急性白血病患者革兰阳性菌血流感染的病原学及临床特征分析

目的 分析急性白血病(acute leukemia, AL)患者合并革兰阳性菌血流感染(bloodstream infection, BSI)的病原学分布、耐药情况及临床特征，为临床诊疗及预后评估提供理论依据。方法 收集2010年1月—2018年12月湖南省3家大型医院血液科1012例AL合并血流感染患者的临床资料，对其中261例革兰阳性菌感染患者的病原学及临床特征进行分析。结果 AL合并血流感染的患者中25.8%为革兰阳性菌感染，主要致病菌有凝固酶阴性葡萄球菌(137株，52.5%)、链球菌(51株，19.5%)、金黄色葡萄球菌(38株，14.6%)。绝大多数革兰阳性菌对苯唑西林、青霉素G、红霉素耐药率较高，而对糖肽类抗菌药物(万古霉素、替考拉宁)及利奈唑胺的敏感率达90%以上。感染性休克、启动敏感抗菌药物治疗时间＞48h是AL患者并革兰阳性菌血流感染30d内死亡的独立危险因素(P＜0.05)。结论 AL患者革兰阳性菌血流感染耐药情况严峻，临床上对考虑合并革兰阳性菌血流感染的AL患者应及早应用糖肽类抗菌药物及利奈唑胺或替加环素，并根据药敏结果及疗效调整用药。

Etiology and clinical features of Gram-positive bacterial bloodstream infection in patients with acute leukemia

Objective To analyze the pathogenic distribution, antibiotic resistance, and clinical features of acute leukemia (AL) patients with Gram-positive bacterial bloodstream infection (BSI), and to provide theoretical basis for clinical diagnosis and prognosis evaluation. Methods The clinical data of 1012 AL patients with BSI admitted to the hematology ward of three large-scale hospitals in Hunan Province from January 2010 to December 2018 were collected. The etiology and clinical features of 261 patients with Gram-positive bacterial infection were analyzed. Results Gram-positive bacterial infection were detected in 25.8% of patients with AL and BSI. The main pathogens were coagulase-negative staphylococci (137 strains, 52.5%), Streptococcus(51 strains, 19.5%), and Staphylococcus aureus (38 strains, 14.6%). Most Gram-positive bacteria have high resistance to oxacillin, penicillin G, and erythromycin. The sensitivity of most Gram-positive bacteria to glycopeptide antibiotics (vancomycin and teicoplanin) and linezolid was more than 90%. Septic shock and time to start sensitive antibiotic treatment >48h were independent risk factors of 30-day mortality. Conclusion The drug resistance of Gram-positive BSI in AL patients is in severe situation. Clinically, patients with AL and Gram-positive bloodstream infection should be treated with glycopeptide agents, linezolid or tigecycline in time, and medication should be adjusted according to drug sensitivity results and efficacy.