胆道手术患者胆汁培养和药物敏感分析的临床研究

A clinical study of bile cultures and antibiotic susceptibility test in the patients with operation on biliary tract

目的分析胆道疾病患者胆汁致病菌的分布特点及耐药情况，以便合理选择抗生素。方法抽取2007年6月至2008年3月在上海交通大学医学院附属仁济医院普外科行胆道手术的195例患者的术中胆汁，并选取24名健康人作为对照，进行细菌培养及药物敏感试验。结果195例胆道疾病患者胆汁培养阳性率为22．6％（44／195），其中混合感染率为25．0％（11／44）。培养菌株55株，菌种16种，其中G^-菌占61．8％（34／55），G^＋菌占34．6％（19／55），真菌占3．6％（2／55）。主要致病菌为大肠杆菌（27．3％）、阴沟肠杆菌（12．7％）、粪肠球菌（12．7％）、屎肠球菌（10．9％）。24名健康人正常胆汁培养阳性率为4．2％（1／24），为大肠杆菌。药物敏感实验结果显示：G^-菌对美洛培南总耐药率最低（2．8％），其次为亚胺培南（5．6％）、头孢哌酮／舒巴坦（22．8％）、阿米卡星（28．7％）。对青霉素类、喹诺酮类、部分三代头孢菌素类等抗生素耐药率较高（〉50．0％）。G^＋菌对万古霉素、替考拉宁总耐药率为0。对青霉素类、喹诺酮类、克林霉素等抗生素耐药率较高（〉40．0％）。结论（1）该院胆道感染以G^-菌为主，主要致病菌为大肠杆菌，肠球菌有上升趋势。细菌混合感染多见于急性感染患者。（2）治疗胆道感染首选对大肠杆菌耐药率低的广谱抗生素。头孢他啶、环丙沙星可用于胆道轻度感染，中重度感染首选头孢哌酮／舒巴坦或阿米卡星，亚胺培南、万古霉素可作为临床二线用药治疗其他药物治疗无效的感染。

Objective To illustrate the bacteriology and their susceptibility to antibiotics in patients with biliary tract diseases and provide information for antibiotic choices. Methods The bile specimens were cultured and pathogens＇ susceptibility to antibiotics was obtained intraoperatively from 195 patients undergoing operations on biliary tract and 24 healthy liver donors from June 2007 to March 2008. Results Among 195 bile specimens collected from the patients intraoperatively, 44 ones were found bacterial growth by culture（22. 6% ）, in which 11 ones were mixed infections（25.0% ）. Fifty-five bacterial strains belonging to 16 species were identified from these bile specimens. They included 34 Gram negative strains （61.8%）, 19 Gram positive strains （34. 6% ） and 2 fungal strains （3.6%）. The commonest pathogens were Escherichia coli （27. 3 % ）, Enterobacter cloacae （ 12. 7 % ）, Enterococcus faecalis （ 12. 7% ） and Enterococcus faecium （ 10. 9% ）. Among 24 bile specimens collected from the healthy liver donors, one was found Escherichia coli growth by culture （4. 2% ）. The results of susceptibility test showed that the resistant rates of Gram negative strains to Meropenem was 2. 8%, followed by Imipenem （ 5.6% ）, Sulperazone （ 22. 8% ） and Amikacin （28.7%）. In this study Gram negative strains were highly resistant to Penicillins, Quinolones, some third generation Cephalosporins and so on （ 〉 50. 0% ）. None of Gram positive strains were resistant to Vancomycin and Teicoplanin. They were highly resistant to Penicillins, Quinolones, Clindamycin and so on （ 〉40. 0% ）. Conclusions （ 1 ） Gram negative strains remain the commonest pathogens in biliary tract infection in Renji Hospital and the commonest pathogen is Escherichia coll. The infection of enterococcus is going up. The mixed infection cases happen mostly in acute biliary infection. （2） To treat biliary infection the broad-spectrum antibiotics which are effective to Escherichia coli are optimal choices. Ceftazidime or Ciprofloxacin may be used in mild biliary infection. Sulperazone or Amikacin may be used in severe biliary infection. Imipenem and Vancomycins may be used as second choice to treat the infection which other drugs are ineffective to.