革兰阳性与阴性菌术后脑膜炎临床特征研究  

A clinical analysis of postoperative meningitis induced by gram-positive and gram-negative bacteria

作　　者：张呈呈 吕世进[1] 夏金明[1] 黄坚 汪叶松[2] 崔巍[2] 胡丽华[4] 张根生[2,5] Zhang Chengcheng;Lv Shijin;Xia Jinmin;Huang Jian;Wang Yesong;Cui Wei;Hu Lihua;Zhang Gensheng(Department of Emergency,Hangzhou Normal University Affiliated Hospital,Hangzhou 310015,China;Department of Intensive Care Medicine,the Second Affiliated Hospital of Zhejiang University School of Medicine,Hangzhou 310009,China;Department of Intensive Care Medicine,the Ninth People's Hospital of Hangzhou,Hangzhou 310020,China;Department of Intensive Care Medicine,Hospital of Zhejiang Province of Chinese People’s Armed Police,Hangzhou 310051,China;Key Laboratory of Multiple Organ Failure(Zhejiang University),Ministry of Education,Hangzhou 310009,Zhejiang,China)

机构地区：[1]杭州师范大学附属医院急诊科,杭州310015 [2]浙江大学医学院附属第二医院重症医学科,杭州310009 [3]杭州市第九人民医院急诊科,杭州310020 [4]武警浙江省总队医院重症医学科,杭州310051 [5]多脏器衰竭预警与干预教育部重点实验室(浙江大学),杭州310009

出　　处：《中华急诊医学杂志》2025年第2期211-219,共9页Chinese Journal of Emergency Medicine

基　　金：国家自然科学基金(82270086)。

摘　　要：目的关于神经外科术后细菌性脑膜炎(PNBM)的临床报道较多,但同期比较不同病原菌引起PNBM临床特征的研究较少。为此,本研究探讨神经外科术后革兰阳性菌与革兰阴性菌PNBM的临床特征与预后。方法回顾性纳入本院2013.2-2023.10期间发生PNBM的所有住院患者,分为革兰阳性菌(GPB)感染及革兰阴性菌(GNB)感染两组,收集医疗电子病历数据,分析比较其临床特征及预后。结果最后纳入PNBM患者401例,其中GPB组占19.5%(n=78),GNB组占80.5%(n=323);两组年龄平均为56(45,64)岁,男性占55.1%;与GPB组相比,GNB组其SOFA及APACHEⅡ评分均显著增高,发生高热(体温>39℃)及意识改变比例更多,脑出血及颅内动脉瘤术后比例更高,接受ICU治疗及机械通气比例也更高(P均<0.05);GNB组炎症指标血CRP及PCT≥2 ng/mL比例明显升高(P均<0.05),谷丙转氨酶(ALT)、谷草转氨酶(AST)及总胆红素(TBIL)均显著增高(P均<0.05),而血红蛋白及白蛋白浓度则明显降低(P均<0.05)。与GPB组相比,GNB组脑脊液中有核细胞数、蛋白浓度、腺苷脱氨酶浓度均显著增高,而葡萄糖含量更低(P均<0.01)。两组共分离出426株细菌,其中GNB为343株(80.5%),GPB为83株(19.5%),其中25例(6.2%)存在2种及以上革兰阳性菌,或革兰阴性细菌感染。GNB组MDR比例及鞘内注射治疗比例显著增高(分别为80.5%vs.68.7%,36.5%vs.2.6%),而抗生素经验性治疗正确率则明显降低(30.3%vs.80.0%)(P均<0.05)。GNB组ICU住院天数明显延长[中位数(四分位间距,IQR),11.5(5.25,22.75)vs.17.0(9.0,30.0),P<0.01],感染性休克和不良预后(出院时GCS≤8)发生率(分别为9.3%vs.2.6%,65.9%vs.32.1%)以及28 d住院病死率(34.4%vs.10.3%)均明显增高(P均<0.05),而7 d病死率和总住院时间两组无差别。结论革兰阴性菌感染主导神经外科术后细菌性脑膜炎的发生,相比于革兰阳性菌感染,其脑膜炎症状更显著、病情更严重,脑脊液变化更异常,治疗更棘手;尽管短期(7 d)�Objective Postoperative neurosurgical bacterial meningitis(PNBM)has been frequently reported,but fewer studies have focused on the contemporaneous comparison of clinical features of PNBM caused by different pathogenic bacteria.This study aimed to simultaneously investigate the clinical characteristics and outcomes of PNBM by Gram-positive bacterial(GPB)or Gram-negative bacterial(GNB)infection.Methods Inpatients with PNBM at our institution were recruited between February 2013 and October 2023.These PNBM patients were categorized into two groups:GPB infection and GNB infection.Data from electronic medical records were collected and analyzed.Results A total of 401 patients with PNBM were finally included,with 78(19.5%)having GPB infections and 323(80.5%)having GNB infection.The average age of the patients was 56 years,and 55.1%were male.Compared to the GPB group,PNBM patients with GNB infection had significantly higher SOFA and APACHEⅡscores,higher proportions of hyperthermia(body temperature>39°C)and altered consciousness,increased ratios of postoperative cerebral hemorrhage or intracranial aneurysm,as well as greater needs for ICU treatment and mechanical ventilation(all P<0.05).The proportions of inflammatory indicators such as blood CRP and PCT≥2 ng/mL,alanine aminotransferase(ALT),aspartate aminotransferase(AST),and total bilirubin(TBIL)were significantly higher in the GNB group(all P<0.05).In contrast,The concentrations of hemoglobin and albumin were substantially lower in this group(both P<0.05).Additionally,the cerebrospinal fluid in the GNB group showed signifi cantly higher nucleated cell counts,protein concentration,and adenosine deaminase concentration,and but lower glucose level(all P<0.001).A total of 426 bacterial strains were isolated,with 343 strains(80.5%)being GNB and 83 strains(19.5%)being GPB.Among these,25(6.2%)patients had 2 or more gram-positive or gram-negative bacterial infections.The proportions of multidrug-resistant(MDR)bacteria and intrathecal treatment were higher in the GNB grou

关 键 词：神经外科术后 细菌性脑膜炎 临床特征 预后 革兰阳性菌 革兰阴性菌 药敏 脑脊液培养 

分 类 号：R651.1[医药卫生—外科学]