腹膜透析相关性腹膜炎的致病菌及其易感因素分析

Analysis of pathogens and predisposing factors in peritoneal dialysis-associated peritonitis

目的分析第四军医大学西京医院腹膜透析中心腹膜透析相关性腹膜炎的易感因素、致病菌谱、药敏情况及预后。方法回顾性分析第四军医大学西京医院腹膜透析中心2013年7月至2015年6月持续性非卧床腹膜透析（CAPD）患者中腹膜透析相关性腹膜炎（PDAP）患者及未发生腹膜炎的腹膜透析患者的透析龄（〈1年组,1~3年组,〉3年组）、文化程度（初中以下组、初中及初中以上组）、培训者工龄（〈5年组,5~10年组,〉10年组）及血清白蛋白水平等临床资料;同时分析腹膜透析相关性腹膜炎患者致病菌谱、药敏等临床资料及转归情况。结果 501例CAPD患者中,87例患者发生106例次腹膜炎,平均腹膜炎发生率为1次/66.8病人月。透析龄〈1年组,1~3年组,〉3年组的腹膜炎发生率分别为18.8%（21/112）、24.0%（56/233）、6.4%（10/156）,三组间差异有统计学意义（χ^2=20.42,P〈0.001）;初中以下文化水平患者腹膜炎发生率（29.1%,59/203）显著高于初中及以上文化水平患者（12.4%,37/298）（χ^2=21.60,P〈0.001）;培训护士的工龄〈5年,5~10年和〉10年组,腹膜炎的发生率分别为25.4%（51/201）、15.4%（23/148）、8.6%（13/152）,三组间比较差异有统计学意义（χ^2=17.55,P〈0.001）。腹膜炎患者的血清白蛋白水平[（26.89±5.16）g/L]显著低于非腹膜炎组[（34.58±6.27）g/L;t=-8.8,P〈0.001]。腹膜炎患者透出液病原菌培养阳性率为58.3%（56/96）,革兰阳性菌比例为78.6%（44/56）。革兰阴性菌中大肠埃希菌占45.5%（5/11）。头孢唑林钠、头孢他啶的经验用药有效率为65.9%（70/106）。表皮葡萄球菌感染共21例次,66.7%（14/21）复发,33.3%（7/21）拔管。结论本中心的腹膜透析相关性腹膜炎的发生率与患者透析龄、文化程度、培训者工龄及血清白蛋白水平密切相关。腹膜炎致病菌以革兰阳性菌为主,其中表皮葡萄球菌所占比例最高,且复发率和拔管率高。

Objective To analyze the predisposing factors, pathogen spectrum, antibiotic sensitivity,and prognosis in peritoneal dialysis-associated peritonitis（ PDAP） patients of Xijing Hospital Affiliated to Fourth Military Medical University. Methods A retrospective analysis was made of clinical data including PD time（ 1 year,1-3 years,and 3 years groups）,education level（ under junior high school,junior high school and above groups）,trainers seniority（ 5 years,5-10 years, 10 years groups）,serum albumin level,the spectrum of pathogens,antibiotic sensitivity,outcomes,and others,in continuous ambulatory peritoneal dialysis（ CAPD） patients with or without PDAP of the Peritoneal Dialysis Centre in Xijing Hospital Affiliated to Fourth Military Medical University from July 2013 to June 2015.Results Among the 501 CAPD patients,87 patients suffered from PDAP for 106 times,with an average PDAP incidence of once per 66. 8 patient-month. In the PD time 1 year group,1-3 years group,and 3 years group,the incidence rates of PDAP were 18. 8%（ 21 /112）,24. 0%（ 56 /233）,and 6. 4%（ 10 /156）,respectively,with significant differences among the three groups（ χ^2= 20. 42,P 0. 001）; the incidence rate of PDAP in the group with education level under junior high school（ 29. 1%,59 /203） was significantly higher than that of the group with education level of junior high school and above（ 12. 4%,37 /298）（ χ^2= 21. 60,P 0. 001）; and in the trainer seniority low than 5 years group,5-10 years group,and above 10 years group,the incidence rates of PDAP were 25. 4%（ 51 /201）,15. 4%（ 23 /148）,and8. 6%（ 13 /152）,respectively,with significant differences among the three groups（ χ^2= 17. 55,P 0. 001）. The level of serum albumin in the group with PDAP（ 26. 89 ± 5. 16 g / L） was significantly lower than that in the group without PDAP（ 34. 58 ± 6. 27 g / L）（ t =- 8. 8,P 0. 001）. Results of culture from peritoneal fluid indicated that the positive rates of pathogenic microorganisms and gram-positive bacteria were58. 3%（ 56 /96） and 78. 6%（ 44 /56）,respectively; and among gram-negative bacilli,the percentage of Eescherichia coli was 45. 5%（ 5 /11）. The effective rate of empirical use of cefazolin sodium and ceftazidime was 65. 9%（ 70 /106）. Staphylococcus epidermidis infection occurred in 21 cases,with relapse in 14 cases（ 66. 7%） and extubation in 7 cases（ 33. 3%）. Conclusion The incidence of PDAP in this centre closely correlated with PD time,education level,trainer seniority,and serum albumin. Gram-positive bacteria played a dominant role in the pathogenic microorganisms of PDAP, in which Staphylococcus epidermidis was of the highest percentage with high rates of both relapse and extubation.