新疆地区急诊医疗保健相关性肺炎成年患者病原体分布及耐药特点分析
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摘要
目的对急诊医疗保健相关性肺炎(HCAP)患者病原体分布及耐药特点进行分析,为地域性抗生素的合理使用提供依据。方法选取2014年11月—2017年4月就诊于新疆医科大学第一附属医院急诊科的标本培养结果阳性的急诊HCAP成年患者783例,根据年龄将其分为非高龄组(364例)和高龄组(419例)。记录并分析患者一般资料、标本培养及药物敏感试验结果。结果高龄组高血压、心血管疾病、糖尿病、慢性肺部疾病、肿瘤、≥2种基础疾病所占比例、收缩压均高于非高龄组,神经系统疾病、血液病、风湿免疫系统疾病、外周血管疾病所占比例、体温均低于非高龄组(P<0.05)。783例患者中,共检出783株病原体,其中痰培养573株(73.2%)、气管支气管吸取物171株(21.8%)、支气管肺泡灌洗液39株(5.0%);包括27种革兰阴性杆菌、9种革兰阳性球菌、1种真菌等。非高龄组与高龄组均以革兰阴性杆菌为主[86.0%(313/364)与85.2%(357/419)],前5位细菌为鲍曼不动杆菌[25.3%(92/394)与29.1%(122/419)]、肺炎克雷伯菌[25.8%(94/364)与21.0%(88/419)]、铜绿假单胞菌[12.1%(44/364)与9.3%(39/419)]、金黄色葡萄球菌[8.5%(31/364)与8.4%(35/419)]、大肠埃希菌[5.8%(21/364)与8.8%(37/419)]。鲍曼不动杆菌的耐药情况最为严重,大部分革兰阴性杆菌对青霉素类、第一代头孢菌素、第二代头孢菌素耐药性高,但对碳青霉烯类、复方新诺明、多黏菌素B敏感性高。肺炎克雷伯菌、大肠埃希菌对第三代头孢菌素的耐药率分别为26.4%、62.1%,而鲍曼不动杆菌、肺炎克雷伯菌、铜绿假单胞菌、大肠埃希菌对碳青霉烯类耐药率分别为71.5%、1.1%、30.1%、1.7%。结论 HCAP成年患者以老年男性居多,年龄对HCAP病原学影响较小。本地区HCAP病原体分布及耐药情况具有地域特点,临床医师应根据具体情况合理使用抗生素。
Objective To analyze the results of the pathogens distribution and antibiogram in patients with emergency healthcare-associated pneumonia(HCAP),so as to provide the basis for rational use of antibiotics in the region.Methods A total of 783 emergency inpatients with HCAP admitted to the First Affiliated Hospital of Xinjiang Medical University,according to the age distribution,were divided into the younger group(364 cases) and the elderly group(419 cases)from November 2014 to April 2017.The baseline data,specimen culture,pathogens distribution and antibiogram were analyzed.Results The elderly group was significantly more likely to have hypertension,cardiovascular disease,diabetes mellitus,chronic lung disease,solid organ malignancy,≥ 2 basic diseases and high systolic pressure(P<0.05),whereas younger group were significantly more likely to have nervous system disorders,hematologic deisease,rheumatologic disease,peripheral vascular disease and lower temperature than the elderly group(P<0.05).Among the 783 patients,783 strains were detected,of which 573 were from sputum culture(73.2%),171 from tracheal or bronchial aspirates(21.8%) and 39 from bronchoalveolar lavage fluid(5.0%).There were 27 kinds of Gram-negative bacilli,9 kinds of Gram-positive cocci and 1 kind of fungus.Gram-negative bacteria were the most common pathogens in both groups[86.0%(313/364) and 85.2%(357/419)].The order of pathogenic bacteria was Acinetobacter baumannii [25.3%(92/394) and 29.1%(122/419)],Klebsiella pneumoniae [25.8%(94/364) and 21.0%(88/419)],Pseudomonas aeruginosa [12.1%(44/364) and 9.3%(39/419)],Staphylococcus aureus [8.5%(31/364) and 8.4%(35/419)] and Escherichia coli [5.8%(21/364) and 8.8%(37/419)],with the drug resistance of Acinetobacter baumannii the most critical.The most Gram negative bacilli was generally drug-resistant to Penicillins,the first and second generation cephalosporin,and sensitive to carbapenem,sulfamethoxazole and polymyxin B.The drug resistance rate of Klebsiella pneumoniae and Escherichia coli to the third generation cephalosporin were 26.4%,62.1%,respectively,and the drug resistance rate of Acinetobacter baumannii,Klebsiella pneumoniae,Pseudomonas aeruginosa and Escherichia coli to carbapenem were 71.5%,1.1%,30.1%,1.7%,respectively.Conclusion The majority of HCAP patients were elderly men.Age has little influence on the etiology of HCAP.The distribution and drug resistance of HCAP pathogens in this region have regional characteristics,clinicians should rationally use antibiotics according to specific circumstances.
