肝硬化合并自发性细菌性腹膜炎患者腹水病原学及耐药性分析

Analysis on ascites etiological pathogen and bacterial drug resistance in patients with active liver cirrhosis complicated with spontaneous bacterial peritonitis

目的分析活动性肝硬化并发自发性腹膜炎（SBP）患者腹水培养的细菌学及耐药变化趋势，为抗菌药物合理应用提供依据。方法选择2012年1月至2016年12月天津市第二人民医院住院治疗的诊断符合SBP且腹水细菌学培养阳性患者140例，根据腹水培养结果将患者分为革兰阳性（G^＋）菌感染组50例和革兰阴性（G-）菌感染组90例。分析其临床资料、细菌学资料及耐药情况。结果从2012至2016年G^＋菌感染在SBP细菌谱中的例数呈逐年上升趋势（分别为3、4、10、12、21例），SBP条件致病菌比例逐年增多，从2012年的33．3％增长到2016年的41．9％。G^＋菌感染组血中性粒细胞比例（N）、腹水白细胞计数（WBC）、多核粒细胞数、降钙素原（PCT）均较G-菌感染组明显减少（均P〈0．05）。从2012年至2016年G菌感染以大肠埃希菌为主占50．O％（45例），其中耐药率较低的3种抗菌药物为头孢哌酮／舒巴坦（0）、亚胺培南（3．33％）、阿米卡星（7．78％），头孢菌素类耐药率最高，依次是头孢唑林、头孢呋辛钠、头孢他啶分别为47．78％、38．89％、34．44％；G^＋菌感染葡萄球菌33例（占64．7％）、肠球菌13例（占25．5％）、链球菌4例（占7．8％），耐药率较低的3种抗菌药物为替加环素、利奈唑胺、万古霉素分别为0、4．0％、8．0％，葡萄球菌对利奈唑胺和替加环素的耐药率均为0，肠球菌对替加环素的耐药率为0。结论对于SBP患者，致病菌仍以菌为主，但G^＋菌感染比例呈上升趋势；治疗首选的药物包括碳青霉烯类的亚胺培南和β-内酰胺类抗菌药与β-内酰胺酶抑制剂合剂头孢哌酮／舒巴坦，肾功能较好者可加用阿米卡星；经验治疗效果欠佳，需要考虑应用抗G^＋菌的药物。

Objective To provide evidence for the rational use of antibacterial drugs based on the analyses on the changing trend of bacteriology and drug resistance of bacteria grown in ascites bacterial cultures in patients with active liver cirrhosis complicated with spontaneous bacterial peritonitis （SBP）. Methods One hundred and forty in-patients consistent with the diagnosis of active liver cirrhosis complicated with SBP and their ascites bacteriological cultures positive admitted to Tianjin Second People＇s Hospital from January 2012 to December 2016 were enrolled. According to the results of ascitic fluid cultures, the patients were divided into gram positive （G＋） bacteria infection group （50 cases） and gram negative （G-） bacteria infection group （90 cases）. The clinical data, bacteriological data and drug resistance were analyzed. Results The trend of number of cases with infection of G＋ bacteria in SBP bacterial spectrum was rising year by year from 2012 to 2016 （3, 4, 10, 12, 21 cases respectively）, and the proportion of SBP conditional pathogen was also increased year by year, from 33.3% in 2012 to 41.9% in 2016. The proportion of blood neutrophils （N）, aseites white cell count （WBC）, muhinucleated granulocyte count and calcitonin （PCT） in the G＋ infection group were significantly lower than those in the G- infection group （all P 〈 0.05）. From 2012 to 2016, the G- bacterial infection was mainly caused by Escherichia coli, accounting for 50.0% （45 cases）, in which the Escherichia coli in some of the cases had relatively low resistance rate to 3 kinds of antibiotics： cefoperazone/sulbactam （0）, carbapenems （3.33%） and amikacin （7.78%）; the rate of drug resistance to cephalosporin antibiotics was the highest, and the sequence of the rates to cefazolin, cefuroxime and ceftazidime were 47.78%, 38.89%, 34.44% respectively; in G＋ bacteria infection, Staphylococci were found in 33 cases （64.7%）, Enterococci in 13 cases （25.5%）, and Streptococcus in 4 （7.8%）. There were 3 kinds of antibiotics, teicoplanin, linezolid, and vaneomycin, the above bacteria had low drug resistance rates to them, being 0, 4.0%, 8.0% respectively. The resistance rates of Staphylococcus to linezolid and tegicycline were both 0, and the resistance rate of Enterococcus to tegicycline was also 0. Conclusion In patients with active liver cirrhosis complicated with SBP, the main infection rate is caused by G- bacteria and the infection rate of G＋ bacteria shows a tendency of ascending; the following medicines are firstly chosen for such patients, including imipenem in carbapenems class, β-lactamase inhibitor mixture cefoperazone/sulbactam, and in the patients with renal function relatively good, amikaein can be added; in patients having obtained unsatisfactory therapeutic results after treatment, the use of anti G＋ bacteria antibiotics should be considered.