【作者】 刘辉；

【导师】 张平；

【作者基本信息】 吉林大学 ， 外科学， 2016， 硕士

【摘要】 目的:通过对我科患者进行胆道胆汁感染细菌的培养,从而进行细菌谱的分析以及对其耐药性进行进一步研究,基于本研究的系统分析能够对于一线临床中遇到胆道感染情况进行合理而及时的治疗。方法:(1)内镜逆行胰胆管造影(ERCP):首先,对患者进行镇静解痉药物的注射,注意观察患者状况,无菌注射器以及无菌管备用。然后通过逆行的十二指肠镜对已准备好的患者进行胰胆管造影,整个过程需要注意的是,一旦肠镜的镜头接触到十二指肠的时候,要从乳头部位进入到胆道之中。继而用做内镜前已准备好的无菌器材:无菌注射器在胆道中抽取5毫升胆汁,然后将胆汁注入到无菌消毒管中等待接种。在操作的最后,行造影注射一边观察。(2)经皮经胆管引流术(PTCD):穿刺点的选择因情况而异,首先行常规的消毒及铺巾,对患者患处采取局部麻醉,在剪刀进行破皮之后,经彩超引导下可行穿刺,将引流包中的PTCD针经过皮肤、肝脏直接穿刺进入胆管内。针芯退出后,针鞘连注射器,抽出患者胆汁5ml,立即将其全部注入到无菌试管中,注意接种要在2h内完成,从而进行后续的细菌培养和他们的耐药性分析[1]。(3)T管引流的胆汁:在行T管引流之后,对于已采集到的胆汁进行下一步的培养。培养方法:将采集的患者胆汁接种于血平板上,于37℃条件下培养12-24h。革兰阴性菌鉴定卡及革兰阳性菌鉴定卡由法国全自动细菌分析系统VITEK 32所提供。相关病原菌的耐药敏感性则用VITEK 32的专用药敏卡GNS-143和GPS-110分别进行检测[2]。统计分析:数据的录入和收集应用Epi Data3.1,采用SPSS18.0进行统计分析。P<0.05视为具有统计学意义。结果:截至2014-2015年,革兰阴性菌在总致病菌中所占的比例有所下降,其比例由6年前的78%下调至2011-2012年度的74%。在进行统计学分析之后得出得出结论,革兰氏阳性菌的变化幅度不具有统计学意义。在所有的胆汁中致病菌进行分析,可看出,混合型的感染目前呈明显增高趋势,特别是其中真菌的感染呈较明显的增多。目前约占4.0%,且患有真菌感染的患者多数合并有混合型细菌感染。本研究显示,对于研究中涉及的几种革兰氏阴性菌的分析,其显示亚胺培南等多种抗生素的耐药率是相对比较低的。其由高到低分别为阿米卡星、头孢吡肟、妥布霉素、舒普深、亚胺培南。革兰阳性菌粪肠球菌,屎肠球菌对万古霉素的耐药率为0,就此本研究得出结论万古霉素对其在临床上引起的严重感染有非常明显而有效的疗效。因此其在临床上具有最佳的应用效果。细菌对庆大霉素、高浓度的链霉素、环丙沙星、利福平及利奈唑胺的耐药率均在15%以下。药敏试验的分析结果表明真菌对氟康唑和伏立康唑相对敏感,而对两性霉素B则敏感性差,耐药性较强。结论:(1)2014-2015我院胆道感染患者的胆汁所含致病菌的前4位依次为大肠埃希菌(36.7%),肺炎克雷伯杆菌肺炎亚种(14.8%),粪肠球菌(14.5%),阴沟肠杆菌(8.2%)。(2)革兰氏阴性菌耐药率分析结果显示,亚胺培南等几种抗生素的耐药率相对较低,其由高到低分别为阿米卡星、头孢吡肟、妥布霉素、舒普深、亚胺培南。其中最低的为亚胺培南。亚胺培南、妥布霉素、哌拉西林/他唑巴坦及阿米卡星因其对阴沟肠杆菌的敏感性强,故而可获得较好的临床疗效。大肠埃希菌的耐药率对亚胺培南、舒普深、哌拉西林/他唑巴坦、头孢西丁均为0,适于临床治疗。肺炎克雷伯菌对氨苄西林和左氧氟沙星等低级别抗生素的耐药率较高,大于50%。革兰阳性粪肠球菌、屎肠球菌感染的患者,万古霉素对其的治疗效果好,耐药率为0。此外,致病菌对庆大霉素、高浓度的链霉素、环丙沙星、利福平和利奈唑胺的耐药率均在15%以下,可在临床上作为备选适当应用。真菌药敏试验结果提示:氟康唑及伏立康唑对真菌感染疗效好。(3)应用抗生素治疗胆道感染的患者,我们首先应该考虑对革兰氏阴性菌敏感的药物,一些轻症患者可采用舒普深或者阿米卡星,而亚胺培南及美洛培南则主要适用于重症患者。经抗生素治疗3天后若疗效不显著,则应考虑革兰氏阳性菌感染或合并感染的可能,并及时改用对革兰氏阳性菌敏感的抗生素,如万古霉素等。若应用抗生素治疗时间超过13天,应联合使用抗真菌药物。更多还原

