本文選題：糖尿病足 + 潰瘍��； 參考：《第三軍醫(yī)大學(xué)》2016年碩士論文

【摘要】：目的及意義:糖尿病足(diabetic foot,DF)的發(fā)生與神經(jīng)、血管病變和感染密切相關(guān),癥狀包括間歇性跛行、缺血性靜息痛、足潰瘍和壞疽等。導(dǎo)致糖尿病足預(yù)后差的因素有很多,如老齡、男性、心臟衰竭、終末期腎病、足潰瘍面積較大、外周神經(jīng)病變、外周血管病變、感染等。其中下肢血管病變和感染是糖尿病足最重要的影響因素。糖尿病足潰瘍(diabetic foot ulcers,DFU)是目前糖尿病患者住院治療最主要的原因之一。在糖尿病足潰瘍中,感染是導(dǎo)致截肢、死亡的直接原因之一。目前關(guān)于DFU感染的細(xì)菌特征已有報(bào)道,但足潰瘍感染類型和病原菌與血管病變的關(guān)系尚待明確。為此,我們納入糖尿病足伴感染且行血管造影證實(shí)血管病變患者133例,探討足潰瘍感染患者的病原菌、感染學(xué)特征及其與下肢血管病變程度的關(guān)系,為促進(jìn)糖尿病足潰瘍愈合提供指導(dǎo)。研究對(duì)象:收集2009年3月至2016年3月于第三軍醫(yī)大學(xué)大坪醫(yī)院高血壓內(nèi)分泌科住院治療并明確診斷糖尿病足潰瘍伴感染且分泌物培養(yǎng)陽(yáng)性的患者133例,其中男性87例,女性46例,年齡67.24±11.49歲,糖尿病病程8.00(3.00,15.00)年,糖尿病足病程1.50(0.50,7.50)月。方法:收集133例于本中心住院的糖尿病足潰瘍患者病例資料,入選患者均在入院時(shí)由本中心醫(yī)護(hù)人員進(jìn)行詳細(xì)病史的詢問(wèn)、查體,完成入院評(píng)估記錄,綜合評(píng)價(jià)并初步制定診治方案。入選患者均在初期完善血壓檢查、ABI、TBI、血常規(guī)、肝腎功、血清總蛋白、血清白蛋白、血脂、尿常規(guī)、空腹血糖、糖化血紅蛋白、足潰瘍局部分泌物培養(yǎng)及細(xì)菌藥敏試驗(yàn)等檢查。所有患者均行下肢血管造影或256排血管CT檢查(CTA),我們的結(jié)果顯示兩者高度一致性,根據(jù)下肢動(dòng)脈造影檢查、下肢血管CTA檢查(CT中心設(shè)備為“飛利浦Brilliance i CT 256層”)結(jié)果,明確下肢血管狹窄程度及病變長(zhǎng)度確定分級(jí),采取TASC分級(jí)標(biāo)準(zhǔn),分為A、B、C、D 4種類型,以此分為4組。根據(jù)感染程度感染分為輕度感染、中度感染、重度感染;根據(jù)感染類型分為單一感染、混合感染。數(shù)據(jù)資料采用SPSS 18.0統(tǒng)計(jì)軟件。結(jié)果:1.TASC分級(jí)中,A級(jí)27例、B級(jí)19例、C級(jí)52例、D級(jí)35例,組間比較D級(jí)患者年齡、糖尿病病程、中性粒細(xì)胞百分?jǐn)?shù)顯著高于A、B級(jí)糖尿病足潰瘍患者,而ABI、TBI顯著低于A、B級(jí)患者。A、B級(jí)糖尿病足潰瘍患者G-菌感染率為44.6%,C、D級(jí)患者G-菌感染率為54.2%,且差異有統(tǒng)計(jì)學(xué)意義。糖尿病足潰瘍患者有抗生素多重耐藥的為60.2%(A、B級(jí)為52.2%,C、D級(jí)為64.4%),A、B級(jí)與C、D級(jí)組間比較差異有統(tǒng)計(jì)學(xué)意義(P=0.028)。2.糖尿病足潰瘍中輕度感染例39例(占29.3%),中度感染66例(占49.6%),重度感染28例(占21.1%)。不同感染程度間比較白細(xì)胞、白蛋白、糖化血紅蛋白、中性粒百分?jǐn)?shù)等均存在差異,且有統(tǒng)計(jì)學(xué)意義。輕度感染耐藥率為51.3%,中度感染為69.7%;重度感染為71.4%,不同感染程度間比較無(wú)統(tǒng)計(jì)學(xué)差異。A、B級(jí)中輕度感染20例,中重度感染26例,C、D級(jí)中輕度感染21例,中重度感染66例,A、B級(jí)與C、D級(jí)間比較有統(tǒng)計(jì)學(xué)差異(P=0.022)。3.133例糖尿病足潰瘍伴感染中革蘭陽(yáng)性菌感染占36.8%、革蘭陰性菌感染占57.8%、真菌感染占5.4%,混合感染占39.1%。共培養(yǎng)出185株病原菌,其中金黃色葡萄球菌35株(18.9%);銅綠假單胞菌25(13.5%);糞腸球菌14株(7.5%),分列前3位。其他葡萄球菌、鏈球菌、肺炎克雷伯桿菌、大腸埃希菌也較常見。A級(jí)患者混合感染占18.5%,B級(jí)患者混合感染占26.3%,C級(jí)患者混合感染占26.9%,D級(jí)患者混合感染占60.0%,且差異有統(tǒng)計(jì)學(xué)意義(P=0.002)。結(jié)論:1.本地區(qū)糖尿病足潰瘍感染以金黃色葡萄球菌、銅綠假單胞菌、糞腸球菌為多,且G-菌感染及耐藥菌株居多,隨著感染程度的加重,細(xì)菌耐藥率增加,與國(guó)內(nèi)外報(bào)道的病原菌不完全一致,提示本地區(qū)糖尿病足潰瘍患者的感染較重,具有本地區(qū)細(xì)菌學(xué)特征。2.隨著下肢血管病變程度的加重,足潰瘍感染程度加重,混合感染比例增加,足潰瘍G-菌感染率增加。
[Abstract]:Objective and significance: the occurrence of diabetic foot (DF) is closely related to nerve, vascular disease and infection. The symptoms include intermittent claudication, ischemic resting pain, foot ulcer and gangrene. There are many factors that lead to poor prognosis of diabetic foot, such as aging, male, heart failure, end-stage renal disease, large area of foot ulcers, peripheral neuropathy. Changes, peripheral vascular lesions, infection and so on. Among them, lower extremity vascular disease and infection are the most important factors of diabetic foot. Diabetic foot ulcers (DFU) is one of the most important causes of hospitalization in diabetic patients. In diabetic foot ulcers, infection is one of the direct causes of amputation and death. At present, D The bacterial characteristics of FU infection have been reported, but the relationship between the type of foot ulcer infection and the relationship between the pathogenic bacteria and the vascular disease remains to be clear. To this end, we have included 133 patients with diabetic foot companion infection and angiography confirmed the vascular disease, to explore the pathogenic bacteria of the patients with foot ulcer infection, the relationship between the infective features and the degree of vascular disease of the lower extremity. To provide guidance for the healing of diabetic foot ulcers. Subjects: 133 patients who were hospitalized in the Department of Endocrinology, Daping Hospital of Third Military Medical University from March 2009 to March 2016, were hospitalized in the hypertension Department of Endocrinology and diagnosed the diabetic foot ulcers with infection and positive secretions, including 87 male, 46 female, 67.24 + 11.49 years old, diabetic disease. Course 8 (3.00,15.00) years, the course of diabetes foot 1.50 (0.50,7.50) month. Methods: collect 133 cases of diabetic