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Article(id=1241067204251284392, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241067197318091153, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202411329, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1731859200000, receivedDateStr=2024-11-18, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773823079407, onlineDateStr=2026-03-18, pubDate=1741536000000, pubDateStr=2025-03-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773823079407, onlineIssueDateStr=2026-03-18, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773823079407, creator=13701087609, updateTime=1773823079407, updator=13701087609, issue=Issue{id=1241067197318091153, tenantId=1146029695717560320, journalId=1227665162245664772, year='2025', volume='52', issue='5', pageStart='769', pageEnd='960', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1773823077754, creator=13701087609, updateTime=1773823268053, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1241067995544482681, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241067197318091153, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1241067995544482682, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241067197318091153, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=916, endPage=921, ext={EN=ArticleExt(id=1241067206306493400, articleId=1241067204251284392, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Investigation of legionella pneumophila contamination and antibiotic resistance in shower water at bathing venues in Shandong Province, columnId=1228016572065837304, journalTitle=Modern Preventive Medicine, columnName=Experimental Technology and Applications, runingTitle=null, highlight=null, articleAbstract=
Objective

To investigate the contamination levels of Legionella pneumophila (Lp) in shower water at bathing venues in Shandong Province, the influencing factors, and antibiotic resistance, providing a scientific basis for formulating prevention and control strategies for Lp infections in the population.

Methods

Using a cluster random sampling method, 2 to 3 public bathing venues were selected annually from 16 cities in Shandong Province from 2020 to 2022 for testing Lp in shower water. The influencing factors on the detection rate of Lp were explored based on the time of water sample collection, the size of water tanks, water supply methods, and whether the tanks were disinfected. Serotyping and antibiotic resistance testing were conducted on positive samples to further analyze the characteristics of antibiotic resistance in Lp.

Results

Among the 143 samples collected, 55 tested positives for Lp, yielding a positivity rate of 38.5%. Serological typing identified that serotype 1 (LP1) accounted for 51% of the positive Lp strains. The detection rate of Lp was influenced by various factors, including different water sample collection times (46.7% in October, 29.4% in April, χ2=4.49, P < 0.05), varying water tank storage capacities (50.8% for tanks with a capacity greater than daily water usage, 18.2%for those with a capacity less than daily usage, χ2=10.39, P < 0.01), and different sampling locations (26.5% at the water inlet of the pipeline, 44.7% at the showerhead, χ2=4.48, P < 0.05), with statistically significant differences observed within the groups. The 55 positive strains exhibited varying degrees of resistance to seven first-line treatment antibiotics, with the highest resistance rate to cefuroxime (90.9%) and the lowest to azithromycin (14.5%).

Conclusion

The positivity rate of Lp in shower water at bathing venues across 16 cities in Shandong Province is primarily influenced by environmental temperature and the retention of shower water in the water supply system. The Lp strains in the environment show significant resistance to antibiotics such as cefuroxime, rifampicin, and sulbactam. It is recommended to strengthen the monitoring of shower water, pay attention to changes in bacterial resistance, ensure the safety of shower water in public places, and protect the health of the population.

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目的

调查山东省沐浴场所淋浴水中嗜肺军团菌（Legionella pneumonia，Lp）的污染状况、影响因素以及对抗生素的耐药性，为制定人群Lp感染的防控策略提供科学依据。

方法

于2020—2022年以整群随机抽样的方法在山东省内16个城市每年抽取2～3家公共沐浴场所，进行淋浴水中Lp的检测。按照淋浴水样采集时间、水箱大小、供水方式、水箱是否消毒等分层探讨Lp检出率的影响因素；对阳性样品中的Lp进行血清分型及抗生素耐药性检测，进一步分析Lp抗生素耐药性特点。

