1、耐药细菌感染暴发与监测吴安华 医学博士,教授中南大学湘雅医院感染控制中心湖南省医院感染管理质量控制中心卫生部医院感染监控管理培训基地(dr_)第1页，共85页。内容提要 为什么会出现耐药菌?耐药菌的危害有哪些?有哪些常见的耐药菌?如何监测耐药菌感染?耐药菌感染暴发举例 如何监测耐药菌感染暴发?如何利用耐药菌监测资料?第2页，共85页。一、为什么会出现耐药菌?内源性 自身细菌如何变成耐药菌 外因与内因 外源性 从哪里来？如何来？第3页，共85页。抗菌药物与细菌耐药性 1998年Stuart B Levy在新英格兰医学杂志发表题为多重耐药-一个时代的标志的文章，认为（1）只要给予抗菌药物的使用足够
2、的时间，就会出现细菌耐药性。使用青霉素25年后耐青霉素肺炎球菌、氟喹诺酮使用10年后出现了肠杆菌耐药的问题，现在我们要考虑万古霉素不敏感的金葡菌和耐红霉素的化脓性链球菌的问题。第4页，共85页。抗菌药物与细菌耐药性（2）耐药性是不断进化的，随着抗菌药物的应用，由低度耐药至中度耐药至高度耐药。（3）对一种抗菌药物耐药的微生物可能对其他抗菌药物也耐药。（4）细菌一旦出现耐药性，细菌的耐药性的消亡很慢。（5）使用抗菌药物治疗后容易携带耐药菌。第5页，共85页。抗菌药物与细菌耐药性 细菌耐药性从医院内向医院外扩散 不仅引起医院内感染，而且引起社区感染，如耐青霉素肺炎球菌，MRSA等 原因？第6页，共8
3、5页。细菌耐药问题日益严重 “目前抗菌药物失去作用的速度与科学家发现新抗菌药物的速度差不多。”第7页，共85页。二、耐药菌的危害有哪些?对患者增加哪些负面影响？对医院增加哪些负面影响？对社会增加哪些负面影响？对医务人员有哪些负面影响？对抗菌药物研发和生产有哪些影响？。第8页，共85页。细菌耐药性对人类健康的影响和造成的经济学损失是巨大的，Holmberg等的研究表明，包括医院内感染和社区获得性感染，耐药菌感染者的住院时间和病死率，至少是同种敏感菌感染者的2倍。对耐药菌的感染可能需要使用毒性更大或/和更昂贵的抗菌药物第9页，共85页。三、有哪些常见的耐药菌?MRS MRSA MRSE MRCo
4、NS VRE PRSP PISP PNSP VRS VRSA VRSE MDR-TB，MDR-GNB ESBLS阳性菌，AmpC 阳性菌 金属酶阳性菌 耐氨苄西林流感嗜血杆菌。第10页，共85页。四、如何监测耐药菌感染?标本送检资料（数量，分布，质量）分离细菌资料（数量、分布、构成比）细菌对试验药物的耐药性 药物对细菌的敏感性 特殊细菌对特殊药物的敏感性 医院内与科室间 医院间与地区间 耐药性与消耗量。第11页，共85页。湘雅医院2007年1-9月份细菌抗菌药物药敏试验报告 第12页，共85页。第13页，共85页。第14页，共85页。第15页，共85页。第16页，共85页。第17页，共85页。
