耐碳青霉烯类肺炎克雷伯菌的分子流行病学分析

doi:10.3969/j.issn.1673-8640.2018.01.007

摘要/Abstract

摘要：

目的分析上海交通大学医学院附属仁济医院分离的耐碳青霉烯类肺炎克雷伯菌（CRKP）的耐药性及同源性,为CRKP感染的临床治疗和医院感染控制提供依据。方法收集分离自上海交通大学医学院附属仁济医院2013年1月—2015年8月感染患者的CRKP 107株,采用纸片扩散法检测其对18种抗菌药物的敏感性,微量肉汤稀释法检测美罗培南和替加环素的最低抑菌浓度（MIC）,聚合酶链反应（PCR）检测碳青霉烯酶耐药基因,脉冲场凝胶电泳（PFGE）进行分子生物学分型,NTSYS（2.1）软件中UPGMA算法进行聚类分析。结果 107株CRKP除对复方磺胺甲噁唑（敏感率67.3%）、磷霉素（敏感率24.0%）、替加环素（敏感率100.0%）相对敏感外,对其余17种抗菌药物均不敏感（耐药率>95.0%）;107株CRKP均检出KPC-2基因;受检菌株经PFGE指纹图谱分析共得出24种型别（A型~X型）,以A型[19.6%（21/107）]、B型[13.1%（14/107）]和C型[11.2%（12/107）]为主。在21株A型CRKP中有15株于1个月内分离自神经外科（6株）、门诊（3株）、血液科（2株）、老年科（2株）、外科重症监护病房（ICU,1株）和泌尿外科（1株）。在6株F型CRKP中有4株分别于2周内分离自普外科（2株）和老年科（2株）,其余PFGE型别菌株分布离散性较大,散发于不同时期和不同病区。结论上海交通大学医学院附属仁济医院分离的CRKP耐药基因主要为KPC-2,院内存在A型和F型菌株暴发流行。CRKP对复方磺胺甲噁唑、磷霉素和替加环素具有一定的敏感性,建议临床治疗首选复方磺胺甲噁唑。临床医护人员应采取合理措施加强对CRKP的耐药性监测,控制其在医院的传播。

关键词: 耐碳青霉烯类肺炎克雷伯菌, 基因分型, 脉冲场凝胶电泳

Abstract:

： Objective To investigate the drug resistance and molecular epidemiology of carbapenem-resistant Klebsiella pneumoniae （CRKP） isolated from patients in Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine,and to provide a reference for clinical treatment and nosocomial infection control. Methods A total of 107 isolates of CRKP were collected from January 2013 to August 2015 in Renji Hospital. The susceptibilities of 107 CRKP isolates to 18 antimicrobial agents were determined by Kirby-Bauer disk diffusion method. The minimum inhibitory concentrations （MIC） of meropenem and tigecycline against 107 CRKP isolates were determined by microbroth dilution method. Carbapenem-resistant genes were determined by polymerase chain reaction （PCR）. The genotypes were identified by pulsed-field gel electrophoresis （PFGE）. Th. Results were analyzed by UPGMA clustering using NTSYS（2.1） software. Results The 107 CRKP isolates were susceptible to sulfamethoxazole （drug resistance rate 67.3%）,fosfomycin （drug resistance rate 24.0%） and tigecycline （drug resistance rate 100.0%） and were not susceptible to other 17 antimicrobial agents （drug resistance rate >95.0%）. KPC-2 gene was determined in all the 107 CRKP isolates. A total of 24 genotypes （A type-X type） were identified,and the 3 major genotypes were A type [19.6%（21/107）],B type [13.1%（14/107）] and C type [11.2%（12/107）]. There were 15 CRKP isolates of A type （15/21） collected within 1 month from departments of neurosurgery （6 isolates）,outpatient（3 isolates）,hematology （2 isolates）,geriatrics （2 isolates）,surgery intensive care unit （ICU）（1 isolate） and urology （1 isolate）. There were 4 CRKP isolates of F type （4/6） collected within 2 weeks from departments of general surgery （2 isolates） and geriatrics （2 isolates）. Other 22 genotypes were collected sporadically in different periods and different wards.Conclusions The major carbapenem-resistant gene of CRKP isolated from Renji Hospital is KPC-2. Outbreaks of A type and F type CRKP appear in Renji Hospital. CRKP isolates are susceptible to sulfamethoxazole,fosfomycin and tigecycline,and sulfamethoxazole is suggested as the first choice for treatment. Infection monitoring should be enhanced to reduce the spread of CRKP.

Key words: Carbapenem-resistant Klebsiella pneumoniae, Genotype, Pulsed-field gel electrophoresis

中图分类号:

R446.5

史玮炀, 刘洋, 韩逸超, 郑丹丹, 戴尔宽, 郑冰, 李敏. 耐碳青霉烯类肺炎克雷伯菌的分子流行病学分析[J]. 检验医学, 2018, 33(1): 37-43.

