烧伤感染

自60年代中期由于开发了几个有效的局部抗菌药物和创面处理方法的显著进步,烧伤总面积和Ⅲ度烧伤面积的ＬＡ50有显著提高,侵袭性感染发生率有一定下降,但以感染和以感染为动因的多脏器功能衰竭仍为烧伤死亡的第一原因。烧伤感染一直是烧伤临床工作所关注研究的热点。本文就烧伤感染的几个主要临床问题:烧伤感染的概念、烧伤创面细菌生态学和烧伤中心细菌耐药性进行回顾和讨论。一、烧伤感染的概念1962年Ｔｅｐｌｉｔｚ提出“烧伤创面脓毒症”概念前,有一个使临床医师感到困惑的问题,发现一部分烧伤病人出现典型的败血症症状,但血培养始终阴…     

烧伤病房728株感染病原菌的分布特点及耐药性分析

目的了解笔者单位近5年烧伤感染病原菌的分布特点及耐药情况。方法收集2001-2006年笔者单位306例烧伤患者创面分泌物等标本中分离的病原菌，对其菌种分布特点及耐药性进行分析。结果革兰阳性菌378株，其中金黄色葡萄球菌的菌株数居首位，尤以甲氧西林耐药金黄色葡萄球菌居多，表皮葡萄球菌和粪肠球菌的菌株数分别位居第2、3位。革兰阴性杆菌338株，其中鲍氏不动杆菌的菌株数居首位，阴沟肠杆菌和铜绿假单胞菌的菌株数分别位居第2、3位。检出真菌12株。结论笔者单位病原菌的分布情况，可能与甲氧西林耐药葡萄球菌呈多重耐药性以及鲍氏不动杆菌产生各种类型的β内酰胺酶有关。     

烧伤病区病原菌分布及其耐药性调查

目的了解烧伤病区病原菌分布特点及其耐药情况，为临床治疗提供参考。方法回顾性分析笔者单位烧伤病区348例住院患者的创面、血液、静脉导管、痰液、尿液及脓液等标本分离而得的菌株，统计其病原菌分布情况及耐药性。结果共检出464株病原菌，其中革兰阴性杆菌244株占52、6％、革兰阳性球菌188株占40．5％、真菌32株占6．9％。主要检出菌株为金黄色葡萄球菌、铜绿假单胞菌、鲍氏不动杆菌、大肠埃希菌。甲氧西林耐药金黄色葡萄球菌（MRSA）对环丙沙星、青霉素G、苯唑西林等的耐药率已达100、0％，只对万古霉素敏感。铜绿假单胞菌对头孢哌酮／舒巴坦、亚胺培南、头孢吡肟的耐药率分别为15、8％、36、8％、33、3％。结论金黄色葡萄球菌、铜绿假单胞菌、鲍氏不动杆菌、大肠埃希菌是烧伤病区感染的主要病原菌；金黄色葡萄球菌、鲍氏不动杆菌对抗生素的耐药率较高。     

热带海岛地区某医院烧伤感染病原菌分布及耐药性调查

目的 了解热带海岛地区烧伤感染病原菌分布及耐药情况。方法 回顾性调查分析2000-2005年笔者单位烧伤病区392例住院患者的病原菌分布情况及其耐药性特点。结果 （1）共检出671株病原菌，其中铜绿假单胞菌、金黄色葡萄球菌、阴沟肠杆菌、不动杆菌是主要菌种。最常见的铜绿假单胞菌检出率为27．7％，较20世纪90年代（33．6％）有下降趋势。（2）铜绿假单胞菌对亚胺培南／西司他丁及头孢吡肟的耐药率分别为32．2％和36．7％，对其余10种常用抗生素的耐药率均在80．0％以上。（3）141株金黄色葡萄球菌中，共检出89株甲氧西林耐药金黄色葡萄球菌，检出率为63．1％；未检出对万古霉素耐药的金黄色葡萄球菌。结论 铜绿假单胞菌、金黄色葡萄球菌、阴沟肠杆菌、不动杆菌等是热带海岛地区烧伤感染的主要病原菌；前两者的抗生素耐药率较高。     

烧伤创面感染细菌1116株分析

对１９８９－１９９１年５３６例烧伤病人创面分离的各种细菌，真菌共３９种１１６株进行分析，结果表明：金黄色葡萄球菌２１７株，检出率为１９．４％，居第一位；铜绿假单胞菌２０８株，检出率为１８．６％，居第二位；乙酸钙不动杆菌１１９株，检出率为１０．６％，居第三倍。同时于创面及烧伤病房环境中分离出了蜡样芽胞杆菌，绿色气球菌，曲霉菌等机会致病菌，且创面分离数量较多的菌在环境中几种均可检出。我们还对分离数量较     

