【作者】 刘微；

【导师】 齐燕飞；

【作者基本信息】 吉林大学 ， 公共卫生硕士（专业学位）， 2016， 硕士

【摘要】 感染性疾病是威胁着人类健康的重大疾病,有关资料显示全世界每年中有将近1700万人命丧于感染性疾病,大概占总死亡人口比例的28~33%,可见危害性极大。在医院里,尤其是具有基础性免疫功能低下的人群(如恶性肿瘤、血液病、低或无丙种球蛋白血症、艾滋病)或长期住院患者(大量应用抗生素等)在接触病原微生物的过程中难以抵御,造成患者感染。而它的元凶病原菌几乎是多重耐药性细菌。有调查显示,感染多重耐药性细菌的患者已占据医院感染总人数的多半,并且综合型医院感染率明显要高于中小型医院。不仅如此,多重耐药(MDR)、泛耐药(XDR)、和全耐药(PDR)细菌的出现限制可选的抗感染治疗方法,提高了感染的死亡率。目的:本研究通过对2012-2014年间齐齐哈尔某三甲医院临床送检的17959份微生物标本进行回顾分析,调查5343株致病菌的来源分布、科室分布和致病菌种类分布情况及其对抗生素耐药状况,剖析感染人群的易感因素,为临床医生、护理人员等高发感染人群提供参考依据。方法:收集齐齐哈尔市某三甲医院2012-2014年重症监护室、新生儿科、儿科、肾内科、呼吸科、急诊科、心内一、二科、骨外科、神经外科送检的微生物标本共17959份。样本主要来源于痰、伤口浓汁、尿、咽部拭子、血液、粪便、导管、穿刺液和引流液(包括脑脊液、脓液、腹水、胸水、胆汁)。根据《全国临床检验操作规程》进行培养,通过梅里埃Vitek-2微生物鉴定系统进行鉴定,采用琼脂扩散法(K-B)和MIC法进行常规药敏试验。菌种类型及构成比、致病菌科室分布以及主要致病菌对常用抗生素的耐药率通过SPSS19.0统计软件和Who net5.6软件进行数据统计分析。结果:1.2012-2014年间,该院5343份阳性样本中革兰氏阴性菌检出率为69.0%,革兰氏阳性菌检出率为19.8%,真菌检出率为11.2%。三年间革兰氏阴性菌的检出率分别为72.1%、69.0%、67.4%;革兰氏阳性菌的检出率分别为21.1%、20.0%、19.0%;真菌的检出率分别为6.8%、11.0%、13.6%。2.三年间革兰氏阴性菌中检出率较高的致病菌分别是肺炎克雷伯菌15.0%、大肠埃希菌12.7%、不动杆菌7.4%、铜绿假单胞菌6.1%;革兰氏阳性菌中检出率较高的致病菌分别是表皮葡萄球菌5.3%、金黄色葡萄球菌3.8%;真菌中检出率较高的致病菌是白色念珠菌9.0%。3.从致病菌的标本类型分布看:肺炎克雷伯菌在痰中最多,占20.4%;大肠埃希菌在尿中占第一位,比例为43.9%;金黄色葡萄球菌在伤口拭子中占第一位,比例为12.4%。从致病菌的科室分布看:克雷伯菌属、不动杆菌属、大肠埃希菌、非发酵菌如铜绿假单胞菌等条件致病菌在呼吸内科、重症监护室、脑外科、急诊科、新生儿科检出率较高,均>10%。4.从致病菌的耐药情况看:肺炎克雷伯菌对头孢菌素类抗生素耐药率高,对哌拉西林/他唑巴坦耐药率低,对美罗培南全敏感;大肠埃希菌对头孢类抗生素、氨曲南、和喹诺酮类抗生素耐药率高,对氨苄西林/舒巴坦、哌拉西林/他唑巴坦耐药率低,2012年和2014年有耐美罗培南菌株出现;铜绿假单胞菌对哌拉西林、哌拉西林/他唑巴坦的耐药率较高,对粘菌素的耐药率较低;不动杆菌属对庆大霉素、阿米卡星、粘菌素的耐药率较低,对粘菌素的耐药率最低,;金黄色葡萄球菌对红霉素、青霉素、克林霉素的耐药率较高,对莫西沙星、氯霉素耐药率低,对万古霉素全部敏感;肠球菌对青霉素、红霉素、氟喹诺酮类耐药率均较高,对万古霉素和高浓度庆大霉素耐药率低。5.2012-2014年间包含有多种耐药机制的耐药菌检出率较高,分别为13.7%、14.6%、12.1%。最常见的耐药类型是:产超广谱β-内酰胺酶的细菌、耐甲氧西林金黄色葡萄球菌、多重耐药铜绿假单胞菌和多重耐药鲍曼不动杆菌。结论:1.该院致病菌的检出中以革兰氏阴性菌为主,革兰氏阴性菌主要是肺炎克雷伯菌和大肠埃希菌两种,革兰氏阳性菌主要是金黄色葡萄球菌,真菌中白色念珠菌检出率最高。该院的致病菌感染情况与国内其他医院情况相一致,在临床工作中需要注重革兰氏阴性菌的防治措施。2.送检标本中,痰液中以肺炎克雷伯菌为首,尿液中以大肠埃希菌为首,伤口拭子中以金黄色葡萄球菌为首,标本中检出的菌种种类与相关疾病相关。3.肺炎克雷伯菌、不动杆菌、大肠埃希菌、铜绿假单胞菌等条件致病菌在呼吸内科、重症监护室、脑外科、急诊科、新生儿科检出率较高,该类科室患者免疫力低下,感染条件致病菌的机会较高,应优化高危人群的治疗管控。4.具有多种耐药机制的耐药菌检出率较高,最常见耐药菌为产超广谱β-内酰胺酶的细菌、耐甲氧西林金黄色葡萄球菌、多重耐药铜绿假单胞菌和多重耐药鲍曼不动杆菌。5.医护人员应该注重规范化操作,避免护理治疗过程中产生菌类的交叉感染。同时,严格管控抗生素类药品的使用,建设良好的监督管理体系,创建更好的医疗卫生环境。更多还原

【Abstract】 Objective : Infectious disease is a serious hazard to human health, the information shows that nearly 17 million people worldwide each year die from infectious diseases, accounting for about 28 to 33% of the total deaths, showing high mortality. In the hospital, especially those with underlying immunocompromised populations(such as cancer, blood disease, low or no agammaglobulinemia, AIDS) or long-term hospitalization of patients(large number of antibiotics, etc.) in the process of contacting pathogenic microorganisms difficult to resist, resulting in patient