Influencing factors and preoperative etiological analysis of urinary tract infectious fever after ureteroscopic lithotripsy
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摘要: 目的 探讨输尿管结石患者输尿管镜碎石术后尿路感染性发热的影响因素及其术前病原菌的构成比和药敏情况。方法 回顾性分析2019年6月—2022年9月在南京医科大学附属淮安第一医院行输尿管镜碎石术的253例患者的临床资料，根据患者是否发生术后尿路感染性发热分为发热组和对照组，采用单因素、多因素logistic回归分析术后尿路感染性发热的影响因素，并对术前尿培养病原菌的构成比和药敏情况进行分析。结果 253例患者中38例术后发生尿路感染性发热，57例术前尿培养阳性。发热组患者的性别、结石数量、术前尿培养、术前血肌酐、术前血清白蛋白与对照组比较差异均有统计学意义(P < 0.05)。多因素logistic回归分析显示，女性、结石多发、术前尿培养阳性和术前低血清白蛋白为术后尿路感染性发热的独立危险因素(P < 0.05)。革兰阴性菌中检出率最高的为大肠埃希菌(21株)，对亚胺培南、哌拉西林/他唑巴坦和阿米卡星的敏感性较高；革兰阳性菌中检出率较高的有无乳链球菌(5株)、粪肠球菌(5株)和表皮葡萄球菌(4株)，无乳链球菌对氨苄西林的敏感性较高，粪肠球菌对氨苄西林、青霉素、利奈唑胺、链霉素和万古霉素的敏感性较高，表皮葡萄球菌对庆大霉素、利奈唑胺、万古霉素、替加环素和利福平的敏感性较高。结论 对于女性、结石多发、术前尿培养阳性和术前低血清白蛋白的患者应加强对其术后尿路感染性发热的防范。输尿管结石患者术前尿培养病原菌以革兰阴性菌为主，尤其是大肠埃希菌。对于术前尿培养阳性者，应根据药敏结果规范使用抗菌药物。Abstract: Objective To investigate the influencing factors of urinary tract infectious fever in patients with ureteral calculi after ureteroscopic lithotripsy as well as the constituent ratio and drug sensitivity of pathogenic bacteria before operation.Methods A total of 253 patients who underwent ureteroscopic lithotripsy in Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University from June 2019 to September 2022 were retrospectively analyzed. The patients were divided into fever group and control group according to whether or not they developed postoperative urinary tract infectious fever. Univariate and multivariate logistic regression were used to analyze the influencing factors of postoperative urinary tract infectious fever. The constituent ratio and drug sensitivity of pathogenic bacteria in urine culture before operation were analyzed.Results Of the 253 patients, 38 cases developed urinary tract infectious fever after operation, and 57 cases had positive urine culture before operation. There were significant differences in sex, number of stones, preoperative urine culture, preoperative serum creatinine and preoperative serum albumin between the fever group and the control group(P < 0.05). Multivariate logistic regression analysis showed that female, multiple calculi, positive urine culture before operation and low serum albumin before operation were independent risk factors of postoperative urinary tract infectious fever(P < 0.05). The highest detection rate of gram-negative bacterium was Escherichia coli(21 strains), which was more sensitive to imipenem, piperacillin/tazobactam and amikacin; The high detection rates of gram-positive bacteria were Streptococcus agalactiae(5 strains), Enterococcus faecalis(5 strains) and Staphylococcus epidermidis(4 strains). Streptococcus agalactiae was more sensitive to ampicillin. Enterococcus faecalis was more sensitive to ampicillin, penicillin, linezolid, streptomycin and vancomycin. Staphylococcus epidermidis was more sensitive to gentamicin, linezolid, vancomycin, tegacycline and rifampicin.Conclusion For female, patients with multiple calculi, positive urine culture before operation and low serum albumin before operation, the prevention of postoperative urinary tract infectious fever should be strengthened. The main pathogens in preoperative urine culture of patients with ureteral calculi were Gram-negative bacteria, especially Escherichia coli. For those with positive urine culture before operation, antibiotics should be used according to the results of drug sensitivity.