1995-2011年解放军总医院第一附属医院烧伤科感染病原菌结构和耐药水平的变化

目的：了解1995年以来解放军总医院第一附属医院烧伤病区病原菌结构及主要病原菌耐药水平的变化。方法：分析1995—2011年烧伤病区标本细菌鉴定及药敏试验结果。结果：1995年构成比最高的病原菌前3位依次为大肠杆菌（ECO,21．35％）、铜绿假单胞菌（PAE,19．53％）和金黄色葡萄球菌（SAU,17．71％）,2011年构成比最高的前3位变为鲍曼不动杆菌（ABA,20．32％）、SAU（19．59％）和PAE（18．29％）。PAE和ABA两种病原菌对亚胺培南的耐药率逐渐升高,至2011年分别接近70％和超过了90％。SAU对苯唑西林的耐药率从1998年开始快速升高,2003年超过70％,而后波动于60％～70％。结论：17年来我院烧伤感染病原菌的结构发生了明显变化。虽然构成比经历了大幅度的变化过程,SAU和PAE依旧保持了主要病原菌的地位;而ABA则异军突起,成为构成比最高的病原菌,且这3种病原菌的耐药水平也达到了非常高的水平。     

A preliminary study of the relationship between antibiotic administration and changes in bacteriological profile of wound infection in a burn unit

Objective:To investigate the relationship between antibiotic administration and the changes in bacteriological profile in a burn unit. Methods: The data of consumption of different kinds of antibiotics, including total antibiotic consumption [expressed as the number of defined daily doses (DDD)] as well as pathogen identification, were collected in a 8-year period. The constituent ratios of different kinds of antibiotics in total antibiotic consumption to isolation rates of various species of bacteria were calculated, and their correlation was analyzed. Results: Within this period, it was found that the aminoglycosides and first generation cephalosporins were used less frequently, while the polypeptides, carbopenem and macrolides were used proportionally more. At the same time, the isolation rates of Staphylococcus aureus, Acinetobacter sp, Enterobacter cloacae, Klebsiella pneumoniae and methicillin-resistant Staphylococcus aureus were gradually increased. The constituent ratios of predominant pathogens were correlated to the different kinds of antibiotics consumption in the burn unit. Conclusion: The results suggested that the consumption of different antibiotics was closely related to the trends of emergence of bacterial isolates from infected burn wounds. The result might imply that to regulate the administration of certain antibiotics might help decrease the emergence of certain pathogenic bacteria in burn infections.     

Infection control in the burn unit

The survival rates for burn patients have improved substantially in the past few decades due to advances in modern medical care in specialized burn centers. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. In addition to the nature and extent of the thermal injury influencing infections, the type and quantity of microorganisms that colonize the burn wound appear to influence the future risk of invasive wound infection. The focus of medical care needs to be to prevent infection. The value of infection prevention has been acknowledged in organized burn care since its establishment and is of crucial importance. This review focuses on modern aspects of the epidemiology, diagnosis, management, and prevention of burn wound infections and sepsis.     

1993～1999年烧伤科细菌学调查及耐药性分析

目的　研究笔者单位近几年细菌动态及耐药性 ,为临床诊治提供参考资料。　方法　对 1993～ 1999年本院烧伤科 784例患者的 345例次阳性创面细菌培养及药敏结果进行回顾性分析。　结果　 (1)革兰阴性 (G-)杆菌占 5 6 .8% ,革兰阳性 (G )球菌占 39.4 % ,真菌占 3.8% ;(2 )金黄色葡萄球菌占G 球菌的 6 5 .4 % ,其中耐药甲氧西林金葡菌 (MRSA)的分离率 1993～ 1999年为 5 3 9% ,1998～ 1999年为 6 4 .3% ;铜绿假单胞菌占G-菌的 37.2 % ;(3)第三代头孢菌素表现了良好的抗菌活性 ,但耐药率有明显增加 ;(4)万古霉素和去甲万古霉素对MRSA无 1例耐药。　结论　本院烧伤科细菌感染仍以G-杆菌为主 ,G 球菌次之。第三代头孢菌素是目前的常用抗生素 ,但耐药率增加的问题不容忽视。MRSA分离率有逐年增高的趋势 ,万古霉素和去甲万古霉素应作为首选用药     

Clinical studies of the High-Intensity Narrow-Spectrum light Environmental Decontamination System (HINS-light EDS), for continuous disinfection in the burn unit inpatient and outpatient settings

Infections are the leading cause of morbidity and mortality in burn patients and prevention of contamination from exogenous sources including the hospital environment is becoming increasingly emphasised. The High-Intensity Narrow-Spectrum light Environmental Decontamination System (HINS-light EDS) is bactericidal yet safe for humans, allowing continuous disinfection of the environment surrounding burn patients. Environmental samples were collected from inpatient isolation rooms and the outpatient clinic in the burn unit, and comparisons were then made between the bacterial contamination levels observed with and without use of the HINS-light EDS. Over 1000 samples were taken. Inpatient studies, with sampling carried out at 0800 h, demonstrated a significant reduction in the average number of bacterial colonies following HINS-light EDS use of between 27% and 75%, (p<0.05). There was more variation when samples were taken at times of increased activity in the room. Outpatient studies during clinics demonstrated a 61% efficacy in the reduction of bacterial contamination on surfaces throughout the room during the course of a clinic (p=0.02). The results demonstrate that use of the HINS-light EDS allows efficacious bacterial reductions over and above that achieved by standard cleaning and infection control measures in both inpatient and outpatient settings in the burn unit.     