SHI Weiyang, LIU Yang, HAN Yichao, ZHENG Dandan, DAI Erkuan, ZHENG Bing, LI Min. Molecular epidemiological analysis of carbapenem-resistant Klebsiella pneumoniae[J]. Laboratory Medicine, 2018, 33(1): 37-43.

图/表 5

参考文献 19

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基因	引物名称	引物序列（5'~3'）	产物大小（bp）
A类碳青霉烯酶基因
bla_KPC_-2	KPC-2F	GCTACACCTAGCTCCACCTTC	989
bla_KPC_-2	KPC-2R	ACAGTGGTTGGTAATCCATGC	989
bla_OXA_-48	OXA48-F	TTGGTGGCATCGATTATCGG	744
bla_OXA_-48	OXA48-R	GAGCACTTCTTTTGTGATGGC	744
B类碳青霉烯酶（金属酶）基因
bla_VIM_-1	VIM-1F	AGTGGTGAGTATCCGACAG	261
bla_VIM_-1	VIM-1R	ATGAAAGTGCGTGGAGAC	261
bla_VIM_-2	VIM-2F	ATGTTCAAACTTTTGAGTAAG	801
bla_VIM_-2	VIM-2R	CTACTCAACGACTGAGCG	801
bla_IMP_-1	IMP-1F IMP-1R	CTACCGCAGCAGAGTCTTTG	587
bla_IMP_-1	IMP-1F IMP-1R	AACCAGTTTTGCCTTACCAT	587
bla_IMP_-2	IMP-2F IMP-2R	GTTTTATGTGTATGCTTCC	678
bla_IMP_-2	IMP-2F IMP-2R	AGCCTGTTCCCATGTAC	678
bla_NDM_-1	NDM-1F	CTTCCAACGGTTTGATCGTC	271
bla_NDM_-1	NDM-1R	ATTGGCATAAGTCGCAATCC	271

基因	引物名称	引物序列（5'~3'）	产物大小（bp）
A类碳青霉烯酶基因
bla_KPC_-2	KPC-2F	GCTACACCTAGCTCCACCTTC	989
bla_KPC_-2	KPC-2R	ACAGTGGTTGGTAATCCATGC	989
bla_OXA_-48	OXA48-F	TTGGTGGCATCGATTATCGG	744
bla_OXA_-48	OXA48-R	GAGCACTTCTTTTGTGATGGC	744
B类碳青霉烯酶（金属酶）基因
bla_VIM_-1	VIM-1F	AGTGGTGAGTATCCGACAG	261
bla_VIM_-1	VIM-1R	ATGAAAGTGCGTGGAGAC	261
bla_VIM_-2	VIM-2F	ATGTTCAAACTTTTGAGTAAG	801
bla_VIM_-2	VIM-2R	CTACTCAACGACTGAGCG	801
bla_IMP_-1	IMP-1F IMP-1R	CTACCGCAGCAGAGTCTTTG	587
bla_IMP_-1	IMP-1F IMP-1R	AACCAGTTTTGCCTTACCAT	587
bla_IMP_-2	IMP-2F IMP-2R	GTTTTATGTGTATGCTTCC	678
bla_IMP_-2	IMP-2F IMP-2R	AGCCTGTTCCCATGTAC	678
bla_NDM_-1	NDM-1F	CTTCCAACGGTTTGATCGTC	271
bla_NDM_-1	NDM-1R	ATTGGCATAAGTCGCAATCC	271

病区	株数（%）	PFGE分型（株）
病区	株数（%）	A型	B型	C型	D~X型
神经外科	20（18.7）	8	4	2	6
外科ICU	20（18.7）	1	2	3	14
普外科	17（15.9）	0	1	2	14
老年科	15（14.0）	3	1	1	10
急诊内科留观室	14（13.1）	1	4	2	7
门诊	10（9.4）	3	1	0	6
血液科	5（4.7）	3	0	2	0
肾内科	2（1.9）	0	1	0	1
泌尿外科	1（0.9）	1	0	0	0
妇产科	1（0.9）	1	0	0	0
肝移植科	1（0.9）	0	0	0	1
呼吸科	1（0.9）	0	0	0	1

病区	株数（%）	PFGE分型（株）
病区	株数（%）	A型	B型	C型	D~X型
神经外科	20（18.7）	8	4	2	6
外科ICU	20（18.7）	1	2	3	14
普外科	17（15.9）	0	1	2	14
老年科	15（14.0）	3	1	1	10
急诊内科留观室	14（13.1）	1	4	2	7
门诊	10（9.4）	3	1	0	6
血液科	5（4.7）	3	0	2	0
肾内科	2（1.9）	0	1	0	1
泌尿外科	1（0.9）	1	0	0	0
妇产科	1（0.9）	1	0	0	0
肝移植科	1（0.9）	0	0	0	1
呼吸科	1（0.9）	0	0	0	1