急诊社区发病的血流感染病原学与临床特征

Etiological and clinical characteristics of community-onset bloodstream infection in adult emergency

目的分析北京某三甲医院急诊科社区发病的血流感染(community-onset bloodstream infection,CO-BSI)病原学和临床特征。方法本研究为单中心回顾性队列研究,纳入北京某三甲医院急诊科2018年CO-BSI患者的临床资料和血培养结果,对病原体分布、临床特征和细菌耐药情况进行分析。结果共纳入107例患者,培养出112株病原体,大肠埃希菌(34.8%)、肺炎克雷伯菌(28.6%)和金黄色葡萄球菌(10.7%)是急诊CO-BSI最常见的病原体。①革兰阳性(gram-positive,G^+)菌BSI中存在慢性肾脏病(32.1%vs.11.4%,P=0.026)的比例高于革兰阴性(gram-negative,G^-)菌BSI。G^+菌BSI患者28 d病死率(46.4%vs.22.8%,P=0.018)和住院病死率(53.6%vs.26.6%,P=0.009)均高于G-菌BSI。②大肠埃希菌约2/3来源于泌尿系统感染,肝胆系统感染不到1/3;肺炎克雷伯菌则来源于肝胆系统(40.6%)、下呼吸道(28.1%)和泌尿系统(25.0%)为主;金黄色葡萄球菌以下呼吸道(33.3%)和皮肤软组织(16.7%)来源多见。③分离菌株中多重耐药(multidrug resistant,MDR)菌比例为44.4%。三代头孢和喹诺酮类耐药的大肠埃希菌分别为30.8%和48.7%,三代头孢耐药的肺炎克雷伯菌为9.4%,耐甲氧西林的金黄色葡萄球菌为8.3%。肠杆菌对丁胺卡那霉素、碳青霉烯类、除头孢曲松外的三代头孢菌素、除氨苄西林/舒巴坦外的β内酰胺类/β内酰胺酶抑制剂及替加环素敏感率均在80%以上。葡萄球菌对万古霉素、利奈唑胺100%敏感。结论急诊科CO-BSI的病原体以G^-杆菌多见,但G^+菌BSI病死率高。CO-BSI的病原体存在多重耐药现象,但对大多数临床常用的抗菌药物保持着较好的敏感性。

Objective To analyse the etiological and clinical characteristics of communityonset bloodstream infection(CO-BSI)in adult emergency.Methods This was a single-center retrospective cohort study which included the clinical data and blood culture results of CO-BSI patients in the emergency department of a tertiary hospital in Beijing in 2018,and analyzed the pathogen distribution,clinical characteristics and drug resistance.Results A total of 107 patients were enrolled and 112 pathogens were cultured.Escherichia coli(34.8%),Klebsiella pneumoniae(28.6%)and Staphylococcus aureus(10.7%)were the most common pathogens of emergency CO-BSI.①The proportion of chronic kidney disease(32.1%vs.11,4%,P=0.026)in gram-positive(G^+)BSI was higher than that in gram-negative(G^-)BSI.The 28-day mortality(46.4%vs.22.8%,P=0.018)and the in-hospital mortality(53.6%vs.26.6%,P=0.009)in G^+BSI patients were both higher than those in G^-BSI patients.②About 2/3 of Escherichia coli were from urinary tract infection while less than 1/3 were from hepatobiliary system infection.Klebsiella pneumoniae was mainly from hepatobiliary system(40.6%),lower respiratory tract(28.1%)and urinary tract(25.0%).The source of lower respiratory tract(33.3%)as well as skin and soft tissue(16.7%)of Staphylococcus aureus was more common.③The proportion of multidrug-resistant(MDR)strains in the isolated strains was 44.4%.Escherichia coli were 30.8%and 48.7%resistant to third-generation cephalosporin and quinolone,respectively;Klebsiella pneumoniae was 9.4%resistant to thirdgeneration cephalosporin,and Staphylococcus aureus was 8.3%resistant to methicillin.The sensitivity of Enterobacter coli to amikacin,carbapenem,third generation cephalosporin except ceftriaxone,β-lactam/β-lactamase inhibitors except ampicillin/sulbactam,and tigacycline were all above 80%.Staphylococcus was 100%sensitive to vancomycin and linezolid.Conclusion The pathogen of COBSI in emergency department is mostly G^-bacilli,but the mortality among the patients infected with G^+BSI is higher.The pathogen of CO-BSI had multiple drug resistance,but it has good sensitivity to most commonly antibiotics.