多重耐药不动杆菌属血流感染74例临床分析

目的研究多重耐药不动杆菌血流感染的菌种分布特点、临床特征、抗菌治疗及其与预后的关系。方法回顾性分析复旦大学附属华山医院2005年1月—2011年12月不动杆菌血流感染患者的临床及微生物学资料。结果 74例不动杆菌血流感染患者入选,其中73例为医院感染,1例为社区获得性感染;原发性血流感染占51.4%（38/74）;继发性血流感染占48.6%（36/74）,继发于肺部感染最常见,占23.0%（17/74）。基础疾病以实体肿瘤最多见,占24.3%（18/74）,糖皮质激素应用、深静脉导管留置、手术及侵袭性操作是常见的诱发因素。发生血流感染后患者外周血白细胞总数及中性粒细胞比例较前升高,血清白蛋白水平下降,APACHEⅡ评分升高。74例血流感染患者中鲍曼不动杆菌感染65例,洛菲不动杆菌7例,琼氏不动杆菌1例,鲍曼不动杆菌和洛菲不动杆菌混合感染者1例;全因病死率为27.0%（20/74）。不动杆菌对头孢哌酮-舒巴坦耐药率最低,为20.0%（15/75）,对碳青霉烯类抗生素耐药率为40.0%～42.7%。患者预后与不动杆菌对抗菌药物的敏感性相关。对碳青霉烯类和含舒巴坦制剂不敏感菌株感染患者的病死率分别为46.9%（15/32）和40.0%（12/30）,显著高于敏感菌株感染患者的11.9%（5/42）和18.2%（8/44）。32例对碳青霉烯类不敏感菌株感染的患者中,20例接受了含舒巴坦制剂的抗菌药物,病死率为20.0%（4/20）,明显低于未使用含舒巴坦制剂药物患者的66.7%（8/,12）。结论不动杆菌血流感染绝大多数为医院感染,多发生于术后及重症患者。不动杆菌属对常用抗菌药物高度耐药,对碳青霉烯类和含舒巴坦制剂不敏感菌株感染患者病死率高,预后极差,应重视医院感染的防控。

Clinical analysis of 74 cases of bloodstream infections caused by multidrug-resistant Acinetobacter

Objective To study the clinical characteristics,antimicrobial restistance of bloodstream infections（bacteremia）caused by multidrug-resistant Acinetobacter and analyze the outcomes of antibacterial therapy.Methods The clinical data were reviewed retrospectively for 74 patients with bloodstream infection caused by multidrug-resistant Acinetobacter who were treated in HuaShan hospital from January 2005 to December 2011.Results During the 6-year period,74 patients were diagnosed with multidrug-resistant Acinetobacter bacteremia,73 of which were nosocomial infections.The remaining one was communityacquired.Primary bloodstream infection accounted for51.4%（38/74）,and secondary infection 48.6%（36/74）,mainly secondary to pulmonary infections（23.0%,17/74）.Solid tumor was the most common underlying disease（24.3%,18/74）.Prior corticosteroid therapy,indwelling deep venous catheter,surgery and invasive procedures were predisposing factors of bacteremia.Acinetobacter-related bloodstream infections were associated with higher white blood cell count,increased neutrophil percentage,higher APACHE Ⅱ score and lower serum albumin level.The bloodstream infection was caused by Acinetobacter baumannii in 65 patients,Acinetobacter lwoffi in 7 patients,both Acinetobacter baumannii and Acinetobacter junii in one patient.The all-cause mortality rate was 27.（1%（20/74）.In vitro susceptibility testing showed that 20.0%（15/75） of the Acinetobacter isolates were resistant to cefoperazone-sulbactam,which was the lowest among all the antibiotics tested.About 40.0%to 42.7%of the isolates were resistant to carbapenems.The outcome was related to the antimicrobial resistance.Carbapenem non-susceptible Acinetobacter was associated with poorer outcome compared with carbapenem-susceptible Acinetobacter（mortality 46.9%vs 11.9%,P〈0.05）.Cefoperazone-sulbactam non-susceptible Acinetobacter was also associated with poorer outcome compared with cefoperazone-sulbactam susceptible Acinetobacter（mortality 40.0%vs 18.2%.P〈