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Surveillance of Antimicrobial Resistance among Clinical Isolates from Medical Wards in Peking Union Medical College Hospital
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摘要:
目的 了解北京协和医院内科住院患者临床分离细菌的分布及对抗菌药物的耐药性。 方法 收集2011年1月1日至2012年12月31日北京协和医院内科临床分离的2767株非重复细菌, 采用纸片扩散法或自动化仪器法进行药敏试验, 按美国临床实验室标准化研究所2012年版标准判读药敏结果, 采用WHONET 5.6软件进行数据分析。 结果 2767株非重复细菌中10种最常见的细菌依次为铜绿假单胞菌(11.5%)、大肠埃希菌(11.2%)、金黄色葡萄球菌(10.1%)、肺炎克雷伯菌(9.7%)、鲍曼不动杆菌(9.4%)、凝固酶阴性葡萄球菌(5.0%)、阴沟肠杆菌(4.1%)、粪肠球菌(3.8%)、嗜麦芽窄食单胞菌(3.6%)和屎肠球菌(3.4%), 其中革兰阴性菌占65.3%(1807株), 革兰阳性菌占34.7%(960株)。耐甲氧西林金黄色葡萄球菌(methicillin-resistant Staphylococcus aureus, MRSA)和耐甲氧西林凝固酶阴性葡萄球菌(methicillin-resistant coagulase negative Staphylococcus, MRCNS)的检出率分别为33.8%(94/278)和75.8%(222/293)。MRS葡萄球菌(MRSA和MRCNS)对β内酰胺类和其他抗菌药物的耐药率明显高于MSS葡萄球菌[甲氧西林敏感金黄色葡萄球菌(methicillin-susceptible Staphylococcus aureus, MSSA)和甲氧西林敏感凝固酶阴性葡萄球菌(methicillin-susceptive coagulase-negative Staphylococcus, MSCNS)]。MRSA中87.2%菌株对磺胺甲噁唑-甲氧苄啶敏感, MRCNS中84.2%菌株对利福平敏感。未发现对万古霉素、替考拉宁和利奈唑胺耐药的葡萄球菌。粪肠球菌对大多数抗菌药物的耐药率明显低于屎肠球菌, 后者对氯霉素的耐药率仅为4.7%。分别发现2株和8株万古霉素耐药的粪肠球菌和屎肠球菌, 根据表型推测为VanA和VanB型耐药; 未发现对利奈唑胺耐药的肠球菌。产超广谱β-内酰胺酶(extended spectrum β-lactamases, ESBLs)的大肠埃希菌、克雷伯菌属细菌(肺炎克雷伯菌和产酸克雷伯菌)和奇异变形杆菌的检出率分别为66.5%、32.6%和30.5%, 产ESBLs菌株的耐药率明显高于非产ESBLs菌株。肠杆菌科细菌对碳青霉烯类抗菌药物仍高度敏感, 总耐药率0.9%~2.9%。泛耐药肺炎克雷伯菌的检出率为0.4%(1/267)。铜绿假单胞菌对亚胺培南和美罗培南的耐药率分别为23.4%和17.4%, 对阿米卡星的耐药率最低(6.6%); 鲍曼不动杆菌对上述两种抗菌药物的耐药率分别为56.8%和57.5%, 对头孢哌酮-舒巴坦和米诺环素的耐药率最低(42.1%和24.0%)。泛耐药鲍曼不动杆菌和铜绿假单胞菌的检出率分别为35.9%和1.6%。流感嗜血杆菌β-内酰胺酶的检出率为19.4%。肺炎链球菌对红霉素和克林霉素的耐药率>94%。 结论 定期进行耐药性监测有助于了解细菌耐药性变迁, 可为临床经验用药提供依据。 Abstract:Objective To investigate the distribution and antimicrobial resistance of clinical bacterial isolates from medical wards in Peking Union Medical College Hospital (PUMCH) between January 1, 2011 and December 31, 2012. Methods A total of 2767 non-duplicate clinical isolates were collected. Disc diffusion test (Kirby-Bauer method) and automated systems were employed to study the antimicrobial resistance. The data were analyzed by WHONET 5.6 software according to Clinical and Laboratory Standards Institute (CLSI) 2012 breakpoints. Results Of the 2767 clinical isolates, gram-negative organisms and gram-positive cocci accounted for 65.3%(n=1807) and 34.7% (n=960), respectively. The 10 most common organisms isolated were Pseudomonas aeruginosa (11.5%), Escherichia coli (11.2%), Staphylococcus aureus (10.1%), Klebsiella pneumoniae (9.7%), Acinetobacter baumannii (9.4%), coagulase-negative staphylococci (5.0%), Enterobacter cloacae (4.1%), Enterococcus faecalis (3.8%), Xanthomonas maltophilia (3.6%), and Enterococcus faecalis (3.4%). Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative Staphylococcus(MRCNS) accounted for 33.8% and 75.8%, respectively. The resistance rates of methicillin-resistance strains to β-lactams and other antimicrobial agents were much higher than those of methicillin-susceptive strains including methicillin-susceptible Staphylococcus aureus (MSSA)and methicillin-susceptive coagulase-negative Staphylococcus (MSCNS). In addition, 87.2% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 84.2% of MRCNS strains were susceptible to rifampin. No staphylococcal strains were resistant to vancomycin, teicoplanin, or linezolid. The resistance rates of E. faecalis strains to most of the drugs tested were much lower than those of E. faecium. However, the resistance rate of the E. faecium to chloramphenicol was only 4.7%. Several strains of both E. faecium and E. faecalis were found resistant to vancomycin. Most of the vancomycin-resistant strains were van-A and van-B types based on their phenotypes. No linezolid-resistant strains were found. Extended spectrum β-lactamases(ESBLs)-producing strains accounted for 66.5%, 32.6%, and 30.5% in E. coli, Klebsiella spp (K.pneumoniae and K. oxytoca), and P. mirabilis, respectively. The resistant rates of ESBLs-producing strains were all higher than the corresponding non-ESBLs-producing strains. The Enterbacteriaceae strains were still highly susceptible to carbapenems, with an overall resistance rate of only 0.9%-2.9%. Only one pan-resistant strain of K. pneumoniae (0.4%, 1/267)was identified. The resistance rates of P. aeruginosa to imipenem and meropenem were 23.4% and 17.4%, respectively. However, the P.aeruginosa isolates showed the lowest resistant rate (6.6%) to amikacin. Also, 56.8% and 57.5% of A. baumannii were resistant to imipenem and meropenem. A. baumannii isolates showed the lowest resistant rates 42.1% and 24.0%, respectively, to cefoperazone-sulbactam and minocycline. The prevalences of pan-resistant strains of A. baumannii and P. aeruginosa were 35.9% and 1.6%, respectively. The detection rate of β-lactamase in H. influenzae was 19.4%. More than 94% of S. pneumoniae strains were resistant to erythromycin and clindamycin. Conclusion Regular monitoring of the bacterial resistance to antibiotics is useful to guide the rational use of antimicrobial agents. -
表 1 2011至2012年北京协和医院内科病房菌种分布
菌种 菌株数 构成比(%) 革兰阴性菌 铜绿假单胞菌 319 17.6 大肠埃希菌 310 17.2 肺炎克雷伯菌 267 14.8 鲍曼不动杆菌 259 14.3 阴沟肠杆菌 112 6.2 嗜麦芽窄食单胞菌 100 5.5 流感嗜血杆菌 72 4.0 奇异变形杆菌 59 3.3 产酸克雷伯菌 42 2.3 黏质沙雷菌 40 2.2 其他 227 12.6 总计 1807 100 革兰阳性菌 金黄色葡萄球菌 278 28.9 凝固酶阴性葡萄球菌* 139 14.5 粪肠球菌 104 10.8 屎肠球菌 93 9.7 肺炎链球菌 36 3.7 鹑鸡肠球菌 17 1.8 草绿色链球菌* 16 1.7 B群链球菌 14 1.5 其他 263 27.4 总计 960 100 *从血液和其他无菌体液分离 
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表 2 2011至2012年北京协和医院内科分离的葡萄球菌属对抗菌药物的耐药率和敏感率(%)