结果

在采集的143份样品中，有55份Lp检测阳性，阳性率为38.5%。血清学分型鉴定发现，阳性Lp血清1型（LP1）占比51%。不同的水样采集时间（10月份为46.7%，4月份为29.4%，χ2=4.49，P<0.05）、不同供水水箱储水量（水箱储水量大于日用水量者为50.8%，水箱储水量小于日用水量者为18.2%，χ2=10.39，P<0.01）及不同水样采集位置（管网入水口为26.5%，淋浴喷头为44.7%，χ2=4.48，P<0.05）等对淋浴水中Lp的检出率有影响，三种不同分组比较的组内差异均有统计学意义。分离出的55株阳性菌株对7种一线治疗药物表现为不同程度的耐药，对头孢呋辛的耐药率最高，为90.9%，对阿奇霉素耐药率最低，为14.5%。

结论

山东省16个城市沐浴场所淋浴水中Lp阳性率的高低主要受环境温度和淋浴水在供水系统中滞留的影响，环境中Lp主要是对头孢呋辛、利福平、舒巴坦等抗生素耐药，建议加强对淋浴水的监管，关注菌群耐药性变化，保障公共场所淋浴用水安全，保护人民群众的身体健康。

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胡彬，E-mail:
董非，E-mail:
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胡彬与董非为共同通信作者

江媛媛（1976—），女，学士，副主任技师，研究方向：公共卫生

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Disease Surveillance, 2019, 34(10): 928-931.(In Chinese), articleTitle=Antibiotic resistance of 101 Legionella strains, refAbstract=null)], funds=[Fund(id=1241067224337806002, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, awardId=ZR2022MH318, language=CN, fundingSource=山东省自然科学基金面上项目(ZR2022MH318), fundOrder=null, country=null), Fund(id=1241067224425886391, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, awardId=202312011009, language=CN, fundingSource=山东省医药卫生科技项目(202312011009), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1241067211129942293, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, xref=1., ext=[AuthorCompanyExt(id=1241067211138330903, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, companyId=1241067211129942293, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Shandong Provincial Center for Disease Control and Prevention, Health Inspection and Testing Institute, Jinan, Shandong 250014, China), AuthorCompanyExt(id=1241067211146719512, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, companyId=1241067211129942293, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1.山东省疾病预防控制中心公共卫生监测评价所，山东 济南 250013)]), AuthorCompany(id=1241067211238994213, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, xref=2., ext=[AuthorCompanyExt(id=1241067211247382821, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, companyId=1241067211238994213, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2.山东省疾病预防控制中心消毒与病媒生物防治所，山东 济南 250013)]), AuthorCompany(id=1241067211352240435, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, xref=3., ext=[AuthorCompanyExt(id=1241067211381600564, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, companyId=1241067211352240435, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3.山东省疾病预防控制中心卫生检验检测所，山东 济南 250014)]), AuthorCompany(id=1241067211486458176, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, xref=4., ext=[AuthorCompanyExt(id=1241067211532595524, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, companyId=1241067211486458176, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=4.上海市疾病预防控制中心健康危害因素监测与控制所)])], figs=[ArticleFig(id=1241067222207099519, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=EN, label=Figure 1, caption=Analysis of antibiotic resistance of Lp in different years, figureFileSmall=+FfJ9ANrxN4pvvQ7982sMQ==, figureFileBig=NkQMmZttdm8riTb5oCoX0g==, tableContent=null), ArticleFig(id=1241067222295179910, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=CN, label=图1, caption=不同年份Lp抗生素耐药性比较

注：*P<0.05。

, figureFileSmall=+FfJ9ANrxN4pvvQ7982sMQ==, figureFileBig=NkQMmZttdm8riTb5oCoX0g==, tableContent=null), ArticleFig(id=1241067222521672341, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=EN, label=Table 1, caption=

Detection of Lp in shower water samples from different states of bathing facilities in Shandong Province from 2020 to 2022

