Multi-channel combination drug treatment of extensive drug-resistant Bacillus intracranial infection 1 case.

Intracranial infection after neurosurgery is one of the most serious surgical complicationsBecause of the presence of a blood-brain barrier, no effective drug concentration can be obtained in cerebrospinal fluid, and intracranial infection pathogenic bacteria are resistant to most antibiotics, so unlike other parts of the infection, the treatment of intracranial infection is more difficultBaumann's non-fermented glachisane, widely distributed in water, soil, hospital environment and human skin surface, has become one of the most important condition-causing bacteria causing hospital infection in recent years; The Subei People's Hospital of Yangzhou City received 1 case of intracranial trauma after opening cranial surgery and concurrently drug-resistant Baumann immobility intracranial infection patients, through multi-channel combination drug treatment achieved better resultsThis study summarizes and analyzes the patient's diagnosis and treatment process, and reviews the relevant literatureThe report is as follows1Clinical Data 1.1 General Information The patient in this case is male, 55 years oldHe was admitted to hospital on 28 December 2017 for "9d, Fever 3d After Traumatic Brain Surgery"The patient was injured by a head injury caused by a 9d car accident, which was treated by the local hospital emergency department, was not conscious after surgery and continued treatment at the local hospital ICU, and had high fever (up to 39 degrees C) before 3d, coughing and coughingThe hospital's emergency head CT examination shows: intracranial brain changes, left frontal temporal lobe, right temporal lobe with multiple hematoma, right-hand upper epidural epidural hematoma, left side ventricle blood build-up, butterfly sinus fluid, cranial multiple fractures (Figure 1A); chest CT show: multiple inflammation of the lungs, both sides of the thoracic fluid (Figure 1B)In the past, he was in good healthFigure 1 The ct and chest CT examination of the head and chest of the patient when admitted to hospitalA: Skull CT; B: Chest CT Check: Body temperature 36.8C, Pulse 80/min, Breath 19/min, Blood Pressure 135/97mmHg, Moderate Coma, Glasgow Coma Scale (Glasgow slea, GCS) Rating 4T Divided, the left side of the forehead can be seen about 28cm arc cut, no obvious seepage, bone window pressure is too high; Diagnosis: Postoperative head trauma; multiple brain bruises in the skull; two-sided lung infections1.2 Laboratory Examination Blood Routine Examination: White Blood Cells 17.47 x 109/L, Percentage of Neutrophils 96.7%, Number of Neutrophils 16.89 x 109/LC-reactive protein 10.20mg/L, calcitonin primary 0.71 ng/mLThe next day of admission, the lumbar puncture cerebrospinal fluid routine and biochemical examination, the number of white blood cells 885.0 x 106/L, glucose content of 6.26mmol/L1.3 Treatment after admission of experience with cephalosporine (2gbid) intravenous treatment The patient continued to have high fever (body temperature of 39 degrees C), after 3D sputum culture is pneumonia Krebs, resistant to cephalosporine, and adjusted antibiotics for amine penan (1gq8h) Because cerebrospinal fluid examination suggests suspicious intracranial infection, then empirically add vancomycin 500 mg intravenous drip, q8h At this time the antibiotic regimen is amine perinan 1g intravenous drip q8h plus vancomycin 500mg intravenous drip q8h Treatment 3d continuous lumbar cerebrospinal fluid examination, treatment of 2d cerebrospinal fluid white blood cells 22860.0 x 106/L; 3d cerebrospinal fluid white blood cells 38593 x 106/L, glucose content of 1.61m/L, protein content of 3.61g/L, calcitonin 1.37/mL Scalp secretion culture shows widely drug-resistant Baumann immobility Combined with the clinical performance of patients and laboratory examination, highly suspected intracranial infection, the implementation of large waist pool drainage Add 50mg venous drips with tricycline, q12h; adjust vancomycin to 1000mg venous drip, q12h And with Qingdamin 80,000 IU with physiological saline 250mL row waist pool drainage rinse, 2 times a day Flushing method: each injection into the drainage tube 10mL dispensing fluid and the return of the same amount of liquid discarded, rinse 250mL after the liquid clamped the drainage tube, 2h after opening; However, at this time, cerebrospinal fluid bacteria culture is still negative, in order to clarify intracranial infection, the cerebrospinal fluid samples sent for examination for infection pathogen high flux genetic testing (Huada Gene, Wuhan Huada Medical Laboratory, license registration number: 59105283X4201917P17P1202); After treatment of 2d, cerebrospinal fluid bacteria culture resulted in extensive drug-resistant Baumanninamy, and drug sensitivity tests showed sensitivity to digarin The diagnosis is clearly an intracranial infection, the infection is more serious Adjusted antibiotic program is, amine perinan 2g intravenous drip q8h plus tick 50 mg intravenous drip q12h plus poly-sticky bacteria B450000IU intravenous drip bid; After continuous treatment of 5d, the patient's body temperature decreased from the previous, the number of cerebrospinal leukocytes gradually decreased, and many cerebrospinal fluid bacteria culture was negative Deactivated amine perinan, Qingdamycin intra-rinward