本文選題：vanM　切入點(diǎn)：萬(wàn)古霉素耐藥屎腸球菌　出處：《浙江大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:本研究通過(guò)分析一位新型vanM基因陽(yáng)性耐萬(wàn)古霉素屎腸球菌(VRE)血流感染患者的臨床表現(xiàn),臨床及周圍環(huán)境45株vanM基因陽(yáng)性屎腸球菌的分子生物學(xué)特征,有助于進(jìn)一步認(rèn)識(shí)這種新型vanM型耐萬(wàn)古霉素腸球菌感染的特征及相關(guān)的預(yù)防治療措施。方法:收集和分析患者的臨床資料,按照我國(guó)2012年發(fā)布的醫(yī)院消毒衛(wèi)生標(biāo)準(zhǔn),進(jìn)行周圍環(huán)境采樣、送檢培養(yǎng)。送檢的標(biāo)本做了以下的檢測(cè):MALDI-TOFMS確定分離菌株為屎腸球菌。E-test法測(cè)定8種抗生素對(duì)屎腸球菌的最小抑菌濃度(MIC)。脈沖場(chǎng)凝膠電泳(PFGE)和多位點(diǎn)序列分析(MLST)確定菌株之間的同源性。多重聚合酶鏈反應(yīng)(PCR)檢測(cè)萬(wàn)古霉素屎腸球菌耐藥基因及毒力基因。質(zhì)粒接合試驗(yàn)驗(yàn)證vanM基因是否可以轉(zhuǎn)移。根據(jù)結(jié)果分析比較臨床和環(huán)境菌株的分子生物學(xué)特征。同時(shí),院感科為預(yù)防該基因型耐藥菌株進(jìn)一步傳播,對(duì)該感染患者進(jìn)行接觸隔離并對(duì)患者周圍環(huán)境進(jìn)行嚴(yán)格消毒。結(jié)果:一位51歲男性患者因?yàn)榉磸?fù)頭痛和肢體活動(dòng)障礙入院。頭顱磁共振(MRI)檢查提示腦膿腫。患者在立體定向穿刺引流術(shù)后轉(zhuǎn)入我院中心監(jiān)護(hù)室(ICU)進(jìn)一步治療。入科后立即留取血液、痰液、顱內(nèi)穿刺引流液進(jìn)行培養(yǎng),予廣譜抗生素亞胺培南-西司他丁(0.5g,q6h)和萬(wàn)古霉素(1.0g,q12h)經(jīng)驗(yàn)性抗感染治療。入ICU后第4天,患者反復(fù)發(fā)熱,再次留取血培養(yǎng),3天后結(jié)果回報(bào)示vanM基因陽(yáng)性VRE,根據(jù)藥敏結(jié)果,停用萬(wàn)古霉素,改為利奈唑胺。盡管臨床癥狀逐漸好轉(zhuǎn),入ICU后第10天患者出現(xiàn)腹瀉,糞便培養(yǎng)示vanM基因陽(yáng)性VRE,加用蒙脫石散止瀉治療。入ICU第13天我院院感科對(duì)該患者周圍環(huán)境采樣培養(yǎng),結(jié)果示周圍環(huán)境存在大量vanM基因陽(yáng)性VRE,而從周圍患者的環(huán)境中未發(fā)現(xiàn)耐藥菌株。留取43株環(huán)境和2株臨床來(lái)源VRE進(jìn)行分子生物學(xué)研究。PFGE顯示,45株攜帶vanM基因的屎腸球菌分為4個(gè)不同的克隆,MLST顯示兩種序列分型(sequence type),ST564和ST78�；颊咧車h(huán)境的vanM基因陽(yáng)性VRE在進(jìn)行環(huán)境消毒后被清除。通過(guò)嚴(yán)格執(zhí)行感染控制措施,有效的阻止了 vanM基因陽(yáng)性VRE感染的爆發(fā)。入ICU后12天該患者轉(zhuǎn)至腦外科病房,3天后患者至當(dāng)?shù)蒯t(yī)院康復(fù)鍛煉。結(jié)論:本研究提示攜帶vanM基因的VRE易于在腸道和患者周圍環(huán)境定植,但是通過(guò)及時(shí)治療和采取有效的感染控制措施,血流感染患者能得到良好的預(yù)后,通過(guò)嚴(yán)格實(shí)施感控措施,可以有效預(yù)防爆發(fā)流行。
[Abstract]:Objective: to investigate the clinical manifestations and molecular biological characteristics of a new type of vanM gene positive Enterococcus faecium (VREE) infected by vancomycin-resistant Enterococcus faecium and 45 strains of vanM gene positive Enterococcus faecium in clinical and surrounding environment. It is helpful to further understand the characteristics of this new type of vancomycin resistant Enterococcus infection and related preventive and therapeutic measures. Methods: collect and analyze the clinical data of the patients, according to the hospital disinfection hygiene standards issued in 2012 in China, Sampling the surrounding environment, The specimens were tested as follows: the isolated strains were determined to be Enterococcus faecium by the method of E-test. The minimum inhibitory concentration of 8 antibiotics against Enterococcus faecium was determined by using the method of the minimum inhibitory concentration (MEC). Pulse field gel electrophoresis (PFGE) and multilocus sequence analysis (MLST) were used to determine the results. Homology among strains. Multiplex polymerase chain reaction (PCR) detection of vancomycin-resistant and virulence genes of Enterococcus faecium. Plasmid conjugation test to verify whether the vanM gene can be transferred. Clinical and environmental bacteria were analyzed and compared based on the results. Molecular biological characteristics of the strain. At the same time, In order to prevent further transmission of the genotypic resistant strain, The infected patient was subjected to contact isolation and strict disinfection of the patient's surroundings. Results: a 51-year-old male patient was admitted to hospital with repeated headache and limb dyskinesia. Cranial magnetic resonance imaging (MRI) showed brain abscess. After stereotactic puncture and drainage, they were transferred to our central care unit (ICU) for further treatment. Sputum, intracranial puncture and drainage fluid were cultured and treated with broad-spectrum antibiotic imipenan-cilastatin 0.5 g / q6h and vancomycin 1.0 g / q12h). After 3 days of blood culture, the results showed that vanM gene was positive. According to the results of drug sensitivity, vancomycin was stopped and changed to linazolamide. Although the clinical symptoms gradually improved, the patient developed diarrhea on the 10th day after entering ICU. Fecal culture showed vanM gene positive and was treated with montmorillonite powder to relieve diarrhea. On the 13th day of ICU, the surrounding environment of the patient was sampled and cultured. The results showed that there were a large number of VRE-positive vanM genes in the surrounding environment, but no drug-resistant strains were found in the surrounding patients' environment. The molecular biology of 43 strains of VRE and 2 strains of VRE from clinical sources were collected for molecular biological study. PFGE showed that 45 strains of feces carrying vanM gene were isolated from the surrounding patients. Enterococci were divided into four different clones. MLSTs showed two sequence typing sequences: ST564 and ST78.The vanM gene positive VRE in the patients' surrounding environment was cleared after disinfection, and the infection control measures were strictly carried out. It effectively prevented the outbreak of vanM gene positive VRE infection. 12 days after entering ICU, the patient was transferred to the brain surgery ward for 3 days. Conclusion: this study suggests that VRE carrying vanM gene is easy to be found in the intestine and in the local hospital. The surrounding environment of the patient was colonized. But through timely treatment and effective infection control measures, blood flow infection patients can get a good prognosis, through strict implementation of sensible control measures, can effectively prevent the outbreak of epidemic.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R515
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本文編號(hào)：1569987