培养阴性腹膜透析相关性腹膜炎的实验室指标及预后分析

Clinic diagnosis and treatment of culture-negative peritonitis in peritoneal dialysis patients

目的探讨培养阴性腹膜透析相关性腹膜炎(CNP)的临床特征及治疗体会。方法2008年1月至2012年12月收治的腹膜透析相关性腹膜炎(PDAP)患者56例,回顾性分析CNP患者的病史、化验室指标、病原菌、治疗方式及转归,并与同期收治的革兰氏阳性(G+)球菌、革兰阴性(G-)杆菌腹膜炎进行分组比较。采用SPSS 15.0软件包进行统计学处理,两组血清不同致病菌PDAP患者血清血红蛋白、白蛋白水平及腹膜透析液白细胞计数采用均数±标准差表示,显著性比较采用t检验,治疗的疗效、近期抗生素使用史及合并症发生率的比较用χ2检验。结果 56例PDAP中CNP组21例,G+球菌组24例,G-杆菌组11例;CNP组有较高的近期抗生素使用史(23.8%);3组患者在腹膜透析液白细胞计数[(2486.9±2576.4)×106/L,(3017.5±1979.4)×106/L,(2526.7±509.7)×106/L,F=0.185,P>0.05]、近期抗生素使用率(23.5%,4.2%,9.0%,χ2=4.48,P>0.05)、合并出口/皮下隧道感染(4.8%,4.2%,0%,χ2=0.5,P>0.05)方面均差异无统计学意义;CNP组血红蛋白(78.2±11.9)g/L最低,与G+球菌组(89.5±16.5)g/L(LSD-t=11.26,P<0.05)及G-杆菌组(89.1±15.8)g/L(LSD-t=10.95,P<0.05)比较,组间差异有统计学意义。CNP组血白蛋白(25.1±4.1)g/L最低,与G+球菌组(31.5±7.5)g/L(LSD-t=6.32,P<0.05)及G-杆菌组(32.5±6.7)g/L(LSD-t=7.31,P<0.05)组比较,组间差异有统计学意义(P<0.05)。在疗效方面,CNP组患者有较低的完全治愈率(66.7%),较高的拔管率(9.5%)、复发率(23.8%),但3组间初始应答率(81%,87.5%,90.9%,χ2=1.68,P>0.05)、完全治愈率(66.7%,75.0%,81.8%,χ2=1.12,P>0.05)、拔管率(9.5%,4.2%,0%,χ2=1.4,P>0.05)、复发率(23.8%,8.3%,0%,χ2=4.42,P>0.05),差异无统计学意义。结论培养阴性腹膜炎的产生与近期抗生素使用无关,其有较重的营养不良;且完全治愈率低,拔管率及复发率均较高,提示其预后相对较差。

Objective To investigate the treatment experiences and clinic features of culture-negative peritonitis(CNP)in peritoneal dialysis (PD)patients.Methods CNP episodes were reviewed retrospectively in our medical center from January 2008 to December 201 2.The clinical manifestations, laboratory indicators,pathogenic bacteria,treatment,recovery rate,extubation rate,and relapse rate were analyzed and compared with those of gram positive and gram negative bacterial peritonitis.Comparing of curative effect,history of previous antibiotics treatment and the incidence of complications were analyzed by chi-squart test.Results Fifty-six patients with peritoneal dialysis-associateel peritonitis (PDAP) were reviewed.There were 21 cases with CNP,24 episodes with gram positive and 1 1 episodes with gram negative bacterial peritonitis in the 56 cases.CNP group had a much higher history of previous antibiotic treatment (23.8%).There were no significant differences in the white blood cell (WBC)count of dialysate (2486.9 ±&nbsp;2576.4 ×1 06 /L,301 7.5 ±1 979.4 ×1 06 /L,2526.7 ±509.7 ×1 06 /L,F =0.1 85,P >0.05),history of previous antibiotic treatment (23.5%,4.2%,9.0%,χ2 =4.48,P >0.05 ),the combined infection of export/subcutaneous tunnel (4.8%,4.2%,0.0%,χ2 =0.5,P >0.05)of the three groups.CNP group had lower hemoglobin(78.2 ±1 1 .9)g/L,compared with gram positive group(89.5 ±1 6.5)g/L(LSD-t =1 1 .26,P <0.05 )and gram negative group(89.1 ±1 5.8)g/L(LSD-t =1 0.95,P <0.05),and there were significant differences among the three groups.At the same time,CNP group had lower serum albumin (25.1 ±4.1 )g/L,compared with gram positive group(31 .5 ±7.5)g/L(LSD-t =6.32,P <0.05)and gram negative group(32.5 ±6.7)g/L(LSD-t =7.31 ,P <0.05),and there were significant differences among the three groups.In the therapeutic effect,CNP group had lower complete cure rate(66.7%),higher catheter removal rate (9.5%),relapse rate (23.8%).There were no significant differences in overall primary response rate(81 %,87.5%,90.9%,χ2 =1 .68,P >0.05 ),the complete cure rate (66.7%, 75%,81 .8%,χ2 =1 .1 2,P >0.05),the catheter removal rate(9.5%,4.2%,0.0%,χ2 =1 .4,P >0.05) and relapse rate (23.8%,8.3%,0%,χ2 =4.42,P >0.05 )among the three groups. Conclusions The appearance of CNP may not be associated with history of previous antibiotic treatment. CNP has severe malnutrition,lower complete cure rate,higher catheter removal rate and catheter removal rate,suggesting a bad prognosis.