【摘要】：目的：通過回顧性分析多重耐藥菌感染患者的臨床資料,得出多重耐藥菌感染的中醫(yī)證候分布特征,進(jìn)一步探討和分析中醫(yī)證候分布的相關(guān)因素。方法：本研究為回顧性分析,收集于2013年5月至2016年5月期間在廣東省中醫(yī)院急診綜合病區(qū)及重癥監(jiān)護(hù)室住院的患者,符合痰、中段尿、血液任一標(biāo)本細(xì)菌藥敏培養(yǎng)結(jié)果提示為多重耐藥菌感染即可入組,共計200例。建立數(shù)據(jù)庫,收集患者年齡、性別、基礎(chǔ)疾病、一般情況、感染菌種、感染部位、細(xì)菌耐藥程度、抗生素使用、APACHEⅡ評分、中醫(yī)證候等內(nèi)容,采用SPSS19.0數(shù)據(jù)包進(jìn)行統(tǒng)計分析。成果：本研究收集2013年5月至2016年5月期間在廣東省中醫(yī)院急診綜合病區(qū)及重癥監(jiān)護(hù)室住院診斷為多重耐藥菌感染的患者共200例,男女比例各為43.5%與56.5%,男性患者87例,女性患者117例。平均年齡為79.85±10.78,以71-90歲患者居多,占73%；其次是51-70歲,占19%；30-50歲和大于90歲的分別占3%和5%。既往病史中順位前五名的疾病分別是高血壓(73.5%)、糖尿病(72%)、腦梗個人史(65.5%)、慢性心衰(27.5%)、支氣管擴(kuò)張(24%)。長期臥床的患者133例,占66.5%；患有低蛋白血癥的有184例,占92%；有廣譜抗生素使用史的患者96例,占48%；長期使用糖皮質(zhì)激素的患者3例,占1.5%；此次住院前30天內(nèi)接受過免疫抑制療法的有9例,占4.5%。侵入性醫(yī)療措施包括機(jī)械輔助通氣、氣管切開、中心靜脈置管、留置尿管、纖維支氣管鏡檢查,比例最高的為留置尿管,發(fā)生率為93.5%；機(jī)械輔助通氣次之,發(fā)生率為92.5%。APACHE Ⅱ評分均值是21.18±5.67,最小值為9分,最大值為37分。多重耐藥菌感染部位的比例中,以肺部感染最多見,200例患者中痰培養(yǎng)結(jié)果陽性的125例,占62.5%；其次為泌尿道感染,占30.5%；血行感染最少,占7%。革蘭氏陰性菌較革蘭氏陽性菌多,陰性菌177例,占88.5%；陽性菌23例,占11.5%。所有菌種中最多見的為鮑曼不動桿菌,占總例數(shù)的26%；其次為銅綠假單胞菌,占總例數(shù)的21.5%；奇異變形桿菌、大腸埃希菌則分別占總例數(shù)的15.5%、14%。引起肺部感染中以鮑曼不動桿菌(36.8%)及銅綠假單胞菌(25.6%)為主,泌尿道感染則以變形桿菌(34.43%)及大腸埃希菌(19.67%)為主,血培養(yǎng)中以葡萄球菌屬(50%)為主。藥敏結(jié)果中,泛耐藥菌株35例,占17.5%。泛耐藥菌中以鮑曼不動桿菌(82.86%)居多,其次為銅綠假單胞菌(14.28%)�？股厥褂靡驭�-內(nèi)酰胺類最多,占84.67%,該類抗生素中3代頭孢菌素和碳青霉烯類的使用率最高；抗生素的聯(lián)用率為14.72%,以兩種抗生素聯(lián)合使用為主。200例患者中,有37例未使用抗生素。證候表現(xiàn)按虛實偏重進(jìn)行分組,按比例大小順位依次為虛實夾雜偏虛證(30.5%)、單純虛證(25.5%)、虛實夾雜偏實證(25%)、單純實證(19%)。在9個具體證候要素中,比例由高到低依次為：氣虛證(72%)痰濁證(28.5%)血瘀證(27.5%)陰虛證(18.5%)實熱證(15.5%)濕阻證(141%)陽虛證(11%)血虛證(10%)、水停證(10%)。虛證類中以“氣虛證”為主導(dǎo),實證類則多見“痰濁證：”與“血瘀證”。證候要素的組合以二證并見的患者居多,占76%；二證并見中以“氣虛血瘀”和“氣虛痰濁”的組合比例最多,分別為16.45%、15.79%；三證并見中以“氣虛、陰虛、痰濁”(25.81%)及“氣虛、陰虛、血瘀”(19.35%)多見。證候要素與年齡、性別的相關(guān)性分析：氣虛證組的患者中,“30-50y”組與“71-90y”組之間、“51-70y”與“71-90y”組之間差異具有統(tǒng)計學(xué)意義,Spearman相關(guān)分析顯示氣虛證與年齡存在正相關(guān),提示隨著年齡增加,研究組中患者出現(xiàn)氣虛證的可能性增大。實熱證組的患者中,“30-50y”組與“71-90y”組之間差異具有統(tǒng)計學(xué)意義,與氣虛證組相反,實熱證與年齡之間存在負(fù)栩關(guān),即年齡較低的患者患實熱證的機(jī)會增加。血虛證組男女患者間比較P0.01,差異具有顯著統(tǒng)計學(xué)意義,女性患者中血虛證的比例(15.93%)比男性患者中血虛證的比例(2.30%)高。根據(jù)多重耐藥菌耐藥的程度不同,分為泛耐藥菌組和非泛耐藥菌組,分析證候要素與耐藥程度的相關(guān)性,結(jié)果顯示痰濁證患者中泛耐藥菌組和非泛耐藥菌組間比較P0.05,差異具有統(tǒng)計學(xué)意義,泛耐藥菌組的患者中患痰濁證的比例(45.71%)比非泛耐藥菌組的患者其比例(24.85%)要高。評估中醫(yī)證候與APACHE Ⅱ評分相關(guān)性的過程中,先對所有患者的APACHE Ⅱ評分進(jìn)行正態(tài)性檢驗,結(jié)果顯示APACHE Ⅱ評分?jǐn)?shù)值符合正態(tài)分布(P=0.319,P0.05)；進(jìn)而對各組進(jìn)行方差齊性檢驗,結(jié)果提示符合方差齊性檢驗(P=0.696,P0.05)；繼續(xù)行單因素ANOVA分析,提示不同的分組其APACHE Ⅱ評分?jǐn)?shù)值存在顯著差異性(F=9.307,P=-0.000,P0.01),故對各組進(jìn)行平均數(shù)的多重比較(Scheffe),進(jìn)一步了解組間差異,最終結(jié)果提示單純虛證組與單純實證組之間比較的P.01(P=-0.001),差異具有顯著統(tǒng)計學(xué)意義；單純實證組與虛實夾雜偏虛證組之間比較的P0.01(P=0.000),差異具有顯著統(tǒng)計學(xué)意義；虛實夾雜偏虛證組與虛實夾雜偏實證組之間比較的P0.05(P=-0.039),差異具有統(tǒng)計學(xué)意義。結(jié)論：多重耐藥菌感染患者的年齡偏高,大部分患者存在長期臥床、低蛋白血癥的情況。在基礎(chǔ)疾病中順位前五名的分別是高血壓(73.5%)、糖尿病(72%)、腦梗個人史(65.5%)、慢性心衰(27.5%)、支氣管擴(kuò)張(24%)。多重耐藥菌感染的部位以肺部感染(62.5%)為主,其次是泌尿道感染(30.5%),血流感染最少(7%)；菌種順位前五名分別是鮑曼不動桿菌(26%)、銅綠假單胞菌(21.5%)、變形桿菌(16.5%)、大腸埃希菌(14%)、肺炎克雷伯菌(5.5%)；痰培養(yǎng)中以鮑曼不動桿菌、銅綠假單胞菌多見,中段尿培養(yǎng)以變形桿菌和大腸埃希菌多見,血培養(yǎng)以葡萄球菌屬多見。所有多重耐藥菌株中泛耐藥菌占17.5%,其中以鮑曼不動桿菌為主要的泛耐藥菌。多重耐藥菌感染的患者以虛實夾雜最多,在虛與實方面則偏向于虛證,證候要素虛證類以氣虛證、陰虛證多見,實證類則多見痰濁證、血瘀證；在證候要素的組合則以“氣虛痰濁”和“氣虛血瘀”的頻次為多。證候要素與年齡的關(guān)系中,隨著年齡增加,患者出現(xiàn)氣虛證的可能性增大,出現(xiàn)實熱證的可能性則降低；與性別的關(guān)系則表現(xiàn)為女性患者出現(xiàn)血虛證的可能性比男性患者高。泛耐藥菌和非泛耐藥菌在證候要素的區(qū)別,在于泛耐藥菌感染的患者患痰濁證的可能性較大。APACHE Ⅱ評分分值與證候分類有關(guān)系,表現(xiàn)為存在正虛時,患者的病情可能更嚴(yán)重,故應(yīng)高度重視,注意早期扶正,增強(qiáng)機(jī)體御邪能力。