Objective To analyze the results of the pathogens distribution and antibiogram in patients with emergency healthcare-associated pneumonia(HCAP),so as to provide the basis for rational use of antibiotics in the region.Methods A total of 783 emergency inpatients with HCAP admitted to the First Affiliated Hospital of Xinjiang Medical University,according to the age distribution,were divided into the younger group(364 cases) and the elderly group(419 cases)from November 2014 to April 2017.The baseline data,specimen culture,pathogens distribution and antibiogram were analyzed.Results The elderly group was significantly more likely to have hypertension,cardiovascular disease,diabetes mellitus,chronic lung disease,solid organ malignancy,≥ 2 basic diseases and high systolic pressure(P<0.05),whereas younger group were significantly more likely to have nervous system disorders,hematologic deisease,rheumatologic disease,peripheral vascular disease and lower temperature than the elderly group(P<0.05).Among the 783 patients,783 strains were detected,of which 573 were from sputum culture(73.2%),171 from tracheal or bronchial aspirates(21.8%) and 39 from bronchoalveolar lavage fluid(5.0%).There were 27 kinds of Gram-negative bacilli,9 kinds of Gram-positive cocci and 1 kind of fungus.Gram-negative bacteria were the most common pathogens in both groups[86.0%(313/364) and 85.2%(357/419)].The order of pathogenic bacteria was Acinetobacter baumannii [25.3%(92/394) and 29.1%(122/419)],Klebsiella pneumoniae [25.8%(94/364) and 21.0%(88/419)],Pseudomonas aeruginosa [12.1%(44/364) and 9.3%(39/419)],Staphylococcus aureus [8.5%(31/364) and 8.4%(35/419)] and Escherichia coli [5.8%(21/364) and 8.8%(37/419)],with the drug resistance of Acinetobacter baumannii the most critical.The most Gram negative bacilli was generally drug-resistant to Penicillins,the first and second generation cephalosporin,and sensitive to carbapenem,sulfamethoxazole and polymyxin B.The drug resistance rate of Klebsiella pneumoniae and Escherichia coli to the third generation cephalosporin were 26.4%,62.1%,respectively,and the drug resistance rate of Acinetobacter baumannii,Klebsiella pneumoniae,Pseudomonas aeruginosa and Escherichia coli to carbapenem were 71.5%,1.1%,30.1%,1.7%,respectively.Conclusion The majority of HCAP patients were elderly men.Age has little influence on the etiology of HCAP.The distribution and drug resistance of HCAP pathogens in this region have regional characteristics,clinicians should rationally use antibiotics according to specific circumstances.
引文
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[6]吴志琴,韩黎,赵玲.ISO15189实验室认证在采血室血液标本质量管理中的应用[J].新疆医学,2011,41(9):153-154.DOI:10.3969/j.issn.1001-5183.2011.09.070.WU Z Q,HAN L,ZHAO L.Application of ISO15189 in laboratory certification of quality management in blood specimen in blood collection room[J].Xinjiang Medical Journal,2011,41(9):153-154.DOI:10.3969/j.issn.1001-5183.2011.09.070.
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[11]JEON E J,CHO S G,SHIN J W,et al.The difference in clinical presentations between healthcare-associated and community-acquired pneumonia in university-affiliated hospital in Korea[J].Yonsei Med J,2011,52(2):282-287.DOI:10.3349/ymj.2011.52.2.282.
[12]NOGUCHI S,MUKAE H,KAWANAMI T,et al.Bacteriological assessment of healthcare-associated pneumonia using a clone library analysis[J].PLo S One,2015,10(4):e0124697.DOI:10.1371/journal.pone.0124697.
