腹膜透析相关性腹膜炎病原菌及其危险因素

目的了解腹膜透析（PD）相关性腹膜炎的细菌谱和耐药情况，为合理使用抗菌药物提供依据。方法回顾性分析某医院 2013 年 1 月-2014 年 12 月收治的 120 例次 PD 相关性腹膜炎患者的临床资料。结果细菌培养阳性 91 例次，阳性率为 75.83%。共培养病原菌 93 株，其中革兰阳性（G+）菌73株（78.49%），革兰阴性（G-）菌13株（13.98%），最常见的菌种G+菌是表皮葡萄球菌（38株，40.86%）和G-菌为大肠埃希菌（3株，3.23%）。G+菌对青霉素（93.65%）、红霉素（69.57%）和苯唑西林（64.41%）有较高的耐药率，对万古霉素（2.90%）和利奈唑胺（1.47%）耐药率较低，对替考拉宁、替加环素和呋喃妥因均敏感。G-菌对头孢唑林（50.00%）、头孢呋辛（37.50%）和氨苄西林（37.50%）有较高的耐药率，对亚胺培南、妥布霉素、哌拉西林均敏感。G+、G-菌对庆大霉素和左氧氟沙星均具有较低的耐药率。换液操作不规范（56.67%）是引起腹膜炎最常见的原因，主要为G+菌感染（79.41%）；而腹泻引起的腹膜炎主要为G-菌感染（52.63%）。G+菌、G-菌和细菌培养阴性腹膜炎的治愈率分别为92.96%、76.92%和86.21%，三者治愈率比较差异无统计学意义（χ2=3.39，P=0.18）。结论PD相关性腹膜炎的病原菌以G+菌为主，多由于换液操作不规范使病原菌经腹透管感染。第一代头孢菌素不能作为对G+菌的经验性用药，而万古霉素仍是最佳选择。第三代头孢菌素和氨基糖苷类可作为对G-菌的经验性用药。特殊情况下庆大霉素和左氧氟沙星可单独作为经验性用药。

Pathogens and risk factors of peritoneal dialysis related peritonitis

ObjectiveTo investigate the bacterial spectrum and antimicrobial resistance of peritoneal dialysis (PD) related peritonitis, and provide evidence for rational antimicrobial use. MethodsClinical data of 120 patients with PD related peritonitis in a hospital from January 2013 to December 2014 were retrospectively analyzed. Results91 cases (75.83%) showed positive result in bacterial culture, 93 pathogenic strains were cultured, including 73 (78.49%) gram positive and 13 (13.98%) gram negative bacterial strains, the most common gram positive bacteria was Staphylococcus epidermidis (n=38, 40.86%)， and the main gram negative bacteria was Escherichia coli (n=3, 3.23%). Gram positive strains had high resistance rates to penicillin, erythromycin, and oxacillin (93.65%, 69.57%, and 64.41% respectively), while resistance rates to vancomycin and linezolid were both low (2.90% and 1.47% respectively), and were sensitive to teicoplanin, tigecycline, and nitrofurantoin. Gram negative bacteria had high resistance rates to cefazolin, cefuroxime, and ampicillin（50.00%, 37.50%, and 37.50% respectively）, but were sensitive to imipenem, tobramycin, and piperacillin. Resistance rates of gram positive and gram negative bacteria to gentamicin and levofloxacin were both low. Non standard operation during dialysate exchange was the most common cause of peritonitis (56.67%), most peritonitis were gram positive bacterial infection（79.41%）；while gram negative bacteria were the main pathogens of diarrhea induced peritonitis (52.63%). The cure rates of gram positive bacteria, gram negative bacteria,and negative cultured peritonitis were 92.96%, 76.92%, and 86.21% respectively, difference was not statistically significant（χ2=3.39，P=0.18）. ConclusionGram positive bacteria are major pathogens in PD related peritonitis, and are usually caused by the bacteria through dialysis catheter due to non standard operation during dialysate exchange. First generation cephalosporins are not recommended as empirical therapy against gram positive bacteria, while vancomycin is still the best choice. Third generation cephalosporins and aminoglycosides are recommended as empirical therapy against gram negative bacteria. Gentamicin and levofloxacin can be used alone as empirical therapy in special circumstances.