多粘菌素B为基础联合治疗泛耐药菌重症肺炎的临床观察  

Clinical observation on polymyxin B-based combination therapy for severe pneumonia caused by extensively drug-resistant bacteria

作　　者：王妍[1] 郭晓芳 陈显成 曹科 冯芜若 尤勇[1] 虞文魁[1] 朱章华[1] WANG Yan;GUO Xiao-fang;CHEN Xian-cheng;CAO Ke;FENG Wu-ruo;YOU Yong;YU Wen-kui;ZHU Zhang-hua(Department of Critical Care Medicine,Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属南京鼓楼医院重症医学科,江苏南京210008

出　　处：《中国感染控制杂志》2020年第11期976-980,共5页Chinese Journal of Infection Control

基　　金：南京市医学科技发展项目(YKK13059)。

摘　　要：目的了解多粘菌素B为基础联合治疗泛耐药鲍曼不动杆菌(XDR-AB)、泛耐药肺炎克雷伯菌(XDR-KP)重症肺炎的疗效及不良反应,为临床医生治疗泛耐药菌重症肺炎提供支持依据。方法选择2018年4月1日—2019年4月30日入住某院重症医学科,经病原学检查确定为XDR-AB和/或XDR-KP所致重症肺炎,选取以多粘菌素B为基础的联合治疗方案的患者为研究对象,观察患者临床治疗效果、微生物治疗效果,以及肝肾功能损害、皮肤黑色素沉着等不良反应情况。结果共入选24例泛耐药菌重症肺炎患者,进行26次治疗,临床治疗有效率为73.1%。共送检139次痰培养,138次药敏结果对多粘菌素B敏感(MIC 0.5~1μg/mL),仅有1次对多粘菌素B耐药(MIC=8μg/mL)。鲍曼不动杆菌组细菌清除率高于肺炎克雷伯菌组(60.9%VS 7.7%),差异有统计学意义(P=0.004)。急性肾损伤(AKI)发生率为42.3%,仅1例患者因肾功能损害而提前结束治疗;AKI存活患者(存活率60.0%)肾功能均恢复正常,皮肤黑色素沉着发生率为20.8%,未发现药物相关性肝功能损害和其他并发症。结论以多粘菌素B为基础联合治疗XDR-AB、XDR-KP重症肺炎的有效率高。尽管菌株对多粘菌素B敏感性较高,但细菌清除率相对较低,多粘菌素B有一定肾毒性,积极治疗原发病后存活患者的肾损害一般可逆。Objective To investigate the therapeutic efficacy and side effect of polymyxin B-based combination therapy for the treatment of severe pneumonia caused by extensively drug-resistant Acinetobacter baumanii(XDR-AB)and XDR Klebsiella pneumoniae(XDR-KP),and provide support for clinicians in the treatment of severe pneumonia caused by XDR bacteria.Methods Patients who were admitted to the department of critical care medicine of a hospital from April 1,2018 to April 30,2019 and received polymyxin B-based combination therapy for pathogenic confirmed extensively XDR-AB and XDR-KP severe pneumonia were selected as research objects.Therapeutic efficacy,microbial treatment efficacy,liver and kidney function damage,pigmentation of skin and other side effects were observed.Results A total of 24 patients with XDR bacterial severe pneumonia were selected,26 times of treatment were conducted,clinical therapeutic effective rate was 73.1%.A total of 139 sputum cultures were sent for examination,138 times of antimicrobial susceptibility results showed that bacteria were sensitive to polymyxin B(MIC 0.5-1μg/mL),only one time was resistant to polymyxin B(MIC=8μg/mL).Bacterial clearance rate of Acinetobacter baumannii was higher than that of Klebsiella pneumoniae(60.9%vs 7.7%),difference was statistically significant(P=0.004).Incidence of acute kidney injury(AKI)was 42.3%,only one patient ended treatment in advance because of renal function damage;renal function of the survival patients with AKI(survival rate 60.0%)all recovered to normal,incidence of pigmentation of skin was 20.8%,drug-related liver damage and other complications were not found.Conclusion Efficacy of polymyxin B-based combination therapy for XDR-AB and XDR-KP severe pneumonia is high,although strains are sensitive to polymyxin B,bacterial clearance rate is relatively low,polymyxin B has certain nephrotoxicity,and the renal damage of patients who survived after active treatment of primary disease is generally reversible.

关 键 词：多粘菌素B 泛耐药 鲍曼不动杆菌 肺炎克雷伯菌 急性肾损伤 

分 类 号：R181.32[医药卫生—流行病学]