降钙素原变化率在重症细菌性肺炎疗效评估中的作用

The role of change of procalcitonin in the therapeutic effect evaluation of severe bacterial pneumonia

目的研究血清降钙素原（PCT）变化率在指导重症细菌性肺炎疗效评估中的作用。方法本研究为前瞻单中心观察性研究。纳入2010年北京协和医院ICU中收治的重症细菌性肺炎患者。人选65例，平均年龄（62±16）岁。诊断为重症社区获得性肺炎5例，院内获得性肺炎32例和呼吸机相关性肺炎28例。入选时临床肺部感染评分（CPIS）7．9±1．8；急性生理及慢性健康状态（APACHE）Ⅱ评分14．5±5．3。有效组44例，失败组21例。在人选时、72h、第7天、治疗结束时测定血清PCT水平。治疗结束后5d内按照卫生部抗菌药物临床研究指导原则完成疗效评估，分为有效（包括治愈及改善）和失败。采用SPSSl3．0进行统计分析。结果两组患者在入选、72h、第7天和治疗结束时的PCT及72hPCT变化率依次为（3．83±2．18）比（4．23±2．64）μg／L（t=1．249，P=0．387）、（2．44±1．05）比（3．48±1．75）μg／L（t=-1．959，P=0．045）、（1．15±0．87）比（3．41±1．58）μg／L（t=-2．904，P=0．006）、（0．51±0．17）比（2．63±1．08）μg／L（t=-3．772，P=0．000）及（32．5±12．4）％vs（14．5±7．1）％（t=-2．376，P=0．009）。72hPCT变化率预测疗效的受试者工作特征曲线下面积AUC为0．823（P=0．002），白细胞、中性粒细胞百分比、体温、72hPCT绝对值预测疗效的AUC依次为0．575，0．543，0．521，0．597（P〉0．05）。多元回归分析显示72hPCT变化率〈30．8％（OR15．2，95％CI3．3-21．7，P=0．01）是影响疗效的独立危险因素之一。PCT变化率（下降〉30．8％）联合CPIS（〈6分）预测疗效的AUC为0．910，敏感度85．2％，特异度92．5％。结论72hPCT变化率可指导重症细菌性肺炎早期治疗效果评估，联合CPIS可进一步提高其预测价值。

Objective The aim of this study is to define if early change of procalcitonin （PCT） may inform about the efficacy evaluation of severe bacterial pneumonia. Methods A prospective, single-center, observational study was conducted in patients with severe bacterial pneumonia admitted to ICU in 2010 years. PCT samples were collected in baseline ,72 hours ,7 days and the ending in the duration of therapy. The efficacy evaluation was assessed at the end of treatment 5 days after and divided into the efficacy group and nonefficacy group according to the guiding principle of clinical research on antibacterial drugs by the Ministry of Health. Sixty-five patients with a mean age of （62. 1 ± 15.9 ） years were evaluated. Five patients were severe community acquired pneumonia, 32 patients nosocomial pneumonia and 28 patients ventilator associated pneumonia. The clinical pulmonary infection score（CPIS） was 7.9 ± 1.8;APACHE I score was 14. 5 ±5.3. There were 44 patients as the efficacy group and 21 patients as the nonefficacy group. SPSS13.0 was used to analyse the results. Results The PCT levels between efficacy group and nonefficacy group were （3.83±2.18）vs（4.23±2.64） μg/L （t=1.249, P=0.387）,（2.44±1.05）vs（3.48±1.75） μg/L （t= -1.959, P=0.045）,（1.15 ±0.87） vs （3.41 ± 1.58）μg/L （t = -2.904, P=0.006）,and （0.51 ±0. 17） vs （2.63 ±1.08） μg/L （t = -3.772, P=0.000） in baseline, 72 hours,7 days and the ending in the duration of therapy. The change of PCT within the first 72 hours were （ 32. 5 ± 12.4 ） % vs（ 14. 5 ± 7. 1 ） % . The area under receiver operating characteristics curve （ AUC ） of prediction clinical efficacy of the change of PCT within the first 72 hours was 0. 823 （P = 0. 002）, the AUC of white blood cell, the neuter granulocyte percentage, body temperature and PCT level within 72 hours were 0. 575,0. 543, 0. 521,0. 597, respectively （P 〉 0. 05）. In multivariate analyses, the change of PCT 〈 30. 8% （odds ratio, 15.2, 95% confidence interval,3.3-21.7, P = 0. 01 ） was independent risk factors of effect predictor. The changes of PCT within the first 72 hours （ 〉 30. 8% ） combined with CPIS（ 〈 6） were the best performance to predict clinical efficacy with a AUC of 0. 910, sensitivity of 85.2% and specificity of 92. 5%. Conclusions The change of PCT within the first 72 hours can be used early to evaluate the effect in bacterial pneumonia. Especially, combined with CPIS can further improve the prediction value.