本文選題：血流感染 + 養(yǎng)老院��； 參考：《上海交通大學(xué)》2015年碩士論文

【摘要】：目的:了解養(yǎng)老院居住者腸道定植產(chǎn)超廣譜β-內(nèi)酰胺酶(Extended-spectrumβ-lactamase,ESBLs)腸桿菌科細(xì)菌的發(fā)生率和耐藥性,并從居住者個(gè)人、醫(yī)護(hù)人員和養(yǎng)老院機(jī)構(gòu)三個(gè)層面確定定植危險(xiǎn)因素;了解瑞金醫(yī)院2012年住院患者血培養(yǎng)分離病原體種類(lèi)和耐藥性,在此基礎(chǔ)上對(duì)2011-2013年該院分離的引起血流感染(Bloodstream infections,BSI)大腸埃希菌的耐藥性和分子流行病學(xué)特征進(jìn)行分析,進(jìn)而為臨床合理使用抗菌藥物、防控醫(yī)院獲得性血流感染和耐藥菌的播散提供科學(xué)依據(jù)。方法:1)以VITEK 2Compact全自動(dòng)微生物分析系統(tǒng)鑒定細(xì)菌作為參考方法,建立聯(lián)合應(yīng)用科瑪嘉定位顯色培養(yǎng)基、吲哚試驗(yàn)、鳥(niǎo)氨酸脫羧酶試驗(yàn)、賴(lài)氨酸脫羧酶試驗(yàn)鑒定常見(jiàn)氧化酶陰性革蘭陰性桿菌的方法并進(jìn)行評(píng)估;2)收集上海市7家養(yǎng)老機(jī)構(gòu)居住者的肛拭標(biāo)本和臨床病歷資料,對(duì)分離出的腸桿菌科細(xì)菌菌株采用上述方法進(jìn)行鑒定,紙片擴(kuò)散法進(jìn)行藥敏試驗(yàn),聚合酶鏈?zhǔn)椒磻?yīng)(Polymerase chain reaction,PCR)擴(kuò)增編碼ESBLs和碳青霉烯酶的基因,應(yīng)用統(tǒng)計(jì)學(xué)軟件從居住者個(gè)人、醫(yī)護(hù)人員、機(jī)構(gòu)水平三個(gè)層面對(duì)所有可能的變量進(jìn)行分析并確定產(chǎn)ESBLs菌株定植的危險(xiǎn)因素;3)收集瑞金醫(yī)院2012年1月1日-12月31日住院患者送檢所有血培養(yǎng)標(biāo)本的菌株信息和患者信息以分析陽(yáng)性檢出率、病原體分布、科室分布、患者特征和耐藥性;4)收集瑞金醫(yī)院2011年6月-2013年6月引起血流感染最常見(jiàn)的大腸埃希菌菌株,紙片擴(kuò)散法進(jìn)行藥敏試驗(yàn),pcr擴(kuò)增編碼esbls和碳青霉烯酶的基因、系統(tǒng)發(fā)生群基因和多位點(diǎn)序列分型(multi-locussequencetyping,mlst)基因,并采用軟件eburst對(duì)序列型(sequencetype,st)進(jìn)行分析以探究菌株間的同源性。結(jié)果:1)采用本次研究所建立的以顯色培養(yǎng)基聯(lián)合簡(jiǎn)單生化反應(yīng)的鑒定方案對(duì)8個(gè)屬10個(gè)種共318株菌的鑒定結(jié)果表明,與vitek2compact全自動(dòng)微生物分析系統(tǒng)鑒定結(jié)果相比,這10個(gè)菌種鑒定的特異性均大于90%,靈敏度為75%~100%;一致性分析表明除弗勞地枸櫞酸桿菌的kappa值為0.5947外,其余均大于0.85;mcnemar檢驗(yàn)p值均大于0.05;該鑒定法成本只有參考方法的10%;2)390位養(yǎng)老院居住者共分離到457株腸桿菌科細(xì)菌,其中183(46.92%)株產(chǎn)esbls;大腸埃希菌(365,79.87%)、奇異變形桿菌(40,8.75%)和肺炎克雷伯桿菌(24,5.25%)是最常見(jiàn)的菌種;ctx-m是最常見(jiàn)的β-內(nèi)酰胺酶(198,99.00%),其中ctx-m-14(84,42.00%)的比例最高;兩株產(chǎn)碳青霉烯酶的肺炎克雷伯桿菌分離自同一家養(yǎng)老院,均攜帶blakpc-2且均為st11;分離菌對(duì)碳青霉烯類(lèi)、tzp,ak,fos,cl和tgc的耐藥率低;侵入性醫(yī)療操作(or=3.112,95%ci1.725-5.615,p=0.000)、喹諾酮使用史(or=1.808,95%ci1.047-3.121,p=0.034)和每周洗澡次數(shù)(or=1.959,95%ci1.163-3.302,p=0.012)是腸道定植產(chǎn)esbls腸桿菌科細(xì)菌的獨(dú)立相關(guān)變量;3)2012年瑞金醫(yī)院5546例住院患者送檢血培養(yǎng)標(biāo)本16428份,血培養(yǎng)陽(yáng)性者384例,陽(yáng)性率為6.92%;檢出病原體398株,其中革蘭陰性(g-)菌272株(68.34%),革蘭陽(yáng)性(g+)菌94株(23.62%),真菌32株(8.04%);61~80歲患者陽(yáng)性率(8.26%)最高,送檢陽(yáng)性率居前5位的科室分別是灼傷整形科、中醫(yī)科、心外監(jiān)護(hù)病區(qū)、移植病區(qū)和創(chuàng)傷外科;g+球菌對(duì)va、tec、lzd保持高敏感率,發(fā)現(xiàn)1株耐萬(wàn)古霉素屎腸球菌;g-桿菌中腸桿菌科細(xì)菌對(duì)ak和碳青霉烯類(lèi)藥物敏感率高,腸桿菌科細(xì)菌、鮑曼不動(dòng)桿菌、銅綠假單胞菌對(duì)碳青霉烯類(lèi)藥物的耐藥率分別為7.51%、70.97%、35.90%;4)2011年6月至2013年6月共連續(xù)收集到引起血流感染大腸埃希菌128株,其中80株產(chǎn)esbls,未發(fā)現(xiàn)產(chǎn)碳青霉烯酶菌株;分離株對(duì)ak,tzp和碳青霉烯類(lèi)抗生素保持高敏感率;ctx-m-14(40/80)是最常見(jiàn)的β-內(nèi)酰胺酶,其次是ctx-m-55(17/80)和ctx-m-15(14/80);b2群是最常見(jiàn)的系統(tǒng)發(fā)生群,但是在產(chǎn)esbls菌株中d群的比例最高;共檢測(cè)到49個(gè)序列型,分為6個(gè)非重復(fù)的進(jìn)化組或克隆復(fù)合物以及33個(gè)單體,其中st131(17/128)是最常見(jiàn)的序列型,其次是st69(12/128)和st648(10/128)。結(jié)論:1)顯色培養(yǎng)基聯(lián)合簡(jiǎn)單生化試驗(yàn)可快速經(jīng)濟(jì)有效地鑒定數(shù)種常見(jiàn)氧化酶陰性革蘭陰性桿菌;2)養(yǎng)老院居住者每周的洗澡次數(shù)、侵入性醫(yī)療操作史和喹諾酮類(lèi)抗生素使用史是產(chǎn)ESBLs腸桿菌科細(xì)菌腸道定植的獨(dú)立相關(guān)變量,抗生素的合理使用、遵循無(wú)菌操作和護(hù)理原則、注意養(yǎng)老院居住者的個(gè)人衛(wèi)生是控制耐藥菌在養(yǎng)老機(jī)構(gòu)播散的重要措施;3)瑞金醫(yī)院血流感染病原體以G-菌為主,老年患者血培養(yǎng)陽(yáng)性率高,引起血流感染大腸埃希菌的同源性低,不存在產(chǎn)ESBLs菌株的院內(nèi)克隆傳播;4)養(yǎng)老院居住者腸道產(chǎn)ESBLs腸桿菌科細(xì)菌的定植率和瑞金醫(yī)院血流感染產(chǎn)ESBLs大腸埃希菌的發(fā)生率均較高(45%),但是后者高于前者,而且后者對(duì)大多數(shù)臨床常用抗生素的耐藥率也高于前者,TZP、AK、FOS、CL、TGC和碳青霉烯類(lèi)可作為治療的良好選擇,ESBL表型均以CTX-M-14、CTX-M-15和CTX-M-55為主。
