多重耐药菌感染的中医证候分布与相关性研究

发布时间：2018-08-26 21:34

【摘要】：目的：通过回顾性分析多重耐药菌感染患者的临床资料,得出多重耐药菌感染的中医证候分布特征,进一步探讨和分析中医证候分布的相关因素。方法：本研究为回顾性分析,收集于2013年5月至2016年5月期间在广东省中医院急诊综合病区及重症监护室住院的患者,符合痰、中段尿、血液任一标本细菌药敏培养结果提示为多重耐药菌感染即可入组,共计200例。建立数据库,收集患者年龄、性别、基础疾病、一般情况、感染菌种、感染部位、细菌耐药程度、抗生素使用、APACHEⅡ评分、中医证候等内容,采用SPSS19.0数据包进行统计分析。成果：本研究收集2013年5月至2016年5月期间在广东省中医院急诊综合病区及重症监护室住院诊断为多重耐药菌感染的患者共200例,男女比例各为43.5%与56.5%,男性患者87例,女性患者117例。平均年龄为79.85±10.78,以71-90岁患者居多,占73%；其次是51-70岁,占19%；30-50岁和大于90岁的分别占3%和5%。既往病史中顺位前五名的疾病分别是高血压(73.5%)、糖尿病(72%)、脑梗个人史(65.5%)、慢性心衰(27.5%)、支气管扩张(24%)。长期卧床的患者133例,占66.5%；患有低蛋白血症的有184例,占92%；有广谱抗生素使用史的患者96例,占48%；长期使用糖皮质激素的患者3例,占1.5%；此次住院前30天内接受过免疫抑制疗法的有9例,占4.5%。侵入性医疗措施包括机械辅助通气、气管切开、中心静脉置管、留置尿管、纤维支气管镜检查,比例最高的为留置尿管,发生率为93.5%；机械辅助通气次之,发生率为92.5%。APACHE Ⅱ评分均值是21.18±5.67,最小值为9分,最大值为37分。多重耐药菌感染部位的比例中,以肺部感染最多见,200例患者中痰培养结果阳性的125例,占62.5%；其次为泌尿道感染,占30.5%；血行感染最少,占7%。革兰氏阴性菌较革兰氏阳性菌多,阴性菌177例,占88.5%；阳性菌23例,占11.5%。所有菌种中最多见的为鲍曼不动杆菌,占总例数的26%；其次为铜绿假单胞菌,占总例数的21.5%；奇异变形杆菌、大肠埃希菌则分别占总例数的15.5%、14%。引起肺部感染中以鲍曼不动杆菌(36.8%)及铜绿假单胞菌(25.6%)为主,泌尿道感染则以变形杆菌(34.43%)及大肠埃希菌(19.67%)为主,血培养中以葡萄球菌属(50%)为主。药敏结果中,泛耐药菌株35例,占17.5%。泛耐药菌中以鲍曼不动杆菌(82.86%)居多,其次为铜绿假单胞菌(14.28%)。抗生素使用以β-内酰胺类最多,占84.67%,该类抗生素中3代头孢菌素和碳青霉烯类的使用率最高；抗生素的联用率为14.72%,以两种抗生素联合使用为主。200例患者中,有37例未使用抗生素。证候表现按虚实偏重进行分组,按比例大小顺位依次为虚实夹杂偏虚证(30.5%)、单纯虚证(25.5%)、虚实夹杂偏实证(25%)、单纯实证(19%)。在9个具体证候要素中,比例由高到低依次为：气虚证(72%)痰浊证(28.5%)血瘀证(27.5%)阴虚证(18.5%)实热证(15.5%)湿阻证(141%)阳虚证(11%)血虚证(10%)、水停证(10%)。虚证类中以“气虚证”为主导,实证类则多见“痰浊证：”与“血瘀证”。证候要素的组合以二证并见的患者居多,占76%；二证并见中以“气虚血瘀”和“气虚痰浊”的组合比例最多,分别为16.45%、15.79%；三证并见中以“气虚、阴虚、痰浊”(25.81%)及“气虚、阴虚、血瘀”(19.35%)多见。证候要素与年龄、性别的相关性分析：气虚证组的患者中,“30-50y”组与“71-90y”组之间、“51-70y”与“71-90y”组之间差异具有统计学意义,Spearman相关分析显示气虚证与年龄存在正相关,提示随着年龄增加,研究组中患者出现气虚证的可能性增大。实热证组的患者中,“30-50y”组与“71-90y”组之间差异具有统计学意义,与气虚证组相反,实热证与年龄之间存在负栩关,即年龄较低的患者患实热证的机会增加。血虚证组男女患者间比较P0.01,差异具有显著统计学意义,女性患者中血虚证的比例(15.93%)比男性患者中血虚证的比例(2.30%)高。根据多重耐药菌耐药的程度不同,分为泛耐药菌组和非泛耐药菌组,分析证候要素与耐药程度的相关性,结果显示痰浊证患者中泛耐药菌组和非泛耐药菌组间比较P0.05,差异具有统计学意义,泛耐药菌组的患者中患痰浊证的比例(45.71%)比非泛耐药菌组的患者其比例(24.85%)要高。评估中医证候与APACHE Ⅱ评分相关性的过程中,先对所有患者的APACHE Ⅱ评分进行正态性检验,结果显示APACHE Ⅱ评分数值符合正态分布(P=0.319,P0.05)；进而对各组进行方差齐性检验,结果提示符合方差齐性检验(P=0.696,P0.05)；继续行单因素ANOVA分析,提示不同的分组其APACHE Ⅱ评分数值存在显著差异性(F=9.307,P=-0.000,P0.01),故对各组进行平均数的多重比较(Scheffe),进一步了解组间差异,最终结果提示单纯虚证组与单纯实证组之间比较的P.01(P=-0.001),差异具有显著统计学意义；单纯实证组与虚实夹杂偏虚证组之间比较的P0.01(P=0.000),差异具有显著统计学意义；虚实夹杂偏虚证组与虚实夹杂偏实证组之间比较的P0.05(P=-0.039),差异具有统计学意义。结论：多重耐药菌感染患者的年龄偏高,大部分患者存在长期卧床、低蛋白血症的情况。在基础疾病中顺位前五名的分别是高血压(73.5%)、糖尿病(72%)、脑梗个人史(65.5%)、慢性心衰(27.5%)、支气管扩张(24%)。多重耐药菌感染的部位以肺部感染(62.5%)为主,其次是泌尿道感染(30.5%),血流感染最少(7%)；菌种顺位前五名分别是鲍曼不动杆菌(26%)、铜绿假单胞菌(21.5%)、变形杆菌(16.5%)、大肠埃希菌(14%)、肺炎克雷伯菌(5.5%)；痰培养中以鲍曼不动杆菌、铜绿假单胞菌多见,中段尿培养以变形杆菌和大肠埃希菌多见,血培养以葡萄球菌属多见。所有多重耐药菌株中泛耐药菌占17.5%,其中以鲍曼不动杆菌为主要的泛耐药菌。多重耐药菌感染的患者以虚实夹杂最多,在虚与实方面则偏向于虚证,证候要素虚证类以气虚证、阴虚证多见,实证类则多见痰浊证、血瘀证；在证候要素的组合则以“气虚痰浊”和“气虚血瘀”的频次为多。证候要素与年龄的关系中,随着年龄增加,患者出现气虚证的可能性增大,出现实热证的可能性则降低；与性别的关系则表现为女性患者出现血虚证的可能性比男性患者高。泛耐药菌和非泛耐药菌在证候要素的区别,在于泛耐药菌感染的患者患痰浊证的可能性较大。APACHE Ⅱ评分分值与证候分类有关系,表现为存在正虚时,患者的病情可能更严重,故应高度重视,注意早期扶正,增强机体御邪能力。
