【摘要】：1.血培養(yǎng)中分離到的鮑氏不動桿菌的耐藥特征和臨床病例特點(diǎn)目的：研究鮑氏不動桿菌血流感染的臨床病例特點(diǎn)、耐藥特征和病死率及死亡危險(xiǎn)因素。對象：病例分析資料是自2006年1月1日至2013年12月31日期間的血培養(yǎng)鮑氏不動桿菌病例,采用醫(yī)院感染國家衛(wèi)生部醫(yī)政司制定的相關(guān)規(guī)定和美國疾病控制預(yù)防中心的血流感染標(biāo)準(zhǔn)確定臨床感染病例并去重得到研究病例(211例)。方法：對于病例資料采用描述性的統(tǒng)計(jì)方法,應(yīng)用EXCEL和SAS9.2軟件統(tǒng)計(jì)相關(guān)指標(biāo)。將病例資料分層分析,分別分為：死亡組和非死亡組,CRAb組和CSAb組,消化道疾病組和非消化道疾病組,監(jiān)護(hù)室組和非監(jiān)護(hù)室組,考察組間在醫(yī)療介入措施應(yīng)用、APACHE-II評分、病死率、科室分布、患者住院時(shí)間、BMI指數(shù)、主要診斷、抗感染藥物和免疫抑制劑應(yīng)用、感染指標(biāo)變化、細(xì)菌耐藥特征方面的統(tǒng)計(jì)學(xué)差異；應(yīng)用約登指數(shù)、ROC曲線及ROC曲線下面積判斷APACHE-II評分對死亡預(yù)測的最優(yōu)指標(biāo);應(yīng)用分類法評估鮑氏不動桿菌血流感染的預(yù)后情況。結(jié)果：病例中男性患者150人,平均年齡51.39±22.13歲,平均住院時(shí)間52.83±71.22天.APACHE-II評分平均值15.D3±9.93分,病死率28.86%,科室分布主要來自外科監(jiān)護(hù)室30%、肝膽外科15%,呼吸科9%和血液科9%,致病菌多為CRAb,對亞胺培南耐藥率達(dá)到70.8%,對美洛培南耐藥率達(dá)72.5%。在是否死亡的轉(zhuǎn)歸分組中,APACHE-II評分和CRAb感染存在組間差異,APACHE-II評分大于19分的患者是死亡風(fēng)險(xiǎn)較高的人群,在是否CRAb的分組中,應(yīng)用碳青霉烯藥物的人群與不應(yīng)用此藥的人群比較,病死率存在統(tǒng)計(jì)學(xué)差異；血流鮑氏不動桿菌感染發(fā)在消化系疾病診斷的患者占52%,消化系疾病與非消化系疾病患者在應(yīng)用靜脈置管(P=0.02)、手術(shù)治療(P0.0001)、CRRT治療(P=0.0339)、和其他引流管使用(P=0.0432)上有顯著統(tǒng)計(jì)差異,消化系統(tǒng)疾病患者在Crab感染率上多于非消化系患者(P=0.0236)。監(jiān)護(hù)室與非監(jiān)護(hù)室比較兩組在介入性操作措施、APACHE-II評分(P=0.0039)BMI指數(shù)(P=0.0131)間存在統(tǒng)計(jì)學(xué)差異。應(yīng)用分類法預(yù)測患者轉(zhuǎn)歸與實(shí)際的符合率在81.5%和76.5%。結(jié)論：血培養(yǎng)為鮑氏不動桿菌的病例多出現(xiàn)在一般情況比較差的患者,病死率為28.86%.科室分布排在前三位的是：外科監(jiān)護(hù)室、肝膽外科、呼吸科和血液科,血培養(yǎng)鮑氏不動桿菌的耐藥特征為多藥耐藥和碳青霉烯類耐藥。APACHE-II評分大于19分和感染了碳青霉烯類藥物耐藥的鮑氏不動桿菌是血流感染鮑氏不動桿菌患者的死亡危險(xiǎn)因素。應(yīng)用碳青霉烯類藥物可能有助于降低鮑氏不動桿菌血流感染患者的病死率。分類法可以較好的評價(jià)鮑氏不動桿菌血流感染患者的預(yù)后情況。在血流感染的鮑氏不動桿菌病例中,以消化系統(tǒng)疾病為主要診斷的病例占大多數(shù),他們接受體腔引流管和中心靜脈置管的比例要高于非消化系統(tǒng)疾病患者,監(jiān)護(hù)室和肝膽外科是發(fā)生耐碳青霉烯藥物鮑氏不動血流感染的主要,臨床科室。2.血培養(yǎng)中分離到的鮑氏不動桿菌的RNA表達(dá)譜的初步研究目的：應(yīng)用高通量RNA測序技術(shù)比較不同來源的鮑氏不動桿菌的基因表達(dá)差異,為研究其生物學(xué)特征和耐藥機(jī)制提供依據(jù)。對象：測序標(biāo)本來自2007年鮑氏不動桿菌院內(nèi)暴發(fā)流行時(shí)血培養(yǎng)菌株1例、痰培養(yǎng)菌株1例、環(huán)境菌株1例及對應(yīng)病例資料、標(biāo)準(zhǔn)菌株為鮑氏不動ATCC19606。方法：應(yīng)用高通量RNA測序技術(shù)對標(biāo)本RNA-seq測序并分析結(jié)果。結(jié)果：血培養(yǎng)鮑氏不動桿菌與痰培養(yǎng)分離的鮑氏不動桿菌在在生物過程中的單一生物體過程和estab l i shment of loca li zation. loca lization. cellular process,存在差異,與標(biāo)準(zhǔn)菌株比OXA-95基因表達(dá)出現(xiàn)了上調(diào)。結(jié)論：在不同生長環(huán)境下分離的鮑氏不動桿菌,其基因表達(dá)特征存在差異,本研究中血流感染的鮑氏不動桿菌對碳青霉烯類藥物耐藥的機(jī)制可能與OXA-95的表達(dá)上調(diào)有關(guān)。
[Abstract]:1. The characteristics of the drug resistance of Acinetobacter baumannii isolated from blood culture and the characteristics of clinical cases: the clinical characteristics, drug resistance characteristics and mortality and risk factors of the blood flow infection of Acinetobacter baumannii were studied. Object: Case analysis data is a case of Acinetobacter baumannii from 1 January 2006 to 31 December 2013, The clinical infection cases were determined by the relevant provisions of the National Health Department of the Hospital and the blood flow infection standard of the Centers for Disease Control and Prevention in the United States, and the case of the study was re-obtained (211 cases). Methods: Descriptive statistics were used for the case data, and the relevant indexes of EXCEL and S9.2 software were used. The case data were divided into two groups: the death group and the non-death group, the CRAb group and the non-death group, the digestive tract disease group and the non-digestive tract disease group, the intensive care unit group and the non-intensive care unit group, the application of the medical intervention measures among the observation groups, the APACHE-II score, the case fatality rate, the department distribution, the patient's hospital stay time, The index of BMI, the main diagnosis, the anti-infection drug and the application of the immunosuppressive agent, the change of the infection index, the statistical difference of the characteristics of the drug resistance were analyzed, and the optimal index of the APACHE-II score on the prediction of death was determined by using the approximate index, the ROC curve and the area under the ROC curve. The