肠球菌属血流感染的临床特征及预后分析

The clinical features and outcomes of 117 patients with enterococcal blood stream infection

目的探讨肠球菌属血流感染(EBSI)患者的临床特征及预后情况。方法收集117例EBSI患者的临床资料,分析其临床特征及预后情况;比较屎肠球菌与粪肠球菌感染患者的临床特征、抗菌药物耐药率及预后情况;同时分析影响EBSI患者30d内病死的危险因素。结果肠球菌属包括屎肠球菌72例、粪肠球菌37例、鸟肠球菌5例,鹑鸡肠球菌3例。EBSI临床表现以发热为主,继发多脏器功能衰竭(MODS)28例,感染性休克25例;2周内抗菌药物使用率为80.3%。117例患者血培养结果提示合并其他病原体的有32例(27.4%)。血流感染时急性生理与慢性健康(APACHEⅡ)评分17~38(25.3±4.6)分。与粪肠球菌感染患者比较,屎肠球菌感染患者APACHEⅡ评分、MODS发生率、接受糖皮质激素治疗的比例、动静脉置管的比例均较高(均P<0.05),住院时间更长(P<0.05);两组患者30d内病死率比较,差异无统计学意义(P>0.05)。屎肠球菌感染患者对青霉素G、氨苄西林、喹诺酮类的耐药率均高于粪肠球菌感染患者(均P<0.05),对利奈唑胺的耐药率低于粪肠球菌感染患者(P<0.05);屎肠球菌与粪肠球菌感染患者对万古霉素、替考拉宁、庆大霉素、替加环素的耐药率比较,差异均无统计学意义(均P>0.05);两组患者对替加环素药物的耐药率均为0.0%,对庆大霉素的耐药率均>40%;检出4株对万古霉素耐药的屎肠球菌,6株利奈唑胺耐药菌株,4株利奈唑胺中介菌株,未发现对替加环素耐药的菌株。EBSI患者30d内病死率为23.9%,接受糖皮质激素治疗(OR=4.62,95%CI:1.10~19.43,P<0.05)、继发休克(OR=6.89,95%CI:1.85~25.65,P<0.05)、未选用敏感药物治疗(OR=0.06,95%CI:0.01~0.33,P<0.05)是30d内病死的危险因素。结论 EBSI病死率较高,接受糖皮质激素治疗、继发休克、未选用敏感药物治疗是30d内病死的危险因素。与粪肠球菌比较,屎肠球菌耐药性更高,其所致感染的比例较高,患者的基础疾病更严重,抗感染治疗更困难。

Objective To discuss the clinical features and outcomes of 117 patients with enterococcal bloodstream infections（EBSI）.Methods Collect the clinical date of 117 patients with EBSI, to analyze the clinical characteristics and outcomes. Comparing the two groups of E. faecalis and E. faecium BSI, to analyze the clinical characteristics,the antimicrobial resistance and outcomes. To characterize the risk factors of EBSI fatality rate within 30 days. Results In this study, there were 72 cases of E. faecium, 37 cases of E. faecalis, 5 cases of E.avium and 3 cases of E. gallinarum. The clinical manifestations were mainly fever.28 cases with secondary MODS, 25 cases with septic shock.80.3% patients had antibacterial drug therapy within 2 weeks.The results of patient blood culture indicated that 32 cases（27.4%） were combined with other pathogens.During bloodstream infections,acute physiology and chronic health（APACHE Ⅱ） score is in the range of17~38（25.3 ±4.6）. According to univariate analysis, patients with E.faecium BSI were likely to have a higher APACHE Ⅱ score, more frequency of Multiple organ dysfunction syndrome（MODS）, received corticosteroid therapy and arteriovenous catheter（P〈0.05）,longer length of hospital stay（P〈0.05）.The fatality rate of patients in the two groups within 30 d was not statistically significant（P〈0.05）. Drug resistance rate of E. Faecium to penicillin G, ampicillin, quinolones was higher（P〈0.05）,but lower to linezolid（P〈0.05）. The drug resistance rates to vancomycin, teicolanine, gentamycin 500 and tigacycline were not statistically significant in two groups（P〈0.05）.The drug resistance rate to tigacycline of both groups was 0.0%, but to gentamicin 500 was 〉40%.There were 4 cases of vancomycin-resistant strains, 6 cases of linezolid-resistant strains, 4 cases of linezolid-medium sensitive stains,none of tigecycline-resistant. The 30-day fatality rate of EBSI was23.9%.The 30-day fatality rate was statistically significantly associated with received corticosteroid therapy（OR=4.62, 95%CI： 1.10-19.43,P〈0.05）, shock（OR=6.89, 95%CI： 1.85-25.65, P〈0.05）, and not receiving active antimicrobial therapy（OR=0.06, 95%CI： 0.01-0.33, P〈0.05）.Conclusion The patients which had EBSI showed high fatality rate. Independent risk factors for the 30-day fatality rate were received corticosteroid therapy, shock, and not receiving active antimicrobial therapy. E. faecium is associated with higher antimicrobial resistance and infection rate. The patients due to E. faecium BSI are associated with more severe underlying diseases,who meet more difficulty in the clinical treatment.