输尿管结石患者术后医院感染病原菌与影响因素分析
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摘要
目的探讨输尿管镜治疗输尿管结石患者术后医院感染的临床特点与影响因素。方法回顾性分析2014年1月-2017年6月于医院行输尿管镜治疗的输尿管结石术患者1 486例的临床资料。分析感染患者病原菌与耐药情况,研究患者性别、年龄、合并高血压、合并冠心病、合并糖尿病、结石直径、输尿管结石部位、手术时间、住院时间及术前使用抗菌药物等临床资料,归纳输尿管结石患者术后医院感染的影响因素。结果输尿管结石患者术后医院感染率为3.77%(56/1 486);共培养分离病原菌87株,其中革兰阴性菌49株占56.32%,革兰阳性菌32株占36.78%,真菌6株占6.90%;以大肠埃希菌、肺炎克雷伯菌、铜绿假单胞菌和金黄色葡萄球菌、粪肠球菌为主。大肠埃希菌对头孢曲松和头孢他啶耐药性较强;肺炎克雷伯菌对头孢吡肟和美罗培南耐药性较强,铜绿假单胞菌对左氧氟沙星和头孢曲松耐药性较强;未检出对氨苄西林耐药的肺炎克雷伯菌;金黄色葡萄球菌对青霉素G和左氧氟沙星耐药性较强;粪肠球菌对青霉素G和利福平耐药性较强,均对万古霉素和替考拉宁敏感;住院时间、手术时间、年龄及合并糖尿病是输尿管结石患者术后医院感染影响因素,术前使用抗菌药物为保护因素(P<0.05)。结论输尿管结石患者术后医院感染病原菌以革兰阴性菌为主,术后医院感染影响因素较多,应采取针对性预防措施,合理应用抗菌药物。
OBJECTIVE To investigate the clinical characteristics and influencing factors of nosocomial infection after ureteroscopic treatment of ureteral calculi. METHODS The clinical data of 1 486 patients with ureteral calculi treated by ureteroscopy from Jan. 2014 to Jun. 2017 were retrospectively analyzed. The pathogens and drug resistance of the infected patients were analyzed. The clinical data of the patients such as gender, age, hypertension, coronary heart disease, diabetes mellitus, stone diameter, location of ureteral calculi, operation time, hospitalization time and preoperative antibiotics were studied. The influencing factors of nosocomial infection in patients with ureteral calculi were summarized. RESULITS The nosocomial infection rate after ureteral calculi surgery was 3.77%(56/1 486). 87 strains of pathogens were isolated, including 49 strains of Gram-negative bacteria(56.32%), 32 strains of Gram-positive bacteria(36.78%) and 6 strains of fungi(6.90%). Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis were the main pathogens. E coli showed relatively high resistance to ceftriaxone and ceftazidime, K pneumoniae was more resistant to cefepime and meropenem, and P aeruginosa was more resistant to levofloxacin and ceftriaxone. No ampicillin-resistant K pneumoniae strain was detected. S aureus was more resistant to penicillin G and levofloxacin. E faecalis were resistant to penicillin G and rifampicin, and sensitive to vancomycin and teicoplanin. Hospitalization time, operation time, age and diabetes mellitus were the influencing factors of postoperative nosocomial infection in patients with ureteral calculi. Preoperative use of antibiotics was the protective factor(P<0.05). CONCLUSION Gram-negative bacteria are the main pathogens of nosocomial infection in patients with ureteral calculi after operation. There are many factors affecting postoperative nosocomial infection. Targeted preventive measures should be taken to rationalize the use of antibiotics.