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表 1 输尿管镜碎石术后尿路感染性发热单因素分析
例(%)，M(P25，P75) 影响因素 发热组(38例) 对照组(215例) χ2/Z P值 性别 23.338 < 0.001 男 14(36.84) 163(75.81) 女 24(63.16) 52(24.19) 年龄/岁 1.735 0.188 >50 21(55.26) 94(43.72) ≤50 17(44.74) 121(56.28) BMI/(kg/m2) 0.532 0.466 < 24 13(34.21) 61(28.37) ≥24 25(65.79) 154(71.63) 合并糖尿病 < 0.001 1.000 是 5(13.16) 28(13.02) 否 33(86.84) 187(86.98) ESWL史 0.872 0.350 是 8(21.05) 61(28.37) 否 30(78.95) 154(71.63) 病程/月 1.792 0.181 < 1 21(55.26) 143(66.51) ≥1 17(44.74) 72(33.49) 结石最大直径/cm 1.2(1.0，1.6) 1.1(0.9，1.5) -1.891 0.059 结石部位 0.177 0.915 输尿管上段 22(57.89) 132(61.40) 输尿管中段 5(13.16) 27(12.56) 输尿管下段 11(28.95) 56(26.05) 结石数量 8.819 0.003 单发 28(73.68) 197(91.63) 多发 10(26.32) 18(8.37) 术前肾积水程度 -1.180 0.238 轻度： < 3 cm 27(71.05) 174(80.93) 中度：3~4 cm 9(23.68) 23(10.70) 重度：>4 cm 2(5.26) 18(8.37) 合并输尿管狭窄 < 0.001 1.000 是 4(10.53) 24(11.16) 否 34(89.47) 191(88.84) 合并输尿管息肉 2.298 0.130 是 5(13.16) 11(5.12) 否 33(86.84) 204(94.88) 术前尿培养 15.807 < 0.001 阳性 18(47.37) 39(18.14) 阴性 20(52.63) 176(81.86) 术前血肌酐/(μmol/L) 77.15(60.05，89.675) 86(73，109) -3.025 0.002 术前血清白蛋白/(g/L) 40.6(38.975，43.15) 43.4(41.4，45.9) -3.783 < 0.001 手术时间/min 0.502 0.478 < 30 4(10.53) 32(14.88) ≥30 34(89.47) 183(85.12) 结石清除情况 0.854 0.355 清除 32(84.21) 195(90.70) 残留 6(15.79) 20(9.30) 
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表 2 输尿管镜碎石术后尿路感染性发热多因素logistic回归分析
影响因素 β SE Wald P值 OR 95%CI 性别 1.347 0.473 8.095 0.004 3.846 1.521~9.729 结石数量 2.019 0.540 13.994 < 0.001 7.534 2.615~21.702 术前尿培养 1.159 0.421 7.573 0.006 3.186 1.396~7.271 术前血肌酐 -0.005 0.005 1.214 0.271 0.995 0.985~1.004 术前血清白蛋白 -0.133 0.054 6.045 0.014 0.875 0.787~0.973
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表 3 术前尿培养病原菌分布情况
病原菌 菌株数/株 构成比/% 革兰阴性菌 29 50.88 大肠埃希菌 21 36.84 摩氏摩根菌 2 3.51 奇异变形杆菌 2 3.51 肺炎克雷伯菌肺炎亚种 1 1.75 克氏(差异)柠檬酸杆菌 1 1.75 洛非不动杆菌 1 1.75 阴沟肠杆菌 1 1.75 革兰阳性菌 23 40.35 无乳链球菌 5 8.77 粪肠球菌 5 8.77 表皮葡萄球菌 4 7.02 溶血葡萄球菌 2 3.51 屎肠球菌 2 3.51 缓症链球菌 1 1.75 金黄色葡萄球菌 1 1.75 麻疹孪生球菌 1 1.75 牛链球菌 1 1.75 咽峡炎链球菌 1 1.75 杂菌 5 8.77 合计 57 100.00
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表 4 主要革兰阴性菌对不同抗菌药物的敏感性比较
抗菌药物 大肠埃希菌(21株) 敏感菌株数/株 敏感率/% 亚胺培南 20 95.24 哌拉西林/他唑巴坦 18 85.71 阿米卡星 17 80.95 复方新诺明 11 52.38 头孢吡肟 10 47.62 环丙沙星 1 4.76 左旋氧氟沙星 0 0
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表 5 主要革兰阳性菌对不同抗菌药物的敏感性比较
抗菌药物 无乳链球菌(5株) 粪肠球菌(5株) 表皮葡萄球菌(4株) 敏感菌株数/株 敏感率/% 敏感菌株数/株 敏感率/% 敏感菌株数/株 敏感率/% 环丙沙星 0 0 - - - - 氨苄西林 5 100 4 80 - - 左旋氧氟沙星 1 20 - - 2 50 青霉素 - - 4 80 0 0 庆大霉素 - - 2 40 4 100 利奈唑胺 - - 5 100 4 100 链霉素 - - 4 80 - - 万古霉素 - - 5 100 4 100 替加环素 - - - - 4 100 复方新诺明 - - - - 2 50 苯唑西林 - - - - 0 0 莫西沙星 - - - - 3 75 四环素 - - - - 3 75 利福平 - - - - 4 100 注：-为未检测。
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