感染抗菌药物使用分析于2013年至2015年对该三甲医院MDR-AB所致呼吸道感染的抗菌药物使用情况进行比较分析。对临床送检的呼吸道标本(痰及肺泡灌洗液)共计2488例进行普通细菌培养,对其中培养AB阳性患者病例依据肺炎和呼吸机相关肺炎(ventilator-associated pneumonia,VAP)的诊断标准及病例纳入排除标准进行筛选,最终筛选出呼吸道感染病例702例;收集入选病例的流行病学信息,根据其体外药物敏感性检测结果分为MDR-AB组和非MDR-AB组,再分别对两组的临床死亡率进行统计学比较,并进一步分析治疗鲍曼不动杆菌感染所使用的抗菌药物情况,并将临床治疗效果分为痊愈、显效、进步及无效四类,对不同抗菌药物使用方案的临床治疗效果及相关危险因素进行MDR-AB组和非MDR-AB组两组的比较分析。研究结果显示,MDR-AB组在患者出院时、感染14天、感染30天的死亡率均明显高于非MDR-AB组。以2015年为例,MDR-AB组出院时的死亡率为46.22%,感染14天时的死亡率为39.49%,感染30天时的死亡率为41.17%,均高于非MDR-AB组的32.08%、22.64%、29.56%,两组比较P值依次为0.011、0.002、0.030,P值均0.05,存在统计学差异。治疗MDR-AB呼吸道感染(包括肺炎及VAP)的抗菌药物以碳青霉烯类中的亚胺培南使用率为最多,可高达47.32%;抗菌药物使用效果评估比较中发现,非MDR-AB组的临床有效率均略高于MDR-AB组,碳青霉烯类药物非MDR-AB组有效率为74.04%,高于MDR-AB组57.89%,比较分析P值小于0.001,具有统计学意义。也不排除可能原因是非MDR-AB组感染症状可能相对较轻,需进一步探索研究。同时对于抗菌药物使用情况,我们又分单药治疗和联合用药治疗进行分析比较,结果表明MDR-AB组碳青霉烯类有效率为57.89%,非MDR-AB组为74.04%,存在统计学差异。两个组的联合用药的有效率均略高于单药治疗,其中碳青霉烯类联合使用加β-内酰胺酶抑制剂青霉素类抗菌药物两组的有效率75.00%和80.00%,均略高于单用碳青霉烯类的有效率的57.89%和74.04%。另外,AB致呼吸道感染患者中男性占70.23%,且MDR-AB组和非MDR-AB组性别分布的差异有统计学意义(P=0.020);年龄60岁以上患者居多,但两组比较分析不存在统计学差异。另外,两组的呼吸机使用率亦不存在统计学差异。综上所述,本研究在对某三甲医院临床分离的鲍曼不动杆菌的抗菌药物耐药性回顾调查分析中发现了呼吸道感染是医院感染发生率最高的感染类型,且AB检出率逐年增多,对许多常用抗菌药物的耐药性也呈逐年上升趋势;MDR-AB呼吸道感染患者的死亡率明显高于非MDR-AB组,临床应引起高度重视,防止多重耐药菌产生与传播;另外,治疗使用抗菌药物临床有效率联合用药方案略优于单药治疗;主要危险因素调查中两组比较分析中发现仅患者性别分布存在统计学差异,患者年龄及呼吸机使用数量两组间不存在统计学差异。通过本研究,我们对AB菌的抗菌药物耐药性变化有了进一步的了解,更为重要的是我们从临床抗菌药物使用效果的角度,对我国临床应对MDR-AB感染的抗菌治疗的实际效果有了较为深入的研究和认识,这为医院内MDR-AB的感染防控及抗菌药物合理使用提供了一定的数据支持。
[Abstract]:Bauman Acinetobacter (Acinetobacter baumannii AB) belongs to non fermentative gram negative bacilli, water and soil widely exists in the nature, at the same time in the hospital environment and human respiratory tract, skin, digestive tract and urinary tract can also be detected, which belongs to the conditional pathogenic bacteria. The bacteria are widely distributed in the hospital and can survive for a long time in the environment, is the most common pathogen of nosocomial infection, cause respiratory tract infection, also can cause urinary tract infections, bacteremia, surgical site infection, secondary meningitis. In recent years, the drug resistance to antimicrobial drugs increased rapidly, causing public health experts and clinicians pay close attention to the.AB can easily become the emergence of multi drug resistance multi drug resistant Acinetobacter Bauman (Multidrug-resistant Acinetobacter, baumannii, MDR-AB), and the detection rate of resistant strains increased, to bring greater clinical treatment Difficult. Reasonable selection of antibiotics for targeted therapy, has important significance on the prognosis of patients with the infection improved. At home and abroad for the AB to carry out more research of popular propagation law and monitoring, to the hospital for treatment of attention MDR-AB antimicrobial drug use status and clinical significance of not much; some research focuses on factors and prognosis effect of MDR-AB induced bacteremia patients, while the MDR-AB of respiratory tract infections and antimicrobial treatment effect evaluation research, especially the lack of the antibacterial effect of MDR-AB infection in the clinical outcome of patients with the use of drugs. To solve these problems, we conducted two part of the study: 1. Clinical isolates of Bauman real investigation of antimicrobial resistance. The analysis in order to understand the current status of the real Bauman coli infection, first in 2014 in a hospital in Beijing had a prevalence rate The survey results show that, on the day of the actual survey to investigate 1447 patients, the actual investigation rate was 100%; 87 cases of patients with nosocomial infection, prevalence rate was 6.01%; 87 cases of nosocomial infection occurred in 45 cases of lower respiratory tract infection, the total number of 51.72% cases of infection; pathogen infection, Bauman does not move coli detection rate was 6.00%. this cross-sectional survey we learned that the hospital infection type of lower respiratory tract infection accounted for a larger proportion of hospital infection, Bauman Acinetobacter is one of pathogenic bacteria infection. We further to the hospital from 2007 to 2013 from the sputum, bronchoalveolar lavage fluid, blood, wound pus, urine, etc. were isolated from Bauman Acinetobacter data were summarized retrospectively, including the detection rate of the different sections of the AB, ICU, respiratory medicine and antibiotics of Neurology three key departments The change of resistance. The results showed that the majority of patients with severe and critical sections of the three treated patients, the isolation rate of AB showed a rising trend from 2007 to 2013, the detection rate showed a rising trend in the ICU, and the trend of drug resistance to antimicrobial agents AB in ICU for another increased year by year. The study also found that, in the Department of respiratory medicine and neurology department of the hospital in severe patients more sections, the separation rate of AB is lower than that of ICU, but overall still rising trend, visible AB has become an important pathogen of nosocomial infection, the clinical need high attention. In addition, the hospital clinical isolates of AB to carbopenems, cephalosporins and penicillin and other antibiotics drug resistance