2007年至2016年苏州地区儿童呼吸道革兰阴性杆菌感染构成及耐药性分析

摘要

目的 分析苏州地区儿童呼吸道革兰阴性(G-)杆菌感染构成及耐药性,为临床合理使用抗生素提供依据.方法 收集2007年1月至2016年12月21 561例因呼吸道感染入住苏州大学附属儿童医院呼吸科的患儿鼻咽分泌物标本G-杆菌培养结果,包括普通病房21 246例和315例重症监护病房(ICU)治疗后转入呼吸科的患儿标本,同时将患儿分为普通病房组和ICU组,比较2组病原菌构成,动态观察细菌药敏变化.结果 呼吸道感染首位G-杆菌是流感嗜血杆菌,其次是大肠埃希菌、肺炎克雷伯菌、铜绿假单胞菌和鲍曼不动杆菌,但ICU组肺炎克雷伯菌、铜绿假单胞菌检出率[16.8％(21/125株)、14.4％(18/125株)]明显高于普通病房组[10.0％(208/2 071株)、9.2％(190/2 071株)].ICU组G-杆菌检出率为33.7％(106/315例),明显高于普通病房组[9.4％(1 997/21 246例)],差异有统计学意义(x2=210.325,P＜0.001).嗜麦芽窄食单胞菌、琼氏不动杆菌、洋葱伯克霍德菌等少见的G-杆菌在ICU组患儿所占比例高达17.6％(22/125株),明显高于普通病房组[6.4％(132/2 071株)].G-杆菌2种或2种以上混合感染ICU组为17.0％(18/106例),明显高于普通病房组[3.4％(68/1 997例)],差异有统计学意义(x2=47.3,P＜0.001),ICU组以肺炎克雷伯杆菌、混合铜绿假单胞菌或大肠埃希菌为主,普通病房组以流感嗜血杆菌、混合铜绿假单胞菌或大肠埃希菌为主.流感嗜血杆菌对氨苄西林、舒他西林、头孢呋辛、头孢克洛及阿奇霉素的敏感率呈下降趋势,对氯霉素、四环素及甲氧苄啶+磺胺甲(嚅)唑敏感率逐年上升,不同年份间差异均有统计学意义(均P＜0.05).大肠埃希菌对头孢他啶敏感率逐年下降,对氨苄西林、左氧氟沙星敏感率逐年上升,不同年份间差异均有统计学意义(均P＜0.05).肺炎克雷伯杆菌对头孢哌酮/舒巴坦、亚胺培南敏感率呈下降趋势,对环丙沙星及左氧氟沙星敏感率有所上升,不同年份间差异均有统计学意义(均P＜0.05).铜绿假单胞菌对头孢哌酮/舒巴坦、头孢曲松敏感率呈逐年下降,对左氧氟沙星敏感率有所上升,不同年份间差异均有统计学意义(均P ＜0.05).肺炎克雷伯菌和铜绿假单胞菌对碳青霉烯类抗生素耐药菌株检出率呈增高趋势,不同年份间差异均有统计学意义(均P＜0.05).结论 呼吸道感染首位G-杆菌是流感嗜血杆菌,G-杆菌特别是G-杆菌混合感染更易发生重症及危重症呼吸道感染.儿童呼吸道G-杆菌感染对常用抗菌药物的耐药率总体呈上升趋势.%Objective To analyze the infection composition and drug resistance to Gram-negative (G-) bacilli in children's respiratory tract in Suzhou,in order to provide evidence for rational use of antibiotics clinically.Methods G-bacilli culture samples were collected from 21 561 cases of nasopharyngeal secretions from patients with respiratory tract infection admitted at the Department of Respiratory,Children's Hospital of Soochow University from January 2007 to December 2016,including 21 246 cases in general wards,and 315 patients who were transferred to the respiratory department after treatment in the Intensive Care Unit(ICU),and the children were divided into the general ward group and the ICU group,and the pathogens were compared and the changes in bacterial susceptibility were dynamically observed between the 2 groups.Results The primary G-bacteria for respiratory infection was Haemophilus influenzae,followed by Escherichia coli,Klebsiella pneumoniae,Pseudomonas aeruginosa and Acinetobacter baumannii.The detection rates of Klebsiella pneumoniae and Pseudomonas aeruginosa in the ICU group were 16.8％ (21/125 strains) and 14.4％ (18/125 strains),respectively,which were significantly higher than those in the general ward group [10.0％ (208/2 071 strains),9.2％ (190/2 071 strains)].The detection rates of G-bacteria in the ICU group were 33.7％ (106/315 cases),which were significantly higher than those in the general ward group [9.4％ (1 997/21 246 cases)],and the difference was statistically significant (x2 =210.325,P ＜ 0.001).The rare G-bacillus such as Stenotrophomonas maltophilia,Acinetobacter junii and Burkholderia onion were higher in the ICU group [17.6％ (22/125 strains)] than that in the general ward group [6.4％ (132/2 071 strains)].The rate that of G bacteria with two or more mixed infection in ICU group [17.0％ (18/106 cases)] was significantly higher than in the general ward group [3.4％ (68/1 997 cases)],and the difference was statistically sigmficant(x2 =47.3,P ＜0.05).For the mixed infection,the ICU group was mainly composed of Klebsiella pneumoniae mixed with Pseudomonas aeruginosa or Escherichia coli,while the general ward group was composed of Haemophilus influenzae mixed with Pseudomonas aeruginosa or Escherichia coli.The sensitivity of Haemophilus infiuenzae to Ampicillin,Sultamicillin,Cefuroxime,Cefaclor and Azithromycin decreased,and the sensitivity to Chloramphenicol,Tetracycline and Trimethoprim + Sulfamethoxazole increased year by year,and there were statistically significant differences in different years (all P ＜ 0.05).The sensitivity to Escherichia coli to Ceftazidime decreased year by year,and the sensitivity to Ampicillin and Levofloxacin increased year by year,and there were statistically significant differences in different years (all P ＜ 0.05).The sensitivity to Klebsiella pneumoniae to Cefoperazone/Sulbactam and imipenem decreased,and the sensitivity to Ciprofloxacin and Levofloxacin increased,and there were statistically significant differences in different years (all P ＜ 0.05).The sensitivity to Pseudomonas aeruginosa,Cefoperazone/Sulbactam and Ceftriaxone decreased year by year,and the sensitivity to Levofloxacin increased,and there were statistically significant differences in different years (all P ＜ 0.05).The detection rate of carbapenem-resistant strains of Klebsiella pneumoniae and Pseudomonas aeruginosa showed an increasing trend,and there were statistically significant differences in different years (all P ＜ 0.05).Conclusions The primary G-bacteria for respiratory infections is Haemophilus influenzae,G-bacilli especially,the mixed infection of G-bacilli,is more likely to cause severe and critical respiratory infections.The resistance rate of G-bacteria infection in children's respiratory tract to commonly used antibiotics is generally on the rise.