终末期肾脏病血液透析导管相关血流感染的临床特征分析

Clinical features of hemodialysis catheter related infections in end stage renal disease

目的分析终末期肾病血液透析导管相关血流感染(CRBSI)发生的原因、致病菌、药物敏感性、临床转归及其危险因素。方法收集2014年11月—2017年11月武汉大学人民医院肾内科随访的终末期肾病血液透析CRBSI患者72例(感染组)的临床资料,分析血液透析CRBSI的原因、危险因素、致病菌、药物敏感性、临床转归。另选择同期无CRBSI患者72例为非感染组,并进行临床比较,结果感染组hs-CRP、AST、WBC、NE、血降钙素原(PCT)水平高于非感染组,而血白蛋白(ALB)、)Na、Cl、Ca、P水平低于非感染组(P<0.05,P<0.01)。血液透析CRBSI发生的主要原因为:导管护理操作不规范20例(27.78%),导管滑脱8例(11.11%),导管引流不畅8例(11.11%),治疗不彻底2例(2.78%),原因不明34例(47.22%)。PCT、ALB是血液透析CRBSI发生的相关危险因素。血液透析CRBSI血培养,其中革兰阳性菌49例(68.06%),革兰阴性菌18例(25.00%),混合菌感染4例(5.56%),真菌感染1例(1.39%)。对血培养标本行致病菌药物敏感试验,其中革兰阳性菌对青霉素和氨苄西林的耐药率分别高达95.00%和70.00%,未发现对万古霉素和替考拉宁耐药菌株;革兰阴性杆菌对氨苄西林/舒巴坦、阿莫西林/克拉维酸的耐药率分别高达63.64%和62.50%,未发现黏菌素、四环素耐药菌株。结论血液透析CRBSI的主要原因为换液操作不规范、导管滑脱、导管引流不畅等,PCT、ALB是血液透析CRBSI发生的相关危险因素,PCT也用于评估感染的严重程度的重要指标。血液透析CRBSI的致病菌以革兰阳性球菌为主,革兰阳性球菌中未发现对万古霉素和替考拉宁耐药菌株,革兰阴性杆菌中未发现黏菌素、四环素耐药菌株。

Objective To investigate the causes, risk factors, drug sensitivity test and clinical outcome of hemodialysis catheter related bloodstream infections（ CRBSI） and provide a theoretical basis for prevention and treatment of CRBSI. Methods Clinical data of ESRD patients receiving hemodialysis in Department of nephrology of Renmin Hospital of Wuhan University from Nov,2014 to Nov,2017 were retrospectively analyzed. The causes,pathogenic bacteria,drug sensitivity and clinical outcome of CRBSI were analyzed. Results The main causes of CRBSI include： non-standard central venous catheterization care,catheter slippage and poor drainage of the catheter. In the total of 72 blood culture, 49 cases（68.06%） were infected with Gram positive cocci, 18 cases（25. 00%） with Gram negative bacillus, and 1 case（1.39%） with fungi. Drug sensitivity test showed that Gram positive cocci had the resistance rate to penicillin（95. 00%） and ampicillin（70. 00%）, but was sensitive to vancomycin and teicoplanin in all cases. The resistance rate of Gram negative bacillus to Amoxicillin and Clavulanate Potassium, Ampicillin and Sulbactam were 63. 64% and 62. 50%,no resistance was found to Colistin and Tetracycline. Conclusion The main causes of CRBSI in hemodialysis patients in our center are non-standard fluid handling, slippage of the catheter, poor drainage of the catheter. PCT and ALB are related risk factors for CRBSI. PCT is not only one of the diagnostic criteria for CRBSI, but also an important indicator for assessing the severity of the infection. The main pathogen of hemodialysis catheter related bloodstream infections is Gram positive bacteria,no resistance was found to Colistin and Tetracycline.