[13]JUNG J Y,PAKR M S,KIM Y S,et al.Healthcare-associated pneumonia among hospitalized patients in a Korean tertiary hospital[J].BMC Infect Dis,2011,11(1):61.DOI:10.1186/1471-2334-11-61.
[14]ITO A,ISHIDA T,TOKUMASU H,et al.Prognostic factors in hospitalized community-acquired pneumonia:a retrospective study of a prospective observational cohort[J].BMC Pulm Med,2017,17(1):78.DOI:10.1186/s12890-017-0424-4.
[15]JAIN S,SELF W H,WUNDERINK R G,et al.Communityacquired pneumonia requiring hospitalization among U.S.adults[J].N Engl J Med,2015,373(5):415-427.DOI:10.1056/NEJMoa1500245.
[16]国家卫生计生委合理用药专家委员会,全国细菌耐药监测网.2014年全国细菌耐药监测报告[J].中国执业药师,2016,13(2):3-8.DOI:10.3969/j.issn.1672-5433.2016.02.001.Committee of Exports on Rational Drug Use National Health and Family Planning Commission of the P.R.China,China Antimicrobial Resistance Surveillance System.China antimicrobial resistance surveillance system report 2014[J].China Licensed Pharmacist,2016,13(2):3-8.DOI:10.3969/j.issn.1672-5433.2016.02.001.
[17]LANSPA M J,PEYRANI P,WIEMKEN T,et al.Characteristics associated with clinician diagnosis of aspiration pneumonia:a descriptive study of afflicted patients and their outcomes[J].J Hosp Med,2015,10(2):90-96.DOI:10.1002/jhm.2280.
[18]MADARASKELLY K,JONES M,REMINGTON R,et al.Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration[J].J Antimicrob Chemother,2015,71(2):539-546.DOI:10.1093/jac/dkv338.
[19]SEONG G M,KIM M,LEE J,et al.Healthcare-associated pneumonia among hospitalized patients:is it different from community acquired pneumonia?[J].Tuberc Respir Dis(Seoul),2014,76(2):66-74.DOI:10.4046/trd.2014.76.2.66.
[20]LIM C W,CHOI Y,AN C H,et al.Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia[J].Korean J Intern Med,2016,31(2):296-304.DOI:10.3904/kjim.2014.256.
[21]BJARNASON A,ASGEIRSSON H,BALDURSSON O,et al.Mortality in healthcare-associated pneumonia in a low resistance setting:a prospective observational study[J].Infect Dis(Lond),2015,47(3):130-136.DOI:10.3109/00365548.2014.980842.
[22]FUKUYAMA H,YAMASHIRO S,KINJO K,et al.Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia:a prospective observational study[J].BMC Infect Dis,2014,14(1):534.DOI:10.1186/1471-2334-14-534.
[23]QUARTIN A A,SCERPELLA E G,PUTTAGUNTA S,et al.A comparison of microbiology and demographics among patients with healthcare-associated,hospital-acquired,and ventilatorassociated pneumonia:a retrospective analysis of 1184 patients from a large,international study[J].BMC Infect Dis,2013,13(1):561.DOI:10.1186/1471-2334-13-561.
[24]LEE H,PARK J Y,LEE T,et al.Intermediate risk of multidrugresistant organisms in patients who admitted intensive care unit with healthcare-associated pneumonia[J].Korean J Intern Med,2016,31(3):525-534.DOI:10.3904/kjim.2015.103.
[25]国家卫生计生委合理用药专家委员会,全国细菌耐药监测网.2015年全国细菌耐药监测报告[J].中国执业药师,2016,13(3):3-8.DOI:10.3969/j.issn.1672-5433.2016.03.001.Committee of Exports on Rational Drug Use National Health and Family Planning Commission of the P.R.China,China Antimicrobial Resistance Surveillance System.China Antimicrobial Resistance Surveillance System.China antimicrobial resistance surveillance system report 2015[J].China Licensed Pharmacist,2016,13(3):3-8.DOI:10.3969/j.issn.1672-5433.2016.03.001.
[26]JWA H,BEOM J W,LEE J H.Predictive factors of methicillinresistant staphylococcus aureus infection in elderly patients with community-onset pneumonia[J].Tuberc Respir Dis(Seoul),2017,80(2):201-209.DOI:10.4046/trd.2017.80.2.201.