[Abstract]:Objective: To retrospectively analyze the clinical data of patients with multi-drug resistant bacteria infection, and obtain the distribution characteristics of TCM syndromes of multi-drug resistant bacteria infection, and further explore and analyze the related factors of TCM syndromes distribution. The results of bacterial susceptibility culture in sputum, middle urine and blood samples of patients hospitalized in district and intensive care unit indicated that 200 patients with multidrug-resistant bacterial infections could be enrolled in the group. Results: From May 2013 to May 2016, 200 patients with multidrug-resistant bacterial infections were collected from the emergency ward and intensive care unit of Guangdong Hospital of Traditional Chinese Medicine. The male-female ratio was 43.5% and 56.5%, 87 male patients and 117 female patients respectively. The average age was 79.85 [10.78], with 73% of the patients aged 71-90, followed by 19% aged 51-70, 3% aged 30-50 and 5% aged over 90, respectively. The top five diseases in the previous medical history were hypertension (73.5%), diabetes (72%), personal history of cerebral infarction (65.5%), chronic heart failure (27.5%) and bronchiectasis (24%). 133 cases (66.5%), 184 cases (92%) with hypoproteinemia, 96 cases (48%) with a history of broad-spectrum antibiotics, 3 cases (1.5%) with long-term use of glucocorticoids, and 9 cases (4.5%) received immunosuppressive therapy within 30 days before hospitalization. Intravenous catheterization, indwelling catheter, fiberoptic bronchoscopy, the highest proportion of indwelling catheter, the incidence of 93.5%; mechanical ventilation followed by the incidence of 92.5%. APACHE II score was 21.18 [5.67], the minimum was 9 points, the maximum was 37 points. The results of sputum culture were positive in 125 cases (62.5%), followed by urinary tract infection (30.5%) and hematogenous infection (7%). Among them, Acinetobacter baumannii (36.8%) and Pseudomonas aeruginosa (25.6%) were the main pathogens, Proteus (34.43%) and Escherichia coli (19.67%) were the main pathogens, and Staphylococcus (50%) was the main pathogen in blood culture. Among them, 35 strains were pan-resistant, accounting for 17.5%. Acinetobacter baumannii (82.86%) was the most common, followed by Pseudomonas aeruginosa (14.28%). Among the 200 patients, 37 did not use antibiotics. Syndrome manifestations were grouped according to deficiency and excess, followed by deficiency and excess mixed with partial deficiency (30.5%), simple deficiency (25.5%), deficiency and excess mixed with partial deficiency (25%) and simple excess (19%). Turbid syndrome (28.5%) blood stasis syndrome (27.5%) Yin deficiency syndrome (18.5%) excess heat syndrome (15.5%) damp obstruction syndrome (14.1%) Yang deficiency syndrome (11%) blood deficiency syndrome (10%) and water arrest syndrome (10%). Qi deficiency and blood stasis and Qi deficiency and phlegm turbidity were 16.45% and 15.79% respectively, and the most common symptoms were Qi deficiency, Yin deficiency and phlegm turbidity (25.81%) and Qi deficiency, Yin deficiency and blood stasis (19.35%). Spearman correlation analysis showed that Qi deficiency syndrome was positively correlated with age, suggesting that with the increase of age, the possibility of Qi deficiency syndrome in