医院获得性革兰氏阴性杆菌血流感染的耐药性及预后影响因素分析

目的探讨医院获得性革兰阴性杆菌血流感染菌株的耐药情况及患者预后影响因素。方法连续收集2013年1月至2016年12月在浙江中医药大学附属第一医院确诊为医院获得性革兰阴性杆菌血流感染的患者533例,回顾分析患者的一般资料、基础疾病、细菌耐药及相关危险因素。根据28天预后将患者分为生存组(417例)和死亡组(116例),采用二分类logistic回归分析影响预后的相关危险因素。结果533例革兰氏阴性杆菌血流感染患者中,大肠埃希菌感染195例(36.6%),肺炎克雷伯菌感染148例(27.8%),铜绿假单胞菌感染42例(7.9%),鲍曼不动杆菌感染38例(7.1%)。大肠埃希菌超广谱β-内酰胺酶(ESBL)阳性率为41.5%,对亚胺培南的耐药率为20%,呈现逐年递增的趋势(P<0.001)。肺炎克雷伯菌对亚胺培南的耐药率高达37.8%,且呈现逐年递增的趋势(P<0.001)。鲍曼不动杆菌对亚胺培南的耐药率达42.1%,而铜绿假单胞菌对亚胺培南的耐药率为21.4%。二分类Logistic回归发现,血液系统疾病(OR=3.387,95%CI:1.869〜6.137,P<0.001)、胃肠外营养(TPN)(OR=5.751,95%CI:3.087〜10.715,P<0.001)、早期未合理使用抗生素(OR=0.267,95%CI:0.143-0.499,P<0.001)、耐碳青霉烯类肺炎克雷伯菌(CRKP)感染(OR=2.541,95%CI:1.399〜4.619,P<0.001)及序贯器官衰竭评估(SOFA)评分≥5分(OR=3.886,95%CI:2.324〜6.498,P=0.002)是医院获得性革兰氏阴性杆菌血流感染的独立危险因素。结论革兰氏阴性杆菌血流感染病原菌以大肠埃希菌、肺炎克雷伯菌和铜绿假单胞菌为主血液系统疾病、TPN、CRKP感染、不恰当的经验性治疗和SOFA评分≥5分均与患者28天死亡率相关。

Objective explore the drug resistance and prognostic factors of hospital-acquired gram-negative bacilli bloodstream infection strains.Methods A total of 533 patients diagnosed with hospital-acquired gram-negative bacilli bloodstream infection in the First Affiliated Hospital of Zhejiang Chinese Medicine University from January 2013 to December 2016 were collected,and the general information,basic diseases,bacterial drug resistance and related risk factors were retrospectively analyzed.The patients were divided into survival group(417 cases)and death group(l 16 cases)according to the prognosis at 28 days,and the risk factors affecting the prognosis were determined by binary logistic regression.Results Among the 533 patients with gram-negative bacilli bloodstream infection,195 cases(36.6%)were Escherichia coli infection,148 cases(27.8%)were Klebsiella pneumoniae infection,42 cases(7.9%)were Pseudomonas aeruginosa infection,and 38 cases(7.1%)were Acinetobacter baumannii infection.The positive rate of Escherichia coli extended spectmm β-lactamase(ESBL)was 41.5%,and the resistance rate of Escherichia coli to imipenem was 20%,showing an increasing trend year by year(P<0.001).The drug resistance rate of Klebsiella pneumoniae to imipenem was as high as 37.8%,and showed an increasing trend year by year(P<0.001).The drug resistance rate of Acinetobacter baumannii to imipenem was 42.1%,and that of Pseudomonas aeruginosa to imipenem was 21.4%.Binary logistic regression showed that hematological diseases(OR=3.387,95%CI:1.869~6.137,P<0.001),parenteral nutririon(TPN)(OR-5.751,95%CI:3.087~10.715,P<0.001),early improper use of antibiotics(OR=0.267,95%CI:0.143~0.499,P<0.00l),carbapenem-resistant Klebsiella pneumoniae(CRKP)infection(OR=2.541,95%CI:1.399~4.619,P<0.001)and sequential organ failure assessment(SOFA)score≥5 points(OR=3.886,95%CI:2.324~6.498,P=0.002)were independent risk factors for hospital-acquired gram-negative bacilli bloodstream infection.Conclusion Escherichia coli,Klebsiella pneumoniae and Pseudomonas aeruginosa are the main pathogens of bloodstream infection by Gram-negative bacilli.Hematological diseases,TPN,CRKP infection,appropriate empiric treatment,and SOFA score≥5 are all associated with 28 day mortality.