北京与银川两家医院耐碳青霉烯类肠杆菌科细菌的流行特征研究

A study on the epidemic characteristics of carbapenem-resistant Enterobacteriaceae in Beijing and Yinchuan area

目的调查研究北京与银川两家医院耐碳青霉烯类肠杆菌(carbapenem-resistance Enterobacteriaceae,CRE)的流行病学特征,为CRE的临床诊治及其传播控制提供依据。方法收集2008年1月至2017年12月间北京地区解放军302医院及银川地区宁夏医科大学总医院的临床标本中分离的CRE,分析其流行趋势、标本来源、病原特点及基因型组成,探讨CRE的流行病学特征。结果两地区10年间分离鉴定出266株CRE,呈上升趋势,北京地区CRE检出率由2008年为0.45%上升到2017年的5.84%;银川地区CRE检出率由2008年的0.26%上升到2017年的3.1%。CRE感染患者以男性为主(159例,59.77%),主要来自重症监护病房(intensive care unit,ICU)70例(26.31%)。北京与银川两家医院分离出CRE的主要标本为痰液(29.4%与26.3%),血液(18.4%与6.5%)和尿液(10.5%与19.7%),血液和尿液标本占比差异显著(P=0.015和0.045)。北京与银川两家医院CRE菌株以克雷伯菌属(66.32%和44.74%)、埃希菌属(20.00%和9.21%)及肠杆菌属(7.89%和36.84%)为主,差异均具有统计学意义(比较P值分别为0.0012、0.0340和0)。266株CRE总体对碳青霉烯类和头孢类抗生素的耐药率较高,对其他类抗生素包括磷霉素和左氧氟沙星的耐药率达到80%以上,对阿米卡星的耐药率近60%;对头孢他啶/阿维巴坦的耐药率为42.86%,耐药率较低的包括替加环素(4.51%)和多黏菌素B(4.14%);北京地区CRE对阿米卡星和左氧氟沙星的耐药率显著高于银川地区。北京地区的blaKPC在克雷伯菌、埃希菌属和肠杆菌属中均占绝对优势(93.75%、61.9%和80%),而blaNDM仅在埃希菌属中检测到;银川地区均以blaNDM基因为主,三个菌属中占比分别为36%、74%和85.71%,两地碳青霉烯酶耐药基因分布差异明显(P=0)。结论北京与银川两地区的CRE菌株流行呈增长趋势,在标本来源、病原特点、碳青霉烯酶耐药基因分布等方面特征鲜明,临床应根据本地区的CRE流行特点采取针对性治疗。

Objective To study the epidemic characteristics of carbapenem-resistant Enterobacteriaceae(CRE)in Beijing and Yinchuan to provide evidence for clinical diagnosis,treatment and controlling transmission of CRE.Methods The strains of CRE isolated from clinical samples from PLA 302 Hospital in Beijing and Ningxia Medical University General Hospital in Yinchuan were collected during January 2008 to December 2017.The epidemic trend,sample source,pathogenic characteristics,and genotype composition of CRE were analyzed and we found the epidemic characteristics of CRE.Results The total 266 strains of CRE were isolated and identified in the two regions during 10 years.The detection rate of CRE increased from 0.45%in 2008 to 5.84%in 2017 in Beijing and increased from 0.26%in 2008 to 3.1%in 2017 in Yinchuan.The patients infected by CRE were mainly male(159 cases,59.77%),and 70 cases(26.31%)stayed in the intensive care unit(ICU).The dominant specimens with isolated CRE were sputum(29.4%vs.26.3%),blood(18.4%vs.6.5%),and urine(10.5%vs.19.7%)respectively.CRE strains were mainly Klebsiella spp.(66.32%and 44.74%),Escherichia(20.00%and 9.21%),and Enterobacter spp.(7.89%and 36.84%)in Beijing and Yinchuan.The differences were statistically significant(P=0.0012,0.0340,and 0,respectively).Apart from high resistant rate of 266 CRE strains to carbapenems and cephalosporins,the resistance rates were more than 80%to other antibiotics including fosfomycin and levofloxacin.Additionally,and the resistant rate was nearly 60%to amikacin and was 42.86%to ceftazidime/avibatam.Relatively,the resistant rate to tegacyclin(4.51%)and polymyxin B(4.14%)was low.The drug resistant rates of CRE to amikacin and levofloxacin in Beijing were significantly higher than those if Yinchuan.Carbapenemase encoding blaKPC genes wers dominant in Klebsiella,Escherichia,and Enterobacteriaceae(93.75%,61.9%,and 80%)in Beijing area,while blaNDM was detected in Escherichia only.But,blaNDM gene mainly accounted for 36%,74%,and 85.71%of the three genera in Yinchuan area,with significant differences in carbapenem resistance gene distribution(P=0)of two regions.Conclusion The prevalence of CRE is increasing in Beijing and Yinchuan.The characteristics of the samples,pathogens,and carbapenem resistance gene distribution are distinct.The clinical treatment should be based on the prevalence of CRE in the region.