OBJECTIVE To investigate the clinical characteristics and influencing factors of nosocomial infection after ureteroscopic treatment of ureteral calculi. METHODS The clinical data of 1 486 patients with ureteral calculi treated by ureteroscopy from Jan. 2014 to Jun. 2017 were retrospectively analyzed. The pathogens and drug resistance of the infected patients were analyzed. The clinical data of the patients such as gender, age, hypertension, coronary heart disease, diabetes mellitus, stone diameter, location of ureteral calculi, operation time, hospitalization time and preoperative antibiotics were studied. The influencing factors of nosocomial infection in patients with ureteral calculi were summarized. RESULITS The nosocomial infection rate after ureteral calculi surgery was 3.77%(56/1 486). 87 strains of pathogens were isolated, including 49 strains of Gram-negative bacteria(56.32%), 32 strains of Gram-positive bacteria(36.78%) and 6 strains of fungi(6.90%). Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis were the main pathogens. E coli showed relatively high resistance to ceftriaxone and ceftazidime, K pneumoniae was more resistant to cefepime and meropenem, and P aeruginosa was more resistant to levofloxacin and ceftriaxone. No ampicillin-resistant K pneumoniae strain was detected. S aureus was more resistant to penicillin G and levofloxacin. E faecalis were resistant to penicillin G and rifampicin, and sensitive to vancomycin and teicoplanin. Hospitalization time, operation time, age and diabetes mellitus were the influencing factors of postoperative nosocomial infection in patients with ureteral calculi. Preoperative use of antibiotics was the protective factor(P<0.05). CONCLUSION Gram-negative bacteria are the main pathogens of nosocomial infection in patients with ureteral calculi after operation. There are many factors affecting postoperative nosocomial infection. Targeted preventive measures should be taken to rationalize the use of antibiotics.
引文
[1] Wang Q,Cai M,Li Z L,et al.Treatment of upper ureteral calculi with ureteroscope after anterograde low-pressure irrigation by percutaneous nephrostomy fistulation:a report of 58 cases[J].Med J of Chin Peo Liber Army,2016,41(2):140-143.
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[5] Patel N,Shi W,Liss M,et al.Multidrug-resistant bacteriuria before percutaneous nephrolithotomy predicts for postoperative infectious complications[J].J Endourol,2015,29(5):531-536.
[6] 李辉,王伟高,谢波.输尿管镜钬激光碎石术对输尿管结石术患者发生感染的可行性及安全性研究[J].中华医院感染学杂志,2015,25(8):1857-1859.
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[8] Xu Y,Lu Y,Li J,et al.A meta-analysis of the efficacy of ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy on ureteral calculi[J].Acta Cir Bras,2014,29(5):346-352.
[9] Sancak EB,Kilinc MF,Yucebas SC.Evaluation with decision tree of efficacy and safety of semirigid ureteroscopy in the treatment of proximal ureteral calculi[J].Urol Int,2017,99(3):320-325.
[10] 中华人民共和国卫生部.医院感染诊断标准(试行)[J].中华医学杂志,2001,81(5):314-320.
[11] Kim SW,Ahn JH,Yim SU,et al.Clinical factors associated with postoperative hydronephrosis after ureteroscopic lithotripsy[J].Investig Clin Urol,2016,57(5):343-350.
[12] 杨沙沙,王喜仁,韩杰.美国CLSI抗菌药物敏感试验操作标准(2010年版)部分变更内容[J].中国感染控制杂志,2010,9(4):303-304.
[13] Kubota H,Takahashi S,Monzawa S,et al.Pictorial review of orthotopic neobladder reconstruction:indication,normal postsurgical anatomy,and complications[J].Abdom Radiol (NY).2016,41(2):356-367.
[14] Mohey A ,Alhefnawy M ,Mahmoud M ,et al.Fluoroless-ureteroscopy for definitive management of distal ureteral calculi:randomized controlled trial[J].Can J Urol,2018,25(1):9205-9209.
[15] 龙清志,李翔,贺大林,等.输尿管镜碎石术治疗肾和输尿管结石2150例的并发症分析[J].现代泌尿外科杂志,2016,21(8):606-609.
