会阴部和/或臀部烧伤患者导尿管相关尿路感染流行病学特点及危险因素分析

郑欣欣; 孔令爱; 吕让; 徐彩娟

doi:10.3760/cma.j.cn501225-20231027-00138

会阴部和/或臀部烧伤患者导尿管相关尿路感染流行病学特点及危险因素分析

doi: 10.3760/cma.j.cn501225-20231027-00138

1.
浙江大学医学院附属第二医院护理部，杭州　　310009
2.
潍坊市人民医院胃肠外科医学中心，潍坊　　261041
3.
湖州师范学院护理学院，湖州　　313000

详细信息

通讯作者:
徐彩娟，Email：xucaijuan@zju.edu.cn

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出版历程
- 收稿日期: 2023-10-27

Analysis of epidemiological characteristics and risk factors of catheter-associated urinary tract infections in patients with perineal and/or hip burns

1.
Nursing Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
2.
Gastrointestinal Surgery Medical Center, Weifang People's Hospital, Weifang 261041, China
3.
School of Nursing, Huzhou University, Huzhou 313000, China

More Information

Corresponding author: Xu Caijuan, Email: xucaijuan@zju.edu.cn

摘要

摘要: 目的探讨会阴部和/或臀部烧伤患者导尿管相关尿路感染的流行病学特点及危险因素。方法该研究为回顾性病例系列研究。2018年1月—2022年12月，浙江大学医学院附属第二医院烧伤与创面修复科收治260例符合入选标准的会阴部和/或臀部烧伤且留置导尿管的患者，其中男192例、女68例，年龄20~93岁。统计会阴部和/或臀部烧伤患者导尿管相关尿路感染总发病率、病原菌检出情况、主要革兰阴性菌与革兰阳性菌对临床常用抗菌药物的耐药情况。根据是否发生导尿管相关尿路感染，将患者分为感染组（43例）和非感染组（217例）。比较2组患者入院时性别、年龄、烧伤总面积、会阴部烧伤深度、臀部烧伤深度、烧伤部位等基本情况，合并糖尿病、吸入性损伤、低蛋白血症情况，气管切开、非会阴部/臀部的清创/植皮手术等有创操作情况，以及导尿管留置时间、导尿次数、膀胱冲洗情况。筛选影响会阴部和/或臀部烧伤患者发生导尿管相关尿路感染的独立危险因素。结果该研究中会阴部和/或臀部烧伤患者导尿管相关尿路感染总发病率为16.5%（43/260）。检出的病原菌以革兰阴性菌为主，其次为真菌；主要革兰阴性菌为肺炎克雷伯菌，主要革兰阳性菌为屎肠球菌。肺炎克雷伯菌对阿莫西林/克拉维酸、氨曲南、阿米卡星、环丙沙星、头孢曲松、左氧氟沙星的耐药率均高于70.0%，对头孢西丁、头孢哌酮/舒巴坦、头孢吡肟、美罗培南、亚胺培南和哌拉西林/他唑巴坦的耐药率为56.3%~68.8%，对头孢他啶、替加环素的耐药率均低于50.0%；屎肠球菌对环丙沙星、青霉素的耐药率均为85.7%，对红霉素、克林霉素、莫西沙星、四环素的耐药率为14.3%~57.1%，对利奈唑胺、替加环素、万古霉素的耐药率均为0。2组患者性别、合并低蛋白血症情况、会阴部烧伤深度、非会阴部/臀部的清创/植皮手术情况、膀胱冲洗情况、导尿次数、导尿管留置时间比较，差异均有统计学意义（ χ ²值分别为7.80、4.85、10.68、9.11、16.48， Z值分别为-4.88、-5.42， P<0.05）；2组患者年龄、烧伤总面积、合并糖尿病和吸入性损伤情况、烧伤部位、臀部烧伤深度、气管切开情况比较，差异均无统计学意义（ P>0.05）。多因素logistic回归分析显示，性别、会阴部深Ⅱ度烧伤、非会阴部/臀部的清创/植皮手术、膀胱冲洗、导尿管留置时间均为影响会阴部和/或臀部烧伤患者发生导尿管相关尿路感染的独立危险因素（比值比分别为2.86、2.63、2.79、2.34、1.04，95%置信区间分别为1.21~6.73、1.03~6.71、1.03~7.59、1.05~5.22、1.02~1.06， P<0.05）。结论会阴部和/或臀部烧伤患者导尿管相关尿路感染发病率较高，其病原菌以肺炎克雷伯菌为主且该菌对临床常用抗菌药物的耐药率较高。性别、会阴部深Ⅱ度烧伤、非会阴部/臀部的清创/植皮手术、膀胱冲洗、导尿管留置时间为会阴部和/或臀部烧伤患者导尿管相关尿路感染的独立危险因素。
- 烧伤 /
- 会阴 /
- 臀 /
- 感染 /
- 危险因素 /
- 导尿管相关尿路感染
Abstract: Objective To explore the epidemiological characteristics and risk factors of catheter-associated urinary tract infections in patients with perineal and/or hip burns. Methods This study was a retrospective case series study. From January 2018 to December 2022, 260 patients with perineal and/or hip burns and urinary catheters indwelling who met the inclusion criteria were admitted to the Department of Burns and Wound Repair of the Second Affiliated Hospital of Zhejiang University School of Medicine, including 192 males and 68 females, aged 20-93 years. The total incidence of catheter-associated urinary tract infections in patients with perineal and/or hip burns, the detection of pathogenic bacteria, and the resistance of major Gram-negative and Gram-positive bacteria to commonly used antimicrobial drugs in clinic were recorded. According to whether catheter-associated urinary tract infection occurred or not, the patients were divided into infection group (43 cases) and non-infection group (217 cases). The basic conditions including gender, age, total burn area, depth of perineal burn, depth of hip burn, and burn site on admission, complications of diabetes mellitus, inhalation injury, and hypoproteinaemia, invasive operations including tracheotomy and non-perineal/hip