中枢神经系统损伤后肺部感染患者血清降钙素原的变化规律

Serum procalcitonin in patients with pulmonary infection and central nervous system injury

目的探讨血清降钙素原（PCT）在中枢神经系统损伤后肺部感染患者的变化规律与诊治价值。方法回顾分析2014年10月至2017年2月中山大学附属第一医院重症医学科中枢神经系统损伤后患者1852例，其中各类感染173例，89例临床资料完整，最后纳入确诊中枢神经系统损伤后单纯肺部感染42例。获取患者血清PCT水平、肺部感染临床征像、影像资料以及感染相关实验室指标，采用单因素和多因素线性回归，分析中枢神经系统损伤后患者血清PCT与肺部感染以及肺部感染严重程度（CPIS）的相关性，并进一步分析血清PCT水平是否受中枢神经系统损伤后天数、疾病种类及手术类型、格拉斯哥昏迷评分（GCS）以及外源性糖皮质激素等因素的影响。结果42例患者CPIS5．50（5．00，7．00）分，血清PCT0．83（0．29，2．79）μg/L。肺部感染期间血清PCT峰值〈0．25ng／ml9例，0．25-0．5μg/L7例，0．5—2μg/L12例，2—10μg/L10例，仅4例患者感染期间血清PCT峰值≥10μg/L。血清PCT与体温（T）、血白细胞（WBC）、中性粒细胞（NEU）比值、CPIS评分无显著相关。PCT〈0．5与PCT≥0．5μg/L两组患者的T、WBC、NEU比值、CPIS差异无统计学意义。中枢神经系统损伤后肺部感染患者血清PCT水平与创伤后时间存在独立相关关系[β=0．19，95％可信区间（0．01，0．36），P〈0．05]；将肺部感染发生时间分为中枢神经系统损伤后0-3、4-7、8-14与≥15d，损伤后不同时间段内肺部感染患者的血清PCT峰值差异有统计学意义（P〈0．05），损伤后0—3d的17例患者感染期间血清PCT峰值1．26（0．47，2．7）μg／L，29．41％的患者PCT〈0．5μg/L，损伤后4-7d9例患者感染期间血清PCT峰值0．23（0．16，0．39）μg/L，77．78％的患者PCT〈0．5μg/L，损伤后7—14d9例患者感染期间血清PCT峰值0．52（0．33，1．12）μg/L，PCT〈0．5μg／L患者减少至44．44％，损伤后≥15d7例患者感染期间血清PCT峰值3．26（2．07，12．40）μg/L，PCT〈0．5μg/L患者数减少至零。血清PCT与GCS评分、疾病种类及手术类型、外源性糖皮质激素使用未发现明显相关。结论中枢神经系统损伤后肺部感染患者血清PCT水平上升不明显，不能依照PCT指导这类患者的抗生素治疗。

Objective To evaluate the influence of serum procalcitonin in the diagnosis and treatment of pulmonary infection in patients with central nervous system injury. Methods From October 2014 to February 2017, a retrospective study was performed. A total of 1 852 patients were screened in Department of Intensive Care Unite, First Affiliated Hospital of Sun Yat-sen University. Among them, 173 patients were identified with different kinds of infection. Finally, a total of 42 patients with pulmonary infection were enrolled. The clinical data of patients with pulmonary infection and central nervous system （CNS） injury was collected. A univariate and multivariate regression analysis was performed to study the correlation of serum procalcitonin （PCT） with clinical symptoms and signs of the pulmonary infection, body temperature（T）, white blood cell count （WBC）, percentage of neutrophils （NEU） and the severity of the pulmonary infection （CPIS）. The relationship of serum PCT with type of CNS injury, GCS, and exogenous glucocorticoid was further studied. Results During the period of pulmonary infection, the peak PCT was 0. 83 （0. 29, 2. 79） μg/L and the CPIS was 5.50 （5. 00, 7. 00）. In 9 of 42 patients, the peak PCT was less than 0. 25 μg/L. In 7 of 42 patients, the peak PCT was ranged from 0. 25 to 0. 5 μg/L. In 12 of 42 patients, PCT was ranged from 0. 5 to 2 μg/L. Only 10 patients had a PCT 2 - 10 μg/L and 4 patients had a PCT more than 10 μg/L. There is no correlation between serum PCT and body temperature, white blood cell, percentage of neutrophils and CPIS. There was no significant differences in patients with PCT 〈 0. 5 or ≥0. 5 μg/L regarding the body temperature, white blood cell, percentage of neutrophils and CPIS. However, serum PCT in patients with pulmonary infection had independent correlation with the post CNS injury day （β=0. 17, 95% C1（0.02, 0.32）, P〈0.05）. The serum PCT was 1.26 （0.47,2.7） μg/L and 29. 41% patients with a PCT less than 0. 5 μg/L within 3 days post CNS injury. Serum PCT level was 0. 23 （0. 16,0. 39） μg/L, and 77.78% patients with a PCT less than 0. 5 μg/L at day 4 to day 7 post- injury. The PCT level was 0. 52 （0. 33,1.12） μg/L, and 44. 44% patients with a PCT less than 0. 5 μg/L at day 8 to day 14. The PCT was 3.26 （2. 07,12.40） μg/L, and no patient with a PCT less than 0. 5 μg/L after day 15 post-injury. There were no significant relationship found between serum PCT level and type of the disease and surgery, GCS, and use of exogenous glucocorticoid. Conclusions Serum PCT had no significant increase and was not able to be used in guiding the antibiotics use in patients with CNS injury and pulmonary infection.