infection. Moreover, the infection caused by pathogens are often multi-drug resistant bacteria. A survey shows that patients with multi-drug-resistant infections have occupied most of the total number of hospital infections, and hospital infection rate was significantly larger than small hospitals. Moreover, multi-drug resistant(MDR), pan-resistant(XDR), and full resistance(PDR) bacteria appear to limit treatment options against infection, infection increases mortality. This study of Qiqihar of a hospital 2012-2014 years of clinical inspection of the 17,959 parts microorganism samples were analyzed retrospectively to investigate the source of the distribution of pathogens in 5343, the department distribution, distribution and types of pathogens for antibiotic resistance, analysis of patient population risk factors, clinicians, nurses treat and care for people suffering from infectious diseases to provide reference.Methods: Collection of a hospital in Qiqihar City, 2012--2014 years, intensive care unit, neonatology, pediatrics, internal medicine kidney, respiratory, emergency department, one or two subjects, bone surgery, neurosurgery submission microbial specimens total 17,959 samples. Mainly from sputum specimens, wound secretions, urine, throat, blood, feces, catheter, puncture fluid and drainage(including cerebrospinal fluid, pus, ascites, pleural effusion, bile), except to repeat the same patient strains isolated. According to the "National Clinical Laboratory Procedures" were cultured and identified by bio Merieux Vitek-2 microbial identification system, using the agar diffusion method(K-B) and MIC method for routine susceptibility testing. Pathogenic type, sample distribution, and distribution departments pathogens to commonly used antibiotics rate case by SPSS19.0 statistical software and Who net5.6 software for statistical analysis.Results: 1.during the period of 2012-2014, the 5343 positive samples in gram negative bacteria detection rate was 69%, gram positive bacteria detection rate was 19.8%, the detection rate of fungi was 11.2%. The detection rate of gram negative bacteria was 72.1%, 69%, 3, respectively. The positive rate of gram positive bacteria was 21.1%, 20%, 19%, respectively. The detection rate of fungi was 6.8%, 11% and 13.6%, respectively. 2. High detection rate of pathogenic bacteria and gram negative bacteria were Klebsiella pneumoniae and 15% Escherichia coli, 12.7%, 7.4% of Acinetobacter, Pseudomonas aeruginosa 6.1%. The high detection rate of pathogenic bacteria in gram positive bacteria were Staphylococcus aureus 5.3% and Staphylococcus aureus 3.8%. The higher detection rate of fungi was Candida albicans 9%. 