flushing changed to 1 time a day, poly-stick mycobacteria B intrauterine injection changed to 1 time the next day After continuing this treatment of 8d, the patient's body temperature is normal, blood routine is normal, the number of cerebrospinal leukoblasts white blood cells drops to 30 x 106/L, cerebrospinal fluid bacteria culture negative, intracranial infection improved In the next day to remove the lumbar large pool drainage tube, the antibiotic program changed to cephalosporine ketone shubatan 3g intravenous drip, q8h; During the patient's hospitalization, the dynamic changes in the number of leukion white blood cells and glucose and protein content were shown in Figures 2 and 3; After the patient is discharged from the hospital, he or she goes to the rehabilitation hospital for rehabilitation treatment After half a month of discharge, the patient's conscious response improved, the vital signs were stable, the body temperature was normal, the test results were not obviously abnormal, the intracranial condition was stable, and no obvious complications were found Figure 2 Dynamic changes in the number of cerebrospinal leukocytes in patients Intheospinal Fluid Glucose and Protein Content Dynamic Changes 2 Discuss the strong ability of Baumann to obtain drug resistance and clone transmission, multi-drug resistance, extensive drug resistance, total drug resistance Baumann donotite is a worldwide epidemic, has become one of the most important pathogens infected in Chinese hospitals Antibiotic-resistant Baumann aureus is divided into three categories: Multidrug-Resistant (MDR), Broad Drug Resistance (XDR) and Total Lydus (PDR) Broadly drug-resistant Baumannanite refers to only 1 to 2 potentially anti-indocrigal drugs (mainly discycline and/or polyscoccal) sensitive strains In this case, patients with persistent high fever after the surgery of brain trauma, the number of leukocytes detected by cerebrospinal fluid increased (885 x 106/L), sputum culture was pneumonia Krebs; After the scalp secretions culture extensive drug-resistant Baumann immobility bacteria, immediately line the waist large pool drainage, and according to the 2012 China Baumann immobility infection diagnosis and prevention expertconsensus, for the multi-drug-resistant Baumann immobility caused by the central nervous system infection recommended combination drug use; Waist pool continuous drainage mainly through the opening of the waist pool drainage tube, the establishment of flushing channel, timely removal of the ventricle and cobweb subcavity inflammatory inflammatory substances and pathogenic bacteria, to avoid its retention caused by secondary damage; The treatment of intracranial infection of Baumann's campylobacter was considered to have good clinical efficacy Zhang Xinhua and other patients with 30 cases of intracranial infection of Bacillus intracranial disease after brain trauma showed that the efficacy of giving lumbar large pool drainage plus qing large mycin flushing treatment group was significantly better than that of the control group, with total efficy inostles of 86.7% and 66.7%, respectively The dicalledcycline is the first variety of glymide cyclin-type antimicrobial drugs, has better antibacterial activity for the broad drug-resistant Baumann immobility bacteria, but due to its wide tissue distribution, low blood concentration, poor ability to penetrate the blood-brain barrier, it is difficult to achieve effective anti-bacterial concentration in cerebrospinal fluid, often need to be used with other antimicrobial drugs; Therefore, the patient's intravenous drug administration at the same time, the joint intra-incarniton injection of cyclin Some scholars reported a case of extensive drug-resistant Baumann innuendo intracranial infection after surgery using intrauterine injections of trigacyclineine, with good follow-up Falagas et al conducted a systematic evaluation study that had a lower mortality rate of high-dose dicyclinine (100 mgq12h) in intravenous use of intravenous lytecycline (100 mgq12h) compared to low-dose (50 mgq12h) in patients with severe bacterial infections, and its pharmacokinetics also showed a better effect on high-dose programmes than low doses Baumann's donot synosis rarely leads to community-acquired meningitis, but it is increasingly related to intracranial infection after neurosurgery and has become the main pathogenic pathogen of intracranial infection in the hospital; Preoperative GCS scores of 5, cerebrospinal fluid leakage, placement of brain outdoor drainage, surgical incision contamination, long surgical duration (?4h), number of operations, accompanied by other site infections, etc are independent risk factors for intracranial infection after neurosurgery In this case, the patient continued to have high fever after surgery, the number of cerebrospinal leukion white blood cells reached 38593 x 106/L, the protein content increased and the sugar content decreased, the scalp secretion bacteria culture for the extensive drug-resistant Baumann donot, but at this time the cerebrospinal fluid bacteria culture is still negative; Suwon test, the result of 1.37 ?g/L, at the same time sent cerebrospinal fluid samples to Huada Medical Examination of the infected pathogen high-throughput genetic testing (NGS technology), the results showed that the cerebrospinal fluid Bowman immobility