【作者】 张巍；

【导师】 刘红箭；

【作者基本信息】 吉林大学 ， 公共卫生硕士（专业学位）， 2018， 硕士

【摘要】 目的:通过对齐齐哈尔市某三甲医院尿路感染患者尿液标本检测数据进行回顾性研究,分析致病菌检出及耐药情况,为制定有针对性的抗菌药物治疗方案,以及临床合理选用抗菌药物提供参考依据。方法:选取2014-2017年期间在齐齐哈尔市某三甲医院诊断为尿路感染且进行一般细菌培养鉴定的1168例住院患者作为研究对象,收集各科室送检的尿路感染患者的尿液标本共计1168份。采用病例回顾性分析法,查阅电子病例,从病例管理系统及LIS系统中收集尿路感染患者的临床相关指标及其进行一般细菌培养鉴定资料。利用Epidata 3.0软件进行数据录入,IBM SPSS 24.0统计软件进行数据的统计分析。结果:1.本研究纳入的1168例尿路感染患者中,男性346例,占29.6%;女性822例,占70.4%。2.1168例尿路感染阳性样本中共收集到主要致病菌1040株,革兰氏阴性杆菌851株(81.8%),革兰氏阳性球菌187株(18.0%),真菌2株(0.2%)。革兰氏阴性杆菌以大肠埃希菌为主(79.1%),其次为肺炎克雷伯菌(11.0%);革兰氏阳性球菌以粪肠球菌为主(43.3%)。3.主要检出致病菌的科室分布前三位依次为肾内科208株(20.0%)、内分泌科131株(12.6%)、泌尿外科112株(10.8%)。肾内科致病菌菌种前三位依次为大肠埃希菌137株(58.1%)、粪肠球菌21株(8.9%)、肺炎克雷伯菌16株(6.8%);内分泌科前三位依次为大肠埃希菌100株(66.2%)、无乳链球菌12株(7.9%)、肺炎克雷伯菌8株(5.3%)。泌尿外科前三位依次为大肠埃希菌63株(48.1%)、肺炎克雷伯菌15株(11.5%);粪肠球菌14株(10.7%)。病原菌的分布在不同性别、年龄段、易感因素中的差异具有统计学意义(P<0.05)。2014-2017年革兰氏阳性球菌中屎肠球菌的比例有升高趋势(P<0.05)。4.革兰氏阴性杆菌中大肠埃希菌对氨苄西林(84.5%)的耐药率最高,其次为环丙沙星(72.2%)、左氧氟沙星(67.6%);对呋喃妥因(8.9%)、阿米卡星(4.0%)、头孢替坦(2.4%)、厄他培南(1.9%)、哌拉西林/他唑巴坦(1.8%)以及亚胺培南(1.0%)的耐药率则相对较低。肺炎克雷伯菌对头孢唑林(56.4%)、氨苄西林/舒巴坦(52.1%)、复方新诺明(48.9%)及头孢曲松(48.9%)的耐药率较高,而对头孢替坦(9.6%)、阿米卡星(5.3%)、亚胺培南(2.1%)的耐药率均较低。革兰氏阳性球菌中粪肠球菌对四环素(86.4%)、红霉素(71.6%)的耐药率较高;对替加环素及氨苄西林(2.5%)、青霉素、呋喃妥因及万古霉素(1.2%)的耐药率均较低,未发现对利奈唑胺耐药的粪肠球菌菌株。5.多重耐药菌中超广谱β-内酰胺酶(ESBLs)肠杆菌的检出率为40.8%,耐甲氧西林金黄葡萄球菌和碳青霉烯类抗生素耐药肠杆菌的检出率分别为4.16%和17.7%。主要多重耐药菌科室分布前三位依次为肾内科76株(21.8%)、泌尿外科46株(13.2%)、风湿科37株(10.6%)。超广谱β-内酰胺酶(ESBLs)肠杆菌的科室分布前三位依次为肾内科70株(22.4%),泌尿外科39株(12.5%),风湿科34株(10.9%);超广谱β-内酰胺酶(ESBLs)肠杆菌在检出细菌总株数中所占比例为30.0%,除骨外科,各科室检出的多重耐药菌均以超广谱β-内酰胺酶(ESBLs)肠杆菌为主,在血管外科(71.4%)、血液科(46.7%)和放疗科(42.9%)的比例较高,其在骨外科的比例与碳青霉烯类抗生素耐药肠杆菌的比例均为11.1%。2014-2017年超广谱β-内酰胺酶(ESBLs)肠杆菌的检出率依次为31.7%、37.8%、42.0%和47.6%,呈逐年递增趋势(χ2trend=9.338,P=0.002);不同性别、年龄段、易感因素中的检出率差异具有统计学意义(P<0.05)。结论:1.尿路感染患者送检标本中致病菌以革兰氏阴性杆菌为主,大肠埃希菌是主要致病菌,其次为肺炎克雷伯菌;革兰阳性球菌以肠球菌属多见,主要致病菌为粪肠球菌。2.主要检出致病菌科室分布前三位为肾内科、内分泌科、泌尿外科。2014-2017年细菌谱发生变化,革兰阳性球菌尤其肠球菌属的比例明显升高。3.大肠埃希菌对氨苄西林、环丙沙星、左氧氟沙星的耐药率较高,对呋喃妥因、阿米卡星、头孢替坦、厄他培南、哌拉西林/他唑巴坦及亚胺培南有较高敏感性;肺炎克雷伯菌对头孢替坦、阿米卡星、亚胺培南也具有较高的敏感性。替加环素、万古霉素和利奈唑胺对革兰氏阳性球菌均有较高的敏感性。4.尿路感染患者送检标本中多重耐药菌以超广谱β-内酰胺酶(ESBLs)肠杆菌为主,其检出率较高(40.8%)。5.三种多重耐药菌的科室分布前三位为肾内科、泌尿外科、风湿科。2014-2017年超广谱β-内酰胺酶(ESBLs)肠杆菌检出率呈逐年上升的趋势。各科室中检出的多重耐药菌均以超广谱β-内酰胺酶(ESBLs)肠杆菌为主,在血管外科、血液科和放疗科的比例较高,而在骨外科超广谱β-内酰胺酶(ESBLs)肠杆菌的比例与碳青霉烯类抗生素耐药肠杆菌的比例相同。更多还原

【Abstract】 Objective:A retrospective study was conducted on the urine specimen test data of patients with urinary tract infection in a classified 3A hospital in Qiqihar in order to analyze the detection of pathogenic bacteria and drug resistance and to provide a reference basis for the development of targeted antimicrobial treatment plans and the rational selection of antimicrobial drugs in clinic.Methods:A total of 1168 inpatients diagnosed with urinary tract infection and identified by general bacterial culture were selected as subjects in a classified 3A hospital