摘要目的 探讨我国呼吸科住院患者下呼吸道和血液分离菌的构成及耐药性.方法 采用多中心回顾性研究,选取国家细菌耐药监测网纳入的7个区域68家三级医院和23家二级医院的呼吸科住院患者48 752例(无疾病类型记载),分析下呼吸道标本(痰和BALF)和血标本中耐甲氧西林金黄色葡萄球菌(MRSA)、耐青霉素肺炎链球菌(PRSP)、耐碳青霉烯大肠杆菌(CREC)和肺炎克雷伯菌(CRKP)、耐碳青霉烯铜绿假单胞菌(CRPA)和鲍曼不动杆菌(CRAB)、产超广谱β-内酰胺酶的大肠杆菌(ESBL-EC)和肺炎克雷伯菌(ESBL-KP)在地区(东北、华北、华东、华南、华中、西北和西南地区)、医院(三级和二级医院)、不同年龄段[老年组(＞ 65岁)、成人组(15 ～ 65岁)、儿童组(29 d至14岁)和新生儿组(≤28 d)]及所住病房(呼吸重症监护和普通呼吸科病房)等的构成和分布.采用SPSS 16.0统计软件对结果进行统计分析,分类变量采用卡方检验.P＜0.05表示差异有统计学意义.结果 48 752例下呼吸道标本(痰和BALF)分离的非重复菌42 751株,血液标本2 649株,其他(尿及分泌物等)标本5 017株,共50 417株.其中90.2％ (45 491/50 417)的菌株来源于63家三级医院.老年组、成人组和儿童组分离菌株分别占46.0％ (23 177/50 417)、29.9％(15 092/50 417)和24.0％(12 112/50 417),其余36株来自新生儿组.普通呼吸科病房来源菌株占93.8％ (47 288/50 417).痰标本占81.6％ (41 131/50 417),其前4位分离菌分别为肺炎克雷伯菌(18.9％,7 784/41 131)、铜绿假单胞菌(13.6％,5 580/41 131)、鲍曼不动杆菌(11.3％,4 644/41 131)和肺炎链球菌(11.1％,4564/41 131);血标本来源菌株占5.3％(2649/50 417),其前4位分离菌为凝固酶阴性菌(42.0％,1 112/2 649)、大肠埃希菌(18.3％,484/2 649)、肺炎克雷伯菌(7.4％,194/2 649)和金黄色葡萄球菌(4.9％,131/2 649).BALF中分离的菌株占3.2％(1 620/50 417),前4位分离菌分别为铜绿假单胞菌(22.0％,360/1 620)、肺炎克雷伯菌(14.8％,239/1 620)、鲍曼不动杆菌(11.9％,193/1 620)和肺炎链球菌(9.6％,155/1 620),与痰标本构成相同.三级医院CRKP、CRPA和CRAB的分离率高于二级医院,分别为5.2％(384/7 439)和2.5％(24/973)、23.8％(1 260/5 304)和12.8％ (101/787)、53.5％ (2 259/4 224)和33.9％ (109/322),差异有统计学意义(均P＜0.01);二级医院ESBL-EC的分离率(63.9％,145/227)高于三级医院(55.0％,1 141/2 074),差异有统计学意义(P=0.011).儿童组ESBL-EC和ESBL-KP的分离率[68.2％ (283/415)和55.3％(183/331)]高于老年组[54.2％(684/1263)和27.1％ (625/2 303)]和成人组[51.1％(317/620)和15.1％(272/1 804)],差异有统计学意义(均P＜0.001).结论 我国呼吸科分离的菌株主要以肠杆菌科细菌和非发酵菌为主.我国基层医院和儿童群体下呼吸道ESBL-EC和ESBL-KP的分离率较高,值得关注.

abstractsObjective To investigate the species and antimicrobial resistance of bacterial pathogens isolated from hospitalized patients in respiratory ward in China.Methods This was a multicenter retrospective study based on a national epidemiological network called China Antimicrobial Resistance Surveillance System (CARSS).The non-repetitive strains isolated from lower respiratory tract and blood samples in 91 hospitals from seven geographic regions of CARSS were reviewed.The distribution of specimen type,hospital level (secondary and tertiary hospital),patient age group [geriatric (＞ 65 years old),adult (15 to 65 years old),pediatric (28 days to 14 years old) and newborn group (≤28 days)] and ward type (respiratory intensive care unit and general respiratory ward) were analyzed for MRSA,PRSP,CREC,CRKP,CRPA,CRAB,ESBL-EC and ESBL-KP.The categorical variables were analyzed by chi-square test using SPSS 16.0 statistical software.P ＜ 0.05 was regarded as statistically significant.Results A total of 50 417 non-repetitive isolates [42 751 isolates from lower respiratory tract (LRT),2 649 isolates from blood and 5 017 isolates from other samples (urine and secretions)] from 48 752 inpatients (without illness type information) were enrolled in the study.90.2％ (45 491/50 417) isolates were obtained from 63 tertiary hospitals.According to patients' age,all cases were divided into 4 groups,i.e.geriatric(46.0％,23 177/50 417),adult(29.9％,15 092/50 417),pediatric(24.0％,12 112/50 417) and newborn group(0.0％,36/50 417).All isolates were obtained from respiratory intensive care unit (6.2％,3 129/50 417) or general respiratory wards (93.8％,47 288/50 417).The majority of bacterial pathogens were isolated from lower respiratory and blood culture samples,which accounted for 90.0％ of all the samples (45 400/50 417).Sputum accounted for 81.6％ (41 131/50 417) of samples,and the leading 4 isolates were K.pneumonia (18.9％,7 784/41 131),P.aeruginosa (13.6％,5 580/41 131),A.baumanni (11.3％,4 644/41 131) and S.pneumonia (11.1％,4 564/41 131).Blood samples accounted for 5.3 ％ (2 649/50 417) of the samples,with the leading 4 bacteria being coagulase-negative staphylococcus (42.0％,1 112/2 649),E.coli (18.3％,484/2 649),K.pneumonia (7.4％,194/2 649) and S.aureus (4.9％,131/2 649).The species distribution of pathogens isolated from bronchoalveolar lavage fluid (BALF),which accounted for 3.2％ (1 620/50 417) of the samples,was similar to that of sputum,and the leading 4 bacteria were P.aeruginosa (22.0％,360/1 620),K.pneumonia (14.8％,239/1 620),A.baumanni (11.9％,193/1 620) and S.pneumonia (9.6％,155/1 620).The prevalence of CRKP,CRPA and CRAB in tertiary hospitals [5.2％ (384/7 439),23.8％ (1 260/5 304) and 53.5％ (2 259/4 224),respectively] was significantly higher than that in secondary hospitals [2.5％ (24/973),12.8％ (101/ 787) and 33.9％ (109/322),respectively] (all P ＜ 0.01).In comparison,the prevalence of ESBL-EC in secondary hospitals (63.9％,145/227) was higher than that in tertiary ones (55.0％,1 141/2 074) (P =0.011).The prevalence of ESBL-EC and ESBL-KP in pediatric group [68.2％ (283/415) and 55.3％ (183/331),respectively] was higher than that in geriatric group [54.2％ (684/1 263) and 27.1％ (625/ 2 303),respectively] and adult group [51.1％ (317/620) and 15.1％ (272/1 804),respectively] (all P ＜0.001).Conclusions In China,the predominant bacterial pathogens in the respiratory wards were Enterobacteriaceae and non-fermentative bacteria.High prevalence of ESBL-EC and ESBL-KP isolated from lower repiratory tract was revealed in primary hospitals and pediatric patients.