一期带蒂组织瓣联合万古霉素骨水泥及颗粒骨治疗小腿创伤后骨髓炎伴骨及软组织缺损

目的探讨一期带蒂组织瓣联合万古霉素骨水泥及颗粒骨治疗小腿创伤后骨髓炎伴骨及软组织缺损的方法及疗效。方法 2008年6月~2013年3月,收治小腿创伤后骨髓炎伴骨及软组织缺损患者36例。男25例,女11例;年龄22~60岁,平均46.5岁。病程1~5个月,平均2.5个月。软组织缺损面积为4 cm×5 cm~13cm×8 cm,骨缺损长度0.5 cm~2.5 cm,平均1.8 cm。采用带蒂组织瓣移位联合万古霉素骨水泥及颗粒骨植入一期治疗。选择带蒂的腓肠肌肌瓣16例,比目鱼肌肌瓣12例,腓肠神经营养血管肌皮瓣6例,远端蒂股前外侧肌皮瓣2例,同时一期联合万古霉素骨水泥填充及颗粒骨植骨,肌瓣表面游离植皮处理。结果 36例患者均获随访,随访时间24~55个月,平均39.5个月。2例组织瓣远端发生部分坏死,经清创换药及游离植皮后愈合,4例术后创面渗出患者经换药处理后愈合,2例感染未控制,经再次手术病灶清除及灌洗引流后愈合。所有骨折均骨性愈合,愈合时间6~21个月,平均12个月。末次随访时按Johner-Wruhs标准评定疗效,优20例,良12例,可4例,优良率为88.9%。结论一期应用带蒂组织瓣联合万古霉素骨水泥及颗粒骨治疗小腿创伤后骨髓炎伴骨及软组织缺损,有利于创面愈合、感染控制及骨缺损修复,可获得良好的临床疗效。     

耐甲氧西林金黄色葡萄球菌对万古霉素敏感性的变迁

目的　通过对近年来耐甲氧西林金黄色葡萄球菌 (MRSA)临床分离株对万古霉素抑菌圈直径的分析 ,研究MRSA对万古霉素敏感性的变化。方法　药敏试验采用纸片扩散法 (K B法 ) ,抑菌圈直径的比较采用t检验。结果　 1994～ 2 0 0 0年每年收集的临床分离的MRSA菌株数分别为 2 18、187、2 92、2 37、35 1、886和 6 5 2 ,各年菌株对万古霉素抑菌圈的平均直径 (mm)分别为 19 9、19 1、18 6、17 4、18 4、18 2和 17 8。 2 0 0 0年的 6 5 2株MRSA对万古霉素抑菌圈的平均直径 (17 8mm)明显小于1994年 2 18株MRSA的平均直径 (19 9mm) ,差异有显著性 (P <0 0 0 1)。 2 0 0 0年分离的MRSA对氯霉素、环丙沙星、红霉素、庆大霉素、四环素和复方新诺明等常用抗生素的耐药率均很高 ,其耐药百分率分别为 44 0 %、73 7%、89 1%、6 5 7%、6 1 0 %和 6 7 0 %。结论　 1994年到 2 0 0 0年MRSA对万古霉素的敏感性在逐年降低 ,加强金黄色葡萄球菌对万古霉素敏感性的监测非常必要。     

Focal injection of vancomycin combined with surgical debridement–dermatoplasty in the treatment of pseudo-epitheliomatous granuloma

Background

Pseudo-epitheliomatous granuloma (PEG) can occur in some small skin wounds with secondary infections resulting from improper treatments. It is difficult to heal and can easily relapse.

Objectives

This study explores the clinical and pathological characteristics of PEG and effective treatments.

Patients and methods

Tissue specimens of PEG obtained from 11 patients (age range: 2–67 years) were sent for microbial examination and histological observation. The local lesions were treated by focal injection of vancomycin combined with surgical debridement–dermatoplasty.

Results

The diagnosis of PEG was based on histological examination, which revealed long epithelial peduncle encapsulated granulation tissue-like honeycomb in which more vessels, macrophages, lymphocytes and mast cells and less extracellular matrix were distributed. Bacteria such as Staphylococcus aureus, Bacillus pyocyaneus, ethylene-type Streptococcus, stool Streptococcus and F-citric acid Bacillus were found in the microbial culture of the specimens. They were tolerant to celbenin but sensitive to vancomycin. PEG could be cured by focal application of vancomycin combined with free skin or skin flap after thorough debridement. The relapse of PEG could be prevented by the therapy.

Conclusion

Focal injection of vancomycin combined with surgical debridement–dermatoplasty is an effective therapy for PEG.     

