本文關(guān)鍵詞： 慢性中耳炎 細(xì)菌學(xué) 細(xì)菌生物膜 掃描電鏡　出處：《新疆醫(yī)科大學(xué)》2013年博士論文　論文類型：學(xué)位論文

【摘要】：目的：慢性中耳炎是新疆最常見(jiàn)的耳鼻咽喉頭頸外科疾病之一,對(duì)新疆各族患者帶來(lái)了嚴(yán)重的社會(huì)和經(jīng)濟(jì)負(fù)擔(dān)。對(duì)新疆地區(qū)慢性化中耳炎患者分泌物的細(xì)菌學(xué)分布及常用抗菌藥物藥物敏感性進(jìn)行動(dòng)態(tài)檢測(cè),以了解慢性化膿性中耳炎致病菌的變化趨勢(shì)和指導(dǎo)臨床合理用藥；對(duì)慢性中耳炎患者的中耳粘膜及膽脂瘤上皮組織進(jìn)行電鏡掃描,了解細(xì)菌生物膜在不同類型慢性中耳炎中的形成情況,同時(shí)對(duì)細(xì)菌生物膜形成患者的中耳分泌物進(jìn)行細(xì)菌培養(yǎng),了解電鏡掃描結(jié)果與中耳分泌物細(xì)菌培養(yǎng)結(jié)果之間的差異,并了解電鏡掃描結(jié)果陽(yáng)性患者主要病原菌分布情況,指導(dǎo)慢性中耳炎在本地區(qū)的診療。方法：回顧性分析2008年1月到2013年6月期間在我院住院治療的慢性中耳炎患者的中耳分泌物進(jìn)行細(xì)菌培養(yǎng)和藥物敏感試驗(yàn),取得細(xì)菌分離率的排序；比較2008-2011,2012-2013兩個(gè)時(shí)間段主要致病菌分布的變化,主要致病菌的藥物敏感度及變化；前瞻性對(duì)手術(shù)中取得的樣本進(jìn)行掃描電鏡檢查,按照不同類型慢性中耳炎入組分析；分析慢性中耳炎細(xì)菌生物膜形成與細(xì)菌培養(yǎng)結(jié)果之間的關(guān)系,并對(duì)細(xì)菌生物膜形成患者病原菌分布進(jìn)行排序。結(jié)果：1、全部共計(jì)409例標(biāo)本中361例檢出病原菌,檢出率88.26%,其中慢性化膿性中耳炎(活動(dòng)期)288例中254例檢出病原菌,中耳膽脂瘤組121例中107例檢出病原菌,兩組間比較,檢出率無(wú)統(tǒng)計(jì)學(xué)意義。共檢出43種病原菌,位于前列的檢出病原菌依次是金黃色葡萄球菌104(28.8%),銅綠假單胞菌63(17.5%),表皮葡萄球菌32(8.86%),奇異變形桿菌22(6.09%)2、慢性化膿性中耳炎(活動(dòng)期)與中耳膽脂瘤主要病原菌構(gòu)成比總體有差異,χ2=29.465,P=0.001,其他陽(yáng)性球菌與革蘭氏陽(yáng)性桿菌的檢出率在慢性化膿性中耳炎中的檢出率較中耳膽脂瘤高,χ2=7.074,P=0.008.其他陰性桿菌的在中耳膽脂瘤中的檢出率較慢性化膿性中耳炎高χ2=18.18,P=0.000。3、各種病原菌不同時(shí)間段總體構(gòu)成比對(duì)比,χ2=9.209,P=0.418,沒(méi)有統(tǒng)計(jì)學(xué)意義。金黃色葡萄球菌,凝固酶陰性葡萄球菌2012-2013年度檢出率與2008-2011年度比較,檢出率有所提高,金黃色葡萄球菌χ2=21.393,P=0.000：凝固酶陰性葡萄球菌χ2=12.876,P=0.000有統(tǒng)計(jì)學(xué)意義。4、金黃色葡萄球菌對(duì)喹努普汀達(dá)福普汀,替考拉寧,萬(wàn)古霉素在兩個(gè)時(shí)間段的敏感性均為100%,對(duì)青霉素G、紅霉素和氨芐西林敏感率較低,分別是17.3%,19.7%和40.3%,2008-2011年度與2012-2013年度比較細(xì)菌的敏感性沒(méi)有明顯變化,頭孢唑啉的敏感性在兩個(gè)時(shí)間段分別是96.4%、75.0%,χ2=4.989,P=0.027。莫西沙星,左氧氟沙星,環(huán)丙沙星為代表的喹諾酮抗生素達(dá)敏感性較高,最低為77.8%,慶大霉素,利福平、復(fù)方新諾明有較高的敏感性。在對(duì)凝固酶陰性葡萄球菌發(fā)現(xiàn),喹努普汀達(dá)福普汀,替考拉寧,萬(wàn)古霉素在兩個(gè)時(shí)間段的仍然保持了100%敏感性。喹諾酮類,還是青霉素類,凝固酶陰性葡萄球菌的耐藥性均提高,特別是青霉素的耐性幾乎接近100%。在對(duì)綠膿桿菌的研究中,主要常用抗生素敏感性莫西沙星90.5%,頭孢他啶72.7%,亞胺培南73.7%,頭孢他啶與亞安培南的敏感性在2012-2013年度有所增高。5、慢性化膿性中耳炎(活動(dòng)期)與中耳膽脂瘤細(xì)菌生物膜形成率分別是85.5%(14/16),81.3%(13/16),卡方檢驗(yàn)(Fisher's Exast Test) P=1.00。實(shí)驗(yàn)組兩組與對(duì)照組慢性化膿性中耳炎(禁止期)細(xì)菌生物膜形成16.7%(2/12),卡方檢驗(yàn)(Fisher's Exast Test) P均0.01,具有統(tǒng)計(jì)學(xué)意義。6、慢性中耳炎掃描電鏡細(xì)菌生物膜結(jié)果與細(xì)菌培養(yǎng)結(jié)果之間的比較.靈敏度Se=70.37%,特異性SP=60.00%,誤診率40.00%,漏診率29.63%,陽(yáng)性預(yù)測(cè)值90.46%,陰性預(yù)測(cè)值27.27%,正確率68.75%YI(Youden index30.37%, Pearson相關(guān)系數(shù)為0.232(P=0.201)。7、慢性中耳炎細(xì)菌生物膜陽(yáng)性患者細(xì)菌培養(yǎng)病原菌分布G+桿菌5例未鑒定具體的細(xì)菌種類,綠膿桿菌5例(23.8%),變形桿菌2例(9.5%),大腸埃希桿菌2(9.5%)例,摩氏根菌1例(4.8%)；,金黃色葡萄球菌1例(4.8%),凝固酶陰性球菌3例,占14.3%,其中人葡萄球菌,麻疹孿生球菌,表皮葡萄球菌各一例。真菌1例,占4.8%,為煙曲霉菌一例。結(jié)論：新疆慢性中耳炎細(xì)菌檢出位于前列的依次是金黃色葡萄球菌,綠膿桿菌,表皮葡萄球菌,奇異變形桿菌。革蘭氏陽(yáng)性球菌與革蘭氏陽(yáng)性桿菌的檢出率在慢性化膿性中耳炎中的檢出率較中耳膽脂瘤高,而革蘭氏陰性菌的檢出率中耳膽脂瘤中較高。不同時(shí)間段慢性中耳炎的主要病原菌構(gòu)成沒(méi)有明顯變化。