[27]中华医学会呼吸病学分会.中国成人社区获得性肺炎诊断和治疗指南(2016年版)[J].中华结核和呼吸杂志,2016,64(4):253-279.DOI:10.3760/cma.j.issn.1001-0939.2016.04.005.Respiratory Society,Chinese Medical Association.Guidelines for diagnosis and treatment of adult community-acquired pneumonia in China(2016 edition)[J].Chinese Journal of Tuberculosis and Respiratory Diseases,2016,64(4):253-279.DOI:10.3760/cma.j.issn.1001-0939.2016.04.005.
[2]CHALMERS J D,TAYLOR J K,SINGANAYAGAM A,et al.Epidemiology,antibiotic therapy,and clinical outcomes in health care-associated pneumonia:a UK cohort study[J].Clin Infect Dis,2011,53(2):107-113.DOI:10.1093/cid/cir274.
[3]KALIL A C,METERSKY M L,KLOMPAS M,et al.Management of adults with hospital-acquired and ventilatorassociated pneumonia:2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society[J].Clin Infect Dis,2016,63(5):e61-111.DOI:10.1093/cid/ciw353.
[4]DE WITH K,ALLERBERGER F,AMANN S,et al.Strategies to enhance rational use of antibiotics in hospital:a guideline by the German Society for Infectious Diseases[J].Infection,2016,44(3):395-439.DOI:10.1007/s15010-016-0885-z.
[5]FAINE B A,MOHR N,DIETRICH J,et al.Antimicrobial therapy for pneumonia in the emergency department:the impact of clinical pharmacists on appropriateness[J].West J Emerg Med,2017,18(5):856-863.DOI:10.5811/westjem.2017.5.33901.
[6]吴志琴,韩黎,赵玲.ISO15189实验室认证在采血室血液标本质量管理中的应用[J].新疆医学,2011,41(9):153-154.DOI:10.3969/j.issn.1001-5183.2011.09.070.WU Z Q,HAN L,ZHAO L.Application of ISO15189 in laboratory certification of quality management in blood specimen in blood collection room[J].Xinjiang Medical Journal,2011,41(9):153-154.DOI:10.3969/j.issn.1001-5183.2011.09.070.
[7]WUBDERINK R G,WATERER G W.Clinical practice.Communityacquired pneumonia[J].N Engl J Med,2014,370(6):543-551.DOI:10.1056/NEJMcp1214869.
[8]尚红,王毓三,申子瑜.全国临床检验操作规程(第4版)[M].北京:人民卫生出版社,2014:578-625.SHANG H,WANG Y S,SHEN Z Y.National operating instructions for clinical laboratory(4th edition)[M].Beijing:People's Medical Publishing House,2014:578-625.
[9]Clinical and Laboratory Standards Institute.Performance standards for antimierobial susceptibility testing;twenty-fifth informational supplement.M100-S25[EB/OL].(2015-01-01)[2017-05-01].https://clsi.org/standards/products/microbiology/documents/m100/.
[10]李凡.医学微生物学(第7版)[M].北京:人民卫生出版社,2008.LI F.Medical microbiology(7th edition)[M].Beijing:People's Medical Publishing House,2008.
[11]JEON E J,CHO S G,SHIN J W,et al.The difference in clinical presentations between healthcare-associated and community-acquired pneumonia in university-affiliated hospital in Korea[J].Yonsei Med J,2011,52(2):282-287.DOI:10.3349/ymj.2011.52.2.282.
[12]NOGUCHI S,MUKAE H,KAWANAMI T,et al.Bacteriological assessment of healthcare-associated pneumonia using a clone library analysis[J].PLo S One,2015,10(4):e0124697.DOI:10.1371/journal.pone.0124697.
[13]JUNG J Y,PAKR M S,KIM Y S,et al.Healthcare-associated pneumonia among hospitalized patients in a Korean tertiary hospital[J].BMC Infect Dis,2011,11(1):61.DOI:10.1186/1471-2334-11-61.
[14]ITO A,ISHIDA T,TOKUMASU H,et al.Prognostic factors in hospitalized community-acquired pneumonia:a retrospective study of a prospective observational cohort[J].BMC Pulm Med,2017,17(1):78.DOI:10.1186/s12890-017-0424-4.