5、第18页，共85页。第19页，共85页。第20页，共85页。第21页，共85页。第22页，共85页。第23页，共85页。第24页，共85页。第25页，共85页。第26页，共85页。第27页，共85页。中国细菌耐药性监测广州医学院一附院广州医学院一附院湖北同济医院湖北同济医院上海市儿童医院上海市儿童医院重庆医大一附院重庆医大一附院甘肃省人民医院甘肃省人民医院新疆医大一附院新疆医大一附院第28页，共85页。2007年CHINET监测网标本类型株数%呼吸道标本1771749.05 尿液标本707219.58 血标本403311.17 伤口渗液17864.94 其他体液(胸、腹水、关节液等)11353
6、.14 生殖道分泌液7772.15 脑脊液4091.13 粪便4551.26 其他27337.57 总计36117100.00 第29页，共85页。CHINET 细菌株数 细菌株数革兰阴性菌革兰阴性菌 产碱杆菌133 大肠埃希菌652727.6 摩根菌属127 铜绿假单胞菌398816.9 志贺菌属122 克雷伯菌属325813.8 卡他莫拉菌95 不动杆菌属315713.4 奈瑟菌属25 肠杆菌属12315.2 普罗威登菌属16 嗜麦芽窄食单胞菌11805.0 沙门菌属12 流感嗜血杆菌755 黄杆菌属6 变形杆菌属548革兰阳性菌革兰阳性菌 其他嗜血杆菌399 凝固酶阴性葡萄球菌43923
7、5.2 其他假单胞菌322 （血培养2019，46%）金杆菌属289 金葡菌338427.1 柠檬酸杆菌属277 肠球菌属263421.1 伯克霍尔德菌属254 溶血性链球菌802 沙雷菌属253 肺炎链球菌694合计35236 草绿色链球菌356第30页，共85页。2007年CHINET监测网各医院产ESBL菌株检出率医院大肠埃希菌肺杆和产酸奇异变形杆菌产ESBLs株数/总株数（%）产ESBLs株数/总株数（%）产ESBLs株数/总株数（%）华山医院280/64043.8 261/55247.3 16/6325.4 瑞金医院528/108248.8 103/31932.3 9/7412.2
8、协和医院407/76853.0 107/39327.2 7/4017.5 同济医院603/83672.1 210/41450.7 7/3818.4 浙医一附院420/65664.0 146/35141.6 0/320.0 广州一附院131/33239.5 59/17733.3 3/437.0 北京医院154/29452.4 35/18718.7 1/128.3 上海儿科医院534/109448.8 178/25270.6 13/7118.3 上海儿童医院255/47254.0 195/30963.1 2/219.5 重庆医大一附院89/18647.8 42/13830.4 0/120.0 甘肃
9、省人民医院54/11049.1 18/11715.4 0/40.0 新疆医大一附院7/5712.3 8/3522.9 0/50.0合计3462/652753.01362/324442.058/41514.012.3-72.112.3-72.115.4-70.615.4-70.6第31页，共85页。2007年CHINET监测网各医院葡萄球菌属MR菌株检出率医院金黄色葡萄球菌凝固酶阴性葡萄球菌MR株数/总株数（%）MR株数/总株数（%）华山医院423/52680.4 261/31283.7 瑞金医院371/55467.0 329/50565.1 协和医院304/53157.3 451/55381.
