多重耐药革兰阴性菌感染对中度重症和重症急性胰腺炎病程和预后的影响

Influence of multi-drug-resistant Gram-negative bacteria infections on the process and prognosis of moderately severe acute pancreatitis and severe acute pancreatitis

目的·分析中度重症急性胰腺炎(moderately severe acute pancreatitis,MSAP)和重症急性胰腺炎(severe acute pancreatitis,SAP)继发胰腺/胰周革兰阴性耐药菌感染的来源、菌种特点及其对病程和预后的影响。方法·回顾2013—2017年上海交通大学医学院附属瑞金医院急诊科、胰腺外科与重症医学科收治的符合研究条件的患者,筛选胰腺/胰周革兰阴性菌(Gram-negative bacteria,GNB)感染的患者,并分为多重耐药(multiple drug resistant,MDR)革兰阴性菌(MDR-GNB)组和非多重耐药革兰阴性菌(non-MDRGNB)组,对比分析基础临床信息、耐药菌的来源、耐药菌感染对病情进展及预后的影响。结果·共收治197例MSAP和SAP患者,胰腺/胰周标本明确GNB感染92例(46.70%),其中MDR-GNB感染患者61例(占66.30%),non-MDR-GNB感染患者31例(占33.70%);胰腺/胰周标本共检出117株GNB,其中MDR-GNB 69株,主要是多重耐药肺炎克雷伯杆菌(Klebsiella pneumoniae,KP)(MDR-KP)(39株,56.52%)和多重耐药鲍曼不动杆菌(Acinetobacter baumannii,AB)(MDR-AB)(22株,31.88%);MDR-GNB组经皮穿刺置管引流(percutaneous catheter drainage,PCD)继发耐药菌感染的发生率显著高于non-MDR-GNB组(36.07%vs 12.90%,P=0.020);耐药菌感染可导致机械通气时间延长[(17.65±11.74) d vs (9.67±9.34) d,P=0.001]、碳青霉烯类和特殊抗菌药物使用增加(P=0.000)、首次开腹手术时间提前[(21.92±11.45) d vs (29.36±21.48) d,P=0.032]、≥2次开腹手术发生率增高(45.90%vs 22.58%,P=0.029)、总住院时间延长(54.44±42.38) d vs (32.51±27.62) d,P=0.011)和病死率增高(34.43%vs 12.90%,P=0.028);死亡患者中MDR-KP的感染率显著高于存活患者(85.71%vs 52.50%,P=0.000),而其他耐药菌在2组中差异均无统计学意义。结论·MSAP和SAP继发胰腺/胰周革兰阴性耐药菌感染的患者中,MDR-KP和MDR-AB占据了主导地位。耐药菌感染的来源中,PCD继发感染的发生率最高。耐药菌感染可导致病程延长、用药和手术增加及预后不良,其中MDR-KP的感染更是与预后不良直接相关。

Objective·To analyze the bacterial origin and characteristics,and their influence on the process and prognosis in moderately severe acute pancreatitis(MSAP)and severe acute pancreatitis(SAP)patients with pancreatic/peri-pancreatic infections due to multiple drug resistant(MDR)Gramnegative bacteria(GNB).Methods·Patients of pancreatitis hospitalized in the Departments of Emergency,Pancreatic Surgery and Critical Care Medicine were enrolled in this study.The patients with pancreatic/peri-pancreatic GNB infections were screened and divided into MDR-GNB group and non-MDRGNB group.The basic clinical features,the source of resistant bacteria,the progress of the disease and the prognosis were analyzed and compared within two groups.Results·92(46.70%)out of 197 MSAP and SAP patients were confirmed as GNB infected,61 cases(66.30%)with MDR strains and 31 cases(33.70%)with non-MDR strains.117 GNB were isolated.The main MDR strains were Klebsiella pneumoniae(KP)(39/69)and Acinetobacter Baumannii(AB)(22/69).The incidence of percutaneous catheter drainage(PCD)associated MDR bacterial infections in MDR-GNB group was significantly higher than that of non-MDR-GNB group(36.07%vs 12.90%,P=0.020).The MDR-GNB infections could lead to prolonged mechanical ventilation[(17.65±11.74)d vs(9.67±9.34)d,P=0.001],increased use of carbapenems and special antibiotics(P=0.000),earlier intervention of first laparotomy[(21.92±11.45)d vs(29.36±21.48)d,P=0.032],increased incidence of multiple operations(45.90%vs 22.58%,P=0.029),prolonged total hospitalization[(54.44±42.38)d vs(32.51±27.62)d,P=0.011]and higher mortality(34.43%vs 12.90%,P=0.028).The incidence of MDR-KP infections in death patients was significantly higher than that in the surviving patients(85.71%vs 52.50%,P=0.000),while the other MDR bacteria did not present statistical difference in the two groups.Conclusion·MDRKP and MDR-AB are the main resistant GNB in MSAP and SAP patients with pancreatic/peri-pancreatic infections.The PCD associated infection is the main source of nosocomial MDR bacterial infections.Infections due to MDR-GNB could lead to prolonged therapy course,increased use of antibiotics,augmented operation,and poor outcome.The infection of MDR-KP is directly related to poor outcome.