, figureFileSmall=null, figureFileBig=null, tableContent=
淋浴水样状态样本
份数		阳性数
(阳性率/%)		χ2值P值
水样采集时间
10月7535(46.7)4.490.034
4月6820(29.4)
供水方式
有水箱储水9336(38.7)0.0070.934
无水箱直供5019(38.0)
消毒情况*
消毒6724(35.8）0.840.359
未消毒2612(46.2）
水质检测#
是7634(44.7）2.700.100
否6721(31.3）
水加热方式
电/燃气12148(39.7）0.490.490
太阳能227(31.8）
供水水箱水量
储水>日用水量5930(50.8）10.39<0.001
储水<日用水量336(18.2）
水样采集位置
管道进水口4913(26.5）4.480.034
淋浴喷头9442(44.7）
合计14355(38.5)——
), ArticleFig(id=1241067224019038878, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=CN, label=表1, caption=

山东省2020—2022年沐浴场所不同状态淋浴水样中Lp检出情况

, figureFileSmall=null, figureFileBig=null, tableContent=
淋浴水样状态样本
份数		阳性数
(阳性率/%)		χ2值P值
水样采集时间
10月7535(46.7)4.490.034
4月6820(29.4)
供水方式
有水箱储水9336(38.7)0.0070.934
无水箱直供5019(38.0)
消毒情况*
消毒6724(35.8）0.840.359
未消毒2612(46.2）
水质检测#
是7634(44.7）2.700.100
否6721(31.3）
水加热方式
电/燃气12148(39.7）0.490.490
太阳能227(31.8）
供水水箱水量
储水>日用水量5930(50.8）10.39<0.001
储水<日用水量336(18.2）
水样采集位置
管道进水口4913(26.5）4.480.034
淋浴喷头9442(44.7）
合计14355(38.5)——
), ArticleFig(id=1241067224115507875, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=EN, label=Table 2, caption=

Serological analysis of Lp in different types of positive water samples ［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
淋浴水样状态LP1型LP2～14型χ2值P值
水样采集时间10月17（44.7）21（55.3）1.870.171
4月11（64.7）6（35.3）
水加热方式太阳能3（42.9）4（57.1）1.650.199
电/燃气25（52.1）23（47.9）
), ArticleFig(id=1241067224211976874, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241067204251284392, language=CN, label=表2, caption=

不同类型阳性水样Lp血清学分析［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
淋浴水样状态LP1型LP2～14型χ2值P值
水样采集时间10月17（44.7）21（55.3）1.870.171
4月11（64.7）6（35.3）
水加热方式太阳能3（42.9）4（57.1）1.650.199
电/燃气25（52.1）23（47.9）
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山东省沐浴场所淋浴水中嗜肺军团菌污染状况及耐药性调查
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江媛媛 1 , 高衍新 1 , 隋少峰 4 , 杜英林 1 , 张晓 1 , 胡彬 3 , 董非 2
现代预防医学 | 实验技术及其应用 2025,52(5): 916-921
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现代预防医学 | 实验技术及其应用 2025, 52(5): 916-921
山东省沐浴场所淋浴水中嗜肺军团菌污染状况及耐药性调查
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江媛媛1, 高衍新1, 隋少峰4, 杜英林1, 张晓1, 胡彬3 , 董非2
作者信息
  • 1.山东省疾病预防控制中心公共卫生监测评价所，山东 济南 250013
  • 2.山东省疾病预防控制中心消毒与病媒生物防治所，山东 济南 250013
  • 3.山东省疾病预防控制中心卫生检验检测所，山东 济南 250014
  • 4.上海市疾病预防控制中心健康危害因素监测与控制所

    • 江媛媛（1976—），女，学士，副主任技师，研究方向：公共卫生

通讯作者:

胡彬，E-mail:
董非，E-mail:
Investigation of legionella pneumophila contamination and antibiotic resistance in shower water at bathing venues in Shandong Province
Yuan-yuan JIANG1, Yan-xin GAO1, Shao-feng SUI4, Ying-lin DU1, Xiao ZHANG1, Bin HU3 , Fei DONG2
Affiliations
  • Shandong Provincial Center for Disease Control and Prevention, Health Inspection and Testing Institute, Jinan, Shandong 250014, China
出版时间: 2025-03-10 doi: 10.20043/j.cnki.MPM.202411329
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摘要
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目的