金黃色葡萄球菌對(duì)青霉素、紅霉素、氨芐西林保持了較高的耐藥性,頭孢菌素耐藥性明顯增高趨勢(shì),氟喹諾酮類抗生素及復(fù)方新諾明保持了一定的敏感性,凝固酶陰性葡萄球菌對(duì)氨基甙類抗生素敏感性較高,氟喹諾酮類,青霉素類敏感性較低,二者對(duì)喹努普汀達(dá)福普汀,替考拉寧,萬(wàn)古霉素保持了較高的敏感性。頭孢他定、莫西沙星、亞安培南對(duì)綠膿桿菌有較高的敏感性,但已經(jīng)有下降趨勢(shì)。慢性化膿性中耳炎靜止期與細(xì)菌生物膜形成的比例較低有關(guān),慢性化膿性中耳炎活動(dòng)期、中耳膽脂瘤與細(xì)菌生物膜的形成有明確的相關(guān)性,慢性化膿性中耳炎活動(dòng)期與中耳膽脂瘤兩種疾病中細(xì)菌生物膜的形成情況基本相似,首次發(fā)現(xiàn)中耳膽脂瘤膽脂瘤上皮中存在者真菌形成的生物膜結(jié)構(gòu)。細(xì)菌培養(yǎng)結(jié)果陰性不能代表慢性中耳炎患者沒(méi)有細(xì)菌生物膜的形成；細(xì)菌生物膜患者細(xì)菌培養(yǎng)結(jié)果與本地區(qū)細(xì)菌檢出情況基本一致,均為本地區(qū)常見(jiàn)細(xì)菌,綠膿桿菌與凝固酶陰性葡萄球菌是慢性中耳炎細(xì)菌生物膜形成主要病原菌。
[Abstract]:Objective: chronic otitis media is one of the most common Xinjiang otolaryngology head and neck surgery, has brought serious social and economic burden of all ethnic groups in Xinjiang patients. The secretions of patients with chronic otitis media in Xinjiang area of pathogens and antimicrobial susceptibility of dynamic detection, to understand the changes and trends of chronic suppurative otitis media pathogens to guide the clinical rational use of drugs; scanning electron microscope on patients with chronic otitis media and cholesteatoma of the middle ear mucosa epithelial tissue, the formation of bacterial biofilm in the understanding of different types of chronic otitis media, while the formation of middle ear secretion in patients with bacterial biofilm bacterial culture, to understand the differences between results of SEM and middle ear secretions bacterial culture results and understand the results of SEM, the distribution of main pathogenic bacteria positive patients, chronic otitis media in the local guide The diagnosis and treatment. Methods: a retrospective analysis from January 2008 to June 2013 for bacterial culture and drug sensitivity test in the middle ear secretions of patients with chronic otitis media in our hospital, to obtain bacterial isolation rate of order; 2008-20112012-2013 two period main pathogen distribution, main pathogens and drug sensitivity changes; SEM examination was carried out on surgical samples obtained prospectively, according to different types of chronic otitis media in the group analysis; the relationship between the analysis of chronic otitis media with bacterial biofilm formation and bacterial culture results, and the formation of bacterial biofilm with pathogen distribution were sequenced. Results: 1 a total of 409 cases, all were 361 cases of pathogenic bacteria, the detection rate of 88.26%, including chronic suppurative otitis media (activity) in 288 cases, 254 cases of pathogens, cholesteatoma in 121 cases of group 107 Pathogens were found, compared between the two groups, there was no statistical significance. There were 43 kinds of pathogenic bacteria, at the forefront of the pathogenic