四川大学华西医院2015～2017年艰难梭菌腹泻致病株的药物敏感性及其变迁
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摘要
目的总结华西医院艰难梭菌腹泻致病株的药物敏感性,比较其变迁,为艰难梭菌感染的治疗和防控提供基础参考数据。方法分离四川大学华西医院2015年8～12月(44株)和强化感染控制措施后2016年7月至2017年7月(29株)两个时间段中腹泻患者粪便样本艰难梭菌致病产毒株共73株,PCR扩增毒素基因后进行测序鉴定。琼脂对倍稀释法测定甲硝唑、万古霉素、克林霉素、莫西沙星、四环素、利福昔明、非达霉素和硝唑尼特9种药物的最低抑菌浓度(MIC)。分析艰难梭菌耐药性,并对比强化感染控制措施前后的耐药性变化。结果所有菌株对甲硝唑和万古霉素高度敏感,对克林霉素、莫西沙星、四环素、利福昔明的耐药率分别为79.5%、26.0%、27.4%、9.5%;对非达霉素和硝唑尼特高度敏感,两药的MIC范围均为<0.008～0.5mg/L。与2015年相比,强化感染控制措施后艰难梭菌对克林霉素耐药率(99.5%vs.44.8%)、莫西沙星耐药率(36.4%vs.10.3%)下降,差异均有统计学意义(P<0.05)。此外,发现一株罕见的利奈唑胺药物敏感性下降的菌株,其MIC达16mg/L。结论华西医院艰难梭菌对克林霉素和莫西沙星的耐药率较高,需限制使用;对甲硝唑和万古霉素高度敏感,可以经验性使用。
Objective To summarize the drug sensitivity and its trends of Clostridium difficile diarrhea pathogenic strains in a large tertiary hospital,so as to provide basic reference data for the treatment and control of Clostridium difficile infection.Methods There were 73 toxigenic isolates collected from fecal sample of diarrheal patients in West China Hospital of Sichuan University during two periods.One was from August to December in2015(44strains),and another was from July 2016 to July 2017(29strains).Enhanced nosocomial infection control measures were implemented during the second sample collection period.The toxin gene was amplified by PCR and sequenced for identification.Minimum inhibitory concentration(MIC)of metronidazole,vancomycin,clindamycin,moxifloxacin,rifaximin,fidaxomicin and linezolid were determined using agar double dilution method.We analyzed the drug resistance characteristics of Clostridiumdifficileand compared the changes of antimicrobial resistance before and after the enhanced control measures implementation.Results All 73 strains tested were sensitive to metronidazole and vancomycin.Resistance rate to clindamycin,moxifloxacin,tetracycline and rifaximin were79.5%,26.0%,27.4%,and 9.5%,respectively.Fidaxomicin and nitazoxanide were highly susceptible in vitro against these strains with MIC ranges<0.008-0.5mg/L(P<0.05).Resistance to clindamycin and moxifloxacin were significantly decreased after enhanced control measures implementation(resistance rates were 99.5% vs.44.8%,36.4% vs.10.3%,P<0.05).Additionally,isolate with decreased susceptibility to tinezolid as MIC16mg/L was found.Conclusion Clostridium difficile is highly resistant to clindamycin and quinolones.Since strains remain highly sensitive to metronidazole and vancomycin in our hospital,empirical application is reasonable without routine antimicrobial susceptibility testing.
Objective To summarize the drug sensitivity and its trends of Clostridium difficile diarrhea pathogenic strains in a large tertiary hospital,so as to provide basic reference data for the treatment and control of Clostridium difficile infection.Methods There were 73 toxigenic isolates collected from fecal sample of diarrheal patients in West China Hospital of Sichuan University during two periods.One was from August to December in2015(44strains),and another was from July 2016 to July 2017(29strains).Enhanced nosocomial infection control measures were implemented during the second sample collection period.The toxin gene was amplified by PCR and sequenced for identification.Minimum inhibitory concentration(MIC)of metronidazole,vancomycin,clindamycin,moxifloxacin,rifaximin,fidaxomicin and linezolid were determined using agar double dilution method.We analyzed the drug resistance characteristics of Clostridiumdifficileand compared the changes of antimicrobial resistance before and after the enhanced control measures implementation.Results All 73 strains tested were sensitive to metronidazole and vancomycin.Resistance rate to clindamycin,moxifloxacin,tetracycline and rifaximin were79.5%,26.0%,27.4%,and 9.5%,respectively.Fidaxomicin and nitazoxanide were highly susceptible in vitro against these strains with MIC ranges<0.008-0.5mg/L(P<0.05).Resistance to clindamycin and moxifloxacin were significantly decreased after enhanced control measures implementation(resistance rates were 99.5% vs.44.8%,36.4% vs.10.3%,P<0.05).Additionally,isolate with decreased susceptibility to tinezolid as MIC16mg/L was found.Conclusion Clostridium difficile is highly resistant to clindamycin and quinolones.Since strains remain highly sensitive to metronidazole and vancomycin in our hospital,empirical application is reasonable without routine antimicrobial susceptibility testing.
