發(fā)布時(shí)間：2018-01-08 04:22

  本文關(guān)鍵詞：某醫(yī)院臨床鮑曼不動(dòng)桿菌耐藥性調(diào)查與抗菌藥物使用分析　出處：《中國人民解放軍軍事醫(yī)學(xué)科學(xué)院》2017年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 鮑曼不動(dòng)桿菌 耐藥性 多重耐藥 抗菌藥物 危險(xiǎn)因素

【摘要】：鮑曼不動(dòng)桿菌(Acinetobacter baumannii,AB)屬于非發(fā)酵革蘭陰性桿菌,廣泛存在于自然界的水及土壤中,同時(shí)在醫(yī)院環(huán)境與人體皮膚、呼吸道、消化道和泌尿道也可檢測到,屬于條件致病菌。該菌在醫(yī)院環(huán)境中分布很廣并可以長期存活,是醫(yī)院感染最常見病原體之一,主要引起呼吸道感染,也可引發(fā)泌尿系感染、菌血癥、手術(shù)部位感染、繼發(fā)性腦膜炎等。近年來其對常用抗菌藥物的耐藥性呈現(xiàn)快速上升趨勢,引起臨床醫(yī)生和和公共衛(wèi)生專家的密切關(guān)注。AB極易出現(xiàn)多重耐藥成為多重耐藥鮑曼不動(dòng)桿菌(Multidrug-resistant Acinetobacter baumannii,MDR-AB),而且耐藥株的檢出率不斷增加,給臨床治療帶來了較大困難。合理的選擇抗菌藥物進(jìn)行針對性治療,對改善感染患者預(yù)后具有重要意義。目前國內(nèi)外針對AB開展的多是流行傳播規(guī)律及監(jiān)測研究,對醫(yī)院內(nèi)針對MDR-AB治療的抗菌藥物使用的現(xiàn)狀和臨床意義關(guān)注不多;有部分研究關(guān)注了MDR-AB所致菌血癥患者的預(yù)后和影響因素,而對MDR-AB所致呼吸道感染以及抗菌藥物治療效果評價(jià)相關(guān)研究較少,尤其缺乏抗菌藥物使用對MDR-AB感染患者臨床結(jié)局影響方面的研究。針對上述問題,我們進(jìn)行了兩個(gè)部分研究:一.臨床分離鮑曼不動(dòng)桿菌抗菌藥物耐藥性的調(diào)查分析為了解鮑曼不動(dòng)桿菌目前的感染現(xiàn)狀,首先于2014年對北京某三甲醫(yī)院進(jìn)行了一次現(xiàn)患率調(diào)查,結(jié)果顯示,調(diào)查日當(dāng)天實(shí)際調(diào)查1447例患者,實(shí)查率為100.00%;醫(yī)院感染患者87例,現(xiàn)患率為6.01%;87例醫(yī)院感染病例中,發(fā)生下呼吸道感染45例,占總感染例數(shù)的51.72%;引起感染的病原菌中,鮑曼不動(dòng)桿菌的檢出率為6.00%。由此橫斷面調(diào)查結(jié)果我們了解到了醫(yī)院感染類型中下呼吸道感染占醫(yī)院感染的比重較大,鮑曼不動(dòng)桿菌是引起感染的病原菌之一。進(jìn)一步我們對該三甲醫(yī)院2007年至2013年從痰液、肺泡灌洗液、血液、傷口、膿液、尿液等標(biāo)本中分離鑒定出的鮑曼不動(dòng)桿菌數(shù)據(jù)進(jìn)行了系統(tǒng)回顧性分析,主要包括不同科室的AB檢出率、重癥監(jiān)護(hù)病房、呼吸內(nèi)科及神經(jīng)內(nèi)科三個(gè)重點(diǎn)科室的抗菌藥物的耐藥性變化等。結(jié)果顯示,這三個(gè)科室收治患者中重癥及危重患者居多,AB分離率從2007年至2013年呈現(xiàn)上升趨勢,其中重癥監(jiān)護(hù)病房的檢出率呈明顯上升態(tài)勢,而AB對抗菌藥物的耐藥性變化趨勢在重癥監(jiān)護(hù)病房表現(xiàn)為逐年增高。另一方面,本研究還發(fā)現(xiàn)在呼吸內(nèi)科與神經(jīng)內(nèi)科這類收治中重度患者較多的科室中,AB的分離率低于重癥監(jiān)護(hù)病房,但總體仍然呈現(xiàn)上升態(tài)勢,可見AB已成為醫(yī)院感染的重要病原菌,需要臨床引起高度注意。另外,該醫(yī)院臨床分離的AB對碳青霉烯類、頭孢菌素類和青霉素類等抗菌藥物的耐藥性均呈顯著上升趨勢,其中對碳青霉烯類藥物的耐藥性在2012年、2013年均已高于80.00%;氟喹諾酮類和氨基糖苷類抗菌藥物的耐藥率也呈上升趨勢,而對頭孢哌酮/舒巴坦的耐藥率相對較低。二.多重耐藥鮑曼不動(dòng)桿菌致呼吸道感染抗菌藥物使用分析于2013年至2015年對該三甲醫(yī)院MDR-AB所致呼吸道感染的抗菌藥物使用情況進(jìn)行比較分析。