糖尿病足感染病原菌构成及耐药情况分析
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摘要
目的了解糖尿病足感染致病菌分布特点,研究临床常用药物敏感性,为治疗糖尿病足感染提供有力依据。方法回顾性分析本地区2016年1月至2018年12月收治的160例糖尿病足患者临床资料。无菌采集标本,并采用全自动微生物鉴定系统进行菌落鉴定。结果 160例患者中≤40岁,41～岁,51～岁,61～岁,71～岁和≥81岁患者分别为6、18、35、40、37和24例,其中60岁以上占63.13%。糖尿病病程≤5年、5～年、11～年和≥20年分别为41(25.63%)、48(30.00%)、45(28.13%)和26例(16.25%)。糖尿病足病程≤1个月、1～月、≥3个月分别为116(72.50%)、39(24.38%)和5例(3.13%)。糖尿病足足趾58例(36.25%)、足背39例(24.38%)、足底37例(23.13%)和足踝26例(16.25%)。鞋子不适52(32.50%)、运动后起泡38例(23.75%)、抓挠伤26例(16.25%)、贴膏药后破溃22例(13.75%)、刺划伤12例(7.50%)、其他原因10例(6.25%)。160份标本中126例呈阳性,阳性率78.75%。其中87份标本分离出单一病原菌,39份标本分离出2种病原菌,共计分离病原菌165株,其中革兰阳性菌83株,革兰阴性菌65株,真菌17株。革兰阳性菌对头孢唑啉、头孢吡肟、四环素、红霉素、阿奇霉素、诺氟沙星、环丙沙星、庆大霉素、阿米卡星和利福平的耐药率依次为54.55%、25.45%、72.29%、68.67%、49.40%、60.24%、40.96%、56.36%、9.09%和19.28%。金黄色葡萄球菌对头孢唑啉、头孢吡肟、四环素、红霉素、阿奇霉素、诺氟沙星、环丙沙星、庆大霉素和阿米卡星的耐药率依次为38.46%、15.38%、50.00%、42.31%、30.77%、46.15%、30.77%、42.31%和7.69%,未对利福平产生耐药性。革兰阴性菌对头孢他啶、头孢克肟、诺氟沙星、环丙沙星、庆大霉素、阿米卡星和亚胺培南的耐药率依次为47.69%、43.08%、53.85%、40.00%、52.31%、10.77%和1.54%。真菌对氟康唑、5-氟胞嘧啶、两性霉素B耐药率依次为33.33%、33.33%和11.11%,未对伏立康唑和伊曲康唑产生耐药。结论混合感染主要集中在Wagner分级3-4级糖尿病足患者,治疗时应考虑对金黄色葡萄球菌,粪肠球菌,肺炎链球菌和大肠埃希菌同时有效的药物。
Objectives To ascertain the distribution characteristics of pathogens causing a diabetic foot infection and their sensitivity to commonly used antibiotics in order to provide a strong basis for the treatment of diabetic foot infections. Methods Clinical data on 160 patients with a diabetic foot who were seen from January 2016 to December 2018 were retrospectively analyzed. Samples were collected aseptically and identified by an automated microbial identification system. Results Of the 160 patients, 6 were under the age of 40, 18 were ages 41-50, 35 were ages 51-60, 40 were ages 61-70, 37 were ages 71-80, and 24 were over the age of 81; 63.13% of patients were over the age of 60. Forty-one patients(25.63%) had diabetes for less than 5 years, 48(30.00%) had it for 5-10 years, 45(28.13%) had it for 11-20 years, and 26(16.25%) had it for longer than 20 years. One hundred and sixteen patients(72.50%) had a diabetic foot for less than 1 month, 39(24.38%) had it for 1-3 months, and 5(3.13%) had it for longer than 3 months. The affected area of the food was the toes in 58 patients(36.25%), the dorsum in 39(24.38%), the sole in 37(23.13%), and the ankle in 26 cases(16.25%). The etiology of a diabetic foot was shoe discomfort in 52 patients(32.50%), blistering after exercise in 38(23.75%), a scratch in 26(16.25%), ulceration after application of a patch in 22(13.75%), a puncture wound in 12(7.50%), and some other cause in 10(6.25%). Of 160 specimens, 126 tested positive at a rate of 78.75%. A single pathogen was isolated from 87 specimens, and two pathogens were simultaneously infected from 39 specimens. One hundred and sixty-five strains of pathogens were isolated, including 83 strains of Gram-positive bacteria, 65 strains of Gram-negative bacteria, and 17 strains of fungi. The resistance of Gram-positive bacteria to cefazolin was 54.55%(30/55), their resistance to cefepime was 25.45%(14/55), their resistance to tetracycline was 72.29%(60/83), their resistance to erythromycin was 68.67%(57/83), their resistance to azithromycin was 49.40%(69/83), their resistance to norfloxacin was 60.24%(50/83), their resistance to ciprofloxacin was 40.96%(34/83), their resistance to gentamicin was 56.36%(31/55), their resistance to amikacin was 9.09%(5/55), and their resistance to rifampicin was 19.28%(16/83). The resistance of Staphylococcus aureus to cefazolin was 38.46%, its resistance to cefepime was 15.38%, its resistance to tetracycline was 50.00%, its resistance to erythromycin was 42.31%, its resistance to azithromycin was 30.77%, its resistance to norfloxacin was 46.15%, its resistance to ciprofloxacin was 30.77%, its resistance to gentamicin was 42.31%, and its resistance to amikacin was 7.69%. Resistance to rifampicin was not noted. The resistance of Gram-negative bacteria to ceftazidime was 45.19%(61/135), their resistance to cefixime was 38.52%(52/135), their resistance to norfloxacin was 48.89%(66/135), their resistance to ciprofloxacin was 37.04%(50/135), their resistance to gentamicin was 46.67%(63/135), their resistance to amikacin was 10.37%(14/135), and their resistance to imipenem was 2.22%(3/135). The resistance of fungi to fluconazole was 35.29%(6/17), their resistance to 5-fluorocytosine was 35.29%(6/17), and their resistance to amphotericin B was 11.76%(2/17). Resistance to voriconazole or itraconazole was not noted. Conclusion Mixed infections were mainly concentrated in patients with a Wagner grade 3-4 diabetic foot ulcer. Simultaneous use of antibiotics effective against S. aureus, Enterococcus faecalis, S. pneumoniae, and Escherichia coli should be considered.