10、6 同济医院233/40158.1 359/45079.8 浙医一附院97/18053.9 588/77276.2 广州一附院74/9974.7 235/28083.9 北京医院265/35474.9 109/15271.7 上海儿科医院31/22913.5 507/73668.9 上海儿童医院78/32923.7 403/45488.8 重庆医大一附院17/5133.3 71/7989.9 甘肃省人民医院57/8864.8 52/6777.6 新疆医大一附院13/4231.0 26/3281.3 总计1963/338458.03391/439277.213.5-80.413.5-80.4 6
11、5-9065-90第32页，共85页。2007年12家医院1362株产ESBL克雷伯菌属耐药率（%）抗菌药物耐药敏感阿米卡星30.966.5庆大霉素57.741.7哌拉西林97.71.6哌拉西林/他唑巴坦27.644.3头孢呋辛96.22.3头孢噻肟81.92.7头孢他啶48.640.9头孢吡肟36.145.4头孢哌酮/舒巴坦14.658.9头孢西丁25.170.5亚胺培南0.998.5美罗培南0.398.7环丙沙星44.940复方磺胺甲噁唑66.430.3对碳青霉烯类耐药率低对内酰胺类、氨基糖苷类、喹诺酮类耐药率均很高第33页，共85页。2007年12家医院1882株非产ESBL克雷伯菌属耐
12、药率（%）抗菌药物耐药敏感阿米卡星7.990.6庆大霉素17.381.8哌拉西林29.150.2哌拉西林/他唑巴坦9.380.5头孢呋辛17.977.7头孢噻肟1084.4头孢他啶7.590.1头孢吡肟3.993.1头孢哌酮/舒巴坦4.291.2头孢西丁10.985.5亚胺培南0.499.5美罗培南0.599.5环丙沙星19.174.7复方磺胺甲噁唑25.871.8对两种酶抑制剂复方、第3、4代头孢菌素和碳青霉烯类耐药率均10%对氨基糖苷类、喹诺酮类、头霉素类亦较敏感第34页，共85页。2007年12家医院46株伤寒沙门菌和副伤寒沙门菌A耐药率（%）抗菌药物耐药敏感氨苄西林21.178.9氨苄
13、西林/舒巴坦8.189.2头孢曲松3.792.6环丙沙星0.089.1复方磺胺甲噁唑13.084.8氯霉素8.791.3第35页，共85页。2007年12家医院81株福氏志贺菌耐药率（%）抗菌药物耐药敏感氨苄西林98.71.3氨苄西林/舒巴坦62.28.1头孢曲松50.746.6环丙沙星966.7氯霉素6826.7磷霉素7.591复方磺胺甲噁唑74.425.6磷霉素、环丙沙星的耐药率10%第36页，共85页。2007年12家医院1180株嗜麦芽窄食单胞菌耐药率（%）抗菌药物耐药敏感头孢哌酮/舒巴坦16.363.4左氧氟沙星12.984复方磺胺甲噁唑11.487.9米诺环素1.597.4第37页
14、，共85页。成人和儿童医院中肺炎链球菌的分布菌株儿童分离株成人分离株株数%株数%PSSP5411.9 12474.7 PISP30767.9 2112.7 PRSP9120.1 2112.7 合计452100.0166100.0第38页，共85页。各医院泛耐药株数医院铜绿假单胞菌鲍曼不动杆菌PDR株数总株数PDR（）PDR株数总株数PDR（）华山医院64/7168.97/4491.6 瑞金医院6/3291.816/3244.9 协和医院14/4733.05/4171.2 同济医院4/5300.78/2573.1 浙医一附院18/4434.129/5505.3 广州一附院5/3291.50/11
15、50.0 重医一附院1/1460.73/1322.3 北京医院16/6162.63/1482.0 儿科医院0/1700.03/1352.2 儿童医院1/1370.70/1060.0 甘肃0/680.02/692.9 新疆0/310.00/160.0 平均129/39883.276/27182.8第39页，共85页。2006-2007年度卫生部全国细菌耐药监测（Mohnarin）结果全国革兰阴性杆菌耐药情况报告2006-2007年度卫生部全国细菌耐药监测（Mohnarin）报告。2007年8月第40页，共85页。临床分离细菌的数量 本年度共收集临床分离108137株细菌的药敏监测结果，其中：革兰
16、阳性菌33278株，占30.8%革兰阴性菌74859株，占69.2%2006-2007年度卫生部全国细菌耐药监测（Mohnarin）报告。2007年8月第41页，共85页。革兰阴性菌分布革兰阴性菌中分离量前4位分别是大肠埃希菌（28.0%）、铜绿假单胞菌（18.3%）、肺炎克雷伯菌（14.1%）和鲍曼不动杆菌（10.2%）74859株革兰阴性菌分布2006-2007年度卫生部全国细菌耐药监测（Mohnarin）报告。2007年8月第42页，共85页。细菌来源分布标明来源的细菌中，列于前六位的细菌来源为：痰、尿、分泌物、引流液、脓和血标本细菌来源分布表明我国感染性疾病仍然以呼吸道感染为主标本来源
17、2006-2007年度卫生部全国细菌耐药监测（Mohnarin）报告。2007年8月第43页，共85页。各地区分离革兰阴性菌情况地区阴性菌肠杆菌属非发酵菌ESBLs率大肠肺克华北地区1951110605837723.6%15.9%东北地区72394683248847.4%40.4%华东地区1980011474862527.4%15.6%中南地区80674115355055.2%38.9%西北地区100546422314847.1%29.8%西南地区101886516286337.5%29.1%合计合计74859438152905135.3%24.6%2006-2007年度卫生部全国细菌耐药监测
18、（Mohnarin）报告。2007年8月第44页，共85页。五、耐药菌感染暴发及调查举例第45页，共85页。HAI Outbreaks Bias towards investigating unusual outbreaks Outbreak of common pathogen(E.coli)in common site(UTI)is likely to be ignored Uncommon pathogen would standout(Stenotrophomonas maltophilia)Distribution of agents,source,modes of transmis