[16] Yan Z,Xie G,Yuan H,et al.Modular flexible ureteroscopy and holmium laser lithotripsy for the treatment of renal and proximal ureteral calculi:a single-surgeon experience of 382 cases[J].Exp Ther Med,2015,10(4):1467-1471.
[17] 晏旭东,谭琳,张可帅,等.输尿管结石术后医院感染的病原菌及其耐药性分析[J].中国卫生检验杂志,2014,24(9):1349-1351.
[18] Ercil H,Alma E,Bas O,et al.Safety and efficacy of pneumatic lithotripters versus holmium laser on multiple ureteral calculi[J].Arch Iran Med,2016,19(11):786-790.
[19] 赵书润,鹿占鹏.后腹腔镜与经皮肾镜用于复杂性输尿管上段结石治疗的术后创伤程度比较[J].海南医学院学报,2016,22(12):1246-1249.
[20] 钱永,王肖,刘彬,等.体外冲击波和输尿管镜治疗输尿管结石疗效评价的Meta分析[J].蚌埠医学院学报,2015,40(2):180-186.
[21] Martov A,Gravas S,Etemadian M,et al.Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal:a matched case-control analysis on antibiotic prophylaxis from the CROES URS global study[J].J Endourol,2015,29(2):171-180.
[22] 廖尚范,卢东明,伊岱旭,等.输尿管镜下钬激光碎石与气压弹道碎石术治疗输尿管结石的效果比较[J].中国现代医生,2016,54(22):40-42.
[23] Liu WG.AB093.Treatment of upper ureteral calculi with trans-ureteroscopic holmium laser lithotripsy[J].Transl Androl Urol,2015,4(1):250-257.
[24] 纪翠雅,林学慧,文智,等.输尿管上段结石微创治疗术后医院感染的临床分析[J].中华医院感染学杂志,2015,25(17):4006-4008.
[25] Ge H,Zheng X,Hou X,et al.Bilateral same-session ureteroscopy for treatment of ureteral calculi:a systematic review and meta-analysis.[J].J Endourol,2016,30(11):1169-1179.
[26] Assimos DG.Re:modular flexible ureteroscopy and holmium laser lithotripsy for the treatment of renal and proximal ureteral calculi:a single-surgeon experience of 382 cases[J].J Urol,2016,195(5):1492-1493.
[2] Zhang LJ,Ye XJ,Huang XB,et al.Comparison of tubeless-percutaneous nephrolithotomy and ureteroscopic lithotripsy in treatment of upper-ureteral calculi sized ≥ 1.5 cm[J].Beijing Da Xue Xue Bao Yi Xue Ban,2015,47(1):170-174.
[3] Cetinel AC,Cahit S,Guzel R,et al.E108 emergency vs elective ureteroscopic management of obstructing ureteral calculi:comparative evaluation of two different approaches[J].Eur Urol Suppl,2015,14(4):39-39.
[4] Jiang JT,Li WG,Zhu YP,et al.Comparison of the clinical efficacy and safety of retroperitoneal laparoscopic ureterolithotomy and ureteroscopic holmium laser lithotripsy in the treatment of obstructive upper ureteral calculi with concurrent urinary tract infections[J].Lasers Med Sci,2016,31(5):915-920.
[5] Patel N,Shi W,Liss M,et al.Multidrug-resistant bacteriuria before percutaneous nephrolithotomy predicts for postoperative infectious complications[J].J Endourol,2015,29(5):531-536.
[6] 李辉,王伟高,谢波.输尿管镜钬激光碎石术对输尿管结石术患者发生感染的可行性及安全性研究[J].中华医院感染学杂志,2015,25(8):1857-1859.
[7] Utangac MM,Sancaktutar AA,Tepeler A.Micro-ureteroscopy for the treatment of distal ureteral calculi in children[J].J Pediatr Surg,2017,52(3):512-516.