[Abstract]:Objective: To retrospectively analyze the clinical data of patients with multi-drug resistant bacteria infection, and obtain the distribution characteristics of TCM syndromes of multi-drug resistant bacteria infection, and further explore and analyze the related factors of TCM syndromes distribution. The results of bacterial susceptibility culture in sputum, middle urine and blood samples of patients hospitalized in district and intensive care unit indicated that 200 patients with multidrug-resistant bacterial infections could be enrolled in the group. Results: From May 2013 to May 2016, 200 patients with multidrug-resistant bacterial infections were collected from the emergency ward and intensive care unit of Guangdong Hospital of Traditional Chinese Medicine. The male-female ratio was 43.5% and 56.5%, 87 male patients and 117 female patients respectively. The average age was 79.85 [10.78], with 73% of the patients aged 71-90, followed by 19% aged 51-70, 3% aged 30-50 and 5% aged over 90, respectively. The top five diseases in the previous medical history were hypertension (73.5%), diabetes (72%), personal history of cerebral infarction (65.5%), chronic heart failure (27.5%) and bronchiectasis (24%). 133 cases (66.5%), 184 cases (92%) with hypoproteinemia, 96 cases (48%) with a history of broad-spectrum antibiotics, 3 cases (1.5%) with long-term use of glucocorticoids, and 9 cases (4.5%) received immunosuppressive therapy within 30 days before hospitalization. Intravenous catheterization, indwelling catheter, fiberoptic bronchoscopy, the highest proportion of indwelling catheter, the incidence of 93.5%; mechanical ventilation followed by the incidence of 92.5%. APACHE II score was 21.18 [5.67], the minimum was 9 points, the maximum was 37 points. The results of sputum culture were positive in 125 cases (62.5%), followed by urinary tract infection (30.5%) and hematogenous infection (7%). Among them, Acinetobacter baumannii (36.8%) and Pseudomonas aeruginosa (25.6%) were the main pathogens, Proteus (34.43%) and Escherichia coli (19.67%) were the main pathogens, and Staphylococcus (50%) was the main pathogen in blood culture. Among them, 35 strains were pan-resistant, accounting for 17.5%. Acinetobacter baumannii (82.86%) was the most common, followed by Pseudomonas aeruginosa (14.28%). Among the 200 patients, 37 did not use antibiotics. Syndrome manifestations were grouped according to deficiency and excess, followed by deficiency and excess mixed with partial deficiency (30.5%), simple deficiency (25.5%), deficiency and excess mixed with partial deficiency (25%) and simple excess (19%). Turbid syndrome (28.5%) blood stasis syndrome (27.5%) Yin deficiency syndrome (18.5%) excess heat syndrome (15.5%) damp obstruction syndrome (14.1%) Yang deficiency syndrome (11%) blood deficiency syndrome (10%) and water arrest syndrome (10%). Qi deficiency and blood stasis and Qi deficiency and phlegm turbidity were 16.45% and 15.79% respectively, and the most common symptoms were Qi deficiency, Yin deficiency and phlegm turbidity (25.81%) and Qi deficiency, Yin deficiency and blood stasis (19.35%). Spearman correlation analysis showed that Qi deficiency syndrome was positively correlated with age, suggesting that with the increase of age, the possibility of Qi deficiency syndrome in the study group increased. On the contrary, there was a negative correlation between the syndrome of excess heat and age, that is, the chances of