急性白血病患者血流感染病原菌及其耐药性六年的变迁
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摘要
目的了解急性白血病患者血流感染病原菌、耐药情况及其变化趋势,为其临床感染治疗提供依据。方法回顾性分析2011年1月—2016年12月某院血液科收治的急性白血病患者血培养获得的病原菌及其药敏结果,比较2011—2013年与2014—2016年病原菌分布及其耐药性变化。结果 221例急性白血病血流感染患者共检出病原菌229株,其中革兰阳性菌68株(29.69%),革兰阴性菌154株(67.25%),真菌7株(3.06%)。前后三年均以大肠埃希菌为主,其次为凝固酶阴性葡萄球菌(CNS)或铜绿假单胞菌。铜绿假单胞菌的构成比从7.08%(8/113)上升至12.07%(14/116),真菌构成比由1.77%(2/113)上升至4.31%(5/116),前后三年病原菌构成比较,差异无统计学意义(P>0.05);前后三年主要病原菌对常用抗菌药物的耐药率比较,差异均无统计学意义(均P>0.05)。革兰阳性菌对万古霉素、利奈唑胺、奎奴普丁/达福普汀保持100%敏感,但CNS中有64.29%~69.57%的菌株耐甲氧西林,金黄色葡萄球菌中有55.56%~66.67%的菌株耐甲氧西林。大肠埃希菌及肺炎克雷伯菌对头孢菌素类抗生素的耐药率较高,对第三代头孢菌素类抗生素的耐药率达25.00%~75.61%;已检出对亚胺培南、厄他培南耐药的大肠埃希菌菌株。2011—2013年热带假丝酵母菌对伊曲康唑、伏立康唑的耐药率均为0,2014—2016年均上升至25%。所有检出真菌对两性霉素B、酮康唑、制霉菌素均敏感。结论大肠埃希菌是急性白血病患者血流感染的主要致病菌,铜绿假单胞菌有增长的趋势,真菌感染比例有所增加,临床应根据血培养及药敏结果合理使用抗菌药物。
Objective To understand pathogens causing bloodstream infection( BSI) in patients with acute leukemia( AL),as well as trend of antimicrobial resistance of pathogens,and provide evidence for clinical anti-infection treatment.Methods Pathogens and antimicrobial susceptibility of pathogens isolated from blood culture of patients with AL in the department of hematology in a hospital from January 2011 to December 2016 were analyzed,distribution and antimicrobial resistance of pathogens between 2011-2013 and 2014-2016 were compared. Results 229 strains of pathogens were isolated from 221 AL patients with BSI,including 68 strains( 29. 69%) of gram-positive bacteria,154( 67. 25%) gram-negative bacteria,and 7( 3.06%) fungus. Escherichia coli( E. coli) was dominant strain in both the first and second three years,followed by coagulase-negative staphylococcus( CNS) and Pseudomonas aeruginosa( P. aeruginosa). Constituent ratio of P.aeruginosa increased from 7. 08%( 8/113) to 12. 07%( 14/116),fungi increased from 1. 77%( 2/113) to 4. 31%( 5/116),difference in constituent ratio of pathogens and antimicrobial susceptibility between the first and second three years were not statistically significant( both P > 0.05). Susceptibility of gram-positive bacteria to vancomycin,linezolid,and quinupristin/dalfopristin were all 100%,64.29%-69.57% of CNS and 55.56%-66.67% of Staphylococcus aureus were methicillin-resistant strains. Resistance rates of E. coli and Klebsiella pneumoniae to cephalosporins were high,resistance rates to third generation cephalosporins were 25.00%-75.61%; imipenem-and ertapenem-resistant E. coli were detected. Resistance rates of Candida tropicalis to itraconazole and voriconazole increased from 0 in 2011-2013 to 25% in 2014-2016. All the detected fungi were susceptible to amphotericin B,ketoconazole,and nystatin. Conclusion E.coli is the major pathogen causing BSI in AL paptients,P. aeruginosa has a growing trend,proportion of fungal infection has increased,rational use of antimicrobial agents should be based on blood culture and antimicrobial susceptibility testing result.
Objective To understand pathogens causing bloodstream infection( BSI) in patients with acute leukemia( AL),as well as trend of antimicrobial resistance of pathogens,and provide evidence for clinical anti-infection treatment.Methods Pathogens and antimicrobial susceptibility of pathogens isolated from blood culture of patients with AL in the department of hematology in a hospital from January 2011 to December 2016 were analyzed,distribution and antimicrobial resistance of pathogens between 2011-2013 and 2014-2016 were compared. Results 229 strains of pathogens were isolated from 221 AL patients with BSI,including 68 strains( 29. 69%) of gram-positive bacteria,154( 67. 25%) gram-negative bacteria,and 7( 3.06%) fungus. Escherichia coli( E. coli) was dominant strain in both the first and second three years,followed by coagulase-negative staphylococcus( CNS) and Pseudomonas aeruginosa( P. aeruginosa). Constituent ratio of P.aeruginosa increased from 7. 08%( 8/113) to 12. 07%( 14/116),fungi increased from 1. 77%( 2/113) to 4. 31%( 5/116),difference in constituent ratio of pathogens and antimicrobial susceptibility between the first and second three years were not statistically significant( both P > 0.05). Susceptibility of gram-positive bacteria to vancomycin,linezolid,and quinupristin/dalfopristin were all 100%,64.29%-69.57% of CNS and 55.56%-66.67% of Staphylococcus aureus were methicillin-resistant strains. Resistance rates of E. coli and Klebsiella pneumoniae to cephalosporins were high,resistance rates to third generation cephalosporins were 25.00%-75.61%; imipenem-and ertapenem-resistant E. coli were detected. Resistance rates of Candida tropicalis to itraconazole and voriconazole increased from 0 in 2011-2013 to 25% in 2014-2016. All the detected fungi were susceptible to amphotericin B,ketoconazole,and nystatin. Conclusion E.coli is the major pathogen causing BSI in AL paptients,P. aeruginosa has a growing trend,proportion of fungal infection has increased,rational use of antimicrobial agents should be based on blood culture and antimicrobial susceptibility testing result.