[8] Xu Y,Lu Y,Li J,et al.A meta-analysis of the efficacy of ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy on ureteral calculi[J].Acta Cir Bras,2014,29(5):346-352.
[9] Sancak EB,Kilinc MF,Yucebas SC.Evaluation with decision tree of efficacy and safety of semirigid ureteroscopy in the treatment of proximal ureteral calculi[J].Urol Int,2017,99(3):320-325.
[10] 中华人民共和国卫生部.医院感染诊断标准(试行)[J].中华医学杂志,2001,81(5):314-320.
[11] Kim SW,Ahn JH,Yim SU,et al.Clinical factors associated with postoperative hydronephrosis after ureteroscopic lithotripsy[J].Investig Clin Urol,2016,57(5):343-350.
[12] 杨沙沙,王喜仁,韩杰.美国CLSI抗菌药物敏感试验操作标准(2010年版)部分变更内容[J].中国感染控制杂志,2010,9(4):303-304.
[13] Kubota H,Takahashi S,Monzawa S,et al.Pictorial review of orthotopic neobladder reconstruction:indication,normal postsurgical anatomy,and complications[J].Abdom Radiol (NY).2016,41(2):356-367.
[14] Mohey A ,Alhefnawy M ,Mahmoud M ,et al.Fluoroless-ureteroscopy for definitive management of distal ureteral calculi:randomized controlled trial[J].Can J Urol,2018,25(1):9205-9209.
[15] 龙清志,李翔,贺大林,等.输尿管镜碎石术治疗肾和输尿管结石2150例的并发症分析[J].现代泌尿外科杂志,2016,21(8):606-609.
[16] Yan Z,Xie G,Yuan H,et al.Modular flexible ureteroscopy and holmium laser lithotripsy for the treatment of renal and proximal ureteral calculi:a single-surgeon experience of 382 cases[J].Exp Ther Med,2015,10(4):1467-1471.
[17] 晏旭东,谭琳,张可帅,等.输尿管结石术后医院感染的病原菌及其耐药性分析[J].中国卫生检验杂志,2014,24(9):1349-1351.
[18] Ercil H,Alma E,Bas O,et al.Safety and efficacy of pneumatic lithotripters versus holmium laser on multiple ureteral calculi[J].Arch Iran Med,2016,19(11):786-790.
[19] 赵书润,鹿占鹏.后腹腔镜与经皮肾镜用于复杂性输尿管上段结石治疗的术后创伤程度比较[J].海南医学院学报,2016,22(12):1246-1249.
[20] 钱永,王肖,刘彬,等.体外冲击波和输尿管镜治疗输尿管结石疗效评价的Meta分析[J].蚌埠医学院学报,2015,40(2):180-186.
[21] Martov A,Gravas S,Etemadian M,et al.Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal:a matched case-control analysis on antibiotic prophylaxis from the CROES URS global study[J].J Endourol,2015,29(2):171-180.
[22] 廖尚范,卢东明,伊岱旭,等.输尿管镜下钬激光碎石与气压弹道碎石术治疗输尿管结石的效果比较[J].中国现代医生,2016,54(22):40-42.
[23] Liu WG.AB093.Treatment of upper ureteral calculi with trans-ureteroscopic holmium laser lithotripsy[J].Transl Androl Urol,2015,4(1):250-257.
[24] 纪翠雅,林学慧,文智,等.输尿管上段结石微创治疗术后医院感染的临床分析[J].中华医院感染学杂志,2015,25(17):4006-4008.
[25] Ge H,Zheng X,Hou X,et al.Bilateral same-session ureteroscopy for treatment of ureteral calculi:a systematic review and meta-analysis.[J].J Endourol,2016,30(11):1169-1179.
[26] Assimos DG.Re:modular flexible ureteroscopy and holmium laser lithotripsy for the treatment of renal and proximal ureteral calculi:a single-surgeon experience of 382 cases[J].J Urol,2016,195(5):1492-1493.