2024, Vol. 53文章信息
- 郭丽洁, 杨书桓, 李富顺, 陈静静, 王齐晖, 褚云卓
- GUO Lijie, YANG Shuhuan, LI Fushun, CHEN Jingjing, WANG Qihui, CHU Yunzhuo
- 2022年沈阳市某三级甲等医院细菌耐药监测结果分析
- Analysis of bacterial resistance monitoring results in a tertiary hospital in Shenyang in 2022
- 中国医科大学学报, 2024, 53(5): 458-463
- Journal of China Medical University, 2024, 53(5): 458-463
-
文章历史
- 收稿日期：2023-06-13
- 网络出版时间：2024-05-15 15:04:30
引用本文 |
郭丽洁, 杨书桓, 李富顺, 陈静静, 王齐晖, 褚云卓.
2022年沈阳市某三级甲等医院细菌耐药监测结果分析[J]. 中国医科大学学报, 2024, 53(5): 458-463.
GUO Lijie, YANG Shuhuan, LI Fushun, CHEN Jingjing, WANG Qihui, CHU Yunzhuo. Analysis of bacterial resistance monitoring results in a tertiary hospital in Shenyang in 2022[J]. Journal of China Medical University, 2024, 53(5): 458-463.
2022年沈阳市某三级甲等医院细菌耐药监测结果分析
1. 中国医科大学附属第一医院检验科，沈阳 110001;
2. 沈阳药科大学药学院，辽宁 本溪 117004
2. 沈阳药科大学药学院，辽宁 本溪 117004
摘要：目的 分析2022年沈阳市某三级甲等医院病原菌分布及其耐药情况，为医院制定抗菌药物应用策略提供依据。方法 收集从2022年沈阳市某三级甲等医院就诊患者中分离的病原菌，按照全国临床检验操作规程的要求进行菌株鉴定及药敏试验，使用Whonet 5.6软件进行数据分析。结果 2022年共分离4 968株病原菌，其中前5位为大肠埃希菌、肺炎克雷伯菌、鲍曼不动杆菌、屎肠球菌和铜绿假单胞菌。大肠埃希菌和肺炎克雷伯菌对碳青霉烯药物耐药率分别为1.9%和17.7%，阴沟肠杆菌对亚胺培南和美罗培南耐药率分别为26.7%和25.0%。耐甲氧西林金黄色葡萄球菌（MRSA）分离率15.6%。万古霉素耐药屎肠球菌、利奈唑胺耐药粪肠球菌分离率分别为7.1%、11.6%。热带念珠菌对氟康唑耐药率>20%。结论 该医院病原菌分布及耐药率与国内其他地区监测结果存在差异，有必要进行医院菌株的耐药监测，及时了解病原菌分布及耐药情况，为抗感染诊治提供依据。
Analysis of bacterial resistance monitoring results in a tertiary hospital in Shenyang in 2022
1. Department of Laboratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China;
2. School of Pharmacy, Shenyang Pharmaceutical University, Benxi 117004, China
2. School of Pharmacy, Shenyang Pharmaceutical University, Benxi 117004, China
Abstract: Objective To analyze pathogen distribution and drug resistance in a tertiary hospital in Shenyang in 2022 and provide evidence-based guidance for this and other hospitals to formulate antibacterial drug application strategies. Methods In 2022, bacterial isolates collected from patients in a tertiary hospital in Shenyang were identified and subjected to drug sensitivity tests based on the requirements of the national clinical laboratory operation procedures. The data were analyzed using Whonet 5.6 software. Results In total, 4 968 pathogenic strains were isolated from this hospital in 2022. The top five isolates were Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Enterococcus faecalis, and Pseudomonas aeruginosa. The resistance rates of Escherichia coli and Klebsiella pneumoniae to carbapenems were 1.9% and 17.7%, respectively. The resistance rates of Enterobacter cloacae to imipenem and meropenem were 26.7% and 25.0%, respectively. The isolation rate of methicillin-resistant Staphylococcus aureus (MRSA) was 15.6%. The resistance rates of vancomycin-resistant Enterococcus and linezolid-resistant Enterococcus faecalis were 7.1% and 11.6%, respectively. The resistance rates of tropical yeasts to fluconazole was>20%. Conclusion The distribution and drug resistance of pathogens in this hospital differed from those in other regions of China. The drug resistance of strains in this hospital should be closely monitored to understand the distribution and drug resistance of pathogens in a timely manner and to provide guidance for the diagnosis and treatment of infections.