bacteria were Staphylococcus aureus (28.8%) 104, 63 Pseudomonas aeruginosa (17.5%), Staphylococcus epidermidis (8.86%), 32 (6.09% of 22 Bacillus proteus 2), chronic suppurative otitis media (activity) and the main pathogenic bacteria of cholesteatoma are different than the overall, X 2=29.465, P=0.001, other positive cocci and gram positive bacilli were detected in chronic suppurative otitis media in the middle ear cholesteatoma tumor detection rate is high, X 2=7.074, P=0.008. other negative bacilli in middle ear cholesteatoma detection rate is relatively high in chronic suppurative otitis media x 2=18.18, P=0.000.3, all kinds of bacteria in different time frame than the contrast, X 2=9.209, P=0.418, not statistically significant. Staphylococcus aureus, coagulase negative Staphylococcus in 2012-2013 years Compared with the 2008-2011 annual rate of detection, the detection rate of Staphylococcus aureus increased, X 2=21.393, P=0.000 x 2=12.876: coagulase negative staphylococci, P=0.000 was statistically significant.4 of Staphylococcus aureus to try Dafoe of leptin leptin sensitivity, teicoplanin, vancomycin in two time periods were 100% of penicillin G erythromycin and ampicillin sensitive low rate were 17.3%, 19.7% and 40.3%, 2008-2011 and 2012-2013 year comparison of sensitivity of bacteria did not change significantly, the sensitivity of cefazolin in two time periods were 96.4%, 75%, X 2=4.989, P=0.027. moxifloxacin, levofloxacin, ciprofloxacin and quinolone antibiotics as the representative of higher sensitivity a minimum of 77.8%, gentamicin, rifampicin, cotrimoxazole has high sensitivity. In the discovery of coagulase negative staphylococcus, of leptin dalfopristin. Ting, teicoplanin, vancomycin in two time periods remains 100%. Sensitivity or penicillins, quinolones, drug resistance of coagulase negative staphylococci were increased, especially near 100%. in penicillin tolerance of Pseudomonas aeruginosa, mainly used antibiotics moxifloxacin 90.5%, ceftazidime imipenem 72.7%, 73.7% the sensitivity, ceftazidime and imipenem increased Yaan.5 in 2012-2013, chronic suppurative otitis media and cholesteatoma (activity) of bacterial biofilm formation rate was 85.5% (14/16), 81.3% (13/16), chi square test (Fisher's Exast Test) P=1.00. experimental group two group and control group with chronic suppurative otitis media (Prohibition) of bacterial biofilm formation in 16.7% (2/12), chi square test (Fisher's Exast Test) of P was 0.01,.6 was statistically significant, chronic otitis media SEM of bacterial biofilm The comparison between the results and the results of bacterial culture. The sensitivity Se=70.37%, specificity SP=60.00%, the misdiagnosis rate was 40%, misdiagnosis rate was 29.63%, the positive predictive