重症监护室术后先天性心脏病患儿院内感染细菌分布及耐药性分析

Epidemiology of Nosocomial Infections and Antibiotic Resistance in Children after Cardiac Surgery in Pediatric Intensive Care Unit

目的分析术后先天性心脏病(先心)患儿发生院内感染后分离所得的所有病原菌,了解心脏病术后患儿在PICU感染的病原菌分布特点和耐药状况,为治疗提供依据。方法 2009年8月-2012年3月本院PICU共557例行先心相关矫治手术的患儿,回顾性分析术后发生院内感染患儿送检的标本培养获得病原菌分布部位及耐药性。结果 557例接受心脏手术中,其中简单型先心313例,复杂型先心244例;发生院内感染152例患儿中简单型先心35例次,复杂型先心117例次;下呼吸道感染16例,泌尿道感染10例,血液感染15例,消化道感染5例,导管感染3例,伤口感染2例及颅内感染1例;分离出152株病原菌。其中革兰阴性杆菌最多(123株,80.92%),其次为革兰阳性球菌(17株,11.18%),真菌(12株,7.89%)。主要的革兰阴性杆菌是铜绿假单胞菌(25株,16.45%)、嗜麦芽寡氧单胞菌(24株,15.79%)、鲍曼不动杆菌(22株,14.47%)和肺炎克雷伯杆菌(20株,13.16%),其他包括大肠杆菌17株(11.18%)、阴沟杆菌4株(2.63%)、产气肠杆菌2株(1.32%)、洋葱伯克霍尔德菌2株(1.32%)、其他杆菌7株(4.61%);主要革兰阳性菌为表皮葡萄球菌(5株,3.29%)、金黄色葡萄球菌(4株,2.63%)和溶血性葡萄球菌(3株,1.97%),其他球菌5株(3.29%);真菌中白色念珠菌最多(8株,5.23%),其他包括光滑球酵母菌1株(0.66%)、近平滑念珠菌3株(1.97%);产超广谱β-内酞胺酶菌37株,主要包括大肠杆菌14株,肺炎克雷伯杆菌11株,嗜麦芽假单胞菌、表皮葡萄球菌及金黄色葡萄球菌各4株;耐甲氧西林金黄色葡萄球菌阳性8株,未发现耐万古霉素及替考拉宁的葡萄球菌。革兰阴性杆菌对其敏感率超过90%的药物为阿米卡星(96.53%)及哌拉西林/舒巴坦(90.13%),稍次者为亚胺培南(86.84%),妥布霉素及复方磺胺异唑(84.21%),头孢哌酮舒巴坦(83.55%),头孢他啶(73.68%)及头孢唑肟(77.63%)。结论复杂型先心患儿术后院内感染的发生率高于简单型先心患儿;下呼吸道是院内感染最常见的部位;院内感染以革兰阴性杆菌为主;不同地区的PICU病原菌菌谱及耐药性有一定差异。实用儿科临床杂志,2012,27(22)

Objective To determine the epidemiology of nosocomial infections（NI） and antibiotic resistance of pathogens in children af- ter cardiac surgery in pediatric intensive care unit（PICU）. Methods Datum of 577 children underwent open - heart surgery were collected between Aug. 2009 and Mar. 2012. The distribution and antibiotic resistant pattern of all the pathogenic microbial isolates were analyzed. Re- suits Of 577 children,313 suffered from simple congenital heart defect（CHD） ,244 cases with complex CHD. One hundred and fifty -two patients suffered from NI after cardiac surgery,in them,35 cases were simple CHD, 117 cases were complex CHD. One hundred and sixteen children were confirmed as lower respiratory tract infection, 15 cases of bloodstream infection, 10 cases of urinary tract infection ,3 case of cen- tral catheter- related infection,2 cases of wound infection and 1 case of meningitis. One hundred and fifty- two pathogenic microbial strains were isolated. Gram - negative bacterium（GNB） was the most frequent isolates（ 123 isolates,80.92% ） ,followed by Gram - positive bacte- rium（ 17 isolates,ll. 18% ） ,and fungi（ 12 isolates,7.89% ）. The main GNB were P. aeruginosa （25 isolates, 16.45% ） ,pseudomonas maho- philia （24 isolates, 15.97 % ）, acinetobacter baumannii （22 isolates, 14.47 % ）, and klebsiella pneumonia （ 20 isolates, 13.16% ）, the other GNB were Ecoli detection （ 17 isolates, 11.18% ）, enterobacter cloacae （4 isolates, 2.63% ）, enterobacter aerogenes （ 2 isolates, 1.32% ）, burkholderia cepacia （2 isolates, 1.32% ）, and others （7 isolates ,4.61% ）. The most common Gram - positive bacterium were staphylococcus epidermis （5 isolates,3.29% ） , staphylococcus aureus （4 isolates, 2.63% ）, and staphylococcus haemolyticus （ 3 isolates, 1.97% ）, and others （5 isolates,3.29% ）. The frequent fungi were candido albicans （8 isolates, 5.23 % ）, the others were torulopsis （ 1 isolate, 0.66% ） , candida parapsilosis（3 isolates, 1.97% ）. The bacteria producing extended spectrum 13 -lactamase were 37 isolates, mainly were Ecoli （14 isolates）, klebsiella pneumonia （ 11 isolates ）, pseudomonas mahophilia （ 4 isolates）, staphylococcus epidermis （ 4 isolates ）, staphylococcus aureus （4 isolates）. There were 8 isolates of methicillin resistant Staphylococcus aureus, no resistance to vancomycin and teicoplan in staphy- lococcus aureus were found. Bacterial resistance survey in PICU indicated that the susceptibility rate of GNB to amikacin was 96.53%, fol- lowed by piperacillin/sulbactam 90.13% ,impenem 86.84% , tobramycin and SMZco 84.21% , cefperazone - sulbactam 83.55% , ceftazidime 73.68%, and ceftizoxime 77.63%. Conclusions The incidence of NI is more frequently associated with complex CHD compared with simple CHD. Nosocomial lower respiratory tract infection is the most common nosoeomial infection after cardiac surgery. GNB is the most frequent bacterium recovered from patients with NI after cardiac surgery. The epidemiology of NI and antibiotic resistance of pathogens are different indifferent areas.