中国临床药学杂志

目的 分析2019至2023年某三级综合医院血流感染(BSI)患者的病原菌分布特征，并分析病原菌耐药性的变化，为精准抗菌药物管理和BSI防控提供依据。方法 回顾性分析2019至2023年送检的BSI患者血培养样本的细菌鉴定、药敏试验及耐药性分析结果，并分析阳性率和耐药率的变化趋势。结果 送检BSI患者血培养样本共38 463份，检出阳性样本3 605份，阳性率为9.37%,2019至2023年的年阳性率变化趋势无统计学意义(P_trend> 0.05)。重症监护病房(14.65%)和急诊科(13.01%)为BSI高发科室。在病原菌方面，革兰阴性菌占68.24%(2 460株)，其中占比较高的有大肠埃希菌(占33.95%)和肺炎克雷伯菌(占11.35%)；革兰阳性菌占30.93%(1 115株)，其中占比较高的有金黄色葡萄球菌(占7.88%)和表皮葡萄球菌(占5.60%)。在耐药情况方面，革兰阳性菌中，葡萄球菌属对青霉素G的耐药率均> 94.9%，对利奈唑胺等100%敏感；革兰阴性菌中，大肠埃希菌和肺炎克雷伯菌对氨苄西林等抗菌药物具有较高的耐药率，肺炎克雷伯菌对头孢他啶和氨苄西林100%耐药；真菌中，光滑假丝酵母菌对5-氟胞嘧啶的耐药率为21.6%。2019至2023年耐甲氧西林金黄色葡萄球菌和大肠埃希菌产超广谱β-内酰胺酶的阳性率变化趋势无统计学意义(P_trend> 0.05)，肺炎克雷伯菌对美罗培南的耐药率变化趋势无统计学意义(P_trend> 0.05)，大肠埃希菌对头孢呋辛酯(口服)的耐药率一直为100%。临床预后方面，头孢呋辛酯完全耐药株感染患者住院时间延长至(9.3±2.1)d，医疗费用增加了2.4倍(P<0.01)；血液内科使用氟康唑时间> 14 d的患者，光滑假丝酵母菌耐药率上升至34.8%。结论 BSI的病原菌以革兰阴性菌为主，其中大肠埃希菌对头孢呋辛酯(口服)的耐药率达到100%。重症监护病房和急诊科BSI高发。建议临床经验性治疗避免使用头孢呋辛酯，严格限制氟康唑的预防用药疗程，加强院内环境消毒，持续强化碳青霉烯类等特殊级抗菌药物处方审核制度，建立区域耐药监测网络以指导经验性治疗。

AIM To analyze the distribution characteristics of bloodstream infection(BSI) pathogens in a tertiary general hospital from 2019 to 2023, and to examine changes in pathogen drug resistance, providing a basis for precise antimicrobial management and BSI prevention and control. METHODS A retrospective analysis was performed on blood culture samples from BSI patients between 2019 and 2023 for bacterial identification, antimicrobial susceptibility testing, and an evaluation of trends in positivity and resistance rates. RESULTS A total of 38 463 blood culture samples from patients with BSI were sent for testing, of which 3 605 samples were positive, with a positivity rate of 9.37%. The annual positive rate trend from 2019 to 2023 showed no statistical significance(P_trend > 0.05). The intensive care unit(14.65%) and the emergency department(13.01%) had the highest incidence of BSI. In terms of pathogens, Gram-negative bacteria accounted for 68.24%(2 460 strains), with Escherichia coli(33.95%) and Klebsiella pneumoniae(11.35%) being the most prevalent; Gram-positive bacteria accounted for 30.93%(1 115 strains), with Staphylococcus aureus(7.88%) and Staphylococcus epidermidis(5.60%) being the most common. Regarding drug resistance, among Gram-positive bacteria, Staphylococcus species showed > 94.9% resistance to penicillin G and were 100% sensitive to linezolid and other drugs, among Gram-negative bacteria, Escherichia coli and Klebsiella pneumoniae had high resistance rates to ampicillin and other antibiotics, and Klebsiella pneumoniae was 100% resistant to ampicillin and ceftazidime, Escherichia coli among fungi, Candida glabrata showed a 21.6% resistance rate to 5-fluorocytosine. From 2019 to 2023, the trends in the positivity rates of methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing Escherichia coli showed no statistical significance(P > 0.05), the trend in meropenem resistance of Klebsiella pneumoniae showed no statistical significance(P_trend > 0.05), and the oral cefuroxime-resistant rate of Escherichia coli(oral route) remained 100%. Clinically, patients infected with cefuroxime-resistant strains had prolonged hospital stays of(9.3 ± 2.1) days, and medical costs increased by 2.4 times(P < 0.01). In hematology patients treated with fluconazole for more than 14 days, the resistance rate of Candida glabrata increased to 34.8%. CONCLUSION Pathogens causing BSI are mainly Gram-negative bacteria, among which Escherichia coli shows a 100% resistance rate to oral cefuroxime. BSI incidence is high in intensive care units and emergency departments. It is recommended that empirical clinical treatment avoid using cefuroxime, strictly limit the prophylactic course of fluconazole, strengthen hospital environmental disinfection, continuously reinforce the prescription review system for special-class antibiotics such as carbapenems, and establish a regional resistance monitoring network to guide empirical treatment.