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食管癌患者围术期预防性抗菌药物应用研究

Perioperative application of preventive antibiotics for patients with esophageal carcinoma

摘要:

目的 分析食管癌患者术后早期痰液中病原菌分布及耐药性,探讨食管癌术后肺部感染的危险因素及围术期抗菌药物的合理应用.方法 回顾性分析2012年1月至2014年6月滨州医学院附属医院收治的414例食管癌患者的临床资料.2012年1-12月收治的181例食管癌患者围术期预防性抗菌药物应用二代头孢;2013年1月至2014年6月收治的233例患者应用三代头孢.患者术前及术后前3d均常规留取痰液标本送检,观察病原菌分布及耐药性.观察两阶段患者术后肺部感染发生率.分析影响术后肺部感染发生的相关影响因素.率的比较和单因素分析采用x2检验,多因素分析采用Logistic回归模型.结果 术后早期痰培养阳性率为24.64% (102/414),其中使用二代头孢者为32.04%(58/181),使用三代头孢者为18.88% (44/233),两者术后早期痰培养阳性率比较,差异有统计学意义(x2=9.502,P<0.05).食管癌患者术后早期痰液中培养出病原菌共131株.其中革兰氏阳性球菌12株,革兰氏阴性杆菌119株.病原菌居前三位的是肺炎克雷伯菌肺炎亚种33株,鲍氏不动杆菌20株和铜绿假单胞菌19株.食管癌患者术后早期痰液中检出的革兰氏阴性杆菌对美罗培南、环丙沙星、左氧氟沙星的耐药率分别为5.0%~25.0%、2.6% ~ 15.2%、2.6%~20.0%.对于头孢类药物,头孢曲松、头孢噻肟、头孢吡肟、头孢他啶、头孢呋辛、头孢唑啉耐药率分别为10.3%~ 20.0%,5.3%~30.0%,12.8%~ 31.6%,15.4%~42.1%,21.2%~ 55.0%,15.2%~60.0%.术后肺部感染率为18.60%(77/414),围术期预防性应用二代头孢的食管癌患者肺部感染率为26.52%(48/181)高于预防性应用三代头孢患者的12.45%(29/233),两者比较,差异有统计学意义(x2=13.326,P<0.05).单因素分析结果显示:吸烟、慢性阻塞性肺部疾病、抗菌药、术后早期痰培养与食管癌术后肺部感染有关(x2=5.149,22.765,13.326,159.092,P<0.05).多因素分析结果显示:食管癌围术期应用三代头孢是术后肺部感染的独立保护因素(OR=2.582,95%可信区间:1.331 ~5.009,P<0.05).结论 食管癌术后早期痰液中病原菌以肺炎克雷伯菌肺炎亚种为代表的革兰氏阴性菌为主,种类复杂,抗菌药物普遍存在耐药,耐药程度不一,三代头孢能有效地预防食管癌术后肺部感染.

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abstracts:

Objective To analyze the distribution and antibiotic resistance of pathogens isolated from sputum in early postoperative patients after esophageal surgery, and investigate the risk factors of pulmonary infections after esophageal carcinoma and reasonable application of antibiotics during perioperative period.Methods The clinical data of 414 patients with esophageal carcinoma who were admitted to the Affiliated Hospital of Binzhou Medical University from January 2012 to June 2014 were retrospectively analyzed.The second generation cephalosporins were used as preventive antibiotics for the 181 patients between January and December 2012 and the third generation cephalosporins were used for the 233 patients between January 2013 and June 2014.Sputum samples were collected and inspected before operation and in the first three days after operation for observing distribution and antibiotic resistance of pathogens.The incidence of postoperative pulmonary infection was observed in the two kinds of patients.The risk factors closely related to the occurrence of postoperative pulmonary infections were analyzed.Comparison of rate and univariate analysis were done by chi-square test.Multivariate analysis was done with logistic regression.Results The positive rate of early post-operative sputum culture was 24.64% (102/414), 32.04% (58/181) in patients receiving the second generation cephalosporins and 18.88% (44/233) in patients receiving the third generation cephalosporins, respectively, with a significant difference between the two generations of cephalosporins (x2 =9.502, P < 0.05).A total of 131 strains of pathogens were isolated from early postoperative sputum samples including 12 strains of gram-positive bacteria and 119 strains of gram-negative bacteria.The top three bacteria were Klebsiella pneumoniae subsp pneumoniae (33 trains), Acinetobacter baumannii (20 strains) and Pseudomonas aeruginosa (19 strains).The resistance rate of gram-negative bacteria in early postoperative sputum samples to meropenem, ciprofloxacin and levofloxacin were 5.0%-25.0%, 2.6%-15.2%, 2.6%-20.0%, respectively.Among cephalosporins, the resistance rate to ceftriaxone, cefotaxime, cefepime, ceftazidime, cefuroxime and cefazolin were 10.3%-20.0% , 5.3%-30.0% , 12.8%-31.6%, 15.4%-42.1% , 21.2%-55.0% and 15.2%-60.0%, respectively.The overall postoperative pulmonary infection rate was 18.60% (77/414).The pulmonary infection rate of patients receiving the second generation cephalosporins was 26.52% (48/181), which was higher than 12.45% (29/233) of patients receiving the third generation cephalosporins (x2=13.326, P < 0.05).The results of univariate analysis showed that smoking, chronic obstructive pulmonary disease, application of the second generation cephalosporins during the perioperative period and early postoperative sputum culture positive were correlated with the postoperative pulmonary infection after esophageal carcinoma surgery (x2 =5.149, 22.765, 13.326, 159.092, P < 0.05).Multivariate statistical analysis with logistic regression demonstrated that application of the third generation cephalosporins during the perioperative period was independent protective factor of postoperative pulmonary infection (OR =2.582, 95% confidence interval: 1.331-5.009, P < 0.05).Conclusions The pathogens from sputum in early postoperative period after esophageal surgery are complicated with gram-negative bacteria as the main pathogens especially Klebsiella pneumoniae subsp, pneumoniae, and different levels of antibiotic resistance are ubiquitous.The third generation cephalosporins can effectively prevent the postoperative pulmonary infection after esophageal carcinoma surgery.

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