Keywords:
drug resistance monitoring drug sensitivity test carbapenem-resistant Gram-negative bacilli
抗微生物药物的耐药性对公共卫生和医疗诊治构成越来越大的威胁[1]。近10年来，多重耐药菌、泛耐药菌的出现，特别是泛耐药革兰氏阴性杆菌的快速增加，不仅增加了对疾病的诊治难度，同时也增加了患者的诊治成本。细菌耐药性监测可了解细菌耐药的变化，也可促进临床合理应用抗菌药物。本研究拟分析2022年沈阳市某三级甲等医院的抗菌药物耐药性，以期为临床抗感染治疗提供依据。
1 材料与方法 1.1 菌株来源收集从2022年1月1日至12月31日沈阳市某三级甲等医院就诊患者中分离的病原菌，同一患者重复菌株只保留第1株。
1.2 菌种鉴定及药敏试验菌种鉴定及药敏试验方法均参照全国临床检验操作规程（第4版）。菌种鉴定使用法国梅里埃公司的VITEK MS和VITEK 2系统，药敏试验使用梅里埃公司配套药敏卡，用KB法或E-test法补充或确认药物敏感性；替加环素及黏菌素采用微量肉汤稀释法（温州康泰生物）确认药物敏感性。每周使用标准菌株进行质量控制，若检测频率<1次/周，需检测日进行质量控制。
1.3 耐药菌检测超广谱β-内酰胺酶（extended-spectrum β-lactamases，ESBL）是指能水解青霉素类，三代、四代头孢菌素及单环类的一类β-内酰胺酶，确证试验采用临床和实验室标准协会（Clinical and Laboratory Standards Institute，CLSI）推荐纸片扩散法。碳青霉烯耐药肠杆菌目菌（carbapenem resistant Enterobacteriaceae，CRE）指对亚胺培南、美罗培南或厄他培南中任一种耐药，采用E-test法确认药物敏感性。
1.4 统计学分析采用Whonet 5.6软件进行统计分析。抗菌药物采用2022 CLSI折点；替加环素采用FDA折点[2]；头孢哌酮/舒巴坦采用肠杆菌目头孢哌酮折点；头孢唑林及头孢呋辛采用注射给药方式折点。
2 结果 2.1 菌株分布2022年共分离4 968株病原菌，其中，21.3%（1 058/4 968）来自门急诊患者，78.7%（3 910/4 968）来自住院患者；住院患者中，主要分离自重症医学科14.8%（578/3 910）、器官移植科12.6%（493/3 910）、呼吸内科8.2%（320/3 910）、神经内科7.8%（304/3 910）、心脏外科7.3%（284/3 910）及神经外科6.3%（247/3 910），见表 1。
表 1 主要病原菌的科室分布
Tab.1 Department distribution of main pathogenic bacteria
| Pathogen | ICU | OTD | EM | RM | NE | CS | NS | PS | UR | HB | ES | GC | IM | ID | Rheum | GI | Other |
| Escherichia coli | 49 | 30 | 63 | 8 | 37 | 7 | 8 | 23 | 56 | 13 | 31 | 9 | 30 | 8 | 37 | 9 | 230 |
| Klebsiella pneumoniae ss. pneumoniae | 50 | 39 | 67 | 47 | 51 | 119 | 26 | 16 | 13 | 17 | 8 | 17 | 8 | 22 | 9 | 10 | 98 |
| Acinetobacter baumannii | 80 | 61 | 43 | 56 | 57 | 22 | 51 | 19 | 1 | 16 | 1 | 11 | 1 | 5 | 2 | 5 | 48 |
| Enterococcus faecium | 50 | 70 | 38 | 21 | 43 | 2 | 17 | 28 | 14 | 18 | 2 | 13 | 0 | 21 | 2 | 13 | 72 |
| Pseudomonas aeruginosa | 45 | 29 | 29 | 40 | 22 | 22 | 27 | 19 | 5 | 11 | 9 | 11 | 3 | 2 | 5 | 4 | 87 |
| Staphylococcus aureus ss. aureus | 5 | 2 | 24 | 14 | 5 | 46 | 16 | 1 | 2 | 4 | 16 | 1 | 9 | 5 | 2 | 2 | 95 |
| Staphylococcus epidermidis | 28 | 13 | 12 | 9 | 8 | 5 | 8 | 5 | 11 | 12 | 11 | 6 | 1 | 3 | 3 | 4 | 79 |
