鲍曼不动杆菌:选哪种抗生素可以“打动”它?

近期在 ICU 会诊了好几例泛耐药或者全耐药的鲍曼不动杆菌,有定值菌也有致病菌,有使用了替加环素控制住感染的,也有使用了替加环素联合多粘菌素 B 等等抗菌药物仍然不能控制的严重感染,患者高热不退,严重的感染引起了多器官衰竭,最终因感染不能控制而死亡。作为医者,让我感到深深的困惑和恐慌。

那么鲍曼不动杆菌是一个什么样的超级细菌?针对这种超级细菌我们该如何治疗?我们院内感染又应该如何预防?

一鲍曼不动杆菌:抗生素孕育出来的超级细菌

鲍曼不动杆菌为不动杆菌属中最常见的一种革兰阴性杆菌,广泛存在于自然界的水及土壤中,也存在于正常人体皮肤、呼吸道、消化道和泌尿生殖道中,为条件致病菌。该菌在医院环境中分布很广且可以长期存活,极易造成危重患者的感染,因此常从被感染患者的血、尿、脓液及呼吸道分泌物等标本中分离出。

鲍曼不动杆菌可引起医院获得性肺炎、血流感染、腹腔感染、中枢神经系统感染、泌尿系统感染、皮肤软组织感染等。根据 CHINET 连续的耐药监测结果,不动杆菌位于大陆大型教学医院临床分离革兰阴性菌第三位 [1]。根据 2017 年全国耐药监测报告结果显示,鲍曼不动杆菌对碳青霉烯类的耐药率分别接近 70%, 均比 2016 年有所上升 [2]。

在医院里,污染的医疗器械及鲍曼不动杆菌工作人员的手是重要的传播媒介。易感者为老年患者、早产儿和新生儿,手术创伤、严重烧伤、气管切开或插管、使用人工呼吸机、行静脉导管和腹膜透析者,广谱抗菌药物或免疫抑制剂应用者等。

二 该如何治疗鲍曼不动杆菌?

首先明确一下耐药分级:

多重耐药不动杆菌(MDRAB)是指对该菌有抗菌活性的三类及以上抗菌药物耐药;

广泛耐药不动杆菌(XDRAB)是指仅对替加环素和/或多黏菌素敏感的菌株;

全耐药不动杆菌(PDRAB)是指对目前大陆所能获得的所有抗菌药物均耐药的菌株 [1]。

(1)鲍曼不动杆菌感染(AB)的抗菌治疗原则

应综合考虑病原菌的敏感性、感染的部位、严重程度、患者病理生理状况和抗菌药物的作用特点。主要原则为如下 [1]:

鲍曼不动杆菌:选哪种抗生素可以“打动”它?

(2)鲍曼不动杆菌感染(AB)常用的抗菌药物

鲍曼不动杆菌:选哪种抗生素可以“打动”它?

(3)鲍曼不动杆菌 MDRAB、XDRAB 或 PDRAB 感染常用的联合用药

MDRAB 感染:根据药敏结果选用舒巴坦 β 内酰胺酶抑制剂的复合制剂或碳青霉烯类抗生素,可联合应用氨基糖苷类抗生素或氟喹诺酮类抗菌药物等。

XDRAB 感染常用的联合治疗方案:

鲍曼不动杆菌:选哪种抗生素可以“打动”它?

在抗感染治疗中即使药敏单提示碳青霉烯类耐药,耐药不等于完全无效,仍需联合给药,碳青霉烯类如美罗培南,增加给药频次、加大给药剂量、延长滴注时间是可以克服低水平耐药的。

(4)治疗鲍曼不动杆菌感染的疗程

疗程取决于感染严重程度、并发症及病原菌的耐药性。

鲍曼不动杆菌:选哪种抗生素可以“打动”它?

三针对院内感染应如何预防?

鲍曼不动杆菌医院感染大多为外源性医院感染,其传播途径主要为接触传播,因此应做到如下管理:

(1)加强手卫生院感管理:良好的手卫生可显著降低耐药菌感染发病率、定植发生率,是减少医院感染发生的关键措施之一 [4]。

(2)规范采集送检,正确解读微生物检测报告:对临床诊断为细菌真菌性感染的病例, 应在开始抗菌治疗前, 及时采集感染部位合格的微生物标本送病原学检测 [5]。

(3)减少抗菌药物不合理使用:对替加环素、碳青酶烯类特殊级抗菌药物应用临床应用监督管理,严格落实抗菌药物分级和医师处方权管理要求;鼓励临床药学部门积极开展药物浓度监测和药代动力学 (PK)-药效学 (PD) 相关研究,杜绝使用不符合 PK/PD 原理的药物。做好抗菌药物临床应用管理工作是促进抗菌药物合理使用、遏制细菌耐药及其造成感染的有效措施。

(4)接触预防 [2]:接触耐药菌感染 / 定植患者的医务人员、家属和陪护人员均应正确执行接触预防措施:包括穿戴个人防护用品、设备专用、限制患者转运和规范管理医疗废物等。

(5)加强环境清洁与消毒等。

参考文献:

[1] 周华,周建英,俞云松。中国鲍曼不动杆菌感染诊治与防控专家共识解读,中国循证医学杂志,2016, 16(1): 26~29。

[2] 中国碳青霉烯耐药革兰阴性杆菌 (CRO) 感染预防与控制技术指引,中华医院感染学杂志,2019,29(13):1921-1926

[3] 徐英春, 肖永红, 卓超, 等. 中国碳青霉烯类耐药肠杆菌科细菌的流行病学和防控策略 [J]. 中国执业药师.2013,10(4):3-8.