19、sion depend on facility,type of patients,disease第46页，共85页。病原体Common outbreak agentsStaphylococcus aureusPseudomonas aeruginosaKlebsiella pneumoniaeSerratia marcescensEnterobacter cloacaeE.coliAcinetobacter baumaniiBurkholderia cepaceaLegionella pneumophilaM.tuberculosisCandida albicansAspergillusRot
20、avirusNorovirusRSVHBVHCVCommon HAI agents8 species of bacteria=75%of all bacterial isolated:Staphylococcus aureusEnterococcus sppHaemophilus influenzaeEscherichia coliKlebsiella sppEnterobacter sppProteus sppPseudomonas aeruginosaStreptococciSerratiaCandida albicans第47页，共85页。病原体第48页，共85页。新生儿病房暴发不动杆菌
21、流行104株药敏试验及质粒分析目的；新生儿病房不动杆菌败血症爆发流行，了解不动杆菌的耐药性和质粒的关系。方法收集来自病儿血培养lO4株不动杆菌，进行对16种抗菌药物的药敏试验和质粒检测。结果lO4株均检出质粒，56株流行型含有4个相同的质粒(3o1、31、25、2Kb)，非流行型的质粒数目不等(16个)。细菌的耐药性与质粒密切相关，对庆大、卡那、妥布、红霉素、萘啶酸、头孢盂多、复方新诺明耐药率流行型显著高于非流行型，在多重耐药菌株构成比中流行型也显著高于非流行型。结论新生儿病房流行不动杆菌呈多重耐药性，耐药率流行型菌株高于非流行型；新生儿不动杆菌感染选择头孢氨噻肟和丁胺卡那霉素为宜。临床流行病
22、学调查质粒分析结合药敏实验效果较好。王岚 张万明，中国现代实用医学杂志，2005第49页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 Middlemore Hospital is a 632-bed general hospital with specialist plastic surgery and orthopaedic units.The ICU is a seven-bed unit with two burns/isolation rooms.Patients who sustain burn injury are admitted to these rooms for
23、stabilization.Surveillance cultures are not done routinely on all patients in the ICU.Investigation of an outbreak of multi-drug resistant Acinetobacter baumannii in an intensive care burns unit 第50页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查In January 1999 an apparent increase in the number of isolates of an A.bau
24、mannii susceptible only to carbapenems,tobramycin and amikacin was noted.The microbiology laboratory records were reviewed.Over the preceding 12-month period,there had been 82 new isolations of Acinetobacter spp.,34 of which were from the ICU.During the three-month period of this outbreak,there were
25、 15 new isolates of Acinetobacter spp.,12 from the ICU.All 15 had the same antibiogram.Standard definitions for nosocomial infection were used and,in the absence of supporting clinical and laboratory signs of infection,patients from whom a positive culture was obtained were considered colonized with
26、 Acinetobacter第51页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 The organism was identified as A.baumanniiusing the API 20NE system for non-fastidious Gram-negative rods not belonging to the Enterobacteriaceae(BioMrieux sa,France).The profile number was 0041473.Antimicrobial susceptibility testing of clinical isolate
27、s was performed by the standard NCCLS method(NCCLS M2-A4).Environmental isolates were identified as previously described and antimicrobial susceptibility testing was also carried out in the same manner as for clinical isolates第52页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 Strain relatedness was assessed by examini