[Abstract]:Objective: to understand the incidence and resistance of Extended-spectrum beta lactamase (Extended-spectrum beta -lactamase, ESBLs) Enterobacteriaceae in the enteric colonization of the elderly in the nursing home, and to determine the risk factors of colonization from the three levels of the inhabited individual, the medical staff and the nursing home institution, and to understand the pathogen of the blood culture separation of the hospitalized patients in Ruijin hospital in 2012. On the basis of the species and drug resistance, the drug resistance and molecular epidemiology of the Bloodstream infections (Bloodstream infections, BSI) Escherichia coli isolated from the hospital were analyzed on this basis, and the scientific basis for the rational use of antibiotics and prevention and control of the hospital acquired blood flow infection and the spread of drug resistant bacteria was provided. 1) 1) using the VITEK 2Compact automatic microbiological analysis system to identify the bacteria as a reference method, the combined application of Colma color culture medium, indole test, ornithine decarboxylase test, lysine decarboxylase test and evaluation of common oxidase negative gram-negative bacilli were evaluated. 2) 7 pension institutions in Shanghai were collected. The resident's anal swab specimens and clinical records were used to identify the isolated bacterial strains of Enterobacteriaceae, drug sensitivity test, polymerase chain reaction (Polymerase chain reaction, PCR) to amplify the genes encoding ESBLs and carbapenem, using statistical software from the inhabited individual and the medical staff. The three levels of the institutional level were analyzed for all possible variables and the risk factors for ESBLs producing strain were determined. (3) the strain information and patient information of all the blood culture specimens in Ruijin hospital on January 1, 2012 -12 month were collected to analyze the positive rate, the distribution of the disease, the distribution of the Department, the characteristics of the patients and the drug resistance. 4) collect the most common Escherichia coli strains that caused the blood flow infection in Ruijin hospital in June -2013 June 2011, the paper diffusion method for drug sensitivity test, PCR amplification of ESBLs and carbapenem gene, systematic gene and multipoint sequence typing (multi-locussequencetyping, MLST) gene, and eburst sequence type (sequ). Encetype, st) analysis to explore the homology between strains. Results: 1) the identification results of 8 genera and 10 species were identified by the identification scheme of color culture medium combined with simple biochemical reaction established by this study. Compared with the vitek2compact automatic microbiological analysis system identification results, the identification of the 10 strains was specific. The sex was more than 90% and the sensitivity was 75%~100%; the consistency analysis showed that the kappa value of citric acid bacilli was 0.5947, the rest was more than 0.85; the p value of McNemar test was more than 0.05; the cost of the identification method was only 10% of the reference method; 2) 390 elderly residents were separated into 457 Enterobacteriaceae, of which 183 (46.92%) plants produced ESBLs; 365,79.87%, 40,8.75% and Klebsiella pneumoniae (24,5.25%) are the most common strains; ctx-m is the most common beta lactamase (198,99.00%), of which the proportion of ctx-m-14 (84,42.00%) is the highest; two Klebsiella pneumoniae producing carbapenenes from the same nursing home, all carrying blakpc-2 and all For st11, the resistance rates of isolated bacteria to carbapenems, TZP, AK, FOS, Cl and TGC were low; invasive medical operations (or=3.112,95%ci1.725-5.615, p=0.000), the history of the use of quinolone (or=1.808,95%ci1.047-3.121, p=0.034) and weekly bath times (or=1.959,95% ci1.163-3.302) were independent variables of Enterobacteriaceae. 