降阶梯、经验性抗生素治疗HBV相关慢加急性肝衰竭合并自发性腹膜炎的效果比较

A comparison between the effects of antibiotic de-escalation therapy and empirical treatment on HBV-related acute-on-chronic liver failure patients complicated with spontaneous bacterial peritonitis

目的研究降阶梯与经验性抗生素治疗HBV相关慢加急性重型乙型肝炎(HBV-ACLF)合并自发性腹膜炎(SBP)的疗效。方法2014年4月至2020年4月104例HBV-ACLF合并SBP患者,采用随机数字表法将104例患者分为观察组和对照组,每组52例。观察组行降阶梯治疗,对照组行经验性治疗。比较两组治疗效果,记录腹水细菌培养结果,分析影响治疗效果的相关因素。结果两组2周时总体疗效比较,差异有统计学意义(P<0.05)。观察组肝性脑病13例,顽固性腹水11例,对照组分别为23例和21例,两组肝性脑病和顽固性腹水发生率比较,差异有统计学意义(P<0.05)。观察组显效患者国际标准化比值(INR)、天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)及终末期肝病模型评分(MELD)显著低于非显效者,差异有统计学意义(P<0.05)。Logistic多因素回归分析显示肝性脑病(95%CI=1.154~9.328,P=0.026,OR=3.281)、肝肾综合征(95%CI=1.522~4.087,P=0.000,OR=2.494)、INR(95%CI=1.375~2.603,P=0.000,OR=1.892)及MELD(95%CI=1.054~3.630,P=0.033,OR=1.956)是HBV-ACLF合并SBP患者疗效的独立影响因素。结论降阶梯方案治疗HBV-ACLF合并SBP患者疗效显著,优于常规经验性抗生素方案,但其临床疗效还受患者INR、MELD及肝性脑病等并发症因素影响。

Objective To study on the effect of antibiotic de-escalation therapy and empirical treatment on HBV-related acute-on-chronic liver failure(HBV-ACLF)patients complicated with spontaneous bacterial peritonitis(SBP).Methods A total of 104 patients with HBV-ACLF and SBP from April 2014 to April 2020 were enrolled in this study.They were divided into an observation group and a control group by random number table method,with 52 cases in each group.The observation group was treated with antibiotic de-escalation and further divided into effective and non-effective subgroups,while the control group was treated with empirical antibiotic therapy.The ascites bacterial culture results were recorded and the therapeutic effects of these groups were compared.Factors associated with the treatment effect were analyzed.Results There was significant difference between the observation and control groups in overall efficacy after 2 weeks’treatment(P<0.05).The incidence of hepatic encephalopathy and refractory ascites in the observation group were significantly lower than those of the control group(13 vs 23 cases,and 11 vs 21 cases,respectively)(P<0.05).In patients of the observation group,the international normalized ratio(INR),levels of aspartate aminotransferase(AST)and alanine transferase(ALT),the model for end stage liver disease(MELD)score of effectively treated patients were significantly lower than those of non-effective patients(P<0.05).By multivariate logistic regression analysis it was showed that the hepatic encephalopathy(95%CI=1.154~9.328,P=0.026,OR=3.281),hepatorenal syndrome(95%CI=1.522~4.087,P=0.000,OR=2.494),international normalized ratio(INR)(95%CI=1.375~2.603,P=0.000,OR=1.892),model for end-stage liver disease(MELD)(95%CI=1.054-3.630,P=0.033,OR=1.956)were independent factors influencing the treatment effect on patients with HBV-ACLF and SBP.Conclusion Antibiotic de-escalation regimen for the treatment of HBV-ACLF combined with SBP is more effective than conventional empirical antibiotic therapy.This efficacy is further associated with factors such as INR,MELD and hepatic encephalopathy.