术中肾盂尿和结石细菌培养及药敏试验对预防经皮肾镜取石术后尿脓毒血症的价值研究

Value of Bacteria Culture of Renal Pelvis Urine and Calculi and Drug Sensitivity Test in the Prevention of Urosepsis after Percutaneous Nephrolithotomy

背景经皮肾镜取石术(PCNL)是治疗上尿路结石的主要方法,其所引起的尿源性感染是术后最常见的并发症,近年来随着细菌耐药率的逐年升高,术后不合理用药现象屡见不鲜,因此,如何降低术后尿脓毒血症发生率,合理、有效地应用抗生素具有重要的临床意义。目的探讨肾盂尿和结石细菌培养及药敏试验对预防PCNL后发生尿脓毒血症的价值。方法收集2016年10月-2018年10月在荆州市中心医院实施PCNL的940例患者的术前中段尿、术中肾盂尿和结石进行细菌培养和药敏试验,分析这三种标本的菌种分布情况及药敏试验结果,根据术中肾盂尿及结石标本的药敏试验结果,筛选出敏感性最高的三种非碳青霉烯类抗生素。收集2018年10-12月在荆州市中心医院实施PCNL的100例术前中段尿培养结果为大肠埃希菌或肺炎克雷伯菌的上尿路结石患者,根据术中/术后是否使用针对肾盂尿和结石细菌培养敏感的抗生素,将其分为对照组和试验组,各50例。对照组:术前、术后均使用中段尿培养和药敏结果显示的敏感非碳青霉烯类抗生素;试验组:术前使用中段尿培养和药敏结果显示的敏感非碳青霉烯类抗生素,术中/术后使用对肾盂尿及结石细菌培养敏感的非碳青霉烯类抗生素,观察两组患者PCNL后1周尿脓毒血症发生率。结果940例患者中,术前中段尿培养阳性171例,术中肾盂尿培养阳性210例,结石培养阳性182例。术前中段尿、术中肾盂尿及结石细菌培养出的菌种多为大肠埃希菌和肺炎克雷伯菌。在术前中段尿培养结果为大肠埃希菌的药敏试验中,头孢他啶、头孢西丁和米诺环素这三种非碳青霉烯类抗生素的敏感率最高;而在术中肾盂尿及结石细菌培养结果为大肠埃希菌的药敏试验中,哌拉西林/他唑巴坦、头孢哌酮/舒巴坦和阿米卡星这三种非碳青霉烯类抗生素的敏感率最高。在术前中段尿培养结果为肺炎克雷伯菌的药敏试验中,左氧氟沙星、头孢西丁和复方新诺明这三种非碳青霉烯类抗生素的敏感率最高;而在术中肾盂尿及结石细菌培养的结果为肺炎克雷伯菌的药敏试验中,哌拉西林/他唑巴坦、头孢哌酮/舒巴坦和阿米卡星这三种非碳青霉烯类抗生素的敏感率最高。术前中段尿、术中肾盂尿和结石中的大肠埃希菌对头孢他啶、头孢西丁和米诺环素的敏感率比较,差异均有统计学意义(P<0.01);其中术中肾盂尿和结石中的大肠埃希菌对头孢他啶、头孢西丁、米诺环素的敏感率均低于术前中段尿(P<0.01);术中肾盂尿和结石中的大肠埃希菌对头孢他啶、头孢西丁、米诺环素的敏感率比较,差异无统计学意义(P>0.01)。术前中段尿、术中肾盂尿和结石中的肺炎克雷伯菌对左氧氟沙星、头孢西丁和复方新诺明的敏感率比较,差异均有统计学意义(P<0.05);其中术中肾盂尿和结石中的肺炎克雷伯菌对左氧氟沙星、头孢西丁和复方新诺明的敏感率均低于术前中段尿(P<0.01);术中肾盂尿和结石中的肺炎克雷伯菌对左氧氟沙星、头孢西丁和复方新诺明的敏感率比较,差异无统计学意义(P>0.01)。对照组术后1周尿脓毒血症发生率为26.0%(13/50),试验组为10.0%(5/50)。对照组术后1周尿脓毒血症的发生风险高于试验组〔相对危险度(RR)=2.600,95%CI(1.002,6.750),P<0.05〕。结论使用对术中肾盂尿及结石细菌敏感的抗生素能够降低PCNL后尿脓毒血症发生率。在PCNL中,应常规进行肾盂尿及结石细菌培养及药敏试验。