| Stenotrophomonas maltophilia | 32 | 28 | 13 | 26 | 17 | 14 | 14 | 9 | 1 | 8 | 1 | 4 | 1 | 3 | 1 | 3 | 33 |
| Enterococcus faecalis | 11 | 18 | 11 | 1 | 11 | 0 | 4 | 4 | 20 | 4 | 9 | 8 | 2 | 3 | 5 | 5 | 49 |
| Staphylococcus hominis ss. hominis | 22 | 4 | 29 | 7 | 2 | 4 | 1 | 2 | 4 | 3 | 4 | 5 | 0 | 1 | 3 | 1 | 48 |
| Enterobacter cloacae | 13 | 14 | 4 | 8 | 5 | 6 | 3 | 11 | 1 | 4 | 2 | 4 | 2 | 2 | 2 | 1 | 38 |
| Candida albicans | 24 | 16 | 9 | 15 | 6 | 3 | 1 | 6 | 3 | 5 | 2 | 1 | 2 | 3 | 3 | 1 | 14 |
| Proteus mirabilis | 11 | 9 | 4 | 4 | 5 | 3 | 1 | 2 | 18 | 0 | 1 | 5 | 0 | 1 | 3 | 4 | 32 |
| Streptococcus agalactiae | 1 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 8 | 0 | 2 | 0 | 33 | 0 | 2 | 0 | 34 |
| Candida parapsilosis | 12 | 16 | 4 | 4 | 0 | 0 | 0 | 4 | 0 | 5 | 1 | 2 | 0 | 3 | 0 | 1 | 19 |
| Staphylococcus haemolyticus | 5 | 6 | 5 | 3 | 3 | 0 | 0 | 4 | 3 | 3 | 3 | 2 | 1 | 0 | 2 | 1 | 19 |
| Acinetobacter pittii | 7 | 22 | 1 | 3 | 1 | 0 | 4 | 1 | 2 | 3 | 2 | 0 | 1 | 1 | 1 | 1 | 9 |
| Candida tropicalis | 10 | 4 | 6 | 8 | 1 | 0 | 3 | 1 | 1 | 0 | 3 | 0 | 0 | 2 | 0 | 3 | 13 |
| Chryseobacterium indologenes | 5 | 32 | 1 | 2 | 1 | 2 | 2 | 1 | 0 | 3 | 0 | 0 | 0 | 1 | 0 | 0 | 3 |
| Other | 118 | 80 | 55 | 43 | 29 | 28 | 26 | 33 | 16 | 20 | 21 | 30 | 7 | 15 | 18 | 12 | 181 |
| Total | 578 | 493 | 418 | 320 | 304 | 284 | 213 | 189 | 179 | 149 | 129 | 129 | 101 | 101 | 100 | 80 | 1 201 |
| ICU，intensive care unit；OTD，organ transplantation department；EM，emergency medicine；RM，respiratory medicine；NE，neurology；CS，cardiac surgery；NS，neurosurgery；PS，pancreatic surgery；UR，urology；HB，hepatobiliary surgery；ES，emergency surgery；GC，geriatric cardiology；IM，internal medicine outpatient clinic；ID，infectious diseases；Rheum，rheumatology andimmunology；GI，gastroenterology. | |||||||||||||||||
病原菌中，革兰氏阳性菌30.4%（1 509/4 968）、革兰氏阴性菌63.3%（3 145/4 968）、真菌6.3%（314/4 968）。菌株主要来自尿液25.1%（1 249/4 968）、痰18.4%（912/4 968）、引流液14.6%（724/4 968）和血液13.5%（672/4 968），见表 2。
表 2 常见标本类型分离的主要病原菌分布
Tab.2 Distribution of main pathogenic bacteria isolated from common specimen types
