乙型肝炎相关慢加急性肝衰竭患者医院侵袭性真菌感染调查及影响因素

Investigation of nosocomial invasive fungal infection of influencing factors in patients with hepatitis B virus-related acute-on-chronic liver failure

目的调查乙型肝炎相关慢加急性肝衰竭(HBV-ACLF)患者医院侵袭性真菌感染临床特征,并分析其影响因素。方法2018年1月-2020年12月内蒙古自治区人民医院收治的HBV-ACLF患者97例,查阅出院病历资料,分析患者发生医院侵袭性真菌感染的临床特点,应用logistic回归分析影响医院侵袭性真菌感染发生的因素。结果97例HBV-ACLF患者在住院期间发生医院侵袭性真菌感染20例(20.6%),所有患者均有咳嗽、咳痰等表现,胸部CT均出现不同程度的变化,其中可闻及肺部湿啰音8例(40.0%),发热7例(35.0%),呼吸困难、胸闷5例(25.0%)。共分离出真菌31株,其中白假丝酵母菌14株(45.1%),曲霉菌属11株(35.4%)。单因素分析显示,感染患者与未感染患者年龄、性别、凝血酶原时间、并发中毒性鼓肠等临床资料差异无统计学意义(P>0.05);中性粒细胞、侵入性操作、广谱抗生素长期应用、并发肝肾综合征、28 d死亡、总胆红素、白蛋白、终末期肝病模型(MELD)评分、住院时间等临床资料差异有统计学意义(P<0.05)。多因素回归分析显示,广谱抗生素应用时间>2周(OR=10.236,P<0.001)、中性粒细胞绝对计数减少(OR=10.165,P<0.001)、接受侵袭性操作(OR=9.934,P<0.001)、住院时间长(OR=9.143,P<0.001)是HBV-ACLF患者发生医院侵袭性真菌感染的独立危险因素。结论HBV-ACLF患者发生医院侵袭性真菌感染以白假丝酵母菌感染为主,这与广谱抗生素长期应用、中性粒细胞减少等因素相关,因此对真菌感染高危群体应予以密切关注,重视诊疗操作规范性及病室环境,以减少此类感染事件发生。

Objective The aim of this study was to investigate the clinical characteristics of nosocomial invasive fungal infection in patients with hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF),and analyze the influencing factors.Methods Ninety seven patients with HBV-ACLF admitted to the hospital were selected between January 2018 and December 2020.The discharge medical records were reviewed to analyze the clinical characteristics of nosocomial invasive fungal infection.Logistic regression analysis was used to analyze the factors affecting the occurrence of nosocomial invasive fungal infection.Results A total of 20 cases(20.6%)were with nosocomial invasive fungal infections during hospitalization among 97 patients with HBV-ACLF,and they had cough and expectoration manifestations and showed varying degrees of changes on chest CT,including 8 cases(40.0%)with lung rales,7 cases(35.0%)with fever and 5 cases(25.0%)with dyspnea and chest tightness.A total of 31 fungi were isolated,including 14 strains of Candida albicans(45.1%)and 11strains of Aspergillus(35.4%).Univariate analysis showed there were no statistical differences in the clinical data such as age,gender,prothrombin time,presence of toxic tympanites between infected patients and uninfected patients(P>0.05).There were significant differences in terms of clinical data of neutrophils,invasive operations,long-term use of broad-spectrum antibiotics,presence of hepatorenal syndrome,28 d death,total bilirubin,albumin,model for end-stage liver disease(MELD)score and hospital stay(P<0.05).Multivariate regression analysis showed that the use time of broad-spectrum antibiotics>2 week(OR=10.236,P<0.001),decreased absolute count of neutrophils(OR=10.165,P<0.001),receiving invasive operations(OR=9.934,P<0.001)and long hospital stay(OR=9.143,P<0.001)were independent risk factors for nosocomial invasive fungal infection in patients with HBV-ACLF(P<0.05).Conclusions Nosocomial invasive fungal infection in patients with HBV-ACLF was mainly caused by Candida albicans,which was related to the factors such as long-term use of broad-spectrum antibiotics and neutropenia.Therefore,close attention should be paid to people of highrisk fungal infections,and diagnosis,treatment and ward environment should be standardized to reduce the occurrence of such infections.