ESBL阳性肺炎克雷伯菌所致肺炎临床特点和耐药性分析

The Clinical Characteristics and Drug Resistance of Pneumonia Caused by Klebsiella Pneumoniae in ESBL-positive Pneumonia

目的研究产超广谱β内酰胺酶(ESBL)的肺炎克雷伯菌的耐药特性及其所致肺炎的临床特点及临床危险因素,为预防ESBL阳性肺炎克雷伯菌所致肺炎的发生和临床治疗中抗生素的合理使用提供参考依据。方法回顾性收集首都医科大学附属北京同仁医院93例(其中包括感染ESBL阳性肺炎克雷伯菌48例,非ESBL阳性肺炎克雷伯菌45例)住院患者的病历资料包括患者性别、年龄、治疗所用抗生素、住院时长、基础疾病以及侵入性操作6方面的信息,以及培养肺炎克雷伯菌的临床药敏结果。并对其危险因素进行单因素和多因素的分析。结果 ESBL阳性肺炎克雷伯菌菌株对阿米卡星的耐药率最低为41.6%,其次为复方新诺明和亚胺培南分别为56.3%和58.3%;对头孢菌素类药物(除头孢替坦外)耐药率为100%。临床治疗用药中单独用药最多见的是哌拉西林、美罗培南;联合用药最常见的是哌拉西林联合舒巴坦、美罗培南联合莫西沙星。感染ESBLs阳性肺炎克雷伯菌的肺炎患者,60岁以上占79.2%,平均住院天数为28.5±11.6天;死亡率为31%;合并高血压的有18例,合并糖尿病的有9例,合并脑梗的有3例,合并呼吸系统疾病的有10例;治疗过程中采用侵入性操作的有35例;感染ESBLs阴性肺炎克雷伯菌的肺炎患者,60岁以上33.4%,平均住住院天数为15.5±5.0天;死亡率6%;合并高血压的有18例,合并糖尿病的有9例,合并脑梗的有3例,合并呼吸系统疾病的有10例;治疗过程中采用侵入性操作的有16例。结论住院时长(≥20天)、侵入性操作(包括气管插管、鼻导管吸氧、鼻饲等)、治疗过程中阿米卡星的使用,都是造成感染ESBL阳性肺炎克雷伯菌肺炎的临床感染危险因素(P<0.05)。在治疗感染ESBL阳性肺炎克雷伯菌的肺炎患者时应根据药敏结果调整临床用药。控制和预防感染ESBL阳性肺炎克雷伯菌的临床高危因素,可减少感染的可能性。

Objective To study the characteristics of Klebsiella pneumoniae with producing extended-spectrumβ-lactamase（ESBL） and its clinical features and clinical risk factors,so to provide references for the prevention of pneumonia caused by Klebsiella pneumoniae due to ESBL-positive pneumonia and rational use of antibiotics in clinical treatment. Methods We retrospectively collected medical records of 93 inpatients of Beijing Tongren Hospital,one affiliate of Capital Medical University,including 48 cases of ESBL-positive K. pneumoniae and 48 cases of non-ESBL-positive K. pneumoniae. The data included patient gender,age,information on the use of antibiotics,length of hospital stay,underlying disease,invasive procedures,and clinical susceptibility results for Klebsiella pneumoniae culture. The risk factors were analyzed by univariate and multifactorial analysis. Results The resistance rate of ESBL-positive K. pneumoniae strains to amikacin was 41. 6%,followed by sulfamethoxazole and imipenem with 56. 3% and 58. 3%,respectively. For cephalosporins（except Cefotetan outside）,the resistance rate was 100%. The most single commonly used drugs for clinical treatment were piperacillin and meropenem. The most common drugs for combination use were piperacillin combined with sulbactam,and meropenem combined with moxifloxacin. Patients with pneumococcal disease who were infected with ESBLs-positive Klebsiella pneumoniae accounted for 79. 2%of patients over the age of 60. The average length of hospital stay was 28. 5 ± 11. 6 days and the mortality rate was 31%. There were 18 patients with hypertension,and 9 with diabetes. There were 3 patients with cerebral infarction,10 patients with respiratory diseases,35 patients with invasive procedures during treatment,and 48 patients with pneumonia with ESBLs-negative Klebsiella pneumoniae,among them 33. 4% over 60 years of age. The number of days of hospitalization was 15. 5 ± 5. 0 days and mortality was 6%. There were 18 patients with hypertension,9 with diabetes,3 with cerebral infarction,and 10 with respiratory disease. During treatment,there were 16 people who received invasive procedures. Conclusion Length of hospitalization（≥20 days）,invasive procedures（including endotracheal intubation,nasal cannula oxygen inhalation,nasal feeding,etc.）,and use of amikacin during treatment are all clinical risk factors for infection of ESBL-positive K. pneumoniae pneumonia（P〈0. 05）. In the treatment of pneumonia patients infected with ESBL-positive Klebsiella pneumoniae,the clinical medicine should be adjusted according to drug susceptibility results.Controlling and preventing the clinical risk factors for ESBL-positive Klebsiella pneumoniae can reduce the possibility of infection