多药耐药铜绿假单胞菌院内感染危险因素及预后因素分析

目的 分析多药耐药铜绿假单胞菌(MDRP)产生的危险因素，并探讨影响MDRP院内感染预后的因素。方法 采用病例对照研究方法。收集北京协和医院1999年1月～2002年12月MDRP引起的院内感染44例，并随机选择同时期敏感铜绿假单胞菌院内感染68例作为对照，采用单因素(t检验，χ^2检验)及多因素Logistic回归进行分析。结果 对112例铜绿假单胞菌院内感染单因素分析发现，下列因素与MDRP感染有关：高龄、高APACHE Ⅱ(acute physiology and chronic health evaluation)评分、2种以上细菌混合感染、院内获得性肺炎(HAP)、机械通气、患有慢性阻塞性肺疾病(COPD)、分离出MCIRP前15天用过氟喹喏酮、分离出MDRP前15天用过亚胺培南／美罗培南。但多因素Logistic回归分析仅确定了2项独立危险因素：机械通气[比值比(OR)=8．19]，分离出MDRP前15天用过亚胺培南／美罗培南(OR，44．80)。44例MDRP院内感染，死亡24例，好转20例，病死率为55％。单因素分析发现，下列因素与MDRP感染死亡相关：高APACHEⅡ评分、机械通气、未恢复对抗铜绿假单胞菌抗生素的敏感性。多因素Logistic回归分析发现了1项独立危险因素：未恢复对抗铜绿假单胞菌抗生素的敏感性(OR=10．70)。结论 机械通气，以及亚胺培南／美罗培南的使用是MDRP感染的危险因素。MDRP未恢复对抗铜绿假单胞菌抗生素的敏感性是MDRP感染预后差的危险因素。     

Sporadic isolations of a multi-drug resistant Pseudomonas aeruginosa clone during a 14-month epidemic in a general hospital in Hiroshima

Background

During 2005–2007, we experienced sporadic isolations of multidrug-resistant (MDRP) Pseudomonas aeruginosa from wards in a general hospital in Hiroshima. The objective of this study was to analyze epidemiology relationships and the mode of spread of the strains.

Methods

Clonality was assessed using pulsed-field gel electrophoresis (PFGE) and serotyping. MICs were determined using the microdilution broth method. Investigations of the affected patients’ movements and environmental sampling from the affected wards were conducted.

Results

An abrupt increase in MDRP isolations began at the end of 2005 and ended in February 2007. A total of 25 MDRP strains were sporadically isolated from nine wards. Fourteen strains were genotypically and serologically identical. Analysis of the patients’ movements identified that six of the 14 MDRP-positive patients became positive for MDRP when they were in the intensive care unit (ICU), and two became positive after the patients moved from the ICU to another nursing unit. Four MDRP strains were isolated from patients who did not stay in the ICU and were in ward E6, which had the second highest number of isolations. In July 2006, environmental sampling of the hospital identified a toilet brush in ward E6 that was contaminated with MDRP that was genotypically and serologically identical to the clinical isolates.

Conclusions

Our study suggests that the sporadic increase in MDRP isolates during 2005–2007 in the general hospital in Hiroshima was due to an epidemic of an MDRP clone. Continuity and spread of infection was probably due to cross infection and contamination in the hospital with the MDRP strain.     

'Break-point Checkerboard Plate' for screening of appropriate antibiotic combinations against multidrug-resistant Pseudomonas aeruginosa

Increase of multiple drug resistant Pseudomonas aeruginosa (MDRP) is becoming a serious problem in the clinical setting. Although the checkerboard method to determine FIC index and synergistic effects of antibiotic combinations is useful, it is not well adapted to a routine test, mainly because of its time-consuming and labor-intensive nature. Here we report 'Break-point Checkerboard Plate', in which breakpoint concentrations, such as 'S' (sensitive) and 'I' (intermediate), were combined in a microtiter plate with 8 antibiotics, including carbapenem, aminoglycoside and fluoroquinolone. The results obtained from 12 strains of MDRP demonstrated a strong synergistic effect of some antibiotic combinations at clinically relevant concentrations. Our data suggest a usefulness of 'Break-point Checkerboard Plate' to screen appropriate antibiotic combinations against drug resistant organisms, including MDRP.     

