耐亚胺培南肺炎克雷伯菌腹腔感染患者的临床特征及预后

Clinical characteristics and outcome of patients with abdominal infection by Carbapenem-resistant Klebsiella pneumoniae

目的研究耐亚胺培南肺炎克雷伯菌所致腹腔感染患者的临床特征、感染危险因素、治疗方案及临床预后。方法回顾性调查2011年1月至2014年10月浙江大学医学院附属第一医院住院患者中由耐亚胺培南肺炎克雷伯菌所致腹腔感染患者的基础疾病、临床表现、实验室指标、微生物学检测结果等临床特征;了解腹腔感染发生前的侵入性操作、手术、抗菌药物使用、免疫抑制剂使用等高危因素;分析腹腔感染的治疗措施及抗菌药物的使用情况,患者对治疗的临床反应及30d病死率。目标变量使用单因素、多因素分析,χ2检验及风险评估进行分析。结果本研究入选43例腹腔感染患者,其病原菌均为亚胺培南耐药的肺炎克雷伯菌。病例年龄17~92岁,平均(54.8±15.9)岁;男性31例(72.1%);APACHEⅡ评分22~33分,平均(27.7±2.2)分。全部患者在其样本培养阳性前2周内有侵入性操作,其中100.0%的患者留置腹腔引流管、95.3%的患者留置导尿管、93.0%的患者留置中心静脉管、76.7%的患者气管插管或切开;有36例患者(83.7%)感染前90d内有手术史(均为经腹腔手术);32例(74.4%)患者曾有30d内ICU入住病史;38例(88.4%)患者在其标本培养阳性前2周内曾接受抗生素治疗。发热(74.4%)为腹腔感染耐亚胺培南肺炎克雷伯菌的主要临床表现,其次为腹痛(44.2%)。分别有13例(30.2%)和6例(14.0%)患者合并血流感染和/或痰液中检出耐亚胺培南肺炎克雷伯菌,17例(37.2%)患者出现感染性休克。在多因素分析中,感染性休克是30d病死唯一的危险因素(OR:0.693,95%CI:1.591~30.245,P=0.010)。累计30d病死率为37.2%,存活时间2~28d,平均(12.3±9.4)d;合并血培养阳性者的病死率为46.2%。使用替加环素治疗后30d病死率较未用替加环素治疗低(19.0%vs 54.5%,P=0.027)。结论腹腔感染耐亚胺培南肺炎克雷伯菌患者的病死率较高,感染性休克是30d内病死的危险因素。使用替加环素进行抗菌治疗能降低30d病死率、改善临床预后。

Objective To study the clinical features,risk factors,treatment options and outcome of abdominal infections caused by Carbapenem-resistant Klebsiella pneumoniae.Methods Clinical data of inpatients with abdominal infection caused by Imipenem-resistant Klebsiella pneumoniae during January 2011 and October 2014 in our hospital were retrospectively analyzed by using univariate analysis,chi-square test and risk assessment.Results A total of 43 eligible cases were included.The average age of patients was 54.8years（SD,15.9）;male accounted for 72.1%.The APACHEⅡscore was 27.7±2.2on average.All the patients received invasive operations within 2weeks before the infection,among whom 100.0% of the patients had intraperitoneal drain catheter,95.3% had urinary catheter,93.0% had central venous indwelling catheter,and 76.7% had tracheal intubation.Patients received surgical treatment within 90 days before the infection accounted for 83.7%;74.4% of the patients had been admitted to ICUs within 30 days before the infection;88.4% of them received antibiotic treatment within two weeks before a positive culture result.Fever was the most common clinical manifestations（74.4%）,followed by abdominal pain（44.2%）.37.2% of the patients complicated with septic shock.Patients who had bloodstream and/or lower respiratory infections accompanied by positive CRKB accounted for 30.2% and 14.0%,respectively.Recent mortality rate was37.2%（within 30days）.The mortality of patients with concurrent bloodstream infection was 46.2%.Septic shock was the only risk factor for mortality within 30days（OR：0.693,95%CI：1.591-30.245,P=0.010）.The mortality within 30 days of patients who received treatment of tigecycline was lower（19.0%vs 54.5%,P=0.027）.Conclusion Abdominal infections with CRKB present high mortality.Septic shock is the unique risk factor for mortality within 30 days.Rational use of tigecycline could lead to a better outcome.