the syndrome of excess heat increased in the younger patients. Different, divided into pan-drug resistant bacteria group and non-pan-drug resistant bacteria group, analysis of the correlation between syndrome factors and drug resistance, the results showed that pan-drug resistant bacteria and non-pan-drug resistant bacteria group in patients with phlegm turbidity compared to P 0.05, the difference was statistically significant, pan-drug resistant bacteria group in patients with phlegm turbidity syndrome (45.71%) than non-pan-drug resistant bacteria group in the proportion of patients with pH In the process of evaluating the correlation between TCM syndrome and APACHE II score, the APACHE II score of all patients was tested for normality, and the results showed that the APACHE II score was in accordance with normal distribution (P = 0.319, P 0.05); then the homogeneity of variance was tested for each group, and the results showed that the homogeneity of variance was in accordance with homogeneity test (P = 0.696, P 0.05). The results of single factor ANOVA analysis showed that there were significant differences in APACHE II scores among different groups (F = 9.307, P = - 0.000, P 0.01). Therefore, multiple comparisons of the average of each group (Scheffe) were conducted to further understand the differences between groups. The final results showed that there was a significant difference between the pure deficiency syndrome group and the pure empirical group (P = - 0.001). Significant statistical significance; P 0.01 (P = 0.000) between the pure empirical group and the deficiency-excess mixed partial deficiency group, the difference was statistically significant; P 0.05 (P = - 0.039) between the deficiency-excess mixed partial deficiency group and the deficiency-excess mixed partial deficiency group, the difference was statistically significant. The top five basic diseases were hypertension (73.5%), diabetes mellitus (72%), personal history of cerebral infarction (65.5%), chronic heart failure (27.5%) and bronchiectasis (24%). Acinetobacter baumannii (26%), Pseudomonas aeruginosa (21.5%), Proteus (16.5%), Escherichia coli (14%), Klebsiella pneumoniae (5.5%), Acinetobacter baumannii (14%) and Pseudomonas aeruginosa (5.5%), Acinetobacter baumannii (5%) were the most common bacteria in sputum culture, Proteus and Escherichia coli (21.5%) were the most common bacteria in middle urine culture, and Staphylococcus aureus Pan-resistant bacteria accounted for 17.5% of all multidrug-resistant strains, of which Acinetobacter baumannii was the main pan-resistant bacteria. In the relationship between syndrome elements and age, the probability of Qi deficiency syndrome and excess heat syndrome increased with the increase of age, and the possibility of blood deficiency syndrome in female patients was higher than that in male patients. The difference between pan-drug-resistant bacteria and non-pan-drug-resistant bacteria is that the patients infected by pan-drug-resistant bacteria are more likely to suffer from phlegm turbidity syndrome.APACHE II score is related to syndrome classification.
【学位授予单位】：广州中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R259

【相似文献】