调查山东省沐浴场所淋浴水中嗜肺军团菌（Legionella pneumonia，Lp）的污染状况、影响因素以及对抗生素的耐药性，为制定人群Lp感染的防控策略提供科学依据。

方法

于2020—2022年以整群随机抽样的方法在山东省内16个城市每年抽取2～3家公共沐浴场所，进行淋浴水中Lp的检测。按照淋浴水样采集时间、水箱大小、供水方式、水箱是否消毒等分层探讨Lp检出率的影响因素；对阳性样品中的Lp进行血清分型及抗生素耐药性检测，进一步分析Lp抗生素耐药性特点。

结果

在采集的143份样品中，有55份Lp检测阳性，阳性率为38.5%。血清学分型鉴定发现，阳性Lp血清1型（LP1）占比51%。不同的水样采集时间（10月份为46.7%，4月份为29.4%，χ2=4.49，P<0.05）、不同供水水箱储水量（水箱储水量大于日用水量者为50.8%，水箱储水量小于日用水量者为18.2%，χ2=10.39，P<0.01）及不同水样采集位置（管网入水口为26.5%，淋浴喷头为44.7%，χ2=4.48，P<0.05）等对淋浴水中Lp的检出率有影响，三种不同分组比较的组内差异均有统计学意义。分离出的55株阳性菌株对7种一线治疗药物表现为不同程度的耐药，对头孢呋辛的耐药率最高，为90.9%，对阿奇霉素耐药率最低，为14.5%。

结论

山东省16个城市沐浴场所淋浴水中Lp阳性率的高低主要受环境温度和淋浴水在供水系统中滞留的影响，环境中Lp主要是对头孢呋辛、利福平、舒巴坦等抗生素耐药，建议加强对淋浴水的监管，关注菌群耐药性变化，保障公共场所淋浴用水安全，保护人民群众的身体健康。

嗜肺军团菌  /  沐浴场所  /  淋浴水  /  耐药性
Objective

To investigate the contamination levels of Legionella pneumophila (Lp) in shower water at bathing venues in Shandong Province, the influencing factors, and antibiotic resistance, providing a scientific basis for formulating prevention and control strategies for Lp infections in the population.

Methods

Using a cluster random sampling method, 2 to 3 public bathing venues were selected annually from 16 cities in Shandong Province from 2020 to 2022 for testing Lp in shower water. The influencing factors on the detection rate of Lp were explored based on the time of water sample collection, the size of water tanks, water supply methods, and whether the tanks were disinfected. Serotyping and antibiotic resistance testing were conducted on positive samples to further analyze the characteristics of antibiotic resistance in Lp.

Results

Among the 143 samples collected, 55 tested positives for Lp, yielding a positivity rate of 38.5%. Serological typing identified that serotype 1 (LP1) accounted for 51% of the positive Lp strains. The detection rate of Lp was influenced by various factors, including different water sample collection times (46.7% in October, 29.4% in April, χ2=4.49, P < 0.05), varying water tank storage capacities (50.8% for tanks with a capacity greater than daily water usage, 18.2%for those with a capacity less than daily usage, χ2=10.39, P < 0.01), and different sampling locations (26.5% at the water inlet of the pipeline, 44.7% at the showerhead, χ2=4.48, P < 0.05), with statistically significant differences observed within the groups. The 55 positive strains exhibited varying degrees of resistance to seven first-line treatment antibiotics, with the highest resistance rate to cefuroxime (90.9%) and the lowest to azithromycin (14.5%).

Conclusion

The positivity rate of Lp in shower water at bathing venues across 16 cities in Shandong Province is primarily influenced by environmental temperature and the retention of shower water in the water supply system. The Lp strains in the environment show significant resistance to antibiotics such as cefuroxime, rifampicin, and sulbactam. It is recommended to strengthen the monitoring of shower water, pay attention to changes in bacterial resistance, ensure the safety of shower water in public places, and protect the health of the population.