Objectives To ascertain the distribution characteristics of pathogens causing a diabetic foot infection and their sensitivity to commonly used antibiotics in order to provide a strong basis for the treatment of diabetic foot infections. Methods Clinical data on 160 patients with a diabetic foot who were seen from January 2016 to December 2018 were retrospectively analyzed. Samples were collected aseptically and identified by an automated microbial identification system. Results Of the 160 patients, 6 were under the age of 40, 18 were ages 41-50, 35 were ages 51-60, 40 were ages 61-70, 37 were ages 71-80, and 24 were over the age of 81; 63.13% of patients were over the age of 60. Forty-one patients(25.63%) had diabetes for less than 5 years, 48(30.00%) had it for 5-10 years, 45(28.13%) had it for 11-20 years, and 26(16.25%) had it for longer than 20 years. One hundred and sixteen patients(72.50%) had a diabetic foot for less than 1 month, 39(24.38%) had it for 1-3 months, and 5(3.13%) had it for longer than 3 months. The affected area of the food was the toes in 58 patients(36.25%), the dorsum in 39(24.38%), the sole in 37(23.13%), and the ankle in 26 cases(16.25%). The etiology of a diabetic foot was shoe discomfort in 52 patients(32.50%), blistering after exercise in 38(23.75%), a scratch in 26(16.25%), ulceration after application of a patch in 22(13.75%), a puncture wound in 12(7.50%), and some other cause in 10(6.25%). Of 160 specimens, 126 tested positive at a rate of 78.75%. A single pathogen was isolated from 87 specimens, and two pathogens were simultaneously infected from 39 specimens. One hundred and sixty-five strains of pathogens were isolated, including 83 strains of Gram-positive bacteria, 65 strains of Gram-negative bacteria, and 17 strains of fungi. The resistance of Gram-positive bacteria to cefazolin was 54.55%(30/55), their resistance to cefepime was 25.45%(14/55), their resistance to tetracycline was 72.29%(60/83), their resistance to erythromycin was 68.67%(57/83), their resistance to azithromycin was 49.40%(69/83), their resistance to norfloxacin was 60.24%(50/83), their resistance to ciprofloxacin was 40.96%(34/83), their resistance to gentamicin was 56.36%(31/55), their resistance to amikacin was 9.09%(5/55), and their resistance to rifampicin was 19.28%(16/83). The resistance of Staphylococcus aureus to cefazolin was 38.46%, its resistance to cefepime was 15.38%, its resistance to tetracycline was 50.00%, its resistance to erythromycin was 42.31%, its resistance to azithromycin was 30.77%, its resistance to norfloxacin was 46.15%, its resistance to ciprofloxacin was 30.77%, its resistance to gentamicin was 42.31%, and its resistance to amikacin was 7.69%. Resistance to rifampicin was not noted. The resistance of Gram-negative bacteria to ceftazidime was 45.19%(61/135), their resistance to cefixime was 38.52%(52/135), their resistance to norfloxacin was 48.89%(66/135), their resistance to ciprofloxacin was 37.04%(50/135), their resistance to gentamicin was 46.67%(63/135), their resistance to amikacin was 10.37%(14/135), and their resistance to imipenem was 2.22%(3/135). The resistance of fungi to fluconazole was 35.29%(6/17), their resistance to 5-fluorocytosine was 35.29%(6/17), and their resistance to amphotericin B was 11.76%(2/17). Resistance to voriconazole or itraconazole was not noted. Conclusion Mixed infections were mainly concentrated in patients with a Wagner grade 3-4 diabetic foot ulcer. Simultaneous use of antibiotics effective against S. aureus, Enterococcus faecalis, S. pneumoniae, and Escherichia coli should be considered.
