动态监测ICU肝病患者PCT水平在判断血流感染和指导抗生素使用中的临床价值

Clinical value of dynamic monitoring of procalcitonin levels in judgment of blood flow infection and antibiotic use in ICU patients with hepatopathy

目的研究动态监测降钙素原(PCT)水平在诊断ICU肝病患者早期血流感染及指导抗生素使用的临床价值。方法监测中国人民解放军第302医院2013年4月至2015年4月30例健康对照者体检当日和530例新转入重症监护病房(ICU)的肝病患者当日血清PCT浓度,对怀疑存在血流感染的肝病患者监测转入ICU后第1、2、3天清晨空腹血PCT浓度、WBC计数、血培养和细菌鉴定。结果有致病菌生长组266例,PCT均值8.0μg/L,阳性率94.3%(251/266);无致病菌生长组264例,PCT均值0.4μg/L,阳性率为35.6%(94/264);30例对照组血培养均阴性,PCT均<0.05μg/L,阳性率为0;真菌生长组40例,PCT均值2.8μg/L,阳性率为60.0%(24/40);革兰氏阳性菌生长组82例,PCT均值6.1μg/L,阳性率为85.4%(70/82);革兰氏阴性菌生长组144例,PCT均值15.1μg/L,阳性率为95.8%(138/144)。有致病菌生长组、无致病菌生长组的PCT浓度均较对照组高,差异均具有统计学意义(P<0.01);革兰氏阳性菌生长组、革兰氏阴性菌生长组、真菌生长组的PCT浓度比较差异具有显著统计学意义(P<0.01),而白细胞(WBC)比较差异无统计学意义(P>0.05);抗生素治疗有效组和治疗无效组在抗生素治疗后第2天和第3天PCT浓度比较差异有统计学意义(P<0.01);抗生素治疗有效组在血流感染后第3天的PCT浓度与峰值PCT浓度相比,下降幅度为87.8%,而抗生素治疗无效组在血流感染后第3天的PCT浓度与峰值PCT浓度相比下降不超过3%,两者比较差异具有统计学意义(P<0.05)。结论动态监测肝病ICU患者的PCT水平将有助于脓毒血症的早期干预和合理使用抗生素的用药指导,从而降低病死率。

Objective To investigate the role of monitoring procalcitonin（PCT） levels for diagnosis of early blood flow infection and judgment of use of antibiotics in ICU patients with hepatopathy. Methods From April 2013 to April 2015, 530 ICU patients with hepatopathy and 30 healthy controls in the No. 302 Hospital of Chinese PLA were randomly selected and tested for PCT levels at admission to ICU. The ICU patients with hepatopathy suspected of blood flow infection then underwent PCT levels monitoring, WBC counts and blood cultures and bacterial identification with the fasting blood in the morning on day 1, day 2, day 3. Results Among the 530 ICU patients with hepatopathy, 266 were detected with pathogens（pathogen group）, and 264 were not（non-pathogen group）. The average PCT level, PCT positive rate were 8.0 μg/L, 94.3%（251/266） in pathogen group and 0.4 μg/L, 35.6%（94/264） in non-pathogen group.The blood cultures of 30 subjects in the control group all showed negative results, with PCT0.05 μg/L, and the positive rate was 0. In the pathogen group, there were 40 cases with fungi（fungi group： average PCT was 2.8 μg/L, and PCT positive rate was 60.0%）, 82 cases with Gram-positive bacteria（Gram-positive bacteria group： 6.1 μg/L, 85.4%）, and 144 cases with Gram-negative bacteria（Gram-negative bacteria group： 15.1 μg/L, 95.8%）. The PCT levels in pathogen group and non-pathogen group were significantly higher than those in the control group（P〈0.01）. The differences were significant in PCT levels among fungi group, Gram-positive bacteria group, Gram-negative bacteria group（P〈0.01）, but not in WBC counts（P〈0.05）. In addition, the difference in PCT levels was statistically significant between antibiotics effective group and antibiotics ineffective group on day 2 and day 3 after antibiotic therapy（P〈0.01）. Compared with the peak PCT concentrations, PCT concentrations in antibiotics effective group on day 3 were decreased by 87.8%, but PCT concentrations in antibiotics ineffective group were decreased by 3%, with statistically significant difference between the two groups（P〈0.05）. Conclusion Dynamic monitoring of PCT concentrations in ICU patients with hepatopathy would be helpful to the early intervention of sepsis and the guidance of reasonable use of antibiotics, thus would reduce the mortality.