prognosis of the blood flow infection of Acinetobacter baumannii was assessed by using the classification method. Results: The average age was 51.39, 22.13, and the average hospital stay was 52.83-71.22 days. The mean value of APACHE-II was 15.3 and 9.93, the case fatality rate was 28.86%. The distribution of the department was mainly from 30% in the intensive care unit,15% in the liver and the liver,9% in the respiratory and 9% in the family, and the pathogen was CRAB. The resistance rate of the imipenem was 70.8%, and the resistance to meropenem was 72.5%. In the outcome of the death, the APACHE-II score and the CRAb infection were different among the groups, and the patients with the APACHE-II score of greater than 19 were the population with higher risk of death, and in the group of CRAb, the population of the carbapenem drug was compared with those who did not apply the drug, and there was a statistical difference in the case fatality rate; The infection of Acinetobacter baumannii was 52% in the patients with digestive system disease, and the patients with digestive system and non-digestive system were treated with intravenous catheter (P = 0.02), surgical treatment (P = 0.0001), CRRT (P = 0.0339), and other drainage tubes (P = 0.0432). The number of patients with digestive system disease was more than that of non-digestive system (P = 0.0236). There was a statistical difference between the intensive care unit and the non-intensive care unit (P = 0.0039) BMI (P = 0.0131). The coincidence rate between the outcome and the actual coincidence rate of the patients was 81.5% and 76.5%. Conclusion: The case of blood culture for Acinetobacter baumannii is more than that in general condition, and the case fatality rate is 28.86%. The drug resistance of Acinetobacter baumannii was the multi-drug resistance and carbapenem resistance. Acinetobacter baumannii with an APACHE-II score of greater than 19 points and with carbapenem-resistant drug resistance is a risk factor for blood flow infection with Acinetobacter baumannii. The application of carbapenem drugs may contribute to the reduction of mortality in patients with Acinetobacter baumannii. The prognosis of the patients with Acinetobacter baumannii's blood flow infection can be evaluated well. In the case of the blood-flow-infected Acinetobacter baumannii, the majority of cases diagnosed by the digestive system disease as the main diagnosis, and the proportion of the body cavity drainage tube and the central venous catheter is higher than that of the non-digestive system disease patients, The intensive care unit and the hepatobiliary surgery are the main and clinical departments for the occurrence of C. carbapenem. Preliminary study on the RNA expression profile of Acinetobacter baumannii isolated from blood culture: The difference of gene expression of Acinetobacter baumannii from different sources was compared by high-throughput RNA sequencing, and the basis for studying its biological characteristics and drug-resistance mechanism was provided. Object: The sequencing samples were from 1 case of blood culture strain,1 case of sputum culture strain,1 case of environment strain and corresponding case data from the outbreak of Acinetobacter baumannii in 2007, and the standard strain was Acinetobacter baumannii ATCC 19606. Methods: The RNA-seq was sequenced and the results were analyzed by high-throughput RNA sequencing. Results: Acinetobacter baumannii isolated from the culture of Acinetobacter baumannii was isolated from the sputum culture in a single biological process in the biological process and in the test of loca li. Loca lization. There was a difference in the cellular process, and the expression of the standard strain was up-regulated than the expression of the OXA-95 gene. Conclusion: The mechanism of the resistance of Acinetobacter baumannii to carbapenems may be related to the up-regulation of OXA-95 in different growth environments.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R516

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