| Bacteria | n | Urine | Respiratory | Fluid | Blood | Secretion | Bile | Catheter | Abdominal fluid | Cerebrospinal fluid | Tissue | Pleural fluid | Other |
| Escherichia coli | 648 | 338 | 27 | 75 | 85 | 78 | 29 | 1 | 7 | 1 | 0 | 1 | 6 |
| Klebsiella pneumoniae | 617 | 109 | 273 | 78 | 60 | 57 | 16 | 9 | 3 | 6 | 2 | 1 | 3 |
| Acinetobacter baumannii | 479 | 42 | 249 | 71 | 34 | 19 | 23 | 17 | 8 | 12 | 0 | 3 | 1 |
| Enterococcus faecium | 424 | 211 | 0 | 90 | 40 | 15 | 39 | 11 | 7 | 4 | 5 | 1 | 1 |
| Pseudomonas aeruginosa | 370 | 33 | 201 | 54 | 13 | 37 | 15 | 5 | 3 | 3 | 3 | 1 | 2 |
| Staphylococcus aureus | 249 | 10 | 98 | 21 | 16 | 91 | 0 | 3 | 2 | 0 | 5 | 0 | 3 |
| Staphylococcus epidermidis | 218 | 34 | 0 | 25 | 79 | 32 | 4 | 18 | 10 | 5 | 5 | 4 | 2 |
| Stenotrophomonas maltophilia | 208 | 13 | 114 | 37 | 4 | 11 | 17 | 0 | 4 | 5 | 0 | 2 | 1 |
| Enterococcus faecalis | 165 | 93 | 1 | 19 | 15 | 19 | 6 | 4 | 0 | 4 | 3 | 1 | 0 |
| Staphylococcus hominis | 140 | 8 | 0 | 4 | 108 | 5 | 0 | 11 | 1 | 0 | 0 | 1 | 2 |
| Enterobacter cloacae | 120 | 20 | 30 | 22 | 15 | 21 | 5 | 3 | 1 | 1 | 2 | 0 | 0 |
| Candida albicans | 114 | 27 | 4 | 37 | 11 | 17 | 7 | 9 | 1 | 0 | 0 | 0 | 1 |
| Proteus mirabilis | 103 | 61 | 12 | 6 | 6 | 14 | 3 | 1 | 0 | 0 | 0 | 0 | 0 |
| Streptococcus agalactiae | 83 | 31 | 3 | 0 | 2 | 14 | 0 | 0 | 0 | 0 | 1 | 0 | 32 |
| Candida parapsilosis | 71 | 8 | 1 | 10 | 37 | 3 | 3 | 5 | 1 | 0 | 1 | 1 | 1 |
| Staphylococcus haemolyticus | 60 | 10 | 0 | 13 | 16 | 11 | 3 | 1 | 2 | 0 | 1 | 2 | 1 |
| Acinetobacter pittii | 59 | 11 | 16 | 13 | 2 | 3 | 5 | 3 | 2 | 3 | 1 | 0 | 0 |
| Candida tropicalis | 55 | 21 | 4 | 6 | 16 | 4 | 0 | 3 | 0 | 1 | 0 | 0 | 0 |
| Chryseobacterium indologenes | 53 | 13 | 5 | 21 | 2 | 1 | 6 | 0 | 1 | 4 | 0 | 0 | 0 |
| Other | 732 | 156 | 125 | 122 | 113 | 96 | 53 | 15 | 13 | 11 | 13 | 9 | 6 |
| Total | 4 968 | 1 249 | 1 163 | 724 | 674 | 548 | 234 | 119 | 66 | 60 | 42 | 27 | 62 |
2.2 革兰氏阴性杆菌对抗菌药物的耐药情况 2.2.1 肠杆菌目
大肠埃希菌对哌拉西林他唑巴坦、头孢替坦、碳青霉烯类、阿米卡星、替加环素敏感>90%。肺炎克雷伯菌对碳青霉烯类药物耐药率17.7%，对阿米卡星及替加环素耐药率均>90%。阴沟肠杆菌对亚胺培南、美罗培南耐药率分别为26.7%、25.0%。大肠埃希菌、肺炎克雷伯菌及奇异变形杆菌ESBL分离率分别为55.4%、35.9%、38%。见表 3。
