消化内科老年重症患者医院感染CRE感染特征及有关危险因素分析

Analysis of characteristics and related risk factors of nosocomial CRE infection in elderly critically ill patients in the Department of Gastroenterology

目的探讨消化内科老年重症患者医院感染耐碳青霉烯类肠杆菌科细菌(CRE)感染特征,并进一步对相关危险因素行多元回归分析。方法选择感染的老年重症患者作为研究对象,根据病原菌药敏试验分为CRE组与碳青霉烯类敏感肠杆菌科(CSE)组,比较两组患者临床特征差异,CRE组患者耐药情况及分析危险因素。结果CRE组合并慢性阻塞性肺疾病、机械通气、中心静脉置管、碳氢酶烯类暴露、喹诺酮类暴露、抗生素使用种类≥2种、抗生素使用时间≥7 d、使用糖皮质激素比例、年龄及APACHEⅡ评分均高于CSE组,差异有统计学意义(χ^(2)=6.120,4.564,5.656,7.792,6.630,6.448,7.697,5.102,t=3.658,4.251,P<0.05)。多因素logistic回归分析显示:合并慢性阻塞性肺疾病、机械通气、中心静脉置管、碳氢酶烯类暴露、抗生素使用种类≥2种、抗生素使用时间≥7 d、使用糖皮质激素是CRE发生的危险因素(P<0.05)。CRE耐药菌种以肺炎克雷伯菌最常见,占83.93%,其次为肠杆菌属(5.36%)、大肠埃希菌(3.57%)。2019年与2020年CRE对头孢菌素类、碳氢酶烯类耐药率均为100.00%,对阿米卡星、庆大霉素、左氧氟沙星的耐药率均较高,目前尚未发现对替加环素的耐药菌株。生存分析发现140例患者28d内死亡26例,占18.57%,其中CRE死亡18例(32.14%),CSE组死亡8例(9.52%),两组比较差异有统计学意义(χ^(2)=11.368,P<0.05)。结论消化内科老年重症患者医院感染CRE感染主要以肺炎克雷伯菌为主,严格把控抗菌药物使用指征,避免侵入性操作,控制激素使用可降低CRE发生率。

Objective To explore the characteristics of hospital-acquired carbapenem-resistant Enterobacteriaceae(CRE)in elderly critically ill patients in the Department of Gastroenterology,and further perform multiple regression analysis on related risk factors.Methods Elderly critically ill patients with infection were selected as the research subjects and were divided into the CRE group and the carbapenem sensitive Enterobacteriaceae(CSE)group based on pathogen susceptibility tests.The clinical characteristics of the two groups of patients were compared,and the drug resistance of the CRE group of patients was analyzed,along with risk factors.Results The CRE group complicated with chronic obstructive pulmonary disease,mechanical ventilation,central venous catheterization,hydrocarbon alkene exposure,quinolones exposure,antibiotic use types≥2,antibiotic use time≥7 d,glucocorticoid use ratio,age and APACHEⅡscore were all higher than those in CSE group,and the differences were statistically significant(χ^(2)=6.120,4.564,5.656,7.792,6.630,6.448,7.697,5.102,t=3.658,4.251,P<0.05).Multivariate logistic regression analysis showed that the risk factors of CRE were chronic obstructive pulmonary disease,mechanical ventilation,central venous catheterization,hydrocarbon exposure,antibiotic use types≥2,antibiotic use time≥7 days and glucocorticoid use(P<0.05).Klebsiella pneumoniae was the most common drug-resistant bacteria,accounting for 83.93%,followed by Enterobacter(5.36%)and Escherichia coli(3.57%).In 2019 and 2020,the resistance rates of CRE to cephalosporins and hydrocarbenes were all 100.00%,and the resistance rates to amikacin,gentamicin and levofloxacin were all high.So far,no strains resistant to tigecycline have been found.Survival analysis showed that 26 of 140 patients died within 28 days,accounting for 18.57%,including 18 cases of CRE(32.14%)and 8 cases of CSE(9.52%).The difference between the two groups was statistically significant(χ^(2)=11.368,P<0.05).Conclusion Klebsiella pneumoniae is the main cause of nosocomial infection in elderly patients with severe gastroenterology.Strictly controlling the indications of antibacterial drugs,avoiding invasive operation,and controlling hormone use can reduce the incidence of CRE.