3. From the perspective of the sample type distribution of pathogenic bacteria: Klebsiella pneumoniae detection rate in sputum samples in 20.4%; Escherichia coli in urine was 43.9%; the highest positive rate of Staphylococcus aureus in wound swab in the highest detection rate was 12.4%. From the view of the distribution of pathogenic bacteria of the Department: Klebsiella pneumoniae, Acinetobacter, Escherichia coli, Pseudomonas aeruginosa and other opportunistic pathogens in respiratory medicine, ICU, Department of cerebral surgery, emergency department of Neonatology, higher detection rate, >10%, the Department in patients with low immunity, high infection condition chance of pathogenic bacteria. 4. From the drug resistance of pathogens to see: Klebsiella pneumoniae to cephalosporins resistance rates are> 30%; to piperacillin / tazobactam resistance is low, <30%; the whole sensitive to meropenem. Escherichia coli to cephalosporins, aztreonam, and quinolone antibiotics resistance rate,> 30%; to ampicillin / sulbactam, piperacillin / tazobactam resistance is low, <30%; in 2012 and 2014, meropenem-resistant strains have appeared. In addition, the resistance rate of Pseudomonas aeruginosa to piperacillin, piperacillin / tazobactam high,> 30%; low resistance rates to colistin, <5%; Acinetobacter gentamicin, amikacin, colistin low resistance rate <30%, in which the lowest rate of colistin resistance, <3%. Staphylococcus aureus to penicillin, erythromycin, clindamycin resistance rate of> 30% for moxifloxacin, chloramphenicol resistance is low, <30%, all sensitive to vancomycin. Enterococci to penicillin, erythromycin, fluoroquinolones resistance were high,> 50%, a high concentration of vancomycin and gentamicin rate, <10%. 5. 2012--2014 years, includes a variety of mechanisms of resistance resistant high detection rate were 13.7%, 14.6%, 12.1%. The most common drug types are: producing extended spectrum β- lactamases bacteria, methicillin-resistant Staphylococcus aureus, multidrug-resistant Pseudomonas aeruginosa and multidrug-resistant Acinetobacter baumannii.Conclusions: 1. The main pathogens causing nosocomial infections were Gram-negative bacteria, followed by Gram positive bacteria. 2, leading to the infection of pathogenic bacteria for the conditions of pathogenic bacteria. 3, different pathogenic bacteria sample distribution law is different. 4, from the distribution of the pathogenic bacteria in the Department of respiratory medicine, intensive care unit, Department of cerebral surgery, emergency department and neonatal department of pediatric patients with immune function. 5, the drug resistance of bacteria is serious.更多还原