表 3 常见肠杆菌目细菌对抗菌药物的耐药率和敏感率（%）
Tab.3 Resistance and sensitivity rates of Enterobacteriaceae to antibiotics (%)
| Antibiotics | Escherichia coli （n = 648） |
Klebsiella pneumoniae
（n = 617） |
Enterobacter cloacae
（n = 120） |
Proteus mirabilis （n = 103） |
Serratia marcescens
（n = 47） |
Klebsiella oxytoca
（n = 45） |
Enterobacter aerogenes
（n = 36） |
Citrobacter freundii
（n = 32） |
||||||||||||||||
| R | S | R | S | R | S | R | S | R | S | R | S | R | S | R | S | |||||||||
| Ampicillin | 80.1 | 18.0 | - | - | - | - | 62.7 | 36.3 | - | - | - | - | - | - | - | - | ||||||||
| Piperacillin | 55.5 | 32.8 | 37.7 | 58.4 | 53.1 | 41.6 | 8.7 | 69.9 | 11.8 | 76.4 | 31.0 | 59.5 | 21.2 | 66.7 | 31.2 | 40.7 | ||||||||
| Amoxicillin/clavulanic acid | 15.8 | 55.0 | 28.0 | 60.7 | - | - | 9.7 | 74.2 | - | - | 15.0 | 70.0 | - | - | - | - | ||||||||
| Cefoperazone/sulbactam | 4.1 | 88.5 | 23.5 | 71.7 | 36.9 | 54.4 | 0 | 100 | 7.1 | 83.4 | 18.4 | 76.3 | 0 | 96.7 | 12.0 | 68.0 | ||||||||
| Piperacillin/tazobactam | 2.2 | 94.3 | 20.3 | 76.9 | 25.8 | 58.4 | 0 | 100 | 4.9 | 85.3 | 4.4 | 86.7 | 5.6 | 80.5 | - | - | ||||||||
| Cefuroxime | 57.1 | 39.3 | 38.3 | 59.3 | 67.8 | 15.7 | 50.5 | 46.6 | - | - | 25.0 | 63.6 | 39.4 | 48.5 | - | - | ||||||||
| Cefotetan | 2.7 | 97.0 | 14.3 | 84.7 | - | - | 0 | 100 | - | - | 2.4 | 97.6 | - | - | - | - | ||||||||
| Ceftazidime | 26.4 | 72.8 | 26.5 | 69.9 | 50.8 | 48.4 | 2.9 | 96.1 | 6.4 | 93.6 | 11.1 | 88.9 | 36.1 | 63.9 | 46.9 | 53.1 | ||||||||
| Ceftriaxone | 55.4 | 44.6 | 36.6 | 63.4 | 56.9 | 42.2 | 35.0 | 65.0 | 26.8 | 68.3 | 22.2 | 77.8 | 42.9 | 57.1 | 46.9 | 53.1 | ||||||||
| Cefepime | 19.8 | 72.6 | 24.5 | 73.7 | 35.8 | 52.5 | 1.9 | 83.5 | 6.4 | 87.2 | 6.7 | 93.3 | 11.1 | 86.1 | 9.4 | 87.5 | ||||||||
| Meropenem | 1.9 | 97.8 | 17.7 | 81.8 | 25.0 | 73.3 | 1.0 | 99.0 | 6.4 | 93.6 | 4.4 | 95.6 | - | 97.2 | 6.2 | 93.8 | ||||||||
| Imipenem | 1.9 | 97.9 | 17.7 | 82.1 | 26.7 | 69.1 | - | - | 8.3 | 91.7 | 4.4 | 95.6 | 5.6 | 72.2 | 6.5 | 90.3 | ||||||||
| Ciprofloxacin | 72.2 | 22.6 | 40.7 | 54.6 | 46.7 | 46.6 | 60.2 | 37.9 | 8.5 | 91.5 | 28.9 | 71.1 | 30.6 | 55.5 | 28.1 | 68.8 | ||||||||