value of 90.46%, negative predictive value of 27.27%, the correct rate of 68.75%YI (Youden index30.37% Pearson, the correlation coefficient was 0.232 (P=0.201).7, chronic otitis media and positive bacterial biofilms were bacteria pathogens the distribution of G+ bacilli and 5 cases without identification of bacterial species specific, 5 cases of Pseudomonas aeruginosa (23.8%), 2 (9.5%) cases of Proteus, Escherichia coli in 2 cases (9.5%), 1 cases (4.8%); 7 root fungus, 1 cases of Staphylococcus aureus (4.8%), coagulase negative Staphylococcus aureus in 3 cases among them, accounted for 14.3%, Staphylococcus aureus, measles twin, Staphylococcus epidermidis in each case. Fungi in 1 cases, accounting for 4.8%, a case of Aspergillus fumigatus. Conclusion: chronic otitis media in Xinjiang at the forefront of the bacteria are Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis, Qi Different proteus. Gram positive cocci and gram positive bacilli were detected in chronic suppurative otitis media cholesteatoma detection rate is high, and the high detection rate of gram negative bacteria. The main pathogens of middle ear cholesteatoma in different time periods of chronic otitis media which has no obvious change. Staphylococcus aureus to penicillin, erythromycin, ampicillin keep high drug resistance, cephalosporin resistance increased, fluoroquinolones and cotrimoxazole to maintain a certain sensitivity, coagulase negative staphylococci on amino glucoside antibiotic sensitivity, fluoroquinolones, penicillin sensitivity is low, the two of Dafoe. Teicoplanin on leptin, leptin, vancomycin keep high sensitivity. Ceftazidime, imipenem moxifloxacin, Yaan has high sensitivity to Pseudomonas aeruginosa, but there have been Decreased. Chronic suppurative otitis media in the quiescent stage and bacterial biofilm formation are low proportion of chronic suppurative otitis media with cholesteatoma formation stage, bacterial biofilm has a clear correlation between bacterial biofilm in chronic suppurative otitis media and cholesteatoma stage two disease formation in similar circumstances for the first time, found the biofilm structure of fungi form cholesteatoma of middle ear cholesteatoma. Bacterial culture results in the formation of negative patients with chronic otitis media can not represent no bacterial biofilm; bacterial biofilm in patients with bacterial culture results and the region of bacteria is basically consistent, are the common bacteria in the region, Pseudomonas aeruginosa and coagulase negative Staphylococcus aureus is a chronic otitis media the main pathogens of bacterial biofilm formation.

【學(xué)位授予單位】：新疆醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R764.21

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