摘要
目的了解我院嗜麦芽窄食单胞菌(Stenotrophomonas maltophilia, SMA)的耐药性及其呼吸道感染的危险因素、临床意义,分析影响呼吸道感染SMA患者转归的因素。
方法测定2009年5月-2010年3月分离到的65株SMA对4种抗菌药物米诺环素、复方新诺明、左氧氟沙星、亚胺培南的敏感性,进行耐药性分析。收集其中33例呼吸道感染SMA患者的性别、年龄、基础疾病、住院天数、分离出SMA前的住院时间、留置导管种类和数目、混合感染情况以及抗菌药物使用情况,及患者入院、其他细菌(除SMA外)培养阳性、SMA培养阳性第一天的体温、血压、呼吸频率、脉搏、血常规、肝功能、血气分析,进行APACHEⅡ评分(急性生理学及慢性健康状况评分Ⅱ,acute physiology and chronic health evaluationⅡ)。采用t检验和Spearman相关分析了解SMA感染的临床意义及转归的影响因素。
结果33例呼吸道感染SMA患者中,男25例,女8例;平均住院日为40.41±27.88天,培养出SMA前的平均住院日是24.41±15.51天。平均年龄为65.24±18.81岁,≥60岁者26例(78.78%)。基础疾病中血液系统疾病占10例(30.30%);恶性肿瘤8例(24.24%);慢性疾病9例(27.27%),三者共达81.81%。所有的患者都有深静脉留置针,导管种类多样包括13例(39.39%)患者留有胃管,11例(33.33%)留有尿管,10例(30.30%)行中心静脉置管,9例(27.27%)行气管插管辅助通气。33例患者合并真菌感染19例(57.58%),鲍曼不动杆菌18例(54.55%),铜绿假单胞菌16例(48.48%),阴沟杆菌12例(36.36%),耐甲氧西林凝固酶阴性葡萄球菌8例(24.24%)。感染SMA之前,27例患者(81.82%)使用了加酶抑制剂抗菌素,24例(72.73%)使用了碳氢酶希类抗菌素,20例(60.61%)进行了抗真菌治疗,10例(30.30%)使用了利奈唑胺,喹诺酮类的使用为9例(27.27%)。转归:痊愈3例(9.09%),显效11例(33.33%),进步1例(3.03%),无效18例(54.55%)。患者入院、其他细菌(除SMA外)培养阳性、SMA培养阳性第一天的APACHEⅡ评分分别为16.34±5.07、18.96±5.36、19.8±6.62*,两两间进t检验,仅入院第一天与SMA培养阳性第一天的APACHEⅡ评分存在统计学差异(P<0.05)。患者入院第一天APACHEⅡ评分≥15分者22例,其中无效12例(71.43%)。入院第一天APACHEⅡ评分与转归两者存在相关性,相关系数为0.382*(P<0.05)。65株SMA药敏结果为:米诺环素、复方新诺明、左氧氟沙星、亚胺培南的耐药率分别为10.77%、13.85%、32.31%、100%.
结论①住院时间长;年龄大;危重的基础疾病;导管的留置;存在混合感染,大量高档抗生素的使用;APACHEⅡ评分>15分可能为呼吸道感染SMA的危险因素。②APACHEⅡ评分分值越高,呼吸道感染SMA死亡率越高。③呼吸道SMA培养阳性可能提示患者病情加重。④我院临床治疗嗜麦芽窄食单胞菌感染可首选米诺环素、复方新诺明进行经验治疗。
Objective:Aimed to analyze resistance of S. maltophilia, identify predictors and clinical sense of positive cultures of S. maltophilia isolated from respiratory tract, and the effective factors of the outcomes.
Methods:Analyzing the resistance of 65 strains of S.maltophilia to Minocycline, Trimethoprim+Sulfamethoxazole, Levofloxacin and Imipenem, from the Second hospital of shanxi medical university between May 2009 and March 2010. Patients'sexuality, age, severity of illness, length of hospitalization, number/types of indwelling catheters, concomitant infections and prior antibiotic exposure of 33 patients with positive cultures of S. maltophilia isolated from respiratory tract, were collected as a retrospective cohort study. Temperature, pressure, breathing rate, pulse, blood routine, hepatic function, blood gas analysis of the first day of admission, positive culture of S. maltophilia and others microbes (except S. maltophilia) were collected to assesse severities of illness by the APACHE II (acute physiology and chronic health evaluation II) score. T test and Spearman correlation analysis were used to determine the clinical significance of positive cultures of S. maltophilia isolated from respiratory tract and the effective factors of the outcomes.
Results:Twenty-five males and eight females were studied. The mean (SD) length of hospitalization and it prior to positive cultures of S. maltophilia were 40.41±27.88,24.41±15.51, respectively. The mean(SD) age was 65.24+18.81.≥60 year was 78.78%. Presence of underlying illness included hematological system disease 10 (30.30%), malignant tumor 8 (24.24%) chronic disease9(27.27%). The sum was up to 81.81%. All patients had intravenous lines. Types of indwelling catheters were various, including gastric tube 13 (39.39%), urinary catheters 11 (33.33%), central venous catheters10(30.30%), tracheal intubation 9(27.27%). Polymicrobial cultures (concurrent with S. maltophilia) were common and including fungus 19 (57.58%) Acinetobacter baumannii 18 (54.55%), Pseudomonas aeruginosa 16 (48.48%), Bacterium cloacae12 (36.36%), methicillin-resistant Staphylococcus aureus 8 (24.24%). All patients had recept the treatment with kinds of broad-spectrum antibiotics, prior to positive culture of S. maltophilia, including penicillins withβ-lactamase inhibitors 81.82%, carbapenems 72.73%, antifungal agents 60.61%, linezolid 30.30%, quinolones 27.27%.3 in 33 patients recovered themselves, while relieved 33.33%, improved 3.03%, mortality 54.55%. The ApacheⅡ(acute physiology and chronic health evaluationⅡ) score on the first day of admission, positive culture of S. maltophilia and others microbes (except S. maltophilia) were 16.34±5.07、18.96±5.36、19.8±6.62*, respectively. T test were performed separately for each variable. The ApacheⅡscores on the first day of admission and positive culture of S. maltophilia with P values of<0.05 were considered statistically significant. The number of patients with APACHEⅡscores on the first day of admission≥15 was 22, in which 12 (71.43%) patients with positive cultures isolated from respiratory tract were dead. The outcome was associated with APACHEⅡscores on admission, with spearman coefficient correlation 0.382* (P<0.05). The resistant rate of S. maltophilia to Minocycline, Trimethoprim+Sulfamethoxazole, Levofloxacin and Imipenem were 17.39%、21.74%、33.82%、100%, respectively.
Conclusion:①prolonged hospitalisation, older age, presence of severious underlying illness, presence of types of indwelling catheters, Polymicrobial cultures, previous therapy with broad spectrum antibiotics, APACHEⅡscores≥15 may be the risk factors for S. maltophilia infection.②Regarding to patients with Positive culture of S. maltophilia isolated from respiratory tract, The higher of the APACHEⅡscores are, the higher the mortality rate become.③Positive culture of S. maltophilia isolated from respiratory tract could suggest that severity of illness has got worse.④Minocycline and Trimethoprim+sulfamethoxazole are the optimal antibiotics of choice for the treatment of S. maltophilia infections in our hospital.
引文
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