肾移植术后重症监护期医院感染病原学特点及危险因素分析

Etiological characteristics and risk factors of nosocomial infection after severe renal transplantation

目的探讨肾移植术后重症监护期内医院感染的病原学特点及相关危险因素。方法选择2014年1月至2016年12月于本院接受异体肾移植手术的患者242例为研究对象,将在重症监护室(intensive care unit,ICU)内出现医院感染的38例患者纳入感染组,将未出现ICU内医院感染的204例患者纳入未感染组。对感染患者的血液、痰液、中段尿等标本进行分离培养鉴定,并进行药敏试验,对可能影响肾移植患者在重症监护期内医院感染的相关危险因素进行分析。结果 242例患者在重症监护期共出现38例医院感染,医院感染发生率为15.7%,感染部位主要是泌尿道和呼吸道。共分离出45株病原菌,革兰阴性菌占71.1%,其中肺炎克雷伯菌10株(22.2%)、大肠埃希菌13株(28.9%);革兰阳性菌占28.9%,其中金黄色葡萄球菌8株(17.8%)、肠球菌5株(1.1%)。药敏试验结果提示,肾移植术后ICU医院感染的致病菌耐药程度整体较高,革兰阴性菌中肺炎克雷伯菌对米诺环素、美罗培南、左氧氟沙星较敏感,耐药率分别为10.0%、30.0%、30.0%;大肠埃希菌对头孢哌酮、米诺环素、美罗培南较敏感,耐药率均为7.7%;革兰阳性菌中金黄色葡萄球菌对环丙沙星、利福平较敏感,耐药率均为25.0%;肠球菌对大多抗生素耐药性均较高;尚未发现对万古霉素、替考拉宁耐药的菌株。单因素及多因素回归分析显示,住ICU时间长、血糖高、留置导尿管>4天、排斥反应、术前血液透析时间≤1年是影响肾移植术后重症监护期医院感染的独立危险因素。结论肾移植术后,应加强对高血糖、出现排斥反应及术前血液透析时间≤1年的易感染患者的预防控制,并密切观察患者的临床表现,及时拔管或转入普通病房,积极降低患者医院感染发生率。对于已出现感染的患者,应根据病原学特点选择合理的抗生素治疗方案,提高医疗质量。

Objective To investigate the etiology and related risk factors of nosocomial infection after renal transplantation in ICU. Method From January 2014 to December 2016, 242 patients who underwent allogeneic kidney transplantation in our hospital were selected as the subjects. 38 patients with nosocomial infection in ICU were included in the infection group, and 204 patients without ICU hospital infection were included in the uninfected group. The blood, sputum, middle urine and other specimens of infected patients were isolated and cultured, and drug susceptibility tests were carried out to analyze the risk factors that may affect the nosocomial infection of renal transplant patients during the intensive care period. Result A total of 38 nosocomial infections occurred in 242 patients during ICU, and the incidence of nosocomial infection was 15.7%, the main infection sites were respiratory tract and urinary tract, 45 strains of pathogenic bacteria isolated from the main Gram negative bacteria, accounted for 71.1%, of which 10 strains of Klebsiella pneumoniae（22.2%）, 13 strains of Escherichia coli（28.9%）, Gram positive bacteria accounted for 28.9%, among which 8 strains of Staphylococcus aureus（17.8%）, 5 strains of Enterococcus（1.1%）. The results of drug sensitivity test showed that the degree of drug resistance of pathogenic bacteria in the intensive care period after kidney transplantation was serious. Klebsiella pneumoniae in Gram-negative bacteria was sensitive to Minocycline, Meropenem, and Levofloxacin, and the drug-resistance rate was 10.0%, 30.0%, and 30.0% respectively. Escherichia coli was sensitive to Cefoperazone, Minocycline and Meropenem, and the drug resistance rate was 7.7% respectively. Staphylococcus aureus in Gram-positive bacteria was sensitive to Ciprofloxacin and Rifampicin, drug-resistance rate was 25.0% respectively. Enterococcus was more resistant to most antibiotics. No strains resistant to Vancomycin or Teicoplanin had been found. Univariate and multivariate regression analysis showed that long ICU stay, higher glucose, indwelling catheter time 4 days, rejection, preoperative dialysis time ≤ 1 years were the independent risk factors of nosocomial infection in intensive care period after renal transplantation. Conclusion After renal transplantation, we should strengthen the prevention and control of the susceptible to patients with high blood sugar, rejection, and pre-operative hemodialysis time ≤ 1 year, and strictly grasp the clinical manifestation, extubate or transfer to the general hospital in time. For patients who existing infections, reasonable antibiotic treatment should be selected through pathogenic characteristics to improve the quality of medical care.