自发性细菌性腹膜炎患者腹水分离病原菌的菌种分布及对抗菌药物敏感性的变化

Distribution of strain of ascitic pathogens and changes of sensitiveness to antibacterials in patients with spontaneous peritonitis

目的 探讨2009至2016年自发性细菌性腹膜炎（SBP）患者腹水分离病原菌的菌种分布及对抗菌药物敏感性的变化.方法 收集2009至2016年在北京佑安医院住院、腹水培养病原菌阳性SBP患者的病历资料,提取腹水培养、病原菌鉴定和病原菌药物敏感试验结果,以2年为一个时段,分析腹水分离病原菌的菌种分布及对抗菌药物敏感性的变化.结果 纳入分析的患者共1 107例,男性816例,平均年龄（54±10）岁;女性291例,平均年龄（57±13）岁;腹水培养细菌阳性患者1 042例（94.1%）,真菌阳性患者65例（5.9%）;原发疾病为终末期肝病者920例（83.11%）,胆道疾病者113例（10.21%）,其他疾病者74例（6.68%）.共分离鉴定出1 441株病原菌,革兰阴性（G-）菌637株（44.2%）;革兰阳性（G＋）菌739株（51.3%）;真菌65株（4.5%）.2009至2016年SBP患者腹水分离病原菌中,居G-菌前4位者依次为大肠埃希菌[213株（14.8%）]、肺炎克雷伯菌[146株（10.1%）]、铜绿假单胞菌[52株（3.6%）]和阴沟肠杆菌[38株（2.6%）];居G＋菌前4位者依次为屎肠球菌[176株（12.2%）]、表皮葡萄球菌[132株（9.1%）]、溶血葡萄球菌[130株（9.0%）]和粪肠球菌[75株（5.2%）];居真菌前2位者为白色念珠菌[36株（2.5%）]和光滑念珠菌[12株（0.8%）].SBP患者腹水病原菌中G-菌构成比2015-2016年明显下降,与2009-2010年比较差异有统计学意义[49.3% （73/148）比39.4%（196/498）,P=0.031];真菌构成比2015-2016年明显上升,与2009-2010比较差异有统计学意义[6.4%（32/498）比2.0%（3/148）,P=0.038];不同时段G＋菌构成比差异无统计学意义.2015-2016年产超广谱β内酰胺酶大肠埃希菌构成比明显高于2009-2010年[57.4%（35/61）比32%（8/25）,P=0.033],同期大肠埃希菌对亚胺培南及美罗培南的耐药率也显著上升（P=0.026,P=0.025）.G-菌对亚胺培南、美罗培南、阿米卡星和哌拉西林他唑巴坦敏感;G＋菌对利奈唑胺、替考拉宁和万古霉素敏感.结论 2009至2016年北京佑安医院住院SBP患者腹水病原菌分布呈现G-菌减少、真菌增加趋势.SBP致病菌主要为耐药菌,大肠埃希菌对亚胺培南、美罗培南和头孢噻肟的耐药率逐年增高.

Objective To investigate the strain distribution of ascitic pathogens in patients with spontaneous bacterial peritonitis （SBP） and the changes of sensitiveness to antibacterials from 2009 to 2016.Methods The medical records of SBP patients who were hospitalized in Beijing Youan Hospital from 2009 to 2016 were collected.The results of ascites bacterial culture of SBP patients were all positive.The results of ascites culture, pathogen identification, and the drug sensitivity test were recorded.The changes of distribution of ascitic pathogens and the sensitiveness to antibacterials were analyzed according to the time interval of every two years.Results A total of 1 107 SBP patients were enrolled in the study.Of them, 816 patients were male with average age （54±10） years, 291 patients were female with average age （57±13） years.There were 1 042（94.1%） patients with positive bacterial culture of ascites and 65 patients （5.9%） with positive fungal culture of ascites among the 1 107 patients, respectively.There were 920（83.11%） patients with end-stage liver disease, 113 （10.2%） with biliary tract disease, and 74（6.68%） with other diseases in the 1 107 patients.A total of 1 441 strains of pathogenic bacteria were identified, comprised of gram negative （G-） bacteria 637 （44.2%） strains, gram positive （G＋） bacteria 739（51.3%） strains, and fungi 65（4.5%） strains.During 2009 to 2016, the top four number of strains of G-bacteria in SBP patients＆#39;ascites from high to low were Escherichia coli [213（14.8%）], Klebsiella pneumoniae [146 （10.1%）], Pseudomonas aeruginosa[52（3.6%）] and Enterobacter cloacae[38（2.6%）];the top four strains of G（＋） bacteria were Enterococcus faecium[176（12.2%）], Staphylococcus epidermidis[132（9.1%）], Staphylococcus haemolyticus [130（9.0%）] and Enterococcus faecalis [75（5.2%）];and the top 2 of fungi in SBP patients＆#39; ascites were Candida albicans[36（2.5%）] and Candida glabrata[12（0.8%）].Compared with the time interval of 2009-2010, the constituent ratio of G（-） bacteria in 2015-2016 was decreased significantly [49.3%（73/148）vs.39.4% （196/498）, P=0.031] , the constituent rate of fungi was increased significantly [6.4%（32/498） vs.2.0% 3/148）, P=0.038].There were no statistical significance in G（＋） bacteria＆#39;s constituent ratio among different time intervals.The constituent rate of extended spectrum beta-lactamases （ESBL） in Escherichia coli was higher in the time interval of 2015-2016 than that in the time interval of 2009-2010 [57.4% （35/61） vs.32% （8/25）, P=0.033].The drug resistance of Escherichia coli to imipenem and meropenem were increased significantly during the same period （P=0.026, P=0.025）.The results of drug sensitivity tests showed that G（-） bacteria was sensitive to imipenem, meropenem, amikacin and piperacillin/tazobactam;G（＋） bacteria was sensitive to linezolid, teicoplanin and vancomycin.Conclusions The distribution of ascitic pathogens in SBP patients who were hospitalized in Beijing Youan Hospital from 2009 to 2016 present the tendency of decreasing of G（-） bacteria and increasing of fungi.The main pathogenic bacteria of SBP are drug-resistant.The resistance rates of Escherichia coli to imipenem, meropenem and cefotaxime have increased year by year.