Legionella pneumophila  /  Bathing venues  /  Shower water  /  Antibiotic resistance
江媛媛, 高衍新, 隋少峰, 杜英林, 张晓, 胡彬, 董非. 山东省沐浴场所淋浴水中嗜肺军团菌污染状况及耐药性调查. 现代预防医学, 2025 , 52 (5) : 916 -921 . DOI: 10.20043/j.cnki.MPM.202411329
Yuan-yuan JIANG, Yan-xin GAO, Shao-feng SUI, Ying-lin DU, Xiao ZHANG, Bin HU, Fei DONG. Investigation of legionella pneumophila contamination and antibiotic resistance in shower water at bathing venues in Shandong Province[J]. Modern Preventive Medicine, 2025 , 52 (5) : 916 -921 . DOI: 10.20043/j.cnki.MPM.202411329
正文
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军团菌是一种广泛存在于自然界水和土壤中的机会致病菌，主要在40～50℃人造供水系统的潮湿环境中生长繁殖。嗜肺军团菌(Legionella pneumonia，Lp) 是军团菌中的主要致病菌，人类主要通过吸入被嗜肺军团菌污染的气溶胶而引发军团菌病（legionellosis），主要症状表现为非典型肺炎[1-3]，如不及时治疗，军团菌病死率高达8%～15.38%[4-5]。鉴于Lp的致病性及其传播的隐匿性，世界卫生组织（WHO）已将由Lp传播引起的以肺炎为主的全身性疾病列入传染病报告范围。
Lp可在肺巨噬细胞内侵入和复制，所以国际公认的能够穿透细胞的抗菌药物如大环内酯类、氟喹诺酮类和利福平等为首选药物。近年来人们开始关注人工水环境中微生物的耐药性研究，国际已有Lp在外环境中获得耐药性的报道，Lp耐药基因的出现，给Lp病的治疗带来了巨大的挑战。
淋浴水作为一种常见的生活用水，其潜在致病性却较少被人们关注。公共沐浴场所在运行过程中，将淋浴水的温度长期维持在40℃左右，同时沐浴场所特有的潮湿环境均为Lp在沐浴场所室内空气中的生长、繁殖、悬浮提供了有利条件，国际上欧洲、美国均有淋浴水引起Lp感染的报道[6]，我国自1982年在南京首次发现Lp病例以来，全国也有多起嗜肺军团病的暴发与散发报道[7-9]。我国于2019年发布GB 37488—2019《公共场所卫生指标及限制要求》明确沐浴用水中不得检出Lp[10]，说明Lp通过沐浴水传播应引起足够重视。目前国外学者对公共场所中Lp产生、传播、致病机理等进行了大量研究[11-12]，但其关于淋浴水中Lp的污染状况及耐药性研究受地理、人文等方面差异的影响较大，其研究结果可能不适用于我国现有情况。国内大多数研究集中于公共场所集中空调冷凝水的污染状况分析，对淋浴水多种可能影响因素，并结合水中Lp耐药性的研究相对较少。本研究采集了山东省不同季节、不同供水模式等淋浴水样品，对其中Lp进行了检测分析，分析其污染特征及耐药特点，为探索山东省人群通过沐浴途径感染Lp的防控措施、降低Lp暴露风险提供科学依据。
1　对象与方法
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1.1　研究对象与调查内容