引文
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[13]郭金华,张爱云,郭金刚.白血病患者并发革兰菌血流感染临床特点及耐药情况的研究[J/OL].中华实验和临床感染病杂志:电子版,2015,10(1):35-36.
[14]Oppenheim BA.The changing pattern of infection in neutropenic patients[J].J Antimicrob Chemother,1998,41(Suppl D):7-11.
[15]Paul M,Yahav D,Bivvas A,et al.Anti-pseudomonal beta-lactams for the initial,empirical,treatment of febrile neutropenia:comparison of beta-lactams[J].Cochrane Database Syst Rev,2010,11:CD005197.
[16]Greene LM,Nolan DP,Regan-Komito D,et al.Inhibition of latestage autophagy synergistically enhances pyrrolo-1,5-benzoxazepine-6-induced apoptotic cell death in human colon cancer cells[J].Int J Oncol,2013,43(13):927-935.
[17]Prasad S,Kim JH,Gupta SC,et al.Targeting death receptors for TRAIL by agents designed by Mother Nature[J].Trends Pharmacol Sci,2014,35(10):520-536.
[18]苗立群,常敏风,李丽,等.大肠埃希菌和肺炎克雷伯菌ESBLs检测及耐药性分析[J].微生物学杂志,2009,29(2):97-100.
[19]刘慧,张虹丽,孙润月,等.白血病患者真菌感染分布及药敏分析[J].中华医院感染学杂志,2015,25(4):813-815.
[2]刘学花,吴琦.导管相关性血流感染的病原菌分布及临床特征分析[J].天津医药,2013,41(8):810-811.
[3]张之南,沈悌.白血病诊断及疗效标准[M].3版.北京:科学出版社,2007:261-263.
[4]Clinical and Laboratory Standard Institute.Performance standards for antimicrobial susceptibility testing[S].M100-S18,CLSI,2008:100.
[5]陈惠仁.儿童急性淋巴细胞白血病预后和治疗研究进展[J].山东医药,2011,51(12):89-90.
[6]Pawar RD,Williams T,Khera R,et al.Inflammatory response following neutrophil recovery postchemotherapy in acute myeloid leukemia cases without evidence of infection:role of homing of neutrophils[J].J Blood Med,2014,5:37-41.
[7]Franke NE,Niewerth D,Assaraf YG,et al.Impaired bortezomib binding to mutantβ5 subunit of the proteasome is the underlying basis for bortezomib resistance in leukemia cells[J].Leukemia,2012,6(4):757-768.
[8]汪复,朱德妹,胡付品,等.2012年中国CHINET细菌耐药性监测[J].中国感染与化疗杂志,2013,13(5):321-330.
[9]陈黎黎,陈永平,戴春蕾,等.白血病患者并发院内败血症的病原菌分析[J].医学研究杂志,2013,1(1):154-157.
[10]张广吉,李巍,林冬,等.急性白血病患者血流感染的临床特征及治疗策略[J].中华医院感染学杂志,2016,26(17):3959-3962.
[11]向永胜,江炳东,杨波,等.急性白血病患者血流感染的病原菌分布特点及耐药分析[J/OL].中华实验和临床感染病杂志:电子版,2016,10(4):440-444.
[12]刘育欣,王婷婷,肖玉玲,等.不同临床分类的急性白血病患者病原学数据分析[J].现代预防医学,2016,43(10):1903-1906.
[13]郭金华,张爱云,郭金刚.白血病患者并发革兰菌血流感染临床特点及耐药情况的研究[J/OL].中华实验和临床感染病杂志:电子版,2015,10(1):35-36.
[14]Oppenheim BA.The changing pattern of infection in neutropenic patients[J].J Antimicrob Chemother,1998,41(Suppl D):7-11.
[15]Paul M,Yahav D,Bivvas A,et al.Anti-pseudomonal beta-lactams for the initial,empirical,treatment of febrile neutropenia:comparison of beta-lactams[J].Cochrane Database Syst Rev,2010,11:CD005197.
[16]Greene LM,Nolan DP,Regan-Komito D,et al.Inhibition of latestage autophagy synergistically enhances pyrrolo-1,5-benzoxazepine-6-induced apoptotic cell death in human colon cancer cells[J].Int J Oncol,2013,43(13):927-935.
[17]Prasad S,Kim JH,Gupta SC,et al.Targeting death receptors for TRAIL by agents designed by Mother Nature[J].Trends Pharmacol Sci,2014,35(10):520-536.
[18]苗立群,常敏风,李丽,等.大肠埃希菌和肺炎克雷伯菌ESBLs检测及耐药性分析[J].微生物学杂志,2009,29(2):97-100.
[19]刘慧,张虹丽,孙润月,等.白血病患者真菌感染分布及药敏分析[J].中华医院感染学杂志,2015,25(4):813-815.