烧伤侵袭性感染的抗生素起始治疗策略探讨

Initiation of systemic administration of antibiotics in treatment of invasive infection of burns

目的 :探讨如何应用病房内连续创面细菌学监测结果的分析 ,适时合理地调整在烧伤侵袭性感染抗生素起始治疗中经验性选择和应用抗生素。方法 :回顾分析 1995— 2 0 0 0年本烧伤中心 6 12例烧伤患者创面和焦痂下组织中分离出 110 9株细菌的监测资料 ,比较前后 3a两个阶段的细菌菌种分布特点、变化及耐药状况 ,并作有关统计学处理。结果 :6 12例患者创面分离出细菌 90 2株 ,焦痂下组织分离出细菌 2 0 7株。1998— 2 0 0 0年的近 3a间创面和焦痂的革兰阴性 (G- )杆菌检出百分比显著高于革兰阳性 (G+ )球菌 ;进一步分析见铜绿假单胞菌和肠杆菌科细菌为 G- 杆菌的主要菌种 ,金黄色葡萄球菌 (金葡菌 )为 G+ 球菌的主要菌种 ;G- 杆菌对第三代头孢菌素和阿米卡星耐药性呈持续上升 ,其中铜绿假单胞菌对奈替米星耐药率由 18.5 2 %下降到 5 .83% ,肠杆菌科细菌对奈替米星耐药性由 18.75 %上升到 5 5 .79% ;金葡菌对奈替米星的耐药性由 2 8.13%下降到4 .70 % ;当铜绿假单胞菌对亚胺培南耐药性进一步升高时 ,肠杆菌科细菌对其敏感性仍保持不变。结论 :近年来本烧伤中心烧伤创面以 G-杆菌为主 ,同时细菌耐药性有所改变 ;对严重烧伤患者发生侵袭性感染时采用抗生素起始治疗的适当策略是亚胺培南和奈替米星联合用药 。

Objective:To optimize the systemic antibiotics in the treatment of the invasive infection of burns based on the successive monitoring of bacterial species harvested from the burn wound and subeschar tissues and their resistance to antibiotics.Methods:The data of bacterialogical monitoring of burn wound and subeschar tissues in our burn center from 1995 to 2000 were retrospectively analyzed,and the characteristics of distribution and resistance to antibiotics of 1 109 strains from the wound in 612 patients and subeschar tissues in 146 patients were compared statistically by dividing them into two periods, i.e. from 1995 to 1997 and 1998 to 2000,respectively.Results:The percentage of Gram negative bacilli in identified strains was significantly higher than that of Gram positive cocci,and the majority of them were Pseudomonas and Enterobacteriaceae;Staphylococcus aureus comprised the majority of Gram positive cocci from 1998 to 2000,compared with the data collected in the period of from 1995 to 1997.The resistance of the Gram negative bacilli to Cephlosporins and Amikacin was increasing while the resistance of Pseudomonas to Netilmicin was decreasing from 18 52% of the tested strains down to 5 83%,and the resistance of Enterobacteriaceae to it was increasing from 18 75% to 55 79%.In addition,the resistance of Staphylococcus aureus to Netilmicin was down from 28 13% to 4 70%.Enterobactriaceae were still sensitive to Imipenem,while the resistance of Pseudomonas to it became higher than that in the period from 1995 to 1997.Conclusion:The percentage of Gram negative bacilli in identified strains is significantly higher than that of Gram positive cocci and the pattern of their resistance to the antibiotics is changed meanwhile.Therefore,the choice of antibiotics for initial treatment of invasive infection in severe burns is a combination of Netilmicin and Imipenem,and,if Gram positive cocci is highly suspected, the first choice is Vancomycin.