胸外科老年患者术后肺部多重耐药菌感染临床特征及危险因素

Clinical features and risk factors of postoperative pulmonary multidrug-resistant organism infections in elderly patients undergoing cardiothoracic surgery

摘要:

目的 分析老年患者心胸外科术后肺部感染病原菌的分布情况及多重耐药菌的耐药性，探讨术后肺部多重耐药菌感染的危险因素。 方法 将2020年1月—2022年12月上海市胸科医院进行心胸外科手术后发生肺部感染的老年患者作为研究对象，依据肺部感染菌株是否为多重耐药菌(MDRO)分为MDRO组和非MDRO组，统计MDRO对抗菌药物的耐药率，并分析术后肺部MDRO感染的危险因素。 结果 共有23 905例老年患者进行心胸外科手术，术后发生肺部感染289例，感染发病率为1.21%；123例为MDRO肺部感染(MDRO组)，166例为非MDRO肺部感染(非MDRO组)。与非MDRO组比较，MDRO组患者患糖尿病、机械通气时间＞10 d、留置导尿管时间＞10 d、留置中央静脉导管时间＞10 d、留置胸腔引流管时间＞10 d、抗菌药物使用种类≥3种的比例更高，入住ICU日数更长(均P＜0.05)；多因素logistic回归分析发现，糖尿病、机械通气时间＞10 d、抗菌药物使用种类≥3种是心胸外科老年患者术后肺部MDRO感染的独立危险因素(均P＜0.05)。术后肺部感染患者痰标本共分离病原菌314株，其中137株为MDRO，以铜绿假单胞菌(38株，27.73%)、金黄色葡萄球菌(31株，22.63%)为主。多重耐药铜绿假单胞菌对亚胺培南、美罗培南、左氧氟沙星、环丙沙星耐药率＞68%；多重耐药的金黄色葡萄球菌对万古霉素、利奈唑胺、利福平的耐药率为0。 结论 心胸外科老年患者术后肺部MDRO感染常见的病原体为铜绿假单胞菌、金黄色葡萄球菌，糖尿病、机械通气时间、抗菌药物使用种类的数量与术后肺部MDRO感染密切相关，应采取针对性干预措施预防术后肺部MDRO感染的发生。

Abstract:

Objective To analyze the distribution of pathogenic bacteria and antimicrobial resistance of multidrug-resistant organisms (MDROs) in elderly patients with pulmonary infection (PI) after cardiothoracic surgery, and to explore the risk factors for postoperative MDRO PI. Methods Elderly patients with postoperative PI after cardiothoracic surgery in Shanghai Chest Hospital From January 2020 to December 2022 were selected as the study subjects. According to whether PI strains were MDROs, the patients were divided into the MDRO group and the non-MDRO group. The antimicrobial resistance rates of MDROs were calculated, and the risk factors for postoperative MDRO PI were analyzed. Results A total of 23 905 elderly patients underwent cardiothoracic surgery, and 289 cases developed postoperative PI, with an infection rate of 1.21%. Among them, 123 cases were classified as MDRO PI (MDRO group), and 166 cases were non-MDRO PI (non-MDRO group). Compared with the non-MDRO group, the proportion of patients with diabetes, mechanical ventilation duration >10 days, indwelling urinary catheter duration >10 days, indwelling central venous catheter duration >10 days, indwelling thoracic drainage tube >10 days, and use of ≥3 types of antimicrobial drugs was higher in the MDRO group, and the length of ICU stay was longer (all P < 0.05). Multivariate logistic regression analysis showed that diabetes, mechanical ventilation duration >10 days, and the use of ≥3 types of antimicrobial drugs were independent risk factors for postoperative MDRO PI in elderly patients who underwent cardiothoracic surgery (all P < 0.05). A total of 314 strains of pathogenic bacteria were isolated from sputum specimens of patients with postoperative PI, 137 of which were MDROs, mainly Pseudomonas aeruginosa (n=38, 27.73%) and Staphylococcus aureus (n=31, 22.63%). The resistance rates of multidrug-resistant Pseudomonas aeruginosa to imipenem, meropenem, levofloxacin, and ciprofloxacin were more than 68%. The resistance rates of multidrug-resistant Staphylococcus aureus to vancomycin, linezolid and rifampicin were 0. Conclusion Common pathogens causing postoperative MDRO PI in elderly patients underwent cardiothoracic surgery are Pseudomonas aeruginosa and Staphylococcus aureus. Diabetes, duration of mechanical ventilation, as well as type and quantity of antimicrobial use are closely related to the occurrence of MDRO PI. Targeted intervention measures should be taken to prevent the occurrence of postoperative MDRO PI.