[4] 黄勋, 邓子德, 倪语星, 等. 多重耐药菌医院感染预防与控制中国专家共识 [J]. 中国感染控制杂志,2015,14(1):1-9.

[5] 中华人民共和国国家卫生与计划生育委员会. 抗菌药物临床应用指导原则 (2015 版).

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Embroidery bird is difficult to train, talk about my plate "embroidery" experience

Recently chatted with friends, often talked about the breeding of embroidery eyes, for embroidery I personally do not play for a long time, just a few years.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

I remember when I started raising embroidery eyes, the biggest headache I encountered was the cage problem. It was the first time I touched the embroidery eye and was attracted by its appearance, and after I brought it back, I was worried that the embroidery eye would be restless in the cage, so I hung it from a long distance every time. It's been like this for about a year, and every time people approach the cage, there will still be a situation of bumping into the cage.

It was precisely because of the failure of the first time that I almost lost confidence in the embroidery eye and planned to give up. However, every time I pass by the bird market and see people's embroidered eyes singing safely and steadily in the cage, my heart will inevitably itch.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

After a coincidence, I met a master of raising "embroidery", so I told him about my situation, and I did not expect that his embroidery cage would not exceed 1 month each time, and it would basically be taken down in half a month. Later I told me that wild birds are afraid of people, as long as they are not old birds, the more afraid of people birds, the better, like the embroidery eyes that have just come down the mountain can directly pick up insects from hand.

Why? Because for birds in the wild, most of them are social. There is also a distinction between them, like that kind of loud, physique, good strips, generally in the bird group is not low, this bird whether it is courtship or fighting has a great advantage, so let a monarch mentality of the bird cage is certainly more difficult than the usual bird, and some old experience of the breeder like this kind of bird with character, once it can be adjusted out is a good product.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

Talking about how to plate the embroidery eye, he said that the new bird is difficult to train at the beginning is normal and cannot be reluctant to let it be injured and eat and drink well and only hang from a distance. This will certainly not make a good bird come out. If you choose your favorite bird, take it home and squat for a week or so, first recognize the environment and change food, you can also try to give some water bathing, this week's time is to observe the problems it carries, so that you have a number.

After a week, if you find that the bird has more problems, or has a big problem, you can consider changing the bird or eliminating it to avoid wasting your time. If you feel that you are okay from the whole state to the habit, then you are ready to start the plate.

Since it is a pan bird, it cannot be soft. Like the large body, large head, thin feathers, good embroidery eyes are not easy to look up. Their status in the life of the clan is not low. Like some leading flights and fights, they generally like to do things, so they can't just look at the outside of the cage, that is fierce, not timid. They have developed a super high alertness, and their experience of survival is richer than that of low-status embroidery eyes.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

Those embroidered eyes with bad strips are generally accompanied by large troops in the field, and they have no opinions and a strong sense of dependence. Even in the wild, when encountering unexpected situations, they rely on the leader to issue a warning, so their alertness is low, their awareness of danger is weak, and once they are locked in a cage, they will use their heads up or turn their heads to avoid danger.

For how to disk, it can be said that the benevolent see the wise. Some people like to walk the bird to grind its temperament and adapt it to the environment as soon as possible. However, he did not do this, and usually the raw birds he chose were the kind that were confident that they would not look up, so they would start devil training after a week. Its training method is very simple, that is, what should I do, put the bird in the place where people often walk, and the more afraid it is, the more people will walk back and forth around it. I don't worry about getting hurt, generally the probability of bird injury or wing bleeding in the early stage is not large, and the back will slowly grow better.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

After two or three weeks of this cruel mental torture, it will become numb to this environment, and no matter how close we get to it, it will not hit the cage, and then we can start training hand-to-hand food.

Since talking to him, I have changed my mind about caged birds a lot. I slowly tried to cultivate and found that using his method was still very practical. As long as the selected bird is strong enough and has a personality, it will not look up and basically half a month's embroidered eyes will be caged.

Embroidery bird is difficult to train, talk about my plate "embroidery" experience

Although this method looks quite violent, it is simple and direct, and the most important thing is that it is very effective. Today to share with you, but also hope to give you a reference. There is no only way to raise birds, all roads lead to Rome, I hope that bird friends can also share their own experience for everyone to learn and make progress together.

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