引文
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[2] Jhamb S,Vangaveti VN,Malabu UH.Genetic and molecular basis of diabetic foot ulcers:Clinical review.[J].J Tis Viab,2016,25(4):229.
[3] Bonnet C,Carello C,Turvey MT.Diabetes and postural stability:review and hypotheses[J].J Mot Behav,2009,41(2):172-90.
[4] Boulton AJ.The diabetic foot:a global view[J].Diabetes Metab Res Rev,2000(16):s2-5.
[5] Noor S,Zubair M,Ahmad J.Diabetic foot ulcer-A review on pathophysiology,classification and microbial etiology[J].Diab Metab Synd Clin Res Rev,2015,9(3):192-9.
[6] Yekta Z,Pourali R,Nezhadrahim R,et al.Clinical and behavioral factors associated with management outcome in hospitalized patients with diabetic foot ulcer[J].Diab Metab Synd Obesity Targ Ther,2011(4):371-5.
[7] Unnikrishnan AG.Approach to a patient with a diabetic foot[J].Nat Med J India,2008,21(21):134-7.
[8] Zucchi P,Ferrari P,Spina ML.Diabetic foot from diagnosis to therapy[J].G Ita Nef,2005,22(Suppl 31):20-2.
[9] Peters EJG,Lavery LA,Armstrong DG.Diabetic lower extremity infection:Influence of physical,psychological,and social factors[J].J Diab Comp,2005,19(2):107-12.
[10] Dinh T,Veves A.Microvascular changes in the diabetic foot[J].2006,5(3):149-59.
[11] 张志.284例糖尿病足患者病例资料的回顾性分析[D].中南大学,2012.
[12] van Schie CH,Whalley A,Vileikyte L,et al.Efficacy of injected liquid silicone in diabetic foot to reduce risk factors for ulceration:a randomized double-blind placebo-controlled trial[J].Diab Care,2000,23(5):634-8.
[13] 范丽凤,陆菊明,郑亚光,等.糖尿病患者足溃疡的危险因素分析[J].中国糖尿病杂志,2006(6):435-7.
[14] 吕然然.2型糖尿病患者发生糖尿病足的危险因素分析[D].吉林大学,2017.
[15] Tiaka EK,Papanas N,Manolakis AC,et al.The role of hyperbaric oxygen in the treatment of diabetic foot ulcers[J].Angiology,2012,63(4):302.
[16] Karnafel W,Juskwa J,Maniewski R,et al.Microcirulation in the diabetic foot as measured by a multichannel laser Doppler instrument[J].Med Sci Monit,2002,8(7):137-44.
[17] Smith AG,Singleton JR.Impaired glucose tolerance and neuropathy[J].Neurol,2008,14(1):23-9.
[18] Davidson MH,Abate N,Ballantyne CM,et al.Ezetimibe/simvastatin compared with atorvastatin or rosuvastatin in lowering to specified levels both LDL-C and each of five other emerging risk factors for coronary heart disease:Non-HDL-cholesterol,TC/HDL-C,apolipoprotein B,apo-B/apo-AI,or C-reactive protein[J].J Clin Lipidol,2008,2(6):436-6.
[19] 赵文霞,李剑芳,邱凯锋.糖尿病足感染患者致病菌分布及药物敏感试验结果分析[J].中国医院用药评价与分析,2017,17(10):1425-7,1430.
[20] Raja NS.Microbiology of diabetic foot infections in a teaching hospital in Malaysia:a retrospective study of 194 cases[J].J Microb Immunol Infect,2007,40(1):39-44.
[21] 王超,邢诒雄,郭帅,等.糖尿病足患者感染病原菌的耐药情况及相关因素分析[J].中国病原生物学杂志,2018,13(2):202-9,212.
[22] Ertugrul BM,Oncul O,Tulek N,et al.A prospective,multi-center study:factors related to the management of diabetic foot infections.[J].Eur J Clin Microb Infect Dis,2012,31(9):2345-52.
