【作者】 钱远宇；

【导师】 孟庆义；

【作者基本信息】 中国人民解放军军医进修学院 ， 急诊医学， 2008， 博士

【摘要】 目的:探讨北京市三甲医院急诊科感染患者的病原菌的分布、流行趋势、药敏状况及抗生素药敏变迁规律;分析急诊科感染患者的临床特点,探讨其细菌分布、药敏状况等与医院感染的区别,并研究感染严重度的临床危险因素及炎性指标、凝血指标变化等内容。方法:选择北京市5家大型三甲医院,收集其2005年至2007年急诊科送检进行细菌培养的患者3536例次,对其培养资料进行回顾性分析。资料内容包括患者细菌培养鉴定号、姓名、年龄、性别、标本编号、标本种类、培养细菌种类、常见抗生素药敏结果等。重点分析各家医院送检标本分布情况及构成比、感染细菌前几位菌株种类及感染率变化等;然后综合几家医院的药敏情况,选择最常见的3种细菌(鲍曼不动杆菌、铜绿假单孢菌和金黄色葡萄球菌)为代表,分析3年来常见抗生素的敏感率及敏感率变迁。选择解放军总医院2007年急诊科送检细菌培养的患者,分析其临床资料并与解放军总医院呼吸科对比,分析二者细菌培养资料和临床资料的区别。主要内容包括两科患者的一般情况、住院时间、疾病谱构成、临床治疗效果、感染细菌种类、抗生素使用情况、主要细菌分布及其对抗生素的药敏变化等方面。对急渗科患者临床资料应用多元回归分析,探讨引起急诊感染细菌种类增加、使用抗生素种类增加的相关危险因素;并对不同感染患者的APACHEⅡ评分、炎性指标CPR和凝血指标进行对比研究。结果:1、北京市大型三甲医院急诊科2005—2007年感染患者的细菌分布和药敏变迁有以下特点:(1)急诊科感染患者培养标本主要为痰、血液、尿、伤口分泌物和腹水,其中痰、血液和尿标本占总量的分别占总量的67%、16%、10%。3年来,痰、血液标本的采取量出现了较快的升高趋势。(2)急诊科培养的细菌谱表现出医院感染的特点,检出前几位的细菌分别为铜绿假单孢菌、金黄色葡萄球菌、大肠埃希菌、鲍曼不动杆菌和肺炎克雷伯菌。而社区感染常见的细菌如肺炎链球菌、流感嗜血杆菌和肺炎克雷伯菌的检出率非常低。(3)近3年来,细菌的抗生素药敏出现明显下降的趋势,尤其以常用抗生素如头孢类、碳青酶烯类和喹诺酮类显著,抗生素耐药形势不容乐观。(4)目前鲍曼不动杆菌仍以碳青酶烯类敏感为主,其他药物敏感率菌不高,但碳青酶烯类的敏感率在下降;铜绿假单孢菌对碳青酶烯类、加酶青霉素类敏感性较高,近年敏感率也出现显著下降;金黄色葡萄球菌敏感药物很少,目前以万古霉素为主,依然保持100%敏感,其他不甚敏感的抗生素药敏也有下降。2、通过与呼吸科感染患者比较,2007年解放军总医院急诊科感染有以下临床特点:(1)急诊科感染患者的疾病谱与呼吸科有很大的区别,但肺部感染/COPD患者的比重在两个科室都占第一位。(2)急诊科感染患者住院时间要短于呼吸科,且抗生素使用的数量要少于呼吸科。(3)急诊科感染主要细菌与呼吸科相似,前5位分别为鲍曼不动杆菌、铜绿假单孢菌、大肠埃希菌、金黄色葡萄球菌和凝固酶阴性葡萄球菌。(4)同样的细菌,两个科室的药敏却相差显著。其中常见抗生素对鲍曼不动杆菌的敏感率呼吸科多数要优于急诊科,对铜绿假单孢菌的敏感率急诊科多数要优于呼吸科,而对金黄色葡萄球菌的敏感率两个科室相近,急诊科总体上略优于呼吸科。(5)急诊科感染细菌种数的增加与患者住院时间长短、是否气管插管、使用抗生素数目明显相关(p≤0.05);同时,使用抗生素数量的多少与患者感染细菌数目、住院时间长短显著相关(p≤0.05)。(6)随着感染细菌种类的增多,特别是感染细菌超过3种时,患者CPR呈现显著升高(p≤0.05)。(7)患者感染细菌数目增加,其凝血指标也发生较大变化,主要表现为向高凝状念发展。结论:北京市大型三甲医院急诊感染患者病原学上更多表现出医院感染的特征,但其药敏情况与医院感染患者又不完全相同。总体而言,3年来急诊感染的细菌药敏出现了较大的下降,包括常见高效的抗生素在内。急诊感染程度的加重与住院时间、抗生素使用、气管插管等有创操作有关;随着感染的加重,患者凝血系统呈现高凝的趋势;血清CPR指标一定程度上可以反映感染的严重程度。更多还原

【Abstract】 Objective: To investigate changes of antibiotics sensitivity of emergency infections in Beijing large hospitals from 2005 to 2007, and study their clinical features including the bacterias distribution, antibiotics sensitivity changes, infection risk factors, infection indicators and blood coagulation changes, et al. Methods: Altogether there were 3536 strains were cultrued in recent three years. All the data such as type of spicemen, bacterium strain identification, antibiotics sensitivity and so on were investigated respectively. Two departments(emergency department and respiratory department) in PLA general hospital were studied with their clinical featrues in 2007. We investigated patients’ hospitalized time, diseases classfication, effect of treatment, strain isolation, antibiotics sensitevity, invasive therapies, high risk factors, APACHE II evaluations, C-reaction protein level and the blood coagulation index and so on. Results: 1. The bacteria distribution and their sensitivity to antibiotics in emergency departments displayed the following charactristics: (1) Sputum, blood and urine were the three main specimen in emergency department. (2) The main bacteria been cultured were P.aeruginosa, S. aureus, E. coli, A. baumannii, and K. pneumoniae, which were similar to the hospital infection. On the contrary, commom bacteria of community infection such as S.pneunomiae and H. influenza were relatively rare. (3) The sensitivity of common antibiotics decreased grately in the recent three years, especially Carbapenems, cephlosporins and quinolones. 2、The emergency infections in general hospital in 2007 had the following characteristics: (1) Lung infection was the first main infection in the two departments. (2) Infection patients hospitalize time in emergency was shorter than respiratory department, and antibiotics number used also was less than respiratory department. (3) The main bacteria were similar in the two departments, but their antibiotics sensitivities were quite different. (4) The severity of infection in emergency department was significant related to factors such as hospitalized time, tracheal intubation and the number of antibiotics used (p≤0.05). (5) Infection bacterium numbers increasing may raise CPR level and promote blood coagulation activity. Conclusion: Emergency infection bacteria in Beijing large hospital mainly showed hospital infection characteristics, but their antibiotics sensitivity were different to hospital infection. In the recent three years, their sensetivity to antibiotics had dropped greatly. The severity of infection in emergency department is greatly related to antibiotics number they used.更多还原