Vancomycin pharmacokinetics in patients with severe burn injuries

Vancomycin is used in patients with severe burns and methicillin-resistant Staphylococcus aureus (MRSA) infection. This study investigated vancomycin pharmacokinetics in people with burns in comparison to people without burns and examined the factors contributing to pharmacokinetic variability. This was a retrospective, case-control study of hospitalised burns patients compared with a control patient cohort administered vancomycin without burn injury. Vancomycin pharmacokinetic parameters were determined using therapeutic drug monitoring data and a population pharmacokinetic modelling approach employing a two-compartment pharmacokinetic model. The impact of patient characteristics on vancomycin clearance was explored. Vancomycin clearance was significantly higher (p < 0.001) in burns patients (5.9 ± 3.1 L/h, n = 37) when compared to control patients (3.4 ± 1.8 L/h, n = 33), as was estimated creatinine clearance, which was correlated to drug clearance in burns patients (r² = 0.64). There was no significant change in volume of distribution between patient groups. The majority of patients received a dosing regimen of 1 g twice daily, resulting in significantly (p = 0.004) lower serum trough concentrations in patients with burns (median, 6.4 mg/L; range, 0.2–22.3 mg/L) than control (median, 9.2 mg/L; range, 4.0–29.8 mg/L). Higher clearance and lower serum vancomycin concentrations in people with severe burn may increase the risk of suboptimal bactericidal action and the development of resistance highlighting the need for dosage individualisation.     

万古霉素类抗菌药物对慢性肾衰竭患者肾功能的影响

目的:探讨万古霉素类抗菌药物对慢性肾衰竭患者肾功能的影响。方法:抽取应用万古霉素或去甲万古霉素的慢性肾衰竭病例,对临床资料进行分析,重点考察用药前后肾功能指标的变化。结果:肾功能衰竭期患者应用万古霉素类抗菌药物前后血肌酐(Scr)和肌酐清除率(Ccr)有显著性差异(P<0.05)。结论:慢性肾衰竭患者应用万古霉素类抗菌药物需注意其对肾功能的进一步损害,特别是肾功能衰竭期患者,更应重视血药浓度监测,实施个体化治疗方案。     

69例使用万古霉素类药物患者的病例调查分析

目的:了解万古霉素类药物的使用情况。方法:对2009年本院69例使用万古霉素类的住院患者,就其用药的指征、用法、病原学检查及处方医师资格等方面进行调查分析。结果:不合理用药表现为:适应证过宽,82.61%的病例没有明确的用药指征,包括未做细菌培养、培养结果阴性或为革兰阴性菌;疗程过长或过短(最长22 d,最短1 d);79.41%的手术病例术后给药预防感染;联合用药比例高达95.66%,最多6种联用,且随意性大,更换频繁;72.86%的处方医师不具备开具特殊使用类抗菌药物的资格。结论:应进一步加强抗菌药物的使用管理,加大对临床用药监护的人力、物力投入。     

万古霉素鞘内注射治疗颅内感染25例疗效分析

目的 探讨鞘内使用万古霉素治疗颅内感染的临床疗效. 方法 对25例颅内感染患者采用万古霉素,每次20.0 mg用生理盐水稀释至5.0 ml,鞘内注射后夹闭2 h再开放引流,1次/d,直至患者体温及脑脊液中白细胞正常. 结果 治愈20例,好转4例,死亡1例,病死率4.0%,预后良好率达96.0%. 结论 万古霉素鞘内注射治疗颅内感染能取得满意疗效.     

复合万古霉素海藻酸钠/壳聚糖缓释载体的体外释放研究

目的探讨复合万古霉素海藻酸钠/壳聚糖(VCM/ACA)缓释系统中万古霉素缓释的动力学规律及影响因素。方法将万古霉素与海藻酸钠质量比分别为5:6和1:1的载体进行冷冻干燥处理和未冷冻干燥处理后制备成4组VCM/ACA载药载体。将载药载体放入pH7.2模拟体液PBS液中浸泡,通过测定浸泡液中万古霉素浓度,观察药物缓释的动力学规律和影响因素。结果 VCM/ACA载药载体的药物释放速度和释放量受载药量、调和比和冷冻干燥处理条件的影响。经冷冻干燥处理后调和比为1:1的载药载体可缓慢释药达250h以上。结论经过冷冻干燥处理万古霉素与海藻酸钠质量比(VCM:ALG)为1:1的载药载体体外能够稳定缓释万古霉素,可以满足临床实际需要。     

高效液相色谱法测定人血清中万古霉素浓度

目的 建立一种快速测定人血清中万古霉素浓度的RP-HPLC法.方法 采用液-液萃取法对血样进行预处理,以去甲万古霉素为内标.色谱柱:依利特C18柱(4.6mm×250mm,5μm).流动相:乙腈-0.05mmo1·mL-1磷酸二氢钾缓冲液(10:94,pH=3.2),流速为1.0mL·min-1,紫外检测波长为230 nm.结果 万古霉素血清浓度在5.00～100.00mg·L-1范围内呈良好的线性关系,(n=5,r=0.9996),提取回收率＞95％,日内、日间RSD均小于10％.结论 该方法方便、经济、无杂质干扰,适用于万古霉素血药浓度监测及药动学研究.     

777株临床分离肠球菌的分布及耐药性分析

目的了解本院临床肠球菌的菌群分布及耐药情况。方法采用回顾性调查分析方法对我院分离自各类临床标本的777株肠球菌进行统计,并对抗菌药敏试验结果进行分析。结果肠球菌菌株来源以尿液(30.5%)、胆汁(25.5%)、分泌物(17.8%)为主;2007～2010年分离的肠球菌对抗生素的耐药率有逐年增高趋势(P<0.05);屎肠球菌对多种抗生素的耐药率明显高于粪肠球菌,且在分离的肠球菌构成比有增高趋势。结论屎肠球菌在临床分离的肠球菌中越来越常见,肠球菌的多重耐药严重。