| Levofloxacin | 66.6 | 12.2 | 28.8 | 52.2 | 28.3 | 40.0 | 37.3 | 33.3 | 8.5 | 85.1 | 22.2 | 68.9 | 5.6 | 50.0 | 18.8 | 62.4 | ||||||||
| Gentamicin | 39.4 | 59.8 | 26.0 | 72.3 | 27.6 | 66.4 | 14.6 | 57.2 | 7.9 | 92.1 | 9.3 | 90.7 | 8.8 | 91.2 | 9.4 | 90.6 | ||||||||
| Tobramycin | 16.5 | 58.6 | 18.7 | 66.5 | 25.8 | 61.7 | 6.8 | 63.1 | 4.3 | 78.7 | 4.4 | 88.9 | 8.3 | 83.4 | 0 | 87.5 | ||||||||
| Amikacin | 2.3 | 97.4 | 4.9 | 95.1 | 9.2 | 90.0 | 1.0 | 99.0 | 0 | 100 | 0 | 100 | 0 | 100 | 0 | 100 | ||||||||
| Trimethoprim/sulfamethoxazole | 58.5 | 41.5 | 25.2 | 74.8 | 34.2 | 65.8 | 54.4 | 45.6 | 0 | 100 | 24.4 | 75.6 | 30.6 | 69.4 | 25.0 | 75.0 | ||||||||
| Aztreonam | 37.8 | 61.7 | 31.1 | 68.4 | 43.3 | 56.7 | 2.9 | 97.1 | 6.4 | 91.5 | 13.3 | 86.7 | 38.9 | 61.1 | 37.5 | 59.4 | ||||||||
| Nitrofurantoin | 2.7 | 91.8 | 35.1 | 15.8 | 23.0 | 31.0 | - | - | - | - | 2.4 | 69.0 | 30.3 | 3.0 | 3.1 | 90.7 | ||||||||
| Tigecycline | 0.5 | 99.0 | 2.1 | 94.5 | 0 | 89.1 | - | - | - | - | - | - | - | - | - | - | ||||||||
| R，resistence；S，sensitive. | ||||||||||||||||||||||||
2.2.2 非发酵菌
鲍曼不动杆菌对黏菌素及替加环素的敏感性>90%。铜绿假单胞菌除碳青霉烯类抗菌药物，其余耐药率均<30%，见表 4。嗜麦芽窄食单胞菌对左氧氟沙星及米诺环素敏感率均>90%。产吲哚金黄杆菌对复方新诺明及米诺环素敏感性>90%，其余耐药率均>90%。
表 4 常见非发酵菌对抗菌药物的耐药率和敏感率（%）
Tab.4 Resistance and sensitivity rates of common non-fermenting bacteria to antibiotics (%)
| Antibiotics | Acinetobacter baumannii（n = 479） | Pseudomonas aeruginosa（n = 370） | |||
| R | S | R | S | ||
| Piperacillin | - | - | 15.2 | 65.1 | |
| Piperacillin/tazobactam | 87.4 | 11.3 | 8.7 | 69.2 | |
| Cefoperazone/sulbactam | 47.7 | 15.2 | 8.1 | 77.3 | |
| Ceftazidime | 85.2 | 13.5 | 13.1 | 73.5 | |
| Ceftriaxone | 59.3 | 20.3 | - | - | |
| Cefepime | 69.6 | 16.6 | 8.9 | 83.0 | |
| Imipenem | 85.2 | 14.4 | 36.1 | 57.4 | |
| Meropenem | 86.8 | 12.5 | 32.4 | 63.8 | |
| Ciprofloxacin | 85.6 | 14.0 | 15.4 | 78.1 | |
| Levofloxacin | 61.8 | 14.6 | 15.3 | 80.6 | |
| Gentamicin | 80.6 | 18.8 | 8.6 | 88.1 | |
| Tobramycin | 79.7 | 19.5 | 8.4 | 90.5 | |
| Amikacin | 80.8 | 19.2 | 1.1 | 97.5 | |
