白血病合并热念败血症临床特征与死亡相关因素分析

Analysis of clinical characteristics and attributable mortality of candida tropicalis fungemia in patients with hematological leukemia

目的了解白血病合并热念败血症的临床特征，并探讨影响其预后的相关因素。方法回顾性分析2008—2015年广东省人民医院收治经血培养证实并伴有临床相关症状的热念败血症的白血病患者23例，描述其临床特征、治疗和转归．应用Kaplan—Meier和Cox回归方法分析生存相关预后因素。结果23例主要临床表现为高热23例（100％），低血压、皮疹各16例（69．6％），咳嗽咳痰12例（52．2％），脾肿大、腹泻各9例（39．1％），肝肿大、关节疼痛各6例（26．1％）等；降钙素原（PCT）正常或轻度升高[0．36（012，0．68）μg／L]。初始治疗16例选择唑类药物，其中15例（93．8％）患者因治疗失败，于第5天转换为棘白霉素类药物治疗。中位随访137d（2-2799d），治疗有效率为63．6％，粗病死率为65．2％，归因病死率为39．1％，其中第28天归因病死率为88．9％。多因素Cox回归分析显示，降钙素原〉3μg／L（B=1．972，95％CI1．441～35．862，P=0．016）是其归因死亡的独立危险因素；而棘白霉素类药物的应用是独立保护因素（B=-1．999，95％CI0．030-0．615，P=0．010）。结论尽早应用棘白霉素类药物可能降低白血病合并热念败血症病死率。

Objective To understand the clinical characteristics and the factors effects the attributable mortality of candida tropicalis fungaemia in patients with leukemia. Methods A retrospective study of 23 hospitalized patients with hematological malignancies and candida troPicalis fungemia was conducted in Guangdong General Hospital from 2008 to 2015. The clinical data were reviewed in terms of clinical characteristics, treatments and outcomes. The prognostic factors associated with survival analysis used Kaplan- Meier and multivariate COX regression analysis. Results Of all 23 patients, the main clinical manifestations were hyperpyrexia （100%）, hypotension （69.6%）, rash （69.6%）, cough（52.2%）, sputum （52.2%）, splenomegaly（39.1%）, diarrhea（39.1%）, hepatomegaly （26.1%）, and joint pain（26.1%）. Procalcitonin （PCT） was normal or slightly elevated [0.36 （0.12, 0.68）μg/L]. Sixteen of all patients （69.6%） received azoles antifungals as initial therap）5 while 93.8% of which convented to echinocandin due to treatment failure on the fifth day. The median follow-up time was 137 （2-2799） days. The overall response rate was 63.6%. The crude mortality was 65.2%. The mortality attributed to candidemia of tropicalis were 39.1%, the twenty-eight day attributable mortality was accounted for 88.9%. Multivariate COX regression analysis indicated that Procalcitonin （PCT）〉 3μg/L （8=1.972, 95%CI 1.441-35.862, P=0,014） was the independent risk factors of the mortality attributed to candidemia tropicalis, while using echinocandin was a protective factor （β=-1.999, 95%CI 0.030-0.615, P=0.010）. Conclusion Early application of echinocandin is pivotal to reduce the mortality of candida tropicalis fungaemia in patients with leukemia. Keywords： leukemia; candidemia tropicialis; risk factors; echinocandin