Pathogenic characteristics and treatment of severe acute pancreatitis complicated with abdominal infection
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摘要: 目的 分析重症急性胰腺炎(SAP)患者合并腹腔感染的病原菌特点及治疗模式，为临床救治提供参考。方法 收集2018年1月—2020年12月我院收治的127例SAP患者资料，其中感染组病例40例。分析患者合并腹腔感染病原菌种类、耐药性、经验性抗生素使用等资料。结果 SAP伴发腹腔感染以两种及其以上细菌、真菌混合感染为主，其中多重耐药甚至全耐药的革兰阴性杆菌以及侵袭性真菌所占比例日趋增多，在感染性坏死组织清除的基础上结合动态病原学培养结果，抗生素调整方面碳青霉烯、万古霉素以及抗真菌药物选择增多；针对超级细菌，头孢他啶-阿维巴坦的使用率也日趋增加。结论 SAP合并腹腔感染患者的病原菌复杂、耐药率高，治疗前需确认主要病原菌的分布情况及药敏结果，同时及时动态送检患者的病原学标本，根据鉴定和药敏结果确保临床用药的有效性和安全性。Abstract: Objective To analyze the characteristics and treatment of abdominal infection in patients with severe acute pancreatitis(SAP), and to provide reference for clinical treatment.Methods Data of 127 SAP patients admitted to our hospital from January 2018 to December 2020 were collected, including 40 cases in the infection group. The types of pathogenic bacteria, drug resistance and empirical antibiotic use of patients with abdominal infection were analyzed.Results The peritoneal infection of severe acute pancreatitis was mainly caused by the mixed infection of two or more bacteria and fungi, in which the proportion of multiple or even full drug resistant Gram-negative bacilli and invasive fungi was increasing. Based on the clearance of infected necrotic tissue and the results of dynamic pathogen culture, the selection of carbapenems, vancomycin and antifungal drugs increased. Ceftazidime-avibatam was also increasingly used against superbugs.Conclusion SAP patients with abdominal infection have complex pathogens and high drug resistance rate. The distribution of main pathogens and drug sensitivity results both are very important. Dynamic samples of patients should be sent to ensure the effectiveness and safety of clinical medication.
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Key words:
- severe acute pancreatitis /
- intensive care unit /
- abdominal infection /
- antibiotics /
- clinical features
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表 1 SAP患者合并腹腔感染病原菌的分布与构成比
菌株 菌株/株 构成比/% 革兰阴性杆菌 25 45.45 肺炎克雷伯菌 11 20.00 大肠埃希菌 6 10.91 鲍曼不动杆菌 5 9.09 产气肠杆菌 2 3.64 其他 1 1.82 革兰阳性球菌 20 36.36 屎肠球菌 9 16.36 葡萄球菌属 8 14.55 粪肠球菌 3 5.45 真菌 10 18.18 白色念珠菌 5 9.09 光滑念珠菌 3 5.45 热带念珠菌 1 1.82 黄曲霉菌 1 1.82 合计 55 100 
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表 2 各种主要病原菌对不同抗菌药物的耐药性比较
抗菌药物 屎肠球菌(n=9) 粪肠球菌(n=3) 葡萄球菌(n=8) 菌株/株 敏感率/% 菌株/株 敏感率/% 菌株/株 敏感率/% 青霉素 1 11.11 2 66.67 2 25.0 红霉素 0 0 0 0 5 62.50 庆大霉素 2 22.22 1 33.33 6 75.0 氨苄西林 1 11.11 3 100.0 6 75.0 环丙沙星 1 11.11 3 100.0 6 75.0 克林霉素 0 0 0 0 7 87.50 万古霉素 9 100.0 3 100.0 8 100.0 利奈唑胺 9 100.0 2 66.67 8 100.0 替加环素 9 100.0 3 100.0 8 100.0 抗菌药物 肺炎克雷伯(n=9) 大肠埃希菌(n=6) 鲍曼不动杆菌(n=3) 菌株/株 敏感率/% 菌株/株 敏感率/% 菌株/株 敏感率/% 氨苄西林 1 11.11 0 0 0 0 氨苄西林/舒巴坦 2 22.22 1 16.67 0 0 哌拉西林/他唑巴坦 4 44.44 5 83.33 0 0 头孢他啶 3 33.33 3 50.00 0 0 头孢曲松 4 44.44 2 33.33 1 33.33 氨曲南 2 22.22 1 16.67 0 0 亚胺培南 5 55.56 5 83.33 0 0 美罗培南 5 55.56 5 83.33 0 0 庆大霉素 4 44.44 5 83.33 1 33.33 环丙沙星 3 33.33 2 33.33 0 0 左氧氟沙星 4 44.44 2 33.33 0 0 米诺环素 2 22.22 4 66.67 1 33.33 厄他培南 4 44.44 5 83.33 0 0 注：因患者自动出院等原因导致检出的肺炎克雷伯菌及鲍曼不动杆菌各2株无法获取相应病原菌鉴定的药敏结果。
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表 3 药敏结果前后抗生素的选择
初始经验性抗生素种类选择 药敏结果后抗生素种类选择 抗菌药物 病例数 抗菌药物 病例数 头孢哌酮/舒巴坦 12 亚胺培南 14 亚胺培南 9 美罗培南 9 哌拉西林/他唑巴坦 5 万古霉素 5 莫西沙星 3 哌拉西林/他唑巴坦 2 头孢他啶 3 莫西沙星 1 头孢噻利 3 替加环素 2 替考拉宁 2 替考拉宁 2 美罗培南 2 氟康唑 3 替加环素 2 卡泊芬净 2 头孢美唑 1 头孢他啶-阿维巴坦 3
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