| Aztreonam | - | - | 23.1 | 55.1 | |
| Trimethoprim/sulfamethoxazole | 74.9 | 25.1 | - | - | |
| Minocycline | 4.2 | 72.6 | - | - | |
| Tigecycline | 1.8 | 93.6 | - | - | |
| Colistin | 0.9 | 97.2 | - | - | |
| R，resistence；S，sensitive. | |||||
2.3 革兰氏阳性菌对抗菌药物的耐药情况 2.3.1 葡萄球菌属
金黄色葡萄球菌MRSA分离率15.6%，凝固酶阴性葡萄球菌MRCNS分离率79%。除复方新诺明，其余抗菌药物耐药率MRSA均高于MSSA。发现利奈唑胺耐药的凝固酶阴性葡萄球菌。见表 5。
表 5 葡萄球菌属对抗菌药物的耐药率及敏感率（%）
Tab.5 Resistance and sensitivity rates of Staphylococcus to antibiotics (%)
| Antibiotics | MRSA（n = 39） | MSSA（n = 211） | MRCNS（n = 381） | MSCNS（n = 101） | |||||||
| R | S | R | S | R | S | R | S | ||||
| Penicillin | 100.0 | 0 | 82.0 | 18.0 | 100.0 | 0 | 81.1 | 17.8 | |||
| Oxacillin | 100.0 | 0 | 0 | 100.0 | 100.0 | 0 | 0 | 100.0 | |||
| Gentamicin | 12.8 | 87.2 | 7.1 | 87.2 | 19.2 | 72.4 | 2.0 | 95.0 | |||
| Rifampin | 0 | 100.0 | 0 | 99.5 | 7.2 | 90.5 | 1.0 | 98.0 | |||
| Ciprofloxacin | 28.2 | 71.8 | 19.9 | 76.3 | 66.3 | 23.9 | 16.0 | 76.0 | |||
| Levofloxacin | 25.6 | 71.8 | 19.9 | 78.2 | 74.8 | 24.4 | 20.8 | 77.2 | |||
| Trimethoprim/sulfamethoxazole | 10.3 | 89.7 | 30.3 | 69.7 | 58.3 | 41.7 | 26.3 | 73.7 | |||
| Clindamycin | 74.4 | 25.6 | 54.0 | 46.0 | 64.6 | 34.4 | 29.0 | 70.0 | |||
| Erythromycin | 82.1 | 17.9 | 69.2 | 30.8 | 87.9 | 10.3 | 68.3 | 30.7 | |||
| Nitrofurantoin | 0 | 100.0 | 0 | 100.0 | 1.1 | 98.2 | 1.0 | 98.0 | |||
| Linezolid | 0 | 100.0 | 0 | 100.0 | 3.7 | 96.3 | 0 | 100.0 | |||
| Vancomycin | 0 | 100.0 | 0 | 100.0 | 0 | 100.0 | 0 | 100.0 | |||
| Teicoplanin | 0 | 100.0 | 0 | 100.0 | - | - | - | - | |||
| Tetracycline | 33.3 | 66.7 | 11.4 | 88.6 | 21.8 | 76.8 | 12.9 | 87.1 | |||
| Tigecycline | 0 | 100.0 | 0 | 100.0 | 0 | 100.0 | 0 | 100.0 | |||
| R，resistence；S，sensitive. | |||||||||||
2.3.2 肠球菌属
屎肠球菌除四环素及利奈唑胺外，其余药物耐药率均高于粪肠球菌。屎肠球菌对万古霉素耐药率7.1%。粪肠球菌对利奈唑胺耐药率11.6%。见表 6。
表 6 屎肠球菌和粪肠球菌对抗菌药物的耐药率和敏感率（%）
Tab.6 Resistance and sensitivity rates of Enterococcus faecium and Enterococcus faecalis to antibiotics (%)
| Antibiotics | Enterococcus faecium（n = 424） | Enterococcus faecalis（n = 165） | |||
| R | S | R | S | ||
| Penicillin | 95.4 | 4.6 | 1.2 | 98.8 | |
