重症与非重症急性期脑卒中相关性肺炎病原学临床研究

Etiology of pneumonia associated with severe and non-severe acute stroke

目的比较神经重症监护病房(NICU)与普通病房急性期卒中相关性肺炎的病原菌分布及耐药特点,指导临床抗菌药物的使用。方法采用回顾性研究方法,对2015-10至2019-12武警江苏总队医院NICU和普通病房收治的急性卒中相关性肺炎(SAP)患者,分析比较其痰培养病原菌构成及药敏试验结果。结果(1)痰培养病原菌比较:NICU组及普通病房组致病菌均以革兰阴性杆菌为主,但NICU组革兰阴性杆菌比例显著高于普通组,其中多重耐药菌来源于NICU组的比例也显著高于普通组,并且真菌感染只发生在NICU组,差异有统计学意义(P<0.05)。(2)痰培养药敏结果:NICU组的铜绿假单胞菌、肺炎克雷伯菌、大肠埃希菌中有较多多重耐药菌(耐药率60.0%~100.0%),存在一定比例混合感染,对美洛培南、亚胺培南的敏感性较高(敏感率59.77%~90.14%),除铜绿假单胞菌外的其他革兰阴性杆菌对替加环素敏感性均较高(83.72%~100%)。常见革兰阴性杆菌由于来源不同,同一细菌对同一抗生素的敏感率存在如下特点:来源于NICU组的较普通病房组敏感率普遍降低。普通病房组所检出的革兰阴性杆菌对常规抗生素耐药率较高(耐药率>75%),对哌拉西林/他唑巴坦、头孢他定有一定敏感性(敏感率60.0%~70.0%),对左氧氟沙星、阿米卡星、美洛培南、亚胺培南、替加环素均较敏感(敏感率>75%)。两组检出革兰阳性菌的比例明显低于革兰阴性菌,其中金黄色葡萄球菌对青霉素、红霉素和头孢唑啉耐药率均达到100%,对替加环素耐药率低,尚未发现对万古霉素、利奈唑胺、替考拉宁的耐药株。结论NICU组SAP患者病原菌以革兰阴性杆菌为主,易发生多重耐药及混合感染,亚胺培南、阿米卡星等可作为主要考虑使用的药物。普通病房组SAP患者病原菌仍以革兰阴性杆菌占多数,可优先选择头孢他定、哌拉西林/他唑巴坦等抗生素,如果疗效不佳,则可考虑亚胺培南、替加环素等。针对不同区域病原菌分布和耐药性进行分析,有助于合理选择感染控制措施和抗菌药物。

Objective To investigate whether the distribution and drug resistance of pathogenic bacteria of acute apoplexy associated pneumonia in the neurointensive care unit(NICU)are similar to those of general wards in order to guide the use of antibiotics in clinic.Methods A retrospective study was conducted to analyze and compare the composition of sputum-cultured pathogenic bacteria and drug sensitivity test results of acute apoplexy associated pneumonia(SAP)patients admitted to NICU and general wards of Jiangsu Provincial Corps Hospital between October 2015 and December 2019.Results 1.Comparison of sputum-cultured pathogenic bacteria:Gram-negative bacilli were the dominant pathogenic bacteria in the NICU group and the general ward group,but the proportion of gram-negative bacilli in the NICU group was significantly higher than that of the general ward group,so was the proportion of multi-drug resistant bacteria in the NICU group.Fungal infections occurred only in the NICU group.There was statistically significant difference between the two groups(P<0.05).2.Sputum culture susceptibility results:(1)In the NTCU group,there were more multiple drug resistance bacteria in pseudomonas aeruginosa,Klebsiella pneumoniae,and e.coli bacterium(resistance rate ranged from 60.0%to 100.0%).There were some cases of of mixed infections and high sensitivity to meroppenem and imipenem(sensitivity rate ranged from 59.77%to 90.14%)and to tiagocycline of gram-negative bacteria except for pseudomonas aeruginosa(83.7%-100.0%).(2)Bacteria from the NICU group were generally more sensitive than those from the general ward group.(3)The gram-negative bacilli detected in the general ward group were more resistant to conventional antibiotics(drug resistance rate>75%),somewhat sensitive to piperacillin tazobactam and cefatadine(sensitivity rate 60.0%-70.0%),and highly sensitive to levofloxacin,amikacin,meropenem,imipenem and tigacycline(sensitivity rate>75%).(4)The proportion of gram-positive bacteria detected in the two groups was significantly lower than that of gram-negative bacteria,among which the drug resistance rate of Staphylococcus aureus to penicillin,rhodoxin and cefazolin reached 100%,while the drug resistance rate of tiagocycline was low.No resistant strains to vancomycin,linezolid or tekoranin were found yet.Conclusions The pathogenic bacteria of SAP patients in the NICU group are mostly gram-negative bacilli,such as pseudomonas aeruginosa,Klebsiella pneumoniae,and Escherichia coli,thus increasing the chance of multi-drug resistance and mixed infection.Imipenem,amikacin,tiagocycline and other drugs should be considered the main drugs to be used,but they are likely to be complicated with fungal double infections.In general wards,pathogenic bacteria are still dominated by ceratadine negative bacilli.Cefatadine,piperacillin tazobactam,amikacin,levofloxacin and other antibiotics should be considered first.