采用横断面调查的方式，按照简单随机抽样的方法，于2020年在山东省每市随机选取2～3家，共38家沐浴场所作为研究对象。为保证研究的连续性，每年调查及采样均在预先选定的场所进行，如因客观原因需更换研究对象则从其经营规模、客流量、沐浴水水源等多方面考虑，选择相同或相似的沐浴场所作为研究对象进行更换。2020—2022年每年均发放调查问卷和进行水样采集，每家沐浴场所采集沐浴用水样2～3份。自主设计调查表，主要内容包括沐浴场所的基本情况、储水方式、加热方式及设备管理等情况。所有调查员均严格培训，统一调查方法，现场调查由调查员询问沐浴场所管理人员，所选择的管理人员知晓该单位的卫生管理等情况，同时为保证回答的准确性，针对设施设备清洗消毒等指标，调查员现场查看有关记录，确保问卷真实有效，三年共收集114份问卷。
1.2　研究方法
1.2.1　样品采集与运输
淋浴水由市政供水（自来水）经加热系统进入供水管道后由喷头出水完成水循环。依据GB/T18204.6—2013《公共场所卫生检验方法第6部分：卫生监测技术规范》分别于加热系统和供水管道之间设一个采样点，淋浴喷头设一个采样点，各采集样本1～2个，共采集143份水样。考虑淋浴水的加热方式及Lp存活的适宜温度，将水样采集时间定在每年的4月（春季）和10月（秋季）太阳能及电加热均正常运营的季节。每家场所均在正常营业4 h后进入沐浴场所打开淋浴器喷头，将水温调至淋浴温度40～50℃时采集水样500 ml。使用无菌水样采集袋，密封后充分混匀备检。淋浴水管网进水选择供水容器出水阀门处采集，打开出水阀门放水半分钟，无菌水样袋采集水样500 ml，密封混匀后备检。水样采集过程遵守无菌操作的要求。各地区采样后24 h内运送到山东省疾病预防控制中心病原生物检验实验室。
1.2.2　军团菌分离鉴定
采用T/WSJD 26—2022《水中Lp检验方法-酶底物法》[13]检测Lp，通过Lp 96孔定量盘（Legiolert，美国）初步定性后，经布鲁克飞行时间质谱仪（MicroFlexSirus）验证确认。
1.2.3　血清分型
利用澳克塞（OXOID）的乳胶凝集试剂盒（296114520210601）对军团菌进行血清分型。将菌株接种于活性炭酵母浸膏缓冲琼脂平板（BCYE，广东环凯微生物科技有限公司），在二氧化碳培养箱（IL-161CI，施都凯仪器设备有限公司）5%CO2 条件下37 ℃培养48 h，按照军团菌诊断血清说明书进行血清凝集及结果判读。
1.2.4　药敏试验
采用E-test法（Etest条，飞驰，意大利）对分离菌株进行阿奇霉素、左氧氟沙星、红霉素、莫西沙星、舒巴坦、利福平、头孢呋辛等七种抗生素的药敏检测，根据欧洲抗生素药物敏感性实验委员会（The European Committee on Antimicrobial Susceptibility Testing，EUCAST）对军团菌药敏检测标准，以Lp菌株ATCC33152菌株作为质控菌株（敏感菌株）（LpATCC 33152，中国疾病预防控制中心传染病所赠送）。菌株耐药与否根据EUCAST所推荐的各种抗生素敏感性标准进行判定[10,13]。
1.3　统计学分析
数据收集及样品检测结果通过EpiData 3.0软件录入，核对无误后用Excel进行数据整理。样本数量等计数资料及其构成比以个数（百分数）表示,组间差异采用χ2 检验进行比较，检验水准α=0.05。数据资料的统计分析采用SPSS 20.0进行；使用Graphpad Prism 9.0制作统计图。
2　结果
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2.1　淋浴水中Lp检测结果
2020—2022年，在山东省16市中共有14市的淋浴水检出Lp阳性，143份水样阳性检出率为38.5%（55/143），逐年阳性检出率分别为2020年54.8%（17/31）、2021年29.4%（20/68）、2022年为40.9%（18/44）。研究对象中38家沐浴场所阳性检出率为84.2%( 32/38)，其中4个城市连续三年样品检测阳性，6个城市连续两年样品检测阳性。
2.2　沐浴场所Lp阳性的影响因素分析
