摘要
目的:总结上尿路结石合并尿细菌培养碳青霉烯类耐药肠杆菌科细菌(CRE)阳性患者行内镜手术后控制感染并发症的经验。方法:回顾性分析清华大学附属北京清华长庚医院2015年1月至2019年12月行内镜手术治疗的14例上尿路结石合并尿CRE阳性患者的临床资料。男7例,女7例。平均年龄58.2(34~71)岁。泌尿系B超、CT、KUB检查确诊为上尿路结石。肾结石13例,输尿管上段结石1例;结石位于左侧8例,右侧6例;单发结石3例,多发结石4例,鹿角形结石7例。14例术前尿细菌培养CRE均为阳性,其中大肠埃希菌7例,肺炎克雷伯菌6例,阴沟肠杆菌1例。术前共有3例发热患者,均行血细菌培养,其中阴性1例,CRE阳性1例(肺炎克雷伯菌),弗劳地柠檬酸杆菌阳性1例。术前经验性应用广谱抗菌药物(喹诺酮类和β内酰胺类)单药10例,联合用药1例;3例发热患者和1例既往有经皮肾镜取石术(PCNL)术后发热病史患者应用CRE目标性抗菌药物(替加环素、多黏菌素、磷霉素和氨基糖苷类)单药2例,联合用药2例。术前抗菌药物平均用药时间7.1(1~24)d,至体温正常,血白细胞、降钙素原(PCT)和C反应蛋白(CRP)正常,尿常规检查结果明显好转后行内镜手术。14例分别行PCNL和输尿管软镜碎石术(RIRS),2组的结石最大径分别为(31.5±10.2)mm和(10.8±2.6)mm。14例共行15次手术,RIRS 4次,PCNL11次,其中1例间隔1周先后行两次PCNL,1例行肾穿刺造瘘术后16 d行PCNL。PCNL均采用F24标准通道,负压超声碎石系统碎石;RIRS均采用外径F13~14的输尿管软镜鞘,采用200μm钬激光光纤碎石。术后2 h内和第1天复查血常规、血生化、PCT和CRP,术后第1~2天复查KUB,术后4周拔除双J管。结果:本组14例手术均顺利完成。PCNL和RIRS平均手术时间分别为(81.6±25.3)mins和(38.7±13.1)mins。术后经验性应用广谱抗菌药物单药7例;应用CRE目标性抗菌药物单药4例,联合用药4例。术后抗菌药物应用至体温正常,生命体征稳定,血白细胞、PCT和CRP正常,肾造瘘管和尿管拔除。抗菌药物平均用药时间6.8(2~17)d。术后发生全身炎症反应综合征(SIRS)3例,为术后24~48 h内出现,应用CRE目标性抗菌药物联合治疗5~11 d,顺利恢复。无脓毒症、脓毒性休克和死亡病例。结石成分分析结果:六水磷酸镁铵8例,均为混合成分;一水草酸钙6例,其中混合成分1例,单一成分5例。结论:合并CRE菌尿的上尿路结石患者,术前在解除梗阻、充分引流的基础上,对于无发热等临床症状、感染指标(血白细胞、PCT、CRP)正常者可先应用经验性广谱抗菌药物,否则需要及时应用CRE目标性抗菌药物联合治疗,直至体温正常、感染指标正常、尿常规检查结果明显好转后才可进行内镜手术,这样可以有效控制感染并发症,同时减少抗菌药物的过度使用。
Objective To evaluate the risk of infectious complication after endoscopic surgery for the treatment of upper urinary tract calculi combined with carbapenem-resistant Enterobacteriaceae(CRE)bacteriuria.Methods The clinical data of 14 patients who were diagnosed with upper urinary tract calculi combined with CRE bacteriuria and treated in Tsinghua University affiliated Beijing Tsinghua Changgung Hospital from January 2015 to December 2019 were analyzed retrospectively.There were 7 males and 7 females,aged from 34 to 71 years old(mean 58.2 years old).The diagnosis was confirmed by ultrasonography,CT or abdominal X-ray.Fourteen cases underwent 15 procedures,including 4 RIRS and 11 PCNL.One patient underwent 2 PCNL procedures at an interval of 1 week,and 1 patient underwent PCNL 16 days after nephrostomy.There were 13 cases of renal calculi and 1 case of upper ureteral calculi.Stones were found on the left side in 8 cases and the right side in 6 cases.There were 3 cases of solitary stone,4 cases of multiple stones and 7 cases of staghorn stone.The maximum diameter of stones was(31.5±10.2)mm in patients who underwent PCNL,and(10.8±2.6)mm in patients undergoing RIRS.The complete blood count,blood biochemistry,procalcitonin and C-reactive protein were tested postoperatively on the same day of the procedure and 1 day after the procedure.Abdominal X-ray was performed 1-2 days postoperatively,and the ureteral stent(double J)was removed 4 weeks after the procedure.Fourteen patients with CRE bacteriuria underwent 15 endoscopic procedures.Urine culture identified 7 cases of Escherichia coli,6 cases of Klebsiella pneumoniae and 1 case of Enterobacter cloacae.Preoperative blood culture was performed in 3 cases,of which 1 case was negative and 1 case was Klebsiella pneumoniae positive.Before operation,11 cases were empirical treated with broad-spectrum antibiotics,including monotherapy in 10 cases and drug combination therapy in 1 case.Sensitive antibiotics against CRE were prescribed in 4 cases preoperatively,including monotherapy in 2 cases and drug combination therapy in 2 cases.Antibiotics were used preoperatively for 1-24 days(mean 7.1 days).Results After the operation,7 cases received monotherapy with broad-spectrum antibiotics.Sensitive antibiotics against CRE were prescribed in 4 cases postoperatively,including monotherapy in 4 cases and drug combination in therapy 4 cases.Postoperative antibiotics were used for 2-17 days(mean 6.8 days).There were 3 cases of systemic inflammatory response syndrome(SIRS)after operation,and there were no cases of sepsis,septic shock or death.The main components of stones were ammonium magnesium phosphate hexahydrate in 8 patients and calcium oxalate monohydrate in 6 patients.Conclusions Effective measures can be taken to reduce or avoid bacteremia caused by CRE,reducing mortality and the use of antibiotics.Endoscopic surgery can be performed only after the clinical symptoms and laboratory tests have significantly improved.Patients with fever and other clinical symptoms and abnormal infectious markers should be treated with targeted antimicrobial therapy.
作者
胡卫国
王碧霄
姬超岳
肖楠
刘宇保
苏博兴
付猛
李建兴
Hu Weiguo;Wang Bixiao;Ji Chaoyue;Xiao Nan;Liu Yubao;Su Boxing;Fu Meng;Li Jianxing(Department of Urology,Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing 102218,China;Department of Clinical Laboratory,Beijing Tsinghua Changgung Hospital,Tsinghua University,Beijing 102218,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2020年第10期764-768,共5页
Chinese Journal of Urology
关键词
肾结石
经皮肾镜取石术
围手术期并发症
多药抗药性
细菌尿
Kidney calculi
Percutaneous nephrolithotomy
Intraoperative complications
Drug resistance,multiple
Bacteriuria
