一起广泛耐药伤寒暴发的临床特征分析

Clinical features of an outbreak of extensive drug resistant typhoid fever

目的分析一起广泛耐药伤寒暴发的临床特征,为耐药性伤寒诊治提供经验。方法纳入2022年1月27日至2月15日于首都医科大学附属佑安医院就诊的7例广泛耐药伤寒确诊患者。通过描述性研究,分析患者的临床特点、药物敏感试验、诊治经过及预后。结果7例广泛耐药伤寒患者中,男3例,女4例,其中1例为孕妇(妊娠32周),年龄为(29.8±6.8)岁,范围为22~42岁。发热7例,热程为6~20 d,腹泻5例,无玫瑰疹、淡漠面容及相对缓脉等伤寒特异性表现。4例并发肠出血,6例并发肝功能损伤。6例嗜酸性粒细胞比例消失/减少,2例白细胞计数降低。药物敏感试验结果示,7株伤寒沙门菌株均对氯霉素、氨苄西林、复方磺胺甲噁唑、喹诺酮类、头孢曲松、头孢吡肟、头孢他啶、头孢呋辛耐药,对碳青霉烯类抗菌药物、替加环素和哌拉西林/他唑巴坦等敏感。7例患者入院前均有抗菌药物使用史,入院后1例予静脉滴注头孢唑肟治疗7 d,出院后予头孢克肟口服7 d序贯治疗;6例患者予静脉注射哌拉西林钠/他唑巴坦钠治疗14 d。经治疗,所有例患者的血/粪便培养均转阴,好转出院。随访中1例患者出现脾脓肿。7例患者均为北京市同一公寓住户,且潜伏期内公寓有断水及水质浑浊异味现象,考虑为水源性传播引起的伤寒暴发。结论随着抗菌药物的使用,伤寒典型临床表现缺乏,伤寒沙门菌对喹诺酮类和第3代头孢菌素耐药率上升,广泛耐药伤寒应选用适当抗菌药物并延长抗感染疗程。

Objective To analyze the clinical features of an outbreak of extensive drug resistant typhoid fever,and to provide experience for the diagnosis and treatment of drug resistant typhoid fever.Methods Seven patients with confirmed diagnosis of extensive drug resistant typhoid fever who visited Beijing You′an Hospital,Capital Medical University,from January 27 to February 15,2022 were included.The clinical characteristics,drug sensitivity tests,consultation and treatment history and prognosis of the patients were analyzed through descriptive study.Results Of the seven extensive drug resistant typhoid fever patients,three were male and four were female,one of whom was pregnant(at 32-week gestation),aged(29.8±6.8)years,with a range of 22 to 42 years.There were seven cases with fever,and the course of fever ranged from six to 20 days.There were five cases with diarrhea and lack of typhoid-specific manifestations such as rose spot,apathetic facial expression and relatively slow pulse.Four cases were complicated with intestinal bleeding and six cases developed liver function injury.Six cases had loss or decrease in eosinophil ratio and two cases had decreased white blood cell count.The results of drug susceptibility tests showed that seven strains of Salmonella typhi were resistant to chloramphenicol,ampicillin,sulfamethoxazole-trimethoprim,quinolones,ceftriaxone,cefepime,ceftazidime,cefuroxime,and sensitive to carbapenem antibiotics,tigecycline and piperacillin/tazobactam.All seven cases had a history of antimicrobial use before admission.One case was administered with intravenous ceftizoxime for seven days after admission.After discharge,cefixime was administered orally for seven days.Six patients were given intravenous piperacillin sodium/tazobactam sodium for 14 days.All blood/fecal cultures were negative and the patients were cured and discharged.During the follow-up,one patient developed splenic abscess.All the seven patients were residents of the same apartment in Beijing City,and there were water cuts and turbid odors in the incubation period,which were considered as typhoid fever outbreak caused by waterborne transmission.Conclusions With the use of antimicrobial agents,the typical clinical manifestations of typhoid fever are absent,and the drug resistance rates to quinolone and third-generation cephalosporins increase.Appropriate antimicrobial agents should be selected and the anti-infection course should be prolonged.