28、ng the chromosomal DNA macrorestriction pattern.PFGE of total chromosomal DNA digested withSmaI was performed according to a ublished protocol16 with minor modifications.Electrophoresis was performed in a CHEF Mapper with a linear ramped current of 535 V/cm for 22 h.The banding patterns were compare
29、d visually.Isolates were arbitrarily designated a PFGE type第53页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 The outbreak investigation involved microbiological sampling of the environment and culturing of the hands of HCWs.Environmental sites were selected for sampling on the basis of a literature review with emphas
30、is placed on ventilator circuits and surfaces suspected of being heavily contaminated by respiratory secretions.第54页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 The hands of the HCWs were sampled to assess the potential of hand carriage,given the multiple manipulations of the ventilator equipment and the other patie
31、nt support equipment in the room.Hand cultures were obtained from medical,nursing and paramedical personnel by having them place their dominant hand in a sterile plastic bag containing 80 mL of trypticase soy broth.The dominant hand was then agitated against the non-dominant hand in a scrubbing moti
32、on for one minute.The broth was decanted into a sterile container第55页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查Fifteen patients were involved in the outbreak,whose infections were all hospital-acquired.The burns room environment was contaminated with the A.baumannii,as was the door handle of the door leading from
33、the ante-chamber between both rooms.This allowed the hands of HCWs to be contaminated by A.baumannii despite appropriate handwashing procedures prior to leaving the rooms.Two staff members were colonized with A.baumannii.One HCW who was directly involved in patient care was found to be heavily colon
34、ized,the other,with less patient contact,was only lightly colonized.Review of handwashing practices revealed that chlorhexidine/alcohol hand wash solution was not used by the HCW whose hands were heavily colonized.第56页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 A combination of a review of handwashing practice,educ
35、ation about the spread of bacteria via hands and contaminated environment,and the revision of infection control procedures in the unit contributed to a prompt termination of the outbreak。第57页，共85页。烧伤ICU多重耐药鲍曼不动杆菌感染暴发调查 Two interventions were required to control the outbreak;cleaning of the environme
36、nt and review of handwashing practise.S.A.Roberts,R.Findlay and S.D.R.Lang，Middlemore Hospital,South Auckland,New Zealand Journal of Hospital Infection(2001)48:228232第58页，共85页。烧伤病房MDR PA 暴发的感染控制研究 Multi-drug resistant Pseudomonas aeruginosa outbreak in a burns unit an infection control study Mark W.