引文
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[6]ZHANG X,WANG X,YANG J,et al.Colonization of toxigenic Clostridium difficile among ICU patients:a prospective study.BMC Infect Dis,2016,16:397[2018-01-12].https://doi.org/10.1186/s12879-016-1729-2.
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[8]LEMEE L,DHALLUIN A,TESTELIN S,et al.Multiplex PCR targeting tpi(triose phosphate isomerase),tcdA(Toxin A),and tcdB(Toxin B)genes for toxigenic culture of Clostridium difficile.J Clin Microbial,2004,42(12):5710-5714.
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[10]Clinical and Laboratory Standards Institute.Methods for antimicrobial susceptibility testing of anaerobic bacteria.Approved standard M11-A8.Wayne,PA:CLSI.2016.
[11]UCAST.Breakpoint tables for interpretation of MICs and zone diameters(Version 7.1).The European Committee on Antimicrobial Susceptibility Testing,2017.
[12]O'CONNOR JR,GALANG MA,SAMBOL SP,et al.Rifampin and rifaximin resistance in clinical isolates of Clostridium difficile.Antimicrob Agents Chemother,2008,52(8):2813-2817.
[13]MAGILL SS,EDWARDS JR,BAMBERG W,et al.Multistate point-prevalence survey of health care-associated infections.N Engl J Med,2014,370(13):1198-1208.
[14]OFORI E,RAMAI D,DHAWAN M,et al.Communityacquired Clostridium difficile:epidemiology,ribotype,risk factors,hospital and intensive care unit outcomes,and current and emerging therapies.J Hosp Infect,2018,99(4):436-442.
[15]JAMAL WY,ROTIMI VO.Surveillance of antibiotic resistance among hospital-and community-acquired toxigenic Clostridium difficile isolates over 5-year period in Kuwait.PLoS One,2016,11(8):e161411[2018-01-12].https://doi.org/10.1371/journal.pone.0161411.
[16]LEFFLER DA,LAMONT JT.Clostridium difficile infection.N Engl J Med,2015,372(16):1539-1548.
[17]HUANG H,WEINTRAUB A,FANG H,et al.Antimicrobial susceptibility and heteroresistance in Chinese Clostridium difficile strains.Anaerobe,2010,16(6):633-635.
[18]吴爱武,唐海先,王丽斯,等.广州地区艰难梭菌耐药检测与耐药机制分析.广东医学,2015,36(12):1859-1863.
[19]WIECZORKIEWICZ JT,LOPANSRI B K,CHEKNIS A,et al.Fluoroquinolone and macrolide exposure predict Clostridium difficile infection with the highly fluoroquinolone-and macrolide-resistant epidemic C.difficile strain BI/NAP1/027.Antimicrob Agents Chemother,2015,60(1):418-423.
[20]KACHRIMANIDOU M,SARMOURLI T,SKOURA L,et al.Clostridium difficile infection:new insights into therapeutic options.Crit Rev Microbiol,2016,42(5):773-779.
[21]KNIGHT DR,GIGLIO S,HUNTINGTON PG,et al.Surveillance for antimicrobial resistance in Australian isolates of Clostridium difficile,2013-14.J Antimicrob Chemother,2015,70(11):2992-2999.
[22]CHILTON CH,CROWTHER GS,TODHUNTER SL,et al.Efficacy of alternative fidaxomicin dosing regimens for treatment of simulated Clostridium difficile infection in an in vitro human gut model.J Antimicrob Chemother,2015,70(9):2598-2607.
[23]CHOW V,KWONG T,SO E,et al.Surveillance of antibiotic resistance among common Clostridium difficile ribotypes in Hong Kong.Sci Rep,2017,7(1):17218[2018-01-12].https://www.nature.com/articles/s41598-017-17523-7.doi:10.1038/s41598-017-17523-7.
[24]BENDER JK,FLEIGE C,KLARE I,et al.Detection of a cfr(B)variant in German Enterococcus faecium clinical isolates and the impact on linezolid resistance in enterococcus spp..PLoS One,2016,11(11):e167042[2018-01-12].https://doi.org/10.1371/journal.pone.0184756.
[2]王晓辉,宗志勇.艰难梭菌感染现状与预防措施.中华临床感染病杂志,2016,9(3):213-223.
[3]MCDONALD LC,GERDING DN,JOHNSON S,et al.Clinical practice guidelines for Clostridium difficile infection in adults and children:2017update by the Infectious Diseases Society of America(IDSA)and Society for Healthcare Epidemiology of America(SHEA).Clin Infect Dis,2018,66(7):987-994.
[4]GOLDSTEIN EJ,BABAKHANI F,CITRON DM.Antimicrobial activities of fidaxomicin.Clin Infect Dis,2012,55(Suppl 2):S143-S148.
