糖尿病足溃疡感染与病原菌种及敏感抗生素的关系

Association between the severity of diabetic foot ulcer infection and pathogenic bacteria and sensitive antibiotics

目的探讨不同病情糖尿病足感染病原菌分布特点及与相应敏感抗生素之间的关系，并分析其影响因素。方法连续选取2013年1月至12月上海交通大学医学院附属瑞金医院200例糖尿病足溃疡感染伴微生物培养阳性的病例资料，足溃疡病情按照Wagner分级和感染程度进行分组，分析足溃疡病情与菌种分布、菌种与敏感抗生素的相关性，应用逐步Logistic回归探讨病原菌分布的影响因素。结果糖尿病足溃疡轻度感染及Wagner1级患者的病原菌菌谱以革兰阳性球菌为主（分别占53．5％和100．0％），其中金黄色葡萄球菌（分别占32．1％和60．0％）、粪肠球菌（在Wagner1级中占40％）、停乳链球菌（在轻度感染中占21．4％）最为常见，这些菌种的抗生素以青霉素、万古霉素等较为敏感。中、重度感染以革兰阴性杆菌为主（分别占83．3％、75．4％），其中Wagner3、4级患者革兰阴性杆菌感染多于革兰阳性球菌（革兰阴性杆菌分别占53．3％和78．7％）；Wagner5级患者则主要为革兰阴性杆菌感染（占93．6％）；最常见的是变形杆菌（在中、重度感染中分别占18．5％和28．8％）、大肠埃希菌（分别占27．8％和10．2％）和铜绿假单孢菌（分别占7．4％和11．O％），敏感抗生素主要包括阿米卡星、亚胺培南、头孢他啶；Wagner级别[比值比（OR）=3．43，95％可信区间（CI）：1．12-5．39]、感染程度（OR=3．17，95％CI：1．49～7．81）、既往抗生素使用情况（OR=I．54，95％CI：1．02。2．19）及患者年龄（OR=I．04，95％CI：1．02-2．14）、血红蛋白（OR=1．14，95％CI：1．08—2．10）、白蛋白水平（OR=I．07，95％CI：1．03～1．39）等共同影响病原菌类型。结论不同程度感染、不同深度足溃疡感染的细菌属有一定差别，细菌药敏结果提示相应治疗抗生素应作调整。

Objectives To investigate the distribution of pathogenic bacteria, sensitive antibiotics, and their association with the severity of diabetic foot ulcers. Methods From January 2013 to December 2013, clinical materials from 200 patients hospitalized in Ruijin Hospital, Jiaotong University School of Medicine for diabetic foot ulcers with positive microorganism culture results were consecutively collected. The foot ulcers were classified according to Wagner grade and the severity of their infection respectively. The distribution of pathogenic bacterial, sensitive antibiotics were analyzed to investigate their association with the severity of diabetic foot ulcers. And factors that affect the distribution of pathogenic bacterial were also analyzed with Logistic regression. Results Gram positive cocci were the main pathogenic bacteria of foot ulcers in Wagner grade 1 and mild infection（100.0% and 53.5% respectively）, of which staphylococcus aureus（32.1% in mild infection, 60.0% in Wagner grade 1）, enterocoecus faecalis（40% in Wagner grade 1）,and streptococcus dysgalactiae（21.4% in mild infection） were the most common ones. Sensitive antibiotics to these bacteria included penicillins and vancomycin. Gram negative bacilli were the main pathogenic bacteria in ulcers with moderate or severe infection（83.3% and 75.4% in moderate and severe infection respectively）. In foot ulcers of Wagner grade 3 and 4, various kinds of bacteria were found, of which gram negative bacilli were slightly more than gram positive cocci（gram negative bacilli accounted for 53.3% and 78.7% respectively）. Gram negative bacilli were the main pathogenic bacteria of foot ulcers of Wagner grade 5（93.6% ）; among them, proteusbacillus vulgaris（18.5% and 28.8% in moderate and severe infection respectively）, escherichia coli（27.8% and 10.2% respectively）, and pseudomonas aeruginosa（7.4% and 11.0% respectively） were most common ones; and the sensitive antibiotics included amikacin, imipenem, and ceftazidime. Wagner grade （ （odds ratio, OR） =3.43, 95% confident interval （CI）： 1.12- 5.39）, severity of infection（OR=3.17, 95% CI：1.49-7.81）, history of antibiotic use（OR=1.54, 95% CI：1.02-2.19）, hemoglobin （0R：1.14, 95%CI：1.08-2.10） and albumin（OR=1.54, 95%CI：1.02-2.19） were the factors that affected type of pathogenic bacteria. Conclusion Bacteria and sensitive antibiotics varied among different infection levels and depth of foot ulcers in patients with diabetes. Antibiotics could be empirically selected according to the severity of diabetic foot ulcers.