重症社区获得性肺炎9项次要诊断标准权重

Weight of the IDSA/ATS minor criteria for severe community-acquired pneumonia

目的 2007年美国感染性疾病协会(IDSA)/美国胸科协会(ATS)指南定义凡符合9项次要诊断标准中3项者为重症社区获得性肺炎(CAP)。每项次要诊断标准的权重是否一致则不清,本研究的目的是探明次要诊断标准权重。方法回顾性分析2005-2009年间收住我院呼吸科的1230例CAP患者。结果符合0、1和2项次要诊断标准患者的院内病死率分别为0.3%、1.0%和3.3%,而符合3项者的则骤升至10.5%。动脉血氧分压/吸氧浓度(PaO2/FiO2)≤250mmHg(1mmHg=0.133kPa)、意识障碍/定向障碍和血尿素氮≥7mmol/L与病死率的相关性最显著(优势比分别是22.162、22.148和16.343)。白细胞<4.0×109/L、体温<36℃和低血压与病死率不存在相关性。意识障碍/定向障碍和血尿素氮≥7mmol/L与病死率存在独立相关性(优势比分别是9.296和8.493)。连续器官衰竭评分(SOFA)分值和住院费用随着次要诊断标准符合项数的增加而显著上升。血尿素氮≥7mmol/L和PaO2/FiO2≤250mmHg与SOFA分值呈最显著相关[等级相关系数(rs)分别为0.352和0.336]。PaO2/FiO2≤250mmHg和意识障碍/定向障碍与住院天数的相关性最密切(rs分别是0.114和0.114)。PaO2/FiO2≤250mmHg和多肺叶浸润与住院费用的相关性最显著(rs分别为0.257和0.196)。结论 2007年IDSA/ATS指南中每项重症CAP次要诊断标准预测院内病死率、SOFA分值、住院天数和住院费用的权重不一。

Objective The 2007 Infectious Disease Society of America（IDSA）/American Thoracic Society（ATS） guidelines defined severe community-acquired pneumonia（CAP） when patients fulfilled three out of nine minor criteria.Whether each of the criteria is of equal weight is not clear.The purpose of this study was to determine the weight of the minor criteria.Methods 1 230 adult patients admitted to our hospital from 2005 to 2009 for CAP were reviewed retrospectively.Results Hospital mortality rose sharply from 0.3%,1.0% and 3.3%,respectively,for patients with none,one and two minor criteria to 10.5% for patients with three minor criteria.PaO2/FiO2≤250 mm Hg,confusion,and uremia had the strongest association with mortality（Odds ratio,22.162,22.148,16.343,respectively）.Leukopenia,hypothermia,and hypotension were not associated with mortality.Confusion and uremia showed independent relationships with mortality（Odds ratio,9.296,8.493,respectively）.Sequential organ failure assessment（SOFA） scores and costs increased significantly with the number of minor criteria present.Uremia and PaO2/FiO2≤250 mmHg were most strongly associated with SOFA scores [rank correlation coefficient（rs）,0.352,0.336,respectively].PaO2/FiO2≤250 mmHg and confusion were in closest relation to hospital length of stay（LOS）（rs,0.114,0.114,respectively）.PaO2/FiO2≤250 mmHg and multilobar infiltrates were most strongly associated with costs（rs,0.257,0.196,respectively）.Conclusion The individual 2007 IDSA/ATS minor criteria for severe CAP were of unequal weight in predicting hospital mortality,SOFA scores,hospital LOS,and costs.