Case of sepsis caused by multidrug-resistant neutropenic-phase Pseudomonas aeruginosa treated successfully with antibiotic combination therapy

Multidrug-resistant Pseudomonas aeruginosa (MDRP), defined as Pseudomonas aeruginosa resistant to aminoglycosides, carbapenems, and fluoroquinolones, has emerged as an increasingly problematic cause of hospital-acquired infection. With parenteral colistin unavailable in Japan, effective antimicrobial options are severely limited. We report a case of MDRP bacteremia successfully treated with antibiotic combination therapy screened by a 'Break-point Checkerboard Plate'. A 54-year-old man with malignant lymphoma who became febrile 9 days after a recent course of chemotherapy had a neutrophil count of 176/microL. Treatment with meropenem and vancomycin was ineffective and high fever persisted. Methicillin-resistant Staphylococcus aureus (MRSA) and MDRP were isolated from blood culture and combination therapy with aztreonam and amikacin was selected for MDRP based on 'Break-point Checkerboard Plate' results. Linezolid was used for MRSA. The patient recovered successfully from MDRP and MRSA sepsis.     

Significance of fluoroquinolone-resistant Escherichia coli in urinary tract infections

Antibiotic-resistant urinary tract infections (UTIs) are on the rise. We investigated the recent emergence of representative resistant strains in patients diagnosed with UTIs at Kobe University Hospital between 2000 and 2006, focusing on resistant strains isolated from the urine of UTI patients, especially fluoroquinolone-resistant Escherichia coli (FQRE), multidrug-resistant Pseudomonas aeruginosa (MDRP), and methicillin-resistant Staphylococcus aureus (MRSA). We found 16 MDRP, 108 FQRE, and 251 MRSA UTI cases, reflecting a significant increase in the incidence of FQRE. Our data demonstrated that isolated ratios of FQRE rose as much as 26.3% in 2006 and that there were significantly more isolated cases in 2003 - 2006 than in 2000 - 2002. The data show a significant trend toward FQRE emergence. This trend should be considered when treating UTI.     

Mortality of COPD Patients Infected with Multi-Resistant Pseudomonas aeruginosa : A Case and Control Study

Abstract Background:   The incidence of infections caused by multiresistant Pseudomonas aeruginosa (MDRP) is increasing, especially in critically ill patients. The relevance of MDRP in the prognosis of chronic obstructive pulmonary disease (COPD) acute exacerbation in patients admitted to the hospital’s general ward is not well known. Patients and Methods:   Case and control study. Cases were patients admitted for COPD acute exacerbation in which a MDRP was isolated from spontaneous sputum. MDRP was defined as the absence of susceptibility to three or more antibiotic families (betalactams, quinolones, carbapenems and aminoglycosides). Patients currently or previously admitted to the intensive care unit (ICU), who had a recent surgery, neoplasia or immunosuppressive treatment were excluded from the study. Patients from the control group were admitted for COPD acute exacerbation and matched 1:1 with each case-patient in terms of age, sex, date of admission and degree of airway obstruction. Pseudomonas aeruginosa susceptible to all antimicrobials or other microorganisms was isolated from sputum. Results:   During the study period (2000–2005), 50 casepatients and 50 controls were included. Crude mortality at 2 years was 60% for the case-patients and 28% for the control group. In the logistic regression analysis adjusted for age, FEV₁ and number of previous hospital admissions, MDRP infection was associated to an increased mortality in comparison to patients without MDRP (OR = 6.2; IC 95%: 1.7–22.1; p < 0.01). Conclusions:   In COPD patients admitted to the general ward, acute exacerbation with MDRP in sputum was associated with higher mortality.     

