重症急性胰腺炎继发感染的病原菌分布特点

The distribution of pathogen in severe acute pancreatitis secondary infection

目的探讨重症急性胰腺炎(SAP)患者继发感染细菌和真菌在不同部位的分布情况。方法回顾性分析2012年1月至2017年12月安徽医科大学第二附属医院重症医学科连续收治的54例有明确病原菌感染依据的SAP患者资料。男性31例,女性23例;年龄19～91岁,平均(52±13)岁。送检标本来源:(1)胰周坏死组织或腹腔引流液;(2)气管导管内痰液或肺泡灌洗液;(3)血液;(4)尿液;(5)中心静脉导管;(6)胆汁。对阳性送检标本进行菌株鉴定,计算细菌、真菌在不同部分及整体构成比。结果 54例患者共送检标本117份,共检出病原菌151株,主要来自腹腔32. 5%(38/117)、痰液28. 2%(33/117)、血液17. 1%(20/117)。其中革兰阴性菌97株(64. 2%),革兰阳性菌30株(19. 9%),真菌24株(15. 9%)。革兰阴性菌前3位的病原菌依次为大肠埃希菌(41. 2%),鲍曼不动杆菌(17. 5%),铜绿假单胞菌(10. 3%)。革兰阳性菌主要以粪/屎肠球菌(53. 3%)及表皮葡萄球菌(26. 7%)为主。真菌以念珠菌属为主,仅检出1株曲霉菌。腹腔病原菌中前3为依次为大肠埃希菌(35. 4%)、屎/粪肠球菌(16. 7%)及铜绿假单胞菌(14. 6%)。痰液中前3位依次为鲍曼不动杆菌(17%)、念珠菌属(17%)及大肠埃希菌(14. 9%)。血液中前3位病原菌为大肠埃希菌(32. 1%)、凝固酶阴性葡萄球菌(21. 4%)、屎/粪肠球菌(14. 3%)。尿液中前3位分别为念珠菌属(40%)、大肠埃希菌(26. 7%)及屎/粪肠球菌(20%)。中心静脉导管共培养出9株病原菌,占比6%,且三类病原菌比例接近;胆汁共培养4株病原菌,其中近平滑念珠菌和克柔念珠菌各1株。结论 SAP患者继发感染最常见部位依次为腹腔、肺部、血液及尿液,以革兰阴性菌为主,其中以肠杆菌科(大肠埃希菌及肺炎克雷伯杆菌)和非发酵菌(鲍曼不动杆菌、铜绿假单胞菌及嗜麦芽窄食单胞菌)为主,而血流与尿路感染的病原菌则分别以革兰阳性菌与真菌为主。

Objective To investigate the spectrum of bacteria and fungi in different sites secondary infection in patients with severe acute pancreatitis （SAP）. Methods The clinical data of 54 SAP patients with infection admitted in Department of intensive care unit（ICU） ,The Second Affiliated Hospital of AnHui Medical University from January 2012 to December 2017 were retrospectively analyzed. There were 31 males and 23 females. Aged from 19 to 91 years,with an average age of （52 刘念 13） years. Samples were collected from ： （ 1 ） peripanereatic necrosis or abdominal drainage ; （2） sputum in the tracheal tube or bronchoalveolar lavage fluid ; （ 3 ） blood; （4） urine; （5） central venous catheter; （6） bile. The strain identification was performed on for the positive specimens. Constituent ratio of bacteria and fungi were calculated in different sites and in all sites. Results A total of 117 samples were collected from 54 patients, and 151 strains of pathogens were isolated, mainly from abdominal cavity 32. 5%o （38/117）, sputum 28.2% （33/ 117 ） , and blood stream 17.1% （ 20/117 ）. Among them,97 strains （ 64. 2% ） were gram-negative bacteria,30 cases （ 19.9% ） were gram - positive bacteria, and 24 cases （ 15.9% ） were fungi respectively. The top three common pathogens of gram-negative bacteria isolated were E. coil （41.2%） ,Acinetobacter baumannii （17.5%） ,P. acruginosa （10. 3% ） respectively. The mainly consist of gram-positive bacteria were E. faecium/faecalis （53.3 % ） and Staphylococcus epidermidisl （26. 7% ）. The main fungus were candidas, and only one strain of aspergillus was detected. The top three common pathogens in the abdominal cavity were E. coli （35.4%） , E. faecium/faecalis （ 16. 7% ） and P. aeruginosa （ 14. 6% ）. The top three in the sputum were Acinetobacter baumannii （ 17% ） ,Candidas （ 17% ） and E. coli（ 14. 9% ）. The top three in the blood were E. eoli （32. 1% ） ,Coagulase negative staphylococcus（CNS） （21.4%） ,and E. faecium/faecalis （ 14. 3% ）. The top three in the urine were Candidas （40%） ,E. coli （26. 7% ） ,and E. faecium/faecalis （20%）. A total of 9 pathogens were cultured in the central venous catheter,accounting for 6% in total,and the proportion of the three types of pathogens was similar. Four pathogens were cultured in bile, including 1 strains of Candida Parapsilosis and Candida krusei respectively. Conclusion Abdomen,lang,blood and urine were the most common sites of patients with SAP secondary infection successively. The gram-negative bacteria are the predominant pathogens, mainly including Enterobacteriaceae bacteria （K. pneumonia and E. coli） and non-fermentation bacteria （Acinetobacter baumannii, P. aeruginosa and Stenotrophomonas maltophilia）. However, The gram-positive bacteria and fungi were mainly pathogens in the infection of blood stream and urinary tract respectively.