| Ampicillin | 94.8 | 5.2 | 0.6 | 99.4 | |
| Ciprofloxacin | 94.1 | 4.7 | 41.8 | 55.2 | |
| Levofloxacin | 94.0 | 5.3 | 42.4 | 55.2 | |
| Erythromycin | 90.3 | 3.8 | 75.0 | 4.3 | |
| Nitrofurantoin | 62.1 | 19.8 | 0.6 | 98.2 | |
| Streptomycin-high | 52.2 | 47.8 | 30.4 | 69.6 | |
| Tetracycline | 41.8 | 58.0 | 80.6 | 19.4 | |
| Gentamicin-high | 34.6 | 65.2 | 53.1 | 46.9 | |
| Vancomycin | 7.1 | 92.9 | 0 | 100.0 | |
| Teicoplanin | 5.3 | 94.7 | 0 | 98.3 | |
| Linezolid | 1.2 | 98.8 | 11.6 | 85.4 | |
| Tigecycline | 0 | 100.0 | 0 | 100.0 | |
| R，resistence；S，sensitive. | |||||
2.3.3 链球菌属
无乳链球菌对克林霉素耐药率>80%，左氧氟沙星及四环素耐药率>50%，未发现青霉素、氨苄西林、头孢曲松、利奈唑胺及万古霉素非敏感株。草绿色链球菌对红霉素及克林霉素耐药率均>80%，头孢曲松、头孢吡肟及左氧氟沙星耐药率均<10%，未发现青霉素、万古霉素及利奈唑胺耐药菌株。
2.4 真菌白色念珠菌对氟康唑及伏立康唑敏感率>98%。热带念珠菌对三唑类（氟康唑、伏立康唑、伊曲康唑）耐药率>20%。近平滑念珠菌对三唑类（氟康唑、伏立康唑、伊曲康唑）耐药率<5%。
3 讨论本研究分析了2022年沈阳市某三级甲等医院的抗菌药物耐药性，结果显示，该医院2022年共分离4 968株病原菌。病原菌78.7%（3 910/4 968）来自住院患者，21.3%（1 058/4 968）来自门急诊患者，部分急诊患者来自急诊观察室及监护室。重症医学科主要以鲍曼不动杆菌分离为主，可能与送检以呼吸道标本为主且多数患者呼吸插管有关；器官移植科主要以屎肠球菌为主，与术后送检引流液为主有关；泌尿外科以大肠埃希菌为主，与其送检尿液为主有关，提示不同科室间菌株分布差异较大，应依据不同科室提供个性化的菌株分布甚至耐药性的变化。菌株来源自尿液25.1%（1 249/4 968）、痰18.4%（912/4 968）、引流液14.6%（724/4 968）、血液13.5%（672/4 968）。病原菌中革兰氏阳性菌30.4%（1 509/4 968）、革兰氏阴性菌63.3%（3 145/4 968）、真菌6.3%（314/4 968）。分离前5位是大肠埃希菌，肺炎克雷伯菌，鲍曼不动杆菌，屎肠球菌及铜绿假单胞菌，这与CHINET 2021年金黄色葡萄球菌分离第3位不一致[3]，可能与2个研究的标本类型分布有一定关系。
本研究显示，分离菌以肠杆菌目细菌为主，其中主要包括大肠埃希菌、肺炎克雷伯菌、阴沟肠杆菌及奇异变形杆菌。虽然大肠埃希菌的ESBL分离率>50%，但是碳青霉烯类抗菌药物耐药率<2%。肺炎克雷伯菌碳青霉烯类抗菌药物耐药率>15%，这与相关研究[4]一致。应注意阴沟肠杆菌碳青霉烯耐药>25%，远高于国内的相关研究[3-4]，且相关研究显示[5]阴沟肠杆菌主要产NDM，限制了用于治疗CRE感染的头孢他啶阿维巴坦的使用。非发酵菌以鲍曼不动杆菌及铜绿假单胞菌为主，碳青霉烯耐药鲍曼不动杆菌分离率>80%远高于国内相关研究[6]。铜绿假单胞菌除碳青霉烯类抗菌药物耐药率>30%，其余均<30%，有良好活性。本研究显示，金黄色葡萄球菌MRSA分离率15.6%，低于相关研究[7]，这与临床医护人员注意手卫生有关。本研究分离到利奈唑胺耐药凝固酶阴性葡萄球菌，与国外研究[8]结果一致，但分离率略高，本研究中菌株主要来自血培养，但均为单个培养瓶阳性，认为污染概率大，不会影响患者治疗，但应注意护士规范采血培训及管理。应注意万古霉素耐药屎肠球菌（7.1%）及利奈唑胺耐药粪肠球菌（11.6%）均高于国内相关研究[3]。本研究还发现，非白色念珠菌的分离率超过白色念珠菌，且高于国内研究[9]，这与该医院以无菌体液送检为主有一定关系。热带念珠菌对三唑类抗菌药物的耐药率>20%，这与国内其他研究[9]一致，应增加棘白菌素等药物的检测，以供临床参考。
综上所述，本研究数据显示，沈阳市某三级甲等医院病原菌分布及耐药性与国内其他地区监测结果存在差异，有必要进行本院菌株的耐药监测，以及时了解病原菌分布及耐药情况，为抗感染诊治提供依据。
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