肝衰竭继发感染的预后分析

Prognosis analysis of liver failure with secondary infection

目的分析继发感染对肝功能衰竭预后的影响.方法回顾性分析中南大学湘雅二医院感染科2015年1月至2017年12月诊断为肝衰竭的住院患者,根据住院期间是否并发感染分为感染组和非感染组,分别检测其肝衰竭病因、感染部位、感染源等.感染组又分为细菌和真菌组,分别检测分析其肝肾功能、国际标准化比值( international normalized ratio, INR)、终末期肝病模型( model for end-stage liver disease, MELD)评分、住院天数、住院费用、病死率等.正态分布的连续变量采用t检验,分类变量采用卡方检验比较.结果共纳入住院肝衰竭患者384例,其中男321例,女63例,年龄(45.5 ± 13.4)岁.整个病程中继发感染者240例(62.5%,感染组),无感染者144例(37.5%,未感染组). 384例患者中乙型肝炎病毒(hepatitis B virus, HBV)感染328例(85.4%),丙型肝炎病毒(hepatitis C virus, HCV)感染8例(2.1%),酒精性肝炎10 例(2.6%);肝衰竭临床类型为慢加急性(亚急性)肝衰竭187 例(48.7%),慢性肝衰竭158 例(41.1%).感染组240 例患者中腹腔感染122 例(50.8%),肺部感染84例(35.0%),尿路感染8例(3.3%),胆道感染13例(5.4%),血液感染11例(4.6%).感染组和未感染组入院30 d后总胆红素、肌酐水平,MELD评分,住院天数、住院费用比较差异均有统计学意义(均P<0.01).感染组240例患者送检各种样本362份进行细菌培养,阳性87份(24.0%),病原菌分别为念珠菌15株、曲霉菌8株、鲍曼不动杆菌13株、葡萄球菌10株、大肠埃希菌11株、肺炎克雷伯菌14株,粪产碱杆菌、人苍白杆菌、嗜麦芽窄食单胞菌、嗜水气单胞菌各4株.感染组240例中诊断为细菌感染者182例,真菌感染者58例,两组患者总胆红素、血肌酐、INR、MELD评分和病死率差异均有统计学意义(均P<0.05).结论肝衰竭继发感染率与患者年龄无关,但肝衰竭患者一旦继发感染,尤其是真菌感染,其预后将显著恶化.

Objective To analyze the impact of secondary infection on prognosis of liver failure. Methods A total of 384 hospitalized patients who were diagnosed with liver failure from January 2015 to Decembet 2017 in the Department of Infectious Diseases of the Second Xiangya Hospital of Central South University were retrospectively analyzed. The patients were divided into infected group and non-infected group according to whether they were complicated with infection during hospitalization. The cause of liver failure, the area and source of infection were recorded. The infected group was divided into bacterial group and fungal group. The liver and kidney function, international normalized ratio (INR). The model for end-stage liver disease (MELD) score, hospitalization days, medical expenditure, and mortality were calculated and evaluated.T test was used for normally distributed continuous variables, and chi-square test was used for classified variables. Results A total of 384 hospitalized patients with liver failure were enrolled, including 321 males and 63 females with age of (45.5±13.4) years. There were 240 patients (62.5%, infected group) who had secondary infection during the whole course, and 144 patients (37.5%, non-infected group) were not infected.Among the 384 patients, 328 patients (85.4%) were infected with hepatitis B virus, 8(2.1%) with hepatitis C virus, and 10(2.6%) with alcoholic hepatitis. As for the clinical types of liver failure, 187 patients (48.7%) were diagnosed with acute-on-chronic (subacute) liver failure and 158 (41.1%) with chronic liver failure.Among the 240 patients in the infected group, 122 patients (50.8%) had abdominal infection, 84 (35%) had pulmonary infection, 8(3.3%) had urinary tract infection, 13(5.4%) had biliary tract infection, and 11(4.6%) had bloodstream infection.The levels of total bilirubin, creatinine, MELD scores, hospitalization days and medical expenditure in the infected group and non-infected group were statistically significant (all P<0.01) after 30 days in hospital.In the infected group, 362 various samples from 240 patients were submitted for bacterial culture, among which 87 samples were positive, including Candida in 15 samples, Aspergillus in 8 samples, Acinetobacter baumannii in 13 samples, Staphylococcus in 10 samples, Escherichia coli in 11 samples, Klebsiella pneumoniae in 14 samples, Bacillus faecalis in 4 samples, Bacillus pallid in 4 samples, Stenotrophomonas maltophilia in 4 samples and Aeromonas hydrophila in 4 samples.Among the 240 patients in the infected group, 182 patients were diagnosed with bacterial infection and 58 with fungal infection. There were significant differences in total bilirubin, serum creatinine, INR, MELD scores and mortality rate between the two groups (all P<0.05). Conclusions The rate of secondary infection in patients with liver failure is not related with age. The development of secondary infection, especially fungal infection, worsens the prognosis of patients with liver failure.