Effectiveness and safety of colistin for the treatment of multidrug-resistant Pseudomonas aeruginosa infections

Purpose:   

To describe the clinical and microbiological outcomes of patients infected with multidrug-resistant Pseudomonas aeruginosa (MDRP) treated with colistin (colistimethate sodium) and the adverse events observed with this treatment.     

多耐药铜绿假单胞菌下呼吸道感染临床分析

目的　分析耐亚胺培南和头孢他啶铜绿假单胞菌下呼吸道感染的临床特点和治疗对策。方法　对2 0 0 1年 1月至 2 0 0 3年 12月收住我院的 15例耐亚胺培南和头孢他啶的铜绿假单胞菌下呼吸道感染患者的临床表现及治疗进行回顾性分析。结果　 15例均患有基础疾病 ,以支气管扩张最多见 ,临床特点有发热 ,咳黄色粘稠痰 ,胸部 X线表现为小斑片状浸润阴影。 6株对亚胺培南、头孢他啶、环丙沙星和哌拉西林均耐药。 15例患者 2例治愈 ,5例好转 ,其治疗选用抗生素药物有亚胺培南 ,头孢他啶 ,头孢哌酮 舒巴坦 ,哌拉西林 舒巴坦 ,环丙沙星等 ,均为联合使用 ;2例无明显改善 ;6例患者死亡。结论　多药耐药铜绿假单胞菌 (MDRP)下呼吸道感染大多合并基础疾病 ;有住院时间长 ,反复多次住院 ,曾使用多种广谱抗生素的特点 ;治疗困难 ,病死率高 ,预后差。抗生素药物选择应避免选用亚胺培南。     

铜绿假单胞菌近7年的耐药性变迁及其抗生素应用分析

目的分析铜绿假单胞菌近7年的耐药性变迁情况。方法收集2001年1月至2007年6月我院分离的铜绿假单胞菌1076株,分析其耐药性变迁及临床抗生素的应用情况;结果对铜绿假单胞菌保持抗菌活性较强而耐药率30%的抗菌药物依次为美罗培南、亚胺培南及阿米卡星,对常用抗菌药物的耐药率有普遍增高的趋势;抗铜绿假单胞菌所用抗生素单用455例(44.4%);二联521例(50.9%);三联48例(4.7%)。结论铜绿假单胞菌耐药率高,耐药率有普遍增高的趋势;对严重铜绿假单胞菌感染、多药耐药(MDRP)或泛耐药(PDRP)的治疗,宜采用联合用药,β-内酰胺类+阿米卡星为较优化的组合治疗方案之一。     

咳嗽变异性哮喘临床特征及诊断初步研究

目的深入研究咳嗽变异性哮喘（CVA）患者的临床特征以及治疗反应对临床诊断的意义,提高对CVA的诊治水平。方法 2009年10月到2010年8月期间在第三军医大学新桥医院门诊及涪陵中心医院就诊诊断为慢性咳嗽,并且支气管激发试验阳性拟诊为CVA的患者,记录其咳嗽的临床特点、伴随症状和咽部体征。并给予沙美特罗/氟替卡松干粉剂50/100μg,2次/d吸入,1-2周后门诊或电话随访,评价疗效和确定诊断。结果共46例患者入选本试验,41例完成随访研究。CVA患者大多数有夜间咳嗽（87.9%）和咽部瘙痒等症状（87.9%）,近半数患者咳嗽剧烈,干咳患者仅占39.0%,45.5%合并鼻炎或鼻窦炎。治疗有效率为80.5%（33/41）。治疗无效组与有效组患者的临床特征比较,显示两组患者夜间咳嗽情况和咽部阳性症状的比例无明显差异,但治疗无效组患者伴随的胃病或反流症状,清喉和咽部体征有明显高于有效组患者的趋势。结论夜间咳嗽和咽部瘙痒等是大多数CVA具有的症状特点,气道反应性测定和抗哮喘治疗反应是确诊CVA的主要依据。对抗哮喘治疗无效的患者,还需要深入研究影响疗效的原因,不宜简单地排除CVA诊断。     