Background Percutaneous nephrolithotomy(PCNL)is the main method for the treatment of upper urinary calculi,and urinary infection caused by this operation is the most common postoperative complication.In recent years,the drug resistance rate of bacteria has increased year by year,and unreasonable use of drugs after surgery is common.Therefore,how to reduce the incidence of postoperative urinary sepsis,and rational and effective use of antibiotics have important clinical significance.Objective To explore the value of bacteria culture and drug sensitivity analysis of renal pelvis urine and calculi in the prevention of urosepsis after PCNL.Methods A total of 940 patients who were carried out PCNL in Jingzhou Central Hospital were collected for the results of bacterial culture and drug sensitivity test of preoperative midstream urine,intraoperative renal pelvis urine and calculi,and the bacterial species distribution and drug susceptibility test results of the three samples were analyzed from October 2016 to October 2018.According to the drug sensitivity test results of renal pelvis urine and calculi,three non-carbapenems antibiotics with the highest sensitivity were selected.A total of 100 patients with upper urinary calculi with escherichia coli or klebsiella pneumoniae who underwent PCNL surgery in Jingzhou Central Hospital from October 2018 to December 2018 were collected.According to whether antibiotics sensitive to bacteria in renal pelvis urine and calculi were used intraoperatively or postoperatively,the patients were divided into control group and experimental group with 50 patients in each group.The patients in control group were treated with sensitive non-carbapenem antibiotics indicated by mid-stage urine culture and drug sensitivity before and after operation,and the patients in experimental group treated with sensitive antibiotics by midstream urine culture+drug sensitivity test in preoperative period,and non-carbapenems antibiotics sensitive to renal pelvis urine and calculi culture in intraoperative/postoperative period.The incidence of urosepsis after one week of PCNL was observed in the two groups.Results Among 940 patients,171 cases had positive culture result in the preoperative midstream urine,210 cases had positive culture result in the intraoperative renal pelvis urine,and 182 cases had positive culture result in the intraoperative calculi.Escherichia coli and klebsiella pneumoniae were the main bacterial species cultured from midstream urine,renal pelvis urine and calculi.Among the drug sensitivity test results of escherichia coli cultured in preoperative midstream urine,Ceftazidine,Cefoxitin and Minocycline were the most sensitive antibiotics of non-carbapenems,and among the drug sensitivity test results of escherichia coli cultured in intraoperative renal pelvis urine and calculi,Piperacillin/Tazobatam,Cefoperazone/Sulbactam and Amikacin were the most sensitive antibiotics of non-carbapenems.Among the drug sensitivity test results of klebsiella pneumoniae cultured in preoperative midstream urine,Levofloxacin,Cefoxitin and Sulfamethoxazole were the most sensitive antibiotics of non-carbapenems,and among the drug sensitivity test results of klebsiella pneumoniae cultured in intraoperative renal pelvis urine and calculi,Piperacillin/Tazobatam,Cefoperazone/Sulbactam and Amikacin were the most sensitive antibiotics of non-carbapenems.There were statistically significant differences in the sensitivity rates of escherichia coli to Ceftazidime,Cefoxitin and Minocycline in preoperative midstream urine,intraoperative renal pelvis urine and calculi(P<0.01).Among them,the sensitivity rate of escherichia coli to Ceftazidime,Cefoxitin and Minocycline in intraoperative renal pelvis urine and calculi was lower than that in preoperative midstream urine(P<0.01),but there was no statistically significant difference in the sensitivity of escherichia coli to Ceftazidime,Cefoxitin and Minocycline in intraoperative renal pelvis urine and calculi(P>0.01).There were statistically significant differences in the sensitivity rates of klebsiella pneumoniae to Levofloxacin,Cefoxitin and Sulfamethoxazole in preoperative midstream urine,intraoperative renal pelvis urine and calculi(P<0.05).Among them,the sensitivity rate of klebsiella pneumoniae to Levofloxacin,Cefoxitin and Sulfamethoxazole in intraoperative renal pelvis urine and calculi was lower than that in preoperative midstream urine(P<0.01),but there was no statistically significant difference in the sensitivity of klebsiella pneumoniae to Levofloxacin,Cefoxitin and Sulfamethoxazole in intraoperative renal pelvis urine and calculi(P>0.01).The incidence of urosepsis 1 week after PCNL was 26.0%(13/50)in the control group and 10.0%(5/50)in the experimental group.The risk of urosepsis 1 week after PCNL was higher in the control group than that in the experimental group〔RR=2.600,95%CI(1.002,6.750),P<0.05〕.Conclusion The use of antibiotics sensitive to bacteria in intraoperative pyelolithiasis and calculi can reduce the incidence of urinary sepsis after PCNL.In PCNL,the bacterial culture and drug sensitivity test of renal pelvis urine and calculi should be performed routinely.