上尿路结石术前尿培养细菌谱分析及抗生素的应用

发布时间：2018-03-16 22:44

  本文选题：上尿路结石　切入点：尿培养　出处：《天津医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：背景和目的尿路结石是泌尿系统的常见疾病之一,我国的发病率为1%-5%。随着我国经济的快速发展和饮食结构的改变,我国尿路结石的发病率呈逐年上升的趋势[1]。尿路结石按部位可分为上尿路结石和下尿路结石,其中上尿路结石约占80%。经皮肾镜取石术(PCNL)和输尿管镜碎石术(URSL)已成为上尿路结石的首选治疗方法,明显提高了结石治疗的安全有效性,但术后尿源性脓毒血症仍不能完全避免。国内外诸多报道认为上尿路结石术后由菌血症或脓毒血症等引起的全身炎症反应综合征(SIRS)与尿白细胞含量、手术时间、通道个数、灌洗液用量和输血多少等有关,但针对上尿路结石中段尿培养细菌谱的分析及抗生素应用的相关研究较少。由于抗菌药物的广泛应用和不合理使用,使许多病原菌耐药性越来越高,给临床治疗带来困难。 方法回顾性分析2012年1月～2013年7月期间天津医科大学总医院泌尿外科收治的143例行经尿道输尿管镜或经皮肾镜碎石取石术的上尿路结石患者的临床资料,所有患者术前均行中段尿培养,阳性者58例,且均行抗生素预防性治疗,术后均监测患者体温、心率、呼吸及血白细胞计数等与SIRS有关的指标。分析术前中段尿培养细菌谱及上尿路结石患者抗生素的应用,并运用统计学方法对抗生素使用天数与SIRS的发生等关系进行分析。 结果入组患者143例,58例尿培养阳性患者中,术后出现SIRS者26例,尿培养为革兰氏阴性菌感染45例(77.59%),革兰氏阳性菌感染13例(22.41%),革兰氏阴性菌感染中以大肠埃希菌感染最多,为30例(51.72%),其对多种p-内酰胺酶复合制剂、头孢西丁等抗菌药物的耐药率为3%-10%；革兰氏阳性菌中以粪肠球菌感染最多,为8例(13.79%),其对呋喃妥因和氨苄西林的敏感性分别为100%和87.5%,未发现对万古霉素和替考拉宁耐药的粪肠球菌和屎肠球菌。术前尿培养阳性患者术后发生SIRS的阳性率明显高于术前尿培养阴性的患者(P0.01),差异有统计学意义,针对上尿路结石患者预防性应用抗生素3天术后发生SIRS的阳性率明显高于应用抗生素≥3天的患者(P0.05),差异有统计学意义,女性结石患者和鹿角形结石患者尿培养阳性率相对较高(P0.05),差异有统计学意义。 结论泌尿系统结石合并尿路感染(UTI)十分常见,结石、梗阻和积水是一个相互促进的恶性循环。术前中.段尿细菌培养结果主要以革兰氏阴性杆菌为主,即大肠埃希菌,p-内酰胺酶复合制剂和头孢西丁可用于革兰阴性杆菌的经验性抗菌治疗。粪肠球菌对红霉素、克林霉素、四环素及喹诺酮类耐药率较高,不宜作为上尿路结石合并尿路感染的首选药物。术前中段尿培养阳性和预防性使用抗生素不足3天是感染性休克的危险因素。上尿路结石患者术前进行中段尿培养,且根据药敏结果选用敏感抗生素预防治疗≥3天,对预防取石术后SIRS的发生具有重要意义。
[Abstract]:Background and objective urinary calculi are one of the common diseases in the urinary system. The incidence of urinary calculi in China is 1-5. With the rapid development of our economy and the change of dietary structure, The incidence of urinary calculi in China is increasing year by year [1] .Urolithiasis can be divided into upper urinary calculi and lower urinary calculi according to their location. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL) have become the first choice for the treatment of upper urinary calculi. However, urinary sepsis can not be avoided completely after operation. Many reports at home and abroad believe that the systemic inflammatory response syndrome (SIRSs) caused by bacteremia or sepsis after upper urinary tract calculi is associated with urinary white blood cell content, operation time, and the number of channels. The amount of lavage fluid was related to the amount of blood transfusion, but there were few studies on bacterial spectrum analysis and antibiotic application in the middle part of upper urinary tract stone, due to the extensive use and irrational use of antimicrobial agents. Many pathogens become more and more resistant, which brings difficulties to clinical treatment. Methods the clinical data of 143 patients with upper urinary calculi treated by transurethral ureteroscopy or percutaneous nephrolithotomy from January 2012 to July 2013 in General Hospital of Tianjin Medical University were retrospectively analyzed. All the patients were treated with midstream urine culture before operation, 58 cases were positive, and all of them were treated with antibiotic prophylactic therapy. The body temperature and heart rate were monitored after operation. Respiratory and white blood cell count were related to SIRS. The bacterial spectrum of urine culture and the application of antibiotics in patients with upper urinary calculi before operation were analyzed. The relationship between the days of antibiotic use and the occurrence of SIRS was analyzed by statistical method. Results of the 143 patients with positive urine culture, 26 had SIRS, 45 had Gram-negative bacteria infection, 13 had Gram-positive bacteria infection, and the most common Gram-negative bacteria infection was Escherichia coli. The resistance rate of cefxitin and other antimicrobial agents to various kinds of plactamases was 3- 10. Among Gram-positive bacteria, Enterococcus faecalis infection was the most. The sensitivity to furantoin and ampicillin were 100% and 87.5, respectively. No vancomycin and teicoplanin resistant Enterococcus faecalis and Enterococcus faecium were found. The positive rate of SIRS in patients with positive urine culture before and after operation was clear. It was significantly higher than that of patients with negative urine culture before operation (P 0.01), and the difference was statistically significant. The positive rate of SIRS in patients with upper urinary calculi after 3 days of prophylactic antibiotic application was significantly higher than that in patients with upper urinary calculi 鈮，

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