對臨床送檢的呼吸道標(biāo)本(痰及肺泡灌洗液)共計(jì)2488例進(jìn)行普通細(xì)菌培養(yǎng),對其中培養(yǎng)AB陽性患者病例依據(jù)肺炎和呼吸機(jī)相關(guān)肺炎(ventilator-associated pneumonia,VAP)的診斷標(biāo)準(zhǔn)及病例納入排除標(biāo)準(zhǔn)進(jìn)行篩選,最終篩選出呼吸道感染病例702例;收集入選病例的流行病學(xué)信息,根據(jù)其體外藥物敏感性檢測結(jié)果分為MDR-AB組和非MDR-AB組,再分別對兩組的臨床死亡率進(jìn)行統(tǒng)計(jì)學(xué)比較,并進(jìn)一步分析治療鮑曼不動(dòng)桿菌感染所使用的抗菌藥物情況,并將臨床治療效果分為痊愈、顯效、進(jìn)步及無效四類,對不同抗菌藥物使用方案的臨床治療效果及相關(guān)危險(xiǎn)因素進(jìn)行MDR-AB組和非MDR-AB組兩組的比較分析。研究結(jié)果顯示,MDR-AB組在患者出院時(shí)、感染14天、感染30天的死亡率均明顯高于非MDR-AB組。以2015年為例,MDR-AB組出院時(shí)的死亡率為46.22%,感染14天時(shí)的死亡率為39.49%,感染30天時(shí)的死亡率為41.17%,均高于非MDR-AB組的32.08%、22.64%、29.56%,兩組比較P值依次為0.011、0.002、0.030,P值均0.05,存在統(tǒng)計(jì)學(xué)差異。治療MDR-AB呼吸道感染(包括肺炎及VAP)的抗菌藥物以碳青霉烯類中的亞胺培南使用率為最多,可高達(dá)47.32%;抗菌藥物使用效果評估比較中發(fā)現(xiàn),非MDR-AB組的臨床有效率均略高于MDR-AB組,碳青霉烯類藥物非MDR-AB組有效率為74.04%,高于MDR-AB組57.89%,比較分析P值小于0.001,具有統(tǒng)計(jì)學(xué)意義。也不排除可能原因是非MDR-AB組感染癥狀可能相對較輕,需進(jìn)一步探索研究。同時(shí)對于抗菌藥物使用情況,我們又分單藥治療和聯(lián)合用藥治療進(jìn)行分析比較,結(jié)果表明MDR-AB組碳青霉烯類有效率為57.89%,非MDR-AB組為74.04%,存在統(tǒng)計(jì)學(xué)差異。兩個(gè)組的聯(lián)合用藥的有效率均略高于單藥治療,其中碳青霉烯類聯(lián)合使用加β-內(nèi)酰胺酶抑制劑青霉素類抗菌藥物兩組的有效率75.00%和80.00%,均略高于單用碳青霉烯類的有效率的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組和非MDR-AB組性別分布的差異有統(tǒng)計(jì)學(xué)意義(P=0.020);年齡60歲以上患者居多,但兩組比較分析不存在統(tǒng)計(jì)學(xué)差異。另外,兩組的呼吸機(jī)使用率亦不存在統(tǒng)計(jì)學(xué)差異。綜上所述,本研究在對某三甲醫(yī)院臨床分離的鮑曼不動(dòng)桿菌的抗菌藥物耐藥性回顧調(diào)查分析中發(fā)現(xiàn)了呼吸道感染是醫(yī)院感染發(fā)生率最高的感染類型,且AB檢出率逐年增多,對許多常用抗菌藥物的耐藥性也呈逐年上升趨勢;MDR-AB呼吸道感染患者的死亡率明顯高于非MDR-AB組,臨床應(yīng)引起高度重視,防止多重耐藥菌產(chǎn)生與傳播;另外,治療使用抗菌藥物臨床有效率聯(lián)合用藥方案略優(yōu)于單藥治療;主要危險(xiǎn)因素調(diào)查中兩組比較分析中發(fā)現(xiàn)僅患者性別分布存在統(tǒng)計(jì)學(xué)差異,患者年齡及呼吸機(jī)使用數(shù)量兩組間不存在統(tǒng)計(jì)學(xué)差異。通過本研究,我們對AB菌的抗菌藥物耐藥性變化有了進(jìn)一步的了解,更為重要的是我們從臨床抗菌藥物使用效果的角度,對我國臨床應(yīng)對MDR-AB感染的抗菌治療的實(shí)際效果有了較為深入的研究和認(rèn)識(shí),這為醫(yī)院內(nèi)MDR-AB的感染防控及抗菌藥物合理使用提供了一定的數(shù)據(jù)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.

【學(xué)位授予單位】：中國人民解放軍軍事醫(yī)學(xué)科學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R446.5

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