242例肺移植受者的感染病原菌分布及耐药特征分析

Distribution and drug resistance characteristics of pathogens for infection after lung transplantation from 2010 to 2016

目的探讨肺移植受者术后感染病原菌分布及其耐药状况，指导临床合理使用抗菌药物。方法回顾性分析2010年1月至2016年12月无锡市人民医院肺移植中心242例肺移植受者的临床资料，其中男性182例，女性60例，年龄为（52±15）岁，送检标本采用VITEK-2全自动分析鉴定仪鉴定病原菌，用K-B法行耐药试验。结果2 373份送检标本中共分离出1 005株病原微生物，检出率为42.35%（1 005/2 373），其中革兰阴性菌共822株，占81.79%（822/1005），标本来源主要为痰液（76.19%）及支气管灌洗液（19.76%）。排名前五位的病原菌依次为鲍曼不动杆菌（28.76%）、铜绿假单胞菌（16.62%）、肺炎克雷伯菌（14.33%）、大肠埃希菌（5.57%）、嗜麦芽窄食单胞菌（4.88%）。鲍曼不动杆菌对多种抗菌药高耐药，耐药率为59.52%～100%，仅对头孢哌酮/舒巴坦的耐药率低于50%。铜绿假单胞菌对头孢唑林、头孢曲松、头孢替坦、氨苄西林、氨苄西林/舒巴坦高耐药，耐药率为80.24%～98.80%，对其余抗菌药耐药率均低于50%。嗜麦芽窄食单胞菌对复方新诺明、头孢哌酮舒巴坦、哌拉西林他唑巴坦、左氧氟沙星、环丙沙星耐药率分别为12.24%、14.29%、32.65%、16.33%、18.37%，而对亚胺培南天然耐药（100%）。肺炎克雷伯菌及大肠埃希菌等肠杆菌科细菌对亚胺培南高度敏感，其耐药率分别为24.31%、7.14%；对头孢他啶、头孢哌酮舒巴坦、哌拉西林他唑巴坦、氨曲南、阿米卡星、妥布霉素也具有较高的敏感性，耐药率〈50%。革兰阳性菌占9.35%，以金黄色葡萄球菌、溶血性葡萄球菌及表皮葡萄球菌居多，对万古霉素耐药率均〈20.00%。真菌占8.86%，以白色假丝酵母菌、丝状真菌为主，其对5种抗真菌药物的耐药率均〈20.00%；光滑假丝酵母菌和克柔假丝酵母菌对氟康唑的耐药率较高，分别为80.00%和100.00%。结论肺移植后革兰氏阴性菌以及多种菌群混合感染发生率高，其中非发酵菌对多种抗生素表现为高耐药，临床需根据药敏结果合理选用抗菌药物，以提高肺移植受者存活率。

ObjectiveTo investigate the pathogen distribution and drug resistance condition in patients after lung transplantation so as to guide the reasonable use of antibiotics.MethodsThe clinical specimens from 242 lung transplantation patients in Wuxi People＇s Hospital between Jan. 2010 to Dec. 2016 were retrospectively analyzed. Among the 242 patients, 182 were males and 60 were females with the average age of （52±15） years old. Automatic analysis instrument VITEK-2 was applied for pathogen detection and K-B method was used to test drug resistance.ResultsFrom 2373 specimens, 1005 strains of pathogens were isolated and the detection rate was 42.35% （1005/2373）, in which gram-negative bacteria accounted for 81.79% （822/1005）. The specimens mainly resulted from sputum （76.19%） and bronchoalveolar lavage （19.76%）. Among those strains, acinetobacter baumannii （28.76%）, pseudomonas aeruginosa （16.62%）, klebsiella pneumonia （14.33%）, escherichia coli （5.57%） and Stenotrophomonas maltophilia （4.88%） ranked the top five species. Acinetobacter baumannii strains were highly resistant to most of antibiotic agents, with the drug resistant rate from 59.52% to 100%, except cefperazone-sulbactam （〈50%）. Pseudomonas aeruginosa strains were highly resistant to cefazolin, ceftriaxone, cefotetan, ampicillin, ampicillin-sulbactam with the resistance rate of 80.24%-98.80%, while compared to other anibiotics with the resistance rate less than 50%. Stenotrophomonas maltophilia strains with intrinsic drug resistance to imipenem were sensitive to trimethoprim-sulfamethoxazole, cefperazone-sulbactam, piperacillin-tazobactam, levofloxacin, ciprofloxacin with the drug resistance rate of 12.24%, 14.29%, 32.65%, 16.33% and 18.37% respectively. Klebsiella Klebsiella pneumoniae and escherichia coli, whose resistant rate to ceftazidime, cefperazone-sulbactam, piperacillin-tazobactam, aztreonam, amikacin and tobramycin was all less than 50%, were highly sensitive to imipenem, with the resistance rate of 24.31% and 7.14% respectively. Gram-positive bacteria were accounted for 9.35%, mainly Staphylococcus aureus, Staphylococcus haemolyticus and Staphylococcus epidemics, and drug resistant rate of them to vancomycin was all less than 20.00%. Fungi were accounted for 8.86%, mainly Candida albicans and Filamentous fungi, whose drug resistance rate to 5 antifungal drugs was less than 20.00%. The drug resistance rate of C. glabrata strains and C. krusei strains to fluconazole was 80.00% and 100.00%, respectively.ConclusionThe incidence of gram-negative bacteria infection and multiple bacterial strain infection in patients after lung transplantation is very high and the non-fermentation bacteria are highly resistant to multiple antibiotics. So, the rational antibiotics＇ use in clinical practice should be based on drug sensitivity results in order to improve the lung transplant recipients＇ survival rate.