[23] 孟晶茜,王建生,赵瑛瑛,等.尿路感染分离金黄色葡萄球菌的耐药性研究[J].中国病原生物学杂志,2017,12(2):165-8.
[24] 雷超奇.74例糖尿病足感染患者病原菌特点及药敏回顾性分析[D].北京中医药大学,2012.
[2] Jhamb S,Vangaveti VN,Malabu UH.Genetic and molecular basis of diabetic foot ulcers:Clinical review.[J].J Tis Viab,2016,25(4):229.
[3] Bonnet C,Carello C,Turvey MT.Diabetes and postural stability:review and hypotheses[J].J Mot Behav,2009,41(2):172-90.
[4] Boulton AJ.The diabetic foot:a global view[J].Diabetes Metab Res Rev,2000(16):s2-5.
[5] Noor S,Zubair M,Ahmad J.Diabetic foot ulcer-A review on pathophysiology,classification and microbial etiology[J].Diab Metab Synd Clin Res Rev,2015,9(3):192-9.
[6] Yekta Z,Pourali R,Nezhadrahim R,et al.Clinical and behavioral factors associated with management outcome in hospitalized patients with diabetic foot ulcer[J].Diab Metab Synd Obesity Targ Ther,2011(4):371-5.
[7] Unnikrishnan AG.Approach to a patient with a diabetic foot[J].Nat Med J India,2008,21(21):134-7.
[8] Zucchi P,Ferrari P,Spina ML.Diabetic foot from diagnosis to therapy[J].G Ita Nef,2005,22(Suppl 31):20-2.
[9] Peters EJG,Lavery LA,Armstrong DG.Diabetic lower extremity infection:Influence of physical,psychological,and social factors[J].J Diab Comp,2005,19(2):107-12.
[10] Dinh T,Veves A.Microvascular changes in the diabetic foot[J].2006,5(3):149-59.
[11] 张志.284例糖尿病足患者病例资料的回顾性分析[D].中南大学,2012.
[12] van Schie CH,Whalley A,Vileikyte L,et al.Efficacy of injected liquid silicone in diabetic foot to reduce risk factors for ulceration:a randomized double-blind placebo-controlled trial[J].Diab Care,2000,23(5):634-8.
[13] 范丽凤,陆菊明,郑亚光,等.糖尿病患者足溃疡的危险因素分析[J].中国糖尿病杂志,2006(6):435-7.
[14] 吕然然.2型糖尿病患者发生糖尿病足的危险因素分析[D].吉林大学,2017.
[15] Tiaka EK,Papanas N,Manolakis AC,et al.The role of hyperbaric oxygen in the treatment of diabetic foot ulcers[J].Angiology,2012,63(4):302.
[16] Karnafel W,Juskwa J,Maniewski R,et al.Microcirulation in the diabetic foot as measured by a multichannel laser Doppler instrument[J].Med Sci Monit,2002,8(7):137-44.
[17] Smith AG,Singleton JR.Impaired glucose tolerance and neuropathy[J].Neurol,2008,14(1):23-9.
[18] Davidson MH,Abate N,Ballantyne CM,et al.Ezetimibe/simvastatin compared with atorvastatin or rosuvastatin in lowering to specified levels both LDL-C and each of five other emerging risk factors for coronary heart disease:Non-HDL-cholesterol,TC/HDL-C,apolipoprotein B,apo-B/apo-AI,or C-reactive protein[J].J Clin Lipidol,2008,2(6):436-6.
[19] 赵文霞,李剑芳,邱凯锋.糖尿病足感染患者致病菌分布及药物敏感试验结果分析[J].中国医院用药评价与分析,2017,17(10):1425-7,1430.
[20] Raja NS.Microbiology of diabetic foot infections in a teaching hospital in Malaysia:a retrospective study of 194 cases[J].J Microb Immunol Infect,2007,40(1):39-44.
[21] 王超,邢诒雄,郭帅,等.糖尿病足患者感染病原菌的耐药情况及相关因素分析[J].中国病原生物学杂志,2018,13(2):202-9,212.
[22] Ertugrul BM,Oncul O,Tulek N,et al.A prospective,multi-center study:factors related to the management of diabetic foot infections.[J].Eur J Clin Microb Infect Dis,2012,31(9):2345-52.
[23] 孟晶茜,王建生,赵瑛瑛,等.尿路感染分离金黄色葡萄球菌的耐药性研究[J].中国病原生物学杂志,2017,12(2):165-8.
[24] 雷超奇.74例糖尿病足感染患者病原菌特点及药敏回顾性分析[D].北京中医药大学,2012.