37、Douglas*,Kathy Mulholland,Vicky Denyer,Thomas Gottlieb Department of Microbiology and Infectious Diseases,Concord Repatriation General Hospital,Hospital Road,Concord,NSW 2139,Australia第59页，共85页。中中LisbonLisbon医院医院MDR-TB MDR-TB 暴发调查暴发调查 An increase in the number of new cases of tuberculosis(TB)combine
38、d with poor clinical outcome was identified among HIV-infected injecting drug users attending a large HIV unit in central Lisbon.M.M.Hannan,H.Peres*,F.Maltez，Investigation and control of a large outbreak of multi-drug resistant tuberculosis at a central hospital。Journal of Hospital Infection(2001)47
39、:9197 第60页，共85页。中中LisbonLisbon医院医院MDR-TB MDR-TB 大暴发调查大暴发调查A retrospective epidemiological and laboratory study was conducted to review all newly diagnosed cases of TB from 1995 to 1996 in the HIV unit.Results showed that from 1995 to 1996,63%(109/173)of the Mycobacterium tuberculosis isolates from H
40、IV-infected patients were resistant to one or more anti-tuberculosis drugs;89%(95)of these were multidrug-resistant,i.e.,resistant to at least isoniazid and rifampicin.Eighty percent of the multidrug-resistant strains(MDR)available for restriction fragment length polymorphism(RFLP)DNA fingerprinting
41、 clustered into one of two large clusters.第61页，共85页。中中LisbonLisbon医院医院MDR-TB MDR-TB 大暴发调查大暴发调查 Epidemiological data support the conclusion that the transmission of MDR-TB occurred among HIV-infected injecting drug users exposed to infectious TB cases on open wards in the HIV unit.Improved infection
42、control measures on the HIV unit and the use of empirical therapy with six drugs once patients were suspected to have TB,reduced the incidence of MDR-TB from 42%of TB cases in 1996 to 11%in 1999.M.M.Hannan,H.Peres*,F.Maltez，Journal of Hospital Infection(2001)47:9197第62页，共85页。控制MDR AB在ICU和外科的暴发We des
43、cribe an outbreak of multi-drug-resistant Acinetobacter baumannii(MRAB)that occurred in an intensive care unit(ICU)and a surgical ward from December 2003 to March 2004.Mapping patient movements on a timeline indicated that the outbreak was confined to these two areas.Investigation by the hospitals i
44、nfection prevention service found that apossible source of spread was improper cleaning methods used on respiratory equipment.Pulsed-field gel electrophoresis analysis of available isolates indicated the presence of two distinct strains.One strain was seen in patients from the ICU and the other stra
45、in was seen in the surgical ward patients.Cleaning and environmental decontamination as well as staff education were implemented to halt further immediate spread.The deficiencies identified during the investigation were also resolved.The final outcome was the successful termination of this outbreak.
46、J.D.Pimentela,b,*,J.Lowb,K.Styles，Journal of Hospital Infection(2005)59,249253第63页，共85页。控制MDR AB在ICU和外科的暴发第64页，共85页。10 steps of an outbreak investigation10 steps of an outbreak investigationPrepare for field work Prepare for field work 准备现场工作准备现场工作Confirm an outbreak Confirm an outbreak 证实暴发存在证实暴发存在
47、Verify the diagnosis and conduct hypothesis generating interviews Verify the diagnosis and conduct hypothesis generating interviews 核实诊断，进行假设产生的访谈核实诊断，进行假设产生的访谈Develop case definition Develop case definition 确定病例定义确定病例定义 Identify and count cases Identify and count cases 识别并计数病例识别并计数病例Characterize pe
48、rson,place and time Characterize person,place and time 确定人、地点和时间特征确定人、地点和时间特征Develop and test hypotheses Develop and test hypotheses 提出并检验假设提出并检验假设Refine and test hypotheses Refine and test hypotheses 推敲并检验假设推敲并检验假设Implement control measures Implement control measures 实施控制措施实施控制措施Communicate finding
49、s Communicate findings 沟通交流发现的结果沟通交流发现的结果曾光第65页，共85页。Person to Person Spreaddays流行曲线第66页，共85页。医院感染暴发的实验室检查 容易采样 分型对于调查很重要 环境采样培养 如果流行病学有联系则有帮助 环境中存在不一定与传播有关 有流行病学资料支持时才做培养 工作人员采样 如果流行病学有联系则有帮助 定植者不一定就是传播者第67页，共85页。分子生物学技术Plasmid or Chromosomal DNAWhole or Fragmented:Restriction endonuclease cuts DNA
50、 molecules at restriction sites Enzymes selected carefully to generate appropriate fragments Some are frequent cutters,others not Amplified by Polymerase Chain reaction(PCR)millions copies of specific DNA segment produced in few hours.Product can then be digested and separated by electrophoresis.maj
