医疗机构相关性感染性心内膜炎的流行病学特点及其预后

Epidemiology and prognosis of healthcare-associated infective endocarditis

目的描述医疗机构相关性感染性心内膜炎（HAIE）的特点，并分析引起感染性心内膜炎（IE）死亡的危险因素。方法连续收集1992年至2012年复旦大学附属华山医院确诊的IE患者，分为HAIE和社区获得性IE（CAIE），比较HAIE和CAIE的流行病学及临床特点。采用Logistic回归筛选引起IE患者住院死亡的危险因素。结果共纳入154例IE患者，其中126例为CAIE，占81．8％，28例为HAIE，占18．2％。HAIE与CAIE患者比较，发病前基础情况较差（Charlson合并症评分≥2分患者比例为35．7％比15．1％；χ^2=6．382，P=0．012），更多人造瓣膜置换史（35．7％比7．1％；χ^2=17．291，P〈0．01），风湿性心脏病史（35．7％比10．3％；χ^2=11．631，P=0．002），免疫抑制剂或糖皮质激素治疗史（21．4％比4．0％；χ^2=10．530，P=0．005）和并发急性心力衰竭（17．9％比4．8％；χ^2=5．923，P=0．029）。CAIE以草绿色链球菌感染为主（χ^2=5．489，P=0．019），而HAIE以葡萄球菌、肠球菌感染为主（50．1％），其他病原体感染也多见于HAIE（χ^2=5．870，P=0．026）。住院期间共死亡10例，住院病死率为6．5％。HAIE的病死率显著高于CAIE（17．9％比4．0％；χ^2=7．278，P=0．018）。多因素回归分析表明，未手术治疗（OR=0．081，95％CI：0．008～0．873，P=0．038）、低白蛋白水平（OR=0．754，95％CI：0．587～0．967，P=0．026）、脑卒中（OR=33．777，95％CI：2．751～414．743，P=0．006）和HAIE（OR=11．952，95％CI：1．045～136．709，P=0．046）是引起IE患者死亡的独立危险因素。结论HAIE常见且流行病学特点有别于CAIE，可增加患者的病死率。

Objective To describe the characteristics of healthcare-associated infective endocarditis （HALE） and to investigate the risk factors of infective endocarditis （IE） case fatality. Methods All consecutive cases of definite IE diagnosed from 1992 to 2012 were collected and categorized into HAIE and community acquired IE （CAIE）. The epidemiological and clinical features of HAIE and CAIE were compared. Risk factors for in-hospital case fatality were analyzed by Logistic regression. Results One hundred and fifty-four patients with IE were enrolled; 126 （81.8%） were CAIE and 28 （18.2%） were HAIE. Compared with CAIE patients, HAIE patients were in poorer condition （Charlson comorbidity scale≥2： 35. 7% vs 15. 1% ;χ^2= 6. 382, P= 0. 012）, more frequently associated with a history of prosthetic valve replacement （35.7% vs 7.1% χ^2= 17. 291, P〈0.01）, more rheumatic heart disease （35.7 % vs 10.3 % ; χ^2= 11.631, P = 0. 002）, more recieved immunosuppressive or glucocorticoid therapy （21.4% vs 4.0% ;χ^2=10. 530, P=0. 005） and more acute heart failure （17.9% vs 4.8% ;χ^2==5. 923, P=0. 029）. Viridans group streptococci infection predominated in CAIE （χ^2=5. 489, P=0. 019）, while staphylococci and enterococci infections （50. 1%） were frequent in HAIE. Other bacterial pathogen infections were more common in HAlE （%2 =5. 870, P=0. 026）. Ten patients died before discharge and the case fatality rate in-hospital was 6.5% （10/154）. Case fatality rate in HAIE （17.9%） was significantly higher than CAIE （4. 0%;χ^2=7. 278, P= 0. 018）. Surgery treatment, albumin level, stroke and HAIE were independent risk factors for IE-related deaths. Odds ratios （OR） were 0. 081 （95% CI：0.008-0.873）, 0. 754 （95%CI： 0.587-0. 967）, 33. 777 （95MCI：2. 751-414. 743） and 11. 952 （95%CI：1. 045-136. 709）, respectively. Conclusion HAIE is common and distinctive from CAIE in epidemiology and prognosis,which increases patient fatality.