【Abstract】 Objective: To analyse the changes of biliary bacteria spectrum and drug sensitivity of patients with biliary infection and make better clinical pharmacotherapy.Methods: 1. Endoscopic retrograde cholangiopancreatography(ERCP): Antispasmodic medicine must be injected to patients firstly, remember to be aware of the patients’ condition. Sterile syringes and sterile tube should be set aside. Duodenum mirror was then used for the patient line of ERCP, when the lens hit the duodenum, inserting tube into the bile duct through the duodenum big nipples. Injecting 5 ml bile into asepsis pipe that have already prepared and waiting for inoculation before injecting contrast material. 2. Percutaneous transhepatic cholangial drainage(PTCD): Choosing the puncture point varies according to different situations. Firstly,we need to prepare the conventional disinfection and spread towels,and then make the patient get local anesthesia. After using a sharp knife to broken skin, taking PTCD percutaneous needle puncture into the bile duct through the liver under the guidance of color doppler ultrasound. Pulling out the needle core and linking the stylophore to the injector. Extracting bile from patients for 5ml and take it all into the sterile tubes immediately. Pay attention to the overall process should be completed within 2 hours in order to take the subsequent analysis of the bacterial culture and their drug resistance[1].T tube drainage of bile: The T tube drainage of biliary tract infection patients were sent to culture.Training method: The collected bile of patients should be inoculated on blood plate and developing 12 to 24 hours under the condition of 37 ℃. Gram-negative bacteria identification cards and gram-positive bacteria identification cards were provided by the French automatic bacteria analysis system VITEK 32.The resistant sensitivity of certain pathogenic bacteria were detected with VITEK 32 appropriative drug susceptibility card GNS-143 and GPS-110, respectively[2].Statistical analysis: The data were collected using Epi Data 3.1and all the statistical analysis were calculated by the SPSS 18.0 software. P<0.05 were considered statistically significant.Results: By the end of 2014-2015, the proportion of gram-negative bacteria in the total pathogenic bacteria were decreased significantly, and its proportion from 78% six years ago dropped to 74% in 2011-2012.While considering the gram-positive bacteria, there is no significant change during these years. Of all the infectious bile, the propotion of mixed infection is on the rise, especially the fungal infection which accounting for nearly 4.0%. It’s worth noting that patients with fungal infection were often suffered from mixed bacteria infection.The analysis of drug resistance rate of several kinds of gram-negative bacteria in our study can be concluded as follows: the drug resistance rate of gram-negative bacteria from high to low were amikacin, cefepime, tobramycin, Shu Pu depth and Lmipenem. The drug resistance rate of gram-positive bacteria dung enterococcus and excrement enterococcus to vancomycin were 0, so we have resons to believe that it has a perfect clinical effect in application. The drug resistance rate of pathogenic bacteria to gentamicin, high concentrations of streptomycin, ciprofloxacin, rifampicin and rina thiazole were all less than 15 percents.The analysis of drug susceptibility test results showed that the fungi were sensitive to fluconazole and voriconazole but not to amphotericin B.Conclusion:(1) The first four pathogenic bacteria in patients with biliary tract infection in our hospital were e. coli(36.7%), klebsiella pneumoniae pneumonia subspecies(14.8%), dung enterococcus(14.5%) and sewer e. coli(8.2%).(2) The drug resistance rate of gram-negative bacteria from high to low were amikacin, cefepime, tobramycin, Shu Pu depth and Lmipenem.Lmipenem, tobramycin and piperacillin/he thiazole ba and amikacin were sensitive to the enterobacter cloacae and thus has a good clinical efficacy.Resistance of e. coli to imine culture deep south shope piperacillin/he thiazole ba jotham cefoxitin are 0, so its is suitable for clinical treatment.Klebsiella pneumoniaeare of high antibiotic resistance to some low levels of antibiotics such as ampicillin and levofloxacin,which the drug resistance rate are higher than 50%.To the patients who sufferd from gram-positive dung enterococcus and excrement enterococcus, vancomycin has a good clinical effect because of its low drug resistance rate. The drug resistance rate of pathogenic bacteria to gentamicin, high concentrations of streptomycin, ciprofloxacin, rifampicin and rina thiazole were all less than 15 percent, which could be applied in clinic as an appropriate.Fungi susceptibility test results indicated that Fungi are sensitive to voriconazole and fluconazole.(3) To the patients with biliary tract infection who has taken the antibiotic treatment, we should first consider the drug sensitive of gram negative bacteria. Shu Pu depth and amikacin can be used in patients with slight symptom. But to the patients with serious symptom, Lmipenem and Meropenem are suitable. After 3-days’ antibiotic treatment,if there is no significant curative effect, we should then turn to the gram-positive bacteria infection and timely use of gram positive bacteria sensitive antibiotics, such as vancomycin. If the use of antibiotics for more than 13 days, it is necessary to take combination therapy with antifungal drugs.更多还原