foot ulcer patients in the center of the hospital, the selected patients were enrolled in the hospital by the center medical staff for detailed medical history inquiry, examination, complete admission assessment records, comprehensive evaluation and preliminary formulation of the diagnosis and treatment program. Selected patients All patients were in the early stage of improving blood pressure examination, ABI, TBI, blood routine, liver and kidney work, serum albumin, serum albumin, blood lipid, urine routine, fasting blood glucose, glycosylated hemoglobin, partial secretion culture of foot ulcers and bacterial susceptibility test. All patients underwent lower limb blood tube angiography or 256 row blood vessel CT examination (CTA), our results showed both high Degree conformance, according to the lower extremity arteriography examination, lower extremity vascular CTA examination (CT center equipment is "PHILPS Brilliance I CT 256 layer") result, clear the lower extremity vascular stenosis degree and pathological length determine classification, adopt TASC grading standard, divide into A, B, C, D 4 types, in order to divide into 4 groups. According to infection degree infection, divided into mild infection, medium infection, According to the type of infection, the data were divided into single infection and mixed infection according to the type of infection. The data used SPSS 18 statistical software. Results: in 1.TASC classification, 27 cases, 19 cases of B grade, 52 cases of class C, 35 cases of D class, the age of D level, the percentage of neutrophils were significantly higher than that of A, B level diabetic foot ulcer, ABI, TBI. The infection rate of G- bacteria in patients with.A and B level diabetic foot ulcers was 44.6%, C, G- bacteria infection rate was 54.2%, and the difference was statistically significant. The multidrug resistance of diabetic foot ulcers was 60.2% (A, B grade 52.2%, C, D grade 64.4%). There were 39 cases of mild infection in urinary foot ulcer (29.3%), moderate infection in 66 cases (49.6%) and severe infection in 28 cases (21.1%). There were differences in white blood cells, albumin, glycated hemoglobin and percentage of neutrophils among different infections. The drug resistance rate of mild infection was 51.3%, moderate infection was 69.7%, and severe infection was 71.. 4%, there were no statistical differences among different degrees of infection.A, 20 cases of mild infection in grade B, 26 cases of moderate to severe infection, 21 cases of moderate and mild infection in C, 66 cases of moderate to severe infection, A, B grade and C, D level was statistically different (P=0.022) in.3.133 cases of diabetic foot ulcers with infection of gram positive bacteria 36.8%, Gram-negative infection accounted for 57.8%, true Bacterial infection accounted for 5.4%, mixed infection accounted for 185 strains of 39.1%., including 35 (18.9%) Staphylococcus aureus (18.9%), Pseudomonas aeruginosa 25 (13.5%), 14 (7.5%) Enterococcus faecalis (7.5%), and the first 3. Other Staphylococcus, Streptococcus, Klebsiella pneumoniae, and Escherichia coli were also more common. A mixed infection of class A patients was 18.5%, and B patients were mixed. Infection accounted for 26.3%, C patients mixed infection accounted for 26.9%, D patients with mixed infection accounted for 60%, and the difference was statistically significant (P=0.002). Conclusion: 1. local diabetic foot ulcer infection with Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus faecalis, and the majority of G- infection and resistant strains, with the severity of infection, the rate of bacterial resistance The increase is not exactly consistent with the pathogenic bacteria reported at home and abroad, suggesting that the infection of the patients with diabetic foot ulcers is heavier, with the local bacteriological characteristics.2. with the aggravation of the degree of vascular disease of the lower extremities, the aggravation of the foot ulcer infection, the increase in the proportion of mixed infection and the increase of the infection rate of G- bacteria in foot ulcers.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R587.2

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