Nosocomial infection by multidrug-resistant Pseudomonas Aeruginosa (MDRP) presumably spread a radiation technician

Isolated of multidrug resistance Pseudomonas aeruginosa (MDRP) that the receptivity pattern of the antimicrobial suscepti respectively resembled isolated from clinical specimens (sputum) in two patients of each internal medicine ward in Kitasato University East Hospital for two days from September 18 and 20, 2004. Both of bacteria were formed small colonies of a smooth-type on dollargalluskey improvement-type BTB agar plates, and the judgment of ClassB (metallo)-beta-lactamase by biochemical properties and disk diffusion method sodium mercaoto-acetic acid (SMA) was mutually corresponding. Moreover, it was same serotype C according to the serotype, and it was confirmed that it was the same bacterial strain from the molecular epidemiology analysis by Random amplified polymorphic DNA polymerase chain reaction (Random amplified polymorphic DNA polymerase chain reaction: RAPD). From the investigation of clinical backgrounds of two patients who isolated bacterial strains, September 18, 2004. 10 : 20 a.m., and 10 : 40 a.m., other chances that can become with contact infection in this hospital, except conducted X-Ray or roentgenograph of the chest and abdomen of Portable X-ray device continuously done by one radiation technician was not seen. Because it had turned out that a radiation technician who had taken charge had been neglecting the hand washing at the time of each X-Ray or roentgenograph, it was guessed the case with nosocomial infection by contact infection occurred via specific radiation technician.     

局灶性机化性肺炎40例误诊分析

目的探讨局灶性机化性肺炎(FOP)的临床表现、病理学特征和影像学特点,以提高临床医师对本病的认识。方法回顾性分析2013-2018年江苏省人民医院住院手术切除的40例误诊为肺癌的FOP患者的临床资料,对其临床表现、病理学特征、影像学特点、实验室检查等综合分析。结果(1)40例FOP患者中,男34例,女6例,年龄范围为26~82岁,平均年龄(55.55±10.52)岁。(2)临床表现中,咳嗽咳痰21例,发热6例,咯血8例,胸痛12例,体检发现14例。(3)病变在肺野外、中、内带及各肺叶均有发生。CT表现多样,除结节影和实变影外,合并有分叶状、边缘毛刺征、支气管充气征、空泡征、密度不均、胸膜牵拉等。病灶范围≥3 cm的26例,<3 cm的14例。(4)共有8例患者行PET-CT检查,其中6例患者均有不同程度氟代脱氧葡萄糖代谢增高,提示恶性病变可能;2例未见氟代脱氧葡萄糖代谢增高,考虑炎症后改变。(5)40例患者中,癌胚抗原、糖类抗原199均正常,仅有1例神经元特异性烯醇化酶轻度增高,D-二聚体均正常。(6)病理提示间质纤维组织增生,肺泡腔扩张,腔内见纤维素样黏液栓形成,间质多量淋巴细胞浸润伴淋巴滤泡形成。(7)40例手术患者中,1例患者半年后复查手术缝线周围复发;余复查均正常。结论FOP临床相对少见,因其特殊影像表现极易误诊。临床医师需不断加强对FOP的认识,通过基本信息、临床特征、影像、实验室检查、病理特征等综合诊断,以减少临床误漏诊。     

Association of clinical features of bone and joint lesions between children and parents with Kashin–Beck disease in Northwest China