debridement/skin transplantation surgery, duration of catheter retention, number of urethral catheterization, and bladder irrigation of patients between the two groups were compared, and the independent risk factors influencing the occurrence of catheter-associated urinary tract infections in patients with perineal and/or hip burns were screened. Results The total incidence of catheter-associated urinary tract infections in patients with perineal and/or hip burns in this study was 16.5% (43/260). The pathogens detected were predominantly Gram-negative, followed by fungi; the main Gram-negative bacterium was Klebsiella pneumoniae, and the main Gram-positive bacterium was Enterococcus faecalis. The resistance rates of Klebsiella pneumoniae to amoxicillin/clavulanic acid, amitraz, amikacin, ciprofloxacin, ceftriaxone, and levofloxacin were higher than 70.0%, the resistance rates of Klebsiella pneumoniae to cefoxitin, cefoperazone/sulbactam, cefepime, meropenem, imipenem, and piperacillin/tazobactam ranged from 56.3% to 68.8%, and the resistance rates of Klebsiella pneumoniae to ceftazidime and tigecycline were lower than 50.0%. The resistance rates of Enterococcus faecalis to ciprofloxacin and penicillin were both 85.7%, the resistance rates of Enterococcus faecalis to erythromycin, clindamycin, moxifloxacin, and tetracycline ranged from 14.3% to 57.1%, and the resistance rates of Enterococcus faecalis to linezolid, tigecycline, and vancomycin were all 0. The differences were statistically significant between the two groups in terms of gender, status of complication of hypoproteinaemia, depth of perineal burn, status of non-perineal/hip debridement/skin transplantation surgery, status of bladder irrigation, number of urethral catheterization, and duration of catheter retention of patients (with χ ² values of 7.80, 4.85, 10.68, 9.11, and 16.48, respectively, and Z values of -4.88 and -5.42, respectively, P<0.05). There were no statistically significant differences in the age, total burn area, complications of diabetes mellitus and inhalation injury, burn site, depth of hip burns, and status of tracheotomy of patients between the two groups ( P>0.05). Multifactorial logistic regression analysis showed that gender, deep partial-thickness perineal burns, non-perineal/hip debridement/skin transplantation surgery, bladder irrigation, and duration of catheter retention were the independent risk factors for catheter-associated urinary tract infections in patients with perineal and/or hip burns (with odds ratios of 2.86, 2.63, 2.79, 2.34, and 1.04, respectively, with 95% confidence intervals of 1.21-6.73, 1.03-6.71, 1.03-7.59, 1.05-5.22, and 1.02-1.06, respectively, P<0.05). Conclusions The incidence of catheter-associated urinary tract infections is high in patients with perineal and/or hip burns, with Klebsiella pneumoniae as the predominant pathogenic bacteria having a high resistance rate to commonly used antimicrobial drugs in clinic. Gender, deep partial-thickness perineal burns, non-perineal/hip debridement/skin transplantation surgery, bladder irrigation, and duration of catheter retention are the independent risk factors for catheter-associated urinary tract infections in patients with perineal and/or hip burns.
- Burns /
- Perineum /
- Buttocks /
- Infection /
- Risk factors /
- Catheter-associated urinary tract infection
郑欣欣：研究设计、数据收集、论文撰写；孔令爱：论文修改；吕让：统计分析；徐彩娟：研究指导、论文修改