in Qiqihar from 2014 to 2017.As well as,the total number of 1168 urine specimens of patients with urinary tract infection were collected from each department.The clinical indicators of patients with urinary tract infection and the identification data of general bacterial culture were collected from the case management system and LIS system and they are analyzed by using retrospective analysis.Epidata 3.0 software was used for data entry,and IBM SPSS 24.0 statistical software for data statistical analysis.Results:1.Among the 1,168 patients with urinary tract infection included in this study,346were males,accounting for 29.6%.and 822 were cases of women,accounting for 70.4%.2.The amount of 1,040 strains of major pathogenic bacteria were collected from1168 positive urine infection samples,851 strains of gram-negative bacillus（81.8%）,187 strains of gram-positive coccus（18.0%）,and 2 strains of fungi（0.2%）.Gram-negative bacillus was dominated by escherichia coli（64.6%）,followed by klebsiella pneumoniae（9.0%）.Gram positive cocci were mainly fecal enterococci（7.8%）.3.The first three major pathogenic bacteria were 208 strains in nephrology department（20.0%）,131 strains in endocrinology department（12.6%）and 112 strains in urology department（10.8%）.And,the top three strains in renal medicine were 137strains（58.1%）of escherichia coli,21 strains（8.9%）of enterococcus faecalis,and 16strains（6.8%）of klebsiella pneumoniae.What’s more,the top three in the department of endocrinology were 100 strains of escherichia coli（66.2%）,12 strains of Streptococcus agalactiae（7.9%）,and 8 strains of klebsiella pneumoniae（5.3%）.The first three in urinary surgery were 63 strains of escherichia coli（48.1%）and 15 strains of klebsiella pneumoniae（11.5%）.14 strains of enterococcus faecalis（10.7%）.The distribution of pathogenic bacteria in different genders,ages and susceptibility factors was statistically significant（P<0.05）.The proportion of enterococcus faecium in gram-negative bacilli increased from 2014 to 2017（P<0.05）.4.Among gram-negative bacilli,escherichia coli had the highest resistance rate to ampicillin（84.5%）,followed by ciprofloxacin（72.2%）and levofloxacin（67.6%）.Resistance rates to furantoin（8.9%）,amikacin（4.0%）,cefotetan（2.4%）,ertapenem（1.9%）,piperacillin/tazobactam（1.8%）and imipenem（1.0%）were relatively low.The drug resistance rate of klebsiella pneumoniae to cefazolin（56.4%）,ampicillin/sulbactam（52.1%）,compound xinomine（48.9%）and ceftriaxone（48.9%）was higher,while the drug resistance rate to ceftetan（9.6%）,amikacin（5.3%）and imipenem（2.1%）were lower.The resistance rate of gram-positive coccus to tetracycline（86.4%）and erythromycin（71.6%）was higher.The drug resistance rates of tigacycline,ampicillin（2.5%）,penicillin,furantoin and vancomycin（1.2%）were low.No strain resistant