increased significantly, which of carbapenem resistance in 2012, 2013 years has been More than 80%; fluoroquinolones and aminoglycosides antibiotics also showed an upward trend, while the Cefoperazone / sulbactam is relatively low. Two. Multi drug resistant Acinetobacter Bauman respiratory tract infection caused by use of antibiotics in 2013 to 2015 in the hospital MDR-AB respiratory tract infection caused by the use of antibacterial drugs to compare the analysis of clinical inspection. Respiratory tract samples (sputum and bronchoalveolar lavage fluid) a total of 2488 cases of common bacterial culture, the culture were AB positive patients according to pneumonia and ventilator-associated pneumonia (ventilator-associated pneumonia, VAP) of the diagnostic criteria and inclusion and exclusion criteria were screened and screened 702 cases of respiratory tract infection epidemiology; information collection of selected cases, according to the in vitro drug sensitivity test results were divided into MDR-AB group and non MDR-AB group. On two groups of clinical mortality were compared, and further analysis of the treatment of Bauman real used bacillus infection of antibiotics, and the clinical effect is divided into cured, markedly effective, and four ineffective progress, clinical therapeutic effect of different antibacterial use and related risk factors of MDR-AB group and non MDR-AB group of two groups were compared and analyzed. The results showed that in the MDR-AB group of patients were discharged, 14 days of infection, infection in 30 day mortality rates were significantly higher than non MDR-AB group. In 2015 for example, the MDR-AB groups of the hospital mortality rate was 46.22%, the infection 14 day mortality rate was 39.49%, the mortality rate of infection for 30 days 41.17%, were higher than those in non MDR-AB group 32.08%, 22.64%, 29.56%, P values were compared between the two groups of 0.011,0.002,0.030, P value was 0.05, there was no significant difference. The treatment of MDR-AB infection of the respiratory tract (including pneumonia and VAP) antibacterial drugs Carbapenems imipenem in use was the most, up to 47.32%; comparison of antibacterial drug use evaluation found in clinical effect, the effective rate of group MDR-AB was higher than that of group MDR-AB, carbapenem non MDR-AB group was 74.04%, higher than 57.89% in group MDR-AB, the P value is less than 0.001 compared the analysis, with statistical significance. It does not exclude the possibility of reason is the non MDR-AB group, symptoms of infection may be relatively minor, need further exploration and research. At the same time for the use of antibacterial drugs, we divided the monotherapy and combination therapy were analyzed and compared, the results show that the MDR-AB group carbopenems rate was 57.89%, non MDR-AB group 74.04%, there was a significant difference between the two groups. The effective rate of combined treatment was slightly higher than the single drug treatment, including carbapenems combined with beta lactamase inhibitor penicillin antibiotics for two groups of effective The rate of 75% and 80%, were slightly higher than that of single 74.04%. with 57.89% and the efficiency of the carbapenems in male patients accounted for 70.23% of respiratory tract infection caused by AB, and there was significant in MDR-AB group and non MDR-AB group differences in gender distribution (P=0.020); the majority of patients over the age of 60, but the two group comparative analysis there was a significant difference between the two groups. In addition, ventilator utilization is not statistically significant. In summary, the study of antimicrobial resistance of Acinetobacter retrospective investigation and analysis were found in respiratory tract infection is the nosocomial infection rate was the highest in the type of infection in clinical isolates in a hospital in Bauman, and the detection rate of AB increased year by year. There was an increasing trend for many commonly used antimicrobial drug resistance; MDR-AB group was significantly higher than that of non MDR-AB mortality in patients with respiratory tract infection, clinical should attach great importance to prevent production of multi drug resistant bacteria Life and communication; in addition, the treatment efficiency of clinical use of antibiotics combination regimens is slightly better than that of single drug treatment; investigation of major risk factors in the two groups there were significant differences found in the analysis only gender distribution, age and the number of patients using ventilator between the two groups there is no significant difference. Through this study, we AB bacteria the drug resistance changes with the further understanding of the more important is that we use of antibacterial drugs from the clinical point of view, the study and understanding deeply the actual effect of antibiotic treatment in our clinical response to MDR-AB infection, which provides the data support for the rational use of prevention and control of hospital infection in MDR-AB and antibiotics.

【学位授予单位】：中国人民解放军军事医学科学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R446.5

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