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参考文献(20)

[1]	DerkenneC,RonchiL,PrunetB.Management of burns[J].N Engl J Med,2019,381(12):1188.DOI: 10.1056/NEJMc1909342.
[2]	MichielsenDP,LafaireC.Management of genital burns: a review[J].Int J Urol,2010,17(9):755-758.DOI: 10.1111/j.1442-2042.2010.02605.x.
[3]	BordesJ,Le FlochR,BourdaisL,et al.Perineal burn care: French working group recommendations[J].Burns,2014,40(4):655-663.DOI: 10.1016/j.burns.2013.09.007.
[4]	ClemensMS,JanakJC,RizzoJA,et al.Burns to the genitalia, perineum, and buttocks increase the risk of death among U.S. service members sustaining combat-related burns in Iraq and Afghanistan[J].Burns,2017,43(5):1120-1128.DOI: 10.1016/j.burns.2017.01.018.
[5]	HarpoleBG,WibbenmeyerLA,EricksonBA.Genital burns in the national burn repository: incidence, etiology, and impact on morbidity and mortality[J].Urology,2014,83(2):298-302.DOI: 10.1016/j.urology.2013.10.039.
[6]	KranzJ,SchmidtS,WagenlehnerF,et al.Catheter-associated urinary tract infections in adult patients[J].Dtsch Arztebl Int,2020,117(6):83-88.DOI: 10.3238/arztebl.2020.0083.
[7]	DeeterL,SeatonM,CarrougherGJ,et al.Hospital-acquired complications alter quality of life in adult burn survivors: report from a burn model system[J].Burns,2019,45(1):42-47.DOI: 10.1016/j.burns.2018.10.010.
[8]	卫生部办公厅导尿管相关尿路感染预防与控制技术指南(试行) 2010-11-29 2023-05-13 http://www.gov.cn/gzdt/2010-12/14/content_1765450.htm 卫生部办公厅.导尿管相关尿路感染预防与控制技术指南(试行)[EB/OL].(2010-11-29)[2023-05-13].http://www.gov.cn/gzdt/2010-12/14/content_1765450.htm.
[9]	张可祥,李风.烧伤患者泌尿系医院感染病原体调查与临床研究[J].重庆医学,2009,38(10):1225-1226.DOI: 10.3969/j.issn.1671-8348.2009.10.037.
[10]	向军,郇京宁.烧伤患者抗碳青霉烯类抗生素肺炎克雷伯菌感染的再认识及抗菌治疗策略[J].中华烧伤杂志,2018,34(11):790-795.DOI: 10.3760/cma.j.issn.1009-2587.2018.11.014.
[11]	LanP,JiangY,ZhouJ,et al.A global perspective on the convergence of hypervirulence and carbapenem resistance in Klebsiella pneumoniae[J].J Glob Antimicrob Resist,2021,25:26-34.DOI: 10.1016/j.jgar.2021.02.020.
[12]	曾凌,徐珍,戴小华,等.烧伤患者耐碳青霉烯类肺炎克雷伯菌感染的环境追踪研究[J].中国感染控制杂志,2022,21(12):1179-1184.DOI: 10.12138/j.issn.1671-9638.20223116.
[13]	张娇珍,林秀慧,张新平,等.尿路感染患者尿液标本分离肠球菌的临床分布、耐药性及毒力特征[J].中华医院感染学杂志,2023,33(5):713-717.DOI: 10.11816/cn.ni.2023-221016.
[14]	全国细菌耐药监测网.2020年全国细菌耐药监测报告[J].中华检验医学杂志,2022,45(2):122-136.DOI: 10.3760/cma.j.cn114452-20211118-00721.
[15]	ZamparEF,AnamiEHT,KerbauyG,et al.Infectious complications in adult burn patients and antimicrobial resistance pattern of microorganisms isolated[J].Ann Burns Fire Disasters,2017,30(4):281-285.
[16]	刘琰,王际壮.烧伤应激反应及其调控策略[J].中华烧伤杂志,2021,37(2):126-130.DOI: 10.3760/cma.j.cn501120-20201125-00499.
[17]	VinaikR,BarayanD,ShahrokhiS,et al.Management and prevention of drug resistant infections in burn patients[J].Expert Rev Anti Infect Ther,2019,17(8):607-619.DOI: 10.1080/14787210.2019.1648208.
[18]	韩春茂,王新刚.《国际烧伤协会烧伤救治实践指南》2018版解读[J].中华烧伤杂志,2021,37(2):196-200.DOI: 10.3760/cma.j.cn501120-20191129-00447.
[19]	赵旭,赵璐,严向明,等.细菌生物膜的形成与导管相关性尿路感染的关系[J].中华医院感染学杂志,2017,27(18):4154-4158.DOI: 10.11816/cn.ni.2017-172466.
[20]	鲁虹言,王淑君,李方容,等.大面积烧伤患者卧翻身床尿袋放置方法的改进[J].护理学杂志,2016,31(10):66-67.DOI: 10.3870/j.issn.1001-4152.2016.10.066.

