导致肝脓肿的肠杆菌科细菌的耐药性分析

Drug resistance of Enterobacteriaceae bacteria causing liver abscess

目的分析导致肝脓肿的肠杆菌科细菌耐药情况,指导抗生素应用。方法以2014年1月-2017年12月在绍兴市人民医院住院并分离到肠杆菌科细菌的肝脓肿患者为研究对象。分析其临床资料、一般实验室检查结果、病原体耐药数据、治疗方法及结局。结果 53例患者中,基础疾病主要包括胆囊、胆道疾病或手术史28例(52.8%),高血压病20例(37.7%),糖尿病18例(34.0%);临床表现:发热51例(96.2%),肝区疼痛或胃肠道症状33例(62.3%),休克6例(11.3%)。31例(58.5%)白细胞计数>10×109/L,37例(69.8%)中性粒细胞计数升高,50例(94.3%)CRP升高,17/19例(89.5%)PCT升高,32例(60.4%)ALT升高,22例(41.5%)AST升高。血培养阳性11例,其中肺炎克雷伯杆菌7例(63.6%),大肠杆菌4例(36.4%)。脓液或胆汁培养肠杆菌科细菌株53例,包括肺炎克雷伯杆菌35例(66.0%),大肠杆菌12例(22.6%),摩氏摩根菌亚种2例(3.8%),彭氏变形杆菌、雷氏普罗威登斯菌、弗氏柠檬酸杆菌、奇异变形杆菌各1例(1.9%)。肺炎克雷伯杆菌中产超广谱β内酰胺酶2例,对常用抗生素敏感;大肠杆菌中产超广谱β内酰胺酶9例,对二、三代头孢菌素、喹诺酮类、氨基糖苷类耐药率较高。所有分离菌对碳青霉烯类抗生素敏感率高。结论导致肝脓肿的肠杆菌科细菌产超广谱β内酰胺酶率不高,三代头孢菌素及含β内酰胺酶抑制剂类抗生素可作为初始经验性治疗的主要方案。

Objective To investigate the drug resistance of Enterobacteriaceae bacteria which cause liver abscess,and to guide the application of antibiotics. Methods The patients with liver abscess who were hospitalized in our hospital from January 2014 to December 2017 and were found to have Enterobacteriaceae bacteria by isolation were enrolled as research subjects. Their clinical data,laboratory examination results,drug resistance data,treatment method,and outcomes were analyzed. Results Among the 53 patients,28（ 52. 8%） had gallbladder and biliary diseases or a surgical history,20（ 37. 7%） had hypertension,and 18（ 34. 0%） had diabetes; as for clinical manifestations,51（ 96. 2%） had pyrexia,33（ 62. 3%） had liver pain or gastrointestinal symptoms,and 6（ 11. 3%） had septic shock. Among these patients,31（ 58. 5%） had a leukocyte count of〉 10 × 109/L,37（ 69. 8%） had an increase in neutrophil count,50（ 94. 3%） had an increase in C-reactive protein,32（ 60. 4%） had an increase in alanine aminotransferase,and 22（ 41. 5%） had an increase in aspartate aminotransferase; among the 19 patients who underwent procalcitonin（ PCT） measurement,17（ 89. 5%） were found to have an increase in PCT. A total of 11 patients had a positive blood culture,among whom 7（ 63. 6%） had Klebsiella pneumoniae and 4（ 36. 4%） had Escherichia coli. Pus or bile culture identified Enterobacteriaceae bacteria strains in the 53 patients,among whom 35（ 66. 0%） had Klebsiella pneumoniae,12（ 22. 6%） had Escherichia coli,2（ 3. 8%） had Morganella morganii subspecies,and 1（ 1. 9%） each had Proteus penneri,Providencia rustigianii,Citrobacter freundii,and Proteus mirabilis. Among the 35 patients with Klebsiella pneumoniae,2 had extended-spectrum beta-lactamase（ ESBL）-producing Klebsiella pneumoniae,and among the 12 patients with Escherichia coli,9 had ESBL-producing Escherichia coli; Klebsiella pneumoniae strains were sensitive to common antibiotics,while Escherichia coli strains had high drug resistance rates to second-and third-generation cephalosporins,quinolones,and aminoglycosides. All isolates were highly sensitive to carbapenems. Conclusion Enterobacteriaceae bacteria causing liver abscess has a low ESBL-positive rate. Third-generation cephalosporins and antibiotics containing β-lactamase inhibitors are major regimens for initial empiric therapy.