交通伤患儿创面鲍氏不动杆菌耐药性及其与抗生素使用的相关性分析

Analysis of drug resistance ofAcinetobacter baumannii in wound of children with traffic injury and its relationship with antibiotic use

目的了解交通伤患儿创面鲍氏不动杆菌的耐药性及其与抗生素使用的相关性。方法收集笔者单位2010年1月-2015年12月收治的226例交通伤患儿的创面分泌物，采用API细菌鉴定板条及全自动微生物鉴定系统进行菌株鉴定，通过K—B纸片扩散法测定检出菌株对阿莫西林／棒酸、哌拉西林／他唑巴坦、亚胺培南等18种抗生素的耐药性。统计各年度患儿创面病原菌检出情况。检出鲍氏不动杆菌对18种抗生素的耐药情况。将鲍氏不动杆菌检出阳性的46例患儿，根据鲍氏不动杆菌对亚胺培南是否100％耐药分为耐亚胺培南组19例和非耐亚胺培南组25例（2例患儿排除），比较2组患JESt面鲍氏不动杆菌对18种抗生素的耐药情况。统计鲍氏不动杆菌检出阳性患儿抗生素使用情况，比较2组患儿抗生素使用强度。对数据进行Fisher确切概率法检验、独立样本≠检验、校正t检验。结果（1）2010--2015年患儿创面病原菌检出率分别为95．6％（43／45）、89．8％（53／59）、81．3％（148／182）、81．1％（107／132）、81．6％（120／147）、77．5％（62／80），呈逐年递减的趋势。共检出665株、75种病原菌，检出率居前5位的病原菌从高到低依次为鲍氏不动杆菌、铜绿假单胞菌、阴沟肠杆菌、表皮葡萄球菌、大肠杆菌。（2）鲍氏不动杆菌对阿莫西林／棒酸、头孢唑林、氨曲南、哌拉西林100％耐药，对多黏菌素100％敏感，对其他13种抗生素总体耐药率均高于50％。2010--2015年各年度患儿创面鲍氏不动杆菌对哌拉西林的耐药率均较哌拉西林／他唑巴坦高。（3）除亚胺培南、阿莫西林／棒酸、头孢唑林、氨曲南、哌拉西林、多黏菌素外，耐亚胺培南组患儿创面鲍氏不动杆菌对其他12种抗生素的耐药率均显著高于非耐亚胺培南组（P值均小于O．01），且该组患儿创面鲍氏不动杆菌对碳青霉烯类、氨基糖苷类、喹诺酮类等3类以上抗生素均100％耐药，属于多药耐药鲍氏不动杆菌。（4）鲍氏不动杆菌检出阳性的46例患儿共使用32种抗生素，其中使用强度前10位的抗生素从高到低分别为头孢哌酮／舒巴坦、哌拉西林／他唑巴坦、头孢唑林、亚胺培南、头孢唑肟、阿莫西林／克拉维酸、头孢他啶、头孢吡肟、阿莫西林／舒巴坦、头孢美唑。（5）21种抗生素因使用量小，未列入进行比较。其他11种抗生素中，2组患儿仅甲硝唑使用强度差异有统计学意义（t=-3．104，P〈0．05）。2组患儿抗生素总体使用强度比较，差异无统计学意义（t=0．368，P〉0．05）。结论鲍氏不动杆菌是交通伤患儿创面主要病原菌之一，耐药率高，高强度使用抗生素可能诱导其产生耐药性。本研究中使用强度居前列的抗生素与鲍氏不动杆菌的耐药抗生素一致，提示抗生素使用的规范性有所欠缺。

Objective To know the drug resistance of Acinetobacter baumannii （AB） in wound of children with traffic injury and its relationship with antibiotic use. Methods Wound exudate of 226 chil- dren with traffic injury admitted to our unit from January 2010 to December 2015 were collected. API bacte- ria identification panels and fully automatic microbiological identification system were used to identify pathogens. Kirby-Bauer paper disk diffusion method was used to detect the drug resistance of pathogens to 18 anti- biotics including amoxycillin/clavulanic acid, piperacillin/tazobactam, and imipenem. The detection situation of pathogen of children＇s wounds and drug resistance of detected AB to 18 antibiotics in each year were collected. Forty-six AB positive children （2 children excluded） were divided into imipenem-resistant group （ IR, n = 19） and non imipenem-resistant group （ NIR, n = 25） according to whether AB was 100% resist- ant to imipenem. Drug resistance of AB in wounds of children to 18 antibiotics in two groups was compared. The antibiotic use of AB positive children was collected, and the antibiotic use intensity of children in two groups was compared. Data were processed with Fisher＇s exact test, independent sample t test, and corrected t test. Results （ 1 ） The detection rates of pathogen in wounds of children in 2010 - 2015 were 95.6% （43/45）, 89.8% （53/59）, 81.3% （148/182）, 81.1% （107/132）, 81.6% （120/147）, and 77.5% （62/80） , respectively, showing a trend of decreasing year by year. A total of 665 strains and 75 pathogens were detected, and the top 5 pathogens with detection rate from high to low were AB, Pseudomonas aeruginosa , Enterobacter cloacae , Staphylococcus epidermidis , and Escherichia coli , respectively. （2） Drug resistance rates of AB to amoxycillin/elavulanic acid, cefazolin, aztreonam, and piperacillin were all 100% , while AB was 100% sensitive to polymyxin, and the total drug resistance rates of AB to the other 13 antibiotics were all above 50%. The drug resistance rate of AB in wounds of children to piperacillin was higher than that to piperacillin/tazobactam in 2010 - 2015. （3） Except for imipenem, amoxycillin/clavulan- ic acid, cefazolin, aztreonam, piperacillin, and polymyxin, the drug resistance rates of AB in wounds of children in group IR to the other 12 antibiotics were higher than those in group N[R （with P values below 0.01 ）. Besides, AB strains in wounds of children in group IR were completely resistant to at least 3 kinds of antibiotics including carbapenems, aminoglycosides, and quinolones, so that they were muhidrug-resistant AB. （4） A total of 32 antibiotics were used in 46 AB positive children, and the 10-top-used antibiotics with use intensity from high to low were cefoperazone/sulbactam, piperacillin/tazobactam, eefazolin, imipenem, ceftizoxime, amoxycillin/clavulanate, ceftazidime, cefepime, amoxycillin/sulbactam, and cefmetazole, re- spectively. （5） Twenty-one antibiotics were not included in the comparison because of their small amount of usage. For the other 11 antibiotics, only the use intensity of metronidazole of children in two groups was sta- tistically different （ t = -3. 104, P 〈0. 05）. There was no statistically significant difference in total antibi- otic use of children in two groups （ t =0. 368, P 〉 0.05）. Conclusions AB is one of the main patho- gens in wounds of children with traffic injury, with high drug resistant rate. The high intensity of antibiotic use may lead to its drug resistance. In this study, the top-used antibiotics were in accord with AB resistant drugs, indicating a lack of normative use of antibiotics.