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表1 5年间会阴部和/或臀部烧伤患者CAUTI发病率

表1. Incidence of CAUTI in patients with perineal and/or hip burns over a 5-year period

年份	患者总数（例）	发生CAUTI患者数（例）	发病率（%）
2018	38	6	15.8
2019	49	9	18.4
2020	51	13	25.5
2021	57	9	15.8
2022	65	6	9.2
合计	260	43	16.5
注：CAUTI为导尿管相关尿路感染

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表2 260例会阴部和/或臀部烧伤患者337份尿液标本病原菌检出情况

表2. Detection of pathogenic bacteria from 337 urine specimens of 260 patients with perineal and/or hip burns

病原菌种类及名称	菌株数（株）	构成比（%）
革兰阴性菌
肺炎克雷伯菌	32	21.6
铜绿假单胞菌	15	10.1
鲍曼不动杆菌	11	7.4
奇异变形杆菌	6	4.1
大肠埃希菌	5	3.4
阴沟肠杆菌	5	3.4
摩根摩根菌摩根亚种	1	0.7
雷极普罗维登斯菌	1	0.7
革兰阳性菌
屎肠球菌	7	4.7
粪肠球菌	5	3.4
金黄色葡萄球菌	4	2.7
纹带棒状杆菌	4	2.7
棒状杆菌	1	0.7
溶血葡萄球菌	1	0.7
其他	2	1.4
真菌
白色念珠菌	22	14.9
热带念珠菌	19	12.8
近平滑念珠菌	3	2.0
葡萄牙念珠菌	2	1.4
光滑念珠菌	1	0.7
阿萨希毛孢子菌	1	0.7
合计	148	100
注：其他指极少数非常见病原菌

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表3 2组会阴部和/或臀部烧伤患者临床资料比较

表3. Comparison of clinical data between the 2 groups of patients with perineal and/or hip burns

组别	例数	性别（例）		年龄（例）		烧伤总面积［%TBSA， M（ Q ₁， Q ₃）］	合并糖尿病（例）	合并吸入性损伤（例）
组别	例数	男	女	<60岁	≥60岁	烧伤总面积［%TBSA， M（ Q ₁， Q ₃）］	合并糖尿病（例）	合并吸入性损伤（例）
感染组	43	24	19	28	15	70.0（30.0，85.0）	8	16
非感染组	217	166	51	149	68	54.0（29.5，83.5）	21	74
统计量值		χ ²=7.80		χ ²=0.21		Z=-1.03	χ ²=2.06	χ ²=0.15
P值		0.005		0.648		0.304	0.152	0.696
注：感染指导尿管相关尿路感染（CAUTI），感染组统计确诊CAUTI前医疗处置情况；TBSA为体表总面积

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表4 影响会阴部和/或臀部烧伤患者发生CAUTI的独立危险因素的多因素logistic回归分析结果

表4. Multivariate logistic regression analysis results of independent risk factors influencing the occurrence of CAUTI in patients with perineal and/or hip burns

自变量与分类	比值比	95%置信区间	P值
常量	0.01	—	<0.001
性别	2.86	1.21~6.73	0.016
会阴部烧伤深度
深Ⅱ度与浅Ⅱ度比较	2.63	1.03~6.71	0.043
Ⅲ度与浅Ⅱ度比较	1.84	0.67~5.14	0.242
非会阴部/臀部的清创/植皮手术	2.79	1.03~7.59	0.044
膀胱冲洗	2.34	1.05~5.22	0.038
导尿管留置时间（d）	1.04	1.02~1.06	<0.001
注：CAUTI为导尿管相关尿路感染；“—”表示无此项