Common pathogens in burn wound and changes in their drug sensitivity

Infection is an important cause of mortality in patients with burns. Rapid emergence of hospital pathogens and antibiotic-resistant organisms necessitate periodic evaluation of bacterial colonisation patterns and antibiogram sensitivity in burn wards.In this study, which was conducted in a 3 months’ period in 2009, 106 samples from the wounds of 59 patients admitted in a burn ward were taken, one in the 1st and one between the 3rd and the 7th days.Pseudomonas aeruginosa, Acinetobacter and Klebsiella were the most common Gram-negative and Staphylococcus aureus was the most common Gram-positive organisms recovered from the patients.This study showed a high rate of resistance to the administered antibiotics. The prevalent Gram-negative organisms in our ward were resistant to ceftazidime and imipenem in nearly 90% and 20% of cases, respectively.     

抗生素诱导革兰阴性杆菌释放内毒素的实验研究(二)

目的　探讨 β 内酰胺类抗生素在诱导革兰阴性菌释放内毒素 (LPS)及对感染动物保护效能方面的差异。　方法　制备大鼠烫伤创面脓毒症模型。将大鼠随机分为单纯抗生素治疗组 ,半乳糖胺 (GalN)敏化后治疗组及爱兰苔胶 (CGN)封闭后治疗组。分别用亚胺培南 (IMP ,5mg)和头孢他啶 (CTZ ,10mg)单剂量腹腔注射治疗 ,对照组施以同量无菌等渗盐水 ,敏化组加用GalN 5 0mg ,封闭组在敏化组的基础上加用CGN 1mg。于抗生素治疗后不同时相点检测血中细菌浓度、血浆LPS水平 ,观察敏化组和封闭组大鼠 10d后的死亡率。　结果　IMP和CTZ均能显著降低大鼠血中细菌量 ;IMP和CTZ在杀菌过程中能诱导PA10 3释放大量LPS ,但CTZ组血浆LPS水平显著超过相应的IMP组 (P<0 .0 5～ 0 .0 1) ;敏化组大鼠的死亡率CTZ组明显高于IMP组 (P <0 .0 5 ) ;封闭组两者间的差异消失(P>0 0 5 )。　结论　IMP和CTZ的杀菌效能无显著性差异 ,但在诱导细菌释放LPS的能力方面CTZ>IMP ;两者间的差异直接影响到对感染动物的各自保护作用 ,提示临床应用时 ,选择低诱导力的抗生素 (如IMP)可能更为合理。     

从LPS、TNF和ET的改变评价银锌霜、离子流和湿润烧伤膏的疗效

采用大鼠１５％Ⅲ度烫伤模型，创面涂绿脓杆菌（１０~９／ｍｌ）后，分为涂银锌霜（ＡｇＳＤ＋ＺｎＳＤ＋Ａｚｏｎｅ）组、照射ＨＭ弥散离子流组、涂湿润烧伤膏组及不治疗的对照组。对四组大鼠血浆内毒素、肿瘤坏死因子和内皮素水平变化进行了检测，旨在比较不同疗法控制创面感染的作用。结果表明，银锌霜与离子流照射效果好，而湿润烧伤膏效果差。     

Epidemiological and bacteriological profiles in children with burns

Objectives

The aim of our study is to determine the most prevalent bacteria responsible for nosocomial infection (NI) in burned children.

Materials and methods

A prospective analytic study was conducted over a period of 30 months at the Children's Hospital of Tunisia. All burned children were enrolled.

Results

A total of 185 children were hospitalised during the study period. The mean age was 30 months (interquartile range, IR:18; 48). The gender ratio of the study population was 1.3 (104 males and 81 females). The mean total body surface area burned (TBSA) was 10% (IR:6; 16). The incidence rate of NI was 39.1 NIs per 1000 patient-days and two-thirds of the infections were polymicrobial. The most common isolated micro-organisms were methicillin-susceptible Staphylococcus aureus (MSSA, 57.7%), wild-type Pseudomonas aeruginosa (35.9%) and wild-type Enterobacter cloacae (26.9%). The case fatality rate was 5.9% corresponding to a crude death rate of 1.32 deaths per year. Septic shock with multiple organ failure was the leading cause of death.

Conclusion

The most common micro-organisms responsible for NI in our series were of the wild-type phenotype. Thus, on suspicion of sepsis, empiric antibiotic treatment combining piperacillin, oxacillin and gentamicin can be proposed until identification of the causative microorganism is available.