[5]WANG X,CAI L,YU R,et al.ICU-Onset Clostridium difficile infection in a university hospital in China:a prospective cohort study.PLoS One,2014,9(11):e111735[2018-01-12].https://doi.org/10.1371/journal.pone.0111735.
[6]ZHANG X,WANG X,YANG J,et al.Colonization of toxigenic Clostridium difficile among ICU patients:a prospective study.BMC Infect Dis,2016,16:397[2018-01-12].https://doi.org/10.1186/s12879-016-1729-2.
[7]YANG J,ZHANG X,LIU X,et al.Antimicrobial susceptibility of Clostridium difficile isolates from ICUcolonized patients revealed alert to ST-37(RT 017)isolates.Diagn Microbiol Infect Dis,2017,89(2):161-163.
[8]LEMEE L,DHALLUIN A,TESTELIN S,et al.Multiplex PCR targeting tpi(triose phosphate isomerase),tcdA(Toxin A),and tcdB(Toxin B)genes for toxigenic culture of Clostridium difficile.J Clin Microbial,2004,42(12):5710-5714.
[9]PERSSON S,TORPDAHL M,OLSEN KE.New multiplex PCR method for the detection of Clostridium difficile toxin A(tcdA)and toxin B(tcdB)and the binary toxin(cdtA/cdtB)genes applied to a Danish strain collection.Clin Microbiol Infect,2008,14(11):1057-1064.
[10]Clinical and Laboratory Standards Institute.Methods for antimicrobial susceptibility testing of anaerobic bacteria.Approved standard M11-A8.Wayne,PA:CLSI.2016.
[11]UCAST.Breakpoint tables for interpretation of MICs and zone diameters(Version 7.1).The European Committee on Antimicrobial Susceptibility Testing,2017.
[12]O'CONNOR JR,GALANG MA,SAMBOL SP,et al.Rifampin and rifaximin resistance in clinical isolates of Clostridium difficile.Antimicrob Agents Chemother,2008,52(8):2813-2817.
[13]MAGILL SS,EDWARDS JR,BAMBERG W,et al.Multistate point-prevalence survey of health care-associated infections.N Engl J Med,2014,370(13):1198-1208.
[14]OFORI E,RAMAI D,DHAWAN M,et al.Communityacquired Clostridium difficile:epidemiology,ribotype,risk factors,hospital and intensive care unit outcomes,and current and emerging therapies.J Hosp Infect,2018,99(4):436-442.
[15]JAMAL WY,ROTIMI VO.Surveillance of antibiotic resistance among hospital-and community-acquired toxigenic Clostridium difficile isolates over 5-year period in Kuwait.PLoS One,2016,11(8):e161411[2018-01-12].https://doi.org/10.1371/journal.pone.0161411.
[16]LEFFLER DA,LAMONT JT.Clostridium difficile infection.N Engl J Med,2015,372(16):1539-1548.
[17]HUANG H,WEINTRAUB A,FANG H,et al.Antimicrobial susceptibility and heteroresistance in Chinese Clostridium difficile strains.Anaerobe,2010,16(6):633-635.
[18]吴爱武,唐海先,王丽斯,等.广州地区艰难梭菌耐药检测与耐药机制分析.广东医学,2015,36(12):1859-1863.
[19]WIECZORKIEWICZ JT,LOPANSRI B K,CHEKNIS A,et al.Fluoroquinolone and macrolide exposure predict Clostridium difficile infection with the highly fluoroquinolone-and macrolide-resistant epidemic C.difficile strain BI/NAP1/027.Antimicrob Agents Chemother,2015,60(1):418-423.
[20]KACHRIMANIDOU M,SARMOURLI T,SKOURA L,et al.Clostridium difficile infection:new insights into therapeutic options.Crit Rev Microbiol,2016,42(5):773-779.
[21]KNIGHT DR,GIGLIO S,HUNTINGTON PG,et al.Surveillance for antimicrobial resistance in Australian isolates of Clostridium difficile,2013-14.J Antimicrob Chemother,2015,70(11):2992-2999.
[22]CHILTON CH,CROWTHER GS,TODHUNTER SL,et al.Efficacy of alternative fidaxomicin dosing regimens for treatment of simulated Clostridium difficile infection in an in vitro human gut model.J Antimicrob Chemother,2015,70(9):2598-2607.
[23]CHOW V,KWONG T,SO E,et al.Surveillance of antibiotic resistance among common Clostridium difficile ribotypes in Hong Kong.Sci Rep,2017,7(1):17218[2018-01-12].https://www.nature.com/articles/s41598-017-17523-7.doi:10.1038/s41598-017-17523-7.
[24]BENDER JK,FLEIGE C,KLARE I,et al.Detection of a cfr(B)variant in German Enterococcus faecium clinical isolates and the impact on linezolid resistance in enterococcus spp..PLoS One,2016,11(11):e167042[2018-01-12].https://doi.org/10.1371/journal.pone.0184756.