We investigated the clinical features of bone and joint lesions in children with Kashin–Beck disease (KBD) and the association of these features with their parents to determine specific clinical features for diagnosing KBD. A total of 2,248 children (4 to 18 years old) and their parents were examined by stratified cluster sampling from 33 villages in six endemic counties and from six villages in a non-endemic county. We collected individual information, clinical symptoms, and radiological signs of the right hand. KBD in children and their parents was assessed using the “Diagnosis Criteria of Kashin–Beck disease in China (WS/T207-2010).” Univariate and multivariate analyses were used to examine the correlation of clinical features between parents and offspring with KBD. The rates of clinical features in children were correlated with those in parents (P?<?0.01). The parents of child cases had higher rates of clinical features than the parents of child controls. The prevalence of radiographic alterations in the distal end of the phalanges in the parents of child cases was significantly higher than that in the parents of child controls (father, χ ²?=?14.83, P?=?0.001; mother, χ ²?=?10.41, P?=?0.001). The parents of child cases were more likely to be KBD cases than the parents of controls (adjusted odds ratio, 4.4–12.1). Recognizing significant correlations in clinical features between children and their parents with KBD is helpful for early clinical diagnosis and evaluation of disease severity. Some clinical features of KBD, such as radiographic alterations in the distal end of the phalanges, might be useful for diagnosing KBD.     

继发于干燥综合征的间质性肺病21例临床分析

目的探讨继发于干燥综合征(Sjogren′s syndrome,SS)的间质性肺病(interstitial lung disease ILD)的诊断治疗方法。方法对21例继发于SS的ILD患者的临床表现、肺部X线、HRCT、肺功能、实验室检查及治疗情分析。结果本组继发于SS的ILD患者的主要临床症状为咳嗽、气促。肺部HRCT主要表现为肺容积缩小、网格影、毛玻璃影、胸膜下小叶间隔增厚、胸膜下弧线影、牵拉性小支气管扩张、胸膜增厚粘连,在诊断方面优于胸部X线。肺功能检测异常主要为弥散功能降低和限制性通气障碍。实验室检查多见血沉增快,自身抗体阳性,免疫球蛋白升高。经糖皮质激素单用或联合细胞毒性药物治疗,临床症状有改善。结论继发于SS的ILD的诊断主要包括:临床表现、肺功能、肺部影像学、相关实验室检查。糖皮质激素和细胞毒性药物对继发于SS的ILD患者有良好疗效。     

Dieulafoy病19例诊治分析

目的探讨Dieulafoy病的发病情况、临床特征、诊断与治疗。方法收集我院1996年~2008年7月间收治的上消化道出血病人1 470例,对其中检出的19例Dieulafoy病病例的临床特征、内镜下表现及治疗方法进行回顾性分析。结果Dieulafoy病约占上消化道出血的1.3%,19例Dieulafoy病中,病灶位于胃底5例,胃体10例,胃窦部2例,贲门部1例,十二指肠球部1例,其中17例均于胃镜下可直接见破裂血管,有10例可见活动性出血。病灶直径1.0~3.0 mm。于内镜下行病灶黏膜下局部注射5%鱼甘油酸钠,1例因再出血予手术治疗。结论Dieulafoy病是上消化道大出血的少见而重要的病因,该病诊断主要依靠胃镜检查,通过内镜早期诊断和治疗可以取得很好的疗效。     

误诊为肿瘤的腹腔结核

目的 探讨腹腔结核（TB)的临床病理特征和诊断。方法 对1962－1997年间，临床上被误诊为肿瘤（其中31例被误诊为恶性肿瘤），术后经病理检查确诊的45例腹腔TB作回顾性研究。结果 腹腔TB以青年人（≤40岁者29例，64％）和女性（28例，62％）多见。临床主要表现为腹部包块37例（82％）和腹痛30例（67％），其中伴发热17例（38％）、腹胀、便秘或腹泻15例（33％）、体重减轻14例（29％）。手术所见：病变均为肠、腹膜和淋巴结多处受累，病变处有大小不等的包块和结节，酷似癌。镜检：增生型25例，干酪样坏死型14例，混合型6例。结论 腹腔TB的临床诊断与癌的鉴别困难。要提高对腹腔TB临床病理特征的认识，对经各种检查难以确诊的病例，作剖腹探查活检是必要的，以免造成误诊误治。     