Lp阳性率影响因素单因素分析显示，不同季节采集的水样（10月份为46.7%，4月份为29.4%）、供水水箱储水量是否大于日用水量（水箱储水量大于日用水量者为50.8%，水箱储水量小于日用水量者为18.2%）、不同水样采集位置（管网入水口为26.5%，淋浴喷头为44.7%）等因素之间Lp阳性检出率差异有统计学意义（P<0.05）。不同供水方式、水箱是否消毒、沐浴场所对水质是否定期检测、沐浴水的加热方式等因素之间Lp阳性检出率差异无统计学意义（P>0.05）。见表1。
2.3　Lp血清分型
分离出的55株阳性样品经血清凝集试验，血清分型有2个组别，分别为Lp1占51%(28 株) 、Lp2～14型占49%(27 株)。不同采集时间的水样及不同加热方式的水样血清分型两者均无统计学差异（P>0.05），见表2。
2.4　耐药结果
对淋浴水中分离出的55株阳性样品进行了耐药性检测。研究结果发现，淋浴水环境中Lp对7种抗生素表现为不同程度的耐药。耐药率由高至低依次为头孢呋辛（90.9%，50株）> 利福平（76.4%，42株）>舒巴坦（63.6%，35株）> 莫西沙星（60.0%，33株）> 红霉素（50.9%，28株）> 左氧氟沙星（30.9%，17株）> 阿奇霉素（14.5%，8株）。见图1。
由于2020年采样15例，2021年采样17例，样本例数较少，因此将两年的数据合并，与2022年的23例耐药率进行比较。在2020—2021年的32株淋浴水Lp种，耐药率最高为头孢呋辛（93.8%，30株），最低为阿奇霉素（6.25%，2株）。2022年耐药率最高为头孢呋辛（87.0%，20株）和利福平（87.0%，20株），最低为左氧氟沙星（13.0%，3株）。经χ2检验，不同年份的Lp对左氧氟沙星的耐药率不同，2022年的耐药率低于2020—2021年，差异有统计学意义（P<0.05）；不同年份阿奇霉素耐药率的差异也有统计学意义（P<0.05），2022年的耐药率高于2020—2021年。
3　讨论
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调查结果显示，在2020—2022年山东省调查的16个城市中，先后有14个城市淋浴水Lp检出阳性。采集的143份水样总的阳性检出率为38.5%，略高于马鞍山市[14]（29.7%），北京市[15]（22.7%）的调查结果，与四川省[16]（39.59%）调查结果基本一致。不同研究者报道的Lp阳性检出率的差异可能与监测样本量、采样范围、检测技术水平和试剂等因素有关。
本研究发现供水水箱储水量大于日用水量时，其淋浴水中Lp阳性检出率明显较高，提示水箱中存在残留供水可能是导致Lp污染的重要因素之一。同时Lp滞留在供水管道内与原虫、微生物形成共生关系，菌体嵌入原虫细胞外基质的细胞生物膜层[17]，使Lp耐受含氯消毒剂的侵蚀，更保持了持久的致病力。建议沐浴场所合理设计水箱容量，储水量小于日用水量，减少积水情况发生，每日营业前先将水箱、水管中残留的水放掉，供水管道、水箱等储水设备采用表面光滑不易产生生物膜的材质，降低军团菌感染风险。影响Lp污染程度的另一个因素是环境温度，李娜[16]李达[18]严燕[19]等做的季节变化与水中Lp阳性率的关联性研究，发现环境温度与Lp的污染有相关性，本次调查中，秋季淋浴水水样阳性检出率明显高于春季，建议在高发季节增加淋浴水的监测、消毒频率。调查发现淋浴喷头出水阳性检出率明显高于供水管网入水口的阳性检出率，说明供水管道及淋浴喷头是Lp污染的重点部位，应考虑针对供水管道和淋浴喷头等关键部位[20]进行深度清洗和浸泡消毒。本次调查中发现水箱消毒与否，Lp阳性检出率无统计学差异，目前公共场所管理部门对淋浴水消毒管理工作不够重视，清洗消毒使用消毒剂的浓度及消毒时长等没有统一技术要求，导致消毒效果不理想，亟需结合消毒效果研究制定淋浴水的消毒指南，进一步指导淋浴水科学消毒。加强对淋浴水的管理，更多从预防角度关注并控制淋浴水中Lp的污染，对潜在的风险进行预警，防控Lp的传播，以达到保护人群健康的目的。
