混合性念珠菌血症的临床特征及危险因素分析

The clinical characteristics and risk factors of mixed Candida/bacterial bloodstream infections

目的探讨混合性念珠菌血症的临床特征及相关危险因素方法回顾性收集2012年1月至2015年6月期间入住浙江大学医学院附属第二医院重症医学科混合性念珠菌血症的临床特征、微生物学检查及临床结局等,与同期单一念珠菌血症患者进行对照分析,并应用Logistic回归探讨相关危险因素。结果念珠菌血症患者共136例,其中混合性念珠菌血症组40例(29.4%),单一念珠菌血症组96例(70.6%)。尽管最常见仍为白色念珠菌,但非白念珠菌(69例,50.7%)已超过白色念珠菌(67例,49.3%);两组比较,念珠菌菌种分布差异无统计学意义(P>0.05)。在40例混合感染组患者中,细菌血症以革兰阳性球菌为主(25例,62.5%),余为革兰阴性杆菌(15例,37.5%)。与单一念珠菌血症组相比,混合性念珠菌血症组所需抗真菌疗程更长[12.0(4.0-25.0)d vs. 7.0(3.0-13.5) d, P=0.027],但不增加30 d和90 d的总病死率(分别为:40.0% vs. 32.3%;45.0% vs. 36.5%;P>0.05)。单因素分析显示,感染前住院天数、感染时入住ICU、输血、输注白蛋白、机械通气、利奈唑胺使用、序贯性脏器功能衰竭评分(the Sequential Organ Failure Assessment,SOFA)为混合性念珠菌血症感染的危险因素(均P<0.05),但多因素回归分析显示仅SOFA评分高为独立危险因素(P=0.003)。结论混合性念珠菌血症以革兰阳性球菌为主,入住ICU时间和住院时间更长,抗真菌治疗疗程更长,但对病死率无影响;SOFA评分高,病情严重,是发生混合性念珠菌血症的独立危险因素。

Objective To investigate the clinical characteristics and associated risk factors for patients with mixed Candida/bacterial bloodstream infections (BSIs). Methods A retrospective study was conducted in the Second Affiliated hHospital of Zhejiang University School of Medicine from February 2012 to June 2015. The clinical data of cases was collected, and the clinical characteristics, the microbiology data and outcomes in patients with mixed Candida/bacterial BSIs confirmed by blood culture were compared with those with candidaemia. A Logistic regression analysis was performed to investigate the independent risk factors. Results A total of 136 candidaemia cases were analyzed including 40 cases (29.4%) of mixed Candida/bacterial BSIs and 96 cases of candidaemia. Among the 136 candidas strains, the proportion of non-albicans exceeded the albicans (50.7% vs 49.3%), although the later was still the predominant one. There was no significant difference in the distribution of candidas strains between patients with mixed Candida/bacterial BSIs and patients with candidaemia. In patients with mixed Candida/bacterial BSIs, 25 strains (61.0%) of gram-positive cocci and 16 strains (39.0%) of gram-negative bacilli were isolated. Compared with patients with candidaemia, patients with mixed Candida/bacterial BSIs needed longer period of antifungal therapy [12.0 (4.0-25.0)days vs 7.0 (3.0-13.5) days, P=0.027], but the crude 30-day and 90-day mortality did not differ between the two groups (40.0% vs 32.3%;45.0% vs 36.5%;both P>0.05). Univariate analysis revealed that the prior hospital stay, ICU admission at the onset of candidaemia, blood transfusion, human albumin infusion, mechanical ventilation, linezolid use and high SOFA score were related with the occurrence of mixed Candida/bacterial BSIs (all P<0.05). Multivariate analysis showed that only high SOFA score was the independent risk factor (P=0.003). Conclusions Gram-positive cocci were the predominant species in mixed Candida/bacterial BSIs. Compared with candidaemia, mixed Candida/bacterial BSIs needs a longer ICU stay, a longer hospital stay, and a prolonged antifungal therapy. High SOFA score is the independent risk factor for mixed Candida/bacterial BSIs.