摘要
目的探讨上尿路结石合并多重耐药菌尿路感染的急诊处理,为优化临床诊治提供参考建议。方法回顾性分析湖南省人民医院泌尿外科2017年1月至2020年1月收治的110例上尿路结石合并多重耐药菌感染的急诊诊治患者资料,根据患者急诊治疗方式不同将患者分为四组:输尿管插管组为急诊置输尿管导管插管或双J管内引流组(24例),输尿管镜碎石组为急诊输尿管镜钬激光碎石组(42例),肾造瘘组为急诊肾造瘘组(24例),切开取石组为急诊腹腔镜或开放切开取石组(20例),分析感染患者病原菌与耐药情况及对比治疗效果,收集术后结石样本,进行结石成分分析。结果110例多重耐药菌感染患者中革兰氏阴性菌96(87.27%)例,革兰氏阴性菌中β-内酰胺酶(ESBLs)阳性75(78.13%)例;革兰氏阴性菌中大肠埃希菌76(79.17%)例,大肠埃希菌感染中ESBLs阳性69(90.79%)例;革兰氏阳性菌14例,其中粪肠球菌6例,屎肠球菌5例,金黄色葡萄球菌3例。在手术并发症发生率方面,输尿管插管组为8.33%,输尿管镜碎石组为26.19%,肾造瘘组为20.8%,切开取石组为15%,输尿管插管组的手术并发症发生率明显低于其他三组。输尿管镜碎石组并发症发生率明显高于其他三组。对结石样本行结石成分分析,结果显示:六水磷酸镁铵61.5%、羟基磷灰石19.2%、碳酸磷灰石11.5%、草酸钙结石5.8%、尿酸结石1.9%。感染性结石(六水磷酸镁铵、羟基磷灰石、碳酸磷灰石)共占比92.2%。结论上尿路结石合并多重耐药菌尿路感染的患者中以大肠埃希菌感染占大多数,结石成分以六水磷酸镁铵为主。急诊处理提示需要快速判断患者的病情,综合评估来决定最终诊治方案和具体手术方式。
Objective To investigate the emergency treatment of upper urinary tract calculi combined with multidrug-resistant urinary tract infections,and Provide reference suggestions for optimizing clinical diagnosis and treatment.Methods A retrospective study was conducted on the data of 110 patients with upper urinary tract calculi combined with multidrug-resistant urinary tract infections who were treated in the Department of Urology of Hunan Provincial People’s Hospital from January 2017 to January 2020.The patients were divided into four groups according to different emergency treatment methods:the ureteral intubation group which were treated with ureteral catheterization or double-J stent drainage(24 cases),the ureteroscopy lithotripsy group which were treated with ureteroscopy and holmium laser lithotripsy(42 cases),the renal fistula group which were treated with percutaneous nephrostomy(24 cases),and the incision and stone removal group which were treated with laparoscopy or open surgery for kidney stone removal(20 cases).The pathogenic bacteria and drug-resistance condition of infected patients were analyzed and a comparative analysis on the effect of different treatment methods was conducted.Postoperative stone samples were collected for the analysis of kidney stone compositions.Results Among the 110 cases with multidrug-resistant bacteria infections,96(87.27%)cases were affected by Gram-negative bacteria.Among the 96 cases infected by Gram-negative bacteria,75(78.13%)cases wereβ-lactamases(ESBLs)positive;there were 76(79.17%)cases of Escherichia coli,of which 90.79%(69/76)were ESBLs positive.14 cases were infected with Gram-positive bacteria,including 6 cases of Enterococcus faecalis,5 cases of Enterococcus faecium and 3 cases of Staphylococcus aureus.In terms of the incidence of surgical complications,the ratio of incidence in the ureteral intubation group was 8.33%,the ratio of the ureteroscopy lithotripsy group was 26.19%,the ratio of the renal fistula group was 20.8%and the ratio of incision and stone removal group was 15%.The ureteral intubation group had significantly fewer incidents of surgical complications compared with the other three groups.The ureteroscopy lithotripsy group was observed with a significantly higher ratio of surgical complications than the other three groups.A total of 52 calculi samples were collected from 62 patients in the ureteroscopy lithotripsy group and the incision and stone removal group for kidney stone composition analysis.The results showed the following compositions:61.5%magnesium ammonium phosphate hexahydrate,19.2%hydroxyapatite,11.5%hydroxyapatite,5.8%carbonate apatite,and 1.9%uric acid stone.Infectious stones(magnesium ammonium phosphate hexahydrate,hydroxyapatite,carbonate apatite)accounted for 92.2%of the entire compositions.Conclusions The majority of the patients with upper urinary tract stones combined with multidrug-resistant urinary tract infections were infected with Escherichia coli,and the primary composition of the kidney stone was magnesium ammonium phosphate hexahydrate.The emergency treatment prompts that the patient’s condition needs to be quickly judged,and a comprehensive evaluation is made to determine the final diagnosis and treatment plan and the specific surgical method.
作者
伍学成
李远伟
陈尚明
李曾应
卢强
段燚星
高智勇
Wu Xuecheng;Li Yuanwei;Chen Shangming;Li Zengying;Lu Qiang;Duan Yixing;Gao Zhiyong(HunanProvincial People's Hospital(The First Affiliated Hospital of Hunan Normal University),Changsha,China)
基金
湖南省卫计委一般项目(项目编号:C2016007)
湖南省教育厅课题(项目编号:16C0966)
关键词
上尿路结石
多重耐药菌感染
脓毒症
急诊处理
Upper urinary tract stones
Multi-drug resistance
Sepsis
Emergency treatment
作者简介
通信作者:李远伟,E-mail:liyuanwei@163.com