[15]JAIN S,SELF W H,WUNDERINK R G,et al.Communityacquired pneumonia requiring hospitalization among U.S.adults[J].N Engl J Med,2015,373(5):415-427.DOI:10.1056/NEJMoa1500245.
[16]国家卫生计生委合理用药专家委员会,全国细菌耐药监测网.2014年全国细菌耐药监测报告[J].中国执业药师,2016,13(2):3-8.DOI:10.3969/j.issn.1672-5433.2016.02.001.Committee of Exports on Rational Drug Use National Health and Family Planning Commission of the P.R.China,China Antimicrobial Resistance Surveillance System.China antimicrobial resistance surveillance system report 2014[J].China Licensed Pharmacist,2016,13(2):3-8.DOI:10.3969/j.issn.1672-5433.2016.02.001.
[17]LANSPA M J,PEYRANI P,WIEMKEN T,et al.Characteristics associated with clinician diagnosis of aspiration pneumonia:a descriptive study of afflicted patients and their outcomes[J].J Hosp Med,2015,10(2):90-96.DOI:10.1002/jhm.2280.
[18]MADARASKELLY K,JONES M,REMINGTON R,et al.Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration[J].J Antimicrob Chemother,2015,71(2):539-546.DOI:10.1093/jac/dkv338.
[19]SEONG G M,KIM M,LEE J,et al.Healthcare-associated pneumonia among hospitalized patients:is it different from community acquired pneumonia?[J].Tuberc Respir Dis(Seoul),2014,76(2):66-74.DOI:10.4046/trd.2014.76.2.66.
[20]LIM C W,CHOI Y,AN C H,et al.Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia[J].Korean J Intern Med,2016,31(2):296-304.DOI:10.3904/kjim.2014.256.
[21]BJARNASON A,ASGEIRSSON H,BALDURSSON O,et al.Mortality in healthcare-associated pneumonia in a low resistance setting:a prospective observational study[J].Infect Dis(Lond),2015,47(3):130-136.DOI:10.3109/00365548.2014.980842.
[22]FUKUYAMA H,YAMASHIRO S,KINJO K,et al.Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia:a prospective observational study[J].BMC Infect Dis,2014,14(1):534.DOI:10.1186/1471-2334-14-534.
[23]QUARTIN A A,SCERPELLA E G,PUTTAGUNTA S,et al.A comparison of microbiology and demographics among patients with healthcare-associated,hospital-acquired,and ventilatorassociated pneumonia:a retrospective analysis of 1184 patients from a large,international study[J].BMC Infect Dis,2013,13(1):561.DOI:10.1186/1471-2334-13-561.
[24]LEE H,PARK J Y,LEE T,et al.Intermediate risk of multidrugresistant organisms in patients who admitted intensive care unit with healthcare-associated pneumonia[J].Korean J Intern Med,2016,31(3):525-534.DOI:10.3904/kjim.2015.103.
[25]国家卫生计生委合理用药专家委员会,全国细菌耐药监测网.2015年全国细菌耐药监测报告[J].中国执业药师,2016,13(3):3-8.DOI:10.3969/j.issn.1672-5433.2016.03.001.Committee of Exports on Rational Drug Use National Health and Family Planning Commission of the P.R.China,China Antimicrobial Resistance Surveillance System.China Antimicrobial Resistance Surveillance System.China antimicrobial resistance surveillance system report 2015[J].China Licensed Pharmacist,2016,13(3):3-8.DOI:10.3969/j.issn.1672-5433.2016.03.001.
[26]JWA H,BEOM J W,LEE J H.Predictive factors of methicillinresistant staphylococcus aureus infection in elderly patients with community-onset pneumonia[J].Tuberc Respir Dis(Seoul),2017,80(2):201-209.DOI:10.4046/trd.2017.80.2.201.
[27]中华医学会呼吸病学分会.中国成人社区获得性肺炎诊断和治疗指南(2016年版)[J].中华结核和呼吸杂志,2016,64(4):253-279.DOI:10.3760/cma.j.issn.1001-0939.2016.04.005.Respiratory Society,Chinese Medical Association.Guidelines for diagnosis and treatment of adult community-acquired pneumonia in China(2016 edition)[J].Chinese Journal of Tuberculosis and Respiratory Diseases,2016,64(4):253-279.DOI:10.3760/cma.j.issn.1001-0939.2016.04.005.