26例肝窦阻塞综合征临床及影像分析

目的了解肝窦阻塞综合征患者的临床特点及影像特征。方法回顾性分析2010年11月至2019年2月在解放军总医院第五医学中心住院诊治的26例肝窦阻塞综合征患者的临床资料,归纳总结其主诉、临床表现、实验室检查、影像学特征及病因。结果26例肝窦阻塞综合征患者以腹胀、乏力、纳差、腹水为主要症状,1例为肝移植术后患者,1例为肾移植术后患者,均有明确的化学治疗史,1例患者病因不明,23例患者有明确的中草药服用史,其中21例服用土三七。ALT升高17例,AST升高20例,糖类抗原CA125升高23例。CT及MR影像学显示,脾脏增大11例,腹水24例,肝脏密度及信号不均21例,增强扫描强化不均匀23例,肝静脉变细或显示不清11例。结论肝窦阻塞综合征的病因以服用土三七为主,临床表现为腹胀、乏力、纳差,可有肝功能异常及CA125升高,影像学表现以肝脾肿大、腹水、肝脏密度及信号不均,增强扫描强化不均及肝静脉变细或显示不清为主。     

弥漫性泛细支气管炎的诊断:18例分析

目的 探讨弥漫性泛细支气管炎(diffuse panbronchiolitis,DPB)的临床特点、影像学表现、诊断和鉴别诊断.方法 对在北京协和医院诊断为DPB的18例患者进行回顾分析.结果 病理确诊10例,临床诊断14例.18例均以慢性咳嗽、咳痰及活动气促为主诉.14例有肺部哕音.15例有鼻窦炎.肺功能以阻塞性通气功能障碍为主.本组病例冷凝集试验阳性率低.所有胸部影像见弥漫小结节影,大部分伴支气管扩张;影像学分型和临床严重程度无明确相关性.初诊误诊率100%.结论 本组DPB患者有典型临床表现,但某些临床特点有别于日本患者.DPB影像学有特征性表现.DPB误诊率高,应提高对其认识.     

脾脓肿19例临床资料分析

  目的 分析脾脓肿的临床诊治情况,为其诊疗提供参考。方法 回顾1991年1月—2012年3月北京协和医院19例脾脓肿患者的诊疗情况,分析其一般情况、基础疾病、临床表现、影像学特征、病原学依据、治疗方式、转归等临床资料。结果 19例脾脓肿患者从发病到就诊北京协和医院的中位时间为29 d,9例治愈,8例好转,2例死亡。大多数患者具有脾脓肿的危险因素,如肿瘤、糖尿病和免疫抑制状态等。脾脓肿临床表现不特异,19例患者脾脏均存在影像学变化;最多见的3种临床症状为发热（18例）、畏寒（12例）、寒战（11例）;最多见的3种体征是腹部压痛（9例）、左季肋区叩痛（7例）、脾大（4例）;病原菌培养结果显示最多见者为革兰阴性杆菌（9例）,革兰阳性球菌（8例）,真菌（4例）,7例患者存在2种或2种以上病原菌感染。结论 脾脓肿患者临床表现特异性不高。对于具有危险因素者,应进行相关临床检查,避免漏诊。结合超声等影像学检查,尽早诊断并开始经验性抗感染治疗;及时留取脓液等寻找病原学资料;根据患者情况,个体化选择治疗方案。        

糖尿病合并肺炎克雷伯杆菌性肝脓肿的临床特点及误诊分析

目的提高对糖尿病合并肺炎克雷伯杆菌肝脓肿的诊治水平。方法回顾性分析16例糖尿病合并肺炎克雷伯杆菌性肝脓肿的临床资料。结果糖尿病合并肺炎克雷伯杆菌性肝脓肿占同期收治糖尿病性细菌性肝脓肿的57.1%。临床主症有畏寒、发热、乏力,腹痛、肝区叩击痛。脓肿多为单发、局限于右肝。首诊确诊率仅37.5%,首次B超误诊率37.5%。本组在有效抗生素及B超引导下经皮肝脓肿穿刺抽脓/置管引流后均好转,无一例死亡。结论糖尿病并发肺炎克雷伯杆菌肝脓肿的临床表现不典型,易漏诊误诊。及时超声引导下行肝脓种穿刺引流,缩短疗程,预后佳。