抗菌药物 MSSA(184株) MRSA(94株) MSCNS(71株) MRCNS(222株) 耐药率 敏感率 耐药率 敏感率 耐药率 敏感率 耐药率 敏感率 青霉素 84.2 15.8 100 0 58.3 41.7 100 0 苯唑西林 0 100 100 0 0 100 100 0 头孢西丁 0 100 100 0 0 100 100 0 庆大霉素 30.4 68.5 72.3 26.6 9.8 90.2 42.7 50.9 环丙沙星 13.7 85.7 84.3 15.7 8.7 89.1 64.8 33.2 红霉素 67.9 31.5 82.8 16.1 49.2 47.5 91.9 3.6 万古霉素 0 100 0 100 0 100 0 100 利奈唑胺 0 100 0 100 0 100 0 100 替考拉宁 0 100 0 100 0 100 0 100 磺胺甲噁唑-甲氧苄啶 32.1 67.9 12.8 87.2 31.1 68.9 72.0 28.0 克林霉素 37.0 61.4 64.9 34.0 18.0 82.0 34.4 62.9 利福平 3.3 96.7 63.8 36.2 3.3 93.4 15.8 84.2 MSSA：甲氧西林敏感金黄色葡萄球菌；MRSA：耐甲氧西林金黄色葡萄球菌；MSCNS：甲氧西林敏感凝固酶阴性葡萄球菌；MRCNS：耐甲氧西林凝固酶阴性葡萄球菌
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表 3 2011至2012年北京协和医院内科分离的粪肠球菌和屎肠球菌对抗菌药物的耐药率和敏感率(%)
抗菌药物 粪肠球菌(104株) 屎肠球菌(93株) 耐药率 敏感率 耐药率 敏感率 氨苄西林 15.5 84.5 94.4 5.6 高浓度庆大霉素 37.4 56.6 70.1 27.6 环丙沙星 47.6 24.3 91.1 4.4 红霉素 76.2 4.0 98.9 1.1 万古霉素 1.9 96.2 8.6 90.3 利奈唑胺 0 100 0 100 替考拉宁 0 100 4.3 95.7 氯霉素 30.9 59.3 4.7 85.9 四环素 76.0 23.1 49.5 47.3 利福平 68.4 9.2 87.5 8.0 磷霉素 4.8 90.4 8.1 81.1
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表 4 2011至2012年北京协和医院内科分离的肺炎链球菌对抗菌药物的耐药率和敏感率(%)
抗菌药物 肺炎链球菌*(36株) 耐药率 敏感率 青霉素 0 94.4 左氧氟沙星 8.6 91.4 莫西沙星 0 97.1 磺胺甲噁唑-甲氧苄啶 83.3 11.1 红霉素 93.9 0 利奈唑胺 0 100 万古霉素 0 100 氯霉素 22.9 71.4 克林霉素 100 0
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表 5 2011至2012年北京协和医院内科分离的大肠埃希菌和克雷伯菌属耐药率和敏感率(%)
抗菌药物 大肠埃希菌 克雷伯菌属 ESBLs(+)(206株) ESBLs(-)(104株) ESBLs(+)(101株) ESBLs(-)(209株) 耐药率 敏感率 耐药率 敏感率 耐药率 敏感率 耐药率 敏感率 哌拉西林 97.8 1.1 20.0 53.3 93.6 5.1 9.7 80.6 氨苄西林-舒巴坦 58.0 18.8 12.4 75.3 57.7 17.9 7.8 86.3 哌拉西林-他唑巴坦 6.5 85.9 2.2 97.8 9.1 72.7 2.0 94.1 头孢哌酮-舒巴坦 8.2 63.6 0 97.8 12.8 53.8 1.0 99.0 头孢呋辛 98.8 0.6 6.2 90.0 90.4 9.6 6.0 88.5 亚胺培南 0 100 0 10.0 1.3 96.2 0.5 98.1 美罗培南 0 99.5 0 100 1.3 97.4 0.5 99.5 厄他培南 1.1 96.2 0 100 2.6 85.9 1.0 98.0 头孢他啶 46.7 42.9 2.2 97.8 37.2 46.2 2.4 96.6 头孢噻肟 98.4 1.1 3.3 95.6 89.7 7.7 5.3 91.3 头孢吡肟 26.8 45.9 1.1 98.9 20.8 61.0 0 99.5 氨曲南 67.2 20.8 2.2 96.7 59.0 29.5 3.4 96.1 庆大霉素 71.0 28.4 37.5 62.5 51.3 48.7 5.4 94.1 阿米卡星 11.5 84.1 3.3 96.7 11.5 87.2 2.4 97.1 环丙沙星 89.7 8.2 51.6 45.1 51.3 26.9 11.2 84.4 磺胺甲噁唑-甲氧苄啶 81.4 18.0 56.2 43.8 80.8 16.7 18.9 80.1 米诺环素 28.9 56.3 16.9 75.4 56.7 28.3 14.0 79.1 ESBLs：超广谱β-内酰胺酶
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表 6 2011至2012年北京协和医院内科分离的非发酵糖菌对抗菌药物的耐药率和敏感率(%)
抗菌药物 鲍曼不动杆菌
(259株)铜绿假单胞菌
(319株)嗜麦芽窄食单胞
菌(100株)耐药率 敏感率 耐药率 敏感率 耐药率 敏感率 氨苄西林-舒巴坦 54.3 39.0 替卡西林-克拉维酸 60.9 37.5 24.6 75.4 哌拉西林 63.4 24.4 12.1 78.7 哌拉西林-他唑巴坦 60.2 35.9 7.9 81.6 头孢哌酮-舒巴坦 42.1 40.9 8.8 82.0 亚胺培南 56.8 42.8 23.4 73.4 美罗培南 57.5 42.5 17.4 78.8 氨曲南 16.6 63.3 头孢他啶 57.4 40.7 12.0 85.4 头孢吡肟 60.2 35.5 8.9 84.7 庆大霉素 62.5 36.3 10.3 87.1 阿米卡星 57.8 39.9 6.6 92.1 环丙沙星 63.3 36.3 9.2 86.7 左氧氟沙星 58.9 37.2 13.6 81.6 10.0 89.0 磺胺甲噁唑-甲氧苄啶 53.9 41.9 5.0 93.0 米诺环素 24.0 63.0 0 96.1
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表 7 2011至2012年北京协和医院内科分离的流感嗜血杆菌对抗菌药物的耐药率和敏感率(%)
抗菌药物 流感嗜血杆菌(72株) 耐药率 敏感率 头孢呋辛 14.3 85.7 头孢噻肟 0 91.5 头孢克洛 16.9 81.7 左氧氟沙星 0 97.2 阿奇霉素 0 94.4 磺胺甲噁唑-甲氧苄啶 56.7 43.3 氨苄西林 19.7 71.8 氨苄西林-舒巴坦 16.9 83.1 氯霉素 12.7 76.1 环丙沙星 6.9 93.1
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