the study group increased. On the contrary, there was a negative correlation between the syndrome of excess heat and age, that is, the chances of the syndrome of excess heat increased in the younger patients. Different, divided into pan-drug resistant bacteria group and non-pan-drug resistant bacteria group, analysis of the correlation between syndrome factors and drug resistance, the results showed that pan-drug resistant bacteria and non-pan-drug resistant bacteria group in patients with phlegm turbidity compared to P 0.05, the difference was statistically significant, pan-drug resistant bacteria group in patients with phlegm turbidity syndrome (45.71%) than non-pan-drug resistant bacteria group in the proportion of patients with pH In the process of evaluating the correlation between TCM syndrome and APACHE II score, the APACHE II score of all patients was tested for normality, and the results showed that the APACHE II score was in accordance with normal distribution (P = 0.319, P 0.05); then the homogeneity of variance was tested for each group, and the results showed that the homogeneity of variance was in accordance with homogeneity test (P = 0.696, P 0.05). The results of single factor ANOVA analysis showed that there were significant differences in APACHE II scores among different groups (F = 9.307, P = - 0.000, P 0.01). Therefore, multiple comparisons of the average of each group (Scheffe) were conducted to further understand the differences between groups. The final results showed that there was a significant difference between the pure deficiency syndrome group and the pure empirical group (P = - 0.001). Significant statistical significance; P 0.01 (P = 0.000) between the pure empirical group and the deficiency-excess mixed partial deficiency group, the difference was statistically significant; P 0.05 (P = - 0.039) between the deficiency-excess mixed partial deficiency group and the deficiency-excess mixed partial deficiency group, the difference was statistically significant. The top five basic diseases were hypertension (73.5%), diabetes mellitus (72%), personal history of cerebral infarction (65.5%), chronic heart failure (27.5%) and bronchiectasis (24%). Acinetobacter baumannii (26%), Pseudomonas aeruginosa (21.5%), Proteus (16.5%), Escherichia coli (14%), Klebsiella pneumoniae (5.5%), Acinetobacter baumannii (14%) and Pseudomonas aeruginosa (5.5%), Acinetobacter baumannii (5%) were the most common bacteria in sputum culture, Proteus and Escherichia coli (21.5%) were the most common bacteria in middle urine culture, and Staphylococcus aureus Pan-resistant bacteria accounted for 17.5% of all multidrug-resistant strains, of which Acinetobacter baumannii was the main pan-resistant bacteria. In the relationship between syndrome elements and age, the probability of Qi deficiency syndrome and excess heat syndrome increased with the increase of age, and the possibility of blood deficiency syndrome in female patients was higher than that in male patients. The difference between pan-drug-resistant bacteria and non-pan-drug-resistant bacteria is that the patients infected by pan-drug-resistant bacteria are more likely to suffer from phlegm turbidity syndrome.APACHE II score is related to syndrome classification.
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R259

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