Lp不同血清型致病性不同，LP1型为主要致病血清型[21]，是引起社区获得性肺炎和医院内感染性肺炎的重要病原体。山东省16市淋浴水中检出的Lp以高致病风险的LP1型为主，占51%（28 株），略高于四川省[16]（40%）、马鞍山市[19]（40.9%）的调查结果，与漳州市[22]（58.43%）和江门市[23]（56.06%）的调查结果基本一致。本研究发现对于不同季节及不同加热方式的水样，血清分型均无统计学差异，淋浴水中的Lp的血清型不受季节性和水加热方式的影响，均存在发生军团病的健康风险。
耐药研究显示，淋浴水中的Lp对七种抗生素均表现为不同程度的耐药，对于目前抗军团菌药物首选的阿奇霉素（14.5%）耐药菌株最少，临床治疗军团菌病时仍可考虑其作为首选治疗药物[24-25]，但红霉素（50.9%）耐药率较高，远高于肖士林[26]等对其他环境水的耐药性研究结果。通过对3个年份淋浴水样的Lp药物敏感性进行的调查，发现细菌的耐药基因会因为外环境的各种因素发生变化。目前Lp涉及患者生物样品的耐药检测国内文献极少，时间跨度也很大，外环境菌群耐药性的研究是在监测人群Lp感染状况和耐药特征存在困难的条件下，通过监测外环境中Lp耐药性，以评估人群可能存在的感染风险，为应对Lp引起的突发性公共卫生事件提供临床用药参考。
本研究在山东省内16个城市随机选择沐浴场所，尚未将每个城市涉及覆盖的场所情况、人口参数进行综合考虑，因此监测点的代表性存在选择偏倚，2020年因疫情原因沐浴场所出现停业、顾客人数下降、用水量减少，水样采集较少，2021—2022年总结前期检测数据，优化了采样方案，调整了采样数量，三年采样数量存在差异，对山东省整体上沐浴场所Lp的检测、分析会产生一定影响。后续拟扩大监测点的覆盖范围，增强监测结果的代表性，弥补本调查研究的局限性。
综上所述，目前山东省淋浴水中的Lp作为被使用人及监管部门一定程度忽视的健康危险因素，可能存在军团菌病的爆发和流行风险。建议相关部门高度重视沐浴场所水质卫生问题，提高沐浴场所管理人员对淋浴水系统清洗消毒的意识，建立相应的卫生管理制度，同时监督部门应加强淋浴水卫生监督管理的力度，从规范水箱设计、科学选用供水管网材质等硬件设计方面及合理选择清洗季节、加强关键部位清洗消毒、优化消毒管理等软件管理方面入手，保障公共场所淋浴用水的安全，切实保护人民群众的身体健康。
基金
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  • 山东省自然科学基金面上项目(ZR2022MH318)
  • 山东省医药卫生科技项目(202312011009)
文献
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doi: 10.20043/j.cnki.MPM.202411329
  • 接收时间：2024-11-18
  • 首发时间：2026-03-18
  • 出版时间：2025-03-10
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  • 收稿日期：2024-11-18
基金
山东省自然科学基金面上项目(ZR2022MH318)
山东省医药卫生科技项目(202312011009)
作者信息
    1.山东省疾病预防控制中心公共卫生监测评价所，山东 济南 250013
    2.山东省疾病预防控制中心消毒与病媒生物防治所，山东 济南 250013
    3.山东省疾病预防控制中心卫生检验检测所，山东 济南 250014
    4.上海市疾病预防控制中心健康危害因素监测与控制所

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胡彬，E-mail:
董非，E-mail:
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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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