detection sequence is high, is the main infectious bacteria; Traditional microbial detection methods involve more experiments, cumbersome operation, training time is long, preparation and finishing work is numerous, and the resolution is low, and microbial reproduction speed, the emergence of new strains, but also make the efficiency of traditional detection methods greatly reduced Using a new generation of gene sequencing platform, the pathogen microbial population is no longer separated one by one, but after DNA is extracted for sequencing, through the large number of sequence information obtained, from the overall grasp of the composition of the pathogen microbial population, but also can obtain low-content pathogen sequence, and through unknown sequence identification of new species Further, if the characteristic sequence spectrum of each pathogen microorganism is pre-defined, the sequence of each pathogen can be compared one by one in the sequencing results, which can quickly identify all kinds of pathogenic microorganisms, so that the diagnosis time is shortened and the diagnosis results are more accurate Studies have shown significantly higher levels of calcitonin in cerebrospinal fluid in patients with bacterial meningitis compared to patients with viral meningitis or meningitis-free Calcitonin in cerebrospinal fluid may be a valuable marker for the diagnosis of bacterial meningitis, especially in patients with neurosurgery Some scholars have shown that the level of cerebrospinal calcin in patients with postoperative bacterial meningitis is higher than that of non-infected people, and the difference between the two is statistically significant; Therefore, the primary detection of cerebrospinal calcitonin can be used to guide the use of drugs for suspect intracranial bacterial infection before bacterial culture and NGS technical results, ngS technology can shorten the diagnosis time and accurate diagnosis results, which can bring great help to the diagnosis and treatment of bacterial infection diseases, and realize early diagnosis prevention and treatment The result of the treatment of 2d post-cerebrospinal fluid bacteria in this case was extensively drug-resistant Bacillus, and drug sensitivity tests showed sensitivity only to dicarin Due to the diagnosis of intracranial infection, the original treatment effect is not good, the number of cerebrospinal fluid white blood cells is still very high, the replacement of antibiotic strains, the discontinuation of vancomycin, the addition of poly-stick mycobacteria B450000IU intravenous injection of 50000IU, the remaining treatment is the same before Polyustics have a high bactericidal activity against Baumann's dobacillus, and the drug resistance rate is also low in multidrug-resistant and carbon penicillin-resistant strains New research evidence suggests that for the widely drug-resistant Bacillus meningitis, intrauterine or intra-brain polyscoccal indoctic sedatives are safe and effective treatments In a retrospective study, in 51 patients with meningitis after surgery with multiple treatment options, monovariate analysis showed that polyscoccal venous and intrauterine combination therapy improved survival rates, although the results did not persist in the multi-model Karaiskos et al summarized 36 studies and a total of 81 patients diagnosed with post-neurosurgery meningitis, a total of 89% (72/81) in intrauterine/brain injection polyscoccal intheura treatment cases were eventually cured, and reached the median time of sterile cerebrospinal fluid of 4d Piparsania and other reports, the brain room injection poly-stick bacteria B combined with nitricein and poly-stick bacteria B successfultreatment of multi-drug-resistant Baumann aureus neonatal meninges-ventricular itis; Guo and others reported a case of extensive drug-resistant Baumann intracranial infection after brain trauma, recovered by using brain chamber injection poly-stick mycobacteria B combined with intravenous multi-stick mycobacteria B and dicarvertin therapy; Based on the above research results, and combined with the patient's condition, the end of the intrauterine injection program will be developed as poly-stick mycobacteria B (50000 IUbid) plus dicarin (5mgbid) and gingdamycin flushing (2 times a day); After 5d treatment, the patient's body temperature is normal, the number of cerebrospinal leukean white blood cells drops to 30 x 106/L, glucose 8.63mmol/L, protein 3.26g/L, bacterial culture negative, intracranial infection is effectively controlled After many cerebrospinal fluid test results are normal, many cerebrospinal fluid bacteria culture is negative; Intracranial infection after neurosurgery is one of the most serious and common complications, and because of the presence of the blood-brain barrier, antibacterial drugs are difficult to pass through the blood-brain barrier, the concentration of drugs in the skull is relatively low; In this case, the patient's intracranial infection after the trauma of brain trauma, and the condition is critical, sustained high fever, the number of cerebrospinal leukele white blood cells once reached 38593 x 106/L; In consecutive days amine perinan, the drug used in the veins of the amine penan, the cyclin, the poly-stick mycoccin B, the joint qing damycin intra-flush and the intra-rhyboinjection injection poly-stickmyin B and the dicaron.