3) in 2012, there were 16428 samples of blood culture specimens from 5546 hospitalized patients in Ruijin hospital and 384 positive blood culture cases, the positive rate was 6.92%, 398 strains of pathogens were detected, including 272 gram-negative (g-) strains (68.34%), 94 (23.62%) and 32 (8.04%) strains of gram-positive (23.62%) bacteria (23.62%); the positive rate of 61~80 years old (8.26%) was the highest, and the positive rate of inspection was in the former laboratories. They were burn plastic department, Department of traditional Chinese medicine, external heart monitoring area, transplant area and trauma surgery; g+ Staphylococcus maintained Gao Min susceptibility to VA, TEC, LZD, found 1 strains of vancomycin resistant Enterococcus; g- bacilli had high sensitivity to AK and carbapenems, Enterobacteriaceae, Acinetobacter Bauman, Pseudomonas aeruginosa The drug resistance rates of alkenes were 7.51%, 70.97%, 35.90%, 4) from June 2011 to June 2013. 128 strains of Escherichia coli causing blood flow infection were collected continuously. 80 of them produced ESBLs, and no carbapenem producing strains were found; the isolates kept the Gao Min susceptibility to AK, TZP and carbapenems; ctx-m-14 (40/80) was the most common beta lactam. Enzyme, followed by ctx-m-55 (17/80) and ctx-m-15 (14/80); B2 group is the most common phylogenetic group, but the proportion of D groups in ESBLs producing strains is the highest; 49 sequences are detected, divided into 6 non repetitive evolutionary groups or cloned complexes and 33 monomers. ST131 (17/128) is the most common sequence type, followed by st69 (12/128) and st648 (10) /128) conclusion: 1) the color culture medium combined with simple biochemical test can quickly and efficiently identify several common oxidase negative gram-negative bacilli; 2) the weekly bath times, the history of invasive medical operation and the history of the use of quinolones are independent variables of intestinal colonization of ESBLs Enterobacteriaceae. The rational use of the elements, following the principle of aseptic operation and nursing, and paying attention to the personal hygiene of the residents in the nursing home is an important measure to control the spread of drug resistant bacteria in the pension institution. 3) the main pathogens of the blood flow infection in Ruijin hospital are G- bacteria, the positive rate of blood culture in the elderly patients is high, the homology of the Escherichia coli in the blood flow infection is low, and the ESBLs production does not exist. 4) the rate of colonization of Enterobacteriaceae ESBLs and ESBLs Escherichia coli in Ruijin hospital were higher (45%), but the latter was higher than the former, and the latter was also higher than the former, TZP, AK, FOS, CL, TGC and carbapenems. The class ESBL can be used as a good choice for treatment. The phenotype of CTX-M-14 is mainly CTX-M-15, CTX-M-55.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R446.5

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