结石细菌培养在PCNL术后感染性并发症治疗中的作用

目的探讨结石细菌培养在经皮肾镜取石术(PCNL)后感染性并发症治疗中的作用。方法回顾性分析广州医科大学附属第一医院2016年9月至2018年9月收治的1060例行一期PCNL肾结石患者的临床资料。男614例,女446例。年龄(52.4±12.2)岁。结石负荷(1499.6±1435.3)mm^2。收集清洁中段尿及术中结石标本用于细菌培养鉴定及药敏试验。记录患者膀胱中段尿和结石的细菌培养结果、药敏试验结果、围手术期抗菌药物应用情况以及术后感染发生情况,分析结石细菌培养阳性者与阴性者术后发热和尿源性脓毒血症发生率的差异。结果本研究1060例,膀胱中段尿培养出22种细菌,结石培养出52种细菌。结石细菌培养阳性率高于中段尿31.8%(337/1060)与20.9%(222/1060),P<0.001]。中段尿和结石中最常见的细菌均为大肠埃希菌,但大肠埃希菌阳性率中段尿高于结石52.3%(116/222)与43.6%(147/337),P<0.05]。中段尿和结石来源的大肠埃希菌对氨苄西林、头孢唑啉、头孢曲松、头孢噻肟、左氧氟沙星、环丙沙星等耐药率均高于40%,而对亚胺培南、美罗培南、头孢哌酮/舒巴坦、哌拉西林/他唑巴坦、阿米卡星等药物耐药率均低于10%,两者的耐药率差异无统计学意义(P>0.05)。术后出现发热111例(10.5%),尿源性脓毒血症22例(2.1%)。结石细菌培养阳性患者术后发热和尿源性脓毒血症的发生率均高于结石细菌培养阴性患者23.7%(80/337)与4.3%(31/723);4.2%(14/337)与1.1%(8/723),P均<0.05]。术前膀胱中段尿细菌培养阴性患者中,结石细菌培养阳性者的术后发热率高于阴性者17.9%(30/168)与4.2%(28/670),P<0.05]。结石细菌培养阳性患者中,术后抗菌药物与结石药敏试验结果一致者的术后发热率低于与结石药敏试验不符者17.5%(22/126)与27.5%(58/211),P<0.05]。结论结石细菌培养阳性率高,细菌菌谱复杂,多重耐药比例高。即使术前中段尿细菌培养为阴性,结石细菌培养阳性仍是PCNL术后感染的危险因素。结石细菌培养结果在PCNL术后感染性并发症治疗中具有重要的指导作用。

The effect of stone urine bacteria culture on the treatment of postoperative infection in percutaneous nephrolithotomy

Objective To assess the effect of stone and urine bacteria culture on the treatment of postoperative infection in percutaneous nephrolithotomy(PCNL).Methods Between September 2016 and September 2018,1060 patients with kidney stones treated with first-stage PCNL were included in the study.There were 614 male and 446 female patients,with the mean age(52.4±12.2)years.The mean stone burden was(1499.6±1435.3)mm^2.The midstream urine sample and the stone sample were sent for bacterial culture,identification of bacterial strain and antimicrobial susceptibility tests.The results of urine culture(UC),stone culture(SC)and their antimicrobial susceptibility,the details of perioperatively administered antibiotics and postoperative infections were recorded.The relationship between the postoperative infection and the SC was analyzed.Results In 1060 patients,22 bacterial species were identified in UC and 52 bacterial species were identified in SC.The positive rate was higher in SC than in UC31.8%(337/1060)vs.20.9%(222/1060),P<0.001].Escherichia coli was the most common bacteria in both UC and SC,but was more prevalent in UC than in SC52.3%(116/222)vs.43.6%(147/337),P<0.05].E.coli cultured from UC and SC had high resistance to ampicillin,cefazolin,ceftriaxone,cefotaxime,levofloxacin,ciprofloxacin(all resistance rate>40%),but were sensitive to meropenem,cefoperazone/sulbactam,piperacillin/tazobactam,and amikacin(all resistance rate<10%).There was no statistical difference in the antibiotic resistance rates of E.coli from the UC and SC(all P>0.05).There were 111(10.5%)patients who developed fever and 22(2.1%)who developed urosepsis postoperatively.The incidences of postoperative fever and urosepsis were higher in the patients with positive SC than the patients with negative SC23.7%(80/337)vs.4.3%(31/723);4.2%(14/337)vs.1.1%(8/723),P<0.05].Even in patients with negative UC,The incidence of postoperative fever was higher in the group with positive SC than the group with negative SC17.9%(30/168)vs.4.2%(28/670),P<0.05].The incidence of postoperative fever in SC positive patients was lower if they were treated with sensitive antibiotics to the bacteria in stone than those treated with nonsensitive antibiotics17.5%(22/126)vs.27.5%(58/211),P<0.05].Conclusions The SC had high rate of culture positive,complicated bacterial species and high rate of multi-drug resistant.Positive SC was associated with increased incidence of postoperative infection even if the patients had negative UC.The SC might have a importance clinical value in the treatment of postoperative infection in PCNL.