to linazolamide was found.5.The detection rate of ESBLs is 40.8%in Multi-resistant bacteria,the detection rates of methicillin-resistant staphylococcus aureus and carbapenem antibiotics were4.16%and 17.7%,respectively.The top three of the major multi-drug resistant bacteria were 76 strains in nephrology department（21.8%）,46 strains in urology department（13.2%）,and 37strains in rheumatology department（10.6%）.Ultra broad spectrum beta lactamase（ESBLs）order of enterobacteriaceae and top three department distribution is renal medicine 70 strains（22.4%）,urology 39 strains（12.5%）,rheumatology 34 strains（10.9%）;The proportion of ESBLs in total bacterial strains was 30.0%,in addition to bone surgery,the multi-drug resistant bacteria detected in each department were mainly enterobacter coliform withβ-hypoplaxin-lactamase（ESBLs）.From 2014 to2017,the detection rate of ESBLs was 31.7%,37.8%,42.0%and 47.6%,respectively,showing an increasing trend year by year(χ²_trend=9.338,P=0.002).The differences of detection rates in gender,age and susceptibility factors were statistically significant（P<0.05）.Conclusions:1.The main pathogenic bacteria in the samples of urine infection patients were gram-negative bacillus,escherichia coli was the main pathogenic bacteria,followed by klebsiella pneumoniae.Gram-positive cocci were mostly enterococcus,the main pathogenic bacteria were enterococcus faecalis.2.The first three major pathogenic bacteria of pathogenic bacteria were nephrology department,endocrinology department and urology department.The bacterial spectrum changed from 2014 to 2017,and the proportion of gram-positive cocci,especially enterococcus,was significantly increased.3.Escherichia coli bacillus had higher drug resistance rate to ampicillin,ciprofloxacin and levofloxacin,and higher sensitivity to furantoin,amikacin,cefotetan,ertapenem,piperacillin/tazobactin and imipenem.Klebsiella pneumoniae is also highly sensitive to cefotetan,amikacin and imipenem.Tigecycline,vancomycin and linazolamide are highly sensitive to gram-positive cocci.4.In the specimens submitted to patients with urinary tract infection,the multi-drug resistant bacteria were mainly ESBLs,and the detection rate was higher（40.8%）.5.The first three departments of multi-drug resistant bacteria were nephrology,urology and rheumatology.From 2014 to 2017,the detection rate of enterobacter coli with ultra-broad spectrum betabeta-lactamase（ESBLs）increased year by year.The multiple drug-resistant bacteria detected in all departments were mainly enterobacter betabeta-lactase（ESBLs）,with a higher proportion in vascular surgery,hematology and radiotherapy departments,while the proportion of enterobacter betabeta-lactase（ESBLs）in osteosurgery was the same as that of enterobacter carbapenems antibiotic resistance.更多还原