腹膜透析相关性腹膜炎病原菌及其危险因素

Pathogens and risk factors of peritoneal dialysis-related peritonitis

目的了解腹膜透析(PD)相关性腹膜炎的细菌谱和耐药情况,为合理使用抗菌药物提供依据。方法回顾性分析某医院2013年1月—2014年12月收治的120例次PD相关性腹膜炎患者的临床资料。结果细菌培养阳性91例次,阳性率为75.83%。共培养病原菌93株,其中革兰阳性(G^+)菌73株(78.49%),革兰阴性(G^-)菌13株(13.98%),最常见的菌种G^+菌是表皮葡萄球菌(38株,40.86%)和G^-菌为大肠埃希菌(3株,3.23%)。G^+菌对青霉素(93.65%)、红霉素(69.57%)和苯唑西林(64.41%)有较高的耐药率,对万古霉素(2.90%)和利奈唑胺(1.47%)耐药率较低,对替考拉宁、替加环素和呋喃妥因均敏感。G^-菌对头孢唑林(50.00%)、头孢呋辛(37.50%)和氨苄西林(37.50%)有较高的耐药率,对亚胺培南、妥布霉素、哌拉西林均敏感。G^+、G^-菌对庆大霉素和左氧氟沙星均具有较低的耐药率。换液操作不规范(56.67%)是引起腹膜炎最常见的原因,主要为G^+菌感染(79.41%);而腹泻引起的腹膜炎主要为G^-菌感染(52.63%)。G^+菌、G^-菌和细菌培养阴性腹膜炎的治愈率分别为92.96%、76.92%和86.21%,三者治愈率比较差异无统计学意义(χ~2=3.39,P=0.18)。结论 PD相关性腹膜炎的病原菌以G^+菌为主,多由于换液操作不规范使病原菌经腹透管感染。第一代头孢菌素不能作为对G^+菌的经验性用药,而万古霉素仍是最佳选择。第三代头孢菌素和氨基糖苷类可作为对G^-菌的经验性用药。特殊情况下庆大霉素和左氧氟沙星可单独作为经验性用药。

Objective To investigate the bacterial spectrum and antimicrobial resistance of peritoneal dialysis （PD）-related peritonitis,and provide evidence for rational antimicrobial use.Methods Clinical data of 120 patients with PD-related peritonitis in a hospital from January 2013 to December 2014 were retrospectively analyzed. Results 91 cases （75.83%）showed positive result in bacterial culture,93 pathogenic strains were cultured,inclu-ding 73 （78.49%）gram-positive and 13 （13.98%）gram-negative bacterial strains,the most common gram-positive bacteria was Staphylococcus epidermidis （n=38,40.86%）,and the main gram-negative bacteria was Escherichia coli （n =3,3.23%）.Gram-positive strains had high resistance rates to penicillin,erythromycin,and oxacillin （93.65%,69.57%,and 64.41 % respectively）,while resistance rates to vancomycin and linezolid were both low （2.90% and 1 .47% respectively）,and were sensitive to teicoplanin,tigecycline,and nitrofurantoin.Gram-negative bacteria had high resistance rates to cefazolin,cefuroxime,and ampicillin（50.00%,37.50%,and 37.50% respec-tively）,but were sensitive to imipenem,tobramycin,and piperacillin.Resistance rates of gram-positive and gram-negative bacteria to gentamicin and levofloxacin were both low.Non-standard operation during dialysate exchange was the most common cause of peritonitis （56.67%）,most peritonitis were gram-positive bacterial infection＆nbsp;（79.41 %）;while gram-negative bacteria were the main pathogens of diarrhea-induced peritonitis （52.63%）.The cure rates of gram-positive bacteria, gram-negative bacteria,and negative-cultured peritonitis were 92.96%, 76.92%,and 86.21% respectively,difference was not statistically significant（χ2 =3.39,P =0.18）.Conclusion Gram-positive bacteria are major pathogens in PD-related peritonitis,and are usually caused by the bacteria through dialy-sis catheter due to non-standard operation during dialysate exchange.First-generation cephalosporins are not recom-mended as empirical therapy against gram-positive bacteria,while vancomycin is still the best choice.Third-genera-tion cephalosporins and aminoglycosides are recommended as empirical therapy against gram-negative bacteria. Gentamicin and levofloxacin can be used alone as empirical therapy in special circumstances.