糖皮质激素长期应用宿主合并社区获得性肺炎的临床特征及预后分析

Clinical characteristics and prognosis of long-term glucocorticoid users with community-acquired pneumonia

摘要目的探讨糖皮质激素长期应用宿主合并社区获得性肺炎（G-CAP）的临床特征及预后。方法回顾性分析2014年1—12月入住全国11家三级甲等医院呼吸科或重症监护病房（ICU）的G-CAP患者100例（G-CAP组）的临床资料，选取同期无免疫功能低下的CAP患者100例（nICH-CAP组）作为对照。对两组患者的年龄、性别、基础疾病、糖皮质激素应用情况、症状、疾病严重程度、影像学表现、病原学特征、是否合并呼吸衰竭、机械通气、是否应用血管活性药物、抗菌药物应用情况、住院病死率等进行比较分析，并运用Logistic回归探讨G-CAP的预后因素。结果G-CAP组外周血淋巴细胞[1.06（0.70，1.68）比1.44（0.87，1.98）]低于nICH-CAP组（P〈0.05）；而肺间质病变（28.6%比9.9%）、呼吸衰竭（25.0%比7.0%）、有创机械通气（9.0%比2.0%）、无创机械通气（12.0%比2.0%）、脓毒性休克（9.0%比2.0%）、住院病死率（13.0%比3.0%）均显著高于nICH-CAP组（均P〈0.05）；G-CAP组以细菌感染为主（61.3%），其次为病毒感染（19.4%）和混合感染（16.1%）；其中细菌感染者以铜绿假单胞菌比例最高（47.4%）；外周血淋巴细胞（OR＝0.004，95% CI：0.000～0.234；P〈0.05）和呼吸衰竭（OR＝17.766，95% CI：4.933～131.0；P〈0.05）为G-CAP组住院死亡的独立预测因子。结论G-CAP患者疾病严重程度和住院病死率较高，若合并低淋巴细胞血症和呼吸衰竭提示不良预后。

ObjectiveTo explore the clinical features, etiological features and prognostic risk factors of long-term glucocorticoid users with community-acquired pneumonia （CAP）.MethodsA retrospective study included 100 long-term glucocorticoid users with CAP （G-CAP group） from 11 hospitals of China between January 2014 and December 2014, while 100 non-immunocompromised patients with community-acquired pneumonia were enrolled as controls （nICH-CAP group）. Characteristics including age, gender, underlying diseases, corticosteroids, symptoms, disease severity, imaging manifestations, etiology, respiratory failure, mechanical ventilation, whether the application of vasoactive drugs, antibiotics application, hospital mortality rate between the two groups were compared, and the prognostic factors of G-CAP were investigated using Logistic regression.ResultsThe peripheral blood lymphocytes[1.06（0.70, 1.68） vs 1.44 （0.87, 1.98）]in G-CAP group was less than nICH-CAP group （P〈0.05）. CT with pulmonary interstitial change （28.6% vs 9.9%）, the proportion of patients with respiratory failure （25.0% vs 7.0%）, mechanical ventilation （9.0% vs 2.0%）, noninvasive mechanical ventilation （12.0% vs 2.0%）, septic shock （9.0% vs 2.0%）, and the hospital mortality rate （13.0% vs 3.0%） in G-CAP group were significantly higher than in nICH-CAP group （all P〈0.05）. Bacterial infection accounted for the highest proportion of infection （61.3%） in G-CAP group, but also virus infection （19.4%） and mixed infection （16.1%）. Pseudomonas accounted for the highest proportion （47.4%） in bacterial infection of G-CAP. Logistic regression analysis showed that peripheral blood lymphocytes （OR=0.004, 95% CI： 0.000-0.234; P〈0.05） and respiratory failure （OR=17.766, 95% CI： 4.933-131.0; P〈0.05） were independent predictors of death in G-CAP group.ConclusionsThe proportion of severe pneumonia and the mortality rate of patients with G-CAP are higher than the patients with nICH-CAP. Lymphopenia and respiratory failure are associated with poor outcome of patients with G-CAP.